Medicine like a Storm

As I was taking the train to my first interview for residency, crossing my fingers that it would keep going to my destination and not be thwarted by wind or rain, I was running through my Plan B, Plan C, and even Plan D for every part of this travel adventure, and realized that practicing good medicine is a lot like travelling in a storm.

First, collect the right data from diverse sources with different perspectives.  Patient history, journal articles, residency training, nursing notes, etc.  Or in a storm, weather reports, news stories, calling friends and family in the area.

Second, create a plan.  Every step - know how it's going to work, know the tools you need and how you will get them.

Third, create a Plan B, a Plan C, and a Plan D - at least one of these should include asking for help.

Fourth, think about any particularly difficult steps where things are more likely to deviate from the plan - try to predict how they would go wrong, and create a plan for those.

Fifth - and possibly most important - communicate your plan.  Keep your team in the loop as the plan changes, ask for feedback on the plan, take into consideration new information provided by the team, and whatever you do, continue to let everyone know what's going on so they can adapt accordingly.

Sixth, stay calm and adapt easily, as you know you have prepared as much as possible.


I was also feeling very grateful in my interview travels for just how much I am cared for by the people I love.  Even with all the craziness of travelling, that is a wonderful feeling.

~~~~~~~~~~~~~~~

"Sometimes God calms the storm.  Sometimes He calms the sailor"

- Unknown

Tuesday Poetry: all here

This week a poem by my new favorite poet, David Whyte, who is just fantastic.

His writing is beautiful, thought-provoking, and speaks to my soul.

(he also writes and speaks in at least four different languages).

Hearing him speak is on my DREAM BIG list.

~~~~~~~

IN THE BEGINNING

Sometimes simplicity rises

like a blossom of fire

from the white silk of your own skin.

You were there in the beginning

you heard the story, you heard the merciless

and tender words telling you where you had to go.

Exile is never easy and the journey 

itself leaves a bitter taste. But then,

when you heard that voice, you had to go.

You couldn't stay by the fire, you couldn't live

so close to the live flame of that compassion

you had to go out in the world and make it your own

so that you could come back with 

that flame in your voice, saying listen....

this warmth, this unbearable light, this fearful love...

It is all here, it is all here.

Choosing What We Show

Recently, I interacted with a woman around my age who had come to the clinic where I was working with the intention of terminating her pregnancy.  It's been so long I can't remember how many weeks along she was, but not far.  Women enter these difficult and emotionally wrought visits with a clinician in all styles.  Some openly weep, some list all the reasons why this is the right decision - as if convincing themselves, some are silent and refuse to make eye contact, many are curious - about the pregnancy, about their options, about what they might see or not see, how their lives may be different depending on how they choose.

I feel so lucky to live in a country, in a time, when women get to make these decisions - though saddened that their decisions were not instead the less emotionally draining one of choosing effective birth control or choosing not to have sex in the first place.  I feel even more lucky to have worked in a clinic that allowed women the space to feel, think, and process whatever they needed.

This woman, let's call her Sarah* (*obviously not her real name), knew she was pregnant but was not sure how many weeks - so we did an abdominal (on the belly) ultrasound to take measurements to date her pregnancy.  There has been a good deal research on interactions with ultrasound technicians by women considering termination and the data is surprising.  But first, because ultrasound is a tricky subject these days, let me set the facts straight: everyone who is seeking or considering a termination usually has an ultrasound to date the pregnancy, because this determines many things about the possible procedures and counseling.  In the vast majority of cases, this ultrasound is done abdominally (on the belly) and is only done transvaginally (in the vagina) if the pregnancy is too early, and therefore the uterus too low in the pelvis and too small to see through the abdomen.  There are some people trying to pass laws about ultrasound and pregnancy termination that require very different things, including transvaginal ultrasounds, narration of ultrasounds, listening to heart beats, seeing moving images, etc.  This has not been my experience.  

In research investigating how to interact with a woman considering termination when conducting an abdominal (on the belly) ultrasound, the results are surprising in that many women are interested in seeing the image, many would even like an image printed to take home.  Even more fascinating is that there does not seem to be a pattern with the choices women make (in terms of keeping the pregnancy or terminating the pregnancy).  Additionally, when ultrasonographers (the people who do the ultrasounds) and clinicians are interviewed, they largely believe that women should not see the ultrasound if they are considering or have decided to terminate a pregnancy.  There are still many questions to be answered - including if the age of gestation matters (many of these papers were only involving women who were intending to have first trimester terminations), larger sample sizes, longer term effects, correlation with other factors such as parity and reasons for termination.

Planned Parenthood has a national policy where every woman is asked, before stepping into the ultrasound room, if she would like to know if she has more than one pregnancy (twins, triplets, etc), and if she would like to see any images.  Anecdotally, I have been told that most other clinics don't ask and do not offer unless the woman asks explicitly to see a picture.  

As I have had more experience with this, and after hearing an amazing presentation on some soon to be published data on women's experiences of ultrasound before a termination, I decided that I am going to ask women if there is anything they would like to see or not see, know or not know.  And I have been fascinated by the results.  

Which brings me back - finally - to Sarah*.  Sarah was very quiet when I brought her to the ultrsound room.  I had already asked Sarah the same question I ask everyone and she had said she would like to see an image.  Again, based on experience, the teaching I have received, and the data I have seen, whenever I show anyone an image, I zoom out so that there's slightly more realistic perspective of the size of the pregnancy, and I point out the abdominal wall, the uterus, and the pregnancy, as well as any other obvious structures.  When I did this for Sarah, she started crying.  In my desire to comfort her, I quickly turned the ultrasound away from her and sat in a chair next to her.  I asked her what was going on her in head at that moment, and if there was anything I could help with.  When she shook her head No, I put my hand on her back and reminded her that the next step at our clinic is to talk in depth with a counselor.  I asked her if she wanted to see any other images, and when she said No, I walked with her to the counselor's office, where the three of us sat and talked for a long time.

To be continued in the next post, as it takes this thought in a slightly different direction.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"I pointed out that she was, by definition, pro-choice.  In its simplest form all it means is that the woman gets to decide".

-Susan Wicklund, Physician and Author of This Common Secret

(click the link to see a NYT review of her book)

Poetry Tuesday: a poem for travels

I have been feeling a need for more poetry in my life.  I'm not sure if that's because this month has brought me to a lot of profound philosophical thoughts, or if its the seasons changing, or my traveling as a nomad again.  But I am going to start, for now, a poem every Tuesday, followed by a question or two that the poem brings up for me.

For my first Poetry Tuesday, I wanted to start with a poem by Pablo Neruda that has resonated with me in my travels lately (though they certainly have not been to uncharted lands).
He has a way.

What stubborn lands have you traveled in lately?  
What questions do you wish you had been asked?

~~~~~~~~~~~~~

Another

From so often traveling in a region

not charted in books

I grew accustomed to stubborn lands

where nobody ever asked me

whether I like lettuces

or if I prefer mint

like the elephants devour

and from offering no answers

I have a yellow heart

Otro

De tanto andar una region

que no figuraba en los libros

me acostumbre a las tierras tercas

en que nadie me preguntaba

si me gustaban las lechugas

o si preferia la menta

que devoran los elephantes

y de tanto no responder

tengo el corazon amarillo

Picking A Watermelon

this past summer, I went to a fruit stand with the most amazing peaches I had ever seen (see below) and the best watermelon sign possibly known to humankind.

"picking out a watermelon is like pick'n out a wife...

you can look at it...thump it...turn it around...and squeeze it.

but you never know much about it until it is TOO LATE."

whahahahahaha.  the owner of the fruit stand was this older man 

he saw me taking a photo of the sign and kinda giggled.

:)

Biking Partners

Two very good friends just got married this past summer

- and for their honeymoon (and maybe the rest of their lives) they will be biking all over.  

so when thinking about what to get them, 

the manfriend and I decided to create team jerseys:

(these pictures are delayed - we got them to them in time for the honeymoon)

aren't they the cutest?

"sometimes in the middle of an ordinary life, the universe gives us a fairy tale"

- unknown

Newport Photo Shoot

It was a stormy afternoon, but just as Pachebel's canon started and our friend walked down the aisle, the clouds cleared making way for blue sky and the best camera lighting we've seen in a while

(these photos are from my phone!)

October

October's Bright Blue Weather

by Helen Hunt Jackson (1830-1885)

O SUNS and skies and clouds of June,

And flowers of June together,

Ye cannot rival for one hour

October's bright blue weather;

When loud the bumble-bee makes haste,

Belated, thriftless vagrant,

And Golden-Rod is dying fast,

And lanes with grapes are fragrant;

When Gentians roll their fringes tight

To save them for the morning,

And chestnuts fall from satin burrs

Without a sound of warning;

When on the ground red apples lie

In piles like jewels shining,

And redder still on old stone walls

Are leaves of woodbine twining;

When all the lovely wayside things

Their white-winged seeds are sowing,

And in the fields, still green and fair,

Late aftermaths are growing;

When springs run low, and on the brooks,

In idle golden freighting,

Bright leaves sink noiseless in the hush

Of woods, for winter waiting;

When comrades seek sweet country haunts,

By twos and twos together,

And count like misers, hour by hour,

October's bright blue weather.

O suns and skies and flowers of June,

Count all your boasts together,

Love loveth best of all the year

October's bright blue weather.