I haven’t written in a long time.

This is how writing always starts for me, with an apology for not having written sooner. I don’t know what that’s about, the deferral and the delay, the email that is left in the inbox a few days (or weeks) too long, the stories and ideas that sit in the on-deck circle of my mind as the earth spins around itself and then around the sun, unwritten, undone. It’s on a long list of things that I’d like to change about myself, that I try to change about myself, that I may never quite manage to change about myself. Things always happen for me in ebbs and flows. There are long periods of constant accomplishment followed by a day when it takes me three hours to get dressed in the morning, periods of thrift followed by a lethal trip to IKEA, a sense of all being right in the world alternating with the sense that the quest stands on the edge of a knife. In the midst of it all, there’s almost nothing, other than eating, peeing, and thinking of my family with love, that I consistently do every single day, or on a schedule at all. Because my job is what it is, I can’t even put sleeping on that list, because sleeping is not something I necessarily do in every 24 hour period. Each of my days feels like it is invented from scratch.

I went to an Integrative Medicine conference two weeks ago which was dreamy, in the sense that I was surrounded by people who are interested not only in making people better, but also making their lives better, and also making our own lives better. The issue of physician wellness came up a lot. On the one hand, we are an infinitely privileged group of people and what can people possibly complain about who are eating organic steel cut oats and fresh strawberries on a resort veranda in the cool desert morning?  On the other hand, so many people spoke of burnout, of struggling to provide good care in a system more concerned with efficiency and documentation, of seeing numbness and dis-ease in their colleagues and trainees, of finding the weight of the world’s unsolvable problems too heavy to bear, of bearing the heaviness of the world with grace but wondering, deep down, about what good medicine might truly look like. It was good to remember what I had dreamed of, when I started on this path. And to know that other people still dream of it.

As part of the conference, several people gave mini-TED talks, two of which centered on the concept of daily practices — in one case a daily gratitude practice, in the other a daily practice of writing morning pages, a practice suggested by Julia Cameron in her book “The Artist’s Way.” Each of the speakers had been doing their daily practice for over a year. And each of them spoke about the profundity of practice, of doing the thing every day no matter what.

I belong to a number of different cohorts that espouse daily practice. I’m Jewish, to begin with, and if you practice Judaism to the letter of the law, your day is one long daily practice of prayers and blessings and prescribed acts. Then there’s meditation and more broadly mindfulness, which I’ve been dancing with for more than a decade. I’m mindful every day, but I don’t meditate every day and that is without question the recommendation. Then there’s writing. Most people who are serious about writing — or any art practice — do it every day or most days.  (People who talk about their daily practices don’t often make fully clear whether it’s truly EVERY DAY or just most days, and even though the stickler in me kinda wants to ask, maybe it doesn’t fully matter, because either one would be progress.) So I’ve become adept at feeling guilty about my daily non-doing in multiple of life’s domains.

I had a wellness session with a few of the interns this week. We watched a TED talk together about the power of positive psychology. We talked a bit about the research presented in the talk that shows that by doing something positive for two minutes everyday for 21 days, you can retrain the way your brain thinks. I’m kind of allergic to the whole notion of the “21 day fix” because it implies that there is something that needs fixing (I’m doing the best I can and it’s pretty damn good, thank you very much!) and that anything that needs fixing could really be changed in 21 days. As a concept, it seems (very) reductive and simplistic. But on the other hand, I’VE NEVER BEEN ABLE TO DO IT. So who am I to say it isn’t true? Maybe it really is that simple.

We broke into small groups and talked about what we might try to do every day for the next 21 days. I promised to write every day. Then I didn’t write that day, Friday, or the next day, Saturday. Now it’s Sunday, and I’m writing. So I’m not sure whether to classify this as a failure or a success. I’m not sure if it’s day 3 or day 1. But regardless it feels so good, like an awesome first date that is also tea with an old friend. Because it’s been so long, but sentences are still a sweet road to understanding.

So I guess I’m going to try to write every day. 21 days. Just 21 days! It feels insurmountable. Right now, for example, my daughter’s nap has gone on longer than it should have. There are some work emails I haven’t answered that will have to wait a little longer because I was writing this instead. Two minutes isn’t really a feasible time frame for writing, so what I’m committing to is more significant than that. But if I can do it, I’m pretty sure I’ll be glad I did. And if I don’t make it every day, maybe I’ll make it most days, and that would still be a lot.

Anyone want to join me? Write the thing you are going to do every day for 21 days in the comments and we can check in on each other and see how it’s going and then in the end, we can see how it went, and maybe we’ll even keep going.

Can it really be six months since I last wrote? There is this perpetual sense of the days and weeks and months tumbling out of my hands like so many marbles covered in margarine. They cannot be grasped. I keep trying to send down an anchor, to carve out a quiet homestead for myself in the wilds of all the things that must or could or should be done. If I just get the house organized, I am always thinking to myself, then it’ll all fall into place. Meanwhile things both large and small are happening: Residency ended and I started a new job. We bought a house and moved into it. C has a stable job situation for this year and we’re the most relaxed we’ve been since before I started medical school. We’ve been eating lots of salad and going for walks together and instead of me collapsing into an insensate, dreamless sleep at 8pm and C working until midnight every night to make up for the long days of solo parenting, we go to bed together and it’s the sweetest. Last Friday, I got home at 8pm after a wonderful, tiring second week of being an attending and E and I had a rocking dance party courtesy of YouTube. It was the first time in a long while that I completely forgot myself in the moment. I was just a body and a smile and a beating heart. We spun and spun and spun around each other. C was watching — the perpetual sole audience member for our crazy dances — and I did a little (extremely tame) strip tease for her which mainly consisted of removing my stethoscope and hospital badge. The song “Uptown Funk” came on, which we used to time compressions during CPR simulations in the ED, and there it all was: love and sex and death and all the extreme things I have witnessed and the crazy privilege of being there for others at the borderlines of life and the feeling of having no escape from the intensity of that. And, since I’m a parent and a pediatrician, running through it all, the awesome sense of responsibility for the gift of a child, and the pleasure in it.

It’s been a puzzling time. Things have unequivocally improved: I’m working so many fewer hours. I’m getting paid more. I have more time with my family. I enjoy my job. But I’m still waking up in the morning with a sore jaw and a sore neck from the worries that don’t sleep. There’s this new anxiety that stems from not being in survival mode all the time. During residency, I was just trying to make it through. I didn’t expect much of the months: Just to do a good job at my job and to take some delight in my family. If money ran out before the next paycheck, there was a credit card and a nod to some future pay-off. Now, there are so many things I want to do, so many ways I want to be better, so many thirsty parts of myself that haven’t been watered in so long. After three years of chronic pain, my body is in desperate need of concerted attention. I want to be more involved in all the communities I belong to. I want to write more and build out a professional niche for myself that feels authentic. I want to feel like I have some control over my finances. I want to finally get better at keeping up with email and be much more organized. I feel accountable to myself in a new way and so, oddly, though everything is better, I’m feeling more pressured and anxious and distracted than before. I’m expecting more of myself than is reasonable. It’s harder to put down my smart phone. It’s harder to just be at the table with my family. It’s harder to just sit on the couch with E and play Dinosaur Family. I’m finding it harder to just be. I’m having to relearn how to live in long arcs and it’s not going smoothly quite yet.

Today is Rosh Hashanah, the Jewish New Year, which this year has coincided with the beginning of fall, though the calendar won’t catch up for a few weeks. It was legitimately cool this morning. For the first time in a while I had to run back into the house to grab a long-sleeved shirt for E. The house has fallen quiet in the absence of all the fans and air conditioning that have kept us going and the air coming in through the windows has a point to make: the circle is about to turn again. There is something so comforting about the changing of the seasons, about another Rosh Hashanah, about another chance to be made new again. When I was young, the promise of Rosh Hashanah was the opportunity to reinvent myself. Now that I’m older, it’s more about the opportunity to reinvest. We spent the evening last night with friends from our neighborhood — our gaggle of five kids were running around shrieking with delight — and I could feel the roots we have been working to put down wending their way into the soil. Amidst the swirl of my usual worries about how to fulfill on my potential in this life, I had the sense that the answers are close at hand.

For someone who does not quite believe in God — at least not as traditionally defined — I have quite a potent response to attending synagogue. It’s all I can do while I’m there to keep from weeping. There are lots of reasons — the comfort of the familiar, the opportunity to reflect — but I think the main thing is that when I’m there, I feel like part of something, both in now time and in historical time. Lots of people have sung these songs, are singing these songs, will sing these songs. I hold hands with E as much as she’ll let me in synagogue and I can feel all the love that went into my creation flowing through me and into her. It helps that I attend about the warmest, funkiest, most progressive, most diverse synagogue imaginable where you can wear your sneakers if you want and it’s ok if your kid whispers “Is it lunchtime yet?” during the silent prayer.

At today’s services, there were five aliyot — five readings from the Torah scroll. Before each reading, a different group of people was invited to come up to offer a blessing and receive a blessing. First, there were the families who had welcomed babies in the previous year. They scraggled to the front, their little ones in carriers, in arms, in someone else’s arms. How could I not weep for them, for all the joy and the challenge of it, and for the hope for the future that is contained in the decision to bring new life into the world? Then there was an aliyah for people experiencing an ending, and one for people experiencing a beginning. How, I wondered, can one category not contain the other? But you could tell that the people who chose to mark an ending — mostly people mourning loved ones — were different from those who were marking a beginning — mostly newlyweds. You could feel the warmth of the congregation embracing them both. Then the fourth Aliyah was for people in need of healing, or praying for healing for others, or for those who work in healing professions, and given that all three categories apply to me, I decided to rise, and my mother also rose, for her own reasons, and E came with me because that’s how we roll. We gathered under a prayer shawl, surrounded by many others, and spoke the familiar blessing. I knew some of the other people up there from work — and I felt proud of them, proud of us, for all that we give of ourselves to heal others. After the Torah reading, the whole congregation sang a meditative prayer for healing — ana el na rafa na la  — the brief, poignant prayer that Moses spoke on behalf of his sister Miriam. Please God, please God, heal her. People called out the names of people who were in need of healing. I wanted to speak the names of all my little patients, who have had to start life by fighting for it, but of course I couldn’t because: HIPPA. So I just thought about them, their little fingers curled up around their breathing tubes.

In this world where people are killed because they are black and refugees are washing up on unwelcoming shores and millions of children die each year from diseases that vaccines could prevent and medicines could cure, it is a bit narcissistic to claim a spot amongst those who are in need of healing, but that’s how I’m feeling these days: not quite whole. So for me, this year is going to be about healing: healing myself, helping others heal, trying to heal the wounds of the world in the small ways that are available to me. May it be a good year. And it spite of all that is difficult, may it also be sweet. To quote a T-shirt that my mother wears: Lord, give me coffee to change the things I can and wine to accept the things I cannot change. And maybe some honey along the way.

It’s been so, so, so long since I wrote. Part of writing for me is figuring out what the hell is going on in my life, so if you ask me what’s been going on in my life these past months, I’ll quite honestly tell you: I have no idea. It’s like the tupperware drawer, all containers and tops that don’t fit on the containers, some stray tops from containers that never made it home from daycare, a misplaced frog magnet, beads with no strings to connect them, a day then a day then a day.

Which is not to say that these have been empty months. Quite the contrary. I’ve been surfing wave after wave of check boxes. Every to-do list is a redo of the one before and a preview of the one to come. As residency winds down, and the-easier-life-that-has-been-promised rises over the horizon, there has been so much bureaucracy to take care of: medical licensing, credentialing, job application, disability insurance, life insurance. We are are thigh-deep in a house purchase that seems likely to actually happen (super exciting! And so much work!). I continue to try to accomplish more than is possible per unit time. The endless cycle of toys going into and being dumped out of bins continues (If you want to do an interpretive dance about parenting, all you have to do is put on yesterday’s pajamas and repeatedly stoop, pretend to pickup ten small objects with your two hands, stand and pretend to put them into bins.) All of these things are good things and necessary things but also seem far from the soul somehow. What was it again that was burning in my inner hearth those many years ago? Something about transcendence and understanding what it means to be alive and being fiercely present to suffering and always feeling the beauty of the world against my skin like a hot sun?

I got an email from my insurance broker yesterday congratulating me on my successful application for life insurance. “This is great news,” it began, and I couldn’t help but snort with laughter. “This is great news!” saith the prophet in the marketplace. “She hath died, yet her ashes are now transmuted into 1.5 million dollars.” I have been trying, really trying to change my relationship with money recently. I have read, without irony, with full hope for a life transformed, such books as “Your Money or Your Life” and “Think and Grow Rich,” the latter of which is truly a masterpiece of capitalist sociopathy. I have made spreadsheets of all my expenses. I have read several books on how to get organized and have made a few lists of things I should be doing (“Organize desk area” for example, which has appeared on every one of my to-do lists since 1996). I have manged to reduce my monthly electric bill from $197 to $165 after a borderline obsessive — ok, actually obsessive — household campaign during which I overheard my three year old say to her stuffed dinosaur “It’s ok. If your hands are cold, you can just put them in your pockets.” And yet I still cannot shake the feeling that none of this matters one little bit. I want to believe that once I have purchased a home, am fully insured (health, car, disability, life), have an emergency fund totaling three months of living expenses, and have paid off my credit card debt, nirvana will open its hungry mouth and swallow me whole, but I feel farther than ever from a sense of spiritual purpose. There is only so much room in my head and when part of that empty space is occupied with questions like “I wonder if volatility in the bond market will result in higher mortgage rates tomorrow?” and “Is the light in the basement off?”, there’s just not much room left for Mary Oliver’s worn-but-still-new question, “What are you going to do with your one wild and precious life?” I feel like more of a grown-up than ever these days, but I think I might have been closest to the truth at the age of 23, when I lived for long conversations with friends over tea and I was spending 1-2 hours a day sitting on a cushion, staring at a candle and trying to empty my mind.

E and I were in the kitchen one recent evening after dinner. As I mentioned above, I’ve been trying to keep more on top of things around the house, so I try to clean up after dinner these days instead of piling all the dishes in the sink and turning out the light (n.b. this can feel almost as satisfying as cleaning). E is not such a fan — she would rather I stare into her eyes or color with her or play “I’m Elsa. You’re Anna.” So it can be a tense time, me doing dishes, which I hate, while E literally hangs off my back pockets, shrieking for my attention. I opened the freezer to assess the dinner possibilities for tomorrow and E grabbed a row of Pedialyte Pops leftover from a past illness. “Let’s have a popsicle party!” she exclaimed. I decided to be done with kitchen cleaning. E broke off a cherry pop and I broke off one of the green ones that tastes like nothing nature ever made. We sat on the couch and E stretched her legs out onto my lap and we were just sitting there for a while, sucking on our frozen rehydration solution and listening to the Paul Simon Pandora station. Van Morrison’s “Into the Mystic” came on and I suddenly felt like my younger self, glowing with uncertainty and desire, waiting for something to happen. “We were born before the wind/also younger than the sun.” “What are you thinking about?” I asked E. “Dragons,” she said, without any hesitation. “Dragons and sheep.” She closed her eyes and licked her popsicle. It’s an odd experience, being so intimately bonded with a person whose cognitive world is almost totally inscrutable. Her feet starting bobbing to the music and I felt the wildness of chance that made her, the life energy that has flowed from me to her into forever. I thought about what lessons I would want my life to teach her by example: “Get good insurance”? Perhaps. But not only. Also, and much more so, “Love fiercely” and “Feel everything.” I guess it’s a matter of figuring out how to weave them together, the life of sober preparation and the life that carries you away toward an unknown destination.

As a pediatrician-mama, I find that Thanksgiving is — to use a timely cliche — easy as pie. I don’t have to search my mind for even the shortest moment to access my gratitude place: My child is alive and healthy (*gods, do not be tempted by this statement*). The ocean of gratitude I feel for this has no bottom. I am aware of it dozens of times in the course of my day taking care of sick children: How lucky my partner and I are. How tenuous and temporary and fragile our luck is. How we can claim no credit for this fortune. There are many, many other things I am grateful for, but even if all those other things evaporated, this one thing, this everything, would still fill me up on Thanksgiving day and every day.

Yesterday, as a pre-Thanksgiving treat, my partner came and picked me up from work so we could pick our daughter up together from school. It was a gray, cold day and little specks of icy rain were making it hard to keep my eyes open as I waited just outside the entrance of the hospital. I’m on Jeopardy call all weekend but if I’m not called in, I get to have four days with my family in front of our slightly creepy ventless gas fireplace. (Where does all that CO and CO2 go? Whatever — pass the pumpkin pie!) So I closed my eyes and sent a surge of warmth towards each of my co-residents, wishing for their well-being and the well-being of their families. Sure, it started from a place of self interest and humor, but then it felt good and right to be sending them little non-denominational blessings in honor of the holiday. There is a special place in my heart forever for the people I am training with — a certain affection and protective instinct and a huge folder of moments in which these people have awed and inspired me, sometimes unexpectedly.

Then my mind turned to all the families I have cared for who are without a child this Thanksgiving. The babies who never made it into the world, the babies who stayed for only a few hours or days, the babies who left this world after a long struggle in the NICU, the babies who arrived to our ED in the early hours of the morning already cold and pulseless, the children whose otherwise healthy lives were shortened by cancer or trauma, the children with chronic illness who were in and out of the hospital for months or years before a cold or stomach bug proved to be more than they or we could fight. Then I thought of all the children whose lives have been shortened by war or preventable disease or treatable disease or famine or — this week especially — by racism or homophobia or genocide or hate-motivated injustice of any kind. I thought of their parents and the huge, gaping unfairness of what they were given by luck, or the universe, or God, or just random chance, depending on what you believe. I wondered how they go on with things like Thanksgiving. Would I be able to? In Judaism, when someone dies, the thing you say to the people who love them is: zachur li’vracha. May their memory be a blessing. And so, my eyes closed against the rain, I sent this out to all the parents who have lost children: May the memory of your children be a blessing and may there still be things to be grateful for.

On the Jewish holiday of Passover, we leave a cup of wine out on the table for the prophet Elijah. The teaching is that Elijah will one day come as an unknown guest and you want to be ready to welcome him. This year at my Thanksgiving table, I’m going to leave out a cup for all the parents who have lost children, that they may know they and their children are not forgotten. That they should feel welcome back into the rhythm of ritual and community, whenever they are ready. Also, that we may never take our good fortune for granted. And that we may fight in whatever way we can to prevent parents from losing children needlessly.

It has been so long since I wrote that to say “It’s been a long time since I wrote” doesn’t even capture the situation. It’s more like I am beginning from scratch. Welcome to my blog again for the first time! Thanks for being patient with me.

People write for a lot of reasons. When I have a chance to write, I get excited because there exists the chance that I will understand what is going on in my own life.  I write to discover the threads of meaning in the otherwise purely chronological progression of minutes and days and months. And so, for the last few months a lot has been going right – lots of playdates and dinner parties and meet-ups, lots of progress towards a professional vision, somewhat more organized and on top of things than previously – but don’t ask me what it all means because I haven’t been writing, so I don’t know.

Here’s what I do know: it’s Fall. And how do I know this? Because of the pumpkins. The almighty pumpkin reigns. Pumpkin lattes, pumpkin cookies and breads and bars and pancakes and scones, pumpkin butter, pumpkin paper thingies hanging from the rafters, pumpkin earrings, pumpkin sweaters, pumpkin pins affixed to the aprons of many a hip barista. Every year the world gets pumpkin-ier, it seems. Sipping a pumpkin chai, you can begin to wonder: Is anything I am experiencing in my life singular? Are my feelings about Fall really mine, or have they been manufactured to stimulate the economy? At the coffee shop this morning, I was trying to decide between zucchini bread and pumpkin bread and the cashierperson said: “I prefer the zucchini bread myself. Or maybe it’s just that I’m pumpkin-ed out.”

But the truth is, I am loving every last pumpkin minute. Fall has been big in our household this year. In an effort to help E understand the season, we have visited pumpkin patches, gone on leaf hunts, eaten apple-cider donuts, and decorated the house with things like mini-scarecrows and jack-o-lantern lights. One of the gifts of parenthood is that the responsibility of orienting your child to the world brings you back into contact with the basics: The fall leaves are beautiful. Holidays are fun. Eating sweets feels good. Not complicated. I have become accustomed to living somewhat outside of the normal, so joining the pumpkin wave is both comforting and discomforting. But watching E cavort in the Halloween parade with her neighborhood buddies, I am so grateful to be living in a place (blessings upon West Philly!) and a time where joining is even a possibility for the child of gay parents. Making space for singularity in this world has been a source of struggle but also of strength in my life, but for my child I wish a measure of easy belonging. May she have to struggle just enough to learn but not enough to suffer. So maybe it’s a little complicated.

Lately, E has been asking me the same question every morning: “Where am I going?” by which she means “What’s going to happen today?” It has made me aware of the undifferentiated wash of time that E inhabits, in which she cannot know from day to day what the heck to expect. It’s as likely to be a regular school day as it is to be the day that we move into a new house. So I’ve started to make a calendar with her every Sunday, drawing out together the major events of each day of the next week in pictures. She calls them her “artworks” and insists on hanging them side by side on her wall, rather than replacing the previous week’s calendar each Sunday, so the past is as likely a topic of discussion as the future these days. She stands on her bed and points to each day in turn, reciting their highlights to herself: “Saba (grandfather) day. Rainbows (school) day. Dinosaur museum day.” The days that have passed surprise and delight her as much as the days to come.

One of the basic tenets of mindfulness is that the present moment is all there is, that both past and future are problematic fictions. I spent a lot of anxious years taking deep breaths and trying to embrace the present moment, but now that I’m a parent I’m willing to sacrifice a measure of anxiety for the sweetness of memory and anticipation. Looking at E, I can see her month-old self and her six-month-old self and her five-year-old self and her grown-up self in various states of recession and evolution. This year’s Halloween was made so much sweeter by last Halloween and the Halloweens to come. Which is not to say that the present moment doesn’t have a lot going for it, but watching E emerge into the consciousness of time is convincing me that this consciousness is absolutely inherent to the human experience. It’s why we mark time with rituals and holidays. It’s why we cleave to calendars. It’s why watching E’s excited face bathed in the orange glow of our string of plastic jack-o-lantern lights makes me feel like crying. Because time stretches backward and forward for what seems like forever.

So pumpkin bread it is.

*          *          *          *          *

Where I am going? The question has been knocking around in my head a lot lately, maybe because of E’s daily query, maybe because I’ve had some easier residency months in a row. When you finally have a chance to raise your head above the swirling bat colony of responsibilities and groceries and new lab results, the horizon you find can seem both eeirly foreign and eerily familiar. Those reds and yellows and pinks, that sliver of sun — phew! I think, I’ve seen them all before. But also, have the colors of this world always been so vivid and arresting? It’s amazing what a couple of weeks of consistent sleep can do to your brain biochemistry.

I found a notebook of mine from medical school, full of errant notes — some meticulously organized lecture notes, some wildly scribbled reminders — “Student loan form” and “Review Kreb’s cycle.” On one page in the middle of the notebook there is just one line: “To better understand what is means to be a human being that lives and dies.” I remember this moment, though not the lecture or even the lecturer who had asked the question: “Why did you decide to go to medical school?” This is, of course, not the only answer, then or now. “To be of service” was and is actually the number one reason. Then there are things I couldn’t know then about the physician role: “To provide high-quality, safe, evidence-based, efficient care in the context of a health care system and institution.” But there remains a spiritual motivation to make contact with people at the limits of mortality where love and beauty and terror live.

At work these days, I’ve been seeing an epidemic of a disease entity that I will call “soul-itis.” This month, I am serving in the role of the admit resident, admitting patients during the morning hours when the floor teams are rounding. I meet patients, hear their stories, write their orders and get them settled, and then turn their care over to the primary team. I am like the ghost of hospital admissions present, from whom the patients awaken at noon to meet the people that will be their real doctors. Unencumbered by the simultaneous care of 20 other patients, I have had the opportunity to have in-depth conversations with these patients, and the theme has been a kind of suffering no MRI or blood test can identify. Abdominal pain, headaches, shortness of breath, altered mental status – all of these symptoms have been the face of soul-itis over the past couple of weeks. Of the patients I admitted, fewer than half of them ended up having a diagnosable and/or treatable problem. The rest of them had some combination of depression, anxiety, intractable family conflict, peer bullying, life trauma, or an inability to trust the people around them to act in their best interest. What, as a doctor, can I offer them? I try to listen and validate and acknowledge pain. I want to do more, but the soul isn’t really in my legal scope of practice. There are guidelines for how to treat asthma, bronchiolitis, fever, and seizure, but when it comes to helping people learn to live with the ache in their lives, I am not sure what my mandate is.

I have been feeling envious of chaplains recently, who are empowered to cut straight to the life of the spirit in their interactions with patients. Patients expect me to consider organic causes for their symptoms and are usually less than receptive when I suggest that the origin of their problem might be emotional or spiritual or psychosocial. At best, I can present this possibility alongside a lab test or imaging study I am ordering “to rule out the scary things.” I am not minimizing the value of ruling out the scary things – it’s part of my mandate, especially as a pediatrician – but I wish the conversation could turn to other scary things, like loneliness or shame or fear itself.

For my elective last month I rotated with the pediatric palliative care team and it reminded me how much healing is possible even when cure it not. It also reminded me how traumatic illness (either acute or chronic) can be for a patient and family even if death is not the outcome.  When you are responsible for the medical care of a patient, success is measured in a downtrending fever curve, normalizing lab values, tumor shrinkage, improved respiratory status, increasing oral intake. When improvement is no longer the expectation, the metrics change. Now you have to ask questions like: “To what extent are the things we are doing congruent with this family’s values and wishes for their child?” and “Are the things we are doing in any way preventing this child from enjoying their life right now?” It is a head spinning switch and it can be difficult for both families and clinicians. And yet, as I sat in on family meetings and listened to these discussions unfold, I felt like something bright was peeking through the cracks in the dark landscape of pain and trauma. It felt right to be hearing about family traditions and places of worship and siblings and grandparents. It felt right to be acknowleding the web of people strung by love to the sick child in the bed. It felt right to be broadening the conversation and finding hope — for comfort, for peace, for family time, for beautiful memories — where hope may have previously been elusive. The crazy thing about hope is that it can survive anything. “And sweetest in the gale is heard,” to quote Emily Dickinson.

In a study by Chris Feudtner of how parents of very ill children define the priorities of their parental role, he found that the number one priority for these parents is “making sure that my child feels loved.” This trumped even “focusing on my child’s comfort” and “making informed medical decisions.” It is rare that science makes me cry, but when Dr. Feudtner presented these findings at Grand Rounds, that is just what I did. It changed the way I think about my physician role, and not only in the setting of end-of-life discussions or critical illness. In addition to serving others, providing high quality care, and facing human frailty, it is my job to help parents ensure that their children feel loved, to help them love their children as best they can.

So where am I going with all this? Soul-itis is rampant and I want to make it a more central part of my business as a doctor. Love — especially parental love — is one of the wonders of the world and I want to be an expert in it. I want to be a master love-ologist. There is an infinitude of important things in this world — global food supply chains, how mitochondria make energy, the right way to build buildings so they don’t topple in the wind — but this is going to be my thing. I’m going to use the training I already have and acquire whatever additional training I need to make medicine a tool in the service of the love that burns and burns and burns and burns all around us. I’m not sure yet what that specifically that looks like in terms of a job description, but it helps to have something to point the compass arrow toward.

Here are some photos of the joy that was the Halloween parade. They’re out of focus but when are toddlers still enough for photos? E is the happy dinosaur.

Some weeks have passed since I last wrote. For those of you who have been reading for a while, I’m on staycation again, which means taking stock in coffee shops, sleeping, trying to improve upon myself, and playing with E. I’m in a coffee shop called L’Aube in Fairmount. It’s a Parisian-style creperie, complete with art-deco windows, better-than-usual coffee, unsmiling waitstaff, and a sense of timeless remove from the busy world. Outside the window, two young shirtless guys are pulling up weeds and talking about girls. The neighborhood kids are coming home in ones and twos from wherever they spend their summer days.

We’ve been traveling a lot in the last few weeks to spend time with loved ones. Lots of hours in the car. Lots of rolling farmland and rest stop bathrooms and spotty cell phone reception. Little feet wading into creeks. Waterfalls. Ladybugs. Raccoon (which I learn upon googling is its own plural). Not to mention E’s first contact with tents and trampolines. Standing in the backyard of C’s childhood home at night, thousands of fireflies flicker on and off in the surrounding trees and fields at every height and depth into the vanishing horizon. It is more light and movement than the eye can track — dazzling in the most literal sense. I try to capture it on video but all you can see is a black square of night. It’s one of those shows you have to see live.

C and I have been spending lots of time together and I am reminded how lucky I am to find such enjoyment in it. We found out recently about the end of a long marriage among my parents’ friends and, holding hands with C across the gear shift through the streetlight-lit miles home, I can feel the weight of what they have lost. They had, at one time, seemed like an irrevocable couple. I think about the moments when a sarcastic barb comes to mind that you know would hit a soft spot, when the rhythms of daily life feel suddenly a little stale, when a chance flirtation arises with a stranger. Can the dissolution of love be prevented by a series of intentions and choices? I wonder. To quote Tina Fey, “It’s a burden, being able to control situations with my hyper-vigilance, but it’s my lot in life.” Whether it’s magic or a reflection of good habits of behavior or a little of both, I never take it for granted, that which always seems to be renewed between us. (Do you hear that universe? I don’t take it for granted! I am so, so grateful! Give me this continued comfort. Oh, and let my child be healthy. Just those two things. Does this count as a prayer?)

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Ok, so that last part shouldn’t be in parentheses. Since rotating on oncology last month, I’ve been saying quite a few of these little unstructured, non-religious prayers to no one and everything for no particular reason (what is the relationship between praying and the bargaining stage of grief? Discuss!). Up to this point, I have managed to (mostly) avoid reading on E’s body the signs of every dreaded thing, but last month I found myself staring at her across the breakfast table and wondering: Does she look a little paler than usual? She is a little sweatbox at night and even though she  was just as sweaty as on every other night I would run my hand through her damp hair and think: Are these the night sweats that you hear about? Almost every story on oncology begins with “So-and-so was an otherwise healthy child until…” Is today the day? I wonder sometimes. The last day of normal life? The day before the story changes forever? One of E’s favorite songs these days is “The Lion Sleeps Tonight” and I’ve decided it’s the only viable lullaby for parents. The lion is out there but tonight he sleeps and so you can also sleep. But as far as tomorrow goes….. awemoweh awemoweh, awemoweh awemoweh.

Oncology was a difficult rotation for me, and not only because of parental anxiety. One of the cardinal rules of medicine is to first do no harm, but in oncology you have to get used to doing as much harm as the body can possibly tolerate. The children have to get much sicker before they can get better, and a percentage of them die of the treatment. When the conventional therapies fail, hope is kept alive via increasingly experimental therapies. Without the experience of having seen lots of children cured of their cancer, with only one month caring for the sickest of them, it was hard to draw the line between worthwhile and futile suffering. On rounds we discussed the ethics of stopping curative treatment for dying patients but privately I found myself struggling more with the ethics of continuing. Even though I knew rationally that chemotherapy would be the only path to survival for these patients, my affective instinct was to let these little people with their steroid-swollen cheeks and bruises at every vascular access point have some peace.

My first call night I went to the bedside of one of the patients to draw blood for a test that couldn’t wait until the morning. When I opened the door, my first thought was, this is a dying person. I have never before had that thought about a patient, at least not in such a visceral and immediate way. She was asleep and I wanted to back quietly out of the room, out of respect for what comfort sleep might afford her. Instead I got my supplies together and proceeded with what would be two failed attempts at sticking her while she cried weakly. It was her family’s wish at that point that we do everything to prolong her life but now that she has died, I can’t say that sticking her was the right thing to do. But it was not the wrong thing either.

I will say this about my month on oncology: Pediatric cancer patients and their parents are tough as nails. The rest of us out here in healthy-kid land are playing for the farm team. I was humbled by them every single day. There was humor where humor should be impossible, generosity and kindness towards us as providers that was neither expected nor necessary, unblinking courage in the face of the previously unimaginable. I have always felt that the parental drive is one of the most ingenious and miraculous of nature’s innovations, but my appreciation for its force is on a whole new level.

If I had to distill what I learned from my oncology rotation into one sentence it would be this: Sadness and joy are not opposites. That, and love. Always love. Don’t waste a minute of it. The Bible, Hafiz, all the pop songs, they’re all right.

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On the Saturday night of one of our trips, I found myself in a small wood-beamed concert hall listening to chamber music. My mother offered to spend the evening with E so that I could attend the concert, a rare event for me these days. Prior to E’s birth and residency, in the 31 years I in retrospect understand to have been my youth, music was my ground water. Bach was the first thing in the morning and the last thing at night. Ear buds were always in my ears. At least half of the most impactful moments of my life happened during concerts. Now I can’t keep ear buds in my ears, for how then would I hear my child asking for more milk, please? Also, the classical music radio station in Philadelphia is not good (Are you listening, rich people with so much money that you have already stamped out hunger and refrozen the polar ice cap? Give them more money!). But I digress.

The first few pieces on the program were atonal, challenging, but full of pleasure, thrumming with novel sounds and unexpected vibrations. I had forgotten how music can bypasses cognition, like a spinal reflex but in your soul. Then came the first simple chords of the Schubert song “Wanderers Nachtlied.” The singer, a student, had a tremendous, gorgeous, rich voice — a gift. At the song’s most dramatic crescendo, her pitch wavered, but this only added to the music’s immediacy and passion. Every cliche happened at once: my heart skipped a beat. The breath caught in my throat. I got goosebumps. I wanted it to last forever but of course it didn’t. Live music is like life: No replays. The sweetest things come and then are gone and you have to hope you were paying attention.

A few days prior to the concert, I had been practicing neonatal resuscitation maneuvers on a simulation doll, and so as I was listening to the singer, all I could see in my mind’s eye were the doll’s vocal cords as visualized during an simulated intubation attempt. For those who haven’t been on the operator end of a laryngoscope, placing a breathing tube involves inserting a lighted scope — the laryngoscope — into the mouth, pushing the tongue out of the way, lifting the soft structures away from the larynx and visualizing the vocal cords through which the tube has to pass. The cords are white to pink, thin but tough, oriented exactly like an upside down V below the epiglottis and above the esophagus. The dark triangle between them is all you can see of the trachea beyond. Like many of the body’s parts, the vocal cords look much too simple for the complex task they perform. Due to their location and a number of other factors, it can be difficult to see the cords and so laryngoscopy is an anxious business, especially under emergency circumstances. On the other hand, when you a good view of the cords and can see the breathing tube pass through them, they are like the runway lights that guide a pilot toward some hope of safe landing on a stormy night.

I have visualized plastic vocal cords dozens of times and real cords several handfuls of times, but I had never connected them with the act of singing. When you train as a medical student and a resident, you are always being warned against becoming disconnected from the patients you are treating. If I had a nickel for every time a lecturer in medical school used the famous William Osler quote, “It is much more important to know what sort of patient has a disease than what sort of disease a patient has,” I would have about $15, which is a lot of nickels. Starting off down on the path of medical school, it is hard to imagine how such a thing could occur: How could you possibly become disconnected from the patient? As a medical student, you are focused on learning to take a history and do a physical exam, tasks which are inseparable from the unique humanity of the patient before you. As training proceeds, the skills and knowledge you strive desperately to master involve less the question of what happened to Mr. X and more questions like how do I maintain a perfusing pressure in a septic patient and which antibiotics cover Enterococcus and how do I intubate a baby who has been born through meconium? These questions are undeniably important, but they can lead you away from people into a world of numbers. Once you are in a world of numbers, it is easy to focus on physiology for its own sake — normalize lab values, get the heart pumping again, get fluid off. If you are not careful, you can lose sight of the WHY of it all, the inside jokes and love affairs and rugby games and chamber music concerts that make people who they are, for which they live, without which life is a rhetorical question. You can become disconnected from your patients not out of a lack of empathy or hard-heartedness but because there is so much happening at the level of the cellular membrane. I mean, what’s more important, breathing or singing?

It may be that some clinical distance is necessary to successfully intubate someone, but next time, once I’ve gotten the view, once the tube is through the cords, once position has been confirmed and the carbon dioxide detector changes color and the patient’s vitals start to calm down, I’m going to try to remember to speak a little incantation to myself: “That they might one day sing.” That I might continue to listen for the song.

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I left the concert at intermission to get back to E. In the parking lot, I looked up the words to the Wanderers Nachtlied (how has the internet changed life? Let us count the ways). Like many of Schubert’s songs, the text is by Goethe. It is imbued with that Romantic ardor for both death and the natural world that could be paradoxical but isn’t:

Over all the hilltops

is calm.

In all the treetops

you feel

hardly a breath of air.

The little birds fall silent in the woods.

Just wait… soon

you will also be at rest.

It’s a beautiful poem, and a beautiful promise, but it’s not the only way to go. For my part, I’m hoping for all the snarls and sighs of the forest, things eating and being eaten, the dance of a thousand lustful fireflies, to be released from fear into the chaotic tangle of everything.

Ah vacation. Two weeks of vacation and two weeks of elective. One whole month of remembering myself. People have been asking whether I went away for vacation and I say: Why would I? What could be more exotic than actually spending time every day with my own spouse? The calm quotidian is my tropical island. I have been reading E a couple of books before school in the morning. I have been cooking and doing a better-than-usual job of trying to clean. I sleep in my own bed every night. I wake up after the sun. I can participate in things like day care pick-up and happy hour. A couple of times, I had half a beer with dinner. To quote Natalie Merchant for probably the first and last time: These are the days, the days you will remember (unless, of course, residency and parenthood has destroyed both your short- and long-term memory, but that’s a whole other thing). I’m in love with my own life again.

Not to mention that Spring finally arrived. It’s just as good and even better than I remembered. Every afternoon now, E and I walk around the neighborhood, soaking the sun into our pale skin, delighting in the tiniest little flowers and stray stones. There is a small hilly yard outside of an apartment building a few blocks over that is covered with well-maintained grass and E plays on it like it’s several acres of wild field. Hey E, I say. Wanna walk over to the grassy knoll? And she always does. Only spring could make a destination of this humble little square of green.

Vacation has allowed me to realize that raising a child and maintaining a household, a marriage, friendships, and one’s place in a community takes a lot of time. These tasks, these labors of love and fellowship and participation, used to constitute an adult person’s entire job in each household. Expecting people to do these things in the small cracks of time between work and work is asking too much. For the past 22 months C and I have been trying to do all these things in addition to each working double full time and parenting and it’s just not possible. Over the past three weeks, I managed to finally purchase an appropriate dining room table, to finally buy new shoes for E several months overdue, to finally RSVP to upcoming weddings and a baby shower, to host several dinners, to volunteer at E’s school, to open the last four months of mail. Every day, every week, every month I live with guilt and shame and panic at the things that are undone. There’s so much toxic negative self-talk in my head that sometimes I can’t hear what other people around me are saying. It’s time to acknowledge reality: Our household doesn’t have a full-time manager. We have two people doing the best they can. And looking ahead into the future, I want there to be dedicated time in my schedule for these things. These things are as important to me and, in the case of raising E, more important to me than work.

As I write this, it feels like a transgressive sentiment. More important than work? I hope that no one who might employ me in the future reads this! I think to myself. But then I think: in what world would people be expected to prioritize work above their children? And then I remember: our world. And more specifically: America.

I am reading an interesting book by journalist Brigid Schulte called “Overwhelmed: Work, Love, and Play When No One Has the Time” (highly recommended! Buy it here from Ann Patchett’s independent bookstore). The book is full of interesting information about the history of our relationship to work, the frazzled state of American working mothers, and many statistics that illustrate just how work-obsessed Americans are when compared to other industrialized countries. But the thing that has been catching in my throat is the chapter titled “The Ideal Worker Is Not Your Mother.” In this chapter, Schulte describes the ideal worker thusly:

“The ideal worker, freed from all home duties, devotes himself completely to the workplace. He is a face-time warrior, the first one in in the morning and the last to leave at night. He is rarely sick. Never takes a vacation, or brings work along if he does…. So tied to his job is the ideal worker that he works endless hours, even if it costs him his health and his family.”

She then goes on to describe study after study showing that Americans perceive mothers to be less committed, less competent, less worthy of promotion, and deserving of less compensation than women without children or, of course, men. She describes several case studies of mothers and fathers who were striving to be ideal workers, who were embodying the ideal in every way possible, who were nonetheless passed over for promotion because they were perceived to be less committed. (Not to mention the women who were instructed to have abortions by their employers. Yes, this does happen.) She also reports the high cost of the ideal worker model in lost productivity due to burnout and chronic workplace dissatisfaction. I don’t know how these statistics are derived, but apparently it is costing us 1.5 trillion dollars a year.  So I guess we should be calling it the not-so-ideal worker.

Much has been made lately of whether women are leaning in or opting out and why. Are women who opt out weak? Afraid of challenge? Falling back on tired gender paradigms? What I suspect is that many women who opt out are quietly rejecting the ideal worker paradigm because it contradicts their values. They do not want to leave sick elders and children with other caregivers, no matter how competent. They do not want to miss school recital after family wedding after anniversary. They do not want to lose touch with their spouses. So maybe instead of gritting our teeth and leaning in, we should be working to retire the not-so-ideal worker and replace him with a worker who is healthy and productive across all of life’s domains. A worker who is allowed to admit, for goddess’s sake, that their children are the most important thing. A worker who can choose to be present for their dying parent without fear of losing their job. A worker who can take time every year to rest and renew their energy. The good news is: a lot of other countries are doing it. It is possible. In fact, a more proportional and reasonable relationship to work was the norm for centuries:

“In the Middle Ages, though peasants and serfs worked in the fields from sunup to sundown, they broke for breakfast, lunch, afternoon nap, dinner, and midmorning and midafternoon breathers. Church holidays, Sabbath days, saints’ days, official rest days, public feasts and festivals, and weeklong “ales” to celebrate major milestones like births, marriages, and deaths took up about one-third of the year in England. In Spain and France, Schor estimates that even the hardest workers had nearly half the year off.”

Smoke on your pipe and put that in!

In the midst of this feast time of ecstatic normalcy we hosted Passover seder for the first time. Here I must pause and acknowledge my mother, who hosted a beautiful and delicious seder for 15+ people every year. Making Passover seder is hard! When it comes to life, I stand on the shoulders of giants! But I digress…. Now that E understands what we are saying but doesn’t really understand much context, I didn’t have much appetite to go through the ten plagues. Killing of the first-born? I think not. In fact, a lot of the passover story is not really rated G. Instead, I opted to talk more generally about justice and freedom, and then about spring and fertility and the renewal of life.

Jews are commanded that in every generation they are obligated to see themselves as having personally come out of Egypt. So I got to thinking about the difference between slavery and freedom, what slavery might feel like, what newfound freedom might feel like. As Americans in 2014 we are all of us freer than most of the rest of humanity past and present. But still, in every life there is an echo of slavery and the possibility of greater freedom. Freedom from addiction, from fear, from shame. Freedom to be more self-actualized. These days we are more than likely our own slave-masters. I asked the people gathered around our seder table to focus on their own experience of moving toward freedom. And the first thought that came to my mind was:

I want to be free to rest.

It’s not a lofty goal. It’s a first-world problem. It’s nothing to be all that proud of. But that’s the exodus for me this year. From restlessness to rest. From the not-so-ideal-worker to something else that we will all have to create together.

I guess it’s becoming a habit: me writing post-call. Just finished number six out of seven calls this month. More and more hallucinogenic each time.

Here is a complete list of all the things I ate while on call: 6am yogurt with peanut butter en route (lucky breakfast). 9am (EnDLeSS ROUNdsssss are killlaaaah!) a single pack of graham crackers with single-serving peanut butter. 11:45am: free resident lunch. it’s either boneless, surprisingly tender chicken (kosher) or pork (verboten). I don’t ask too many questions. 3:15pm: a single packet of saltines and a nonfat milk (aka: restraint!). 5:00pm: sushi. 9pmish: peanut butter cracker four-pack (transitioning to the hard stuff). 11:15pm: a 100calorie packet of goldfish crackers and a single serving vanilla ice cream from the not-so-secret cardiac post-op recovery freezer (culinary highlight). 3:55am: The last serving of french fries from the cafeteria grill station 5 minutes before closing. Cold. Four packets of ketchup. 6:55am: Cheese eggs, a biscuit, hot tea (thanks, A!). 7:15AM: A slice of chocolate cake (Thanks again, A!). EnDDDLessss Rououounddsss, round t-t-t-t-t-wo. Too focused on avoiding failure to eat. 11:30AM: Second slice of chocolate cake (Thanks thrice and finally, A!) Made it downstairs in time to partake of free lunch number 2 of the endless day but my heart’s just not in it. Free food can’t keep this engine running anymore.

I am seeing the light at the end of the tunnel and it’s all blue skies and palm trees and Audrey Hepburn or is it Lucille Ball? It’s me on my staycation in 6 days from now. One call, two day shifts and one overnight moonlighting shift from now I’ll have 13.5 days off in a row.  Last time I had a vacation, I went to the dentist, organized my mail, did dishes and POOF! it was over. I am determined to make this one count.

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Had a nice conversation with one of the NPs last night about the anxieties of leaving your child with a babysitter in the evenings. And mothers and mothers in law. And being a mother. If I’m honest with myself it was one of the most friend-like interactions I’ve had in a while. The sharing of oneself with someone else. Ye olde “Oh, me too!” and “I know, I feel the same way.” Both parenting and residency are so isolating. Sometimes I talk to myself silently in the bathroom mirror while I’m brushing my teeth in the dark before dawn. I say things like “What did you dream about?” and “Hmmmm, interesting.” I look at my reflection and try to read the passage of time on my face and body. This weekend my best friend in all the world called while I was asleep during E’s nap and I was so happy to hear her voice, like diving into a cool pool of water which used to be my favorite sensation before sleep became my favorite sensation. Just as I had finished the “what’s going on with me” part of the conversation and my friend started to talk about what’s going with her, E woke up and started crying out for Mommy. My heart sped up because I was excited to see her after her two hour nap (parenthood is such a miracle of self-sustaining energy, like the eight crazy nights of Hannukah oil for the rest of your life) but it was friendus interruptus yet again. I put my friend on speaker phone and E said a few words. I have to hope that the people who love me are ok with this form of conversation. Maybe I’ll call my friend back later instead of sleeping after I write this instead of sleeping.

Just to be clear a lot of laughing and camaraderie goes on in hospital work rooms. The days of the month are long and every combination of people each month develops its own culture, it’s own jokes that no one else can understand, it’s own rhythms of dividing and conquering the work at hand. As a result there are a cadre of people that I care a lot for, my co-residents, my interns, my fellows, NPs and nurses and pharmacists: we’ve shared some things. And yet, it’s a different kind of friendship. What shape would it take outside the hospital? Sometimes joking around in the work room I imagine a dinner party with whomever is doing a spot-on interpretation of the uptight mean consult attending. How would it go, me and them and my partner and whoever is their partner? Contextual collision! Whenever I get the chance to spend time with folks outside of work it’s awesome and bittersweet because I know what has to be important right now and that’s my time with little E. It’s like that line from Moonstruck when Olympia Dukakis is walking home with her impromptu dinner partner and he asks her to invite him in and she says “I can’t invite you in because I’m married and I know who I am.” It’s the strange emotion of confidence mixed with nostalgia mixed with sadness mixed with pride. I can’t go out for happy hour because I’m a mama and I know who I am. All of which is to say to my co-residents: You guys are awesome and I wish we had more time to get to know each other.

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OK, this might seem like a non-sequitor but when I’m post-call I squander at least an hour when I should be sleeping getting caught in the internet’s stickiest spider webs. It’s a huffingtonpost-buzzfeed-top-10-lists-how-to-keep-your-romance-alive-celebrity-childhood-photos psychosis. When it’s 12:09 I say I’ll do it until 12:15pm but then it’s 12:17 so I keep going until 12:20 and so on. Today I stumbled upon a you tube video of Billy Joel singing “In the jungle” with Jimmy Fallon:

Which led to a video of Jimmy Fallon singing with the Roots and Miley Cyrus:

Which led to a video of Jimmy Fallon in a lip-syncing contest:

Which led to a video of Jimmy Fallon singing with someone named Robin Thicke and once again the Roots, which was my favorite:

You may or may not believe me when I tell you that I am so far removed from popular culture that prior to this internet tangent I had only a vague sense of who Jimmy Fallon and Miley Cyrus were and no idea who Robin Thicke is. Ditto Stephen Merchant. Had to google them all. But what I liked about these videos were that the people involved seemed to be having some fun doing a thing that they are good at. I have always been taken by watching performers inhabit the moment, inhabit themselves, take risks and share their talents. It’s sexy and brave and energizing and inspiring. I know all of these things are staged and half the people are probably unbearable prima donnas, but they look like they’re having a good time together and it’s fun to watch. There’s the concept of deep play coined by Diane Ackerman, the state of ecstatic flow and sensory immersion associated with intense play at every age — whether its music, sports, theater, sex, hiking, rowing, writing, painting or just tumbling with your two year old on the couch. Watching these videos I suddenly remembered the feeling of deep play.

There’s a poem I love by Yehuda Amichai called “Forgetting someome:”

Forgetting someone is like
forgetting to turn off the light in the back yard
so it stays lit all the next day.

But then it’s the light
that makes you remember.

That’s how is was in that moment with deep play: I remembered it thus realized I had forgotten it thus remembered it. And I missed it.  A lot.

Also, I have to admit that I have a sudden crush on Jimmy Fallon for the past hour or so. He can really wear a tie. And I’ve always been a sucker for falsetto. I’m so tired right now that I can’t feel my feet. I didn’t get to lie down at all last night. I haven’t slept in 33.5 hours and I had to use my fingers to calculate that just now.

I’m trying to figure out how much of my upcoming staycation to protect from the tentacles of work. There’s a research project I’m woefully behind on. There are several project in my residency program that I want to get cracking on. There is oil to be changed and the house to get cleaned. But maybe I need to just clear my schedule for some Jimmy-Fallon-with-the-preschool-toys-music-making-time. For some adventuring, or as much adventuring as can be accomplished between daycare drop-off and pick-up, or the kind of adventuring that only a curious toddler can make possible. Maybe it’s playtime. Is that even allowed? But why should only beautiful people and rich people and people without student loans get to play? Don’t we all deserve to play?

Meanwhile it’s 2:47pm and I have 45 minutes to sleep before going to pick up my little joy machine. It’s going to be sweet, all of it. Playtime.

Here a funny thing that happens when your child turns two. You are supposed to have another child. Like, right away. Suddenly all anyone wants to talk to you about is when you will be having another child. Not if. When. Your lack of a second child is almost a source of anxiety for people, like a dissonant chord that has been allowed to linger without resolution.

For example, a few weeks ago I was in my hunkered down work mode (aka lightening fast typing fingers, wry jokes, case management to-do lists) when one of the house physicians on my current service came to sign me out (cue chorus of divine angels). Let me preface this by saying that I had only known this person for maybe three or four days at this point. And by the way she is very lovely and I don’t mean to single her out here because what follows is a conversation that has played itself out in one form or another with everyone from total strangers to my closest friends. So anyway, a few minutes into sign-out I mentioned my daughter off hand and she asked, “Oh how old is your child?” and I said “She’s two” and she said “Oh, when are you going to have another child?” and I said “Oh, we’ve been thinking a lot about it and we are pretty happy as a three-person family” (note here how suddenly intimate the conversation has become, because any honest answer about procreative plans is not really small talk anymore). At this point she looked a bit shocked and dismayed, “Oh, but your daughter is going to be so lonely!” to which I just said again, rather more weakly, “Oh, we are pretty happy” and she gave me another look akin to the look you might give a woman leaning over to give her toddler a big sip of her Manhattan. A look that says: “Your parental judgment is seriously impaired.”

I have this kind of conversation at least once a week these days, with grocery store cashiers, neighbors, fellow parents at daycare.  Some people react as my colleague did, invoking my parental duty to provide E with a sibling. People have even used the word “abuse” in reference to only childhood which I guess makes me the potential abuser? Which is a disturbing thing to imply over a pile of avocados at the Trader Joe’s. Other people smile and say “Oh just you wait. You’ll want another one.” Which always makes me think of that old ad for potato chips: “Betcha can’t eat just one!” As if you might pad downstairs to satisfy a midnight salty-food craving and end up + 1. Some people talk about how two kids isn’t twice as hard as one kid, it’s only 1.5 times as hard, as if I’m not having another child because I’m afraid of hard work, to which I want to say a) my child is a pure delight to me so why wouldn’t I want to multiply that by two? and also b) I just worked for 30 hours in a row. Again! What absolutely no one has said when they find out I am planning on stopping at one is: “Awesome!” or “Cool!” or even “Tell me more about that.”

The fact is that I always planned on having two children. I have vivid memories of lying in bed as a five or six year old imagining the one boy and one girl child I would one day have. When we settled on E’s name towards the end of my pregnancy, I made a secret list of sibling names for boys and girls. Even during E’s first year I saved every piece of clothing for the second child. But now that E is two and more verbal every day and she can both ask and answer the question “What are you thinking about?” I’m just so excited to keep moving forward with her. I don’t want to start all over again. I want to travel with E and take her to concerts and gardens and plays and support her in every curiosity. I want her life to be full of every vividness that money and time and energy can provide. I don’t want to divide up those resources, even though I know it’s possible to do so well.

At the same time, I am beginning to realize that I need to be able to write in order to live well inside my own life, which for me means blocks of quiet daylight hours and also some time for reading and maybe even an occasional week far away from the quotidian in a new environment by myself. Which has to be on top of full time work if we are to eat and be clothed and pay off our student loans, the mortgages we have taken out on ourselves. All of which is also true for my partner. Right now, the financials kind of work out, the logistics kind of work out, and we are all of us kind of getting the things we need (except sleep and retirement savings but that’s for a later time, right?) I don’t want to tempt the gods by saying it out loud, but there’s enough joy in our household to balance out the stress, even during residency. While one of us does the dishes, the other of us has a dance party or does alphabet puzzles in the living room with E. Then we switch and one of us does bathtime while the other catches up on work email. Adding another person to the  mix seems like asking too much of ourseves and the universe. Then there’s the matter of my destroyed post-pregnancy sacroilliac joint and the pain of every step for the last two years and the possibility of that getting even worse….. It just gives a person pause.

I am sad for E that she might not have the potentially good experiene of having a sibling but I think it is important to acknowledge that when it comes to that experience there are no guarantees. I know people with siblings for whom their sibling relationship is one of the core narrratives of their lives and people who haven’t spoken to their siblings in twenty years. I know people who have great relationships with their siblings, neutral relationships with their siblings, and some sad examples of horribly acrimonious and damaging sibling relationships. People often invoke the importance of siblings in the care of elderly parents and yet I know many people with siblings who have still shouldered the lion’s share of the care of their aging parents, whether due to geography, preference, or family politics. Having a sibling is no guarantee of fellowship in life’s struggles and the absence of a sibling does not preclude experiences of intense mutual commitment and support with spouses, friends, and other relatives.

But I didn’t set out here to defend my decision (that is not even really a final decision yet. Check back in five years for the final child tally!). What I wanted to convey is that we should not need to defend the choices we make about how our families are structured.

When I heard on NPR that someone had written a book on being and having an only child, I literally pulled my car over to the side of the road to look it up. I didn’t realize until that moment how isolated I felt. Even with all the diapproving looks and talk of lifelong loneliness, I don’t think I had ever fully identified the stigma associated with having an only child. The book is called “One and Only: Why Having an Only Child, and Being One, Is Better Than You Think” by Lauren Sandler and it seeks to present both a scientific argument and series of personal anecdotes that argue for the benefits of being and having an only child. While I was grateful for the author’s meticulous and thought-provoking research and her articulations of some of the joys of parenting an only child (like the smallest things: being able to call your child your favorite smoos in the whole wide world), I found myself thinking: why do we have to prove that having an only child is better or even as good as having more than one child? Do we need society’s permission NOT to grow another human being in our uteri? Which, of course, is an old can of worms…..

A few nights ago E was sitting on C’s lap and watching Schoolhouse Rock. I was sitting on the bed folding laundry when the following clip came on:

My eyes actually filled with tears. “It’s our song!” I kept saying to my two loves. Which is funny because it’s all about a man and a woman having a baby and that’s not our story at all. But it captures something that is special about our family. It takes all three of us to hold the table up! It feels good to say what I’m about to say: I am so proud of my family.

Three is not everyone’s magic number. Some people are happiest in a family of one. Some parents are raising various numbers of children alone or with people who don’t live with them. Some people can’t imagine being happy unless their family is big enough to fill the pew at church (shout out to my friend KP whose family I very much admire and enjoy following through the years on facebook!). Two adults and two kids is working for a lot of folks. Unto each and every one of these: a blessing!

I guess what I’m saying is: Next time you are tempted to ask someone if or when they are planning on having another kid (or when they are planning on marrying their boyfriend or whether they are dating someone, for that matter), maybe instead ask them: What’s your magic number? Or better yet, what’s awesome about your kid or kids or spouse or life? Have you read any amazing books lately? What is the thing you are most looking forward to today? Can you imagine the conversations we could be having with one another?

What’s your magic number?

I am post-call, so this post will be post-call, angular, unedited or strangely so. Like the jokes you make post-call, this post may be just a little too sloppy, a little too specific, a little too true.

The worst part of call is the anticipation of call. The night before, everything feels extreme and over-precious. I have to read just one more book to E because I won’t see her again for almost FORTY-EIGHT WHOLE HOURS. I stroke her hair. I snuggle her little body close. “I have to remember her smell,” I think to myself, as if I am being deported to interstellar space on a mission of national importance with no return ticket. Later, instead of sleeping, which is the only rational way to prepare, I decide to stay up with C watching a movie, because I deserve it in advance. Or I waste a precious hour of sleep reading about the 27 most important things your grandparents would want you to know on buzzfeed. On some level, it feels like if I don’t go to sleep, call won’t come.

The vibrations of my phone alarm signal the worst hour of the whole enterprise. I lie in bed and worry. What if E doesn’t wake up from her sleep? What if the brief migraines I have been having turn out to be a massive AVM and I bleed into it and die before I see C and E again? I’m too tired to do it. I just can’t do it, I think to myself. I just can’t do it again. I don’t have it in me. I wish for death. Not really. But sort of. Or maybe just a permanent disability. Then I get up and stumble through the dark like a blind person getting ready as my most loved ones sigh and shift in their sleep. I only own five pairs of scrubs and have spent more than 5000 hours in them since medical school. In my scrubs I am neither fat nor thin, short nor tall, beautiful nor ugly, girl nor boy. I am just a person who is capable of continuing to function no matter what. The drive to work in the shuttered, sleeping world is ethereal. On the radio, BBC world is telling me about Italian tire factories or sex workers in Malaysia and I am balancing my open container of yogurt between my thighs and trying to avoid black ice. I pray to nobody and everybody: Please don’t let me make a mistake and hurt someone.

Here’s what I love about my job: The faces of children, marked by whatever emotion they are inhabiting in the moment. I love the moment when, despite the chronic exhaustion, despite the parent’s fear and frustration, despite the child’s innate distrust of strangers, you make a connection. You make them laugh, or you acknowledge their fear, and something in the room shifts. You answer a scary question and it is less scary. The kid who is initially clawing at their mother and crying ends up holding the stethoscope against their own chest and they look up at you with curiosity as you hear the familiar acoustics of a beating heart.

Once I step into the workroom to get signout on my patients, the worst part of call — the resistance to call — is over. Now the only way through is through. My co-resident confided to me that he writes the hours 1 – 30 out on a piece of paper and X’s off each hour as it passes. The inevitability of time’s motion will carry you through. As I assemble the little idiosyncratic bundle of checklists and signouts that will be my point of orientation for the next 30 hours, I feel like I imagine any athlete might before the jump, before the climb, before the big game. I’ve done this before, I remember. I can do it again.

What is a more effective method of teaching and learning: Meticulous apprenticeship or trial by fire? Nurses at the hospital where I work are oriented for weeks, even months, to a particular floor before they are allowed to work independently. They work alongside an experienced nurse, first watching them, then being observed and critiqued by them. They are taught exactly what to do. As a resident I switch to a new floor every month — which usually means a new organ system or set of diseases — and am lucky if someone tells me where the staff fridge is. Maybe there is a handout or binder with information on the most common order sets for that floor or the phone numbers of the case manager and social worker. But as far as decision-making goes, it’s luck and guts and humility and intuition and misses and near misses. There are always people you can reach out to for advice, but you have to know what you don’t know.

Yesterday I arrived on the Cardiology floor for the first time ever at 6am and twelve hours later I was the one fielding all the floor calls from nurses who in some cases have been taking care of cardiac patients for 10-15 years. “Can we give the anti-rejection meds for this heart transplant patient late? They’re down at radiology.” Um, sure? Or no? “Is 2000mg of magnesium too much for a patient with heart failure?” (Me making a thinking sound as I madly look up magnesium dosing in the hospital formulary.) “Baby P with the BT shunt looks a little blue and his sats are down. Can you come take a look?” You better fucking believe I’ll come take a look. I will be running there. All I know about BT shunts is what was in the handout I was given just this morning: “BT shunts carry 15% mortality. They can clot off anytime. If anyone is concerned about a patient with a BT shunt, assess them right away.” The last resident on this rotation told me that he was paged about a BT shunt patient who was vomiting and before he could slip on his shoes the child went into bradycardic arrest. As I am staring down at the patient’s tiny blue hands, I am grateful for each of the thousands of hours I have spent assessing patients and watching other people assess patients. At least I know where to begin. Mental status, perfusion, vitals, physical exam. All the hard-won habits.

When I am called to a bedside to assess a sick child, I try to assemble as many other people around me as possible — the parents, the nurse, a respiratory therapist.  Anyone with eyes and, preferably, more experience than me. I listen, I try to make a good decision, I elicit feedback on my decisions. As more time passes and I get a little better at this job, I am more confident about what I know and more confident in admitting what I don’t know and asking for help. During a 30 hour call, one thought dominates: What could I be missing?

For me, all calls contain the following elements:

1) The click: Sometimes only once, sometimes more than once, you make a decision, you have a good conversation with a family, you get in the groove with a nurse, you help a patient get better and you think: I nailed that one. Maybe I am, in fact, learning something. This moment is usually followed by:

2) The total fail: No matter how many times you make your list and check it twice, you will inevitably miss something — you didn’t look in the ears?! you didn’t order a lipase?! or bigger, scarier things like forgetting to get antibiotics approved. Often this mistake will become the disproportionate focus of the team on rounds. I have learned to embrace the total fail. It’s like the imperfection in the Persian rug through which God is allowed to enter. I am imperfect!, I want to shout into the whirring fluorescent hospital lights, I am broken and divine! (Actually, I obsess endlessly over these mistakes whether small or large and have great difficulty forgiving myself.)

Corollaries to the click and the total fail are:

3) The tiny point of light: The attending turns to you and asks a question like, “What was the last bicarb on the previous admission?” And from somewhere in the recesses of your exhausted, addled, overstuffed mind, the right answer pops out: 16! The human brain is a miraculous thing. Everyone seems impressed even though they are all also using the electronic medical record via which this piece of information is readily available. There there’s:

4) The endless sea of ridiculously specific questions you don’t know the answer to: “What dose of metoprolol was this patient on in 2012?” “Was the pancreatic duct visualized on the CT scan three years ago?” “Do you know if this patient has ever seen a dermatologist?” Um, no idea, don’t know, and no. This was my sixth admission last night and I’m not a soothsayer.

And no call would be complete without:

5) An assortment of bizarre physical sensations: A hand momentarily goes numb. I am awoken from the abyss of sleep by my pager and I jerk out of bed, convinced that I am lying in a pool of water. I catch a glimpse of one of my own hairs out of the corner of my eye and am momentarily convinced that there is a squirrel running up the wall. The exhausted human mind is a den of snakes. And:

6) An interpersonal glitch: On every call someone will do something so strangely anti-social, so rude, or so galling that you have to sit back and marvel. It might be a nurse, a fellow resident, and attending, a patient or a patient’s parent, or (most likely) a subspecialist consultant whom you are forced to call overnight. The other night I had to call the dermatologist on call (key words being “on call”) and he said, “Um, I’m trying to sleep.” Ha! Sorry, buddy, we’re all here in the hospital trying to take care of sick people! Everyone who is working overnight is at least a little tried and stressed out. It’s a cauldron of bad behavior. Then again, people are also the kindest to each other during these moments. It can go one of two ways. When you encounter people who are kind to you in spite of an annoying request you are forced to make of them, you remember that forever. Similarly, when someone lets slip a racist comment or yells at you over the phone, you remember that forever too. The stress of call has a searing effect on memory (though not the kind of memory that helps you memorize the nuances of pathophysiology).

Call time is a vortex. Admitting a patient at 2am, you have to keep asking them, “Do you mean yesterday, like the yesterday that just happened or the yesterday before yesterday?” The cafeteria closes at 7:30pm and you can almost never make it there even if you start trying to get there at 4:30. You can complete a five page note in ten minutes and then it can take you 45 minutes to figure out what the right home dose of a seizure medication is. One minute it’s 5pm, then next its 2am and you still haven’t finished your admission notes from the daytime. I am getting off the elevator on my way out of work and a woman gets on the elevator with two pieces of pizza and a Diet Coke. “Ew,” I think to myself, “who eats sausage pizza for breakfast?” Then I remember that it is actually noon. Since I started work, that woman had gotten up, eaten breakfast, come to work, eaten lunch, worked some more, went home, ate dinner, slept all night, gotten up, eaten breakfast, come to work, worked all morning, and gotten her lunch. No matter how you cut it, it’s just crazy. As the hospital doors slide open, my eyes sting with the light and the cold and the wind.

The end of call should be the best part, but for me the best part is when the first of my colleagues arrives for signout in the morning. A blessing on the head of each of my co-residents who, moored to their own undulating schedule of exhaustion and relief, has rescued me from the solitary crucible of call. It’s so nice to be able to run a decision by someone, to laugh about that crazy thing that mom said, to hand a patient back to the clinician who knows them best, hopefully none the worse for their time in your care. It is a tradition that the on call person brings the post-call person breakfast and no eggs are ever sweeter than those eggs. The only thing worse than call would be having to take it all alone.

And then it all begins again. Driving home, I have to put the car in park at each stop light because I am nodding off. My body feels too light and too heavy at the same time. This afternoon, I will sleep without any awareness of time and space, then the ecstatic reunion. “Mommy!!!” E will shout and then run in the opposite direction because that’s her way of saying hello. There will be cuddling. There will be cookies. I will not demand anything of myself nor will I make healthy food choices. I will rest because I will be capable of almost nothing else. The post-call flop-out doesn’t cancel out the exhaustion and stress but it does help.

One thing I have learned from residency is that it is hard to kill a human. The patients I am taking care of these days have one, two, even more holes and misdirected parts in their hearts. They undergo surgery after surgery, unattaching and reattaching their vessels too many times, and yet still, the blood finds its path through the madmade maze. Life is amazingly committed to its own continuation. The same, I think, can be said of people’s souls. People are remarkably resilient! They find a way, in spite of everything, to survive.