recalibrating

I know there's a touch of irony in adding this disclaimer given that I haven't updated this blog in, like, half a year, but: LONG ENTRY AHEAD.

There's a snippet of a cartoon I remember from my childhood--I can't remember if it was "Tom and Jerry" but if it wasn't it was in a similar vein--where a mouse is reclining in a hot tub. He's sitting back with his arms along the rim of the tub, maxing and relaxing as cartoon mice do, wearing that look of smug satisfaction he was prone to. (As an aside: I never liked Jerry. I always thought he was a real jerk to Tom, a cat who was just fulfilling his evolutionary imperative after all. Ditto Road Runner. Ditto those capering harpy kids that keep taking the Trix away from the rabbit. JUST GIVE HIM A BOWL, YOU ASSHOLES.)

So anyway, the mouse. He's enjoying the hot tub. He's relishing the water, the heat. But the water starts to get a little bit hotter. And a little bit hotter still. Suddenly it's not so comfortable anymore. Not hot enough that he wants to get out of the tub or anything, but just...hotter. He starts sweating. His fur starts getting a little frizzy (from the humidity, you understand). Then, finally, he turns around and notices the cat behind him, slicing onions and carrots to add into the now boiling water. (My memory of this part is not quite as clear, but the cat may have been wearing a chef's toque.)

I've thought of that cartoon clip a lot in the last year.

But let me back up for a second.

If you've ever followed this blog with regularity in the past (though I'm sure with my sporadic updates I've winnowed that number down to only the die-hardest of die-hards) you've probably noticed that I haven't had the time to write much of substance since I went back to work after my maternity leave last September, and that I haven't updated basically at all since December. The reasons are all those that you could probably expect: busy job, three kids, and the responsibilities and duties associated therein. The explanations are always boring because everyone's reasons for being busy are pretty much the same, but to put it in medical terms: it's just a matter of triage.

It's hard to know where the tipping point was--though I have to presume that it was at least in part associated with the addition of our much-beloved third child into the mix--but at some point in the last year, things started getting hard. Not impossible, not un-doable, but subtly, Joe and I started to notice just how tight things were getting. Time was tight, at home, with the kids, with each other. Emotional resources were tight. Patience was less of a resource we could reliably depend on. The days and weeks started becoming these things that we were enduring, rather than living, let alone enjoying. Again, the imagery from an old movie comes to mind--inmates in a prison, grimly notching off yet another day on the wall of their cell.

I don't mean to imply that our life is a joyless dirge--far from it. We love our family, we love our jobs. Even working the hours that we do, we try carve out quality time when we can--long weekends, holidays, family vacations where they fit in. We bolus our family time because our basal infusion rate is so parsimonious, but we do make an effort to compensate. And we liked to tell ourselves that this bolus dosing was sufficient, and it worked...not well, but well enough.

But it didn't change the fact that over the past few years, and over the last year in particular, the feeling of our everyday lives becoming something that we were tolerating started to feel more an more pervasive. When you only see your kids for an hour or two at the very tail-end of each day, only to perform the most basic of maintenance for them (bath! brush teeth! yell at them for not taking their baths and brushing their teeth quickly enough because I'm tired and they're tired and everyone's tired so LET'S ALL GO TO BED AS SOON AS POSSIBLE) you start to feel like you're consisting on a diet of discarded crusts in an otherwise empty pizza box. Maybe you can piece together a life in these scraps of the day, but split between three kids, it's simply not enough time.

Joe and I have been discussing for years our long-term outlook for modifying (read: decreasing) the work hours for at least one of us to have more time with the kids, and for the longest time, our party line has been: soon. We're going to do it soon. "Maybe in a few years or so," was the stock phrase. But there was always the next thing. We'll think about it when I finish my fellowship. We'll figure it out it when I get more settled in my job. We'll do it if I make partner in my group. Later. We'll do it. But later. Meanwhile, time marches on.

Then: I was talking with one of my partners at work a few months ago. He has four kids, the oldest of whom had just turned eight. "I just realized," he said as we were chatting in the front hall of the OR, sidestepping a stretcher careening down the hallway from the PACU, "that he's eight. In another eight years, he's going to be in high school, driving, getting ready to go to college. Half my time with him is already done. I mean, they come home after they go to college and all, but you know what that's like. It's not the same. Half my time of having my son in my house is over already."

There feeling that I had after having that conversation was not unlike being wrapped in a piece of wet burlap and gently asphyxiated. Because Cal was turning eight too. Half our time raising our oldest son in our home was done, and not only had this particular calculus not ever occurred to me, but looking back, I can't say I really know where those eight years went.

Because see, we've always lived like this. Cal was born when we were residents. His entire life--and thus of course, Mack and Nina's entire life too--we've worked. Both Joe and I have worked our tails off. We're not residents anymore of course, and some of the specifics of our jobs have changed from year to year, but the fact of it is that we each work on average 50-60 hours a week, more if we're taking weekend call, and although we've been saying for years that we were going to try to get more control of our work schedules to put some more time into our family life, it hadn't happened yet. The decision point was always pushed off down the road. Later. Soon. Not yet. Someday. And now Cal was turning eight and I have no idea how time passed so fast.

If I'm going to be completely honest with myself I'm sure some of this particular grim inertia was also linked to a perverse macho pride. I've always spoken a lot about work-life balance in medicine and how these antiquated notions, about doctors functioning as around-the-clock automatons sacrificing their personal lives for the greater good, would have to evolve along with the rest of the world. But I think that in some ways I felt safe championing the choice for others to go part-time because I myself chose to work full-time. You do what works for your family, everyone's definition of work-life balance is different. But saying it from the vantage point of someone with three kids and still worked full-time herself felt like a secure platform from which to proselytize, like I was somehow above reproach from people who might accuse all part-time doctors of being lazy or uncommitted. DO WHAT YOU NEED TO DO; BUT AS FOR MYSELF, I AM DOING ALL THE THINGS.

And to be honest, we were getting by. It wasn't wonderful, but it was OK. We were surviving. Maybe we weren't "living our best life" to invoke an Oprah-ism (and I don't even know how I know that since I never even watched Oprah) but...day to day, we were getting by.

And then, the week before Memorial Day, our nanny of five years quit. With no warning, and giving zero notice. She just left one day and mentioned on her way out the door that she wasn't coming back.

Boom. Game-changer.

I'm not going to talk too much about the nanny thing because frankly, after probably the most stressful two months of our lives, I'm just over it. It wasn't even so much the issue of finding a new nanny--though that, obviously, was a huge part of solving our problems, at least in the short term.  But the larger and more important part was having to honestly evaluate our life, our choices, and just how much time we did indeed spend at work, away from our children. It was like turning the stark, faintly buzzing fluorescent exam light onto the fish-white underbelly of what kept things functioning at a level that passed as "OK" for the past five years. And what we realized was that: it really isn't OK. Having to outsource this much of our children's care--of our children's lives--to someone else, particularly someone who after five years could walk out on them without so much as a backwards glance...is not OK.

(This is putting aside the obvious logistical difficulty of finding a non-live-in person to work 50-60 hours a week. It's a tough sell to say the least. One suggestion, perhaps less helpful than most, was that we should just hire two nannies. To which my reaction was, if you have to hire two people to take care of your kids while you're at work, it's possible you're not spending enough time with your kids.)

So. Joe and I discussed and agonized and number crunched and evaluated. We talked to a lot of people. We agonized some more. And what's going to happen now is this: as of September 1st, I will be going part-time at my job. Joe and I would have been fine with either one of us working less, but because of the ways our jobs are structured, it makes more sense right now for the part-time working parent to be me. My new schedule will have me working three days a week, mixed in with my share of nights, weekend and holiday call. And my main goal for the other two days of the week? To do some of the things that I've never been able to do with my kids because I've haven't had the time. Simply to be around more.

I know this all seems unnecessarily melodramatic of an announcement to some, because plenty of people in a multitude of fields choose to work part-time. But for me, it is a big deal, because to be honest, when you're accustomed to following a prescribed path, swimming against the current for a change can be scary. And there are a lot of issues--job guilt, fear of resentment from co-workers or being perceived as less than fully committed to medicine, concerns about crippling my career potential--that I'm working through having finally made this decision. There's a fear of not wanting to let people down.

But that's it on the other side too, isn't it? I don't want to let people down. I want to do my job well. All my jobs. And I think that right now, I need to spend more time with my kids. Nothing's broken, I still love being an anesthesiologist, and the fact that I've worked full-time for the first eight years of parenthood wasn't the wrong call nor has it damaged our family. It's just that our choices then are not the same as our choices now, and when we have better options we owe it to ourselves to take them. We could be making more of this life. We could be doing better.

I'm not going to be there hovering in the periphery for every single second of my kids' lives, nor frankly should I be. But I'm looking forward to just being around more.

So that's what's going on with us. In most ways, it's really no big thing. But in other ways, it's the biggest thing.

continuity of care

Let's talk, for a moment, about childcare.

It's a topic that I've meant to discuss for a while, and certainly I addressed it a little bit in my book, but as a family with two parents who work long variable hours outside of the home full-time, our childcare issues fall into a specific subset.  That is to say, without putting too fine a point on it, that we are utterly, utterly dependent on full-time, reliable childcare in order to function day-to-day.  Neither Joe nor I work part-time or any kind of variable/abbreviated hours.  We both work in the OR, which means we invariably leave home before sunrise, before the kids wake up.  We both take overnight call on a rotating basis.  This is not to be self-congratulatory or masochistic, and does not make us better or worse parents (though I'm sure there are those that would argue each side), it's just the life we lead and we've found a solution that works best for us.

However, before I get into the specifics of childcare, let me say first that none of this could work without an equal, fully-invested partner in parenting.  Joe and I had Cal early on in our medical residencies.  We were both at a critical point in our training, and both of us had responsibilities to our jobs and our patients that were equivalent and inarguably important.  So we've always, always, always viewed the division on parenting responsibility 50-50.  There were some minor variances here and there (for example: more difficult rotations month-to-month, the fact that Joe never got post-call days off but occasionally would get to leave for work later than I did, etc.) but on the whole, from the moment we first became parents, it's been right down the line.  We make sure one of us is always home every single night--if we need to, we'll trade call or make pre-emptive schedule requests to ensure that this is the case.  If I'm going to be home late, Joe tries to get out earlier.  If Joe has a journal article that he's getting ready to submit, I watch the kids.  We both have demanding jobs but this obviously doesn't make parenthood itself any less so, therefore when it comes to childcare, we've always been of the philosophy that "if you can't do it, I'll try to do it" and vice versa.

However, the fact is that both of us work all day on most days, and as such, we need to have a childcare solution to cover those working hours.  What we have, and what we have always had, is a full-time nanny.  I know this is a bad word for some people, and I can almost hear the squelching sound from the pile of shit that I am stepping in by telling you that I choose to practice medicine full-time and employ a nanny, but there it is.  We pay someone to watch our kids during the day so that we can go to work.

In residency, it was unavoidable.  We were in New York at the time, but having family members take care of the baby was not an option (both of my parents are also physicians that work full-time, and besides, they did not want nor should they have felt obligated to drop their practices in order to take care of their grandchild--they worked full time even while raising their own kids, after all; and Joe's parents, while both retired, live in Ohio).  We also had the kinds of jobs that were not amenable to a daycare-type solution.  I know that some dual-resident families make daycare work for them, but like I mentioned before, Joe and I both have OR-based specialties, and as such, we were both expected to be at work well before most daycare centers opened--and yes, this includes the hospital-based daycare at Columbia.  So we hired someone to come to our house, take care of the baby, and stay with him until one of us got home in the evenings.

As I've undoubtedly pointed out many times in the past for those in similar situations, finding a nanny, particularly as a medical trainee, is not simple.  First of all is the matter of the hours--it is difficult to say the least to find someone willing to show up at 5:45 every single morning, and for most nannies it's a dealbreaker.  The variability of the hours is also a problem--you have to understand that most nannies in New York (and certainly elsewhere) can find much more agreeable hours in basically in basically any other household.  A third issue is, obviously, the cost.  Childcare to this day is our number one largest household expense, but that's probably as it should be.  There was a period of time (before we finished residency) where our nanny was getting paid more than either Joe or I was for working at the hospital.  But this is the solution that has worked best for us--the only tenable solution really--and over the past six years, we've always had a full-time nanny.  Our current nanny has been with us for the past three and a half years, since we first moved to Atlanta.  She loves the kids, and they love her.  She's family.

Even now, that both of our kids are in school (Mack goes to preschool all day, three days a week), we still employ our nanny full-time, because Joe and I leave for work too early to drop off, and for the most part work too late to pick up from school.  And there are all the school holidays that are not hospital holidays.  Presidents Day and MLK Day and Teacher Planning Day (SO MANY DAYS FOR PLANNING) that we need someone to stay with the kids, to say nothing for the unexpected off days--snow days, ice days, sick days.  I know in the eyes of many Joe and I must be monsters for not taking off days from work when the kids are home sick from school, and who knows, maybe we are, especially since we are leaving our sick kids in order to go take care of sick strangers.  But the fact of it is that school aged kids get minor stay-home-from-school illnesses, like, all the time, and as long as I assess that they are OK--and by that I mean able to take and keep down fluids, making good urine, not stuporous--I make them chicken noodle soup the night before and stock up on juice and Motrin and keep in touch with our nanny throughout the day.  And then in the evenings, either Joe or I gets home--occasionally even both of us--and we'll take it from there.

In many ways, our childcare model is much like the practice of medicine.  It's about continuity of care.  The way our household works, no one can be with the kids all the time, around the clock every single day--but we have a team, and we have a system, and we make sure that handoffs are careful and that the time each of us does spend with the children is of the highest quality.  One could argue that abbreviating the work schedule of one or both parents might be better for our kids (oh, who am I kidding--no one ever thinks that of Joe, mostly people ask me, "So, do you think you'll eventually go part time?") and I think that, for each individual household, that can be difficult to say.  But I choose--choose--to work full-time.  I don't speak for anyone else, I'm certainly not telling anyone else what to do, but this is what works best for our family.

I'll tell you something that I've noticed in particular.  Whenever the discussion comes up about work-life balance and the choices that we (mostly women) make, the discussion essentially gets boiled down an issue of financial burden versus parental responsibility, and it invariably seems that the sentiment is that if parents (mothers) have the option to work part-time or opt out of working outside the home, they should, for the good of the children.  That choosing to work outside the home full-time is either born of financial necessity ("we can't afford to get by on less than two full incomes") or selfishness, abdicating the responsibility of caring for ones own children in favor of escaping the drudgery of the homestead and having more disposable income for your minks and Rolexes and Lego Star Wars sets or what have you.  To this, I would like to present a third viewpoint.  The fact of it is: I like working.  Not because I feel indebted to the medical machine, not because I have to, I just like what I do.  I like being a doctor, I like practicing anesthesia.  I trained for almost a decade to take care of patients, I want to do it more than part-time, and I want to do it well.  This does not mean that doctors who work part-time (men or women) don't like medicine, or are worse/lesser doctors, or cheating the system.  It also does not mean those who choose to spend the working day apart from their children care any less about the well-being or upbringing of those children.  I can only speak for myself, but I honestly enjoy my responsibilities outside the home too, and my choice is to work full-time.

Are there weeks that I spend a little too much time at work and miss my kids?  Certainly.  Are there weeks that I wish I had an extra day or two outside of the hospital to just catch up with them, with myself, with anything?  No doubt.  Are there things that I miss for work that I wish I didn't have to--performances, class parties, sports days?  Oh lord, almost every month.  But no one said adulthood was easy, and parenthood is almost certainly less so.  One thing it is about is adaptation and compromise, and finding your niche in balancing parenthood and career, perhaps in some cases deciding to choose one over the other entirely.  And I feel fortunate in many respects to be in a profession fulfilling enough that the decision of how I want to divide my time between work and home is, indeed, a difficult one.

Thanks to the commenter in the last entry for bringing up the topic, and reminding me that it's one I've long wanted to talk about.  There are lots of niches, lots of solutions, we found the one that, for now, works best for us.  What about you?  Other working parents, what's your niche, and what adaptations and compromises have you found that work best for you?  (Everyone be nice please.)

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Oh, and here's one for you, pregnancy enthusiasts/perverts.  Me and Thing 3 at 15 weeks.  Unlike with Cal, I didn't take many expanding midsection pictures the last time around (until it got, like, crazy), but this time I am acutely aware that this is almost certainly the last time I will go through this particular fascinating biological process so I'm trying to savor it in all its bloaty, body-snatcher-y glory.  I took this picture inside my closet but cropped out the edges because no one needs to see that many pairs of scrubs and long sleeved T-shirts, NO ONE.

(If you work with me, I apologize--please try to unsee these pictures by the time we run into each other in OR or in the doctor's lounge while pretend not to be fighting over who gets to the coffee machine first.)