The element

In his NYT bestseller 'The Element', Ken Robinson argues that we are in our element - doing what we should be doing - when we do the thing we love, and in doing it feel like our most authentic self. 

This got my attention. I've often felt that the place I am most me is in the clinic, and I find that somewhat disturbing: how can that be, if my children and closest friends never experience me in that context? I feel I'm less the real me at home - or maybe that's wishful thinking. At any rate, I like myself best at work, and the following description by Robinson of people in their element holds true: 

". . . time passes differently and they are more alive, more centred, and more vibrant than t any other times." p21

He suggests that we find ourselves in our element when four things align: aptitude, passion, attitude and opportunity. Because his description of the attitude necessary to find one's element (perseverence, ambition,  wanting something strongly and being willing to exert oneself for it) is, I think, almost universal among physicians, I've 've taken the liberty of replacing "attitude" with "need" for the purposes of applying this to medicine. 

And so, the four pieces that fit together when in one's element: 

  1. aptitude (what you're good at)
  2. passion (what you love)
  3. a̶t̶t̶i̶t̶u̶d̶e̶  need (in the world, that your work fills)
  4. opportunity (a position where you can do the work)

I'm a good physician, I love medicine, I provide primary care to refugees, and I work in the only such clinic in the province. Perfect score. 

Thinking over other positions from which I've moved on, or avoided, or wished for, I can identify which of the above was missing. I lost my passion for work in Vancouver's downtown east side when I came to view the work as palliative. In private practice in an affluent neighbourhood of Vancouver's worried well, the preponderance of women complaining that their hair had lost its lustre left me feeling my work wasn't filling a genuine need. I've avoided high acuity settings (emergency room, deliveries) because I haven't kept up those skills. And I don't work in a medical practice where I'm given paid time to write because I haven't found the opportunity. 

I do think that health care workers have an advantage in finding our element in that the need is so obvious in our work. We care for sick people; what's more basic than that? It's less tangible for people like my husband, who works in business software. And I think it's more difficult still for artists to define and defend the need for their work.

The concept of opportunity trips me up a little.  My current job, and the one before that (HIV clinic) were both positions that I did not seek out. They were offered to me. Sometimes I second-guess myself: isn't accepting an opportunity a passive choice? Picking the low-hanging fruit? Shouldn't I be actively pursuing the perfect, hard-to-get position, chasing it down? (But what would that even be?)

Maybe we can increase our work satisfaction by changing what fills those four criteria. If I were to increase my skills (say, learning some basic surgical skills like appendectomies) and set up shop where there is greater need (rural Zambia) would I be even more satisfied? Perhaps that's why so many 50+ physicians do exactly that. 

I like the idea of applying this framework to job considerations in the future. I've been dipping my toes into administrative work. There's a need for (young) medical administrators, and plenty of opportunities. But I haven't had enough experience yet to determine whether I have a passion for it, and whether I have (or can develop) the necessary skills. Whether I would find myself in my element there remains to be seen. At least I know what to look for:

"One of the strongest signs of being in the zone is a sense of freedom and of authenticity. When we are doing something that we love and are naturally good at, we are much more likely to feel centred in our true sense of self - to be who we feel we truly are." p90

And you? Are you currently in your element? If not, which is missing: skill, passion, need or opportunity?

[cross-posted at]

I put an embryo on a daycare waitlist

September 2001

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

January 2002

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

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

Looming deadline for professional success: age 40?

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

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

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

More here at Mothers in Medicine.


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

Well, now it is. 

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

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

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

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

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

My aptitude for family medicine: poor, apparently

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

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

Pathology and radiology ranked at the top. 

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

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

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

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

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

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

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

(Cross-posted at Mothers in Medicine.)

Why infectious disease docs are so likeable, Exhibit A

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

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

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

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

Exhibit B would be their penchant for bow ties.

Now that is creative nursing

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

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

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

A waterbed covered with flannel

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

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

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

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

Examining teeth with a stethoscope

I was examining a patient with Parkinson's disease.

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

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

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

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

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

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

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

There are no refugee camps in Canada

We are expecting a group of Bhutanese refugees to arrive in Vancouver next spring.

I recently received a copy of the bulletin that is being handed out by Canadian visa officers to each family interviewed at the camp. It explains the next steps in the resettlement process and introduces the refugees to Canada, in English and Nepali. Some highlights:

  • Once you have passed all exams and your documents are ready, you will be taken to the IOM centre in Kathmandu. You will stay there for a few days to learn more about life in Canada. You will also learn about airports and airplanes to help prepare you for the trip to Canada.
  • Rumours that you will be “sold” for slave labour or forced to fight in Iraq are false.  It is also false that you will be forced to live in a refugee camp. There are no refugee camps in Canada.
  • Water in Canada is safe to drink. Every home has its own hot and cold running water. You can get water any time of the day or night. All you have to do is turn the tap on and then off when you are finished.
  • During even the coldest months, buildings and houses are well heated and comfortable. To stay warm in winter when they are outside, people wear outdoor clothes like an overcoat, boots, gloves and a hat. They also wear several layers under their outdoor clothes such as an undershirt, a shirt and a sweater.
  • People from many different cultures live in Canada. You can find most of the foods you usually eat, such as rice, green vegetables, spices, lentils and chicken, in a grocery store near you. Canada also has many other stores that carry specialty products, such as goat/lamb meat, which are not usually sold in most grocery stores.  
  • In Canada, the law lets you practise your religion freely. You will not be asked or forced to change your religion. Freedom of religion is one of Canada’s basic freedoms. There are many Buddhist and Hindu temples, and Christian churches across Canada. In many cities, you can invite Hindu Pandits home for religious ceremonies.
  • Canada is a large country and is almost 68 times bigger than Nepal. You might be resettled to any one of a number of cities. Most of these cities are in the southern parts of Canada. Attached is a map of Canada to show you where some of our cities are located.

Having my own country presented to me this way was profoundly moving. It's Canadian Thanksgiving, and I am so thankful for my country.

The glorification of gout

My residency research project was on the glorification of gout in 16th- to 18th-century literature.

While the other residents were investigating parental attitudes to the (then new) varicella vaccine, and interviewing injection drug users about why they routinely cut their hospital stays short, I had my nose buried in old issues of the Bulletin of the History of Medicine. My preceptor encouraged me to pick a topic that I enjoyed, and I did just that.

We concluded our final year with a research day. We were assigned to one of three rooms to give our presentations, which ran back-to-back throughout the day. When we weren't giving our own talks we attended the ones that most interested us.

There was a prize. It was something paltry, a $30.00 gift certificate to the Health Sciences Bookstore or something, but few things motivate doctor types more than the chance to win a prize. My colleague always says that our clinic administrators could get us to do anything if they just hung a star chart in the office.

So I was determined to win. The room was packed when I did my presentation, which went without a hitch.

At the end of the day, we gathered in a study hall for the day's concluding remarks and the announcement of the prize-winning research project.

It wasn't mine.

And when I saw what we had been graded on, I knew why. One of the categories was 'relevance.'

Anyway, I feel somewhat vindicated, because (a condensed version of) my paper was published in the CMAJ this week.

Although I got chest pains when I saw that they had edited a comma splice into the final sentence of the article.

Someone sat on her

A young African man was interpreting for his grandmother, who came in with right upper quadrant pain of three days' duration.

"When the pain started, did it start gradually or suddenly?" I asked.

"It started when someone sat on her, " he replied.

I waited expectantly.

"We went to a feast," he said simply.

Wanting to respect any tribal customs, I picked my questions carefully. "How big was the person who sat on her?"

"A sixteen-year-old girl. A big girl."

I pictured the banquet table. Maybe her granddaughter had come over to greet her and affectionately sat on her lap. "How long did she sit on her?"

"One hour."

I jettisoned all efforts at cultural sensitivity. "Why?"

"There wasn't enough room in the car."

"You drove one hour to the feast and your grandmother had another adult sitting on her lap?"


Thinking maybe I had misunderstood the time line and this had occurred in Zimbabwe, prior to immigrating, I clarified, "What city was this?"


I examined the patient's abdomen, and filled out the requisitions for some investigations. I decided I couldn't ignore the issue of their transportation methods. "In Canada, you aren't allowed to travel in a vehicle with another adult on your lap."

"You're not?" He was genuinely amazed.

"No. It's an issue of safety. If the police catch you, you'll be fined." He looked alarmed, and I reassured him, "I'm not going to call them. But you need to know that each adult must travel in their own seat, with a seat belt."

He looked like a reprimanded schoolboy. "But we had to do that," he said earnestly. "Or someone would have been left behind."

Doctor, you are hot!

I read with interest this CNN article about Pakistan's president complimenting Sarah Palin on her looks:

Zardari then called her "gorgeous" and said: "Now I know why the whole of America is crazy about you."

"You are so nice," Palin said, smiling. "Thank you."

And then, when Zardari quipped that he would like to hug her, "Palin smiled politely."

I was reminded of the similarly awkward exchanges that occur between female physicians and patients or colleagues. Palin employs two responses that are favourites of mine. First, receiving the compliment as an innocent remark. Then, reacting with a cool silence to an inappropriate, but not quite lewd, suggestion. It would have been interesting to see what she would have done had it escalated.

I'm curious what others think of Palin's response. Should she have been less amiable? Used a different tactic? How do you deal with positive references to your physical appearance in the workplace?

I find this tricky. Sexual comments and overt invitations are obviously inappropriate and need to be dealt with immediately and decisively . . .

Continued at Mothers in Medicine.