On deaths and dying

I've had more time to think lately and I've been reminded of the time 3 years ago when we went through that third miscarriage. I also think more about it because we so clearly have a toddler now and not a baby anymore. (Later I think I may discuss my adventure attempting to get to the airport in morning traffic in LA and the hours spent contemplating a very different world, but for now, just the grief.)

The dying part is hard too. My friend who has been dying for some time is now at the end of hospice care waiting to die. She's in so much pain and not really eating any more and it's hard. Obviously not so hard for me as it is for her and her family but it's had me pretty frozen. It's a really good thing I'm not keeping track of how many brain candy books I've read in the past few weeks. I'd say it's about 50% escaping reality and 50% trying to fill the time with more cheerful thoughts rather than the gloom and doom and death hanging around everywhere. Happy Festive Winter Holiday to me?

I guess the two events, aside from both occurring in December, really bring up a lot of survivor's guilt for me. I never feel worthy to be on this side of things with a toddler and no cancer. My friend has the most perfect spouse and four awesome children and I wonder why her and not me. I never feel like I'm enough. It matters that I get these second chances and I'm trying to seize them and do some good in the world but it's a struggle to kick the feelings of unworthiness. I haven't descended into feeling worthless but it's hard to avoid that pitfall. I suppose I might say that grief has me standing at the edge of the pit of worthlessness and I can see how it would be easy to fall but also that the way to whatever is next in life is walking along the edge of the pit and not falling in or going across.

Anyway, the most intriguing thing happened last week. I was feeling mopey about life and how many of my favorite Festive Holiday ornaments have been ruined when yanked off the tree by Little Monster (and/or Fluffinella and/or the Kid) and then I was checking FB yet again (nervous habit I suppose?) and ran into a friend posting about the Mental Illness Happy Hour. It turned out to be the day a new weekly podcast came out and it was the above linked episode... about miscarriage.

I figured that I'd better share it with you all. The guest in that episode is a fellow infertile with multiple miscarriages and she talks about her experience with a full-spectrum doula. So much of what she says is so familiar and wonderfully put. You should go listen. Then maybe if you need it, read what she wrote about the closure ceremony part here as well.

So I feel better now. Still freaked and unworthy of all the amazing things happening in my life and totally unworthy to be applying for residencies but I'm trying to psych myself up and stop putting anything off. Today has awesome parts even if the transition to whatever happens after life is circling in close. On the whole, just getting to breathe is pretty awesome, let alone getting to snuggle a grumpy toddler for 5 hours while she watches the yellow hat dude and some critter wander around a city. Bonus!

Baby shower blues

I still hate baby showers. They are a great kick in the guts every time, a reminder of everything that didn't work in our attempt at family building. I've kind of resolved that I will excuse myself from as many of them as possible because there's no sense in me attending and being a glum bunny. It's just a thing and I'm stuck feeling the way I feel until it gets better maybe some day. For special people I am willing to put on a happy face and stuff my feelings briefly. Some people are worth celebrating.

So here we are (I am, actually), with the most recent baby shower invite to an event happening this weekend. This one is for a family friend who's the closest thing to my spouse's sister that exists (closer than my sister-in-law, that's for sure). Based on family relation alone this is one I'm pretty obligated to attend. Then there's the infertile club membership we share. It took a couple years for her to get pregnant with her first (two)and the twins were born at 22 weeks just about a year ago. This baby happened remarkably soon after that and is expected in late January. It hasn't been an easy pregnancy as you might imagine so I feel bad there too. I get it, at least more than the perfectly fertile folks. I want to be there in solidarity.

But. Oh I hate baby showers. I'm also flying to the ASHP meeting (that giant pharmacy conference which is in California this year) that same afternoon so I get to leave the baby shower early at least. But I hate flying so much. Usually I get to the airport 4ish hours early so I have plenty of time to panic before I get on the plane. Attending the baby shower cuts my pre-flight airport loitering time down to only 90 minutes.

I'm debating the merits of skipping the thing so I can go hide at the airport. I asked weeks ago if it was ok for the girls to come so I can pawn them off on my MIL while the spouse drops me off at the airport. This week the sister of mom-to-be has been discouraging everyone else from bringing kids and their mom was doing the same. If the answer was no children, why on earth did you say they could come? I hate passive aggressive baloney. Ugh.

I don't know what to make of my selfish motivations. I suppose that means I make an appearance and pretend I hate it less than I am likely to. It's possible it might not be awful. Maybe my motivations will straighten out and I'll figure out whether I can go or whether it's better to send my regrets.

The Relocation Shuffle

It's APPLICATION SEASON!

I'm in a place where I mostly think I am totally capable of not only getting an interview but getting a residency and yet I wake up from dreams where I am counting by 5 and the phone is ringing and the printer is beeping about a paper jam and someone is yelling at my tech about something that the tech has no control over and it is 2pm and I haven't had a break and I won't get one. So I guess I could say my confidence is not high all the time but is high enough that I'm getting along with applying to residencies.

And jobs. Also applying for jobs. I have had 7 interviews so far and one "forget this, we aren't hiring you" response, so overall not bad.

In all things, we are free to relocate if my job dictates. I think we can move the kid to one new city between now and when she's grown so this is actually a very big choice. There's some consideration that I will go during the week for a job and the family will stay here so we can move after a residency. One of the local pharmacies (we had 1 in a grocery store, 3 at big box stores, 1 chain, 2 independents, 2 at the hospital) just closed and another shrank its hours so I worry that working in town won't be an option.

When I'm not debating which of the zillion residencies to focus on applying for, I'm considering how on earth we could leap and move for a job. One of the considerations is that we have a lot of great things in place for the kid now and that's hard to find. She has a tiny class (that is 25% Caucasian, a bit less than our neighborhood but not too far out from the under 12 population demographics) and a small school that supports her with all the quirky services she needs to thrive. I don't think it would be impossible to find this again but we got really lucky to live in a neighborhood that has an elementary that exactly meets her particular needs.

The other big thing on my mind is respite care. It's hard to manage a kid who is challenging all of the time. It's hard to find anyone willing to take care of her for any length of time if her label is known. We aren't stupid so we haven't told our usual respite care friends around town her diagnosis and they are still happy to have her for a few hours. She behaves like a saint at someone else's house right now so that's helpful. I don't expect it to last. Overnights we have mostly been relying on family but they live far enough away that we can only do that maybe 3 times a year. If we move farther away we lose that help. Maybe. We could move closer to a big chunk of family too. Maybe. There's some discussion that my in-laws would visit us more if we lived somewhere more interesting/near their vacation home, even if it were the same distance from their vacation home that we live at now where they come down twice a year at best.

We've also been discussing if we really want to move for good reasons or if we want to move because we just aren't used to staying put this long. This is our third year here and the longest we've lived anywhere since we got married. I really found this video over at Rage Against The Minivan an interesting discussion. Does where you live shape your life? Tremendously so, yes. In my experience it does. Are there communities around you can join or are they all closed (or nonexistent)? [By communities, I mean things like churches or book groups or scouts or community service groups or the PTA.] Are there things you want to do nearby? What about shopping and restaurants? Do you want to do either of those in town or would you rather take a weekend trip somewhere?

My criteria for a place to live is as follows:

• Must have pizza restaurant, preferably delivery
• Must have a community of faith I'm comfortable being a part of
• Must have a job for me and accessibility to a job for the spouse
• Must have schools with support for the kid or that are willing to figure out how to support her
• Must have childcare available
• Strongly prefer a red big box store be within 90 minutes
• Strongly prefer it is possible to get package delivery beyond the mail
• Strongly prefer interesting outdoor recreational opportunities be readily available
• Prefer limited constant wind

That doesn't actually narrow things down one bit. I'm feeling like caution is warranted rather than jumping at the perfect job, but at the same time, I'd rather go somewhere and have a great job than stay here with ho-hum options and no real reason to be here aside from "we already are" and pretty good schools.

Grace under pressure

Tonight both girls are in a horrid mood. There is screaming from one, then the other, then together. Little Monster is cutting molars and the kid is... Herself? Something is wrong but she has no idea what and is a terror because she's upset. We went out to dinner because the house is a disaster and we host thanksgiving Thursday and exhaustion and long commute are winning. At dinner the kid didn't eat until we were ready to leave and she was suddenly ready to eat enough so she could have dessert. This rotation's 2.5 hour daily commute is decidedly taking its toll on me especially, but all of us at least some.

I never understood grace before this year. I mean, I'd heard the word over and over. I'd heard it defined as poise, as the free pass we get when we are forgiven for something. I'd heard about giving yourself grace as a way to cut yourself some slack. I don't know about you, but I am terribly hard on myself. In many ways it's deserved; I'm a person and therefore imperfect, and I'm a particularly ordinary person with some reasonably common flaws that run riot in my life if I don't work hard to keep them in check. Most of the time, I am too hard on myself and I attack my flaws perhaps more than I ought. It's easy to dwell on how nothing is ever right.

In the past little while, I've been practicing forgiving myself for being human. It works sometimes and others it doesn't. Grace is there if I want or need it. Well, when I want and need it. All I can ever do is my best.

But then there is life. Everything crowds my little tiny bubble of "I don't have to be right, I don't have to have all the control, it will be fine probably so stick to the next right thing" affirmations. I yell. I curse a great deal. I lose my temper after the first test of my boundaries instead of the tenth (my goal). It is so hard to find grace in the screaming (usually not me for too long) that I lose faith in the whole exercise of allowing myself to be imperfect. In an awful lot of messy situations, I have been collected and said and done sane things, the right things even. I know that I have access to that grace within myself. I just don't know how to operate day after day with children prodding at my weak points constantly and still find that place where I can think and act from a place that allows them grace too.

Little Monster is sure she is 2 and yells and tantrums to demand things. For the most part, that I cope with all right. I get so frustrated with myself when I can't cope with the kid doing much the same thing. After all, we have had the best part of 5 years to adapt to her tantrums and screaming... and yet it is impossible lately for me to cope. That makes me think I totally missed the mark learning about grace and that I have a very long way to go before I can hang onto any semblance of grace under child-inspired pressure. 

The best part is that I have tomorrow to try again to be a smidgen better than I was today. And please, all that is holy, let there be less screaming tomorrow.

There and back again

It's strange to go home after a month away.

I can tell you I have learned the value of having a pharmacist in your healthcare team. From chatting with patients in this clinic pharmacy, I know it takes an hour or more sometimes to check in to see a doctor and that they only see walk-in appointments for a few hours a day. It takes at least 2 hours and sometimes much longer to get a call back if you leave a message for the nurse of a provider. If a patient called the pharmacy, they spoke to a pharmacist within 3 minutes. Sometimes we could triage what was wrong (go to the hospital if you take a blood thinner and fell and now you have a headache, go to the ER if you are throwing up blood after taking a new medication, try taking your medicine with food or on an empty stomach if it makes you sick or isn't working, you are supposed to take 3 every day and not just one so see if that works, etc) sometimes we couldn't (make an appointment if you need a refill on that medication that was stolen... again...) but at least people got their questions answered rather than waiting hours. That accessibility of pharmacists is sure valuable. Then again we are often too accessible. No other healthcare provider is as likely to work overnights as a pharmacist. Doctors take turns covering nights but not regularly working them, we have a regular rotation of night pharmacists in hospitals and community pharmacies. It's really easy for people to demand to see us too, and they sure do, often to ask silly questions like:

• "I want a flu shot. Where do I sign up?" while standing under a sign that points to "Check in for your flu shot here!"
• "Where are the paper towels?"
• "I need a refill of my medication." "OK, you can talk to my technician over there." SuperTech: "Which medication would you like refilled?" Patient: "The little green one." ST: "What do you take it for?" Patient: "Because my doctor says I need to take it."
• "Why won't you vulcanize my tires while I wait?" 

So maybe that last one is a Clerks reference, but you get the gist. Because you can see the pharmacist in a community pharmacy and because we answer our own phones in the hospital, people make demands on a pharmacist that they would never dream of making on a doctor and yet we have similar educational backgrounds. Somehow pharmacists let themselves be used by everyone else, helping out people and getting nothing in return to the point that we make ourselves miserable.

Anyway, home. I've learned a lot and I'm really glad I had this experience, but it is so hard to be home. While I was gone, Little Monster learned to say "I love you." She wouldn't say it to me when we video chatted for the first few days after she learned it, but then she did it with no coaching or prompting at all, for like 3 minutes straight. She's so big. It boggles my mind.

Compromised values

I'm getting ready to apply to residencies and this brings to the forefront a few things.

First, I really don't want to work for a religious institution. I think. Probably. Or at least not a particularly prevalent one that runs an awful lot of health care establishments. Think hospitals named after saints and you've got the right idea. I'm too lazy to disguise the name of this particular religion and I don't want to invite a legion of angry commenters here by using its name.

My major reason for not wanting to work for one of these institutions is the disservice done to women in the face of obstetric problems. Nobody with pPROM who wants labor induced should have to wait until signs of infection to do so. Nobody with an ectopic should have her tube removed because using the standard of care medication amounts to an "indirect ab.orti.on." I'm perfectly content to let anyone think whatever they want and use their own thoughts to decide on appropriate obstetric treatments for themselves, but I absolutely don't want a hospital to prevent a woman from getting appropriate care for any reason.

It gets a bit more complex though. I live in an area where the closest non-this-faith-based hospital is an hour and a half away across state lines. I don't think the hospitals nearer are doing any terrible things most of the time. They're just the only hospitals around and they happen to be run by some extension of this particular faith. The level to which they subscribe to the official doctrine varies but it isn't one of those things it's easy to ask before you work somewhere.

My personal job acceptance line has been "absolutely no job is worth having at a certain big blue box store" and "if at all possible, a job at a giant red pharmacy chain should be avoided." Beyond that I'd consider myself open but I continue to have mixed feelings about even considering such a religious institution while finding that an awful lot of the places that are otherwise appealing are also religiously affiliated... I'm continuing to consider the merits of maintaining my line as previously defined or to change my values to allow for working for a health system that has a faith-based sponsor.

Then I wonder if I'm compromising too much. There are lots of places similar to this one that we could move to that have secular health systems where I could work.

Second is that I am more likely to get a really satisfying job in a community pharmacy if I take a job offer sooner rather than later. Specifically the job interviewing season is starting in November and my classmates who work for a big chain are starting to be offered jobs there already. I really feel like we live in a decent place now and it would be nice to stay put if we can manage it, but that means working for a faith-based hospital system or getting a job with a chain community pharmacy.

Third is that I'm trying to avoid just going with the flow, or seeming to just go with the flow. My plan is to cultivate a few possible paths, to explore even the ones that are scary and that I'm likely to fail at, and to be on the look out for the ideal opportunity that is the right fit. I'm sure that I will know it when it arrives but I am impatient as ever. I want the certainty of saying, "Here are my career goals and I really want to meet them and I clearly see how I can accomplish that" instead of the liminal space that exists now where I have some pretty good ideas for what I'd like to do but I am unsure which direction is the right one for me, for us. If things go perfectly smoothly, I would love to work in a hospital doing clinical and technical pharmacy. If things go in another direction, I'd be very happy working in a community pharmacy. If things go in a third direction, I'd really enjoy working in an ambulatory setting.

So I guess I know what I'd like most but I'm not sure how to articulate the "I don't commit to one way yet because I don't trust my certainty of my own judgment" place that I'm in. I stick with the next right thing and I do that and then I do the next right thing after that. If I try to plan for years ahead I usually am wrong because I skipped that next right thing in favor of dreaming.

To scale or not to scale?

I have never personally owned a scale. Not in a great many years now have I even had regular access to a scale. None of my roommates had scales so I haven't had access to one at all since I moved out of my parents' house better than a decade ago.

Lately I've been pondering if a scale would be a useful thing or a detrimental one. Obviously I'm attempting to get into proper shape which should eventually come with a good deal of weight loss. I'm also healthier now than I have been in a long time so I'm not visiting the doctor all too often so I have no accidental/coincidental scale access either.

My memory of having access to a scale is not friendly. The scale was a source of stress and a way to control something in a world that was spiraling out of my grasp. My weight became the only thing I even attempted to control and I did that through very damaging eating patterns.

So on the one hand, I think it would be motivating and helpful for me to know how I am doing in attempting to lose weight. On the other hand, I never want that disordered eating in my life again and I'm afraid of what having a chart of my weight would do to me.

On the third hand, I like to think I'm overall much healthier now than I have been before. Most days I think my mental health is pretty well taken care of and my physical health is improving with exercise. Maybe I'm giving the scale control of my life without it even being present to impact it at all. Maybe it would be no big deal to weigh in once a week or once a day.

But there again, I don't know. I want to make sure my girls develop some kind of healthy relationship with eating and their bodies. The kid eats so little and at most meals, Little Monster eats at least as much if not more (sometimes by double or more) what her older sister eats that I worry their approaches to food are going to set them apart as they get old enough to notice how different they are. We are probably already ruining them by pointing out the good things Little Monster does when presented with a new food ("Look, she's picking it up and smelling it up close! You could try that too! Why don't you just touch the fish stick? Oooh and now she's taking a bite! What a brave Little Monster! See? She likes it! That fish stick might be your favorite food and you are missing it, Kid!") and how great it is that she eats her food instead of ignoring it at meals and demanding 5 desserts afterward (and I'm sure Little Monster will also do that when she has words for it but since nobody ever gets 5 desserts, no matter how much they whine and tantrum, she hasn't tried to develop words for it yet).

I remember times when my mom spent days and weeks weighing herself a couple times a day before giving up or before giving up dessert and then dinner in favor of some fad diet snack she'd eat before we all did. I bet that stuff influenced me more than I realize. It isn't something I consider often but I know my body image is very skewed.

So where do you stand? Scale or no scale? Should I get one? How long of a trial do I give it? How would I even recognize if the scale were a problem?

The weight of balance

I had a revelation the other week about life-work balance.

First I should explain how I'd always thought about balancing work and non-work life. I'd imagined one of those old torsion balances (we use those in the pharmacy with weights on one side and stuff on the other and a dial in the middle for adjusting it so the plates are even when it's empty) or maybe even just two plates hanging on a point in the middle. I imagined one side labeled "work" and the other either "family" or "non-work" or "life." I envisioned my day split into little identical weights that represented an hour each and I imagined myself putting 8 of them aside as sleeping time and then having the other 16 to divide between the two sides. I always envisioned balancing exactly 2 sides in a zero sum game (zero sum games are ones where there is always one winner and a corresponding loser, where resources go to one person or to the other person, where when someone gets something it is taken away equally from someone else).

It dawned on me the other day that balance can also be a very different thing. In a dance we balance too, weight on one foot or the other or both or neither. I heard an interview with a band talking about how they get people to dance to their unusual music (well, non-western sounding and with very different rhythm patterns). They said they try to dance along too as a way to show people where to put the weight in the dance.

So I realized that work-life balance doesn't have to be zero sum. It isn't choosing work or family or friends over the other where one inherently loses if the other is winning. Instead it can be a dance and I can put weight in different places at different moments but there is no winner or loser, it's all a beautiful mess together but the parts add up together to be the dance. If you never change where you put your weight in a dance, you crash or you are standing still. The ups and downs mix together and sometimes we need someone to show us where to put the weight but the dance is never meant to be a zero sum game. A leap in the air doesn't mean the ground is less important or less valuable or less important to keeping the dance going.

I feel like an important part of this is mentors. Someone who is already dancing who shows you how it might be done, who displays balance so you can emulate them at first and then do your own thing later. I think that's an important thing we can and should be sharing with each other - how are we actually making it work or not. That's one reason I am an avid blog reader of real blogs and not commercial ventures that pretend to be blogs. I like to hear how other people make life work with all the everything that happens to complicate what seems so straightforward.

I've added to my list of questions I ask myself every day now. It went from just "What are you doing to help other people today?" to include "What would you do if you weren't afraid?" and then "How are you being vigilant today?" Now I'm asking myself "Where are you putting the weight today? How do you stay in balance?"

Sandwiched

Have I mentioned how much I dislike being in the sandwich generation? It is so much. SO MUCH.

In case you're unfamiliar with those in the sandwich generation, it's folks who are adults caring both for parents and children. I'm a double sandwich in that I help a bit in caring for my grandma in addition to keeping an eye on what my parents are up to.

There's someone in my life who has a chronic condition that can be kept in check pretty well with medication. Medications need to be refilled and then picked up from the pharmacy for this to work. Once every now and again an appointment with a doctor needs to be made for more refills to happen. These sorts of resource-management and scheduling tasks are ones I could do with no problem. Many people do these sorts of things for parents and grandparents all the time.

Of course providing care for another adult isn't that simple. If the patient doesn't want to take their medications or if they are too busy to pick up a refill for a week or a month, it becomes the care provider's problem to deal with.

Thus far, I am opting out of managing anyone else's medications for a couple of reasons. Firstly, this person hasn't asked me to help and I am not going to offer. I am a busy person and I don't need to be stupidly signing up for more work than I already have. It's a way of preemptively saying no to work I don't really have time for, to just not offer to help.

Secondly, I want to encourage the maximum independence possible. I am part of an extended family that gets really codependent and way too involved in each other's business. It is healthy for everyone to take care of themselves. It keeps them from playing the victim if they don't get exactly the care they expected (which would inevitably spiral from "please make sure my medication refills get ordered" into "but why didn't you pick up the other 10 things I didn't tell you I needed from the pharmacy that I won't pay you back for despite them being expensive?") and it gives them control over a part of life that it's possible to control. It's rewarding to know you can influence your life. In this case, it's rewarding to know that taking medications improves life so dramatically.

It honestly starts to feel like I'm teaching or parenting every time I set the expectation that, despite it being easy for me to just order refills for someone online, I will let medication management be this person's thing for as long as possible. I am getting really fed up that there are no consequences I can levy if this person does a terrible job taking care of medications and makes noises like "this would never happen if you just took care of me!" I think that's the real trap of being sandwiched between elders and children, caring for both. You have to set boundaries and expectations and clearly divide up jobs, but there are few consequences you as child/grandchild/niece get to give to your elder if they behave badly.

Not that I'm totally convinced that giving misbehavior a consequence is convincing my kid to behave one bit better. Maybe it does but mostly I think that well-timed, brief, loud expressions of my feelings about something she did that was out of line seem to work better. Example: we had a several month stretch where she would get frustrated, be sent to her room "until she was steady," and would get upstairs and immediately start throwing things down at us. Most of the things in the girls' room aren't breakable so it was mostly annoying and irritating. Her consequence was to have to come pick up all the things she had thrown (which entailed much whining and complaining and more throwing of the very same things) and then losing some privilege (TV the next day, story before bed, dessert, TV the next day, a trip planned for the weekend, etc). One day she actually broke a thing and hit me in the head doing it while I stood at the bottom of the stairs listening to hear her actually step into her room. I yelled that I was very upset because she was disrespecting property, that she hurt me by throwing the thing, that it was now ruined and she wouldn't get a new one, if anything else was thrown down the stairs it was going straight into the trash, and that she had lost TV for the week and was also not allowed to play outside of our back yard for the same week.

Since then, she's thrown things down the stairs maybe twice and we haven't made her clean up the things but I did discard them all (I think it was some flashcards or crayons or something). The throwing hasn't been aimed at anyone's head and nothing heavy has been thrown. When she cooled down that first time, we talked about how to use words and explain what was wrong and to use words even if she didn't know what was wrong to say she was upset. Some of that has helped but mostly we established a firm boundary (this behavior is NOT acceptable) and she recognized that no further testing was needed.

Adults though, they know your weaknesses implicitly enough to exploit them and to know that it's hard to keep up a new boundary. Maybe that's just my family, but it is so hard to have my new boundaries poked at all the time. That's really what makes it so hard to be sandwiched, that the boundaries are shifting and the aging parent has to allow more care (and hopefully confess what's really going on) while the adult child has to figure out where to set the boundary for how much care can be given before it's too much.

Meditations on "first, do no harm"

I've been wondering lately if it makes me either a bad person or a terrible almost-pharmacist (or both) if I think death would be the most humane outcome for a patient. 

I would like to take a moment to frame this musing with a patient vignette. His is a totally made-up story but it reminds me of a number of patients I have cared for already. The patient is in his 30s, has a traumatic car wreck but walks away unscathed... until a few days later when massive internal bleeding is discovered in the ER when he turns up dizzy and then stops breathing. But despite what becomes a sudden cardiac arrest, he lives. Kind of. He can't swallow or breathe alone or respond to the world, has constant seizures that require him to be restrained, and shows zero improvement after a month in the hospital. Or maybe she's in her late 70s, has a big blood clot in her lungs and loses consciousness a few minutes before her daughter finds her. The clot was caused by cancer. She has been in a coma for 3 weeks and the family wants aggressive chemo. Or maybe he is in his late 60s, just had a third heart attack, and is now taking 15 medications a day to combat heart failure but is not improving and his decline is only marginally being slowed by all the medications and the frequent short trips to the hospital.

I should also add that my routine is to pray and/or think good thoughts about every patient I come across every day with every prescription I fill and every one I hand out. It helps me keep it in perspective, that everything I do counts and is for someone with a family and friends who matters. This gives me a lot of opportunities to think about what would be the best outcome (I hope this patient gets better or gets to go home or isn't in pain any more or gets a good diagnosis soon or... dies soon so the suffering ends?).

When we enter a healthcare profession, there's a code of honor or ethics or whatever it's called in that profession. Here's a copy of the Pharmacists' Oath. http://www.pharmacist.com/oath-pharmacist I often think about the Hippocratic Oath too, the Declaration of Geneva being the modern version that I find keeps the spirit of the original well. http://www.wma.net/en/30publications/10policies/g1/ Of course I also consider the idea that in the health professions, we might want to  or ought to "first do no harm."

I worry that too often we get busy doing everything we can to extend life and we forget to consider what kind of life it is we are extending. If it's a life that requires multiple machines to permanently sustain and there's no ability to interact with the world, I'm not sure it is one I want for anyone. In some ways I'm disappointed that any ethics committee anywhere lets families lobby for this. In other ways, I get it. It's hard to think about death and harder still to accept that the time for letting death happen has come for someone you love. But I keep asking myself if we are harming patients and their families by preventing death at such great lengths with such extraordinary measures. (You will note that I don't mention about if we should offer assisted suicide to terminal patients, and I think that's a separate issue and maybe I'll write about that eventually but not now.)

This year for the Festive Winter Holiday, I'm asking my extended family for copies of their advanced directives and living wills. I don't want to find myself sitting in a hospital room with an almost-dying loved one who had a stroke and not know if they want the full court press to live the maximum number of days even with some or severe cognitive impairment or if they'd rather have no intervention and jut be allowed to die. I don't have lots of siblings or siblings-in-laws to consult about parents and grandparents or each other if we have really bad luck. I spent many hours considering my choices about what I want and what I'd want for my girls if I were unable to make decisions for them and they were still under 18. Now that I have seen more patients with end of life stalling interventions, I am updating a few things but for the most part, I'm feeling secure in my choices. I want no treatments that extend my life unless they extend my capacity to be me as well. I want only palliative care if I have stage 4 cancer or a cancer with a low increased survival with treatment. If there is no chance of recovering nearly all of my mental faculties, I want no feeding tube or ventilator.

But above all, I hope that we all talk more about the choices we can make at the end of life and that we do so well in advance of needing to make them so it's simpler and family and friends don't have to feel guilty if they don't demand full code (all the resuscitation possible) for a patient who is unconscious, on dialysis, a ventilator, and has a feeding tube permanently placed.

If you are curious about how to write a legal document for your state, here is a link to a wealth of resources that can help you and your loved ones puzzle through it all. If there's one thing I've learned from working in hospital and clinic pharmacies, it's that it is never too soon to consider what you want the end of your life to look like because it might come remarkably soon. http://www.nhdd.org/public-resources

Firsts, lasts, and middles

Last Sunday as we left a building to go retrieve the kid and spouse from a nearby playground via the parking lot, I asked Little Monster to hold my hand. Just like that, she did. She held on tight and walked beside me across the parking lot and down the path to the playground.

I got a first out of her. Most of her firsts have been shared between us parents or ignored while I was busy or happened at daycare but this time, just me. I bet if I asked around she's done this before but it was a little triumph anyway. First time walking In the parking lot holding my hand.

This evening I was tampering with something on the computer and I heard someone say "hi mommy" just out of sight over my shoulder. I turned and started to say "hi there Kid" but saw Little Monster instead. Sneaky baby, growing into a toddler. She owns a tiny plastic potty now and she can drink from a real cup and eat ice cream with a spoon and little mess.

It's easy to see now that there are so many lasts piling up too. Last time she calls a fox KITTY! Last time she screams about a bath (now she demands them often and splashes with glee). As cute as it is that she has mixed up "on," "off," "down," and "up," I'm not sure I will miss her shouting OFF! while struggling to zip her sweatshirt or put on socks. The hands outstretched to reach for me while shouting "down, Mommy?" will certainly be missed though.

It's interesting because I don't see any leaps in the kid's development lately. She's plowing along toward reading and adds a couple of words a week but no leap yet. Practicing her violin was too boring and yet too hard and there was never a proper time for it so we've given up for a bit. I keep hoping today is the last time she does one of her infuriating things (you know the things that make you nuts about your 3 year old? All that stuff only she's taller, stronger, and has more words to argue) but I'm sure it won't be so I'd be content to stretch the interval between moments.

I'm in the middle of rotations and it's scary how fast it's all going by. From this end I might buy the "oh, pharmacy school went so fast!" story I've heard from many pharmacists. Maybe. I suppose it's like parenting a preschooler. The hours take forever but the months fly by. I'm trying to gather all the lists of things I need to do and lists I need to make so I can try to keep it together. It isn't working so I'm going back to keeping my head above water. This next rotation is absolutely out of town so that's exciting and terrifying and all levels of panic to elation.

Hidden work or why I can be abnormally stressed

Let's talk about hidden work. When you are in the realms of parenting especially but really any long-term relationship where you are both working toward a common goal, there is the risk of doing hidden work. There isn't any complex definition to hidden work as it's defined in the social science literature beyond "work that goes unrecognized by those who aren't doing it." Usually in parenting hidden work describes all the things that (stereotypically) are done by women that men seem totally surprised need doing.

A good example from my life is scheduling well child visits. I keep track of them for the most part by entering them in my digital calendar and inviting my spouse to them. I have been away from home more or less from May until August and didn't attend Little Monster's 15 month appointment back in May so I didn't schedule her 18 month appointment afterward. With the kid I usually took her to well child visits by myself since usually my spouse was working, and with Little Monster we have gone together up until the 15 month appointment during which I was working (my spouse was very underemployed last year and thus had plenty of time to come with). I had never explicitly stated that at the end of every well child visit, I walked over and scheduled the next well child appointment. I just always did that, and for what is still a majority of the well child visits our girls have attended, I did it with nobody else knowing it's what I always did. It was hidden work from the other person in the relationship who needed to be working on the same parenting project as me. As you might imagine, I mentioned when Little Monster was 17 months old that I was curious about when her 18 month appointment was since I'd be in town then and might be able to attend it if it were in the afternoon... and there was no appointment yet. It meant that she just had that visit this week when she is now 18.75 months old. Is that the end of the world? No. But it's representative of the sort of trouble a lot of couples run into.

For us specifically, playing Chore Wars is a way for us to explore ALL the work and to make it all explicit. We don't have much hidden work but it's important that we keep working at it so we are both aware of the silent contributions the other person is making to keep things going smoothly. The other night, the baby woke up and I slept through it (nights aren't my thing because I get up much earlier than my spouse so I wouldn't have gotten up even if I had known she was up). Without a way to communicate that happened, I would never have known that Little Monster held a baby party from 1am to 1:40am in the living room. We have a weekly family meeting now where we all share something that's going well, something that could go better, and something we personally are going to improve. This week we've split it so I should be emptying the dishwasher and my spouse should be loading it. I actually think we need a white board where we write what everyone is doing to improve this week so we don't lose sight of it.

I have heard from a variety of folks that my spouse and I have such a good relationship. From my seat inside it, I'd say it's pretty typical and nothing especially great. We struggle just like everyone else but in different ways, some of which won't be appearing on this blog, most of which are about our non-traditional division of labor and how weird that is for everyone else. What is different about our relationship compared to those around us is that we have very little hidden work so nobody feels like they get no recognition for the great things they do. When you earn points for doing the dishes, it adds a little oomph to get it done AND your spouse knows you did it, even if there is no evidence. Say I empty the dishwasher and then reload it and then run it again before my spouse gets home from an evening meeting or my spouse does the same while I'm at work one day. Without Chore Wars, it's easy for my spouse to completely miss that I did anything because the dishwasher went from full of clean dishes to... still full of clean dishes! Obviously this means we need to be diligent and add all the parts of the various tasks we work at around the house to Chore Wars so we can record what we do. The reporting aspect keeps us accountable to each other as well.

It's my natural instinct to take on more hidden work than my spouse. I like to organize things and plan and have my living space tidy while my spouse values this much less and would rather relax. I have a hard time relaxing when it's a mess. This means that I have to be diligent about not hoarding that sort of job, that I have to let my spouse do some of it and trust that it will be done adequately even if it gets done totally differently than I had envisioned. We had our office full of boxes, with one wall floor to ceiling boxes from when we moved 2 years ago that was blocking a closet full of MORE boxes. I'd always meant to put shelves into the closet once the boxes were gone or to hold the things that were in the boxes, but my spouse decided to hang some sweater organizers and pile in some totes of stuff, and that's fine. It doesn't matter how that work of organizing the closet happened, just that it happened. PLUS the boxes are out of the office. It's a lovely space now that there's room to move without dodging the boxes. The danger of me taking on all of the work is twofold: if I don't get something done, nobody knows and so whatever it is can get to a critical level of neglect since nobody else is checking in, and I can make sure I never sleep while I get the house organized totally and spotlessly clean. Neither of those is good so it's important that I give up tasks. I explain all the steps I have been taking completely and don't assume my spouse will know one thing about how the job is done (there is much eye rolling usually but sometimes there's a moment of surprise where something I have been doing is explained and my spouse can then more fully do the job), then trust it will be done.

Trust is tricky and building it is still a work in progress (I ask if my spouse can do something, the response is affirmative, the thing is still not done after what I deem to be far too long, I point this out, it either gets done by me or my spouse... or we repeat). I still feel, despite getting let down often, that it's worth it to give up control of some things. We have a much happier relationship if I sleep and if we both pitch in to keep things running smoothly.

Winning and losing all at once

Let's talk Chore Wars! I adore this game.

Here's the very brief version of its rules. Everyone in your "party" creates a character by choosing their skills and a picture. Your party could be your immediate family, your office mates, your neighborhood, or a random bunch of people you meet online. Then the party leaders create Adventures. Every job is an adventure. The adventures are worth experience and earn gold, plus each has attributes that increase your skills (so the stats are strength, constitution, dexterity, charisma, intelligence, and wisdom... every job is high, medium, low or n/a for each stat and doing the job increases your character's stat in that area over time when you gain enough experience). For example, I just created a job for scrubbing a toilet. It's worth 5-10 xp (experience) and requires medium constitution (strength is for physical exertion jobs, constitution for physical jobs that take a long time, dexterity for lighter chores that require precision manual work, charisma for interacting with people outside of the party, intelligence is knowing something specific, wisdom is inventively applying knowledge). When completed it's worth 6-8 gold and there is no chance of a treasure or a wandering monster for this job because I was too lazy to think of something not creepy/gross. Watering the plants in the garden has a chance of finding a treasure like a Leaf of Awesome Proportions or being attacked by a wandering monster Weed of Doom in addition to xp and skill growth.

Then once you earn stuff in the game, you can develop a system to redeem that stuff for real world rewards. We are collecting exercise tokens and can redeem 15 earned in a month for $10 in fun spending money. Soon we're going to set out how game Gold translates into allowance for the kid too.

We started to assign all the work in our house points once before based on how long it took to do the job multiplied by a "everyone hates this" factor (so cleaning the cat box takes 5 minutes a day or 35 minutes a week but we hate it so it's worth 70 minutes' worth of work a week because it's awful, while cooking supper takes 30 minutes a day or 210 minutes a week but we both like it, so it's worth only 105 minutes' worth of work). Then we gave up because it was hard to track and assign and nobody was encouraged to do the really awful stuff despite it meaning less overall work since it included a theoretical rest time.

Why making it a game works: leveling up a character in a game is fun. Haven't tried it? I highly suggest it. It's a very satisfying experience to know you accomplished something. If I spend all day making sure a patient's medications are perfect and appropriate, at the end of the day something changes in the patient's health and all those changes are for nothing. That's frustrating. I love coming home and going on a little ridiculous video game or card game adventure where I know exactly how to succeed and when I have succeeded and all the steps to follow. In a video game I also tend to get visual cues to tell me I'm succeeding like a progress bar that shows me I'm getting close to my next level (in a board game you see your little car advance around the board toward victory).

It's also fun because chores become a competition. I'm totally winning right now in our family Chore Wars game because I am more competitive. I taunt my spouse that I'm going to win, that I'm going to get to some chore first so I get all the points, all in good fun and with a laugh... and yet I am totally winning. I am rarely winning in game stats though. My spouse started playing in June and I didn't join up until July so I have been playing catch-up in overall experience but recently I pulled ahead! When the kid does something that will earn her Chore Wars points, she dances around us until we enter the points in the computer. She isn't reading yet but she inspects her character's numbers after every job she completes (hers are picking up things and doing homework but I think we will add more this week since she has been so excited about it) because she is SO into it.

But even if my character isn't winning by gaining the most experience points or the most gold in a month or a week, I win anyway because THE JOBS GET DONE. The dishes are done more often, the laundry gets put away more often (this is worth double the points of washing and drying because it so seldom happened before). Whether my character wins or loses, I WIN!

As time goes by, we will add silly conditions to the chores to make it harder to complete the adventures like that something must be done with nobody catching you in the act or on a Thursday (like taking out the trash from all around the house must happen on only a certain day or is worth double experience on a particular day). Goofy conditions keep it fun and challenging to stay ahead in the points.

In the next post, I'm going to touch on "hidden work" and why we count everything (or are trying to) in Chore Wars so it continues to feel equitable.

Fixing reality part 2

Let's talk some more about Game Theory, shall we? This is more of the discussion of the really excellent book Reality is Broken that I started talking about in Part 1.

Game theory! I've studied it mostly in the context of math and education and sociology, but there's obviously the other part that's about designing games people like to play and find valuable. In math, game theory is about the set of equations that can predict outcomes of different games. This gets adopted in education and sociology to be used in discussions of why people play games, how we are fooled into thinking we are more likely to win games of chance than we are (hint: you will never win the lottery or in the casino), and how to best use our human nature to our advantage (ie how to win the Prisoner's Dilemma and what "winning" means, extending into the realms of positive psychology where we try to sneakily make people engage in behavior that makes them happier).

The pieces of Game Theory that I think are most important to consider are: that we have been playing games for probably as long as we have been people and that our societal involvement in playing games as opposed to doing other things follows societal change, that we play games because they fulfill a need we have in our lives and when that need goes away the games likewise disappear, and that the New Games movement of the mid-20th century probably changed those of us who have grown up since then substantially from generations before us.

Playing games: the tidbit I really liked from this book is that in the past, playing games increases as our perceived ability to change our life circumstances and have perceived meaningful input into our own working lives decreases. In other words, when we feel like we have no ability to change our working lives, we play more games because it's a realm in which we have a lot of perceived control. When you consider the stereotypical video gamer, this holds up and that stereotypical guy (isn't it always a guy?) is someone smart who is working in a dead-end job that is really boring. I think it was the 18th century in England (but sorry, no paper copy to double-check this) where card games became wildly popular and at the same time, people were very dissatisfied with their work lives.

Defining games: remember, Game Theory is bigger than just video games, although the author of this book is a game designer who has almost exclusively designed video games (perhaps exclusively even). Games range from the prototypical World of Warcraft or Halo to Farmville  and Words With Friends in the online realm to chess and cribbage or Cards Against Humanity and tic-tac-toe in the purely physical realm.

The New Games movement toward collaborative playful games started in the 1970s and is very widely spread now, which is neat. I just bet you have at some point played a parachute game with a beach ball or one of those "everyone in a circle" sort of games where people take turns. I think the important thing to know is that the idea was that games are an innate part of being human and that we can use the fun of games to help us develop skills and work together better. There's research to back up that theory but I haven't read it in quite a number of years. I do suspect it would be fun to read.

Why Game Theory anyway? This is sort of the convergence of positive psychology that studies what makes people happy (like the opposite of what psychology spent most of the 20th century looking at, the things that make people unhappy and/or mentally unstable) and its practical application: getting people to do things that are beneficial for them or that we want them to do for some reason. The premise of Reality is Broken in particular is that since people as a whole are choosing games as a way to spend free time, we should design games that inspire people to do useful work instead of just leveling up our online avatars or winning at 2048 or whatever. In the US alone there are 183 million people who play an online game for 13 hours a week or more. That's nearly 2.4 billion hours a week that is spent outside of physical reality playing games. If we could harness that time to engage people in something fun but also productive in the real world, wouldn't that be amazing?

Speaking as a new Chore Wars player, I am at least three times more likely to do a job now than I was before. I get excited about increasing my lead in points for the month. We set up a system so if we exercise enough times in a month, we can turn in our Exercise Tokens for our fun spending money. $20 a month doesn't seem like much but since I also get to win (sorry family, I am way too competitive to not win...) and have to keep up my lead by continuing to work on things so there's no resting on my laurels either. Here is a game that I play online and that improves my physical reality at the same time.

Sadly, blog posts don't earn me any points toward my next level so I am off to go empty the dishwasher, walk the dogs (even though they aren't mine, I get points just like if I were cleaning the cat box), and then take a walk.

Fixing reality part 1

I'm listening to a variety of audio books on my commute and my very favorite is Reality is Broken: How Games Make Us Better and How They Can Change The World. The only reason I'm not listening to it right this minute is that I get all excited and inspired listening to it and then I can't sleep (one of the reasons for the audio book indecision, the other being that sometimes a book gets too sad and I just can't listen anymore for a time).

So far, I have learned a whole variety of things about how game theory and game design can be applied to making the real world better and I am super excited to get a physical copy so I can read the bibliography of this and read even more on the subject. BUT today I want to share a little bit about why games are so awesome. This is my very short interpretation of her book and you should just go listen to Jane McGonigal's TED talk and read the book yourself because it's totally worth it.

First is that while we know a bunch of things that make us happier, they seem hokey and we avoid doing them because they make us feel sheepish and silly when we do them alone. BUT when we do them in a group we are willing to be silly and then we are happier as a result! So it is important to get together and be silly by dancing or complementing strangers or whatever. If we need a game to do that, so be it.

Second is the really cool game that helps your household/office/etc group get all the chores done in a fun way. It's called Chore Wars and team leaders set up adventures for team members to complete with experience points and prizes (digital ones) just like in those silly MMORPGs so you get to level up! If you have never leveled a character up, you are missing out. There's a bunch of stuff in this book describing in detail why it is so satisfying to play a video game and have your character earn a new level, but if you haven't ever tried it, you totally should just to see the high the gamers of the world are enjoying. We just started playing but I am competitive enough that I'm doing extra work around here to rack up some points. I even exercised an extra 15 minutes to earn more experience points.

I'm looking forward to going on at great length about this book and how much I adore it but that's coming in part 2. For now I am sure I have homework to finish for next week that I could be working on (organizational skills! I am also practicing those!). Be excellent to each other and know that I'm peeking in to read blogs periodically but mostly am swamped with life and this "in the moment" project of mine.

Side effects

One of the interesting things about being on rotation is the strange things that are happening that are unrelated to my current actual day to day working experiences. In other words, rotations are supposed to teach me pharmacy things and other things I learn or skills I develop are mere side effects.

Since I am clearly procrastinating, here's a short list of my side effect lessons.

1. I do not especially like having a dog. I'm staying in a place with 2 big dumb dogs who are very sweet but also a nuisance. Compared to Fluffinella (our superior resident feline who is probably napping on a pedestal at home right now), these dogs are far too much trouble. One gets so excited to go outside that zie jumps 5 or 6 feet straight into the air. It is ridiculous.

2. Birds are weird. I dodge the chickens leaving my parking space in the very large driveway, then the ducks paddling in the ditch near the road before I leave the driveway, then the pheasant who likes to dart across to the other swamp at the first corner, and THEN there's a family of wild turkies a block away. The tom turkey likes to strut ever so slowly across the road while the hen and chicks just hover in the bushes JUST TO MAKE ME NERVOUS. I also commute passed a pond with 2 pairs of geese nesting in it that take their combined chicks for a stroll along the shoulder of the road every morning JUST as I drive by. Fools are just begging to be smashed and yet they appear to have at least 4 communal chicks. I'm unclear if they are actually aware of which chicks belong to which parents as they even have adjoining nests that I noticed on a walk last week.

3. I still don't like driving in city traffic. It is infuriating to just sit in the car on the road waiting. I don't mind the drive when the traffic moves but gridlock is too much. It is a shame that I can't arrange a carpool or take some kind of transit to this specific rotation.

4. It's very weird being a "grown up." I'm staying with a friend who's in her 50s and there's a resident child of hers who is not that much younger than me, say 5 years or so, yet I'm an "adult" and I feel compelled to do things like empty the dish washer and pretend/avoid knowledge of a variety of things (did I see that when my friend was out of town, there was an extra guest overnight? No, I have no knowledge of that per se because a whole group of folk was here when I went to bed and I saw nothing about any extra cars in the morning, it's a mystery!).

5. I still forget where I put my car all the time. I have learned to accept that I just need to park in the same place every time and not fret about it because I can only remember so many things. When I am in a strange parking ramp, I just take the reminder slip about where I parked with no shame anymore. Getting lost is silly if I can avoid it.

6. It will be important in the future to remember to keep a change of clothes either in the car or in the office in case of coffee-related difficulties that necessitate a change of attire.

7. I am pretty happy with my "right sized" lunches and I may translate that into unit dosing my dinners as well. (Aside: "unit dosing" is something that happens often in a hospital pharmacy, where a large bottle gets purchased and then each dose gets put into its own packaging so it is ready to be given OR where a special single dose package gets purchased.) Once a week or so I make something for lunches and portion it out into 400-600 calorie servings in a variety of jars. I'm finding that now that I'm a few weeks in, I am happy enough and survive the commute home with my stomach rumbling. I keep reminding myself that being hungry isn't a bad thing, just a part of life, and that I should adapt and that I WILL adapt in time. I haven't ventured onto the scale yet but I think I've lost maybe an inch at my waist thus far so that's something.

8. I am really lazy after work and will need to plan my daily exercise to happen BEFORE work if it is going to happen at all.

9. Sleeping remains crucial and I am going to go attempt to do some more of it. I still fail miserably at a sensible bed time but I am doing all right at getting up on time despite not enough sleep.

Living the lies

So let's talk about the truth. Clearly there are lots of truths and lots of levels of truth, and since we are here on my blog, you're stuck with the truth that matters to me right now, as much of it as I've figured out.

The obsession (or whatever it is) that I have with figuring out what truths I'm hiding and from whom is over a decade old now and in all honesty, it started with a crazy guy asking me a question that I had never considered before. What's something you think about but don't tell anyone else?

So here and now, the levels of lies in my life are multiple. I don't find this necessarily all bad but mostly a part of being a person. If we were capable of being totally honest the world would be remarkably different. All people can't handle the whole truth, whatever that might be. I think we catch glimpses of the truth about ourselves and about the world and maybe about divinity but we are incapable of grasping the whole truth.

Right now there are a few levels of lies that are playing out sharply in my life: the lies of omission where I fail to correct people's assumptions about me and the lies I tell myself that materialize as excuses are most notable. There's also the obvious set of lies that underpin this blog, the ones that hide my identity, obscure my location and my spouse's identity, the pictures I'm not posting, the significant but identifying things in my life I'm omitting, but I feel like these are among the lesser sins at the moment.

So the lies of omission. What's the first thing every single person in a pharmacy asks a pharmacy student they've just met? "What do you want to do when you graduate? Do you want to work in a hospital or...?" I'm still working on a good answer beyond "well, I don't really know." I have some ideas but I'm not sure enough to narrow it down to one of three very different paths. Later on, maybe a half hour into the conversation at most but sometimes less if the other person is lobbying for a residency as the best way to go, we come to the "oh I' sure you'll match somewhere" point. (Aside: pharmacy residencies are the hot new thing what with the crunch in the market where there are not nearly enough hospital jobs to go around for new grads who want them so extra credentials are required to get those entry-level jobs. There's an application process in the fall, interviews lasting a day in January and February, and the Match happens afterward. Last year 2/3 of people who applied actually matched and a small chunk of residencies didn't match so some of those who didn't match likely scrambled to get those spots filled.) The problem is much more complex than that of course. While technically I have limitless options to apply to the perfect residency anywhere, I am cautious and want to avoid moving if it's at all possible. It might be possible but it would mean a long commute and maybe taking a less than perfect residency position (if I could get it at all). I'm then at the corner where I could mention that I'm not applying everywhere or just anywhere because of my family and omitting it.

The assumption made by everyone in the pharmacy is that, like most pharmacy students, I have no children and probably no spouse either. Furthermore the assumption is that I'm young and immature and pretty innocent. For the most part I let this slide because I am pretty private and would prefer to be remembered for my work and not for my non-traditional student status. I have been joking about how I appreciate being called a kid and could my superiors please try to work that in a few more times, especially when giving me verbal feedback so I can bask in being a kid just a tiny bit longer? It's only a little bit of a joke though. I  am reveling in the last bit of youth I have left before being a professional. There is also a little bit of ribbing of my superiors who are only a year or two older than me to remind them that not all pharmacy students are such babes in the woods. Obviously many are lost little sheep but not everyone and perhaps they should watch the lumping of us all into the "silly little kids who know nothing" heap.

I also am wary of making plans because I know exactly how well my plans have worked in the past: hahahahahahahahahahah no. My plans were wrong, sometimes exactly opposite of what has turned out to be the right direction.

One of the books I have been assigned to read so far (aside from a vast swath of things on a certain pharmacy association's website, to the tune of 175 printed pages of very dense text) is about adapting to constant change and being ready to change when the time comes (and it was pretty hokey and I don't even know how to make sense of its combination of hokey and useful). One of the main characters reluctantly and eventually changes to take a new path and starts writing messages on the wall for the other anti-change character in the hopes he'll follow, and one of the things shocked me.

"What would you do if you weren't afraid?"

I realized that maybe my hemming and hawing and not committing to applying for a residency might be because I'm afraid I'll fail. Then I had this moment of clarity where I realized I have already failed so spectacularly that there is no failure that will top that. If I apply for residencies and I get zero interviews, there is no public failure at all unless I let on that I applied. If I apply and interview for a residency but don't get it, that's not a failure. Getting the interview is huge! If I manage to interview and then match, that's a few levels of spectacular. There is no failure at all except if I fail to try. If I weren't afraid, I would go for it with no hesitation at all. I would dig in, research thoroughly and find a good fit and then apply.

So now that I recognize the lie that's been playing out in my life, I will squash it.

The other big omission that keeps playing out is mentioning my family. They aren't around right now so it feels monumental to me to avoid talking about them because I've already set up a situation where I am away, probably for the best but it's HARD to be away. I sat in on an interview and one of the candidate's reasons for wanting the new job is to have a shorter commute and therefore more time with the kids. At the time, I sort of went, "Aww how sweet, more time with kids..." and didn't look further. Then I considered what would happen if I was the person being interviewed looking for a change for that reason. Would I be that candid? Would I have a different answer? What would my response have been if the candidate looked different (more masculine, more feminine or pregnant)? And what does it say about me that I don't know for sure if I would treat a job candidate of a different gender identity the same when exactly the same words were spoken? Big questions that I'm sure I will consider at more length later.

So this brings me to the second significant category of lies that's been influencing my life lately: the lies I tell myself. I turn these lies into excuses and the excuses fuel my laziness. Example: I am tired after I get home from rotation, the traffic psyches me out, I really just want to eat pizza and relax afterward. I use being tired as an excuse to avoid a whole host of things, from eating healthier (takes more time) to exercising (too tired and sore) to being social (too tired, too hungry to wait to see if anyone else is around for dinner, etc). Sometimes I make excuses for why I can't get groceries after work so I can justify getting a fast food breakfast.

Today I did pretty well for the first part of the day. I was tired when I got home and hungry on the way but I resisted getting a snack and then went for a walk after dinner. Then I walked an extra 5 minutes beyond my goal (one way, I'm just timing the walk out for now and hoping to make it back in rather than timing the whole walk) and made it back. Of course then I had an ice cream bar while surveying the freezer for tomorrow's lunch prospects, but up to that point I was really good! I squashed all my excuses and did it anyway. I chose to think about the things I don't have to do (have a second ice cream bar, eat a snack before dinner, take a nap or watch TV ) and to skip the excuses and get to doing what needs to happen.

The lie I tell myself the most often is "tomorrow things will be different" and a close second is "just this one (or once) won't hurt that much so it isn't a big deal." But I know that now and today I have the chance to change things. I will not change my rocking out to a song from a musical in the car reminding myself "there's only this, forget regret, for life is yours to miss... there's no day but today." I can change things now, today. I can stop buying the lie that tomorrow will cure everything and that once is harmless. Once is only in the moment - in retrospect, all those "just once" events pile up.

Today I get to choose to keep living the lies or to move beyond the lies I've discovered into uncharted territory, and I get to keep making that choice all day long and I get to start over again when I inevitably am human and imperfect.

Discernment

Now that I'm on rotations, I imagine I will either post more because it's lonely or less because it's exhausting and busy. Or maybe more in conjunction with this next thing I'm up to.

After "what's your name?" and "where do you go to school?" the next question every person I've met so far on rotations asks is "what do you want to do when you graduate?" I know I've written about this before but I'm too lazy at the moment to go hunt up old posts. If you're a long-time reader or have bothered with my archive, this is not new ground just a new time.

There are three major pathways to very different sorts of careers after pharmacy school. One is a community pharmacist job, at one of those chain pharmacies would be typical. The upside is lots of interacting with patients and caregivers. The downside is lots of standing all day long and night and weekend shifts. The other most common is a hospital pharmacist job. It's rare that anyone in public sees a hospital pharmacist but every patient in a hospital who gets a medication has it double checked by a pharmacist. Instead of interacting with patients, most hospital pharmacists interact with doctors and nurses. The third route is what I'll describe as "other" and it includes managed care pharmacists who work for insurers or other entities that manage healthcare somehow, nuclear pharmacists who prepare the medications used to do radioactive imaging among other things, and ambulatory care pharmacists who operate in a clinic setting. When I started pharmacy school I had no idea what an ambulatory care pharmacist did and here's how I understand it now in a little example. Say Harry Potter goes to see his doctor and discovers he has diabetes and high blood pressure. His doctor orders some labs, schedules him an appointment to see a dietician, and a follow up visit in a few weeks after he sees the diabetes educator. In some practices (say that national one that's had long wait times in the news recently) at that follow-up visit, Mr. Potter would see a pharmacist to talk about his medications first and then the doctor after that, both in the clinic, often in the very same exam room with a hand-off between providers or sometimes (rarely) both with some overlap. Then the pharmacist would schedule a follow up visit sooner or later than the next doctor visit. In some practices, patients see the doctor once a year and the pharmacist changes medications at any point in between those annual visits with follow ups based on patient needs.

The job market for pharmacists is tight. After finishing a PharmD there is the option to do a year or two of residency. These are competitive to get (mostly) and are almost all focused on hospital pharmacy. Most people who do a year of residency stop there but a few go on to the second year or do two year combined programs. Jobs are split 60-65% community, 20-30% hospital, 5-10% other. In cities with a population over 200,000 people a residency is required to be considered for a hospital job in most cases and depending on the area it may be required in smaller cities too.

Of course it isn't so bleak as "there are no jobs unless you do a residency and only 75% of people who apply get one" overall. There are jobs in community pharmacies but not always immediately nice positions with a fixed home store or not without willingness to relocate. Ambulatory care is expanding as medical homes start to be a thing. Managing healthcare costs is similarly a growing area where more and more pharmacists are employed.

The areas I feel I have the most skills in are informatics and patient care of the sort that happens in an ambulatory setting. Informatics is the computer stuff that happens to make a pharmacy work so there are informatics pharmacists in all realms of pharmacy but mostly in hospitals since it's so complex to manage the wide range of patients in a hospital. To work in a hospital in particular would require both a first year general residency and a second year informatics residency (probably). Similarly ambulatory care would require either a residency for a year or two, or waiting a few years to start applying for jobs in that specialty area.

So then there's the residency debate. If my life were different and there were zero children involved, we would find the best residency program and move wherever to complete it. I think that if I had the whole nation to search and apply, I could find a program that would be a good fit and that I might match with (or be able to scramble for). But that isn't my life and I don't have unlimited flexibility. Given the kid's very poor adjustment the last time we moved, I think we can move one more time to a new school and that's it. So that doesn't exactly prevent me from looking at residencies outside driving distance of where I live now but it does mean we would need to be really sure about accepting a position that requires moving.

At the moment I'm getting ready to structure a period of discernment for myself so I can consider the options and figure out what's the right or most right path for now. The cool thing about pharmacy is that it's very possible to change specialties if you want at any point. Although it's rare for a community pharmacist to switch to being a hospital pharmacist, it happens occasionally. Discernment is something I've done before and I'm looking forward to planning it out. I'm going to do more prayer and meditation, read some sacred texts and some sacrilegious ones and probably some self-help books too, and make some lists. Then I will deliberate and consider the merits of each path and then reflect on them. At the end is some prayerful consideration and listening for cues and clues to point me in the right direction and then accepting whatever my heart and gut point me to.

Memorial day

Today was a nice day. I went to the lake with some friends for a picnic. There was bocce and Frisbee and iced beverages in coolers and all that jazz.

As usual in my doom and gloom way I thought a lot about a friend who wasn't there today. A guy I went to high school with was killed in the war in Iraq. His brother put up pictures today of his tombstone with some flowers and such. I think about his longtime love who he never even got up the courage to ask to marry him, let alone actually got married. He died too young. Another friend had a stop loss baby to get her out of the military before a second deployment overseas to a war. Her spouse has been on 5 combat deployments. That's huge when you think about it. It's horrific really. In the Vietnam War one tour oversees was considered enough and going back for a second was rare and discouraged.

My spouse and I were talking the other day about how different things are now than they were once when most young men served in the military if there was a war. Today it's the broke, the directionless, those desperate for college who can think of no other way to pay for it who serve. It is so unfair that we benefit from their sacrifices. It is so unfair that anyone should ask young people to make such a sacrifice.

So as usual, as I do every day, I pray for peace. I pray for peace for veterans who come home broken and wind up homeless. I pray for peace among peoples. I pray for peace for the families of the soldiers who have died in or because of wars.

Here's my sound track for the day too.

The Field
"When you joined the war we were so proud of you
You seemed so grown up, living life the way we taught you
Then your first letter came, it sounded nothing like you
It took all my strength to keep myself from running to you
...
I don't want no victory, I just want you back."


Penny Evans "They say the war is over, but I think it's just begun."

It haunts me that I live in a time where we send young people to die and for what? It's hard for me to say it has been a just war or that anyone wanted liberating. When my girls are old enough to ask, I won't have even a few words of "they did their duty by serving their country" for them because there's no good that's come from these wars that I can see. I tell the kid that her friend's daddy is a soldier and we pray he stays safe and never has to go to war again because wars hurt everyone.

So in all the joy of a long weekend, remember that we are still losing our young people to wars. Work for peace because it matters.

Cloth diapers at 15 months

Can you believe Little Monster is now 15 months old? It's just insane how fast she is getting big. Tonight she said "uh-oh" after she had been crying and I about died laughing. When she is crying we say "uh oh! Did you fall?" and I guess she learned that's what you way when you cry.

So. Many bloggers I read have mentioned cloth diapering. Here's a really nice summary post (that links to other posts on the topic) if you haven't read a similar post. Actually I really found this one helpful too. Over the years I've read many other cloth diaper posts in this vein all over the place.

Brief disclaimer: I do not care one bit whether you use cloth diapers or not, it's all good. Life happens and we do what works for us. I do not expect anyone to be insane and do things my way because it often feels like an eternally uphill battle in many respects. We chose cloth diapers because we are broke most of the time and overall the cost is much lower to do cloth (in dollars and because we are failures at taking out the trash so we need to reduce our trash production wherever possible).

The thing other people haven't written about is using prefolds instead of all in one or pocket diapers. That's something we are doing that is pretty unusual (maybe?) so I thought I'd talk about it (plus I'm in a gloomy mood so I'm hoping it will at least be a break from my grumbling gloom that I hope will go away soon).

Here are the questions I have heard or not heard but seem implied from folks and our answers (along with some pictures because why not?).

How are prefolds different from diapers my grandma used?

What makes them prefolded is the number of layers of cotton. Back in the day, diapers were one thickness (and all cloth obviously) and you needed to fold a bunch to get more bulk where you needed it. Now the diapers are made with a middle third that is double the thickness of the edges so fewer folds are needed or none depending on how you attach them to the baby.

Why would you pick prefolds instead of all in one diapers?

For us the reasoning was twofold. One, it's easier for us to not add a step to the end of laundry like stuffing pocket diapers or even putting away all in one diapers. We get busy, laundry gets left in a basket for a week, and prefolds are easy to grab from the basket, fold in thirds, and stick into a cover. Two is the advantage of each part wearing separately and being able to be laundered in a way that makes it last the longest. We wash diapers in a warm short cycle (this is mostly a rinse) and then a hot wash while the covers only get washed warm with other baby clothes (and the liners too, then they go for another hot wash after the other clothes and covers are removed). This means covers last longer and diapers that wear out or are damaged can be tossed out while we keep the cover. A bonus we discovered is the cleaning power of a cloth diaper. We use them for spills on the carpet, as burp rags for tiny humans, to dust, for potty training incidents, all over the house. It's really handy to know that we have that level of absorbency handy for cleaning up.

Don't all those diapers stink? I don't think I could handle the smell.

I gag every time I wash diapers and throw up on occasion. I gag a lot when I change a poopy diaper so I am not representative of someone who tolerates stink very well. However, we do a few things to cut down the smell. We have soiled diapers in a trash can with a foot pedal, soiled baby clothes and diaper liners and used wipes in a mesh wire basket on the counter because they smell very little. We add baking soda to the diaper pail when it gets smelly and it gets washed out periodically too. When we leave home we use wet bags and the smell is pretty well contained in them.

How do you get them clean? Aren't they really icky?
We use Rockin Green laundry soap and never bleach them, warm rinse with a dash of soap and hot wash with a full dose of soap, and they either go on the line or in the dryer. Our dryer is geriatric so they get dried on low because anything hotter and it overheats and won't work for a week and the repair human who fixed it up last time it quit heating said it's at a high risk of starting on fire at any moment if we use the high heat. Sometimes we dry the diapers twice on low so they are really dry. The covers we turn inside out (well, flip inside out) and put into the warm wash and they generally come clean in only one load.

When it's sunny we dry the diapers on the line. One drying rack holds about 2 dozen large size prefolds or 3 dozen of the small ones. In the winter it took 3-5 sunny days to whiten the diapers but in the summer one afternoon gets out most stains. I discovered recently that clothespins fit right over the rods on the drying racks so that saves some time hanging them up. Here's my laundry assistant demonstrating that her big sister's mini golf set needs to have a hole inside the drying rack.

You can see we have another very short drying rack in silver in addition to the main white one. That's the one we got when the kid was a baby and after umpteen moves, its legs vanished. When stretched it holds 3 dozen large prefolds if it has its legs. Now it holds about a dozen at most but it's my overflow. I think we have between 3 and 4 dozen diapers in circulation. We bought 1 dozen new and 2 dozen used ones retired from the local cloth diaper service and there are some strays from the kid's babyhood around but not nearly as many as I'd thought. I assume I'll discover a box of cloth diapers about the time Little Monster is potty trained since so many things are missing and have yet to be found. 3 dozen would be plenty and it's kind of risky to have so many diapers because we can go too long between washes and still have diapers.

I tried cloth diapers, those all in one things with all the snaps, and I hated them so I sold the lot.

Aside from the diaper portion being a factor in choosing prefolds, the closure for the diapers was a major factor as well. One of us adults has moderate limitations to manual dexterity which makes snaps very difficult. I don't think an all in one diaper exists that comes with the loop and hook closure (ve.lcro is a trade name for this stuff). Combining a hard time getting snaps to work with a squirmy kicking baby just seemed like a bad idea to us so we didn't.

Isn't it a pain in the neck having all those parts to keep track of?

Maybe yes, mostly no. We do covers, trifold the diaper to fit in the cover, add a fleece liner, and attach the diaper to the baby. If we used all in ones, we'd only lose one piece to that trio. It isn't that much effort and only nominally less than if we did all in ones, plus we don't need to worry about doublers or adding special pieces to the all in one.

What about diaper creams? How does that work?

Little Monster has mild eczema and she needs lotion or creams of some sort about 3 weeks a month to keep it in check and stop her from scratching until she bleeds. We started off thinking rashes would be rare and we could just put her in disposables for a day or two while we used the cream but now we've gotten some fleece from a craft store and chopped it into liners that we use with each diaper change.

Wait... what do you use for wipes?

Washcloths. Specifically we bought a big pack of them meant for washing your car at a price of about 40 cents apiece. As they get destroyed by being laundered often we just toss them. I think we started with about 6 dozen and we're down to maybe 4 dozen now (some barely lasted 1 wash though). We also have some plain white washcloths in the mix too but most were the kid's during her diaper years. Many people get all excited about some fancy wipes solution but we don't do that at all. Just plain water for us and so far it works well. Both girls get a rash from aloe so we are cautious about products we put on their skin and try to keep it to a minimum. We have an insulated water pump deal like this except in a really amazing plaid pattern for when the diaper station isn't in the laundry room with a sink like it is now so water is always handy.

What about bleaching or yeast infections?

Some all in ones have in their cleaning directions to bleach them sometimes but that's more because the cover makes it hard or impossible to get the sewn-in liner clean all the way. That's a benefit to prefolds. Unless you do something awful to them like forget to wash them before a week long vacation, there's no need to bleach them probably. If Little Monster is having trouble with a yeast infection we iron the diapers with a very hot iron and lots of steam and that helps quiet things down. Heat kills the nasty yeasts so some folks also use really hot wash water. Our diapers already get washed in water hot enough to kill most yeast so the iron seals the deal (plus obviously the dryer never gets all that hot).

What kind of covers do you like?

We have a variety of covers. Little Monster is a long body baby and relatively narrow as babies go, plus she's in the 25th percentile so she's a petite baby. I imagine some covers that don't work wonderfully for us would be better on a differently shaped baby. We mostly have Thirsties (no affiliate links, I'm much too lazy for that) and Flip covers. We had intended to just get Thirsties but the cloth diaper store was out and some Flips were on clearance so we got some and I think I like them better. Thirsties have the double leg gusset that my spouse likes but I find the inner elastic is worn out now. They also come in size 1 and size 2 so higher cost overall than the Flip that in theory fits all along. We got our first Flip cover about 6 months ago so I can't speak to how it would fit a newborn but my bet is not as well as the Thirsties size 1 did. Despite weighing not much more than 20 lbs Little Monster needs the tallest size in both covers now so I'm unsure they will last her tall body to potty training, but then maybe they will. She's still pretty near the narrowest on all her covers as well. We also have a Sweet Pea all in one cover that is just not at all the right cut for Little Monster so we rarely use it, and a single all in one diaper that I like pretty well and would consider having more of despite the snaps. In the legacy diaper cover category we have a few Bummis covers that are much less awesome than the current models but that got the job done well enough. They were the small size and are outgrown now and we didn't buy any more but not for any special reason beyond sales and easy availability. Somewhere we have the full set of barely-used mediums from the kid's toddlerhood but due to need those may just stay lost.

If you had unlimited money and were just starting out with cloth diapers, what would you suggest?

I really like the multipurpose prefolds so I'd say go with those and pick some cute covers. We've convinced 5 different in-home daycares to use them if they have the hook and loop closure. I prefer the hook and loop closure but I bet the snaps last longer so might be better if you are planning for many children. I would suggest a few different covers to start with (say 4 but maybe 4 different varieties or brands), 3 dozen of the small prefold diapers plus 1 dozen large ones and you can add the other 2 dozen larges and another 2-6 covers over the first few months of babyhood as the budget allows. We have to have at least 8 covers because at daycare each cover is used once and that gives us 2 days' worth of covers if we are behind on laundry. I'd suggest either a big wet bag or a cheap foot pedal trashcan to store soiled diapers and a little one for soiled covers.

Scars

I had a skin biopsy a few weeks or months or something ago. In pharmacy school time, it is recent enough that I don't have a scar yet but not so distant as to have been last semester or even before midterms and that's as close as I can pinpoint the event.

Anyway.

Since the stitches went in, a scar has been forming. I have had this same size biopsy a few times now on various patches of skin and I somehow hadn't noticed the time from stitches to scar so acutely as I have now. This scar has been taking way too long to form, I thought.

In the first week while I waited for the stitches to come out I was sure it was infected. It burned, it ached, it bugged me, it woke me up (or other things woke me up and once I was awake I was very bothered by it).  I was sure something must be wrong in how long it was taking to heal. It oozed and all that stuff. I was out of sorts. I went in to have it inspected and it was deemed perfect. The creepy unhealed mess that it was, that was perfect and exactly how it was meant to be at that stage of healing, according to someone who knows what's what after having seen oodles of these.

Lately I've been thinking about where I expected to be now and where I am and if it matters that my expectations were wildly wrong. One of my professors has mentioned to me or us several times about "over the last 3 years" in pharmacy school and stuff about how I finished a requirement (that requires reflection afterward of course) in my first two years so I didn't do anything to meet it this year and it is bugging me. It just grated on my last nerve so much that my bonus year gets glossed over. I didn't finish that requirement in my first two years of school, it took me the full three but here I am at the end of the third year of school after four years. It's also that it isn't just me that it grates when people gloss over the extra time. I think it's about 15% of my class who started with me and is starting rotations soon. It feels rude to me that we get ignored as a group. The dean's pep talk included a "did you imagine you'd be here 3 years ago? Did you think you'd make it? It all goes so fast!" section and I was tempted to walk out. 3 years ago? I thought I'd be somewhere very different than this. I thought I'd get lucky and have the perfectly timed after 2nd year baby and then graduate and have a job and a 2 year old and a 6 year old. Here and now? No job, no 2 year old, no graduation, just a funk where I feel like a screw up.

Anyway, I think that most of what's broken in me is my expectations and that I'm disappointed that life isn't meeting them. I get gut punched when I see someone with the middle child we don't have. It stings a lot when my classmates are having second children during pharmacy school or just after. One classmate has the almost 2 year old we'd have if pregnancy 4 had gone well (perfectly timed for summer break of course) and will have another in the next couple of months, that elusive 2 year spacing I always thought would be ideal. I had thought that I'd have a job now and be studying for board exams and going somewhere. Instead I'm getting ready for my rotations and spending a lot of time away from home. I suppose I just have the itch for change since such big changes were in the plan originally but are delayed some more now. Limbo is a lonely place to be and the bonus year of school has in many ways been one of limbo.

But that pesky new scar that's slowly forming on my arm reminds me that just because I think things should move at some speed doesn't mean they will or that they ought to. I bet if someone had seen thousands of cases of expectations and plans dashed they'd say that sometimes it works out better to have the delay. It is entirely possible that I am impatient and things are moving along at just the right speed. It might even be probable that everything is fine in the big picture and I will get where I ought to be only this way. I'm really looking forward to the scars of pharmacy school healing completely so I can get back to my life or I settle down enough to realize there is no destination to life, that it's all a journey to somewhere we will probably never recognize. Hopefully this year of rotations is that opportunity.