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.

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!

No more cornflakes

Today is Day 38 of no school for my kids and Day 33 of shelter-in-place. It’s 1:48am and I am up again. We’ve been battling bedtime with one of my kids for what seems like an eternity (a year perhaps?). With the extra time at home, less need to be at work first thing in the morning, and generally more exhaustion, I have started falling asleep on the floor of his room (his preferred sleeping arrangement) more often than I would like to admit. After sleeping a good 3-4 hours, I find it tough to seamlessly transition to my own bed. Thus why I am up right now – writing for the first time in ages.

The past few weeks have been an adjustment, to say the least. Before I go into details, I first have to say that we have been very fortunate. My husband and I are still employed and no one we know or love has been ill with COVID-19, despite much of our family living in New York and New Jersey.  I work at a hospital but my department has made patient, faculty and staff safety a priority, and this has helped to relieve a lot of exposure anxiety. I am also 19 weeks pregnant and my colleagues immediately volunteered to take over some of my riskier patient care responsibilities, as the evidence regarding COVID-19 and pregnancy continues to evolve (fortunately, it has been mostly reassuring, but we are learning more each day).

We are very blessed and acutely aware of this, but also affected by the monumental change that occurred in our lives these past few weeks as well as the uncertainty regarding the future. What began as a two-week hiatus from school after there was a confirmed positive in the larger school community was gradually extended, until they just recently announced that school would be out until the fall. Summer camps have started to cancel. There is talk of the 2020-2021 school year looking dramatically different.

I do feel fortunate that my children are young (1, 3 and 5). Mostly they have reacted to the news with glee. For them, it is an extended vacation and their parents are home all day on most days (I am currently going into the office one day a week for essential procedures). They say they do not miss school or their friends. We live in a warm climate where they can go outside each day – even if it is only in our backyard or a short trip around the neighborhood. But I do worry about the change in structure. This week in particular was tough became it came with some change in behavior. My 1 year old is undergoing a sleep regression – often crying before bed, waking up in the middle of the night (he woke up as I was typing this), and a few mornings waking up before 5am. My 3 year old finds his way into our bed more often than not (perhaps related to my falling asleep on his floor most nights?). My 5 year old, who is generally very well-behaved, started to act out this week. Small things, for sure, but they pile up quickly when my husband and I are home all day, trying to fit work into any snippets of time we can find, and generally exhausted/operating on fumes. Parenting 3 kids 5 and under while both working full-time was hard at baseline and then COVID happened and it seemed almost impossible. (But I remind myself daily that at the height of my struggle with infertility I would have prayed for this conundrum. No matter how many kids I’ve had, there is no way to forget that burning desire for motherhood, the disappointment that came with every negative pregnancy test, and the fear of it never coming to fruition.)

And yet. Today was a hard day (also a hard night, it seems, with 2/3 of the kids already up 2 times each) and I started thinking about one of my favorite books from childhood – No More Cornflakes by Polly Horvath. I had forgotten the general plot and had a good chuckle when I read the Amazon synopsis: “Hortense seeks the advice and friendship of her eccentric Aunt Kate when her mother spends her days eating cornflakes and hopping around in public, pretending to be a rabbit”. It is about a girl growing up in a changing household – her mother is pregnant (and apparently losing her mind?  I should go back and read this now that I am an adult), her older sister is out more/becoming more independent, and she finds solace in a deepening relationship with her quirky aunt. The one thing I vividly recall, even decades later, is her aunt’s advice to find an “oasis”, a small ritual you have for yourself each day – one that is yours and only yours, one that brings joy always.

I love this concept even more now. As our world has become smaller – confined largely to the walls of our home – as our social interactions have become non-existent, as our opportunities for experiences, vacations, etc., have dissipated before our eyes, how do we find solace in our day? What can we do to bring a sense of peace, calm and fortitude into our lives? I’ll be thinking about this deeply in the next few days, as we continue to refine our daily schedules, to bring small rays of sunshine into our lives.

For now, I am trying to focus on the positives. I have had the opportunity to experience staying at home with my children (I went back to work with all 3 when they were ~4 months old). They have had the opportunity to experience a different childhood (I sometimes joke that it is my childhood) – one without planned activities, playdates, structure. We, as parents, are working on encouraging more creativity and independent play. We are trying to find small pockets of time for ourselves while the kids are awake, so that we don’t have to cling so desperately to the post-bedtime hours. My 1 year old’s language has taken off exponentially now that his brothers are home full-time. My 3 year old rode his bike for the first time today without training wheels. My 5 year old has been reading on his own and doing math. We are eating at home every night (we always ate together, but did often eat out) and I am so incredibly fortunate that my husband cooks for us every day. We are finding the time to complete random items on our to-do list that always fell to the bottom of our busy days.

One day, as long as everyone stays healthy and safe, we may look back on this time with some degree of fondness. I wonder if it is the closest we will ever be as a family. Soon, if we are still sheltering in place and socially isolating when this fourth baby arrives, we will be even closer!