I Left My Heart In ...

Unless you are in the Bay Area, you may not have heard all of the hullabaloo stemming from a Facebook comment by a restaurant patron here in San Francisco about taking children out to eat in public dining venues.  So as not to bastardize, let me quote directly.  After an, apparently, particularly disruptive experience at a small sushi bar in the Cole Valley neighborhood, this diner said:

This may shock you, but choosing to have children means you can't go out to eat for roughly three years.  Please.  Accept your fate -- you're killing me. 

The hubbub that ensued was not just because this -- kind of hilarious and kind of true statement -- was simply offensive to some in its own right (which it clearly was), but because Jennifer Bennett Piallat is the owner of a very popular and somewhat family-friendly restaurant in the very same neighborhood. Yes, both of my kids have eaten there.

So, obviously, I'm not here to take down Ms. Piallat.  I totally feel her pain. I mean, I lived in Berkeley for many years.  That place is like a haven for tiny Kasper Hausers with the parents looking deep into their home brews or bong water while the kids take over Chez Panisse with their mothers' knitting needles.  I did however, make a call to a local radio program when talk of this incident turned into a full on take-down of children in San Francisco.  I felt that this truly pointed to the larger problem of a growing intolerance toward children in this city, or perhaps in the culture at large.  (Though, I really can't say with any authority, as I have lived in the Bay Area for twenty years now.)  But it is true that there is a real disdain for children in many parts of this city.  Not just restaurants, but museums, parks, markets and certain districts altogether.  When I pointed this out to the public radio listeners, someone responded to me with the following comment:

SF is an adult city for adults.  Only ten percent of SF's population are in elementary schools.  Per SF Unified [School District], of children born in San Francisco, one-fourth will leave before they reach Kindergarten age.  Half will enroll in public school.  Of these, 13% will leave before eighth grade.  

Funny, this somehow doesn't seem to me like some sort of boon for the city of San Francisco. Also, just for a quick history lesson for my statically-rich friend: it is also a city of urban renewal movements in which historically black communities (read: families and their children), like the Western Addition and The Fillmore, were totally displaced.  This movement by landowners and developers is not so different from that occurring today in traditionally ethnic communities like The Mission District.  So, yes, San Francisco is moving toward becoming an "adult city for adults" but the cost is very, very high.

It is well-known in this area that there is a flight of families from the city to the suburbs because it is unwelcoming in its prohibitive cost, its poor public school system and its inhospitable position toward children, particularly those in poor and 'minority' families. That is making the city "older, whiter and richer".  It's like Hamlin.  All of the children are led out of this city before they can cause any trouble. Doesn't that strike anyone as both sad an ironic?  That we displace children so that we can have a little peace?  Would we like for those children to grow up without all of the culture, art, history and beauty that this city has to offer? Once the children and their families are gone, isn't the city less culturally rich?  We would rather that children grow up in the suburbs without the influence that we, as city dwellers, could exercise?  I mean, as urban adults, we have a lot to offer.

And so do the the children.

In the end, I found the argument that followed the Zazie incident very disappointing.  The moral tone about the right kind of child and the right kind of parent feels very heavy handed (and very, very dominated by the elite, upper middle class in this once-diverse city -- myself included.)

I have been raising two children in this city for fifteen years and it is still a very difficult place to feel welcome as a family, no matter the behavior of the parent or the child.  We have navigated the very treacherous public school system and put our hearts, souls and wallets into its arts and music programs. And we have the time, the energy and the resources to do that.  Many life-long San Francisco residents do not.

Parenting is a difficult transition under any circumstance, but it really helps to have a community that makes you feel welcome and tells your children that they are valued and loved.

At least as much as the dogs.

...So Rudely Placed

Well, what do you know?  A big thanks you to a super-friend who reads the blog and passed along a recent reference to this research article entitled  "The Impact of Rudeness on Medical Team Performance: A Randomized Trial".  Or, if you don't read research articles, here is the referential article from New York Magazine.

In short, the research supports my premise from the post entitled "There's A Hole in the Sky" that aggressive behaviors between health care providers can negatively affect health outcomes.  This study, published in the September issues of Pediatrics, assessed 24 NICU teams during a simulation involving a preterm infant with a seriously deteriorating condition.  During the simulation, half of the teams were exposed to rudeness by a third party provider and half were not.  Blind judging of performance and decision making determined a 12% variance in diagnostic and procedural outcomes for those exposed to rudeness.  

Don't think that's particularly significant?  Statistically speaking it is.  In fact, that is almost 3 of the 24 cases where mistakes were made.  Now isn't that something? Especially when you imagine 3 in 24 preterm infants with rapidly deteriorating conditions being treated by teams whose communication is so impacted by this kind of mistreatment that procedures and diagnoses fail. Tragic.  

Oh, the Milk Train Used to Rumble My Shack

A troubling pattern in obstetrics is the absolute insistence on exclusive breastfeeding for every woman and her child.  And I don't have to say too much about it, because Courtney Jung did so very nicely in her NYT piece entitled Overselling Breast-Feeding.  

From my own perspective as a women's health provider, I would put far more emphasis on the cultural and social norms that we often overlook when insisting on breast exclusivity, and specifically what it means to be young and/or poor and/or the victim of some sort of sexual violence and how this insistence negatively affects those women long-term, specifically in relationship to their children.

Let's support women to be mothers rather than enforce moral positions about what we expect of womanhood and motherhood.    

There's a Hole in the Sky

Nursing education dedicates a great deal of time to scaring nurses to death.   There are two ways that this is accomplished.  The first is to show innumerable films, provide massive amounts of literature and invite endless speakers to discuss the endemic problem of medical error.  The Josie King story was presented to my graduate cohort twice and it was presented once again when I began my current job. Rightfully so.  Medical errors kill 44 thousand people every year in the U.S. alone. Consider, by comparison, that 347 people died last year from drowning, 10,000 in drunk driving accidents, and 23,000 from drug overdose.  Add those up and it still doesn't number those lives lost to preventable medical error.  

The second scare tactic in nursing education is to "prepare" student nurses for inevitable hazing by doctors and senior nurses in the workplace.   This horizontal and lateral violence is described very matter-of-factly, as a sort of ritual for becoming a good and seasoned nurse, as if we were about to rush a fraternity, but without any choice in the matter - or a sweatshirt to wear after its all over. Perhaps that is because it isn't ever over.  

After having experienced this abuse first hand, and having witnessed a fair number of medical errors in my seven short years as a nurse, how is it, I wonder, that these two issues have never been discussed in tandem, as directly correlated, one to the other?   

This all came to me just last week when I was working with a particularly difficult provider.  She not only undermined my skill as a nurse, but resorted to nuanced, but embarrassing, condescending and personal attacks.  This was in the room of a patient and her family.  Because it went on for the good part of an hour during a particularly long procedure, I had the time to reflect on how I would deal with the situation out of the company of the patient, in a forward but politic manner.  My decision, in the end, was not to address it at all.  This is what we are taught:  ignore this unnecessary and inappropriate exercise of power, or lash out to "gain respect" from those providers who are notoriously abusive.  The latter is a widely accepted social mechanism within the culture of medicine that is, to my eye, sophomoric.  It would be ludicrous in any profession to retaliate, but particularly shameful in medicine where peoples' lives are at stake and promoting anything but cooperation among caregivers is an utter absurdity.  

During my own recent incident, I became acutely aware of the effect that the shaming - or to call it out as what it truly is, the bullying - was having on my physical and emotional state and my critical mental processes. I pride myself in being pretty cool, calm and collected in medical emergencies and being a critical thinker under virtually all circumstances.  Both of those assets seemed to totally dissipate with each abusive remark and, instead of  thinking about the work at hand, I became aware of a number of physical and mental changes: 

• I felt hot and sweaty.  I felt flushed. My skin was prickly and my heart was beating hard and fast. That is to say, I was aware of my heartbeat and breathing which any healthcare provider will tell you is not normal. 
• I was having trouble making decisions and responding to requests, directions and questions from other people in the room.   I didn't feel that I was "tracking" well and found it difficult to make decisions and to move as quickly as I typically do while performing tasks that require full concentration: administering medications, changing IVs, attending to the patient, using the EMR, setting up instruments, lights, taking/transcribing verbal orders, etc. for the provider, supporting my patient and her family.  I was basically finding it impossible to multi-task because I was so focused on not responding to the bullying.  The single task to which I was attuned was my dynamic with the provider.  

This is essentially the worst position to find yourself in as a nurse, because you are running an extraordinarily high risk of making a mistake.  Had I not been in my then-current-but-atypical self-possessed state-of-mind, I would have reacted and responded without much self reflection, almost immediately, which is a terrible approach.  It is the absolute wrong thing to do because the patient then has two providers operating in the same reactionary way toward one another and their actions and thought processes are totally unrelated to patient care. 

According to an American Nurses Association study, 56.9% of nurses report having been threatened or experienced verbal abuse at work.  48% report "strong verbal abuse" on a regular basis. Physiologically, the reaction to stress is embodied in such a way as to make goal-directed decision making impossible. Studies have shown that plasma levels of glucocorticoids and catecholamines increase, causing "increased cardiac output, skeletal muscle blood flow, sodium retention, reduced intestinal motility, cutaneous vasoconstriction, broncho-dilation and behavioral activation" while insulin drops, leading to stress related hypogylcemia, which essentially explains all of the physiological symptoms I had in the interaction with my provider.  Furthermore, when this happens there is an imbalance in hormone levels that can also produce functional neurological changes causing us to resort to habitual coping mechanisms rather than higher level decision-making strategies.  If I were a patient or family member, I would never want a nurse or doctor with inhibited decision-making processes providing care. 

The last thing healthcare providers need in our already chronically stressful work environment is a social and communicative structure that normalizes institutionalized abuse leading to even more stress. The question is how to go about breaking the cycle of power and the incessant bullying that goes on in these work environments.

For once, I think I have nothing to say on this matter: no solutions, no recommendations, no ideas. And the reason being is that the bad interactions that I have had in the last few weeks have been so demeaning and demoralizing that all I can do is replay them.  This does not mediate the unhealthy dynamic nor diminish the power of the shame.  In order to dedicate oneself to the mindful intention of living a good, meaningful and quiet life - and being an effective healthcare provider -  it seems impossible to carry these incidents long enough to come up with a logical solution.

Basically, in penning this post, I have demonstrated that this kind of abuse immobilizes us all - even those, like myself, who virtually always have something to say.  It paralyzes those trying to do right by others as much of the time as possible, those seeking peace in their everyday lives, and those who we inherently expect to protect and preserve the lives of others.  

How can that be? How can we let it be?  

But Always a Woman

Don't look at the #justanurse hashtag.  Don't do it.

Okay, so you did it.  Regrettably, so did I.  And yes, I watched both the Kelley Johnson monologue as well as the play-by-play commentary on The View.  Proud to say a couple of firsts - both for the talk show and the pageant.

So, anyway,  let's have a conversation here, nurses, because the reactions to this thoughtless and, yes, purely sexist response are, for the most part, not helping matters.
For example:



Here are some of the above reactions (those which aren't shameless selfies) in words:

"Nurses be like, that bitch said what?"
"One does not simply insult a nurse and get away with it"
Man in drag cocking handgun: "Nurses be like.. say Dr's stethoscope again"
"I'm more than smart enough to be a doctor but I choose to be a nurse." 

And, finally, while there is so much more to make your heart heavy,  please tell me what healthcare provider - what nurse -  took this photograph, in a medical setting, and deemed it appropriate (an not a humongous HIPAA violation, not to mention seriously ethically repugnant) to post to social media - specifically, for the sake of some inane argument about whether or not nurses use stethoscopes. Wildly, wildly inappropriate and - along with the other examples above - some of the likely reasons nurses are disrespected in the media and, more troubling, in the workplace.

So, what's the problem here?  I'm not even going go to the trouble of mentioning that this started with the Miss America Pageant.  Because didn't we protest this outdated and, frankly hilariously ugly step-sister to real life sexual politics, in like 1969?  And we are talking about  - and defending it as a legitimate forum for professional women - why?

But this being CircusNurse, let's talk for just a minute or two about nursing.  And let's talk about how is it that you would like your profession to be represented.  As better than doctors?  As charity? As a profession of martyrs?  As tough?  As kind?  As a profession of women with a few nice men thrown in for good measure? (These are by no means my ideas; they have been repeated in spades over the past two days.)

First of all, let's stop with the feigned machismo.  Nursing is a profession, meaning that we are supposed to be professional.  This does not mean wearing tee-shirts exalting how we are here to "save your ass, not kiss it" or proclaiming that one should "Be kind to nurses. We keep doctors from accidentally killing you."  This nonsense needs to stop.  Particularly if we want to be taken seriously in the field of medicine.

Secondly, nurses are not doctors.  And our general education and ability to accept the fates and circumstances of other people  - without exerting power - is quite poor, or at least suspect, much of the time.  But I discuss that, at length, here.

Finally, nursing is not about being a saint.  It is not about charity.  My husband and I were just having this conversation last night: once something is deemed charitable, it becomes an inherent exercise of power. Nursing, at its very best, and, frankly, at its very worst, should be about bearing witness.  It is not our place as nurses to co-opt another person's experience, but to be a testament to it.  As healthcare providers, we, hopefully, extend our kindest and strongest professional hands and minds to guide patients though difficult times.  And we witness the joys and sorrows therein.  But we should never mistake this experience for our own.  Many nurses will disagree with me here.

I think there is a really difficult truth attached to the identity of nurses that was illustrated by the monologue which generated this whole debate: once caregiving becomes an interpersonal exercise and identity, we abandon the professional role and we can no longer fairly provide our patients with appropriate guidance.  Many nurses pride themselves in the feelings of nursing, the feeling of being a nurse -  but feelings become a very slippery slope when they can't be separated from one's identity and politics.  We have to stop and ask ourselves, what is behind casting ourselves in a specific light? What is hidden beneath our self-proclaimed altruism?  I have never heard a person who truly provides care for and is compassionate toward other people discuss that care in a self referential manner: that is what makes it selfless. Being a nurse should never be about what one is - or what one is not - in relationship to our patients.

This "just a nurse" rhetoric - which has been around for years and is not actually a clever creation of Ms. Johnson - is a detractor and a way to prioritize the experience of the caregiver over that of the patient.  Listen to that monologue again with this in mind and tell me if is is about the experience of the Alzheimer's patient in this nurse's care or the nurse and her identity.  Now listen to it yet again and convince me that her retelling of the story in that particular forum is not about her politics. Finally, sit back and think about it for a few minutes and offer to me any part of her story that feels like it serves the patient and his family in any meaningful way.    

But, I digress.  Back to square one.

This is all actually about the image of the nurse in American society, right? No.  It really isn't.  Even though I've stood so tall on my soapbox for these many paragraphs, I take my thesis back.  It is actually about the role and the image of women in our society.  And, as usual, we are called out in a sexualized and objectifying forum as not being woman enough.  And we are, yet again, called out... by other women.

Hasn't anyone else grown tired of this yet?

The Little Dog Came From You

Yeah, I admit it.  Calling your dog your child is pretty irritating to me.  I hate to be one of those parents, but I am. (For the record, I was that kind of person before I was a parent.) I grew up around lots and lots of animals and we called them pets, or cattle or fowl or the horses - what have you; we didn't call them people.  But that is beside the point, really.

I have been struggling to figure out how to respond when someone likens their "son" (dog) to my "son" (not dog) as in: "My son (dog) got me up in the middle of the night last night to pee!" My son (not dog)  got me up in the middle of the night, too: for a wet diaper, and to nurse and then to be put back to sleep. And my other son (not dog) kept me up the first half of the night, I terrified, because he is a teenager and well, that is life with a teenager (not dog). "Can you believe these children?" (your dog/ my not dog). No, I can't. These children, humans, little souls, astound me every day.

I mean, I appreciate the sentiment and the love, so I don't want to be inhumane to the 'animal people'. So, I mentioned it to a friend. What to do?  How do I hide my disdain?  How can I be more open and tolerant and appreciative of this boarding-on-disordered-personality* doglove?

I thought she hadn't heard me until later when she said, "Hey! I took my animals to the Santa Cruz beach boardwalk this weekend.  Want to see a picture of them on the roller coaster?"  Best response ever.

*Cluster A: Odd or eccentric behavior / Cluster B: Dramatic, emotional or erratic behavior / Cluster C: Anxious behavior.  See? 

How About a Thank You

John Stewart: Patron Saint of Liberal Smugness   

This pretty much sums up perfectly my longtime feelings about Jon Stewart and most self-described liberals that I run across these days - which is fairly often, this being the Bay Area and all.

"Many liberals, but not conservatives, believe there is an important asymmetry in American politics. These liberals believe that people on opposite sides of the ideological spectrum are fundamentally different. Specifically, they believe that liberals are much more open to change than conservatives, more tolerant of differences, more motivated by the public good and, maybe most of all, smarter and better informed....And Mr. Stewart, who signed off from “The Daily Show” on Thursday, was more qualified than anybody to puncture this particular pretension. He trained his liberal-leaning audience to mock hypocrisy, incoherence and stupidity, and could have nudged them to see the planks in their own eyes, too. Instead, he cultivated their intellectual smugness by personifying it."   

Follow the above link for this very thoughtful piece from the NY Times.

And while we are on the topic, particularly in light of Stewart's take on race and violence and his call to face our "depraved" racial history, I think it is important point out how truly fatiguing it is to listen to people whose superiority on issues is at odds with their actions*. A particular cringe-worthy expression, which one hears all too often in certain circles, is the claim "I don't see race".  Oh really? Because that kind of makes you sound racist. Sorry. There is a lot you are not seeing if you don't see race.  Especially as a white person. I suspect that this is where Stewart was coming from in this much publicized problem with Wyatt Cenac. We all, as white - specifically liberal - Americans are at a risk of  this very same thing: of not recognizing our capital and power and, if criticized and defensive, we are at an even higher risk of revealing what lies beneath.

So in light of The Times piece, isn't it just a simple truth that self reflection requires some real generosity toward whomever is on the other side? This remains the problem I have with Stewart and his legions of fans:  detractors, whether they are conservatives, opposing network talking heads or peers and colleagues who disagree with your position, cannot simply be dismissed as stupid, sensitive, cultureless and oblivious. You have to understand the perspective of other people in order to truly understand yourself and the impact you are making on the world - even if, like Stewart, you claim it is not your job.  Particularly as a public figure, even if satire is your game, it should be a weight that you carry, knowing that what you are putting out into the world - even if it is fake news, or "perspective" news -  may be is the primary source of influence for many, many people.  It is your job, perhaps more than anyone else's, because it is like parenting, where your actions and words completely and totally inform those who aspire to be like you... whether you like it or not.

*If you listen to this full clip entitled "Stewart Eviscerates Stewart", it fits perfectly with Alexander's critique of Stewart's self-effacing yet aggrandizing approach that tends to mock his detractors rather than offer any real self reflection or demonstrate to his audience how to be even the least bit contrite.  

Ghosts and Empties

Thank you, New Yorker, this is something else. 

We Are Not Makers Of History, We Are Made By History

It never fails to surprise - strike that - shock me how healthcare providers talk about patients.  For a long time I thought it was the result of intolerance -  religious, ethnic, cultural, economic - or doctors and nurses feeling superior to and wanting to control the behaviors and experiences of patients. However, the more I truly listen to what providers are saying to patients, and, perhaps more telling, to one another, the more I realize that it is fundamentally about a lack of historical understanding.  How are we situated in this particular cultural and historic moment and what has come before that has informed our current consciousness?  I have lamented here many times that I am struck by our very poor historical memory.   I have come to realize this is not the issue at all, for how can one remember something that was never learned?

Recently, I have begun to think about how both medical and nursing training are sorely lacking in any basic, general education.  Bizarre, I know.  How could we not be educating the professionals whose sole purpose it is to understand people, not only by way of the body, but through culture, day-to-day lived experience, family, work, etc?  How can an educational system train providers to diagnose without teaching them to situate absolutely every situation presented in history? Why do doctors and nurses speak with such confidence and attitude in regard to their own judgement of patients, but often lack any real understanding of the historical experience that has informed a patient's entire existence?  

Undergraduate study in the United States is, to my eye, a sad reflection of our general society in its total lack of basic education.  As for medical school, it teaches the minutiae of pharmacology, pathophysiology, microbiology, microorganisms, pathogenesis and much more precise practice and knowledge geared toward specialization. Medical students, as a whole, have some grounding through a four year university education in which, during the first two years, they fulfill the basic requirements which probably include things like reading The Yellow Wallpaper or sampling a bit of Aristotle.  Nursing school, on the other hand, is solely focused on systemic education and the making of healthcare providers. And while it may include some cursory ethics and "cultural competence" classes, it totally and completely lacks any rounded general education, even in the simplest form.  

Read Mark Twain? How about James Baldwin? Can you find Uganda on a map? How about Yemen? Can you name a logical fallacy? Can you tell me about Plato's cave?  Have you seen the work of Jacob Lawrence? Can you tell me about the Dawes Act or perhaps Japanese internment or what about American eugenics?  In my experience with both groups, for the most part, the answers are no.

So this lack of historical understanding and educational/ cultural paucity leads us to one place, the place where I end up stuck many times when interacting with healthcare providers.  On an almost daily basis I ask myself: What is it about poor people and procreation that healthcare providers find so intolerable?  I hear said that it has to do with  "dependence upon the system", "skyrocketing healthcare costs" and "inappropriate/ overuse of social services." (Direct quote "I'm all for discouraging the poor from having many children").  I also hear this animosity couched as concern, as in "risks of multiple pregnancies", "poor maternal and fetal outcomes" and "welfare of the children".  These concerns, however relevant, are never discussed in reference to middle class/upper middle class nor, specifically, white families having more than two children.  It is true that it is not the norm, generally speaking, for the upper middle and upper classes to have large families, but it is true of the rural poor and I suspect the same feedback would be found regionally.  That having been said, as you may have gathered or intuited, fertility trends by social status tend to show a decrease in reproductive rates as a group gains higher status.  The simple explanation is that this can, of course, be influenced by education about, and access to, contraception. But there are much more complex social patterns related to education, women in the workforce and the perceived social potential of a childfree lifestyle.  Additionally we would have to consider the historical trend toward more children in the lower classes as a form of familial support, historically high death rates and, of course, the growing gap between the rich and the poor. If you want to take the evolutionary biology perspective you could argue that this is simply the result of growing up in a "harsh, unpredictable environment... where you might die young [and therefore requires] a fast reproductive strategy - grow up quickly, and have offspring early and close together." Interestingly, the desire to attain a higher social status has a direct correlation to the decrease in fertility among individuals; research indicates, however, that maintaining one's social status does not necessarily have this same attributable effect on decreased procreation.

So what about being in healthcare has this influence upon perception of other people's fertility and personal life choices?  I heard recently a woman who had three children at 24 years-old referred to, with absolutely no irony, as a "repeat offender".  There will be audible "tsks" if a woman is a gravita in the double digits, regardless of the number of children she has borne and without consideration of the number of losses whether terminated pregnancies or spontaneous abortions, because we have no access to this information unless we are a clinician providing direct care.  Not that these numbers should matter in our treatment of the patient for her current pregnancy.  The most recent untoward discussion to which I was privy was in regard to mandatory hormonal contraception upon discharge from a hospital or birth center for women of lower SES after delivery of the third+ child.  I should say here that this discussion did not take place in the institution where I was educated nor where I work, nor was it presented as a recommendation (though one of the providers did claim that it was a standard practice in a medical center in which s/he had worked several years prior).  The idea was being tossed about more as an illustration of how one might control behavior via procreative limitation: specifically, controlling the behavior of people who just happen to be poor and largely from minority groups.  When I called the plan out as dangerous in terms of its ignorance of our history of eugenics, I was quickly rebuffed with the response that it was simply "making free birth control available to the poor."

So you can call it paternalistic or call it an effort to "save people from themselves" (more common hyperbole) but if you're going to call it anything, you'd better also include calling it a contemporary branch of the eugenics movement and way to control behaviors that we find repugnant.   Namely all of the behaviors associated with being poor. And if you want to do something about it, start with a history book and a bit of mercy.  

Blindlessness

For your viewing/listening pleasure.

You're welcome.

"I don't think we did go blind, I think we are blind, blind people seeing, blind people who can see but do not see." 
- José Saramago, Blindness

Raise Up, Baby, Get Your Big Leg Offa Mine*

Sphinx #2, From The Full Body Project by Leonard Nimoy

An important piece appeared in the NYT Science Times yesterday discussing weight and bullying. I wanted to share it here because of some significant, if nuanced, facts that arose toward the end of the article. Specific to healthcare and the way in which patients are treated in the medical setting, it seems advantageous to both parties, understanding how body size does not necessarily reflect any measurable health outcomes nor tractable patient behavior.  I have reflected here before on the use of BMI as an outdated standardized measurement of health and lifestyle and have lamented that it seems particularly problematic when assigned as a health marker in my field of obstetrics.  Here is the bit from the NYT article that is taken from a 2014 CDC report:

"A study of more than 400 doctors found that one in three listed obesity as a condition they responded negatively to, ranking it just behind drug addiction, mental illness and alcoholism."  What's more, "while some healthcare experts acknowledge that individual genetic and metabolic differences mean that some people are more prone to gain weight than others, the most widely disseminated public health message is that anyone can achieve a desirable weight by eating less and exercising regularly."

Drug addiction, mental illness, alcoholism, obesity: I think we can agree that these are all very sensitive issues among healthcare providers. I would include pain and poverty in the list of things that can send doctors and nurses into a tailspin. (Is the patient rating her pain an "8" while she talks on the telephone or eats a hamburger and does that make you angry?  Do you sound off to your colleagues when a patient takes an ambulance to the hospital for nothing other than early labor, or a twisted ankle, perhaps because she has no transportation and lives in a dangerous part of town? Then you have experienced the problem, maybe without even knowing it.)

My suspicion is that these issues reflect one simple, unifying vexation of the healthcare provider. That, quite simply, is control.  Whether grounded in a belief that the patient has no self control, no pain control, no control of the everyday necessities of living, or of the provider's desire or need to exert control, it seems that patient experience (which some may label "behaviors") and differential existence (as in, different from our own) are something that we need to learn to incorporate in a more inclusive and open way.

Perhaps an interesting reflection point for us all the next time we have a patient who is just simply rubbing us the wrong way: "Is it the patient... or is it me?"

   *From Big Leg Blues, by the amazing and inimitable Mississippi John Hurt

The Image and The Body

There was a research article out of the University of Notre Dame last May entitled "Nobody Likes a Fat Talker" by Dr. Alexandra Corning.  Thinking this was a brilliant piece of post feminist inquiry, I posted a link on facebook promoting it as the research I had secretly been conducting for years. Anecdotally, this is not so far from the truth. In short, this research, like many others on the 'fat talk' phenomenon examines how women react to one another when they speak negatively about the size and shape of their own bodies and the social/ psychological impact of that dialogue on peers. Much of the research has found that those participating in studies perceive fat-talk and self-degradation of body image as normative. The Notre Dame study suggests, however, that fat talk is not innocuous and, in fact, has a negative impact on both the "fat-talker" and the person engaged with her in the exchange. In the end, in true facebook fashion, no one had much to say about it.  Such is the nature of social media. 

Since I have been pregnant, I have had an inordinate amount of attention paid to my ever-changing body. As for all pregnancies, I am sure, there is a continuous running dialogue about weight, exercise, hair, food, specific body parts and functions - all directed at the gestator. I thought this a good jumping-off point to start a conversation about the way women objectify one another and continuously reinforce notions of the ideal body - often without even knowing it.  This is a good spring board because in pregnancy the body and its many changes are amplified and accelerated.  Again, I made a facebook post about some of the more outlandish comments I have had to field over the past few months such as: "You sure it's not twins, right?" "I think it's time to move up a scrub size!" and "HOLY COW!  No pun intended...."  This time, in good social media form I received tons of feedback, mostly negative commentary directed toward the purveyors of said comments. I should note here that I do not believe any of these people making the original observations/ comments meant offense or harm in any way.

But the truth? Those commentators of the body are the very same people discovered in the fat-talking research.  They are the very same people who will talk through your workday meal  about the number of carbohydrates we're consuming, how she skipped her workout this morning and how guilty she feels, who she feels has the best highlighting hairdo at that particular moment or who looks hottest in her designer jeans. We are the very same people that talk about what makes a good mother, wife, girlfriend, lover.  We are the very same people that criticize ourselves, ad nauseum, at the expense of the those around us that feel a little less comfortable in their skins, who have less cultural capital and who take our self depreciation as a sort of reflective impression of how they should feel toward their own bodies and selves.  In short: "I have met the enemy and they are ours."

Over the years this has become a particular interest, if not obsession/torment of mine: understanding the compulsion of women to comment on our own and one another's bodies and behaviors.  I have mentioned it with annoyance to coworkers when a comment is made about my dinner or what another woman might be wearing that particular day; if someone looks tired or rested, put together or a little rumpled.  I have tried to gently redirect the constant remarks because when I deflect directly, I am usually met with resistance such as, "I meant it as a compliment!"  which is by no means a false statement.  I believe this wholeheartedly to be true.  But the underlying truth is, all of the positive commentary directed at the body of any one woman has a negative consequence for that woman and all of the other women surrounding her.

Take the example of complimenting a woman on weight loss.  What are the underlying issues being conveyed?  I value the thin body.  I was not satisfied with the way you looked before today.  I am aware of your eating and exercise routine.  The image of your changed body has more value to me than X sitting across the table who is eating chocolate cake or who is not as thin/ attractive/ motivated.  And, most importantly, I want you to notice MY body. What lies beneath is endless.

In the end, I feel that much of this is a real failure of feminism, the new "4th wave" or "lean in" feminism (which a friend brilliantly dubbed "lean over" feminism) in which women are hypercritical of themselves with expectations way beyond reason in the name of gender equality, rights and justice.  My work in nursing offers prime examples on a daily basis.  Much commentary is directed toward the "right way" to accomplish childbirth.  Foregoing pain medication is often seen as superior to employing pain relief options, a right for which women fought hard in the 19th century, before which time labor pain was seen as God's Will. Today, does  a woman's declination of medication in childbirth have an impact on what kind of mother she will be? Certainly not, but it is implied in the effort to direct women toward a natural childbirth, even the word "natural" implying pain relief is somehow aberrant.  How about number of children a woman has borne?  Once a patient starts getting up over the three-children-to-one-woman social zenith, specifically if she is poor or a minority, the commentary flies, "Sounds like she needs to stop having sex!"  "Time to sign those tubal ligation papers."  It is an every day occurrence in the obstetric arena and virtually every time these words are uttered, they are coming from the mouth of another woman.   Simone de Beauvoir's idea of women's lack of solidarity still rings true in such callus remarks.

Women "live dispersed among the males, attached through residence, housework economic condition, and social standing to certain men - fathers or husbands - more firmly than they are to other women.  If they belong to the bourgeoisie, they feel solidarity with men of that class, not with the proletarian women."  How does not having a concrete "correlative unit" work to compel women toward - and thus away - from one another with this strange objectification?

The contemporary French feminist Elisabeth Badinter addresses the issue quite eloquently by describing how feminism over the past two decades has eroded and segregated the female gender - not from the male gender - but from itself.  This fracturing of feminism in which women see themselves as oppressed and victimized has lead to nothing more than a dependence on male counterparts rather than developing an autonomous self.  Clearly this can be accomplished only if the female gender itself stop with its focus on the individual and work toward a gender unity in which we establish that sovereignty on the shoulders, rather than the backs, of one another.  Simply speaking, we work toward something better by cutting out the prattle that works unconsciously to break us apart,  both individually and collectively, figuratively and literally.

So how does this all fit together into a new way of relating based on mutual respect and understanding?  Perhaps it doesn't.  But perhaps it gives us a chance to sit down and take a look back over our shoulders at the work we have done to make ourselves whole through family, education, work, friendships, parenthood and self-fulfillment, to develop as individuals and make that work reflect a more tenacious group. We can certainly start by simply thinking about the way that we address one another.  Given the leaps and bounds made for women historically, this seems like a small step.  But the fact that such baby steps are still needed to get a firm footing on our expectations of ourselves and one another, without the distracting and demeaning commentary, is disheartening.  

Female-to-female banter based on unfulfilled expectations we have of ourselves reflected off of our mothers, sisters and friends does not build a foundation to legitimize us at all; it works to break down the autonomy that each woman has established through her self-work, perception and motivation.  So while a casual compliment or remark may feel benevolent in the moment, we need to reflect on how such generosity is oftentimes just another exercise of power.

Illustration by Alexander Morel: "The pattern is based on insults or qualifications towards women that use animal names (old cow, bitch, chick...) mixing the body of the animal to the legs of pin-up girls."  

Delia

near the intersection of rivera
and the great highway
stone once holding the earth in place
uncovered by wind and last night's rain
lay open to daylight

the inscription read only
REST

DELIA PRESBY
wife of 
E.B. OLIVER
died April 9, 1890.
Aged 26 years.
10 months.
27 days.
REST

you and i
we wandered
searching for words
inscribed in the sand
and i never told you
how i breathed relief
not to find them nor to discover
your shared day of birth and death.
i chanted some earthy prayer
not to uncover her stone
after so many years of
holding still the earth
and the dead.

i singing:
did you hear this
on the day you were born,
the tide crashing against your
stone pillow, the waters roiled by wind?
did you imagine yourself
buried beneath the sand
heavy with salt and sea?
did you dream this,
your eternal home?
your inscription reading only
REST

121 years.
7 months.
10 days.
REST


*http://www.sfexaminer.com/sanfrancisco/ocean-beach-gusts-reveal-headstones-sf-history/Content?oid=2199952

Christmas Eve Can Kill You

Time is the Enemy

"Language is the cake with the file in it."

Photo by Tim Ellis

The title of this post is a quote by  B. Blanton sent to me by my ever-clever father-in-law with the byline "a quote to get us through the day." And it did just that.  It also got me thinking about language and how it tricks us, often without our even knowing it. So I thought I'd apply this idea to the area of medicine with which I am most familiar by laying out a few of the phrases I would like to expunge from the obstetric lexicon. So, here goes nothing:

1. Incompetent cervix
- There is nothing incompetent about any part of woman's pregnant body. Period.

2. Low pain tolerance / low pain threshold
- First, why is pain, especially labor pain, not inherently valuable? Why is it an experience that needs to be tolerated? Why is it a problem for a person to have a physical or emotional reaction when the intensity of pain has exceeded a certain magnitude? And if a woman wants pain relief at this juncture, isn't there some serious paternalistic behavior being exhibited if she doesn't get it? Finally, how in the hell can we objectively judge what the patient is experiencing? But all of this is yesterday's news.

3. Terrible pusher
- What can I say about this? Really nothing except that our patients aren't freshman linebackers.... or novice drug dealers.

4. Dysfunctional uterus / dysfunctional contraction pattern 
- Dysfunction implies impairment, something that is flawed, decayed, defective - a deviation from the norm.  So we should ask, who is defining the normal?

5.  Failure to progress
- Failure: collapse, defeat, fiasco. As in "I'm sorry Ma'am, but your labor has failed.  Now you get a cesarean section. And all because you made no progress."

6. Elderly primigravida / Advanced maternal age
- Up until the 1960s, women were often having children well into their 40s.  Modernity does not necessarily equate with progress. And I think even my teenage son will agree that thirty-five is certainly not elderly even if he categorizes The Smiths as "classic rock".

7. Stalled labor 
- The body is not a '64 Impala.

8. Late to care 
- I am pretty sure that most of these women care.  They may have been late to medical oversight, late to obstetric assistance, but they are not late to care.

9. Failed homebirth
- Again with the failure.  It's a homebirth transfer.  Let's say it aloud: no one is a failure in this scenario.

... and, for the all time most heinous of our many articulations:

10. Give the woman a tubal, already! (or) Please tell me she's signed her tubal papers.
- This is one for future scrutiny in the form of an academic paper. And I am totally on it. All I can say for now is that I know Americans are terrible with history, but our collective memory cannot possibly be that short-term.  Ever heard of sterilzation? If not, follow the link for an easy primer.  We need to think about these not-so-distant days of yore, and think hard, before uttering these words ever again.


So, as the good Mr. Blanton says, language is indeed the cake with the file in it.  The question is, does that file set us free or does it cut our throats?  You decide.

The Problem of Pain

Pain.  Pain is something that, as health care providers, we learn is subjective.  Subjective: meaning belonging to the subject (patient) rather than the object (the “objective” practitioner).  Subjective pain: pain that is perceived by the patient and not by the provider.  Pain: an area of healthcare where the objective practitioner can have the ability to, and often does, perhaps unconsciously, objectify his or her subject.  This may be doubly true in assessing laboring women who all present differently at different stages and who may or may not meet certain clinical expectations in response to the pain of childbirth.

I won’t talk about patriarchy and women’s experiences of their bodies.  I won’t talk about how women punish one another into utilizing or forgoing modern pain relief methods for some weird feminist ideal of woman/motherhood.  I won’t even talk about language such as “low pain threshold” or “no pain tolerance” in discussing another person's pain.  No. Just for today, I won’t. Instead, I will give you this anecdote.

A patient is admitted for intractable pain, not in labor.  This intractable pain is accompanied by some intermittent vomiting… and a suspicion by providers that this patient might be drug seeking. It is never totally clear why. She is poor.  She is a minority.  So there are two strikes against her from the get go.  She is perceived as something before she is anything in the clinical realm... before she is even a patient. “What makes you think that? About the drug seeking?” someone asks in team meeting.  “Well,” responds the attending provider, “Her pain seems very out of proportion to her early labor status and no one has ever witnessed her vomiting.  Also, we were going to perform a tox screen but she can’t seem to void, which I find very suspicious.”  Suspicious.  Not concerning but suspicious. A good practitioner should, right about now, have counted at least five symptoms that could be used to rule out a host of issues other than drug seeking behavior. But this is where we are.  So a wise doctor seated beside me addresses the pain issue by asking, “And have you given her anything for this pain?”  “No,” responds his colleague, “Nothing but an antiemetic for the supposed vomiting.” 

The inquiring doctor rolls his eyes and turns to me, sotto voce, “Drug seeking for ondansetron. Now that’s a problem.”

*The Problem of Pain is a very brief and worthy little book written by C.S. Lewis and Virginia Woolf touches on the subject in her essay On Being Ill.  For a little non-medical perspective to inform practice, you can also read some Heidegger and Nietzsche among others. 

As Dear to Life As Breathing*

One of the doctors from our hospital spoke on a local radio program last evening, albeit briefly, on the issue of Licensed Midwives in California having the right to practice without supervision by a physician.  You can hear the piece on the KALW program Crosscurrents. I posted the piece to Facebook with the request for people to share opinions, a wildly regrettable move on my part, always, because that forum appears to be for a  large majority of people who peruse (i.e. express impressionistic reactions) and who do not read.  But the great thing about radio is that if you're not a reader you can be a listener and you can do that here.

The crux of the story is one that lays out all of the apparent advantages of legislation known as AB 1308 (which also requires reading).  Admittedly, the proposal was explained fairly accurately in the Crosscurrents piece.  The big omission was the differentiation between Licensed Midwives and Certified Nurse Midwives and the conflation of CNMs with Obstetricians who practice inside the hospital.  That and the rather big assumption that all pregnancies and births are low risk and therefore all women are, by default, candidates for home birth. These issues definitely remain firmly stuck in my craw. Every day. It is irresponsible for us, as healthcare providers in obstetrics and women's health, to let women believe that prevention is akin intervention.  It is equally irresponsible to guilt women into thinking there is a "right" way to experience birth and to become a mother.  Childbirth and motherhood are hard enough.

But what we're talking about here is AB1308.  Current legislation allows Licensed Midwives at alternative birth centers to practice under a Physician or a Certified Nurse Midwife.  This distinction was not clear in the Crosscurrents piece.  In 2010, there were 1,500 Certified Nurse Midwives in practice in the state of California, many of whom practice homebirth exclusively.  Very few, in fact, are hospital-based providers. CNMs are educated and trained under a medical model, equipping them with strong clinical skills by way of training as advanced practice nurses.  CNMs must be registered nurses and must receive a master's degree in a nurse-midwifery program that is accredited by the American College of Nurse-Midwives in order to practice legally. These midwives can treat patients throughout their pregnancies, attend births, prescribe medication and are highly trained in the pathology and physiology of childbirth to be able to recognize a women or baby who may be in distress and in need medical intervention, a real and unfortunately common occurrence.  (Consider maternal and neonatal mortality rates in parts of the world where medical intervention is *not* accessible).  Licensed midwives, on the other hand, may or may not have a bachelor’s degree and their training varies depending upon length of apprenticeship, mentorship and at home study.  I think making this distinction is central to a conversation about the role of midwives in the community and what AB1308 means for the profession of Midwifery as a whole.

Of the responses I received to this post, most didn't even address the point of the radio piece.  Many made the fallacious argument that a midwife-attended "homebirth is (statistically proven to be) more  safe than a hosptial-based birth" -- an argument I can't deny (not unrelated, I am sure, to the fact that it was the basis of my senior thesis as an undergraduate.) But it's a poor logical argument, a base rate fallacy.  Statistically, outcomes for homebirths are quite positive.  This is true.  Personally, I fully support and advocate for homebirth with a Certified Nurse Midwife under the condition that both mom and baby are in good health.  But the statistics of it are somewhat confounding.  I am hesitant to embrace statistics comparing midwifery to hosptial-based care because it is fraught with problems - in that there are certain variables for which there is no control. For example, high risk patients are treated in hospitals and have "worse" outcomes (higher rates of epidural use, episiotomy, vacuum or forcep extraction, neonatal admission to the NICU, maternal blood transfusion, cesarean section).  All because hospitals have access to these interventions and treat sicker patients.  This is fact.  Providers in medical settings have the tools and the knowledge to manage extremely difficult situations and to keep babies and mother's alive.

I guess the question always lurking in the back of my mind is "how many bad outcomes would I, as a practitioner, accept?" (A bad outcome, in my mind being a maternal or neonatal death, not a cesarean section).  For me, personally, the answer is zero.  I wish I had, in my lifetime, seen zero.

The confusion between high and low risk birth, maternal right and choice, information and knowledge, security and safety is complicated.  It is complicated by history, complicated by access, complicated by perceived understanding, complicated by stories like these and specifically by women who stake claim over what is right for other women in the name of liberation.  I have said this before and will say it again: Prevention of poor maternal and neonatal outcomes, or death, should never be mistaken for unnecessary medical intervention.  It is so disheartening to me that obstetrics has become this strange and difficult place for feminist convergence and collision and thus is the ONE area of healthcare in this country where preventative medicine is shunned as counter to choice.  When the outcomes are poor, it is also the most litigious area of healthcare.  And in these cases it is the most heartbreaking because it is here that we have the most to lose.

If women lose the right to say where and how they birth their children, then we will have lost something that's as dear to life as breathing. - Amy McKay, The Birth House 

Out of the Marvellous

Lightenings viii

The annals say: when the monks of Clonmacnoise
Were all at prayers inside the oratory
A ship appeared above them in the air.

The anchor dragged along behind so deep
It hooked itself into the altar rails
And then, as the big hull rocked to a standstill,

A crewman shinned and grappled down the rope
And struggled to release it. But in vain.
'This man can't bear our life here and will drown,'

The abbot said, 'unless we help him.' So
They did, the freed ship sailed, and the man climbed back
Out of the marvellous as he had known it.

“If you have the words, there’s always a chance that you’ll find the way.”

   ~ Seamus Heaney (1939-2013)

There is No Them

2013 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
Persons in family/household	Poverty guideline
For families/households with more than 8 persons, add $4,020 for each additional person.
1	$11,490
2	15,510
3	19,530
4	23,550
5	27,570
6	31,590
7	35,610
8	39,630

This week in the break room a few of the nurses were asking one another, "If you had the power and the resources to take on one cause, what would it be?"  I remembered reading the night before a mind boggling statistic about poverty in the United States:  more than 35 million Americans now live below the poverty line - which is saying quite a lot given than the poverty guideline for a four person household is a measly $23,550 per year. To put that in perspective, imagine a family of two parents and two children with the primary wage earner* making about $12.25 per hour over a 40 hour work week.  The current federal minimum wage is $7.25 per hour. Needless to say, the standards set by our government are ridiculously and embarrassingly low. 

And then there's the Affordable Care Act.  Apparently drafted in an effort to insure all, under the ACA, many of those working poor who make a wage above poverty line are not eligible for coverage.  Because the government made Medicaid optional, and 27 states opted out, those individuals and their families who make between the poverty line (but not below) and four times that amount are ineligible for both government subsidies under ACA for private insurance and Medicaid benefits.  Which states opted out?  Those with the highest number of families living just at the poverty line.   

As a nurse in a public hospital in a large urban setting, this really strikes a cord.  Every day we are the eyes and the ears of the war on the poor in this country, from the front lines.  But how many times are there grumblings from both nurses and doctors about patients who have not sought out preventative care, who's BMI is "too high", with uncontrolled, underlying conditions, who have had multiple pregnancies, abortions, losses, births, addictions. And how many times are these people blamed for their "lack of initiative" in caring for themselves.  Every day there is someone blaming a patient for poor health outcomes -- or for being overweight or impoverished or having multiple prior pregnancies or for being addicted -- and every day I wonder how these people can care for themselves when we can't - not even for 24 hours - suspend our judgement to simply care for them.  As we should without doubt and without question, as this is the root of our profession.

You aren't cared for because you care for yourself.  You're cared for because others care for you. 

*No the second parent doesn't work because they can't afford childcare.