WHEN THIS IS ALL OVER.

Dedicated to the doctors, nurses, healthcare workers and all those fighting the enemy with the least of protection and most of the burden. COVID-19

The malls will reopen
Restaurants will be buzzing,
Noise filled streets, roadways humming
Planes will again soar up roaring!

School back in session,
Mornings once more alive,
Schoolyards will reclaim:
Their cheerful chaos.
Spring dances and graduations,
Days with meaning, weekend plans.
Work will be joyful,
May be boring or testing.
Daily grind, again driving us crazy
Rushing home, honking and yelling:
Cuz someone else isn’t fast enough -isn’t moving.

Handshakes and hugs, high fives and gatherings,
Workouts and practices, ballgames and swimming,
Neighbors rejoicing and backyard grilling!

Enemy weakened, defeated will retreat
Air will breath, a sigh of relief!!
Scared no more, nor anxious or unsure,
No TV blaring, no pandemic overload,
No #stayhome, no curve to flatten,
Memes and cat videos, back in fashion!
High tide will break, calm seas gleaming.

We will come out on the other side!

But until then,
It is ———-

A war with this enemy, with an army unarmed,
No plans for weapons, no armor around.
Helpless yet selfless,
Scared, still onwards,
Realizing they are, all but on their own.
They keep on marching,
To a battle unplanned, nuance and unnerving.
McGyvering, tinkering and crafting along,
With Makeshift masks, recycled gloves,
Not enough gowns, not enough beds,
Not enough voices to raise the alarm.

On a ship without a captain, the compass awry
They steer unarmed, unwavering
Towards an iceberg, too large to avoid.

I watch and wonder, how long and how far?
It has to get better, it has to get clearer.

Or is Tennyson saying “but to do or die?”

How long doctors and nurses will get by?
Without gloves, gowns, masks and beds:
Do healthcare workers really have to die?

So —-

When this is all over and life returns,
I worry - what will we be standing on?
A mountain of regret, steps mistaken?
Pleas unheard, warnings not heeded?

When this is all over, damage recounted:
I worry, what will we be standing on?
The Triumphant Zumwait, with glory abound?
Or the Titanic with her wreckage, her heroes unfound?

Mental Health - The New Old Boogie Man Part 3 & Counting

Here we go again.  two more shootings this weekend, more loss of life and more empty promises.  I don't know why I keep writing these posts because it's so futile to look back to 2012, 2014 and realize that what I wrote then, can verbatim be applied to each subsequent post and to this one and will probably continue.  So I won't repeat.   

I said here "United States doesn't have a monopoly on mental illness but it seems like we definitely are the worst in using mental illness as a scapegoat.  Please help me understand what sort of unique "mental illness" is so prevalent in this country that we have over 30,000 firearm deaths every year and more mass shootings than any other developed country in the world?"  My stance hasn't changed and the common denominator of gun access is still true.  

My hope lost it's light when kindergartners died in this country and nothing changed.  I remember my heart exploding with pain and despair driving to pick my children from daycare on that day.  No rain was falling from the sky but my windshield was clouded.  There are very few instances in my life, where the pain is etched so deep in my heart, that years later I still vividly feel it.  This is one of those.  

As a psychiatrist, I am a master at necessary ambivalence but sending my children to school every day, thinking of my children moving on to high school, college, being in theaters, malls, grocery stores, places of worship and trying to grow up in general, is more than just necessary ambivalence.  I now realize that all of us are just daily taking the risk knowingly because we can't just be locked in our homes.  This isn't ambivalence anymore, it's learned helplessness.  I can no longer just hush my nagging head.  It gets worst when I hear politicians talk about mental health, God and thoughts and prayers, every single time.  It doesn't do anything for my anguish when the words continue to sound hollow and the feeling of everyone being sitting ducks, doesn't abate.  

Every shooting is the "worst one in US history" since the last one.  Every shooting happens where "we never thought" it would happen here and it's beyond my cognitive reserve to make sense of the repeated De Ja Vu.  

Whatever these politicians think the reason for over 200 mass shootings and over 1100 Americans being hurt since the beginning of this year is, I am done worrying about those reasons/justifications.  Whatever boogieman it takes for them to not feel like they are betraying their sponsors, I don't care anymore.  For these people, facts don't matter, numbers don't change selfish agendas, and the cowardice is astounding.  

Our children are braver than the politicians, as they suffer through active shooter drills and get repeatedly traumatized, but continue to go to school.  But I don't want their bravery to be an excuse for the political cowardice and inaction.  I am disgusted by the continued defamation of psychiatric patients, despite research showing that this is simply not why US has a mass gun violence problem.  But at this point, I don't care.  If the political will to do anything is only going to be mustered on the backs of our children and our patients, it won't be the first time that the real victims of this epidemic will provide a hand out to the begging politicians.  

So I am begging this country's powers to be......DO SOMETHING.  PLEASE!!!!  

Please feel free to stand upon our children's shoulders, our patient's illness BUT DO SOMETHING.  But stop forcing Americans to continue digging graves for their children, wives, fathers, mothers, husbands and neighbors because you are unable to call out evil for what it is, as you stomp on the fresh graves and spew your hollow talking points.  

When will this end?  

Medicine - The Art of Heart

I have contemplated this post for over 2 months.  My grief is new and strange.  It ebbs and flows, comes and goes but never totally leaves me.  I don't think it ever will.   I can't seem to write anything that can describe, what I have felt or what I don't know how to feel?  Years of work with a human being, the sense of being caught off guard, the recognition of the ultimate risk and the realization of my limits; the loss is immense and deeply personal.

I had plans of "As long as it takes."  I had to delete the recurring appointment from my calendar.  The act of ultimate acceptance of what had happened, accepting another human being's decision to handle their pain in a way, we were working to avert and accepting that one of us had a different timeline for "as long as it take."  I have struggled with continuing to do therapy work, at least at this time.  The wound is deep and it doesn't look like it's filling anytime soon because it's so entwined with what I do every day.  We all operate on a certain ambivalence towards our patient's wishes of annihilation, as it helps us circumvent the risk staring at us everyday, and helps us choose hope for our patients.  Those of us who have lost patients, lose the comfort of hope for a while.

I recently came across a profound comment by a fellow psychiatrist, on a post I was following.  "There are two kinds of psychiatrists.  Those who have lost a patient to suicide, and those who will."  Though I usually don't look at things in such black and white, but this deserved attention.

The patient suicide, in psychiatry is the ultimate heartbreak club.  A not so sought after club, with a high priced membership and only an entry door.  There are no exits, no detours, and no one is excused.  At some point, anyone of us can become members, and find ourselves on the other side of the door.

Meg Murry describes the pain of tessering, when she found herself traversing dimensions of our universe, looking for her father, in "A Wrinkle in Time."  The journey through the door of the heartbreak club for a psychiatrist, may as well be tessering to a different dimension.  Nothing prepares you for this.  Sure, we have all read about patient suicides, heard other psychiatrists, therapist and clinicians, talk about their experiences.  But it doesn't become visceral, until it's your own patient.

We have different kinds of relationships with our patients, when we see patients for the afflictions of mind and try to help them the best we can.  Some of us are lucky enough to practice psychotherapy along with medication management.  The therapy relationships are different from medication management.  One isn't better than the other, but one is more intense and pulls on the heart strings more.

When we decide to become physicians and take care of patients, we assume the risk of having heartache and hurt.  As psychiatrists at one point we find out that with the best of our intentions, care and investment in our patients, sometime we can't prevent the final outcome.  Our knowledge of another human being is limited to only, what they present to us, nothing more, nothing less.

I will just have to wait for the heart to mend itself and get back to doing the work that I love so much.

As the saying goes, 
“To practice medicine with good spirit does not mean to be in a place where there is no noise, trouble or hard work. It means to bring your calm and loving heart right into the midst of it.” 
Unknown Author 

Defamation Of The Defamed - Resist!

The Facts

I am on a mission.  As a psychiatrist my mission is to push back and resist, any and all attempt to disrespect my patients and their suffering.  A week after the FL high school shooting, the rhetoric surrounding the mental illness has gotten uglier, more cruel and is trickling down from the top.  Never in my wildest imaginations, I thought that the derogatory terms used to describe patients with mental illness, would be thrown around from one of the highest offices of our country.  I have heard words like, "sicko savage", "insane monster", "lunatics", "crazy", "nuts", "wacko", "madman", and the list goes on.

Please put the breaks on!!

This irresponsible and disrespectful course of using derogatory terms about patients, who suffer from mental illness, has to stop.  There is a difference between colloquial use of these terms and actual clinical relevance of such descriptors.  We call ourselves, our friends, and our adversaries, any and all of these words in our heads, out loud, jokingly or sometimes seriously, but with the understanding that these are expressions of frustration, humor or at times, anger.  Never do we use those words, full well knowing about someone who has a truly diagnosed mental suffering.  So why is it okay to vilify a whole specific population, in this manner?

Is it because they are already vilified and easy to target, or is it because the arguments of these patients as the root cause of a massive national problem, i.e. access to guns, are hollow and don't hold much ground, unless they are dragged in the mud?  Mud slinging always emerges from weakness and lack of substance.  It's not like, mentally ill patients aren't already defamed enough.  What is the point of further dehumanization, other than a pathetic spin on a problem that is not of their making?

The defamation of defamed, has to be called out.  We must resist!!!

Mental Health - The new Boogie Man Part 2

Here we go again.  I have lost count of how many times I have written posts like this.  Exhibit 1, Exhibit 2,  and Exhibit 3 . 
Before I start, let me clear the ground for anyone who would want to jump on me, curse me, threaten me and/or call me names.
 - Mass shootings by people with serious mental illness account for < 1% of annual gun related homicides. (1)
- Patients with serious mental illness count for 3% of violent crimes and even less in gun related violence. (1)
- This Epidemiological Research brings to light complex nature of violence and negates the absurdity of "Mental illness" talking point as a cause and effect, simplistic concept in context of the rampant gun violence problem in the United States.(2)
- According to The National Safety Council's report on the leading causes of death in the United States listed are: 1/370 people under the category of assault with a gun, death by a mass shooting 1/15,325, and accidental death with a gun 1/6904.  All these numbers are higher than the chance of dying by an attack from a foreign terrorist and dying by being in a tornado or cataclysmic storms. (3),(4)
I can keep citing and trust me, I have done my research but I am not the one who needs convincing that guns ARE the problem.
Since the start of the year 2018 multiple gun related incidents have happened across the United States in various schools.  Whether you want to quote the numbers with or without counting the number of children dead or not, is up to you.  Take your pick.  How many is too many? What is your threshold?  What are you comfortable with? Please feel free to pick a number.
But I refuse to play this game anymore.  In May 2014, I wrote this blog post that I would now call, De ja Vu after the Santa Barbara shooting.  Since then, every time a shooting has happened, I have gone back and read it.
How many times I have felt that things are finally turning around? ZERO. And how many times I have felt that we are sinking down, deeper and deeper in this hole....100% of the time.
I am sick and tired of thoughts and prayers, because they don't bring back the dead children but only pander to the sold out, cowardly, selfish politics of our country.
I am refusing to be the next casualty of the economics of the gun industry's bottom line.
I do not want to hear another person telling me that guns don't kill.....because THEY DO.  They are weapons made to KILL and to be used by willing humans, to do exactly what they were made to do.
I am not going to give up my right as a human being, as a mother and as a citizen of this country, to have my children go to school in the morning and to have the 100% expectation of them coming home in the afternoon, like they are supposed to.   Or do you want to tell me that the right to bear arms, is somehow more important than a parent's right to not to have to bury a child, after being sprayed with bullets?
I refuse to be labelled as part of the problem because the sold out politicians have decided to trample on the mentally ill and point the finger, as they simultaneously take money from the gun manufacturers through the NRA, while they slash funding for mental health, public education, safety nets and refuse to do anything about enforcing the gun laws.

The two knee jerk responses; mentally ill and/or over medicated, need to STOP!!!!
Which direction do we go as providers? Because don't we full well know that there are millions of people with particularly violent ways of thinking, that has nothing to do with chronic mental illness and they don't come knocking on our doors to get help with changing their way of thinking?
We are losing our voice in this because the talking points are shaping the public perspective in our direction by lumping every angry, unhappy, disturbed and at times racially motivated individual as "mentally ill"?  Before we know it, this will solely be a mental health problem.
It is our job as physicians, parents and mental health providers to speak up and point out that lumping every disturbed, psychopathic, angry, and criminal person, as a mentally ill patient, actually completely bars congress from doing anything at all.  It's a cowardly cover for the incompetence of our political will.
Why do our patients have to suffer even more, when statistically we know that SMI patients are most dangerous to themselves and to those who intimately take care of them, (when acutely sick) and not just random students or mall goers?
Why do we have to keep making amends with every new shooting, only to repeat the heartache until the next "biggest mass shooting in U.S history"?   Isn't every shooting bigger than the last one?
Why do we not talk about the trauma our first responders are subjected to every shooting, when they witness the carnage of these lethal weapons, used by a "law abiding citizen" who legally bought the gun/guns. tactical gear, magazines?
Why do we keep allowing the peripheral trauma to spread from these weapons to our every day life?
Why do I have to be okay with my young children being terrified of active shooter drills and that this is the norm in their education? Why don't we talk about the generation of traumatized children, who are growing up in this culture of people's right to own such weapons? Why do we keep giving up on their right to live their lives and hopes and dreams of future olympians, doctors, scientist, ballet dancers, cops, teachers?

United States doesn't have a monopoly on mental illness but it seems like we definitely are the worst in using mental illness as an scapegoat.  Please help me understand what sort of unique "mental illness" is so prevalent in this country that we have over 30,000 firearm deaths every year and more mass shootings than any other developed country in the world?

I am sorry but you may need to take a vacation from hunting a deer with an AR-15 and use the good old fashioned hunting rifle along with your hunting skills, because we need to figure this out...NOW!!!
As a psychiatrist who treats SMI patients, I refuse to simply take this excuse that somehow the United States has a more seriously mentally ill population than the rest of the world, and by association, hand off the entire responsibility of the mass massacre culture onto my most vulnerable patients. I will not be an accomplice in making our children a walking target of this epidemic of inaction.  This is not on my profession to fix.  This is not on our children to fix, but this is on us to say ENOUGH!!!

I am here to say, mental illness is NOT evil and EVIL is not mental ILLNESS.  Is that loud and clear enough for us to move on to the actual problem????
When will we be ready?????
When will be the time?????
When will we choose our children?????
When do we start saying and voting #NOTME #NOTMYCHILD ?

1- Gun Violence and Mental Health - APA 2016
2- Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015). Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Annals of Epidemiology, 25(5), 366–376. http://doi.org/10.1016/j.annepidem.2014.03.004
3- Causes of Death in USA
4- http://www.nsc.org/learn/safety-knowledge/Pages/injury-facts-chart.aspx

Hello, I am a physician. Who are you?

Many years ago when I embarked on my journey to become a physician, I didn't anticipate practicing medicine in the United States, one day.  My training in the medical school was pretty straight forward, not only in terms of my role and responsibility as a physician, but also regarding the roles and responsibilities of the ancillary team members.  Now over a decade later while practicing in the United States, I find myself in an uncharted territory.  A territory where I have to justify my place as a physician and actively try to keep the scope of practice boundaries from getting blurred, by a slew of political and economical motives.

The ground rule of practicing medicine, "First do no harm.", seems to have become a mere philosophical inconvenience, for everyone else but the physicians.  As if the onslaught of managed care and the increasing regulation, telling me about how I should practice wasn't enough; now I am to welcome with open arms; warmly and happily, the next best thing, or I will be labeled arrogant, angry and an obstructionist. 

Enter the world of mid level non-physician providers and the expectation of the system, that the physicians would and should assimilate.  All this in the name of access, cost, and teamwork.  The political lobbying and the financial investment in the gradual but surefire, decimation of a physician's unique place in health care; is something that I never expected to have to deal with.  

How does someone deal with the indifference of a whole system towards your own existence?  What does one tell the politicians and lobbyist who don't seem to understand that becoming a physician takes years out of an individuals life and is more than just how many number of hours of clinical training one has vs a mid level provider? Where does one draw the line between collegial and advisory relationship with another profession that also threatens and actively tries to devalue your own profession, by assuming a false equivalence not only in scope of practice but in fundamentally trying to change the definition of your hard earned place as a physician?  How does one start a conversation with the agents of change, when citing facts about glaring discrepancies in basic education and competency are deemed, territorial and unproductive?  

The rising cost of health care in the United States, because of the failed system of managed care and divisive politics, has turned the blame somehow on the physicians.  The current environment is literally putting a target on the backs of a profession that takes more than half of our lives to learn, perfect and practice.  

Practicing as a physician in the United States, isn't a walk in the park.  Just because you are done with residency and/or fellowship, doesn't mean you are done.  There are certifications, MOC, continued CME requirements, ever increasing regulatory pressures that claim to reduce physician burden by the way of MIPS or APM, but rarely do.  Despite all the pressures and demands that a failed and overblown system puts on us as physicians, we are supposedly the problem and not the solution.

The push to let more and more mid level providers ranging from CRNAs, to NP, ARNP, DNP, PA, prescribing psychologists and something called Cathopathic Physicians (yes it is a thing and they are still actually NP) the list goes on and on, practice medicine without having the comparable education, training, testing requirements and frankly ability, to do so, is what a healthy healthcare system wouldn't need to do. 

The false logic of cost containment and improved access, falls right on it's face when organizations actually are replacing physicians with mid level providers at steep salaries and/or exuberant contract rates.  This is where the rubber meets the road because the reality is that that most mid level providers don't go to the rural areas to work but actually end up replacing highly trained and specialized doctors, giving patients no choice in the delivery of their care.  

As a physician in this time of existential threat to my profession, I have learned that if we remain complacent to the trend, we will be part of the problem and eventually be decimated by a monster health care system, that is incapable of reigning itself in and defining boundaries for the sake of the patients it is supposed to serve. 

Elevating mid level providers to the level of a physician by allowing unsupervised independent practice, is not the solution for a sick system but rather a recipe for further sickness, only with a steeper price, i.e. patient safety.  Filling the market with inadequately educated and poorly trained providers from online schools and scarce patient contact hours, is not a healthcare innovation for the future but a ticking time bomb of medical negligence.  

So I wake up every morning and get ready to go do what I do best.  Be a physician!!!  

I make a conscious effort to educate my patients about their choices for their healthcare.  And I am ready to ask every day, to whoever will question or dilute the validity of my place in the system as a physician, "Hi, I am a physician, and I am trained to practice independently.  Who are you?"  

Because if I don't step up to save my profession and be blunt about it, no one else will.  

The Year of the Bear!!!

No, I am not referring to the Chinese year.  If you haven't noticed, my blog didn't get much love from me in 2017.  It is however safe to assume, that I gave myself a lot of time, break, and much needed respite.  Hibernation makes perfect sense to me now.  My last post in Dec 2016 was merely 3 weeks into my cyber lent.  I have been off line for close to a whole year now.  The initial withdrawal, gradually weaned off into a distant longing and with time into an even more distant memory.  What seemed impossible, became natural and even necessary given the fact that things over the last year, have gotten even more disconcerting than before, at least for me.

I can't say that I will be writing regularly.  Anyone who has read this blog from it's inception, knows how I have struggled with a predictable schedule of publishing.  That was when I was fresh with ideas and didn't feel the writer's block I have felt for the last year.  I took aim at coming up with something to write several times this past year, even started a post or two but never got to finish it.  It was hard to wake the bear from the hibernation, because it helped me stay in my own world and served a purpose that I would have never imagined prior to this year.

The ability to sit with my feelings, sit with them, live with them, keep them inside and let them be.  When we feel happy, excited, upset or angry or disappointed, we all vent in our own ways.  I used to write here.  Mostly happy, apprehensive, and excited thoughts.  Those are easier to share and more palatable for the audience.  It's the feeling of disappointment, despair and disbelief, which poses a challenge in both suppression and expression, particularly when it pertains to a macro level disruption in the normalcy of life.  Nonetheless, many a times it's important to learn to live with this feeling without any expression but to work towards an internal reset of your own limits.

This year has shown me that at times one of the best things you can do for yourself, is to disconnect from all that threatens the very core of everything you held dear for the life as you knew it.  The constant stream of information, news bytes, the tweets (the darn tweets), headlines and chaos exists to blur the mind.  At times, letting it all go dark and focus only inwards, is just what the doctor ordered.  So not surprisingly, I practiced what I preached.  Many of my patients did disconnect and did significantly better than they themselves expected. 

However, disconnecting doesn't mean that you accept the disruption as a new normal and be complacent, nor does it mean that you don't care.  But simply that may be you care so much that you can't productively continue to do your part unless you actually, actively refuse to engage in the disruption.  Just because a bear is hibernating, doesn't mean he is unaware, weak and unambitious.  Au contraire, he is just getting ready to face the jungle with a new purpose, power and well deserved introspection.  So whether I come back to my perfect writing spot or not, I know that the time off was much needed and appropriately timed. 

After all, author Ralph Ellison said,

"Hibernation is a covert preparation for a more overt action."
  

Disconnect to Connect

9 weeks after my last post here, I had the best news of my long walk to board certification.  4 weeks ago, the email stopped me in my tracks.  I forwarded it to my other half and asked him to tell me the news.  As if, that would change anything, if I had not made it.  But I like, my self created buffers.  You have probably figured it out by now.  So, yes I am board certified.  As one of my colleagues said, "It's a big deal."  So YES, that's done!!!!

Funny thing that I started writing this post 3 weeks ago and never made it past the first few lines, which I had to edit today.  This is the last day of 2016 and the year has come to an end and what a year this has been.  I finished my training, started my first job, passed my board exam, managed another move and America had an election like no other.  This year has finally made me disconnect from the cyber life.  This probably has been one of the longest breaks from this blog.  I have disconnected from Facebook and this should be interesting to see how will some of my readers now read this blog from here on, since some of the traffic was generated by Facebook.   But I needed to disconnect.  Sometimes the best thing to do is, to do nothing.  I learned that there are limits to my ability to absorb the hostility and negativity.

May be most of us don't think about the 24/7 assault on our senses, when we are constantly scrolling down a screen and may be over time, we just become numb to all of it but in reality it's nothing to become numb to.  The commonest rationalization that I have heard is that, it's not possible to disconnect or this is the way now or it's not practical to disconnect.  Mostly because we don't know what will it be like to not have the constant stream of mostly nothingness coming at us.  I believe that for a lot of us, it takes something incredible to happen to take that leap.  And once that happens the first few days are hard, like an addict coming off of a drug.  Eventually the detox is complete and life opens up in other ways of communication.  The brain and heart gets a break from the light from the screen and the scroll showing an ongoing plethora of memes, news fake/real, opinions, judgments and righteousness, along with faces, places, foods and lives being lived online.  It's refreshing, renewing and relaxing.

Immersing self in community, family, people around you, and living in your own village, when the city starts to plummet in the direction that makes you lose sleep at night; is probably the most natural instinct and survival skill humans know.  So as I heard one of the journalists on NPR, say that their new year resolution was to disconnect and why?, I truly knew what he meant and the feeling he was looking for.  So my 2017 and hopefully many years afterward, will continue to be connected to my village while discontinuing from the noise around me.

Happy 2017 to all.  Here is to hoping that the world survives the brewing storms ahead.  

Tonight I Kept My Promise!!!!

Once upon a time, years ago when I was a new mother.

Actually no, scratch that.  I started writing this and realized that the last 10 years of my life have actually been a prelude to tonight.  I have been a mother for 10 years now and from the day I brought my first born home, to the day my second and youngest baby came home, to the time they both started school and moved from grade to grade, to finally tonight; there has not been a single year that I wasn't in school, or studying to get in the residency, or studying for an in-service, and then now recently studying for boards.

My children have grown up watching me move from one stage of my career to the next, public health to residency, resident to Chief and then trainee to my current full time job.  They have dutifully followed my schedule and adopted to what I needed to get past one more exam, one more test, one more call, one more weekend, one more moonlighting clinic and many more, one mores.

They have at times complained that I am always busy working, or answering emails, or studying.  They made it pretty clear that they despised, when I worked weekend calls as an intern for a year or when I used to be on call period!!!  I used to have my call schedule handy, so I could tell them when I would be on call the next time, so they could expect me not putting them to bed those nights.

Our night time reading ritual gradually disappeared.  Partially, because they started to read themselves and partially because I had less and less time at the end of the day to lay down with them for 30-40 min and read or talk to them.  I may not have noticed this but those of us with these little people at home, know very well that, what we don't notice, will not go unnoticed.

My 8 year old recently told me that I never lay down with them anymore and my 10 year old complained about not having time with me because "you always have books around you."  To be fair, they are right.  If I thought the last 4 years were the craziest of my life as a physician, I had another thing coming.  The APBN board certification, to be called that elusive Board Certified Psychiatrist, is the end goal of finishing residency.  Get a job and pass the board.  That one.

The madness of last 4 years that led to the craziness since May, wasn't lost on my children.  They have noticed the change in intensity and the pressure I felt.  They have seen me stressed out and struggling to get in a few hours of studying at the end of the day.  How can they not?  It's so personal to them.  I never lay down with them anymore.  I am always rushing on weekends to finish soccer, violin or do grocery or cook for the week, all so I can study on Saturday night or Sunday morning.  But the worst of all, I don't lay down with them anymore.

The 8 year old boy is persistent and crafty.  His solution to the problem is one that suits us both.  When he is done reading, he walks out to me and stands there and says "please come tuck me in."  He doesn't move nor goes back until I get up from my questions or book and has told me "I get what I want." when I have complained that he is a bit pushy at times.  That has been his way of making sure that I don't forget that he misses me.  The 10 year old girl is more forgiving of her mom, so she doesn't complain much.  

May be I missed it too much, so I completely missed it.  All those defense mechanisms that I know and read about.  Suppression, rationalization, denial, at times some undoing.........all of these helped me let it slip.  Until 2 weeks ago, when my 8 year old looked at me and said "you will just break your promise again."  (He is a bit dramatic, if you haven't figured that out yet).  He is also disappointed in the moment that I told him yet again, not tonight.  Luckily, I am aware that this isn't an all encompassing statement, about my value as a mother or a stark picture of his relationship with me.  I told him, that in two weeks, I am done studying and if I pass, I have no more exams for 10 years.  So as soon as I am done with my test, we will lay down together.  He looked at me doubtfully and my 10 year old creeped in the room, from the adjacent room to confirm what she just heard, her eyes bright and excited.

So tonight, I did just that.  I am done with my boards (for now).  I don't know if I passed or not but until I find out otherwise in 12 weeks, I am going to get my time back with my children.  I laid down with them tonight and talked about my grandma's house where we slept on the roof in hot summer nights with portable fans and then I read Mike Mulligan and his steam shovel with them and all was well.  Tonight he didn't need to come get me, to tuck him in and she didn't say much as usual but she knew I didn't break my promise.

Tonight, I kept my promise and I hope I can keep it for next 10 years, if they still want their mother to talk to them before bed, no matter where they are.

  

Checking In

Also making sure to let you all know that I am still alive and kicking, or may be I should say alive and being kicked.  This is middle of week 4 of adulting.  The first week was rough, with literal, heaving panicky moments of wanting to crawl back into the cocoon, I had just left.  That feeling has slowly abated, can't say it's fully gone.  Interestingly, Friday comes really fast but so does Monday.

I am slowly learning, why I was so heavily recruited for this job.  In a moment of realization, I finally admitted to my husband a few nights ago, that I do feel that I can do this and I am seeing what I am bringing to this position.  Talk about late self realization.

Managing doctors is never easy, pleasant or rewarding.  You are talking about people, who do not take orders well and who do not like to be told what to do and how to do it.  While it is a good quality in the context of patient care, though I think that is debatable too, but it poses numerous challenges for administration. 

That being said, doctors are a small part of my challenge in my new job.  It is the lack of processes, procedures and organization, that drives me up the wall.  I had thought, I would be walking into a house that needs slight renovation, but I walked into one of my dreams, prior to starting this job. 

It was the house that needed a complete gut job and had only one bathroom, that was fully remodeled, functioning and beautiful, right in the middle of a hoarder's family's worst nightmare.  I remember interpreting the dream for my therapist and while it seemed to make perfect sense, about my anxiety with the new job, I never realized how vivid that dream was, until I started working. 

All I know right now is that, it didn't get this way overnight and I won't be able to mend it overnight.  I tell myself this everyday and I try to focus on one thing at a time.  It is a struggle every day because my impatient self wants to fix everything but my rational side keeps me grounded and realistic.  I don't want to crash and burn, so I have decided to let the fire build slowly, so it can last longer and stronger.  So until I check back next time, which will be probably after my board exam in September, send me "hang in there" vibes. 

On a positive note, no PRITE post this year but something worst than PRITE looms.  The good thing is that once done with the board though, I have a long break from taking anymore exams.  So passing this one, literally means, adios for standardized tests for a long time, or may be forever because who knows, what I will be doing when it's time to renew board certification in a decade.

See you all in a few more weeks.