My Bio

I’ve been procrastinating making my bio for our work website for the past couple of months.  I don’t know why, other than that all the things I wanted to say I knew wouldn’t be appropriate.  The real bio ended up being pretty standard material.  Here is what I wanted it to say:

Dr. Julie Gendler grew up in Kalispell, Montana.  She then spent a really really really long time going to school, longer than the average person even thinks a person can potentially go to school.  She completed her residency in Family Medicine in Boise, Idaho, not that the average person knows what a residency is either other than what they see on Grey’s Anatomy, but it was enough to get her a medical license and that is what counts in the end, right?  She then worked her ass off for 4 years practicing full spectrum family medicine, hardly ever sleeping, and having her soul sucked out of her body via a piece of electronic medical record software appropriately named Epic.  Despite meeting some really nice people and making some great friends in Wisconsin, the alternately freezing temperatures and unbearable humidity as well as the threat to life and limb by all matter of nature’s creations such as floods, mosquitos, tornados, and blizzards led her back to the more temperate climate of Idaho.  After a short stint as a full time mom she joined the faculty at FMRI to escape the incessant screaming of “Mommy! Mommy! Mommy!” that still haunts her to this day.  She enjoys teaching residents and has a focus in preventive care and women’s health.  She doesn’t enjoy being yelled at by patients or prescribing narcotics but it ends up that is part of the gig.  In her free time she enjoys…  Wait, hold it, she actually doesn’t have any free time, but in the hour of time that she carves out for herself on a daily basis she exercises frantically in hopes that she will either one day turn into an athlete again or shed the baby weight that clings to her body like the monkey on her fucking back.  Outside of work she enjoys spending time with her family, not that her 3 lovely children appreciate any of the sacrifices she has made to act as their personal assistant/chauffeur/chef/event coordinator.  When not wasting time on facebook she stares desperately into the mirror wondering where time has gone (duh, all that school!) and what is the meaning of life.  She gets through the mess of it all by telling herself that things will work out in the end and tomorrow is a new day and any other trite, convenient, positive Jack Handyish statement that comes to mind.

Article on 40 Proven Strategies to Improve Public Health

Yesterday I posted this on Facebook:

So... the new obesity data came out last week, and it doesn't look good: "No state met the nation's 'Healthy People 2010' goal to lower obesity prevalence to 15%. Rather, in 2010, there were 12 states with an obesity prevalence of 30%. In 2000, no state had an obesity prevalence of 30% or more." (big sigh) This makes me feel like a failure; I know it's not my fault, but I talk to people about this stuff every day that I'm at work. We should probably just start putting the metformin and statins in the water supply now.

http://www.cdc.gov/obesity/data/adult.html

I didn’t really mean to sound defeatist; I do try to look at things positively when possible.  So I have spent the past 24 hours racking my brain as to how to fix this.  I know I’m not the only person doing this, there are far more powerful, smarter, and important people than me who are racking their brains too.  I was also contemplating how hard it is for those of us who are trying to help; how often we see one person succeed and see 9 others fail. And by “those of us” I mean the doctors, nurses, nutritionists, health coaches, spouses, family, friends and really anyone who cares and supports someone trying to lose weight and create a healthier lifestyle.  We’re pouring our daily energy into this problem and not getting a very good return as far as outcomes.  I am not blaming people out there for their weight and I think the evidence above pretty clearly points that there is a problem in our society.  It is escalating so quickly that even though each of us are individually trying to help, we’re not even slowing down the rapid increase in obesity. 

I was feeling a little down about it, and then I saw this, and while it’s no easy fix it is actual evidence based examples of things that have been PROVEN to work (and by that I mean scientifically, not by some ya-ya pseudoscience person on the TV).  So check it out:

http://consumer.healthday.com/Article.asp?AID=667787

My First Triathlon: Post Race Analysis

For the first time in my life it totally paid off to be OLD!  I won my age group in the beginner division.  Don't believe me?  You can click here and then choose "results by division" and scroll down to "Female Beginner 35-39."

This was a big jump for me to do this triathlon last night.  I have been thinking about doing one for years, really, years!  But I’ve always had a bunch of excuses and fears about it.  Will my shoulder (that I had surgery on almost 17 years ago) start hurting again?  Will I even be able to run after swimming and biking?  I’ll have to learn how to ride a road bike, how will I do that?  How will I learn how to transition?  What will I wear?  How and where will I practice open water swimming? I have no idea what kind of workouts to do, how will I figure that out? Can I even do this without a coach?  Will I be able to stay motivated?  When will I even find the time to train for one sport, yet 3 different sports?  But given time and help from Andrew I just pushed all of that aside and kept talking myself down from this being a big deal and telling myself it was just a trial thing (it is called “Y not Tri”) so I should stop thinking about it and just do it already!  And I’m so glad I did because it was so much more fun than I thought it would be! 

I haven’t really competed in anything in a very long time (I don’t count that half marathon a few months ago, that was not about competing for me, I just wanted to finish) and I was very nervous about the competition aspect, imagining all these amazing athletes in excellent condition.  I was relieved to find a wide array of shapes and sizes and to really see that shape did not predict ability!  And I surprised myself by getting a little bit competitive as I was racing. As soon as I got in the water I started to feel that little bit of competitive spirit coming back, I kept thinking, “well that person is not that far ahead, come on, work harder, you can pass her!”  And that is a fun challenge! 

I definitely wasn’t prepared for this in the way I would have liked, I feel almost like I was faking it a little bit because of that.  In the last couple of months I have only done a handful of actual rides on my bike and the same amount of swim practices.  I have been running 2-3 times a week so at least I had some running training, which is good since I am truly a terrible runner, I don’t think I’ll ever be fast!  (my excuse is that I’m probably 95% slow twitch muscle fibers, so I have endurance but no speed, at all).  I much prefer to feel over prepared, so being underprepared made me very anxious too.  I was so thankful that Andy really helped me out; he made sure all my gear was set up right and that everyone was where they needed to be on time and gave me a lot of encouragement to just get out there and try it.  He sent me a text message every couple of hours while I was working that day in clinic reminding of when I was supposed to be eating and reminding me to hydrate, it was awesome to have someone play the support crew role!

Even though I was anxious and underprepared it felt good to just go for it, and the way I made it through was to just focus on the part that was right in front of me; before the swim I was saying to myself, “ok, just figure out how to get into the water, ok, so where is the buoy?  Yes, I see it, just get to the buoy, just get there.” And once I got there I was thinking, “just get back to the shore.” And from there I was thinking, “just put on your stuff and get on the bike.” You get the idea.  I don’t know if this is a good strategy or not, it meant that I probably road the bike slightly harder than I should have.  I came out of the water 3^rd in my heat of 40+ people and that felt pretty good, and while biking someone passed me about half way (it was a 6 mile ride, so not very long) and I was annoyed by that and so I kept up with her and ended up passing someone else (which shocked me).  The one thing I was really not prepared for was the way my legs would feel when starting the run because I haven’t done any stacked workouts.  That is a bizarre sensation!  For the first mile of the run my legs felt like they weren’t my own, they were moving but I had very little control over them, they felt like jello, but not in a tired way, just in a weird nonfunctional way.  I can’t really describe it very well.  The run was only two miles and so fortunately during the second mile they finally felt like my own legs again and I could move them a little faster (not fast enough to keep me from getting passed by some people who were clearly very good runners!).

So here is the breakdown of things that went well and things that could use improvement, this is where you are welcome to throw out suggestions that might help me next week when I do a “real” sprint triathlon! 

Things that went well:

-I remembered to bring all of my gear and I even brought back ups for some things!  (thanks to Andrew)

-The pond was not nearly as gross as I thought it was going to be, I pushed thoughts of all the ducks pooping in that pond out of my mind while swimming and pretended it was a lake, which worked.

-I had an extra water bottle at my swim/bike transition and sprayed my feet off before I put my socks on and that helped get all the sand off (supposedly if you’re serious you’re not even supposed to wear socks, you’re supposed to leave your bike shoes clipped into your peddles and put your shoes on while you start the ride, that is WAY out of my ability level!).

-I clipped in fairly quickly without falling down

-The biking portion was flat so I didn’t have to do much changing of gears, I chose to grind up the small hills which I “think” was good?

-I really like the triathlon shorts that I bought, I paid a little extra for nice padding in the butt (like bike shorts) and I was happy I did that, they were super quick drying too!

-I was faster than I expected at both transitions, and at the time I was just wishing I could rest and catch my breath, but I was trying to gain as much advantage as I could going into the run because I knew it would be terrible.

-I wore a number belt/strap instead of pinning the number on for the run, so glad I did that!

-I focused on extending my stride length throughout the run, which always seems to help me when I’m tired (any other running advice is greatly appreciated!).

Things I didn’t expect/could be improved:

-I didn’t know they wouldn’t let us into the transition area during the youth race and so I got anxious about not being able to set up my stuff and had to wait until just before the race to do it (the kids started first and had their own transition area but had to go through the adult transition area to get on the bike course which I didn’t know).

-I need to antifog my goggles, I had to pause halfway and do a little bit of breaststroke to clear them out.

-My shirt could have been tighter, when I bought it earlier this week (paying more money for it than I planned, which means I’m pretty much stuck with it) the woman at the triathlon store told me I might want it tighter but the idea of running in a really tight shirt didn’t appeal to me (I have postpartum flabbiness that I prefer stays hidden under a “partially relaxed cut”), but it did feel like it was billowing around me while I swam.

-I somehow, given my years of not swimming, have gone back to having a 2 beat kick, which is a habit I broke a long time ago, but now I guess will have to work on breaking it again (or should I?)  the good part about a 2 beat kick is that I basically don’t use my legs while I swim, so at least I save energy?

-I could have laid out my transition stuff slightly better so I could have stood on my towel after the swim, this wasn’t totally my fault because a girl racking her bike near me was like, “um, you need to move your bike over because I’m not going to have room to put on my shoes” so she got 3 feet of space and I got 12 inches.  I need to be more assertive.

-I should have had some big gulps of water in the transition area before getting on my bike.  This coincides with the next one:

-I can’t get my water bottle out of the holder without swerving all over the place.  I HAVE to learn how to do this because my mouth felt like a wool sweater from being so dry during the entire 6 miles of the ride (worsened by my total sucking of air).

-I almost missed a turn off into a neighborhood because I didn’t analyze the route enough before the race (assuming there would be a big group of people in front of me and that I would follow them). Fortunately I was not too far off from the girl who had passed me so I was able to follow her.

-I almost hit a person while on my bike, it was another athlete and he was trying to cross (not at one of the designated places and he didn’t even look before he stepped into the road) and I screamed, like a real scream, which I didn’t mean to do, but it made him jump back, so we avoiding colliding.  Glad to know that reflex was there when I needed it but I should probably learn to use my brakes and how to handle my bike better.

-My cadence on my bike was not fast enough, my guess is that it was around 60-70, and Andy has told me it needs to be 80-90 because it’s more efficient, but I really enjoy grinding it out, I like the slow and steady turn of the pedals, is that really a waste of energy?

-I pre-tied my running shoes so that I could just slip them on, and I purposely didn’t double knot them because I didn’t know how well that would work.  Ends up both of those things were a mistake, my shoes felt awkwardly loose AND they came untied, so I ended up wasting 30 seconds retying my shoes about ½ mile into the run.  My husband had bought me some Yankz earlier in the day but I was nervous about trying them for the first time during the race, definitely will next time I run!

-My sports bra was really wet throughout the whole race, anyone have advice on a certain brand or type of sports bra that is ultra quick drying (and relatively tight but also flexible?).

-I drank water (from the little cups they hand out at water stations) while I was running because I was so incredibly thirsty after not being able to drink water on the bike.  Ends   up I’m not very good at drinking water and running hard at the same time because I choked and sputtered both times, maybe I should have just stopped and drank my water?  (I normally carry a water bottle when I run so I don’t know why it was so much harder out of a cup?).

Wow, if you read all the way to the bottom of this then you could totally do a triathlon, it’s less effort, seriously!  And advice about anything triathlon related is totally appreciated!

Follow up on the "no TV on weekdays" experiment

Good news, so far we have adopted this as our new strategy at home and it has been accepted and implemented and is going strong!  The first few weeks were actually harder on us as parents than I think it was on the kids.  I didn’t realize what a gut reaction it is for me when I’m trying to get something done or when I feel like they are irritating me to plop them in front of the TV and say “here, watch something!”  So it was good insight into my own behavior and my own triggers!  They no longer complain about not watching TV on the weekdays, they know the rule.  And they still don’t watch an excessive amount on weekends, typically an hour or two each day.  It feels good that there are 4 solid days of the week that the TV doesn’t come on in our house and I would encourage other people to try it too (I say 4 because Friday is “movie night” at our house and so they get to watch that night).

I am now moving on to Phase 2, which I didn’t know there would be, actually, but now I can see that the TV was not enough.  And I think Phase 2 is going to be more difficult.  What has happened is that because the TV is off limits, the kids have found “the other screen,” the computer screen, and latched onto that.  They have a newfound interest in playing computer games ever since we started the experiment.  The hard part about it is that we already limit them to only educational games (math games, spelling games, etc.) and so technically what they are doing is educational and for Avery it even counts as homework/study time.  So I’m trying to figure out what our limit should be on this type of activity.  I’m leaning toward 30 minutes a day as a limit.  I still think that interacting with a screen (computer or TV) is generally not the kind of “play” that I want for them on an extended basis and so limiting this seems like a good idea.  But I also don’t want to take away educational opportunities either and certainly computer skills are important.  I’m open to thoughts or comments!

A medical test that opens a can of worms!

Despite the rapid advancement of medical technology it is not that common for a new test or medicine or vaccine to really get us (doctors) all riled up.  This week I watched (and participated) in feathers getting ruffled by a new test that will be available in our community next week.  After hearing a talk about it earlier in the day I tried to explain it to my husband, and despite his own large medical knowledge base he was like, “oh, that’s interesting” and I was like IT IS NOT INTERESTING IT IS FREAKING AMAZING AND SCARY AT THE SAME TIME!  

So now you’re wondering what this new test might be?  It is called cell free fetal DNA testing.  It is a test done on a small blood sample from a pregnant woman that is able to differentiate fetal cells from maternal cells and then run DNA testing on those fetal cells.  The results are amazingly accurate (around 98%) even done at a very early gestational age (7 weeks) although it sounds like the commercial tests available recommend testing around 10 weeks, probably to increase accuracy.

Here are the really cool medical things this test will be able to do:  1. Determine trisomy disorders (like Down’s syndrome) at a very early gestational age without any invasive testing (like chorionic villus sampling or amniocentesis) with amazing accuracy.  2.  Determine a male or female fetus in cases where there may be a sex-linked inherited disorder.  3.  Determine the fetus’s blood type so that we can make decisions about whether or not to give rhogam or how much monitoring is necessary in an already isoimmunized patient.  4.  Determine paternity for cases of potentially inherited disorders.

Here is the scary part.  This gives us the ability to potentially analyze every fetal gene at a very early gestational age and not in some weird future reality, but very soon.  Right now the information is limited, but it is certainly possible that in very short order, after a single blood draw, you could be handed a multi-paged report with information about your baby’s DNA.  And you could make decisions about that, like, “hm, I don’t think I want a blue eyed, brown haired boy with a 75% risk of developing X, Y, Z disease, I’ll terminate and try again.”  Self-selecting your child based on the genetic make up of the fetus is now a real possibility without much risk.

I’m actually not that worried about the medical community becoming a gateway for misuse of the test; I trust my colleagues and I think most of us feel an ethical obligation to only use medical tests to help make medical decisions.  I’m more concerned that private companies will get in on this, and in fact, I think it has already started for both paternity and sex determination.  I would imagine the only thing really holding people back right now is the cost (around $1500), although I think there are people out there who would shell out that kind of money to find out the sex of their baby at such an early age and with such accuracy.  It will be very interesting to see how all of this plays out!

Week 1 of the "No TV on Weekdays" Experiment

A couple of weeks ago I was reading an editorial article in parenting magazine about a family that decided to change their TV rules and what happened.  The author said her two daughters (roughly elementary school age) would ask to watch TV a lot and while they had limits on how much they could watch, they did watch some every day.  The parents decided to make a deal with them, that during the week there wouldn’t be any TV and on the weekends they could go crazy and watch as much as they wanted (barring any planned activities).  It ended up working really well for them, and after the first weekend, that they spent obsessively in front of the TV, on the following weekends they watched a couple of hours on Saturday morning and then became interested in other activities and didn’t notice when their mom walked into the family room and turned the TV off. 

I have been pondering what to do about TV watching in our house.  Our kids don’t watch that much TV in the first place, but probably about 30 minutes in the morning and then 30 minutes on some evenings but not most.  While this fits into the “less than an hour a day” rule that I recommend when I’m seeing pediatric patients in the office, it still seems like too much to me.  I don’t think there are any good studies with “no TV watching” as one of the categories, because it’s just not realistic in our current society (sadly) but theoretically I think it is better for them to not watch that much TV.  I also get sick of them asking (or begging) to watch “just one more!” and so I thought we should try this strategy.

We implemented it one week ago and so far it has been really good.  They didn’t take advantage of the rule over the weekend like I thought they would, but they were busy with a lot of activities.  I was impressed though because at one point I offered to let them watch TV and they actually chose to go play instead.  Once the weekdays started there have been occasional complaints about “I hate that rule!” when they have asked to watch something in the morning and we have said “no,” but for the most part they have adapted well.  One morning I came downstairs with the baby and found Avery on the couch reading a book and Asher sitting at the table coloring.  They hadn’t even been told to find something to do, they had done it completely on their own! 

Interestingly, I’ve also found that I am watching less TV too.  I like having the cabinet doors on the media center shut, it makes the room feel nicer to me.  And there isn’t anything I really want to watch so I don’t have the same impetus to mindlessly turn on the TV like I sometimes will do when the doors are open.  I don’t know how long this experiment will last, I feel like with kids you just have to keep trying things and find the things that work, but I have my fingers crossed that this one will stick!

Four Months

Ok, so I’ve been meaning to write about Vivian since she turned 2 months old, but what they say about the 3^rd kid is true, their early existence rarely gets documented in the same manner as the older siblings.  But I thought it would be worth putting some thoughts down for posterity’s sake.

Let me start with the good. Vivian is pure joy in the form of a cuddly baby.  There is something about her, and it could be just me (since she is my last baby), but I am enraptured by her.  When I’m with her I feel like a little bubble of enchantment is surrounding us and time seems to slow down.  It’s almost like she’s a drug and I’m addicted to her; when I’m away from her I feel like a little part of me is dying and I just can’t wait to be with her again.  Every chance I get I snuggle with her, kiss her, and breathe in her sweet baby scent.  I know it doesn’t last forever and so I have been focusing on enjoying every moment that I can.  In fact, the other day I saw this Dreft commercial and at the end they say, “you have a child forever, but a baby for just one year” and I was a crying mess!  Only a year!  And it’s already 1/3 over!   

Other great things about Vivian (aka V, Baby V, Viv, Vivi, Cheeks McGee, or Chunkers) include her general “good behavior” (for a baby).  She started sleeping through the night around 8 weeks.  And by sleeping through the night I mean 10 pm to 5 am, which is a pretty good stretch.  By 3 months she was about 9 pm to 6 am and recently she has even extended that to the occasional 8:30 pm to 7:30 am!  I don’t think Avery slept through the night until she was over a year old, and Asher still wakes up at 5 or 6 in the morning!  I have heard patients tell me about their babies who do this and I tell them to keep it quiet, the other mothers will curse at them if they hear, never thinking that I would potentially have a baby who does that!  Also in terms of being a “good baby” she hardly ever cries and her cues are very clear (it’s easy to distinguish the “I’m hungry feed me now!” shrill refrain from the “I’m poopy” whine from the “I’m tired” whimper).  She can fall asleep pretty much anywhere and she doesn’t fuss, she just gets heavy eyelids and before I know it she is out cold no matter where she is.  She also is the only baby I have known who wakes up smiling.  It is the most amazing thing, because I will hear her in her co-sleeper making those cute little baby squeaks and I look over at her and as soon as she sees me a big smile spreads across her face and she starts to coo and blow raspberries.

The bad things are things I’ve already written about and so they aren’t really news.  We didn’t click with breastfeeding.  The lactation consultant that I was seeing every other week for the first couple of months felt like it was probably because of her being so sick in the NICU.  That combined with her tight jaw, poor tongue movement, weak suck and general distractibility at the breast.  Add to that that I’m not a prolific milk producer and we had the perfect storm for a bad breastfeeding experience.  For the past month I have been mostly pumping, and hating every minute of it and so I finally gave up and am in the process of weaning myself from pumping.  Vivian is oblivious; she doesn’t care and seems happier with the bottle anyways.  I know what we’re missing out on though and so I mourned the loss of our breastfeeding relationship for a couple of weeks before finally deciding to stop pumping.  There was a lot of crying and I don’t think I was very fun to live with during that time, but I have finally worked myself through all the grief stages and reached acceptance.

Another bad thing is the PTSD from watching her be so ill and in the NICU.  It’s only over the past few weeks that I’ve stopped having nightmares in which I go into her hospital room and she isn’t there and I am frantically searching the hospital and can’t find her and no one can help me find her and I wake up panicked and sweaty and shaking.  On a side note, a friend sent me this articleabout NICU PTSD, which is interesting.  Also a move in the positive direction is that I’ve stopped waking up randomly throughout the night to reach over and touch her and make sure she’s still alive.  I try not to think about what would have happened that night she was born if we had just gone to sleep (which is what we were in the process of doing before we decided to have the nurse unwrap her and take a look at her color) and I know that we would have woken up to find her dead and I’ve imagined calling the code and the whole horrible resuscitation scene that would have followed.  I recognize that thought process is not helpful (particularly since that didn’t happen) and so I’m working on letting go of that.  I realize there are so many worries and “what ifs” as a parent and living with that uncertainty is not easy for me, but seems worth striving for in order to live clearly in the moment.  It’s a process.

The final difficult thing is probably the biggest ongoing issue of the balancing act that involves managing 2 children and a baby and a husband and a part time job and a house that seems to want to fall apart all the time.  I may have used the juggling analogy before but I always remember it at times like this.  Someone gave us a lecture in medical school and told us in order to manage our complex lives we should imagine that all of our responsibilities and things we do are like balls that we’re juggling.  The key to making it all work is not to try to juggle more and more balls, or to juggle them better, it’s to figure out which balls are rubber and which are glass and then drop the ones that will bounce and not break.  I’m refocusing my efforts to become better about this because I know how precious my time is, not just with Vivian, but with everyone I care about and I want to be able to really focus on the things that matter the most to me and drop all of the other balls without breaking any.

So as you can see, overall she is the most amazing and wonderful baby on the planet (ok, ok, so I’m biased!)!  But in all seriousness, I do absolutely adore her and appreciate having her in my life; I feel so incredibly lucky.  She is truly a blessing and every day with her is a gift.

A Cautionary Tale of Three Children

Here is what I have discovered over the past 3 months with 3 kids in our house.  Those people (and you know who you are) who said going from 2 kids to 3 kids was not nearly as hard as going from 1 kid to 2 kids were LYING.  It is most certainly as hard, if not harder!  Ok, so maybe this is not something that can be generalized, but the thing is, that Vivian is a really good baby (knock on wood) and so it's not her individually that has made things harder, I think it's more that there is less of me to go around and my coping ability is slightly strained.

Mornings are the worst and on any given morning someone is upset/screaming/whining/having a tantrum.  The increased number of children make it less likely for the stars to align and have every person be in a good mood and capable of handling themselves with decorum.  This morning it was mostly Avery who was being difficult and so I'll use today as an example of how it often goes. 

Vivian woke up around 6:30, she is the only person in the house (other than me, of course) who wakes up smiling and I love to look over at her in the co-sleeper and see her beaming at me.  Andy soaked up some of her good vibes before he walked out the door at 6:45 for an early meeting at work.  Ah, bliss and happiness for 15 minutes as she smiled and nursed.  And then the good feeling was gone as I heard whimpering from the floor by the foot of the bed (where Asher has been sleeping for the past 2 weeks), "uuuuuggghhhh, I have to go poooooop," to which I respond, "well, get up and go in the bathroom," and he replies, "uuuuuuggghhhhh, it's too dark!" and I calmly say, "you'll need to turn on the lights then."  And this continues back and forth for 5 minutes until he finally can't hold it any longer and makes his way to the bathroom, and then after awhile I hear, "mommy, please wipe me."  Well, given the long discussion of getting him there in the first place I gave in to this part, I mean, he DID say please (Avery had this skill mastered by 3 1/2 so I assume this is a boy thing).  I get back in bed and try to feed the baby some more but the whimpering continues; his pull-up is twisted and stuck in his pajamas and he can't get them back on.  I tell him to just go pantless.  He doesn't like that answer, AND he wants to go downstairs and watch TV.  I don't really want him to do that because I don't want to wake up Avery quite yet.  So I get out of bed again to help him with his pants (which he still wasn't happy with and took off anyways) and turn on the TV in the bathroom to PBS kids.  He doesn't want to watch that, and from the bed I say with a note of irritation in my voice, "it's that, or nothing."  I don't get a response so I assume he's watching.  I doze off for 5 minutes but am awoken because he is now whimpering that he is hungry.  No escaping this one!  So we head downstairs to his bedroom to get his clothes on for the day, and since Asher is incapable of reducing the loudness of his voice for any occasion he ends up waking up Avery, and I hear whimper-sobs coming from her bed, "He, he, HE woke me up!"  And I ineffectively but calmly try to talk her out of being angry with him because it was time to get up anyways.  I change Viv's diaper and clothes while they both whine about having to put on their clothes to which I calmly reply, "fine, wear nothing, that will go over well at school." (I think I have said that same phrase hundreds of times so far in their lifetime). 

Before we get upstairs to the dining room Avery begins to worry about something for school.  You see, it's her "share week" (which only happens once a year where she gets to bring in a show-and-tell item one day this week), and to help the students make the most of their singular sharing experience presenting in front of the class her teacher prepared a handout to help them organize their thoughts on what they're going to say.  Most kids probably don't have a problem with this but Avery starts to cry because there is only room on the sheet for 3 sentences, and she wants to include more detail than that.  Her frustration is obvious in the tears dripping all over face and she is begging me to help her.  I take the party line (the current one at our house) which is that I know she can do this and that I'm not going to tell her how to do her homework.  That illicits more tears.  She begs me to give her some guidance, so against my better judgement (it's hard to make decisions when your kids are crying) I tell her that I don't think she needs to include the detail, she can add that when she is actually talking about it.  In response to that reasonable idea she throws herself on the floor screaming, "I'll NEVER remember the details if I don't write them down!" And I say, "well, then write them down, you'll have to write really small to make them fit but I bet you can do it." And she says, "NO I CAN'T, I JUST CAN'T."  And then I'm like, "Ok, well then don't do it, just turn it in blank, or you could work on it later, you still have 2 days to do it, and you REALLY need to eat breakfast, now."  (throughout all of this we had made our way to the dining room and I had poured Asher his cereal and milk, made a bottle for the baby and started to feed her). 

Just to make sure I notice he's still there through all of this Asher pipes up, "Mommy, I'm being SUCH a good boy, aren't I?  I'm not acting like Avery!"  Which incites another round of crying and whispered mean remarks from the 8 year old mess on the floor.  I ask her what cereal she would like and she responds that she doesn't want to eat breakfast.  I'm now starting to get irritated from all the crying, and so with a big sigh I try to stuff the irritation down and say calmly, "Ok, well, it might be difficult for you to learn things this morning at school if you're hungry, but if you insist on not eating then that's your choice."  And she says, "well, I'm going to tell my teacher that I was hungry but you wouldn't feed me because you're so mean to me!"  And that's when I lost it and yelled, "You will NOT tell lies, that is unacceptable, and you will not even touch a horse, ever, if you lie to me or anyone else!"  (current go-to threat involves revocation of horseback riding lessons which she is starting next month).  Ok, so that was over the top, I mean, can't touch a horse, ever?  Sometimes these things just spill out of my mouth. 

She spends the next 5 minutes sitting at the table pouting.  I pull my s**t together and give them both the 5 minute warning that they need to brush their teeth and put their shoes on and what does she say?  "I'm hungry, I want to eat something, something little."  So I tell her that we don't have much time but go ahead and pick out a bowl.  So she picks a 2 oz ramekin.  It barely holds a few cereal flakes but I go along with this ridiculous plan and carefully pour a tiny splash of milk in her tiny bowl and she eats it with her tiny spoon (and I roll my eyes).  Then we proceed to teeth brushing, etc. (all this while I am carrying the baby, because every time I try to set her down this morning she cries).  And I look outside and see it is snowing.  Great.  It hardly ever snows here (to where it sticks) and so I move quickly to get out boots and snow pants.  Avery has finally recovered (mainly out of concern of being late to school, she hates being late, she hates the idea of even being close to late, so she moves quickly if that is a risk).  And now Asher is freaking out about his boots, crying and rolling around on the floor because he can't get his pants inside his boots.  I encourage him to use his words which results in more screaming.  I'm trying to buckle the now screaming baby in her carseat and encourage him to either fix his boots himself or use his words and congratulating Avery on pulling it together and doing a good job with her boots.  Asher says, "but you didn't tell me good job!"  Then they start kicking each other.  I can feel my blood pressure rising and all I can say is, "Out, please open the door and go out, out."  So we get in the car, and I'm actually feeling pretty good, because everyone has their snow stuff and now no one is crying, but I look at the clock and realize that we're too late to drive Asher to preschool first (like we usually do) and we're too early to take Avery by about 20 minutes.  And I have a moment, a real "aha" sort of moment where I think, "is this what I want them to remember about their days?  This screaming crying mess of a morning? NO, I want them to have happy memories."  I also realize at the same time I need coffee.  So we go to our neighborhood coffee place and I get them hot chocolates and I get coffee and all of a sudden the morning is blissful again.  Isn't it amazing how quickly that can turn around?  And they are sharing!  And being nice to each other!  And the baby is not crying, and so cute!


We get back in the car in a much better mood.  After everyone is finally buckled in Asher starts crying, his coat is bugging him (the way it's tucked under the seatbelt and rubbing on his neck).  And the baby is crying because she was almost asleep and Asher startled her, and so I'm calming her and Avery is trying to help Asher take his coat off and rebuckle his seat belt.  I take another deep breath, trying to hold on to the bliss that is slipping through my grasp.  So finally, FINALLY, we drop Avery off at school, and she is even early!  As she is giving me a hug goodbye she says, "sorry Mommy, I think I was just hungry."  I want to cry for that is one of those sweet but painful moments I realize I just spent 30 minutes in motherhood hell for a lesson that she now recognizes but is going to completely forget about by next week when the same scenario is repeated.  Then I drive Asher to his school, and we laugh at Lorenzo Llama together and it is all good feelings and I take him in and drop him off and I'm even a little bit proud of myself because I remembered his snow pants even in all of that commotion!  I drive all the way back home (it's about 10 minutes, so not too far) and gaze at Viv's beautiful sleeping face as I take her car seat out of the car.  And then I see a flash of green and crane my neck over her seat, and sure enough, Asher left his coat in the car.  And all I can think is "that little mother ....  UGH!"  But instead of throwing a tantrum I called his teacher and was happy to hear that a lot of kids had not come to school prepared for snow, so they wouldn't be going outside today.  Sometimes fate throws you a bone. 

So I really wonder how people do this with EVEN MORE CHILDREN.  3 is maxing me out, for sure (as you can see by how easily I lose it!).  4 seems like it would be sheer torture. And more than 4, that is just plain insanity!  Don't get me wrong, I would not trade in Viv, we love her to pieces, and I feel like having 3 kids was right for us, but if I had known I would have adjusted my expectations for a more difficult transition instead of the "oh, it's really hardly a change at all" line of b.s. (from all you crazies who said it was easy!).

Fennel: an underappreciated vegetable

I’ve recently discovered that I love fennel!  And when you’re working hard at getting veggies in your diet like I’m currently doing, finding an entire unique vegetable to add into the mix is very refreshing!  When it’s roasted it has such a beautiful flavor.  I recommend trying this recipe (I add in asparagus at the same time as the green beans, tonight we added the parmesan too and it was good, but not required).  This is a new favorite at our house and Avery asked for seconds!  (Asher eats nothing, he lives off of milk alone so he doesn’t count).

http://www.weeklygreens.com/recipes/roasted-fingerling-potatoes-fennel-and-haricots-verts/

Let me know if you try it and like it!

Trying to lose the babyweight

This is my way of giving myself a pep talk for weight loss, it contains advice I often give patients, so you are all welcome to take it or leave it.  Plus, I’m interested in hearing what my other doctor/nutritionist/health care or other friends out there tell people (and would tell me) so please feel free to comment.

1. It is simple math.  If you create a 500 calorie deficit on a daily basis (from your baseline needs) you will lose a pound a week (3500 calories = 1 lb).  Whether you do it with diet or do it with exercise doesn’t really matter for weight loss (although there is evidence that exercise even without weight loss may prolong your life so it is good in and of itself). People don’t like hearing that it is simple math when I tell them this in the exam room I have been met with eye rolling and people saying, “but I already do that and I STILL am not losing weight.”.  So I encourage food journaling for 3 days (I find asking someone to do it for longer than 3 days is too hard for them to do) and bring in their journal to me and show me.  Do you know how many people have come back to me with that food journal?  ZERO.  Which leads me to believe they either ignore me completely or they do the food journal and realize that they aren’t actually reducing their caloric intake.  I currently am using the Lose It! App on my iPhone for food journaling.  It has some nice little features, like a bar code scanner (so you can scan your cereal container in the morning with your phone and it automatically puts it in your log), it also helps you see where you are in terms of your daily and weekly weight loss goals based on your caloric intake and exercise.  I would be interested in hearing if anyone else has other calorie counting apps or websites that they recommend.

2. When you are trying to lose weight, food should not be your friend.  Food can be a lot of different things for me and for other people too: it can be a creative material (cupcakes!), it can be tradition, it can be celebratory, it can be a show of kindness and love, and it can be fuel.  There are probably other things not on that list that it can be.  But, when food becomes really emotional it puts a level of control over a person that is probably not healthy.  Occasionally I have people in the exam room start crying when we talk about diet/weight loss when they start talking about their relationship with food.  To me that is a sign of an unhealthy emotional attachment to food. I encourage them to seek counseling, and I have seen people finally able to successfully tackle their weight loss goals once they work through their emotional issues.  For me, I do better with changing my diet when I look at food as fuel.  I’m not saying it shouldn’t be enjoyable or taste good, but somehow looking at it as energy for my body is helpful for me in terms of weight loss.  I often recommend the book “Eat what you love, love what you eat” to patients; I saw this author (who is a Family Physician) speak at a women’s health conference and she has a great story and message and if you have an opportunity to hear her speak I would encourage it: http://www.eatwhatyoulovelovewhatyoueat.com/

3. Make small changes.  The human body and mind doesn’t like change.  Trick it if you can.  Substitute whole grains where you would normally have rice or pasta, it’s not as hard as it sounds!  Or make changes in activity that are continuations of routines you already do.  For example, if you walk your kids to the bus stop every day, walk a little farther than the bus stop each day after they leave and soon you’ll be walking a mile or more.  I don’t encourage people to try things that seem painful or hard to do or difficult in terms of timing.  Plus, I really think activity should be fun as you’re more likely to keep doing it.  I also think it’s good to take advantage of your natural attributes as well.  For example, if you’re a competitive person, set a goal for some sort of race or competition to keep you active.  If you’re a social person, find a group activity or class that you might enjoy.  (Personally I’m going to be signing up for a half marathon in late spring to motivate me).

4. Get and maintain support.  Use a spouse, family member, friend, trainer, nutritionist, or anyone you can find who is willing to support your efforts and help you.  It’s good to have someone to bounce ideas off of and to look over things with you to keep you on track and make sure you maintain balance.  Of course it goes without saying you should see a doctor if you haven’t in awhile to make sure that your plan is good as well (it can also be a good motivator if you find out you have high blood pressure or high cholesterol).

5. Accept it will not be easy.  I always laugh a little when commercials make weight loss sound easy.  It’s really hard.  Just accept that your body will hurt sometimes (I mean muscle soreness, not a real injury, which everyone is at risk of having and should make sure to start off slow and build up a good aerobic base before pushing their limits) and that sometimes you will be hungry.  I don’t mean starving, but it’s pretty hard to cut your calories and not be hungry at times, I think it actually helps you listen to your body better when you occasionally can say, “oh, that is what hungry is like, I should fuel my body now.” (instead of always being in a state of semi-fullness, which is where I probably spend too much of my time!).

Breastfeeding Blues

I’m on the verge of throwing in the towel on exclusively breastfeeding Vivian.  It has been a rough road and I don’t know how much longer I can put in this level of effort and get very little in the way of results.  Now, I know many of you out there are really passionate about breastfeeding and so am I; I think it is what is best.  I also know that many people have no problems with breastfeeding and it is very natural without any struggling; their infant latches beautifully and their milk supply flows so freely they could feed 5 infants at a time and still have a freezer full of milk.  I’ll try not to hate you for it if you’re that person (but please don’t rub it in right now please). 

I’ve never been a great milk producer and I have said before that if I was a cow I would definitely be slaughtered for my tender ribeyes and not kept around for milk production.  I was able to exclusively breastfeed Avery for the first 4 months but she probably wasn’t getting that much (she was getting enough to grow but she was scrawny), when her day care provider started giving her formula at 4 months she sort of exploded and rapidly doubled her weight and as one of our friends said when they hadn’t seen her for a couple of months, “wow, this Avery ate the other Avery!”  But I simply didn’t know how much she was getting until I started pumping at work and so I’m letting myself off the hook for that.  With Asher I went back to work when he was 2 weeks old and so he was supplemented a little bit from the beginning and I didn’t worry about it too much.  With Vivian, since I started pumping from the beginning during her NICU stay I knew I was behind the curve in my production from the start.  And then it ended up she has a weak and disorganized suck, a tight jaw and neck, and she is generally a lazy/sleepy nurser.  Those are all things that make it more difficult to breastfeed (maybe SHE should put forth a little more effort!). 

We have been doing a lot to try to make this work.  We have been to the lactation consultant on an almost weekly basis and to the physical therapist a few times and done craniosacral therapy.  Our feeding routine is a little bit crazy (and time consuming) because first I nurse her (which is usually frustrating because I either have to do all kinds of things to keep her awake and well latched or she gets frustrated and screams at the boob) and then afterwards I have to give her 1-2 oz of supplemented previously pumped breast milk or formula (because she can’t empty the breast on her own) and then I have to pump to obtain the aforementioned milk to supplement at the next feeding.  Occasionally I use a syringe and small tube to feed her the milk while she is breastfeeding, which is time consuming and difficult too, getting that little tube into the corner of her mouth while she is nursing without breaking her latch is like threading a needle that you can’t see and I usually end up with milk all over the place.  Then there is the cleaning of all the bottles/syringes/pumping equipment.  We also have to try to do her jaw and neck exercises (which I frequently forget to do because I’m exhausted and they make her cry).  I estimate I spend between 8-10 hours a day with these various breastfeeding related tasks.  With the other 14 hours of the day there is the holding/changing/other baby care activities and of course there is all the normal life stuff like getting the kids off to school, cooking, laundry, etc.  I try to get some sleep too and do what I can to take care of myself (take all my vitamins and herbs and mother’s milk tea) but it’s not easy.  And in my spare time I have (of course) collected the data of when and how much she eats, when and how much I pump, and made a spreadsheet so I can track any trends.  I find it surprisingly therapeutic to record that information, even if it does just point out how badly it is going.

People often say that many of the things you feel you need to do you don’t have to do when you have an infant (like some daily household stuff) and I agree, but sometimes those things also are the things that make you feel human.  The other night I cooked a real meal and it took me about 75 minutes, it was a main course with two side dishes and a dessert, and it was a crazy hour because the baby was crying off and on and it took a lot of pre-planning in terms of when to feed her and everything and Andy was like, “you didn’t need to do that, we could have picked something up.” But the thing is I did need to do that because sometimes I just feel so engrossed in this complicated feeding routine (one that I am not exactly succeeding at) that I need to do something else so that I can, for even an hour, feel like a capable person. 

I won’t even get started with the guilt factor.  I’m going to feel guilty either way (whether I give up the hope of exclusively feeding her or just continue being sub-par with half time breastfeeding) because it feels like one of those things that you are supposed to do as a mother.  You are supposed to provide for your baby.  To fail at that is really crushing.  I have seen patients who go through this, and I support their decision either way, and now I finally understand what a painful decision it is.  I have another lactation appointment today so we’ll see how things go.