Working class

My paternal grandfather worked the grounds at a country club. I imagine the patrons of said country club going about their day – playing golf, swimming, dining, drinking cocktails – all the while ignoring my grandfather as he toiled beneath the sun, skin browned from outdoor labor, hands calloused from hard work. My parents and I would drive down the winding, tree-lined streets of this town, lavish homes behind lavish gates, only a sliver of sky visible above the vast greenery. I wondered who lived in those homes. What did they do? How did they acquire so much wealth? Did they ever speak to or acknowledge my grandfather?

There were two things that my paternal grandmother wanted more than anything. The first was to go to school and the second was to marry her first love. Neither wish came true. Her parents were poor farmers and they needed all of their children to work. My grandmother cried when they pulled her out of elementary school to tend to the farm. She would tell me this story over and over again, encourage me to get an education. I tell this story to my kindergartener now – “Your great-grandmother wasn’t allowed to go to school. Millions of children around the world are unable to go to school. You are so fortunate to have the opportunity.” Does he get it? I doubt it, but it’s an important story for me to pass down. My paternal grandmother fell in love but she wasn’t able to marry him because her older sister had to get married first. He went to fight in World War II and never came home. Her parents arranged for her to marry my paternal grandfather. My grandmother would tell me: “They put me on a boat and I arrived in Argentina and was married to your grandfather.” They were a terrible fit. They had an unhappy marriage and even an unhappier separation. She refused to divorce him, even as he lay dying from lung cancer. Catholics don’t get divorced. My entire childhood I heard two lessons on repeat – never marry someone you don’t love, education is a gift. When I think of my paternal grandmother, I think of regret.

My paternal grandmother worked until well into her 70s. She worked in a convenience store – minimum wage. Storing money away for what? A rainy day? She hoarded items in her small basement apartment. You never knew what you might need. I think of well-to-do women in their 70s who go to brunch and do water aerobics and get their nails done. These luxuries might as well have been a foreign currency for my grandmother.

My maternal grandfather died shortly after I was born. Colon cancer. “From the war”, my mother would say. But was it from the war? Or was it genetic? Who knows where the cancer came from. My maternal grandfather was captured during the war and, after months in captivity, all he wanted was a peaceful life. A quiet life. The only way I knew him was through the photograph that my mom kept tucked away in a kitchen cupboard. How hard it must have been for my mother to lose her father when she was in her 20s.

My maternal grandmother was a firecracker. She was ambitious, stern and short on compliments. She would tell my mom, the youngest of three daughters, that she was too thin, too ugly, that she should spend less time “in the streets” (my mother was going to college) and more time at home. That she needed to get married and have kids. She softened in old age. When I feed my infants, I see my grandmother’s toothless mouth, mashing at her food. “Don’t worry about me,” she would tell my mom, in her last years of life. “Take care of your family. I’m okay.”

“One person’s just do it is another person’s Mount Everest.” I forgot where I read that, but I think of it often. If you grew up wealthy, it’s easy to envision wealth. It’s easy to take a chance on a start-up venture, spend months ruminating on what your next career move should be, job-hop and hope for the best. If you grew up poor, all of that seems like a wild gamble.

My husband and I have done “well”. We were fortunate to have two parents each who loved us, provided stable households, and invested what they could into our education. We both attended Ivy League colleges. My husband started working after college and I completed medical school. But we don’t have the same comfort level as our wealthy friends. Success, to us, is not a guarantee. We know much of it has been luck. We also know that money can be lost as quickly as it was obtained. We don’t have a familial safety net. There is no trust fund at the other end of the rainbow, there is no inheritance awaiting us. The next step is our journey is to support our parents as they grow older. This is our reality.

All of this to say that we have never joined a country club. I wouldn’t even know how to act. I hate having people work in our home or wait on us. It makes me feel awkward. I want them to know that I come from a long lineage of hard workers – that there is no job that is “beneath me”. Recently, an influencer got into hot water for (among other things) describing her cleaning woman as “[the person who] scrubs my toilets”. How demeaning. The sad thing is that I have heard other women use the same description when talking about their “help”. Why? Why do they feel the need to assert their perceived superiority? There is nothing wrong with scrubbing a toilet. I scrub my own toilets when needed, and I would scrub other people’s toilets if it meant I could provide a livelihood for myself.

As a mother, I hope that my children, despite the relative privilege they have been afforded, are able to stay grounded and retain perspective.

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.

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!

Pandemic Pregnancy

When I became pregnant, COVID-19 wasn’t even a thing. It was mid-December and I don’t recall hearing anything about what was happening in Wuhan until January at the earliest. So it was probably a thing, and there were cases, but the thought of closed schools, clinical work on hold and shelter-in-place were not on my radar. I was honestly mostly focused on the application process for private school for my two oldest kids. They were (and I recognize how ridiculous this sounds) applying for entry to pre-K and K, and my biggest worry was where they would be going to school the following year. Now I’m doubtful that they will even get to attend said school in person, but that’s a topic for another day.

On February 25th I screened positive for Trisomy 21 and perseverated over that for a week until my normal cell-free DNA results.

We slowly began to take precautions at work to screen for COVID-19. It began with questioning patients prior to their visit to see whether they had recently traveled from Wuhan (this eventually expanded to all of China, and as everyone knows that question soon became obsolete). We also asked about cough and fever. Carts with PPE were positioned outside of these patient rooms.

I developed a cough on March 6th, which was terribly awkward to have while everyone was on high alert regarding COVID (for the records, I have had a negative COVID-19 PCR and also negative IgG and IgM antibodies). One of my patients even sent me a personal note saying that he was worried about me because I had been coughing (I wore a mask in every patient room during this time) and seemed short of breath. I had to, with some embarrassment, tell him that I was short of breath due to climbing 3 sets of stairs while pregnant. Fortunately he was a patient I knew quite well.

I had an ob appointment March 10th and my ob was pretty close to 0% concerned about COVID. She told me the reports out of China were reassuring. Pregnant women seemed to fare well and there were no cases of vertical transmission. She also told me to drink a glass of wine, which was interesting because she usually errs on the conservative side (also for the record, I did not drink a glass of wine).

My close colleagues, however, were more concerned and ended up encouraging me to drop one of my higher-risk duties – seeing patients in the hospital. I stopped doing that the week of March 2nd. The week of March 9th I made a huge pivot in my career and left one of the clinics I had worked at for 6 years. Too many things weren’t working out. I was losing staff, knew I wouldn’t have any when I returned from maternity leave again (it was a drawn-out nightmare the last time) and was so exhausted from pregnancy and turning 37 that I knew it was finally time to call it quits.

March was a month of major upheaval. Our world paused in March – with school canceled starting March 12th (initially only for two weeks but that eventually progressed to no school for the rest of the school year) and shelter-in-place coming 5 days later. Everything was being canceled. It was such a crazy time.

We largely stopped seeing patients in person, with my last real clinic held on March 16th. Everything has been virtual since. To be honest, it’s been challenging. Some conditions in dermatology are easy to treat virtually (acne, for example). Other things, like checking over someone’s skin to look for skin cancer, are impossible. I have been seeing 1-2 patients a week for skin biopsy and evaluation of more serious rashes, but always wearing ample PPE (I have my own that I cycle through). We have just started talking about opening up clinic more robustly, and I am concerned about the plan (or lack thereof). It doesn’t sound like anything is changing, other than spacing out clinics and appointments to encourage social distancing. Of course, we are asked to wear PPE, although it is unclear whether this is readily available.

Normally, I wouldn’t be too concerned. But last week, at my follow-up ob visit, my doctor was suddenly very concerned. She told me there had been new reports of COVID-19 found in placentas, IgM antibodies in newborns, vertical transmission (from mom to body), second trimester miscarriages, stillbirths and premature births. The numbers of reports were small, but there was definitely more alarm. Moms are tested at the time of delivery at our hospital and COVID-19+ moms are recommended to separate from their newborns. Having had three kids, I can’t imagine how heartbreaking that would be.

In sum, I’m starting to worry about ramping up capacity to see more patients. I’m not reassured by the plan currently in place and now I’m much more anxious about doctoring while pregnant. At the same time, I feel a bit silly, because I don’t work in an emergency room or ICU, and certainly don’t do any high-risk procedures (any biopsies I do near the face are usually relatively quick and nothing compared to an intubation). I also feel a strong obligation to my patients. I know how scary it can be to have a spot that you are worried could be a skin cancer, or a rash that keeps spreading. Our patients have been so wonderful these past few weeks, understanding that we are taking every precaution to keep them safe, but I certainly don’t want anyone waiting months to be seen. Since I am taking maternity leave, I would be gone until early 2021. Finally, I care deeply about my colleagues. Although they might not be pregnant, they could have co-morbidities or take medications that make them immunosuppressed, live with elderly parents or in-laws or immunosuppressed children and spouses. I don’t want to burden anyone else with having to see my patients because it seems to imply that my pregnancy is more important than their personal circumstances.

It’s an uncertain time for all and I don’t envy our management who has to make some tough decisions moving forward. For now, I’ve reached out to my ob to see if she can give me some clarity on making a decision. If need be, I’ll reach out to my colleagues to see how to best mitigate risk. I’m taking leave at 35 weeks so essentially only 13 more weeks to go. Hoping those 13 weeks are as smooth and uneventful as possible!

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.

Maternity leave in review

In two days I’ll return to work after my third maternity leave. That’s one job, three pregnancies, three maternity leaves and three “first days back at work”. My first post on this blog was about returning to work after my second was born (see October 2016 archives) and now here we are again! In honor of this occasion, I wanted to spend some time (kid naps allowing) to reflect on the past few weeks.

This maternity leave started earlier than planned when my contractions started the morning after my last day of work. I had been expecting at least a few days (if not weeks!) of extra time to wrap things up, but baby had other plans. I subsequently spent the first 3-4 weeks wrapping up work. I know that sounds really terrible, but it was actually okay. Everyone knows that newborns don’t sleep, so it gave me something to do in the wee hours of the night, and it was something that would definitely prevent me from dozing off with the baby. I am also fortunate to have a lot of support staff and they helped me make phone calls to patients (since that’s not something that can be done in the middle of the night!).

My husband didn’t take his paternity leave right away, so it was a bit of a whirlwind. Even though we had family helping out, if I had to do it again I would ask him to take a few weeks off in the very beginning. It would have been immensely helpful to have a bit more overnight help those first few weeks and I would have probably been able to take some daytime naps without the baby! It seemed pretty stressful for him to work while so sleep-deprived and this definitely led to more bickering than usual. Fortunately, things improved with time (and sleep!).

We briefly had a night nurse helping us out…until she fell asleep holding the baby. I couldn’t believe it. As my husband always says “why are people so bad at their jobs? You have one job – learn how to do it right!” So I guess another thing I would do differently is not hire a night nanny. Yes, it was helpful to have someone hold the baby for a few hours overnight, but I did enjoy doing the bulk of evenings since so much baby bonding happens during that time. I also found that I didn’t rest easy when she was over, perhaps because I was worried about the above. Fortunately, our little guy persevered and now his sleep isn’t as atrocious (although it is definitely nowhere near ideal for having to go back to work!).

My older kiddos have done really well with their new little brother. Toddler Y (our middle child) had a tough time those first few days, but now he is sweet as pie. One of our major challenges when I return to work will be carving out individual time for all three kids. Right now, the older kiddos have independent activities on Saturday mornings, and I plan to build onto that time.

One of the highlights of maternity leave was seeing a lot of family. My mom spent a few weeks with us right before and after Baby Z was born – not quite as long as the last time, but just the right amount of time during the hardest days. We also had both of our families visit on separate occasions and I was able to visit home twice (the last time for 3 weeks!) during maternity leave. The kids have a blast around family, so it was so nice to see everyone on multiple occasions.

Another highlight was meeting an awesome group of moms with kiddos around Baby Z’s age. I have excellent mom friends whom I met shortly after my first was born. Some had second babies so I didn’t feel the need to branch out much with Toddler Y. But this time around I knew that Baby Z would need some baby buddies and went out of my way to meet people. Well, this group of moms is just awesome, and it’s been great getting to know them.

On an organizational front, I did a TON around the house. I cleaned out the whole attic, donated and threw out a bunch of items from all throughout our home (trying to get a head start on minimalism for 2019!), made headway on two home improvement projects we have been working on, had the guest room painted, reorganized the guest room/soon-to-be Baby Z nursery, cleaned out the entire shed and organized all of the kitchen drawers. I gave away a ton of baby things we no longer needed, worked on Baby Z’s scrapbook and first-year album and also researched and toured a slew of private schools in the area. I did much of this with the baby strapped to my chest, but needed a bit of assistance for the manual labor.

Of course, the highlight of maternity leave was the hours upon hours I got to spend with Baby Z. I wore him almost constantly in a sling (now carrier) during the daytime hours. He often slept in bed with me overnight (not necessarily by choice, but we made sure the bed was as safe as possible for infant sleep) and he accompanied me to appointments, a handful of work meetings and a slew of errands. He’s an excellent eater, and I will forever be grateful to my employer for allowing me to have all of this time with him.

When I return to work, he will be about 4.5 months old. I know international readers will balk at how little that is. However, having had all of my children in the US, I feel so incredibly fortunately to have had 4.5 months of paid maternity leave, as well as the assurance that my position is stable. When I return, I’ll be able to set time aside as I wish to pump and to adjust my schedule as needed to make this year as manageable as can be. In fact, I’m returning part-time this month, and I am so very grateful to be able to rev up gradually.

I will always be sad about leaving my baby. What will it be like for him to not be strapped to my chest all day? (Honestly, probably not as bad as it will be for me!) I will worry incessantly about something going wrong while he is out of my care and I will miss his little noises and tiny fingers and sweet smile. I will stress out trying to give everyone attention in the few hours we have before work and after work/before bed. But I have faith that it will all be okay. Not easy, but okay.

Many moons ago, when I was obsessing about going back to work vs not going back to work (not really an option for me at the time but an interesting hypothetical argument) and then obsessing about daycare vs nanny, the one thing that stuck with me was reading that kids will thrive with a decision as long as the parents are happy with that decision. So I always focus on the positive aspects of my job and the positive aspects of their relationships with other caregivers.

I also have this to get me through: my older kids are alright. They’re happy little clams, in preschool now. My oldest is four. If we repeat his life cycle 4 more times, he’ll be twenty – an adult! In other words: time flies. As my children have grown, I’ve had (some) opportunity to think about who I am independent on them, how my husband and I interact independent of them, what I will do once they leave. Yes, I am not very far in and they are still very, very small and very, very dependent, but there are snippets of time when these opportunities for thought arise. When they have arisen, I have always been very happy to be working. This is what has worked and been okay for me, but it may not be the best case scenario for anyone else, and that’s okay too.

So in less than 48 hours, I’ll be waking up and changing out of my pajamas first thing. I’ll put on make-up, grown-up clothes, triple check my bags to make sure I have my work things plus my pump things, and then I’ll leave my sweet little baby behind. First I’ll have to convince my older kids (who have been out of school for three weeks!) that getting dressed and leaving the house early is also a good idea. I am not sure which of those feats will be harder! And in a few weeks time, doing this will be the new normal, and these lovely (and hard) maternity leave days will be a distant memory!

The Blob Trimester: Baby’s Z’s 1st 3 months

As my youngest (baby Z) is one week shy of 4 months, I find myself fondly reflecting on the fourth trimester haze. If you are not familiar with the term “fourth trimester”, it is common terminology for the first 3 postpartum months. Due to human anatomy and the limitations of the birth canal, human babies are born neurologically premature. Thus my rationale for (very affectionately) calling my newborn a blob.

Let’s put it this way: newborns would never survive in the wild. They can’t hold their heads up, they can’t make meaningful movements with their arms and legs, they can barely see, and they are easily surprised. They can only communicate via crying and they spend a great majority of their days sleeping, drinking milk, peeing and pooing. This is one reason why the fourth trimester is so challenging for new parents: you are suddenly in charge of keeping a small, defenseless human alive. No pressure!

Prety daunting, huh? Couple this with the fact that new parents are chronically sleep-deprived (newflash: babies don’t know the difference between day and night, so you may find yourself pulling a lot of all-nighters), moms are experiencing a hormonal hailstorm (why does everything make me cry? why am I suddenly so angry at my husband? why am I so worried about every damn thing?) and everything you previously knew about yourself has gone out the window (so long hobbies, singular focus on career, social life). Given all of the above, we might as well also call this time period the sob trimester.

Never fear, however. Between 3-4 months, everything gets easier. Yes, there are still challenges (hello 4 month sleep regression!), but your little blob has turned into a reciprocal mini-human who tracks your movements, produces wide-toothed smiles and even cackles with laughter, which makes the experience much more rewarding.

For the sake of preserving my own memories, here’s a recap of Baby Z’s first 3 months:

  • Birth: By far the best of three (third time’s the charm!). Baby X was induced and we barely made it to the hospital with Baby Y. For Baby Z, we went to the hospital as soon as contractions started and were told to walk around until they intensified. We did this for quite some time, even coming home to shower and re-pack, so by the time we returned to the hospital, it was go-time but not baby’s-about-to-fall-out time. I was able to get an epidural (thank you, modern medicine), labor peacefully and when it came time to push, he was out after basically 3 pushes with no tearing involved.
  • Sleep: We purchased a Snoo for this guy, but I wasn’t quite comfortable having him sleep in it from day one. The rocking seemed a bit intense for me and I capped it (there is a function where you can limit the motion) and have kept it as such to this day. In the beginning, he honestly mostly slept in bed with me (my husband would supervise so I didn’t roll on him) and we also lay him down in the Snoo (without turning it on) or put him in the Rock n Play (which he honestly never liked very much and also isn’t safe for unsupervised sleep). We hired a weekend night nanny for those first rough nights and she fell asleep holding the baby on the third night she worked for us! As my husband would say: WTF? YOU HAVE ONE JOB!!! That was pretty traumatic, but baby was okay and we gently told her we were no longer in need of a night nanny. I have to be honest: the sleep was pretty rough early on. He would spend a few hours up each night and I often had no idea what to do with him around 2-5am. My husband was also saving his paternity leave so I tried not to bother him since he had to work the next day. It was pretty intense. I tried to establish an early bedtime for him, but he went to sleep around 11p for a long time! Just recently (close to/when he hit 3 months), he started falling asleep around 9. Early on, he would be up cluster-feeding for quite a few hours (e.g. 8p-11p/12a) but more recently he would do a longer stretch, waking up either at 1a or 3a. So most nights he’ll wake up 1-2 times. The first nap was also the first to fall into place, as it usually does. It’s the one I can actually set him down “drowsy but awake” for! At the moment, we are traveling (good-bye Snoo!) and have him in a Pack n Play. I have to say that he’s not loving it. Last night, he was up every 2 hours, and spent the bulk of the night in bed with me. I’m not sure if this is a Snoo transition issue, a travel/change of environment issue, or the start of the 4 month sleep regression, but I don’t like it.
  • Temperament: When we first brought him home, we were a bit concerned he would be colicky like Baby X. Turns out he was just a normal newborn who wanted to be held, cuddled and carried pretty much all day. With every need attended to/preempted, he’s happy as a peach. He likes tummy time, mat time, play time (songs and the occasional book when he gets his own) and of course still loves when we tote him around all day. So far, he’s a happy, go-lucky baby who can also entertain himself independently (for now, this mostly involves staring at something in the distance).
  • Feeding: Baby Z latched pretty easily. I had one of the nurses remind me of the appropriate position when they are little blobs and can’t hold up their heads, but he quickly got the hang of it. I don’t have him on any particular schedule at the moment. He should technically be eating every 3-4 hours, but sometimes it’s less. Of all the baby things, nursing has always been fairly easy for me. Yes, it was always painful in the beginning. I enrolled in a lactation class prior to the birth of my first, worked with lactation consultants in the hospital the first two times, and also had private lactation consultant visits after the first two were born. These steps allowed me to feel more comfortable nursing. And yes, I worried ALL all of the time whether they were getting enough to eat, especially my first. Was he colicky because he was hungry? Were those tears of starvation? Did he want to nurse all of the time because he wasn’t getting enough milk? I also always pumped just enough and was worried each time about how pumping at work would turn out. Yet I was able to nurse the first two for 15 months and pumped until they were 11 months, using up my freezer stash for months 12 and 13. We’ll see what happens with this guy. I’m a bit worried because I had 187 oz and 300 oz of milk saved up for my first and second, respectively, when I went back to work, but currently have only 55 oz with only a few weeks to go (poor third child!). But I am telling myself that the freezer stash really only helped me to stop pumping a bit earlier, so it isn’t the end of the world that his is so limited. After all, every lactation consultant I’ve spoken with has said you only need enough milk for your first day back (and this is true).
  • Developmental milestones: Baby Z was quick to roll from tummy to back. I know I sound like a delusional mom saying this, but he was doing it month one and still does it to this day. He’s flailing his arms around and kicking his legs much more now. He sees well, follows you around with his eyes, smiles and laughs, has coo-ing conversations, and has started to grip things and bring them to his mouth. Actually, everything is starting to wind up in his mouth – his hands, the carrier strap, teething toys, etc. He can also reach out with his hands to swipe things hanging above him on his playmat or on one of his chairs. His neck is pretty strong and I will often place him forward-facing in the carrier (if it’s not naptime) because he likes to observe the world. He’s actually starting to show interest in food already, which seems early to me, but I’m looking forward to introducing solids.

I honestly can’t believe he’s almost 4 months and am definitely patting myself on the back for getting through those tough first few months. Work is just around the corner (a story for another day), but I feel very fortunate to have had this time with him.