FreshMD

A day in the life

The topic of the week at Mothers in Medicine is "A Day in the Life." Check out the typical day of a neurologist, pediatrician and internist. I describe a typical Tuesday at the refugee clinic here.

The antidote: knitting

Post up at Mothers in Medicine on why I consider knitting the perfect antidote to medicine and parenting.

Testing Flickr's 'Blog this' feature

Leif's scowls make me laugh every time because they require a concerted effort on his part. He carefully arranges his face and announces: "I'm MAD at you!" In this case it was time to head home after picking wild blueberries on Mt. Seymour in the evening.

I put an embryo on a daycare waitlist

September 2001

One year and three months into a two-year residency, I give birth to my daughter. I am eligible for one year of maternity leave, and have every intention of staying home with my sweet, big-eyed Saskia for all fifty-two weeks. Pete and I haven't yet decided what we'll do for childcare when the year is up, but daycare isn't even on the table. I grew up understanding that daycare was for the unfortunate children of selfish mothers. It was fact, just as neighbours who mowed their lawns on Sundays could not be Christians.

January 2002

I sit at the desk in our loft, looking at a list of home daycares. The nine remaining months of residency loom over my days with my infant daughter. I have an irrational fear that I will have a series of consecutive pregnancies - defying all contraceptive measures - causing a perma-maternity leave and precluding any possibility of ever finishing residency. I am desperate to be done with it . . .

Post continued here. The topic today at Mothers in Medicine is childcare, where fifteen of us weigh in with our experiences.

Looming deadline for professional success: age 40?

The effective, moving, vitalizing work of the world is done between the ages of twenty-five and forty.

- William Osler (1849-1919), renowned Canadian physician

I turned thirty-five last month, and what struck me most was how odd it is that it's been thirteen years since I was twenty-two. But apparently what I should have been impressed by is the five short years remaining in which to make a significant professional contribution to the world. I find this idea disconcerting, as I'm waist-deep in raising kids and was banking on my next decade to make some strides career-wise.

More here at Mothers in Medicine.

Dandelion poetry

Thank you for all your kind comments and well wishes on the last post. As suggested, I plan to link to my Mothers in Medicine posts from here. There's a new one up today.

Finished

When I began blogging, a family member unfamiliar with blogs looked over this site and said politely, "It looks nice. Is it almost finished?" 

Well, now it is. 

I feel hamstrung by the mix of personal and professional anecdotes under my real name in the face of increasing readership. I find myself censoring and second-guessing myself and that really dilutes the pleasure of blogging.

I started this blog for the satisfaction of crafting bits of my chaotic days at home and work into a tidy package. But now my domestic and clinical days have settled into a relatively unruffled routine and I'm eager to pursue other projects. Any creative energy (and time) not exhausted by children or patients is in short supply, not enough to slather over multiple projects.

And so I need to absolve myself of this blog. I'm not sure if I'm euthanizing it or inducing an indefinite coma. The site will remain up but expect this post to greet you for the foreseeable future.

I'll still be active at Mothers in Medicine, Twitter and Flickr. 

Thank you to my little band of readers, especially those who commented or emailed over the last year and a half.

Baby names

I have a post up at Mothers in Medicine on the medical implications of baby names, including my own close call with the name Claudia.

(If you've been reading this blog since the beginning, you might remember I did another post on the topic way back here.)

The R-word

There's been a move afoot recently to stamp out the R-word. 

While I agree that the use of retarded as a derogatory term is offensive, I can't help wondering: Why aren't paraplegics protesting the slang use of lame? Why aren't families of schizophrenics fighting the word psycho? 

There are scores of medical words indicating impairment that are used disparagingly in every day speech: Dumb. Idiot. Blind. Imbecile. Moron. 

Some insults are used with no recognition of their medical origins. Cretin is someone who suffers from congenital hypothyroidism, but I've never heard the word used in that context outside of medical school.

I suppose the degree of offensiveness of these words depends on where your sensitivities lie. I cringe when people bandy about terms like brain-dead and on crack; light references to head trauma and addiction bother me as much as the slang use of retarded.

 

I don't oppose efforts to eliminate the R-word. But to be consistent, better ban the L-word, too. And the D-word, the I-word . . .

Island

On the way home as we round one of the final bends before our place, we pass Grey Rocks Island. It's privately owned with a house tucked into the stand of trees. I've never seen any comings or goings; it's always completely still. I imagine the inhabitants lying on the couch reading novels all day. 

As we swing by in the minivan, it almost makes me feel a bit gritty and common, having neighbours and a driveway and a mailbox and all. 

Devils are not real

I took inventory of Saskia's beliefs recently. I asked her to answer 'real' or 'not real' to various characters and she enthusiastically complied.

"Santa?" I suggested.

"Not real!" Said with seven-year-old pride.

"Easter bunny?"

"Not real!"

"Jesus?" 

"Real."

"Tooth fairy?" 

"Not real." (A surprise to me, this was followed by a brief discussion to identify my underminer. Pete.)

"Monsters?"

"Not real."

"Giant whales in the sea?" 

"Real." (What about dolphins, interjected Leif. Are they real?)

"Fairies?" 

"Not real." Said regretfully.

"Angels?" 

"Real." In a soft voice, utterly convinced.

"Devils?" 

"Not real." Said with equal conviction, laughing at the ridiculousness of the idea. "Let's do more!" she urged.

But I was too moved by the last two answers to continue.

Sanatorium

One of my favourite photos in the album from my grandmother is this one, of her brother in a sanatorium in Harderwijk, the Netherlands in the 40's: 

Sanatorium sounds psychiatric, suggesting a place where one's sanity is restored, but it's an institution for medically supervised recuperation from disease, usually tuberculosis. From a medical and a literary perspective, I was admittedly pleased to discover that a relative had suffered from consumption.

 

I love the button-up pyjamas, the drape of the bed sheets, the sun behind the curtains in the high windows and - most of all - the perplexing X where Oma marked her brother in ballpoint pen.

Album

I visited my grandparents the other day, and when the coffee had been served in decades-old flowered teacups and the pastries set out in a ring around the coffee table, Oma shuffled over with a photo album. She settled next to me on the couch and turned to the first page. 

"This is my oldest sister," she said happily, a bejeweled finger resting on a wedding picture. And in the same contented tone: "She died of a heart problem." Her finger slid down to the next photo. "And that is my oldest brother. He died of pneumonia." 

My grandmother had sixteen siblings, a corresponding massive extended family and a slew of friends, and their images were tucked into the book in black and white, in faded vintage tones, on thick matte paper and on Polaroid squares. She paged through the album, briefly remarking on each picture. Every observation included the cause of death. 

"Her husband died in the doctor's office when he was thirty-nine," she said of her niece. "She had five children." Flip. "My brother was in a sanatorium for TB. He was there for a year. He got better but then he died in a boating accident." Flip. "That is the husband of my sister. He died of a heart attack in 1981." 

Half-way through the album, and not one person in the photos was still living. And the strange thing was, Oma kept recounting their relationship to her and how they died in a cheerful, matter-of-fact way. I could smell her sweet old-person breath as she leaned closer to identify a blurred face, and I could tell she was enjoying herself immensely. 

I recognized almost no one in the pictures, save my grandparents and some of their siblings, marked by family resemblances: the small, pretty vandenHoven nose and chin; the full Byl cheeks and red hair. 

She closed the album and gave it to me. I took the book, heavy and oblong with a faded blue fabric cover, and realized that she had just paged through it for the last time.

"You can throw out the pictures of the people you don't know," she suggested. "You can just keep the pictures that you like." 

And so there is an album of dead strangers, of Oma's treasured people, on my desk. One day I'll probably sort and rearrange it, but for now I haven't the heart to disturb those photos' resting place.

A walk to the village for Honey's donuts

My aptitude for family medicine: poor, apparently

I did the University of Virginia medical specialty aptitude test purely for sport recently and was startled to learn that of 36 medical specialties, the one I am least suited for is family medicine. 

I'm not surprised that family medicine did not rank first. I chose it only partially because of any natural inclination toward it, and mostly because the training and practice of it meshed best with other priorities in my life, particularly raising a family. What did take me aback was that it occupied the very last spot on the list.

Pathology and radiology ranked at the top. 

From time to time I flirt with the idea of returning to residency, but what it comes down to is that I would rank my current job satisfaction as a family physician at a 9/10. Is a chance at boosting that to a perfect score worth three more years of residency, a massive reorganization of family roles, a significant reduction in my time spent with the kids and a hefty kick in the pocketbook? I don't know.

William Maxwell, fiction editor of the New Yorker from 1936 to 1975, said upon retirement: "For nearly forty years I have shaved with pleasure in the thought that I was about to come to this job." How I love that quote. What a gift, such perfect happiness with one's work. 

Of course, while he was shaving his wife Emmy was likely frying up the breakfast bacon, readying their daughters for school, preparing for a day of housework and granting him the enviable ability to be single-minded. 

That is what I find most difficult about mixing medicine and motherhood: the diffusion of focus. 

My work in refugee medicine is profoundly rewarding; raising three little ones even more so. The two have proven to be compatible. And yet at some point the efforts put into one require sacrifices made of the other. There simply are not enough hours in the day for me to invest what I wish I could into both spheres. I have erred on the side of mothering, and while I do good work at the clinic, my career trajectory has been modest.

I say this cheerfully. So far, I don't regret any decisions I've made. And every day presents an opportunity for new and different choices. Maybe one day, when the kids are a little older, I'll alter my career track or return to residency.

But for now, and maybe forever, a 9/10 is good enough.

(Cross-posted at Mothers in Medicine.)

The Clinic

The March issue of Doctor's Review alerted me to The Clinic, a medically-themed restaurant and club in Singapore.

* Photos by Yueh-Hua on Flickr, used under Creative Commons license

Patrons sit at operating tables in gold-plated wheelchairs, eat from stainless steel kidney basins and have their drinks hung from IV poles. Operating room lights enhance the ambience.

* Photo by projectnada on Flickr, used under Creative Commons license

* Photo from Max magazine

Apparently the food is fantastic. But what I find most appealing is that medically graphic table conversation would actually be appropriate here: 

So I had this patient today with a massive abscess, and I incised it and it must have taken me ten minutes to drain all the purulent discharge from it, it just kept coming. (Short pause as she takes another bite, her fork ringing against the steel bowl.) And then this afternoon a guy came in with an upper GI bleed and as I was taking the history he started vomiting blood. It was actually splashing on the floor . . . 

* Photo (L) from Travel + Leisure; Photo (R) from Designboom

I wonder if they ever host medical conferences?

Home again, reluctantly

We're home. I had a work meeting this morning and felt disoriented for the first few minutes. Then my recent life of novels and beach fires dissolved in the grey Vancouver rain and I felt as if I'd never left.

Now there's a fridge to stock, suitcases to unpack, photos to sort and patients to catch up on.

California 2009

We're in California (again). I wore shorts today, the warm air washing my bare legs like bathwater. My suitcase is full of books and Internet access is spotty. The cherry trees behind the cabin are in blossom and vibrating with honeybees and I saw a hummingbird as fat as a sparrow this morning. I slapped sunscreen onto three sets of lean little legs and the kids wheeled around on their scooters in the lane for hours. We keep setting out bowls of giant strawberries.

I feel like I have been bounced out of a rut I didn't even know I was in.

In love, age seven

Saskia and I are alone in the van on our way home from school, winding along Dollarton Highway in the slanting afternoon sun. She's in the back seat, quietly looking out the window, when her voice floats over to me: "Can little kids get married?" She asks with sudden great interest, like she can't believe the idea never occurred to her before.

"No."

"Oh." She digests this. She doesn't necessarily sound disappointed.

"Did someone tell you they can?"

"Colin did."

I know who Colin is. He has a sweet round face, brown eyes and hair, reminds me of a bear cub. I had watched him interact with Saskia the other day after school. He hovered around her with obvious adoration. At one point as she brushed by he reached out to play with the bunny tag swinging from her backpack. He looked totally smitten.

"He wants to marry me. In Grade 1 he really liked me. Now in Grade 2, he says he's in love with me." Her voice changes when she says in love, the words weighted with respect.

"That's nice, to have a friend that likes you so much."

She corrects me: "Loves me so much. I'm actually in love with him, too. That doesn't happen every day, does it, that two little kids are in love with each other?"

For once I am completely at a loss as to how to answer.

I know that's she's asking innocently, that a classmate with an older sibling probably introduced the concept. But I don't find anything cute or amusing about children adopting those ideas. I'm always surprised when other mothers chuckle and tell me what a flirt their kindergartner is, or tease their elementary school-aged son about girlfriends. I think friendships between young boys and girls should be considered completely natural. When they're treated as remarkable, I feel that the idea being instilled is that matching up with a member of the opposite sex is the first priority in life, to be pursued right out of the starting gate. That disturbs me. Falling in and out of love (and being consumed by it) is going to happen eventually anyway - why encourage it prematurely at age seven?

On the other hand, I don't want to dismiss her feelings, either. I remember my own intense crushes in elementary school, and they were impervious to other people's validation of them. (There was Chris, who had the affections of every girl in the class, in Grade 3; and Dino, who was a swimmer and reportedly shaved his legs, in Grade 4.)  I wouldn't have dreamed of telling my mother about them, though.

I don't feel prepared for this conversation; I'm unsure of my stance and whether there's even any real importance to the issue. I give Saskia an unsophisticated answer, fumbling, trying to affirm her affection for her friend while dismantling any romantic constructs, steering her away from the idea that she is in love without belittling her experience.

She unhesitatingly accepts what I have to say, then conspiratorially offers an anecdote: "Once I kissed a piece of popcorn and gave it to him and do you know what he did with it?"

"What?"

"He ate it."

Medically relevant prizes for pediatric patients

You know how most doctor's offices hand out Dora or Bob the Builder stickers to kids who take their vaccinations like little soldiers? 

I've found something more appropriate:

Available here at Supergirl Stickers Etsy shop.

And for the real trouper, a set of magnets:

* photos from the Supergirl Stickers Etsy shop site

I really should stockpile some good prizes. Do you know what my pediatric patients currently get at the end of the visit? A tongue depressor. Sometimes when I'm feeling generous I draw a kitty face on it.

Decorating with vintage records

I covered one of Saskia's bedroom walls with vintage record covers.

Collected one or two at a time over a year of thrifting, they cost 25 to 50 cents apiece. Most of them are from the 1950's and 60's. The art on some of these is quite wonderful, and I'd admired them for years but couldn't think of a use that would justify relaxing my efforts to stem the flow of goods coming through the front door.

I keep getting asked how I mounted these to the wall. I drove a nail through each one. All those years of renting as a student, where pounding holes in walls was expressly forbidden, make pock-marking my own walls that much more satisfying.

Now I have a drawer of LPs that I'm sure Saskia would enjoy, but no record player. I don't want a 70's one with giant speakers, but I don't want one that's meant to hook up to a laptop, either. Sony makes this attractive option, but spending $90+ US for a machine to play these two-bit records seems a little self-defeating.

So, another corner of Saskia's room done, another one with which we're equally happy. Really, I should be focusing on the adult living spaces: removing wood paneling, getting some hardwood floors installed, finding a couch. But somehow that feels so much more like work.

Fired

I have a post up at Mothers in Medicine on the futility of rushing kids, a desperate white lie to hurry Leif along and his interpretation of being fired.

Tights

Instructing a patient on how to undress for a pelvic exam the other day, I told her, "Your shoes and underwear need to come off. You can remove your skirt, or lift it above your waist." Her English was minimal, and we didn't have an interpreter, but I was confident we could get by with simple instructions.

As she pulled up the hem of her dress to remove her shoes, I caught a glimpse of brown, fuzzy tights. "You'll need to remove your tights, too," I added.

She looked at me, uncomprehending, and continued to undress.

I noticed later, to my great embarrassment, that she hadn't been wearing tights. The skin on her legs was such a rich homogeneous colour, covered so evenly with down, that I had mistaken it for fabric.

Why infectious disease docs are so likeable, Exhibit A

This is the unedited first paragraph of an infectious disease specialist's response to an email inquiry from our clinic regarding screening for schistosomiasis, a parasitic tropical disease that typically presents with abdominal pain and diarrhea:

Schistosomiasis is so COOL.   I love those little fellows.  They get through your skin, go on safari through your tissues, and then settle down to raise a family, letting their eggs cruise out through the intestinal wall or bladder wall to start life anew : )

I'll bet you've never seen an emoticon used in that context.

Every infectious disease physician and microbiologist I've encountered is that enthusiastic. At the ID conference I attended last fall, every presenter spoke with actual affection for his favourite microbe, announcing that he could talk about the subject all day long and sighing when his time was up.

Exhibit B would be their penchant for bow ties.

Obama

A New Mexican medical student shadowed me the other day. He was part of a group of American medical students learning about Canada's health care system.

I always enjoy having students - their youth and enthusiasm is refreshing - and this one was no exception. He had to duck out early to meet up with his group, and as he thanked me for my teaching he rummaged in his backpack and pulled out a pink envelope. It was deliciously bulky, and I set it aside to open after I had finished seeing patients.

At lunch I pulled out the card, and this fell out:

This amused me for the rest of the afternoon.

I am the least likely person to wear a button of any sort, especially a political one. Especially one touting the politics of another country. Did he assume I would be an Obama supporter because I'm Canadian and ergo a liberal? Because I'm a physician? Had the Republicans won, was there any chance that a medical student would have given me a McCain pin? I imagined how my colleague would have responded had a student given him a W pin four years ago. It would have been evaluation suicide.

I showed my gift to the front staff, who all admired it and hinted that they would like to have it. I declined. It was a thoughtful and unexpected gift, and the optimism of the medical student, the gesture and the prevailing mood of post-inauguration USA all came together for me in this small metal square.

So I'll be keeping it. But I'm as likely to wear it as a New Mexican physician would be to wear a Stephen Harper button.

Scars

The patient, an Iraqi man who spent the past four years in Jordan, heaves himself onto the exam table and settles back, head on the papered pillow. I ask to look at his belly and he pulls up his green knit sweater, then loosens his pants, untucks his checked shirt and tugs that upward, too.

I've seen a lot of abdomens, thousands and thousands, but I'm taken aback by this one. It's riddled with six-inch scars. It looks like graffiti, insolent purple strokes made on the sly. It's illegible to me. The marks aren't from trauma or torture; they're surgical scars in a foreign language.

If you lay a Canadian-born patient on my exam table and ask me to tell their medical story from their abdominal scars, I can give a fairly accurate account. The Pfannenstiel incision, a discreet line skimming the pubic area, suggests a Caesarean section. Three short, neat scars scattered over the right upper quadrant point to a laparoscopic cholecystectomy. The one-inch line angled over McBurney's point is almost certainly from an appendectomy.

But examining patients from the world over at the refugee clinic, I've seen many a scar that's baffled me. What surgery could possibly have required an incision running from under the right ribcage, across the belly to the left lower abdomen? What series of procedures would have resulted in a flank criss-crossed with red finger-length scars? Why is the appendectomy scar five times the length I would expect?

The preceding history is often vague. The Iraqi man tells me simply, "The surgery was to stop the pain in my stomach." I order some blood work and arrange an ultrasound to provide some clues.

There is a wildness to these scars. They startle me sometimes, they're so bold and unsophisticated. They make the Canadian medical system in which I am ensconced feel safe, careful, predictable and tame.

Striped

The Morehouse striped vest is off the needles.

This isn't a Sunday-best vest. It's meant to be worn Deep Cove-style, with rolled up sleeves, shirt untucked, ferns and pine needles snagged onto the back. When I knit something for a four-year-old, I fully expect it to be rolled around in.

It does work just as well worn reading Beatrix Potter in front of the fire.

The vest was a beginner-level project, knit with undyed Morehouse merino 2-ply in brown heather and soft white on 3.25 mm needles. The yarn was coarser than what I'm used to (but not itchy), and the needles smaller, and I enjoyed the change.

I've recently joined Ravelry, the online knit (and crochet) community, which allows you to organize your knitting projects, yarn stash and needles, and provides an extensive catalogue of projects shared by others. You have to apply to be invited to join, but I think that's just a manoeuvre to inflate members' sense of accomplishment and belonging. It's not like you have to mail them a swatch.

I'm feeling undecided about what to tackle next. A stuffed turtle? Some Elizabeth Zimmermann?

Or call it a season? I've been back to gardening already, we're planning our annual March-break California road trip and it feels like we're barreling towards spring.

Now that is creative nursing

I asked my sixty-four-year-old Karen diabetic patient if he got the flu shot this year.

"Yes!" he answered. "At church."

Most of the local Karens attend one of two churches in Langley. Turns out the public health nurse showed up at the patient's house of worship one December Sunday morning and vaccinated the eligible congregants, with the help of the interpreter who had relayed that morning's sermon.

A waterbed covered with flannel

I just came across the most accurate description of the postpartum belly I've ever read, and it wasn't in a medical text. Perhaps you should read this only if you've had a child; it's a bit much for the uninitiated.

People kept trying to prepare me for how soft and mushy my stomach would be after I gave birth, but I secretly thought, Not this old buckerina. I think most people undergoing chemo secretly believe they won't lose their hair.

Oh, but my stomach, she is like a waterbed covered with flannel now. When I lie on my side in bed, my stomach lies politely beside me, like a puppy.

- from Anne Lamott's Operating Instructions: A Journal of My Son's First Year

Nordic skiing

We took the kids nordic skiing for the first time on Saturday afternoon.

Realizing that  - especially for kids - the anticipation and memory of an event can be every bit as pleasurable as the activity itself, we began to whip them into a frenzy already as we ate our breakfast fruit souffle. They promptly donned boots, snowsuits and mittens and spent the rest of the morning with their over-padded selves wedged into their chairs at the kitchen table, trying to cut out paper Valentines with puffy mitts on.

Pete and I didn't have any lofty goals for the trip to Cypress Mountain, seeing it as more of a reconnaissance mission. We planned to check out the children's rental options, introduce the kids to locomoting on two extra appendages and perhaps, if we dared to dream, have hot chocolate at the lodge.

And success! Leif glided around like a true Norwegian. He did fall over a hundred times, maybe two, but he laughed every time. At one point I caught him scrambling out of the track, trying to breach a snowbank to ski into the woods in pursuit of bobcats, he explained.

Saskia sailed down hills with her braids flagging behind her, arms outstretched, pink snowsuit-clad legs wobbling.

We were happy that the kids were so game. I think gameness is an undervalued trait, and I hope they maintain it into adulthood.

Ariana was too small for even the tiniest boots, so Pete pulled her in a pulk. Truth be told, I'm not sure we could have handled a third one on skis.

We made it to the lodge. We had hot chocolate and poutine on a scarred wooden table in a dark room that smelled of wet clothes drying.

Happy and tired in the van at the end of the day, we snaked down the mountain with the lights of Vancouver and beyond sparkling orange against a dark blue-gray evening. Mission accomplished, and then some.

 PS The Sony has been hospitalized with a seizure disorder NYD and so I am back to a compact camera (Canon Powershot SD880) for the time being.

More Charley Harper love

I ordered some Charley Harper prints today. Vigilant Vireos for the living room:

Cozy Chipmunk for Leif's room, which is a similarly sloping, brown-sided space:

And The Sierra Range - my favourite - future hanging destination yet undecided. (Thanks to reader Elizabeth for alerting me to the Charley Harper posters available through the US National Park Service for a song.)

Total cost: $85.00 plus shipping. 

Tidying Saskia's room

I just spent an hour cleaning Saskia's room; most of that time was used to organize her desk. I separated beads from stickers, put the ink pads and markers out of her younger siblings' reach and threw out a million snippets of paper collected from previous cutting sprees.

I sort through Saskia's creative messes carefully. I discover drawings I've never seen filed away in drawers, and notebooks with the sweetest things documented: a list of what we had for Thanksgiving dinner; poems about animals; journaling about her day (I got up at 6:38 this morning. I read On the Banks of Plum Creek and did crafts.)

What strikes me is that for the last couple of years, the things she makes hold value for her whether or not her parents see them. Everything Ariana makes is shown to Pete or me so that we can exclaim over it. All of Leif's projects are gifted to us or Scotch-taped to his bedroom wall. Stumbling upon Saskia's projects that she feels no need to show us is bittersweet.

As it is now, Saskia is pleased when she comes home to a freshly organized desk. But I'm acutely aware that the day will come that she doesn't want me to touch her things. We've currently designated one desk drawer as private. (We discovered at Christmas that all those mornings crafting in the wee hours, she was churning out stocking stuffers and stashing them in the drawer. Six for each of us, and seven for Ariana.)

But that pocket of privacy is going to keep on growing.

And so I find nothing tedious about tidying my seven-year-old's room, and leaving the kitchen floor unswept to vacuum glitter off of the bedroom rug seemed a perfectly reasonable choice this stormy Monday morning.

I have a crush on Charley Harper

This is my current favourite children's book:

I ordered it for Ariana for Christmas. I postponed wrapping it for a week so I could look at it every night before bed. The images are that gorgeous and soothing. Now it resides in the little turquoise backpack Ariana uses to store and transport her prized possessions.

Charley Harper (1922-2007) was an American artist known for his geometric, stylized depictions of wildlife. He commented once that while some artists counted the feathers in the wings, he merely counted the number of wings. His images are simple, playful and brilliantly coloured.

Harper grew up on a farm in Cincinnati and enjoyed wildlife from an early age. I find stories of nature-loving children who grow up to become artists/naturalists immensely appealing. It seems so pure. And what better blend of art and science? (Robert Bateman's story is similarly pleasing - now there's someone who counts every feather in the wing.)

So now I'm trying to pick a print or two for our home. My job would be easier if the man weren't so remarkably prolific and talented. I will soldier on.

Happiness at home and in the clinic

The five recommendations for mental health from my previous post crystallized a few things for me.

First, it offers an explanation for why a day at the clinic is almost always extremely satisfying, whereas a day at home with the kids must be carefully crafted to provide close to the same level of happiness. I'm not talking about long-term gratification or blissful moments, where at-home mothering easily holds its own. I'm referring to my state of mind at dinner time, when I review the day.

Medicine has an advantage in that it inherently ensures that I connect with colleagues and patients, take notice of the details of others' lives, learn continuously and give to others. I tick off four of those five boxes just by going through my day. I check off all five when I hunt for free parking and walk eight blocks to the clinic.

Staying home with the kids, few of those five activities occur spontaneously. When the path of least resistance is followed, a length of time at home seems to naturally tend towards isolation, inactivity, monotony and boredom. Most of my days at home are pleasant ones, but only because of the work I put into making them so. Scavenging in the woods, photographing ruddy cheeks and muddy boots at the beach and meeting up with friends for afternoon tea at Honey's Doughnuts make for good days, but require concerted effort on my part.

Second, the list validates the time I take during the day for pleasurable pursuits. Knitting while the kids nap, bringing The Element of Lavishness along to the beach and fiddling with a setting on my camera during lunch are often accompanied by some guilty twinges. Shouldn't every moment with my children be devoted to them? And any spare ones be spent reading Parkhurst Exchange? 

But I see that all of my hobbies include several of the five happiness-inducing habits: photography involves learning and taking notice; writing requires taking notice, connecting with others and learning; and gardening entails being active, learning and taking notice. 

Now I can articulate why tucking away pockets of time for these activities during the day is not frivolous: it may quite literally preserve my sanity.

Five helpings a day for mental health

A few months ago the UK government's science and technology think tank Foresight concluded its Project on Mental Capital and Wellbeing.

The report includes an evidence-based list of five simple daily habits for mental wellbeing. These activities, which are likened to five daily servings of fruits and vegetables, are recommended to every person in the UK:

1. Connect with other people, be they family, friends, colleagues or neighbours.

2. Be active. Go for a run, walk around the block after dinner, putter in the garden or take the kids sledding.

3. Take notice. Be aware of the details of daily life - the beautiful, the humorous, the surprising. Be conscious of the world around you and your reactions to it.

4. Keep learning. Take a photography course. Learn to knit. Tackle a work problem in a different way.

5. Give. Show kindness to others. Volunteer. Support a charity. Donate blood.

The report, the result of a two year study involving over 400 international experts, concludes that making these five activities a part of daily life can have a profound impact on people's happiness.

We're a few weeks into 2009. Most New Year's resolutions revolve around physical wellbeing - losing weight, eating well and working out. We are attuned to the benefits of unprocessed foods, cardiovascular workouts and moderating caffeine.

But it's a little harder to be specific about pursuing optimal mental health, and therein lies the beauty of Foresight's concise, practical list. With some intention, these five could be seamlessly woven into most people's daily routines with little cost in terms of time or money.

Explanatory arm slings

Want to circumvent being asked "How'd you break your arm?" by every person you encounter for six weeks?

These explanatory slings by Brazilian André Montejorge of Bem Legaus are still in the concept stage and unfortunately aren't available for purchase, or so I gather through Google Translate.

(I first saw these at The Happy Hospitalist.)

Pain in his . . . what do you call it?

"Why did you come to the clinic today?" As the interpreter repeated the question in Kirundi, I admired the patient's hat. It was a crisp navy Canucks ball cap. I'm not into hockey myself, but it warms my heart to see refugees adopting the local sports teams. I wondered if it was a Christmas gift from a new Canadian friend.

"He has pain in his . . . uhhhhhh . . . in his . . . " the interpreter trailed off, stumped. English is her fourth language, and sometimes she struggles for the right word. My pen was poised over the chart, waiting. "Pain in his . . . ass!" she said triumphantly. "His ass." They looked at me expectantly.

I set my pen down. That wasn't going in the chart, not even in quotation marks. Was the pain in his buttocks? Perianal area? Rectum? Perineum? "Could you be more specific?" I asked.

Eventually, with some pointed questioning, I uncovered a story of what sounded like hemorrhoids.

I will not detail the digital rectal exam, but suffice it to say that positioning the patient was even more challenging than getting my patient to disrobe for her complete physical. I did manage to confirm the diagnosis.

After explaining the cause and management of the problem, I offered him some Anusol HC rectal suppositories from my cupboard and explained their use. As the interpreter passed on the information, I finished my notes, flipped the chart closed and stood up. 

"He's wondering, should these be kept in the refrigerator?" the interpreter asked me.

"No. They don't need to be refrigerated."

A long conversation with the patient followed. "Can they go in the fridge?" she asked me again.

"They don't need to be refrigerated. They can be kept at room temperature," I repeated.

Further discussions in Kirundi ensued. I glanced at the clock on my computer screen, eyeing the number of patients in my virtual waiting room. I was glad I hadn't asked about the hat; we couldn't have afforded the pleasantries. The patient's voice became urgent.

"He wants to keep them in the fridge." The interpreter was exasperated.

"Why?"

"His cupboards are very warm. He's worried the suppositories might melt, and then it would be too difficult to insert in his as-"

I cut her off before she could use that decidedly unmedical word again. "Alright. He can keep them in the fridge if he prefers."

As I followed them out to the waiting room, I thought how quirky and exhausting and oddly delightful the encounter had been, and how unremarkable the same visit would have been in a regular walk-in clinic.

That would hurt

Patient [edited to clarify: a recent immigrant]: "My eye hurts."

Me: "When did the pain start?"

Patient: "Five years ago."

Me: "Did anything happen five years ago that you think might have caused this pain?"

Patient: "Yes. I was walking in the bush in Sudan and a snake bit me in the eye."

Last one before I'm back to patients and disease

One feature of visiting Ontario that I particularly enjoy is the relaxing familiarity of Pete's parents' house. Every year as I set my suitcase up against the south wall of the bedroom and flip open the lid, top-heavy with balled-up socks and wads of underwear, it's like déjà vu.

The kids quickly reacquaint themselves with the wonders of Opa and Oma's house. There's the marvel of a dog sleeping in his bed behind the stove. ("I want to pet his hairs!" Ariana said over and over.)

There's another Christmas tree, with new ornaments to discover,

puzzles to do at the kitchen table,

and grandparents with whom to cuddle.

 

As for me, I read Twyla Tharp's The Creative Habit: Learn It and Use It for Life, knit up most of the Morehouse striped vest for Leif, drew up lists for the New Year, roamed around with my camera and didn't have to cook a single meal.

And when my brother-in-law asked me about a pain in his knee, it required supreme effort to recall anything medical.

Even better than brown thistles

So here's the reason we visit Ontario so faithfully:

There are twelve grandchildren and one on the way (that's not an announcement). The oldest is eight and the youngest, to whom I'm trying hard not to be partial, is three-month-old Katja Martina:

Three of the grandchildren are younger than Ariana, and that felt strange. It was odd not to pack a diaper bag and not to request 4L jugs of whole milk whenever Pete's mom headed out to the grocery store. I enjoyed not being responsible for keeping a little one from falling headlong down the spiral staircase to the basement or knocking a glass of red wine onto the cream carpet. Caring for three kids was ridiculously easy, relative to previous years.

My kids have one cousin in BC, but little PJ is regrettably infantile and has yet to realize any potential as a playmate. The Ontario cousins can play Stiga hockey,

* Josh & Saskia

have identical Webkinz (which can be identified by their peculiar scents, according to their owners),

* Saskia & Elle

and share confidences while lounging on the couch.

* Ava & Ariana

One of the best parts of Christmas was watching the cousins open their Christmas gifts at Opa and Oma's place. The afternoon sun slanted in the windows, Uncle Jack handed out the gifts from under the tree and the room overflowed with delighted squeals, shredded paper and one very big and blessed family.

* Opa & Katja

People often ask why I have "so many kids" - "stacks of babies" as one colleague puts it - and, while I think three is fairly modest, part of the reason is that I wouldn't mind being in the position of the matriarch in that first photo myself, one day.

Brown

We're back from visiting the family homestead in Ontario, to which Pete moved on his third birthday. This was my eleventh consecutive Christmas vacation there.

I've finally put my finger on what most defines the southern Ontario winter landscape for me: brown, brown in every shade and texture.

The vegetative architecture amazes me. In Vancouver, generally the expendable plant parts dissolve a month into the fall rains, and the remainder stays green year round. The stark, perfect forms of burrs and spent flowers at every turn were remarkable.

That's the kind of vacation it was - one with all sorts of treasures underfoot, and the luxury of time and energy to enjoy them. I hope your Christmas was similarly lovely.

More to follow.

Snowed in

Looking south from our place this morning. Neighbours staggered up the cliff to the right, Hamber Island to the far left, and SFU/Burnaby Mountain straight ahead, obscured by cloud.

The trails in the woods, over which I've struggled to push a stroller, made for a gentle, undulating toboggan ride to the village. Pete even pulled Ariana down a flight of stairs at one point.

The  south shore of the Cove.

Saskia resists heading out to the woods in the snow. She'd rather sit at home in front of the fire, as would I. I explained that it's good to get out every day, whether or not you feel like it, to avoid cabin fever.

"What's that?"

I defined it, and she remarked emphatically, "I'm glad no one in our family's ever caught that!"

Well, I'm relieved that those times I've been driven stir-crazy at home with the kids appear to have gone largely unnoticed.

A stop for Honey's doughnuts, that Deep Cove specialty that soaks the little brown bag with grease before you've even brought it to your table, and hot drinks.

Can't think of another place in which I'd rather be snowbound.

Advent ring

I wanted to do some kind of Advent countdown with the kids this year, something that would build up anticipation and allow for discussion about the meaning of Christmas, that didn't involve cheap foil-wrapped chocolate or me wrapping twenty-five times three tiny treats.

I found the perfect answer in this birthday ring, which I adapted for Advent. The wooden German-made rings are by Spiel und Holz Design, come in four sections and are available with twelve or sixteen holes. They hold candles, wooden figures, vases and picture holders. 

In our family, a different person selects an item for the ring each day. We light the candles at dinner time, and little hands position the donkey and the ox to gaze at whatever's deemed most exciting in the ring that night. 

The setup is flexible. I've arranged the quarters in all sorts of ways, and in the first week sometimes put out just the piece or two that was in use, not the entire ring.

I'm already looking forward to using this for the next birthday (Ariana's in May). I plan to pick up a few more figures that would particularly appeal to her, and to put photos, cards and notes in the holders with Leif and Saskia the night before.

There's actually a spiral that's intended specifically for Advent. However, the shape doesn't appeal to me, and I didn't want the cost and clutter of buying both the spiral and the ring.

It doesn't bother us that we're only counting down sixteen days until Christmas. I could use a bit of leeway in the first weeks of December, anyway.

* Ring, candles and ornaments purchased from The Wooden Wagon and Nova Natural Toys + Crafts.

Good doctor qualities can be liabilities in family life

Like most physicians, I thrive on competition. It's always motivated me, and winning is powerful affirmation. But motherhood is a different beast from the MCAT, pharmacology prizes and residency applications. No one's going to come out on top, and comparing yourself to other mothers is futile and dangerous ground. The competitive mother after gold stars is the one no one wants to be around.

The satisfaction of measuring performance by objective standards at work cannot be achieved in the same way at home. I can pick up the faintest of heart murmurs, I can suture a laceration beautifully, I run my clinics on time, but how do you grade yourself on raising a daughter well?

- Excerpts from my post today at Mothers in Medicine.

Nativity set

I've been looking for a nativity set for ages.

Several years and many Internet shopping excursions later, I've collected the ox and the donkey. That's it.   

That's because the options out there are these:

the obscene,

the anemic and vacuous,

the wooly Waldorf,

the folksy,

the inaccurately ethnic,

the unaffordable ($1,100),

and the vague and washed out.

Actually, Ostheimer (above) and Engelberger (first photos), both German wooden scenes, appeal to me the most. But I'm not sure I like them enough to go for the entire set. And so we settled for the two Engelberger animals this year.

The hunt for a beautiful, child-friendly, respectful, well-crafted crèche will resume next year.

Examining teeth with a stethoscope

I was examining a patient with Parkinson's disease.

His left hand knocked rhythmically against the exam table at four beats per second, until he sat on it in frustration. His writing sample showed tiny Farsi script. When I extended his forearms, the movement was stiff and jerky, with classic cogwheel rigidity. 

As I rapped on his patellar tendon with my reflex hammer, he interrupted me. "I would be obliged if you would examine my teeth with your scope," he entreated through the interpreter. He hadn't complained of dental pain, and I gestured questioningly at the otoscope. He shook his head and pointed to my stethoscope. I handed it to him. He put the bell over his cheek and I slipped the ends into my ears.

I stood there, the stethoscope pressed against the grey stubble of his jaw, listening. And I was amazed to hear a loud, rapid, relentless drumming. His teeth were chattering. It sounded like the racing heart of a wild rabbit, jackhammering in a little ribcage. Though I had noticed a tremor in his chin earlier, the rattling of his teeth was inaudible to the naked ear.

I finally removed the stethoscope from my ears, and looked at his silent, quivering jaw.

"You learned something!" announced the interpreter. She's watched me use my stethoscope hundreds of times, for a dozen purposes, but this was a new one.

"Did your doctor in Iran listen to your teeth?" I asked the patient.

"Yes." He looked at me owlishly and blinked once, slowly. But even through the Parkinson's mask, I could tell he was pleased.

Affectionate diminutive

Me, handing my card to a patient and tapping the tiny font that spells out my name: "I want you to come back and see me in two weeks. I'm Dr. Scholtens."

Patient, with a thick Farsi accent, after closely inspecting the card: "I call you Dr . . . Scholly?"

Me: "No, no. Dr. Scholtens. Schol-TENS."

Patient, decisively: "I call you Dr. Scholly."

Me, acquiescing because it could be so much worse: "Please come back in two weeks."

Tunic

When our driveway is littered with cedar debris, night falls shortly after Saskia comes home from school and my slippers stay on all day, it's time to knit. The last two winters I took on adult projects. This year I'm knitting for the kids, those perfectly small and forgiving recipients.

I just finished Morehouse Farm's Child's Tunic, in their merino worsted weight natural brown heather with white trim. Merino wool is lovely because it's not itchy. I love Morehouse Farm's undyed wool: this brown heather is 65% white wool blended with 35% brown, which is black wool bleached chocolate by the New York State sun.

After placing my order in October, I waited impatiently for it to arrive. I could track its progress online, and it sat at Customs in Montreal for weeks. It didn't seem right that a small box of wool could be regarded as possible contraband, and I was so annoyed with the wait that I decided I didn't want to knit this season after all. But when the parcel arrived on my doorstep one grey, wet afternoon I forgot my resolution and cast on the first stitches before the cardboard was even in the recycling.

I so enjoy that knitting is portable, and that little bits of my travels get worked into the garment. The cast on was done while Pete's mom was visiting; the stitches were divided for the front and back while waiting for the ferry in Tsawwassen; the back was knit in the atrium of the Empress Hotel; a perfect three needle shoulder bind-off was executed in Parksville one evening while deer grazed outside the cabin; and the sleeve cuffs were finished on a Sunday afternoon at home in front of the fire.

No part of this sweater was knit at a medical conference.

Morehouse included a postcard with my order, and Ariana was enchanted when I explained the link between the sheep and her sweater. She carries the card when she wears the sweater, and it's worn and bent with her two-year-old affection. "Wool! Sheep! Sweater!"

This was an easy, beginner-level project. As always, I tweaked it a bit. I knit buttonholes and sewed on some sweet wooden apple buttons, but disliked the cluttered end result and went for a clean crocheted finish instead. I also lengthened the sleeves.

Now, Saskia wants a toque and Leif has requested a vest, scarf and slippers. I'm happy to oblige.

Forcing bulbs

Every day that I'm home that's not rainy, we head out to the yard for an hour or two. The kids tie their bikes together with skipping ropes and I putter in the garden. There are few things that I enjoy more than moving dirt and rocks around while the kids play, squirrels chatter and boats drone up and down the Arm. But it's almost December, and I know our days are numbered.

When I picked up a few hundred bulbs last week, I decided to get some hyacinths and paperwhites (white daffodils) to force indoors this year. The idea of tricking bulbs into thinking it was time to bloom captivated the kids.

For the paperwhites, we put some pebbles in the bottom of a glass (with much analysis of the merits of each stone as it was carefully placed by little fingers), set the bulb on the rocks and added water until it was just touching the bottom of the bulb.

That was Thursday night. On Saturday morning Saskia and Leif literally screamed with excitement when they noticed the hundreds of little roots budding from each bulb. I have to admit, I was pretty impressed myself. And at a dollar a pop, this is the most affordable fun we've had in a while.

For the hyacinths, we set the bulbs in hyacinth glasses, added water, and set them in a dark cupboard in the cellar. They need an eight to ten week chilling period before they can come upstairs to bloom. I'm limiting check-ins on those ones to once a week. 

I do find the term 'forcing' bulbs a little off-putting. It sounds so unnatural. And when I read that a forced bulb will not usually bloom again because of the tremendous amount of energy required, I felt a little pang of guilt.

Hopefully that will abate when I have a windowsill full of narcissi blooming in December.

For more information, HGTV has a good article on forcing bulbs.

Please remove your clothes

Everything at the refugee clinic is complicated.

Because most patients do not speak English and come from cultures vastly different from Canada's, the simplest tasks become difficult. Taking an obstetrical history, explaining an ultrasound procedure, defining anemia or recommending aspirin are challenging.

Then there's the physical exam.

My obstetrical patient today was due for her complete physical. After explaining the procedure, I handed her a gown. "Please take off all of your clothes," I said, miming the removal of my own shirt and pants, "and put on this gown."

The Swahili interpreter repeated my instructions, the patient smiled and nodded, and I pulled the curtain between us. I heard brief rustling; then all was still. I looked around the curtain to see the patient lying supine on the table, fully clothed.

"Please remove all of your clothes," I reiterated, again supplementing with gestures. "I need you to take off your shirt, pants, bra and underwear. Everything." She made an exclamation of understanding and I turned back to my desk to prepare the requisitions.

When I next pulled back the curtain, the patient was lying full-length on the table, pants on, sweater half over her head, with her bra bunched around her throat. This time I addressed the interpreter directly. "She didn't understand. She's still dressed. All of her clothes must come off."

Shortly thereafter I heard a burst of activity behind the curtain. I looked in to see the patient standing on the table. My six-foot pregnant patient was briskly disrobing while standing on a slender vinyl-covered exam table forty inches above the floor.

I decided it was safer not to intervene, and went back to assembling the speculum and swabs. A moment later she called out that she was ready.

And she was, lying on the table, naked, with the gown rolled up into a ball and tucked beneath her head.