End of an era

I feel a huge sense of relief and a ton of positivity this week. Where do I even start?

Obviously there was the inauguration. I have never been a political junkie. My parents came from a country where there was a military coup during their lifetime, all books with dissenting political ideas were burned at their universities, and friends and acquaintances were taken from their homes in the middle of the night and murdered for having dissenting political opinions. Because of these reasons, my parents were always largely apolitical. We never put out yard signs, protested as a family, or watched States of the Union, inaugurations, etc. I myself have adopted some of this trepidation around openly expressing political opinions – especially in my role as doctor. We are so divided as a country that it seems so loaded to me to bring up politics or, more commonly, to respond to a patient’s comment on politics. But lately, due largely to the impact of social media, I have begun to wonder how much of my reticence to discuss politics comes from a place of privilege. I’m an immigrant who has been a citizen of this country for decades longer than I’ve lived outside of the country. I’m White passing, gender normative, heterosexual, educated, financially comfortable. So I have been trying to step outside of my comfort zone to be more vocal in order to advocate for others. And also, to be honest, because the events of the past four years have been disturbing beyond words – so, so, so much worse than anything I could have ever envisioned in November of 2016.

But now, there is hope. And yesterday, I sat with my two older kids and replayed some of the performances and speeches from the inauguration. The kids celebrated it at school. And I breathed a sigh of relief that my older children, now 4 and 6, would have memories of a President who is decent, humble, honorable and a good human being.

Second: this is my last week before heading back to work. I have a lot of mixed emotions regarding this. I think: this is the last time I will ever have an infant. The last time I will ever hold someone for every nap during the day. The last time I will ever spend so many hours per day, every day, every week, with one of my children. I feel a sense of nostalgia about this moment, but not necessarily sadness. As my husband likes to joke, we have done this four times – and that’s plenty! I am also looking forward to this next phase of my children growing into adults. I already see changes in my 6 year old – bigger worries, harder questions, the ability to read and digest actual novels (he is currently reading the second Harry Potter book). He is losing some of his child-like innocence.

To be honest, being home with four children 6 and under is a lot. As I always say: being a stay-at-home parent is MUCH harder than being a working parent. Yes, work is demanding. Yes, it adds a full-time job on top of full-time responsibility. But work allows you to tap into the essence of who you are. A lot is lost in motherhood – hobbies, memories of who we were pre-children, meaning outside of these small humans. For me, working is a way to hold onto a crucial component of who I am. I’m able to have adult conversations, use my analytical mind, help others in ways that are tangible, eat lunch, go to the bathroom alone, have uninterrupted thoughts, etc. I’m very much looking forward to that. But, in addition to missing the baby snuggles and extra quality time with my kids, there are two things I will miss dearly: (1) flexibility – the ability to make every last-minute school engagement without thinking about it, the ability to attend to a child’s needs 24/7 with no other obligations, the ability to run an errand for the home every day of the week, the ability to pick the kids up when they are not feeling well without having to cancel clinic, the ability to quarantine for 2 weeks without being disruptive and (2) mental space. I have been thinking about this one a lot. For a variety of reasons, I was feeling pretty burnt out before going on maternity leave. Not working has off-loaded work stress from my life (that sounds pretty obvious but it’s true!). I don’t have to worry about having a difficult conversation with a colleague, feeling disrespected by administrators, challenging patient cases. It’s hard for me to leave work at work – to compartmentalize it – especially when I have the ability to be connected 24/7 and also when I do split my workday to make time for pick-up, kids’ activities, etc. I see sick patients and I worry about how they do, and it is impossible for me to turn that off at 5pm. So I am going to see how to compartmentalize the things that I can – non-clinical work – while also feeling relieved that I have dissociated from the more toxic work environment I was previously in.

Third: I received the second COVID vaccine. I am so so relieved by this. I will, of course, continue to use PPE at work and masks when out in public, but I feel so much better knowing that I will be somewhat protected against COVID, especially when seeing positive patients or those who are being evaluated for active disease. My parents have both received one dose of their respective vaccines (they work in healthcare) and my brother and parents-in-law recently recovered from COVID, so I am hoping this all means that we can have some sort of reunion later this year.

Finally, I have restarted on of my favorite past times: reading. I am on my fifth novel this month and have been working to actively carve out time to read each day. Of course, this will be somewhat compromised when I start working, but I am hoping to keep at least 50% of this reading productivity. Reading brings back such great memories for me of reading during childhood and I think it’s so important for the kids to see me reading as well. It has also provided some much needed escapism during a year that has afforded such few opportunities for activities that remind us of normalcy.

Here’s to the end of one era and the beginning of an even better one.

Vaccinated

I received my COVID-19 vaccine today. The Pfizer one was offered to me and I took it. I feel a bit like I did after Election Day this year – ready for a big sigh of relief.

I still remember how we stumbled around COVID in the early days of the pandemic at my hospital. We weren’t quite sure what the precautions should be. When my first patient showed up, having just flown in from China, I went into the room alone, wearing an N95 mask and gown. But we still didn’t wear masks or eye protection in the workrooms and all other patient encounters were routine protocol. I remember the first time a COVID test was run on a patient I had seen on the inpatient service. My colleague called her daughter’s school and they asked her to pick her up. I was so worried that I had been exposed and would be exposing my whole family. Fortunately, that patient tested negative. I remember clinics shutting down completely and being converted to video. A few patients still wished to be seen in person and I would go in to see them. I brought my own Lysol wipes from home and wore scrubs every day. Hair up, N95 on, surgical mask over the N95, face shield in place. I would avoid my children when I arrived home and jump straight into the shower. I was so worried that I would contract COVID while pregnant – so worried that I stopped seeing patients at 34 weeks and took a full month of prepartum leave. At the time, all of these precautions seemed temporary and we thought we’d be up and running full throttle by the summer. And yet, here we are 9 months later.

One disclaimer here is that I am primarily an outpatient physician. I see oncology patients and do round regularly in the hospital on our consult patients, but I am not on the front line (emergency room, ICU, COVID units, etc.). I am in complete awe of the physicians, nurses and hospital staff who have been on the front line this entire time. I do not have it in me to do what they did. My patient population is primarily healthy, but there was still so much fear around pre-symptomatic patients coming to clinic, colleagues coming to work before diagnosis, etc.

All this to say that getting this vaccine was a big deal for me. It was a sign of hope – hopefully the beginning of the end. Although I plan to wear PPE the entire time I am at work, I feel reassured that I am less likely to contract COVID if I am exposed. Although we don’t have the data, I am also hoping that this means I am less likely to transmit COVID if exposed (again, this wasn’t studied, so we won’t know for some time). I am still nursing but decided that the risks to my infant of getting COVID were greater than any theoretical risks related to vaccine administration. I hope that by the time the general public has the opportunity to be vaccinated, we have more information to power the decision-making process. I am not the type of person who jumps on the bandwagon for new therapeutics, but as I always tell my patients who are interested in a new therapy or intervention – you have to weigh the risks against the alternative, not the ideal. Do I wish that we were not in the middle of a pandemic that has kept us away from our families for the past 9 months, kept my kids out of school for much of the year, led us all to wear masks and stay 6 feet apart and completely crippled our social interactions? Of course. But the fact of the matter is that we are in the middle of a pandemic and I will be working through it. It made sense to me to add a layer of protection by receiving the vaccine. And hopefully this truly is the beginning of the end and we can start moving towards relative normalcy sometime in 2021.

Merry

Yesterday, I asked my husband what was on his agenda for work and he responded that it was a “thinking day”. A day to reflect on strategy, innovation, next steps. To be honest, it sounded glorious. A whole day to just think about something unrelated to the home.

Right now, I am enjoying a bit of quiet, thinking time. My oldest three children are with our nanny and my youngest is taking a nap with me, in the carrier. I have decided to return to work next month and am feeling incredibly conflicted about that. On one hand, I really miss working (I’m a physician). I miss my patients, I miss my colleagues, I miss teaching, I miss having adult conversations and I miss being able to THINK – about diagnoses, patient messages, treatment options, research, etc. On the other hand, the flexibility of my maternity leave has been a godsend – especially during this incredibly tumultuous year. In the morning, I don’t have to wake up before the children do to get ready for work. I can let them wake me up, sit with them while I drink my cup of coffee, stay in my pajamas and play. With school closed during this holiday break, we have even less obligations since I am not rushing to get the kids out the door in the morning. This flexibility allows me to be available at the drop of a hat when the school calls because someone is sick and needs to be picked up. If we didn’t get to errands on the weekends, I can run them any day of the week. I can take the kids to appointments whenever they need to go. Honestly, the flexibility is what I will miss the most. Even though my schedule is incredibly forgiving for full-time work, it is still a schedule. It is not easy for me to cancel a full day of patients because I hate letting my patients down (especially when they may have waited months for an appointment) and I hate creating more work for my colleagues and administrative staff.

I have really cherished the time I’ve been able to spend at home with my children this year. 2020 has been an incredibly unpredictable year and, at times, incredibly challenging. But I feel so fortunate to have had this time, and I will hold on to these memories as I transition back to work in the new year. One lesson I’ve learned is that quality is much better than quantity. When I have been home all day with the children, it is impossible to have fun activities planned all day long and to engage with them fully at every moment (especially when there is cleaning to be done, food to be cooked, etc). I feel confident that I can still incorporate a significant amount of quality time with each child when I return to work.

So I will spend these next few weeks cherishing each additional unburdened minute with them and reflecting on how to incorporate more of that time into a busier future. And I will also be looking forward to returning to a sense of normalcy – for myself – through my career.

Phase two

My husband is back at work this week. It feels like the end of a chapter – 3 months in, past the harried days and nights of the newborn stage. For weeks, my husband and I took turns holding the baby days and (some) nights while the other tried to “get things done”. Usually things were a shower, cooking a meal, tidying something up. In the mornings, we tag teamed to get the older kids dressed and set up for virtual school or out-the-door for in-person school. He held the baby in the car when I had an appointment. I held the baby in the car while he went into the store to get groceries. We ate lunch together (and if we got take-out, this was also eaten in the car because of COVID). One of us would stay home while the other drove to pick up the older kids. When we were less sleep-deprived, we checked off some items from our to-do list. We also watched movies, TV shoes and read books. We took walks around the neighborhood. I feel very fortunate that he was able to take 3 months off this time. We talked during the day about our kids – adult conversations, something we can’t do when 4 kids are in the house. This hasn’t been the case after every baby’s birth, and I can tell you that the toughest postpartum period for our marriage was when our third was born. He kept working because the baby arrived 2 weeks early and he had some things to wrap up at work. Then, because we had family help, he decided to save his leave for when I returned to work. But it was hard. As the only person who could help me overnight, he would stay up and then be tired for work. I leaned on him to help around the house as well and this was an added responsibility for him. In sum, I am grateful for this time we had together, and also feel a bit sad that we are closing the chapter on our newborn days. But, as my husband would say, “we’ve done it 4 times. I think that’s plenty!” And he is certainly right about that.

So this week, I am adjusting to our new normal. He’s working from home and I’m in charge of getting the kids ready in the morning, driving them to school, tidying up, planning meals and spending time with our littlest one during the day. I, again, feel incredibly fortunate to have this extra time with my baby. I also have to admit that this is the hardest part of maternity leave for me, because I do think there is an imbalance in our marriage when my husband works and I do not. It is especially exacerbated during COVID since I have no alternative social outlet at the moment. I take great pride in my career. I love working with and helping my patients. I respect the trust they have in me and think about them when I’m not at work. I also have amazing colleagues and feel so indebted to them for keeping me safe during my pregnancy and covering my patients while I am out.

As I start planning for my own return, I am having a hard time deciding what to do. I am worried about going back to work during the winter COVID surge, but also feel that it is my duty to do so since I have “sat out” the past few months. I am concerned about committing to a schedule since the kids’ schedule is so up in the air. There are potential quarantines if any of the children or teachers in the classes test positive, and the kids have also had to stay home for a myriad of “symptoms”. Once, my 4 y/o had a temperature of 99 and “was not acting like himself”. Another time, my 6 y/o thought he might have felt a sore throat but it was gone by the time my husband went to pick him up. He still had to come home and get a COVID test (it was negative). Yet another time we quarantined at home for 14 days because our 2 year old was exposed outdoors to someone who later tested positive for COVID. I very much appreciate how cautious the school is – so far they have had no COVID cases – but it also throws quite a wrench in any plans to work as I so hate having to cancel patient appointments. So, basically, I am now having to deal with COVID reality for working parents. I have had a reprieve during leave and it was immensely helpful during the start of this crazy school year, but now I find myself incapable of being decisive on what 2021 should look like.

For now, I am trying my best to set up some sort of schedule for my remaining days at home while mulling over the return-to-work possibilities in my mind. I am enjoying these last few weeks of snuggles because this is our last baby. Maternity leave seems like a slow uncoupling, in preparation of returning to work. First, there is the full immersion in your newborn – he is held in arms all night, worn in slings or carriers all day, nose to sweet-smelling newborn head. I am there for every minute of his day – obsessing over details like wet diapers, hours of sleep, when he last nursed and on and on. Slowly, there is a move towards (relative) independence. Trying to get him to sleep on his own at night. Working on a morning schedule – now so that he can join me on the car ride to drop off his brothers and later so that I can feed him before heading into work. Soon I will have our nanny hold him for longer stretches so that he can get used to her and her to him. We’ll try a bottle while I pump (we have never followed the “introduce a bottle early” rule with our infants. I know it’s not recommended but so far we have not had issues and it honestly just seems like more work). Maybe I’ll run an errand without him, leaving him home with my husband. And that’s how we’ll transition from spending almost 24 hours joined together to my being away during the day. Again, I am fortunate: I work full-time, but my hours aren’t terribly long. I don’t have to be separated from him at night. I have the option of doing some of my work from home. Despite this, it is clear that this next phase is bringing me closer, day-by-day, to being away from him for longer stretches of time. And even though it is a choice, it is still hard.

Gratitude

If you had asked me this time last year what 2020 would bring, I would have never predicted any of this. A global pandemic, working from home, our children out of school for months, wearing an N95 and face shield to see each and every patient, Zoom classes for a 4 and a 5 year old, walking around downtown wearing a mask, a scarcity of paper towels and hand sanitizer, not seeing our families for months…it seems surreal reading those words back, even though they are things that actually happened (and are happening) this year.

Someone shared this image with me today and it seemed so fitting to read on Thanksgiving Eve. As an adult, I recognize that this holiday is not the idyllic pilgrim/Native American bonding fest that I learned about in school. It also wasn’t a huge holiday in our home. We were immigrants, my parents disliked turkey and I was a vegetarian, so we only really started celebrating when my younger brother was in school because he found out that all of his friends were eating turkey! But through the years we have come to define this holiday on our own terms. At the very beginning of our relationship, my husband and I celebrated at his aunt’s home, a family tradition for them and my first introduction to the extended family. We would drive or take a bus to see our families. Once we moved out West, we enjoyed a number of Friendsgiving festivities, since the holiday break always seemed too short to fly out East.

This year, we will be celebrating alone as a new family of 6. We are ordering a traditional Thanksgiving meal, because the thought of cooking with four little ones running around and no one to entertain them is too much. We’ll surprise the kids with gratitude lists – a compilation of why their parents and siblings are grateful for them. We’ll watch the Macy’s Day Parade, run our own Turkey Trot (a 1 or 2 mile loop around the neighborhood) and choose toys to donate to a local school district. I feel more fortunate than ever to have created this sweet full nuclear family during this incredibly tumultuous year.

While compiling photos for our 2020 photo book, I began to see our adventures this year in a different light. So many photos of the local park, where we went for days upon days upon days, because it was close to home and had bike trails and few people – the place where our then 1 year old learned to ride his strider bike like a champ. Photos of us walking, biking and scooting around the neighborhood – devising different routes to spice things up. The countless workbooks and crafts we coordinated for the kids to do – so many pictures of them gathered around the dining room table working on one thing or another. The forts and pillow creations and countless games of “lava”. The bounce house we finally caved and bought, and how when the wildfires were raging we set it up in our living room to get the wiggles out. The summer weekends spent in an isolated area of the beach, the kids first venturing timidly to the water and then donning wetsuits and bodyboards so confidently that we had to move them to a beach that was safer for little ones to swim in. Reimagining birthdays – photos of home decor, cakes, presents. The time we celebrated the birthday of two stuffed animals in our home just to have an activity for the weekend (also learning that stuffed animals are now called “stuffies”). The boys spending most of the day half-naked in the backyard, doing all sorts of water play and venturing over to the “hot side” of the house to have their picnic lunch. A first day of school photo in front of a laptop and a white board when our oldest child’s school launched a virtual curriculum at the start of the year. So many great memories that warm my heart.

Like most hard things, the photos show only the good times. Missing from them is the fear as COVID-19 spread to our community. The uncertainty at the hospital – when do we wear masks? How do we screen patients? Will we run out of PPE? Seeing patients while pregnant, hoping I wouldn’t get sick. Coming home and showering immediately before allowing the kids to come close to me. The disappointment as we canceled trip after trip – wiping away tears when our children cried to see their grandparents. The fear of having to go to the ED postpartum and worrying about exposing my 3 day old to COVID. My oldest saying “I’m so sick of coronavirus. I’m tired of hand sanitizer and wearing masks. I wish things could go back to normal.” The weight of trying to make everything okay for your kids, when things in the world were so far from okay.

But we have been lucky. We have not gotten sick. Our parents have not gotten sick. My husband and I still have our jobs. We have not suffered financially. Two of our children are able to attend school in person. I am immensely grateful for all of that and more.

So this Thanksgiving, I am choosing to reflect on the positive notes in those photos. Years from now, that is ultimately what I will remember the most. A special time when all 5 (and then 6) of us were able to be safe at home together. No school, working from home, then maternity and paternity leave. A special time to bond while our children were young and wanted to spend time with us. My goal for the next few weeks, in anticipation of returning to work, is to enjoy these moments as much as possible. As difficult as they can be sometimes, I know that I will miss them immensely when they are gone.

Waiting

Well, we somehow made it to mid-August and I will be 37 weeks tomorrow. 37 weeks is technically term and I finally feel like I can take a deep sigh of relief. We’ve made it to this point!

I have checked most of my nesting tasks off of the to-do list. My hospital bag is packed, newborn clothes are washed, two bassinets set up (one in nursery and one in our room). The car seat and base are the in the garage for my husband to install last minute.Our 3 boys have been sharing a room for a month or more and it’s going surprisingly well. The nursery closets have been rearranged and our bedroom has been reorganized to double as a nap station. Postpartum supplies are stocked for me, newborn diapers and wipes are stocked for the baby. We have hand sanitizer and hand soap galore. Tomorrow I’ll have help with the kids and plan to review my list to see if there are any last-minute items to tackle.

I feel ready. I’m anxious about going into labor, of course. As an obsessive planner, it’s difficult for me to NOT know when something will happen or how exactly it will happen. This time around we’ll have the added stress of needing to coordinate childcare quickly. Our families ultimately decided not to fly out. I totally understand their rationale. They are being incredibly cautious – not socializing at all, working from home for the most part. The idea of being on an airplane doesn’t jive with me either. At the same time, it’s difficult not to have family around for this. I’m super pregnant and my husband is working frantically to wrap things up before paternity leave. The kids are also a handful at the moment. It would be nice to have family in town to spend quality time with them and to offload some of our exhaustion. The situation is sad but I can’t perseverate over it – there’s literally nothing I can do. Our plan is to have our amazing nanny (who has saved us over and over again these past few months) “on call” to come over when I go into labor and we are very fortunate that she moved closer to our home earlier this year. I had originally planned to drive myself to the hospital while my husband coordinated childcare, but my ob vetoed that idea. So now, if things seem to be happening quickly, we’ll load all of the kids into the car and have her meet us at the hospital. I am hoping that my contractions start during the day or that I make it to my induction (39+3). I REALLY do not want to have a baby at home or in the car!

So there’s the unknown component to contend with now. But there is also the fear component – what is something goes wrong? What if I have a postpartum hemorrhage? What if baby has some unknown birth defect or there is another complication? Obviously, I have no control over these things and am trying not to fret about them. I am mostly at peace – trying to enjoy these last few days/weeks with my three little boys, with our family of five – loud, crazy, chaotic – but at least it is our normal and well-known. The first few weeks with our newest addition will be a period of constant adjustment.

We have tried our best to prepare for the postpartum period/fourth trimester. We will both be taking parental leave. Our nanny will help out during the day. We hired a night doula for the baby as well. I am still a bit torn on this. Some of my favorite memories are the sleepless newborn nights. I have usually slept alone with the newborn, nursing all night, watching the clock tick towards morning, waiting for the sun to rise, snoozing on the bed or couch whenever I am able to set the baby down. But, in truth, it has always been exhausting. Some nights my husband would have to watch me sleep w/ the baby cradled by my breast because we were unable to get him into his bassinet. Mornings I would be so exhausted. And the truth is, we are going to need all of the energy we can get to parent 4 kiddos through a pandemic. So we hired a night doula five nights per week. I think it will be great to have the help and two nights out of the week I can enjoy solo evening parenting! I am also hoping that working with a night doula will instill good sleep habits early on, because we have always struggled with this and only just sleep trained my youngest at 18 months!

The other huge thing happening during this waiting period is that school is finally starting for my older two. My oldest is entering kindergarten and the first trimester will be all virtual for now. I am torn on this. I don’t feel any emotional need to have him attend in person. He has been in a preschool-like environment since age 2, so I don’t feel like entering kindergarten is a huge momentous occasion. That being said, I worry that he will have a long, intense virtual schedule. The draft they sent show kids “in school” from 8-3. I am hoping this is modified for the younger kiddos because that is a LONG time to be in front of a screen. He’s also a social kid and I worry that he’s going to miss out on that aspect of school this year. And, finally, because we transferred him to a private school, I’m not thrilled to be paying tuition to have him at home! But, alas, this is the situation we are in at the moment and the most important thing is obviously keeping him, our family, his teachers, the school community and our general community healthy and COVID-free.

My second oldest is entering pre-K at this school and, because they are under different state regulations, he will be able to attend in person. I am also a bit torn on this. On one hand, he is harder to teach at home than his brother was and he is also more shy and introverted, so a place where he has rules to follow and friends to play with would be beneficial for him, I think. I also worry that he will get lost in the shuffle at home. Even with our nanny here, if one person is directing online learning all day and one person is trying to make sure our (almost) 2 year-old doesn’t crack his head open jumping off of furniture and one person is tending to a newborn, what happens to our second oldest? Will he get enough attention? Will he learn anything? These worries are counterbalanced by the very real concern that he might get or be exposed to COVID. So ultimately I can’t say that I am entirely at peace with our decision, but for the reasons listed above and some more, we have decided to start his year in-person and continually re-evaluate.

So this is the world we are bringing this baby into. Fortunately, I was able to stop seeing patients in person early on (34 weeks). I completed 2 weeks of telemedicine and then took my earliest maternity leave to date at 36 weeks. I was fortunate to not get COVID and to not be exposed to any COVID + patients during this time. Despite having just started leave – and the baby not even being here! –  I am already stressing out about going back to work. In normal times, it would be sad but doable. In pandemic times, it seems impossible. Who’s going to sit with our oldest to do distance learning if that is still happening in the new year (I believe that the whole school year will likely be remote)? How will we balance that with my second child’s pick up/drop off schedule? There is a very real possibility that I will have to scale back or modify my hours to work around these schedules.

But, for now,  I am going to try to remove worries and outstanding questions from my mind. I am going to try to enjoy one more night of sleeping through (I hope – the kids do still get up sometimes for one reason or another!) without having a newborn to feed. I am going to enjoy this next week of productivity, nesting and time with my three boys. The next time I write anything, I anticipate that our new addition will be here!

This is how it often is

We met on her second day of hospital admission. She was in her early 30s with a newly diagnosed leukemia. Her symptoms had been mild to start, and now she was here, admitted with cancer, about to begin chemotherapy. She had a six year old daughter at home. The walls were filled with artwork, family photographs, the annual Christmas card.

This is how it often is. You don’t have cancer until you do. The symptoms are mild at first – “I thought I had a terrible virus”, “I was so run down but I had been working so hard”, “My back was aching something terrible but I had just started CrossFit”. You’re living your normal life until it shatters.

I am a dermatologist who sees patients in the hospital when they experience side effects from cancer treatment, or have had a bone marrow transplant with skin complications, or have skin disease in either setting. This is not the role we usually envision for dermatologists. When I was an intern at a renowned academic teaching hospital, the ICU attending skipped over me while we were reviewing a chest X-ray on rounds. “You don’t have to know how to read this – in a few months you’ll just be doing Botox.” I was sleep-deprived, short on caffeine and the low woman on the totem pole, so I swallowed my tongue and folded it up as an anecdote I would later share with my own residents. As one of my mentors always says: you have to show skeptics your value, not tell them about it. Eventually they’ll come around.

The things I love most about medicine – the connections I have with my patients, the trust they have in me, the things I learn from them – are sometimes the hardest part of medicine. Patients often share their hopes and fears. They tell me things they have only told their closest families and friends. I had unprotected sex with someone who wasn’t my husband. I tried to kill myself. I don’t want to die. I never wanted to have children. I grew up in foster care and never had a family who loved me. It’s heavy. There is never any judgement, just a deep understanding of how complicated our world is. There is so much loss and pain, and on the flipside so much beauty and love.

Many times, my patients are soon in remission. The cancer was removed surgically, the cancer treatment worked, the bone marrow transplant gave them a new chance at life. I often don’t see these patients again, but some continue to visit me each year for a routine skin check, or because of a new rash. Those are joyful visits. I receive updates on wedding anniversaries, growing children, grandchildren, vacations – general life excitement.

Other times they never leave the hospital. Or they arrive to the hospital a different person. The complications pile on, everything goes wrong. Soon there is a planned discussion between oncology and the patient’s family. How aggressive do they want to be if new complications arise? Is it time to transition to comfort care? Whereas the first time we met they were sharing photographs of their families and explaining the artwork on the walls, they are now hooked up to machines and unable to communicate beyond a blink. I still talk to them when I enter the room. I repeat who I am and what I am doing – “I will be taking a look at your skin. Your oncologist is worried about the new blisters on your legs. Is it okay if I lift up your sleeve?” The syllables fade into the air, surrounded by assorted alarms. I finish my exam, say good-bye.

The next day we arrive to round and the family is huddled around the bedside, family members spilling into the hallway. The daughter is there. This is usually a sign that the patient has a few hours to live. It is a terrible moment for physicians. I wish I could shield my residents from it, in the same way I yearn to shield my children from the terrible things that happen in our world. We move on to the next patient but there is a heaviness in the air. A six year old is about to lose her mother, a husband is about to lose his wife, parents are about to lose their daughter. The hospitalization ends here but the repercussions of this loss will resonate for eternity. Eventually it will be explained as my mother died when I was six, but there were days and weeks and months and years leading up to that moment which were filled with all of the details that make our lives rich.

I sign into the hospital’s electronic medical record at home that evening to finish notes. I see that our patient has died. My children are sleeping in their beds and my husband is working on a deadline next to me but a mother has died. I move on to the next task, almost in slow motion. This is how it often is. You don’t have cancer until you do. You’re breathing until you’re not. You’re alive until you’ve passed.

What I’ve learned is this: there is nothing to do but to keep moving. Cherish the small things in life, keep your family close, take care of your health. Tomorrow is not a guarantee, trite as it may sound. Wealth and accolades will not shield you from disease and death. At the end of the day, we are all left with nothing. Ashes to ashes.

To my fellow physicians-I see you in the trenches, trying your best to keep your academic hats on while retaining your humanity. To patients everywhere-your doctors truly care about you. They think about you long after you’ve left their office and often long after you’ve left this earth.

I still remember my patients who have passed. I keep the trinkets they gave me, write down their quotes and life lessons, and have stored away the memories we’ve shared. Medicine is broken in so many ways – out-of-touch administrators with unreasonable demands, insurance companies refusing access to care, astronomical cost – I could go on and on. But all is not lost as long as the purity of the patient-physician relationship remains.