On the Virtues of Whining about your Illness

Feeling sick is hard. File this one under Things you Don’t Need a Medical Degree to Know. Or file it under Things of which Everyone in this Culture Needs Constant Reminders. No argument from me either way, they’re both true. A few days after Hillary Clinton took her politically disastrous header into a limo I came down with my own respiratory illness that, if it didn’t actually make me pass out, that was probably only because my attending sent me home to lie down. Actually the same attending sent me home three separate times.

I don’t know for sure what I had, but it sucked, both in the absolute sense and the life out of me. First it was just a cough. Then it was a really unpleasant cough productive of truly disgusting sputum. Then I got winded walking a very normal 1.5 miles home from clinic. Then I felt like I had swallowed a hot poker then stuck it down my trachea for good measure. Then came headaches and fevers. Then the malaise, by which I mean I was not up to doing ANYTHING. Like, not even typing in bed. Not even mousing. Although between the cough and the fever I couldn’t actually sleep, I wanted very badly to remain horizontal. Rather than raise my head off the pillow I watched eight episodes of this feculent series in which the only actor of color plays a servant with almost no lines, and the principal female character’s main thing is that she is possessed by Satan every time she has intercourse (oh and somehow the plot just somehow leads to her repeatedly getting put in four-point restraints but not clothing). Just when I thought I was getting better I lost my voice completely.

notgood

Point is, I felt like a dog’s armpit. So it was easy to empathize with the Democratic candidate for president while everyone was debating whether a) getting pneumonia is a sign of weakness b) not staying home when you have pneumonia is reckless c) coming to work with pneumonia is for tough guys d) not mentioning your pneumonia is fishy e) whether Hillary Clinton is being actually being slowly poisoned. It was such a pure distillation of our culture’s perverse relationship to sickness.  I mean, for the record I agree with item b, but most people really have no choice about whether or not to go to work sick. Next year, if all goes according to plan, I will be one of those people.

As a person with the good fortune to expect general physical wellness on a typical day, I usually try to be stoic about illness out of respect for everyone I know that’s living with chronic disease and probably has limited sympathy for my temporary discomforts. I don’t know if it was the fever making me a little loopy, or my frustration at having made it through all of third year without getting sick only to get knocked on my behind in the middle of an elective I’d been looking forward to for months. And also in the middle of residency applications, did I mention that? At the moment I submitted mine my temp was 102.8. I’m certain that I uploaded a picture of myself with my application and not this picture of the kid that dressed as a fart for Halloween, but only because I double checked in the morning. So yeah, I was in a weird mood, and for whatever the reason, this time I threw myself a big, public, pity party.

epicwhine

Really everyone was very sympathetic, even people who endure significant pain on a regular basis. I have great friends and colleagues. But here’s where I’m going with this. I think it is actually good to whine about being sick, or injured, or otherwise uncomfortable in your body. We’re all under a lot of pressure to perform good health. Sometimes for concrete reasons, like fear of discrimination, sometimes for more nebulous reasons, like fear of seeming weak. It’s the worst for people with chronic disease, who paradoxically can expect less sympathy from their support network the longer their disease goes on. When that’s your new normal, everyone expects you to suck it up and accept what’s happening to your body. I see this even in the hospital, a place that exists only so that people can go there when they’re sick. I’ve had numerous patients apologize for complaining about their symptoms, or for feeling upset about them, even though it is literally my job to find out in great detail how they are feeling. But who can blame them? They live in the same world that considers it a personal failing on Hillary Clinton’s part that a bacterium (afaik) colonized her respiratory system.

So I think everyone should whine. People who are acutely ill should whine. People who are chronically ill should feel especially entitled to whine. Because feeling sick is really hard. And when everyone tries to act healthy all the time, it makes it easier to pretend that being sick is an aberration. And it makes it easy to deny how profoundly it affects people’s lives. Maybe being honest about your own experience will make it safe for the next person open up about theirs.

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Why I Don’t Need a Mirror

Like a lot of things that have made my life better, this one started by accident. When we moved into our current apartment, we decided to take the doors off the closets, and the closet doors happened to be where the full length mirrors were installed. I fully intended to put them back up, but in the time it took us to unpack, I began to notice that not having mirrors was changing my behavior. And it was good.

I’m not sure I was fully aware of the Socially Acceptable Outfit Vortex until I was well out of it. But it would go something like this. I would get dressed. I would stop to check myself in the mirror. Something about what I saw made me unhappy–the look I thought was classic turned out to be dowdy, the color combination was too hard to pull off, the length of the hem made my knees look wide. So I would change my top. Back to the mirror. This combination looks weird. Go change into different pants. Back to the mirror. Pretty soon I was just looping between the dresser and the mirror, rejected clothes piling up on the bed. I have been late to work because of this behavior. I have lost so many hours I could have spent doing literally anything else. The cycle never ended in my leaving the house feeling like I had nailed the right outfit, and was ready to take on the world. In fact it almost never left me feeling okay.

SleepingBeauty

When we moved my mirrors to the basement, this behavior essentially ceased. The frankly pretty nutbars routine I’d been performing since early adolescence just fell out of my life. And I did not miss it. In place of the “how do I look” ritual, I was checking in with how the clothes felt. Over time I proved to myself that I could trust my own judgment. It turns out I am sufficiently competent at getting dressed that it’s not usually necessary to check my work.

Life without a full length mirror requires some changes, but some of them I had already made. For example I had gotten rid of the clothes that didn’t fit me. The range of possible sartorial disasters is actually pretty limited when all your clothes fit. On two or three occasions, I got to the office and found that my bike shorts were a tad too long for my skirt. And one time I wore my shirt inside out until 2 in the afternoon. But nothing bad happened because of those mistakes. I turned my shirt right side out and moved on with my life. Eventually I stopped wearing that skirt, and I didn’t miss that either. I began to gravitate to really reliable, low-maintenance garments that required no thought because I knew I liked how they looked on me. Then I went further.

One day I was complaining to my husband about the unfair double standard in professional dress for women and men. I pointed out that his entire process for getting dressed in the morning was 1) Grab the shirt on top of the shirt stack 2) Grab the pants on top of the pants stack. And he has never once tried something on and then come to me for an opinion on whether looks too masculine, or not masculine enough. I told him I just wanted what he had. “Well,” he asked me, “What’s stopping you?”

I took that question seriously. The double standard is real, but it’s up to me how much I choose to bend to it. I started asking myself what, actually, was the point of getting dressed. I’m not using clothes to attract a mate or make a best-dressed list. If I want to intimidate my enemies, I have a better weapons.
Gloria

My work clothes in particular only have one job, which is to perform professionalism. I resent that I am graded on my ability to dress preppy (see also this important piece by Jacob Tobia), but that’s a post for another day. Point is, I do not work at Vogue. Nobody cares if I curate a tasteful capsule wardrobe in a variety of neutrals, or wear a giraffe-print jumpsuit to clinic every day, as long as my cleavage is covered and I don’t wear jeans. If there is a professional advantage to looking trendy, or having a varied and creative wardrobe, the payoff is pretty small proportionate to the amount of time, money, and stress that it requires. I think it’s awesome when other people express themselves creatively through their clothing, but when I looked at it hard I had to admit that most of the time I wasn’t expressing myself, I was just trying to pass for acceptable. So I opted out.

I now wear a black sweater and a black pencil skirt pretty much every day (sub in black jeans on the weekend). Every now and then I have the urge to change things up, but I usually regret it. I can now get ready for work in under ten minutes, and usually don’t have to think about my clothes for the rest of the day unless a baby barfs on me. I don’t wonder how I look cause I know my clothes really well, and I also know my own body.

I always thought of people who didn’t have full-length mirrors as people who couldn’t stand to look at themselves. But I’m pretty sure there are a lot of people with mirrors who also can’t stand to look. I can’t speak for anyone else, but I find I treat my body with more respect when I skip the daily appraisal. I don’t need a mirror to tell me how I look if I know how I see myself.

What are you apologizing for when you apologize for getting sleepy?

What do you say when you yawn? Don’t overthink your answer. And you, trying to pretend you punctuate your yawns by shouting “Dog scrotum!” I am on to you and you are not so cute. When we yawn, we say, “Excuse me.” But why? One school of thought is that your are apologizing for having shown someone your epiglottis. But I don’t buy that, because even if you cover your mouth, you still excuse yourself afterward. Another common objection is that yawning may be interpreted as a sign of boredom. Miss Manners has a helpful etiquette tip for that situation (“I’m afraid I was up late last night. Please do go on with what you were saying. I find it fascinating”), but she still says you shouldn’t yawn. Which would be super helpful if yawning were a voluntary reaction.

That’s right, folks. For this, my 25th blog post (not counting the one where I just embedded the video for “Everything Comes Down to Poo”), I’m finally going to write about the thing I actually study all day long, which is sleep health. Western culture has a pretty perverse relationship to sleep, and most of us seem to be convinced it’s a guilty pleasure. That’s why you apologize when you yawn; deep down you think sleepiness is a character flaw, and if you were really motivated, you’d be more awake. You are wrong.

Sleep is one of a list of important homeostatic activities that are under voluntary control only to a point. We get this intuitively; when a healthy adult needs to pee, she can wait to the end of her meeting to do it. But if she waits long enough, eventually she is going to lose control of her sphincter and void her bladder, no matter how socially inconvenient the time or place. The same is true of the need to drink, or eat, or breathe, or stop touching hot things. Everyone knows that if you stay up long enough your brain is going to take over and you will go night-night. Yet I hear people apologize for feeling sleepy, or for needing to go to sleep, all the time. What are they really apologizing for? Here is list of possible translations.

I’m sorry I’m sleep deprived. Here’s some 101. Broadly, there are two physiologic processes that make healthy people tired: sleep deprivation and circadian rhythm. Sleep deprivation is pretty simple; the longer you go without sleeping the greater your need to sleep. If Elizabeth wakes up at 10 pm because her hospital shift starts at midnight, come noon she will be way more tired than her identical twin Jessica, who woke up at 6:30 am for Crossfit. Duh.

BabyAsleeponFace

If you think this guy is tired, imagine his parents.

Here comes the one and only concession I will make to so-called personal responsibility. If you know you have a breakfast meeting tomorrow but you voluntarily stay up until 1 am putting the finishing touches on your Golden Globes Best Dressed list,* that is on you. But there are lots of serious reasons to stay awake: you’ve got one or more jobs to work, maybe you have a late shift, maybe you have a second shift (or a third), maybe you have a kid, maybe you have laundry, maybe you have homework, maybe you need to exercise, maybe you’re in a long-distance relationship with someone in Iran…Sleep deprivation is nearly ubiquitous in our time. So maybe what you’re really saying is “I’m sorry I am alive right now.”

I’m sorry I can’t stop time. The second normal biological process that induces sleep is circadian rhythm. Sleepiness is tied to specific times of day, so that even if you are well rested, at some point in the night you will want to sleep, and at some point in the afternoon you will want to nap. What time that is varies from person to person, and may be largely genetic. My friend Rachel is a “lark.” She wakes up around 4 am whether she wants to or not. She gets to work at 6 am sometimes, not because she’s trying to make you feel inferior, but because it’s boring to lie in bed waiting for the rest of the world to wake up. Some time around 8 in the evening, Rachel starts to fall asleep. Though she can put off bed time for a while to come out for a girl’s night or some such, as she sits still and relaxes she will probably pass out.

Then there are the owls, whose preference is to stay up late and sleep late. When I asked my friend Josh if I could tell the world about his circadian preference, he said, “Sure. I got to work at 11:30 today!!!! 😦 ” I wasn’t surprised, since Josh routinely stays up till 3 am, and can only fall asleep earlier when he’s deeply sleep deprived. When Josh has to be at work at 6 in the morning, he can wake up with an alarm, but he has described it as physically painful, especially when he has stayed up late the night before. Josh and his fellow owls experience a certain impairment from the mismatch of their internal clocks and mainstream expectations of when human beings should be active, and when they are forced to conform they suffer from “social jet-lag.”

Most people will be somewhere in the middle of these extremes, but may still have distinct tendencies to be morning people or evening people. Nobody is doing this on purpose, so it’s pretty unfair to expect someone to apologize on behalf of their inherited body clock, or to apologize because it is 8:15.

By the way, Josh and Rachel are a couple. As far as I can tell they see each other for about an hour in the evenings, until Rachel falls asleep at the dinner table.

I’m sorry I’m not on uppers (variant: I’m sorry I’m crashing from the uppers I took before). You can’t overcome the biological pressures of sleep deprivation or circadian rhythm by will power, but there are always stimulants. Caffeine is a popular option, as are nicotine and cocaine. Adderall (speed), Provigil, and Nuvigil are all name-brand pharmaceuticals with important medical applications and a robust black market. With such a variety of consumer options around every corner, what’s your excuse?

I snapped this photo at a sleep clinic. No joke.

I’m sorry I used the medication I need. On the flip side, pharmacologically speaking, are the numerous drugs that make you sleepy when you’d rather not be. Perhaps you have taken one of these medications to treat allergies, autoimmune disease, seizures, Parkinson’s, incontinence, depression, anxiety, schizophrenia, or–that old canard–pain. How could you be so selfish? I want to interact with you right now. With no yawning.

I’m sorry I’m not a freak of nature. As with circadian preference, how much sleep you need varies from person to person. 8 hours of sleep a night is one of those nice round numbers from magical fairy land; empirically estimated averages range from seven to nine hours and are the topic of much scholarly debate, but it’s kind of irrelevant to you. You just need what you need. Some people need as much as 12 hours every day (which is a pretty tough disability to live with in an 8-5 world). Other people (like, it is rumored, President Obama) can get by with four. But those are the extreme outliers, and you’re not going to make yourself into one of them through discipline any more than you’re going to make yourself suitable to serve as Commander-in-Chief.

I’m sorry I was born when I was born. Both sleep need and circadian preference can change with age. Toddlers are notorious larks who need a lot of sleep. Teenagers are notorious owls who also need a lot of sleep (so much so that there is a developing body of research trying to determine if school performance could be improved by delaying school start times). Many adults sleep earlier as they get older, and find that they need more sleep and are less resilient to sleep deprivation than in their youth.

I’m sorry I have an undiagnosed sleep disorder. It’s hard to diagnose yourself with a sleep disorder, because most of them take place while you’re asleep. You probably know if you’re experiencing insomnia symptoms, and you might have a shrewd idea that you have narcolepsy (but you also might not). Given that most of us blame ourselves for our sleepiness, just how sleepy would you have to get before you sought medical advice? Passing out behind the wheel? Then once you get to the clinic, will your primary care provider be astute and recently trained enough to recognize the potential for an underlying sleep disorder? Sleep medicine is a pretty young field, and is highly specialized. There’s a strong social pattern to who gets referred for sleep testing, and a lot of people get missed.

https://i1.wp.com/www.rottenecards.com/ecards/Rottenecards_80447284_35nyzw258g.png

In summary, sleep is not a luxury. You cannot prevent yourself needing sleep through self-control. Every time you apologize for getting sleepy, you tell the person whose pardon you are begging that he too should feel ashamed of his own need to sleep. It all contributes to a culture in which people blame themselves more and take care of themselves less.

*Zoe Saldana, Emma Watson, Amy Adams, Lily Rabe, and Julianna Margulies, in that order.


Image credits:
1. Rebecca and Bernhard via photopin cc
2. Myself
3. Rotten eCards

Eyes on your own treadmill

I so very much and so very deeply hate “gym season.” I hate it as a construct and I hate it for making everything at the gym so awkward. But don’t worry, I’m not mad at all the people who join the gym in January to atone for holiday behavior. Look, I get it. You spent the last week of December eating deep-fried peppermint bark, drinking sparkling absinthe, and snorting baby formula to stay awake for the ball drop. We’ve all been there. Now, understandably, you have rebounded to the other extreme, making the maple-vinegar-tea enema cleanse your new year’s resolution, and it’s fine. I would like to say that I sympathize, cause no one enjoys the kind of hangover you’re experiencing, but I can’t sympathize with you because I’m not thinking about you. At least not at the gym. I vaguely sense that you are there, but really I just came to work out cause I like to feel good and not exercising makes me feel otherwise.

No, really, welcome to the gym. Sure, most of you are going to practice your short-lived overexertion with all the faith and all the sanctimony of a neophyte Scientologist, but that is vital to the gym’s business model. Thank you, really, for allowing the doors to stay open, so that people have somewhere to move their bodies when it is -22ºF and the schools are closed to prevent children from freezing to death in the time it takes them to get from their doors to the school bus (not an exaggeration).

The gym regulars, on the other hand, are driving me up the wall, and not in a good, rock wall kind of way. They are scanning the cardio room, taking inventory, making knowing eye contact with other regulars. They are mentally separating the wheat from the chaff that has come to hog the equipment with its chaffy chaff-hands.

I do not look like a gym regular. Who knows if I even count as one; I am more of a gym irregular depending on the vagaries of my personal and professional schedule, and many of my planned gym days end in my living room with Billy Blanks, Jr. I clearly lack a budgetary line item for workout clothes. As a rule I’m fine with that, but now I feel like sticking my phone in the strap of my sports bra cause I forgot to wear the sweatpants with pockets makes me…conspicuous.

Suddenly I am performing. I am this close to laying my elbows on the floor, because that is obviously not something a new year’s newbie could do. On the other hand I will avoid attempting plank because I am rubbish at plank and planking for twelve seconds before collapsing on my face with a bellow is exactly the kind of thing chaff would do.

All I’m saying is gym season hurts gym-goers. It turns half of us into pathetic, projecting, self-censoring children, and the other half into judgmental buttwipes. This is a matter of no importance to medicine, public health, policy, or social justice, but it happens to be true, the end.

stretch

Oh were you watching me stretch? I didn’t even notice.


photo credit: Shar Ka via photopin cc

 

In Praise of C-Sections

You know who makes a really macho crowd? Biological mothers. I have watched people who for most of their lives have espoused a mainstream, less-is-better approach to pain suddenly bragging about it as though the involuntary firing of their nociceptors were an achievement. People who are completely pleasant as a rule will hear the word “epidural” and SHOONK they are transformed into The Uterus Gladiators! With savage glee they race into a totally imaginary arena, to compete with other savagely gleeful person-hatchers, in an epic fight to decide once and for all who had the most pain in childbirth, and–importantly–who sought the least relief for that pain.

Whee! This is fun! Pay no attention to that octopus.

Whee! This is fun! Pay no attention to that octopus.

You’ve probably guessed I have limited patience for this brand of one-upmanship. There are women in my life whom I deeply respect that have chosen home birth (okay only one woman but I respect the living daylights out of her judgment), and lots more that have chosen to forgo pain relief in a hospital delivery. That is a totally awesome choice if it is a thing that you want to do, and I’m glad that activists over the years have succeeded in making these options available to everyone. But if that is not your thing, oy gevult don’t feel ashamed of yourself. Like any kind of treatment there are costs and benefits to pain relief in childbirth, but that doesn’t make it bad. I’m hereby giving you permission: you do not and should not have to justify the decision to relieve your pain.

The Uterus Gladiators, however, are nothing compared to the Vagina Valkyries. You know who I mean. The women who have experienced a vaginal delivery and now feel lifetime superiority over the women who required or–gasp!–chose a surgical delivery.  “I had a baby with no medical intervention,” I hear one of them bragging before yoga class, shortly before sprouting wings and flying off to adjudicate some Norse battle deaths. You’d really think from the sound of it that medical intervention was a vice.

C-sections are often not a matter of choice, but a life and/or death situation. Sometimes they are a measure of last resort after the first, second, and third choices have been exhausted. Some c-sections are elective, but the term “elective” is loaded. Are the consequences of not electing this procedure acceptable? That’s subjective. And that’s what bothers me about the push to shame patients out of seeking medical care by convincing them that they are less–less strong, less brave, less womanly, less maternal, less natural, less smart, less aware, less educated, less thorough, less fierce in standing up for their rights, less resistant to domination by medical practitioners. My husband refers to this movement as “the crunchy granola arm of the patriarchy.” I call it rudeness personified.

Maybe it’s time for c-section veterans to start bragging. “Yeah, boyyyyy, I had a major abdominal surgery, and they took a baby out of me. And then I HEALED. And didn’t have any INCONTINENCE. And my vagina has not lost any TONE. Yeah! Yeah! Wooa wooa!”

This might be the time to warn you there’s a picture of a baby being born via c-section at the bottom of this post. If you’re not so good with such pictures, you may want to scroll slowly.

There is a real public health issue at play here. Per the WHO, ideally 10-15% of all deliveries should be c-sections. Fewer than that constitutes “underuse,” which is common in developing countries, and more constitutes “overuse,” which is common in developed countries. Where I live the rate is close to 30%.  So is this a problem, and if so how big? It’s an area of heated debate. Almost all of the evidence comparing c-sections to vaginal deliveries is observational, meaning it comes from studies that compared outcomes from women who wound up with c-sections to outcomes from women who wound up with vaginal deliveries. Obviously, women don’t wind up in these categories at random, so some factors will predict both choice of a c-section and risk to mother and baby, creating spurious associations. I’m personally skeptical that all such factors can be measured and controlled-for in an observational study.

I’d really like to see some randomized trials to help guide decision making, but to date there are almost none. The evidence base, in short, is lacking. Do remember this when everyone starts shouting. However, be comforted by the fact that one reason there isn’t a huge rush to conduct such a randomized trial is that both methods of childbirth are quite low risk. Even if one does turn out to be safer than the other when all the evidence is in (someday, I hope, sigh), this is still a choice between good and better.

I totally hear the historical argument about how birth has been medicalized, and I’m right there with anybody who wants to argue that pregnancy and birth are normal and should not be treated like diseases. But birth also involves things that are the rightful province of medicine–pain, organ damage, morbidity, mortality. No one should be required to make their decisions about these things differently than they would in another context because they are choosing it for a birth. And they are also not required to justify their choices (I said it again). Every birth is different, and you really don’t know what you would have chosen if you had had someone else’s birth experience–this goes double for cis men.

This is not just another I’m-okay-you’re-okay everybody’s-choice-is-great post for the feminine blogosphere. This is a post in praise of c-sections. I am so glad that this surgery exists. I am so glad that we have come far enough that not being able to expel a baby from your body in the traditional way does not mean that it has or you have to die. Cesarean sections save lives. Sometimes they are awesome. So how about we dismiss the Vagina Valkyries with the eyerolls they have earned, and turn our attention to making this life-saving surgery available to every woman around the world that needs it. Or wants it.

This is objectively awesome.

This is objectively awesome.

Photo Credits
Vaginal birth art: Lynn Friedman via photopin cc
C-section photo: emergencydoc via photopin cc

One of the Ways Doctors Kill Their Patients

A fabulous piece ran in xojane today, which I is incidentally written by one of my oldest, dearest and kickassest friends.

He asked what I ate, but he didn’t wait for an answer. I had to exercise more, he said, having no idea how much I was exercising. I also needed to eat less than whatever it was I was eating which I hadn’t gotten a chance to tell him. Dear god, what cutting-edge medical research! I certainly never thought of “eat less and exercise more,” especially not when I was bulimic, which incidentally is in that file of papers you’re holding which we like to call “records.”

“I’m not concerned about it,” I said tightly, “and if it comes up again I’m going to have to find another doctor.”

“Any other doctor would tell you the same,” he said, as though I hadn’t been coming to him, just as fat as now, for several years.

“Well, I prefer a doctor who at least waits to hear what I eat before telling me to eat less.”

He looked exasperated. “There’s no possible way you’re not eating too much.”

I’m pretty lucky not to have encountered the circular fat logic when I’ve been on the patient side; I suspect one of the privileges of future doctors is exemption from the shaming ritual. But I this assumption is sooo widespread and sooo insidious. The thinking goes that everyone’s weight is a direct result of the quantity that they eat. Therefore, all fat people are eating too much because any amount of food that is eaten while being fat is too much. Any fat person in recovery from an eating disorder can explain to you what’s wrong with that line of reasoning, but, you know, they shouldn’t have to.

Another excerpt I want to make sure you notice (although, really you should just go read the whole thing):

Obese women — by which, just to make it clear, I mean women whose weight divided by their height squared is greater than 30, not any of the more colloquial uses of “obese” like “too fat to be attractive to me” — are more likely to get cervical cancer, and more likely to die from it.  Sure, we could blame this on the very fact of obesity, because blaming things on obesity is a fun party game for some people, but then there’s the inconvenient fact that obese women are also way less likely to get regular cervical cancer screenings.

Since the Pap smear is a towering triumph of public health, with an incontrovertibly strong correlation between regular screenings and lowered cancer rates, it’s not too far-fetched to posit that fat women would be less likely to get lady cancers if they were more likely to get regular exams.

And why, oh why, might you not get regular exams if you were a fat woman?

This is one of the ways doctors kill their patients.