judaism

Slavery, freedom, depression, resurrection: you know, the usual

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Can it be that it is almost April? Can it be that almost a month has passed since I last posted here, since I last stepped back and thought a thought? Who am I again?

Here’s the thing about being a mother, or an intern, and especially a mother who is also an intern: Every moment you spend doing something is a moment that is stolen from something else. My time with my family is time stolen from my job and by extension from my patients. Time for myself is time stolen from my family. Time for friends is time stolen from doing taxes which is time stolen from cleaning something which is time stolen from catching up on sleep which is time stolen from writing which is time stolen from spending time with my family which is time stolen from the practice of medicine and around and around we go. I’m tired of stealing and tired of having to steal. Right now I’m fifteen discharge summaries in the hole, E is sick for the fourth day in a row, I did not sleep more than 30 minutes at a stretch last night, and the list of topics I need to read about is about a year long. But I’m sitting down to write because it reminds me of myself and these days I really need the reminder.

This year I spent Passover at the home of a new friend of mine. I was with E, who lost interest after about 10 minutes, so I spent the rest of Seder chasing her up and down the hall. All she wanted was to lunge down the stairs headfirst and I had to stop her again and again. We had to leave right as the meal was being served because it was an hour past bedtime. But for some reason I was really paying attention this year. There’s a part in the seder — two actually — where you wash your hands as part of the ritual. My friend suggested that we name something we would like to wash ourselves of in the coming year. When it was my turn, I felt unexpectedly that I was about to cry. “I’ve been so, so negative at work,” I heard myself saying. “Just seeing the darkness in everything all the time. I want to be free of this constant negativity.” I looked up and I couldn’t tell if what I was saying was resonating at all with the other people at the table. Eliana shrieked and I was off running down the hall again.

Jews are commanded each year to see ourselves as having been slaves, as having personally come out of the land of Egypt. I’m not sure if this injunction was intended to inspire contemplation of one’s own figurative enslavement or liberation, but I’ll admit, I am feeling like a slave. I know that I am not a slave. I am a person being paid a wage to work a job that I chose. I have a home, a family, and means to provide for them. Hell, I just spent $60 on music classes for my fifteen-month-old. #firstworldproblems. But I do not feel free. Every day as I leave my family to go to work for 12, 13, 14, 15, 16 hours, every time I put Eliana to bed knowing that I will not see her for 48 hours, I feel powerless. Every time I am castigated for something outside of my control at work or make an error that affects a patient out of fatigue, competing stressors, or just lack of knowledge, I feel powerless. Every time I make a commitment to someone I love and have to cancel, every time I answer an email with the line “Sorry for the long delay” (aka every time I answer an email), I feel powerless. Over time this feeling of powerlessness is adding up to a phenomenon that I hesistate to invoke because it carries so much cultural baggage, but at the same time needs to be spoken out loud more often by people in medical training: depression.

Here are the facts: Depending on the study you read, 25–30% of interns experience depression during internship. In one study, up to 12% reported having suicidal ideation at least once during residency. Articles cite many potential contributing factors including long hours, skewed effort-to-reward ratio, stressful experiences of patient suffering and death, lack of control, inadequate time for self-care, sleep deprivation, medical errors, stresses on marital and parental relationships, lack of feedback on performance, and many others. All of these are true. I will add to these a term that I have come up with over my years in medicine: hierarchical stress, the stress of negotiating all the nuanced politics of the medical hierarchy. As an intern, you have to consult anywhere from 1-5 people before making most decisions and any or all of these people might be rude or humiliating or dismissive or condescending or have a bad plan that you are forced to execute. Multiply that by hundreds of decisions per day and that’s a lot of hierarchical stress.

It is comfortable to hide behind statistics and large cohorts. Here are some different kinds of facts: Almost daily on the way to work I fantasize about being in some kind of accident that will render me partially disabled. On worse days, I have suicidal ideation — not the kind where you buy a gun or practice your slip knot, but the kind where you irrationally imagine that some relief might come of it but are not in any real danger of committing the act. I cry either on the way to or on the way home from work at least 2-3 days per week, and sometimes at work. When I get home, I have to remind myself that E brings me joy. I have to consciously remind myself of the possibility of joy and then kind of pretend until I rediscover the emotion. Most of the time, I feel either irritable or drained of all emotion entirely, flat and resigned and without soul. And I am not alone. Multiple of my fellow interns have reported the same experiences, down to the uncanny details. It is for them that I am writing this, because the taboo against discussing it is so strong. It is time for someone to ask the question: Is this the right way to train doctors? Should the people tasked with hearing our stories and healing us have as the foundation of their professional training an experience of profound and prolonged dehumanization? Negative experiences with doctors are a common tale and this does not surprise me. Working 80-90 hours a week may improve your clinical judgment but it does not lead to a greater capacity for empathy or greater compassion at the suffering of others. If anything, survival demands that you become more self-focused, not less.

During the first months of medical school, a lecturer asked us to go around the room and say why we went into medicine. I was the first or second person to go and I answered honestly: I went into medicine because I wanted to gain a better understanding of what it is to live a human life and also to work to alleviate suffering. When I think back on that earlier version of myself I am both proud and a little embarassed at my own naivete. Oh, the things I did not know. Since that time, what has come into clearer focus is that medicine is a business as much as it is anything else. I have taken on a crushing amount of debt that I will be paying off until I die. As a result, money has entered my career calculus to a degree I never expected. Money is also part of my awareness at work to a degree I never expected. We see more patients in less time than ever before. Hospitalizations are shorter and turnover is higher than ever before. Different options are available to public insurees vs private insurees vs out-of-pocket international patients. Someone is getting rich of all this (read this article if you care about health care in America), but it isn’t me, nor would I want it to be me. After all, sick people are not in a position to bargain and thus our ethical position with respect to charges is a tenuous one. The ever presence of money is part of my disillusionment with medicine, but what did I expect?

Everyone says it gets better and I have to trust them. I will survive this year and residency. After that, I hope I can rediscover the wonder and mystery of the human being’s journey through time in a body, and the sense of privelege in being able to serve as a guide and witness to that journey. I hope I can find a way to practice medicine that is both evidence-based and spirit-based, that is efficient and safe but also reaches beyond these towards higher goals. I hope I can heal myself and be the kind of partner and parent I want to be — present, engaged, and at least at times unfrazzled. I hope I can honor my commitment to medicine while also continuing to nurture the dreamer and the poet in me because there are things of importance that cannot be subjected to the scientific method. I hope I can stop being a thief of time and start being a contented inhabitant of it. If in twenty years I am a country doctor (are there country neonatologists?) living off the grid and growing my own rutabaga you will know why: because what is a career if there is not also a life?

Passover and Easter coincide this year, so both freedom and resurrection are on the menu. I think of my grandmother who spent several years in a concentration camp and my grandfather, who liberated her from a cattle car. They helped smuggle Jews through Europe on their way to Israel. Freedom was not a metaphor for them, but a reality lost and found again. In the face of that history, there is a limit to how much a gay Jewish woman living out and in the open can complain (see above re: #firstworldproblems). That said: I hope to be free from debt one day. In other words, I hope my profession feels like a choice again one day. As far as resurrection goes, all doubt and depression and critique aside, I’ve seen it with my own eyes: the limp, blue baby who takes its first breath after a few minutes of positive pressure ventilation. The child who almost died from overwhelming infection who is sitting in your primary care office telling you about their report card. The former substance using teenager who has become an amazing mother and provider. It’s enough to keep me going day after day after day, which feels like its own form of resurrection.

For me, the concept of freedom is embodied by Nina Simone singing the following song. I am including both the recorded version and a blow-your-mind live version that cuts right to the bone.

Recorded version

Live version

2013: The Sabbath Year

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It is 8:56pm and I am in the house alone. C has taken E to Pittsburgh to visit her brother’s family. This is the first time that I have been at home and E has been elsewhere, which is a small but, as it turns out, emotionally significant variation. I have traveled several times during her life, but she has never been out in the world far away from home without me. I ache with missing her. It’s not that I want to be the sort of mother for whom separation is difficult. I want to be the sort of mother who can enjoy her alone time, who can find a measure of freedom and pleasure in the quiet glass of wine, the sort of mother I was a few hours ago at 6pm, sitting in a great new-to-me coffee shop, writing. Now I just want to be kissing my child’s belly while helping her chubby legs into pajamas. Parenthood and addiction are not unrelated phenomena.

I am sitting at my desk which is cluttered with evidence of our life: E’s body lotion which I have been having to apply each night while chasing her around the house; my stethoscope and the pediatric code card I carry at all times while at work; claritin, sudafed, and pepto bismol, because that is how we roll these days. To the right of my mouse (alert: if you find fingernails gross, this will be gross for you) is a little pile of E’s fingernails from this morning’s looney tunes mani-pedi (note: bugs bunny is an effective but very short-lived pediatric paralytic) which I didn’t have a chance to throw out before E was off to her next death-defying adventure.

When I was growing up, my mother kept a little porcelain container with my baby teeth in it. At the time I found this a little creepy and a lot disgusting, but now I understand it. As a parent, your child’s body — its every part — is suffused with your love and your worry and your desperate desire for their life. Precious does not begin to describe it. I am glad that I experienced the ecstatic, terrified love of parenthood before becoming a pediatrician. I have a lot of empathy for the worried parents of ill-but-overall-well children, and even more empathy for the parents of truly ill children. Other people complain about anxious parents, but I just feel for them. In the words of Yehuda Amichai: As for my life, I am always / like Venice: What is just streets in others / in me is a dark streaming love.

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It’s almost the new year and I was reminded by a friend’s lovely blog post that it is time to make New Year’s resolutions. Ordinarily, there is nothing I love more than a self improvement opportunity. Here is a small sampling of the books on the shelf nearest my desk: The Seven Habits of Highly Effective People, The Now Habit, Uncomfortable with Uncertainty, Zen Mind, Beginner’s Mind (all recommended, by the way). I have been to meditation retreats. I have been in therapy. I have bought apps to keep me focused, to track my time, my calories, my money, and the books I read. I have been a vegetarian and a vegan, have eaten no refined sugar whatsoever for a period of 10 months in 2003, and have been following the zone diet on and off since 1999. I have swum and walked a lot of miles and when my midwife told me to train for labor, I woke up every morning at 6am for three months and took my whale-self to the trail along Lake Michigan. One might say that I have made New Year’s resolutions into a year-round side career.

I tell you all this so you can appreciate the gravity of what I am about to say: I feel like I am doing an okay job at life these days. My life is more crowded than ever and as a consequence I make more mistakes than ever. The pile of unopened mail has never been taller and I haven’t been to the dentist since George W. Bush was president. E’s favorite food is Kraft macaroni and cheese and she co-slept with us in our bed every night from birth through twelve months despite my intimate knowledge of the AAP recommendations on SIDS prevention. I am still bad at returning emails, only I’m even worse than I used to be. But every day I get up and drain every last drop of myself in the doing. I am a smoky fire.

There was a time (aka B.C.E., Before the Coming of E), when I devoted time every six months or so to revising my personal mission statement a la Franklin Covey. My mission statement used to extend over two pages. It featured nine separate roles and my goals for each role. It had specific line items for physical exercise, eating well, keeping the house clean, remembering birthdays, meditating, swimming, writing, keeping up with my photography hobby, communicating with my in-laws, sustaining positive mentoring relationships, being a good sister, traveling, and acquiring more scientific knowledge.

Now my mission statement goes something like this:

Be the best parent and partner I can be. Be the best doctor I can be. Try to write as much as I can.

That pretty much covers it. Everything else is extra credit. I have neither the energy nor the time to improve myself. I am just going to have to make do with the me that I already am.

In Judaism there exists the tradition of shnat shmita, or the Sabbath year. Every seventh year, a year of rest and remission is to be observed. Debts are forgiven (here’s looking at you, Sallie Mae). Slaves are freed (here’s looking at you, ACGME). Fields are allowed to go fallow. Planting and harvesting stops and everything that does grow is “hefker” or ownerless, free to everyone. Basically, the machinery of human commerce reboots. The practice is still observed by religious Jews (though notably not by credit card companies). The last actual Sabbath Year was 2007-2008, so the next official one won’t be until 2014-2015 but I’m thinking we may need to move it up a bit and reframe it in more personal terms. It’s Shnat Shmita, my people! Perfectionism is out. Interdependence is in.

So I invite you to join me in resolving not to resolve, in being self-aware but yet filled with humor and gentleness. Let us be no thinner and no more organized. Let us validate ourselves and each other because we are working hard and trying our best. Let 2013 be the year of consolidating our strengths, asking for help when we need it, and setting realistic expectations. Let us view ourselves as we view our children and/or dearest friends: with love and admiration and tenderness.

Happy New Year!

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Epilogue to maternal loneliness: C just sent me this picture of our little E, delighting in the company of her cousin in Pittsburgh. He’s her new bestie, basically. She looks so grown up — it blows me away! She’s having a fabulous time and building the relationships that will sustain her long after her Baba and I have left this life. Meanwhile I am about to go to bed so I can wake up at 5am and go take care of 17 other babies who are just at the beginning of it all. There is much to be grateful for.

E and A

Happy New Year!

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Tonight is the Jewish New Year. We were supposed to celebrate with my family, but since E started daycare last month, there has been about one illness per week and I just couldn’t face packing, traveling, unpacking, packing, returning, and unpacking in the space of several days. It’s work enough just keeping everyone hydrated these days.

Instead, we bought a rotisserie chicken from the supermarket and lit Ikea tea candles. Instead of wine, we blessed a bottle of Beck’s. Instead of challah, we blessed the heel of a loaf of multigrain bread. I was sad not to be with my family, but this version of the holiday was somehow fitting for our current life. E was able to eat all three of the foods in our meal. For some reason, this new fact of her culinary competence delights me every time. I love taking the food right off my plate, cutting it into tiny pieces, and watching her feed it to herself. It may sound odd, but I find it more satisfying than breastfeeding, perhaps because I am in no way anxious about it. What’s mine is hers, no nipple cream required! After dinner, while C put her to bed, I swept and mopped our dining room floor (not as common an occurrence in our household as it should be).

Jews count the years from the creation of the world, from “molad tohu,” or birth from nothing. Apparently some rabbis calculated backwards from the destruction of the Second Temple using the record of successive generations and came up with Monday, October 7, 3761 B.C.E. as the first moment ever. So now it’s 5773. Part of me thinks this is totally ludicrous and part of me is attracted to the ballsy exactness of it. I love that religion continues to stand its ground in the face of overwhelming evidence favoring other explanatory models. Well, I love it minus the bigotry, violence, xenophobia, misogyny, homophobia, and confusingly hypocritical social policy that seem to go along with it. Basically, I just want there to be space in the world for mystery and for that which cannot be articulated. But religion is doggedly specific in its ideology and demands, and thus it’s Ikea tea candles and Beck’s for me!

But back to the first first:

“In the beginning, God created the heavens and the earth. Now the Earth was unformed and void, and darkness was upon the face of the deep; and the Spirit of God hovered over the face of the waters.”

I love the existential and linguistic bravery of these lines. Sure, it’s impossible for there to be something before the first thing, but language forces us to imagine just that. The book could have begun with that first line “In the beginning, God created the heavens and the earth” and gone straight to the third line “And god said, “Let there be light” (the first speech act! I can’t get enough!) but instead the author wants to tell us what there was before anything was. The second line has always slayed me, from a poetics perspective: And the Earth was unformed and void and darkness was upon the face of the deep. In the original Hebrew, there are internal rhymes, alliterations, a cadence that suggests both howling wind and stasis. It’s good stuff. The face of the deep: who has not seen that unseeable face? It’s the kind of language that can be spoken a billion, a trillion times and still remain fresh.

Molad tohu has new meaning for me this year, having been witness to the growth of E from a sub-micron in my darkest insensate recesses to a completely extant being who got tiny broccoli stalks stuck in her eyebrows from playing peek-a-boo during dinner. I have studied every step in the biological process that contributes to this remarkable transformation and yet it retains the quality of total mystery. The science of it does not negate the miracle of it. The science of it IS the miracle of it, and yet, for me, the miracle of it extends beyond the science into the realm of that which cannot be named, that which is unformed and void.

All of which is to say: Happy 5773, that is also 2012 years since the birth of Christ, plus or minus, that is also 13+ billion years since the birth of the universe, that is also a completely subjective experience that each of us is having beginning when we are born and ending when we die. Pass the apples and honey!

May the year be a sweet one.