Moving Toward Re-entry

My providers have been encouraging me to return to work as soon as next week. My department leaders consistently advise me to take my time and not rush back. I’m not sure where I land between these two extremes. My instinct is to stay out longer, because I’m not yet desperate to return to work like I was toward the end of both of my parenting leaves. At the same time, I don’t want to take advantage of the system, so if I am able to return, I think I should. Then there’s a part of me that wonders if I should return at all.

In the last couple weeks, two major periodicals (The Atlantic and The New York Times Magazine) have published articles about physician burnout. Both touch on the exact problem that led to my leave: the ever increasing administrative burden placed on physicians. Taking 5-6 weeks off will not solve the problem, which is why I was hesitant to take the leave in the first place.

In particular, I appreciated Dr. Xu’s analogy to a chef in a busy restaurant:

To understand how burnout arises, imagine a young chef. At the restaurant where she works, Bistro Med, older chefs are retiring faster than new ones can be trained, and the customer base is growing, which means she has to cook more food in less time without compromising quality. This tall order is made taller by various ancillary tasks on her plate: bussing tables, washing dishes, coordinating with other chefs so orders aren’t missed, even calling the credit-card company when cards get declined.

Then the owners announce that to get paid for her work, this chef must document everything she cooks in an electronic record. The requirement sounds reasonable at first but proves to be a hassle of bewildering proportions. She can practically make eggs Benedict in her sleep, but enter “egg” into the computer system? Good luck. There are separate entries for white and brown eggs; egg whites, yolks, or both; cage-free and non-cage-free; small, medium, large, and jumbo. To log every ingredient, she ends up spending more time documenting her preparation than actually preparing the dish. And all the while, the owners are pressuring her to produce more and produce faster.

It wouldn’t be surprising if, at some point, the chef decided to quit. Or maybe she doesn’t quit—after all, she spent all those years in training—but her declining morale inevitably affects the quality of her work.

Do I want to quit? Part of me does. Last week, I remembered the first time I told my husband that I didn’t want to be a doctor anymore. I was midway through an 80 hour week supervising the hospital service. We had admitted a patient with a pulmonary embolism, a blood clot blocking the flow of blood to the lungs, reducing the amount of oxygen that could be delivered to the body. We started our patient on blood thinners to prevent the clot from expanding and requested appropriate monitoring so we could detect clinical worsening as quickly as possible. I also asked the team to order ultrasounds of both legs. “Why?” they asked. “We are already giving the treatment we would use for clots in the legs.” I asked them to imagine what they would do if the patient came to see them in the office three months from now with leg pain and swelling. Especially given the recent history of PE, they would consider the patient to be at higher than average risk of blood clot elsewhere in the body, and would appropriately order a leg ultrasound. “Let’s say a blood clot is detected at that point,” I asked. “The patient will be on blood thinners for this PE for the next 6 months. If they develop a new clot while on anticoagulants, this has long-term ramifications: they will need a longer course of a more expensive medication, potentially lifelong. If we can document the leg clot now, then we would know if that clot identified in 3 months is new or the same one that was present at the time of the PE.” I learned this from working with hematologists over the last decade, and it was really a joy to be able to pass the knowledge on to the young physicians I was supervising.

I was awakened by my pager that night at 11 pm. The resident physician in radiology had just reviewed the leg ultrasound and wanted to report that indeed, a clot had been found. He had called me because my name was on the order as the attending physician of record. He did not see the note from the resident asking that questions be directed to our Family Medicine resident pager. He did not review the clinical record to see that the patient had a known PE and was already on treatment. I was exhausted and overworked, needed to get up the next morning to get to the hospital by 7 am, and I had been woken up by something completely non-urgent. Fortunately my husband was still up working and I was able to cry about it until I was calm enough to go back to sleep, but that was the first time I questioned whether I am getting enough out of this work to be worth the inconvenience and the expectation that I would be always available. 

Then I think about why I decided to be a Family Doctor, and what I value most in my work. I come back to two factors which are central to my practice and to what I want to provide to my patients. The first is maternity care, and caring for families. I have now had the opportunity to help many young women navigate contraception, then when they are ready to start a family they choose me for their prenatal care. I very rarely miss my patient’s deliveries. Often I am asked to be the primary physician for the new baby. I become very connected to these young families as women are asked to come to prenatal visits every 1-2 weeks in the last three months of pregnancy, and babies are seen quite frequently in the first months of life. It isn’t uncommon that the new mother realizes her partner hasn’t seen a doctor in a while and they ask if I can be his or her PCP as well. I am also asked if I can take my patients’ parents into my practice, or their children who are aging out of pediatric care. I am honored by these requests and welcome the opportunity to care for multiple generations within the same family. Since residency, one of my dreams for my career is to eventually be involved with the birth of a child of a patient whom I myself delivered. As my oldest babies in Vermont are about 5 or 6 years old, this will be a while in coming, but it is a strong reason for me to stay in the same practice for 20 more years.

In addition to care across members of a family, the second factor that is important to me is to be able to provide a great depth of care for each person. This includes maternity care and family planning, but is also why I try to stay as current as possible on management of chronic illness. I work hard to provide the best initial care I can, with a good understanding of when I need to ask my patient to see a specialist in their condition, and of which specialist might be the best match for this specific person with these specific concerns. I have also become a buprenorphine provider, and it has been incredibly meaningful for me to be able to create a safe space for patients to talk about their difficulty with substance use, then offer a pathway for treatment that brings them back into our office for maintenance therapy. 

A good friend and colleague recently told me that what she sees as remarkable about my style is that I am able to provide care without any sense of judgment. This is actually something I have cultivated as a priority, because I want patients to feel safe and honored when they come to be seen. Generally people have a lot of stuff they would rather do than come to the doctor’s office. A front office staff member at my first practice out of residency told me that she would always try to be as kind and helpful as possible on the phone and at the front desk, because just about anyone coming in was suffering in some way, and she saw her role as making their day just that much less miserable. In my fantasy world, all of us in health care have this approach. So many people have experienced trauma of some kind, and for self-preservation they are on guard against further hurt. I want people to feel, as soon as we start to talk to each other, that I respect them and want to find a way to help them move forward, however is most important to them. I may be an expert in primary care medicine, but they are the expert in their own lives, and by approaching our relationship as a partnership, I hope we can achieve the best outcomes. This approach seems natural and instinctive to me, but based on what I have heard, it is not universal. I think it must be a gift that I have that I am able to provide nonjudgmental care to everyone, and the more marginalized in society someone is, the more I want to create that open and safe space. I do not want to turn my back on this gift. I want to continue to see the families I have watched develop, and to help more people through recovery, so I know I will return to my practice.

I’ve thought a lot about what it will take for me to return. My leave has triggered increased attention to the well-being of all staff at our office and in our department, as well as awareness of where our support staff might be able to do a little bit more to reduce the burden on providers. This will definitely help but I don’t think anything done locally will solve the bigger problem in the health care system described in the recent articles linked above. My request for my return is to reduce my panel size. Based on a metric that was distributed to us as the vision for Primary Care in our health network, I have over twice as many patients as the goal. I don’t know how we will make this work – how will we decide whom to cull from the list? Whom will they see instead, as all of our providers are stretched thin with more patients than the ideal metric? I guess as I recover I need to let my department figure that stuff out and focus instead on taking care of myself. This will mean a lot more saying no. I think I will only accept new patients if they are household members of current patients, and I’ll need to keep an eye on the numbers to make sure I’m not moving toward overwhelm again. Over-commitment has been a challenge for me since high school, and I guess I finally met my limit. 

Thank you to everyone who has offered me support and affirmation. It really means a lot. 

Self-Doubt

My mind has been all over the place, going around and around about whether taking a leave was the right thing to do, for weeks or maybe even months I guess. Yesterday was my second workday off. I meditated, chose a challenging 50 minute yoga practice, cleaned another trouble zone of the house, took a walk, did a little knitting. I was feeling good - this is exactly what I needed - some time just to be by myself without people asking me to do things every 30 seconds. I felt in control and at peace. I reflected that it is a measure of my degree of burnout that whenever someone asks me to do something now it feels like a punch in the gut. It is not unreasonable for me to need to do things for people. I appreciate that this is my job. Somehow I got to the point where I have no reserve left, and even things that should be simple became almost impossible.

This time is sort of like the vacation I have needed but haven’t been able to take, literally and figuratively. When I am on vacation with my family, it’s great that I don’t have the responsibility of work, but instead I have responsibility to my kids and spouse. I have wanted time to myself so badly that I found myself becoming resentful of what they ask of me. It isn’t the way I want to be. Also, our office has been struggling to maintain adequate provider staffing. My “week off” between Christmas and New Year’s was already shortened by a working weekend at the end, then I added in a full day of patients to help cover for other providers’ absences. I asked for the April vacation week off, and was allowed to take Tuesday through Thursday, but not Monday or Friday, because that would have reduced the office staffing too much. This relentless and bottomless need takes a toll.

Everyone I know seems to be working harder than ever, with more and more constant demands, yet they are completing what is asked of them, even if there are many other things they'd rather be doing. Is there something wrong with me that I can’t get my work done and maintain focus without breaking down? I mean, something other than burnout? Maybe I shouldn’t be a doctor, if I can’t handle the administrative work that goes along with it. It has been pointed out to me that it isn’t the tasks themselves that I can’t handle, but the volume. This is true, but what is the solution? What makes the volume of administrative tasks go down? Being responsible for fewer patients, I suppose, but which ones get asked to see a different provider? Also, there will be a financial impact on our family if I reduce clinical time, both in decreased salary as well as a smaller subsidy for our benefits. I could also take on fewer nonclinical responsibilities, but so much of that is why I want to practice at an academic center: the opportunity to teach and to take advantage of learning collaborations.

I'm struggling a lot with the idea of what is fair and what is luxury. Why do I get to just say, "that's it, I'm done, good luck" and step into a leave with no warning and no obvious endpoint? My colleagues are all suffering in the same way, dealing with the same stuff. I think they are, anyway. If they aren't, then either there is something different about the tasks that are sent to me, or something different about how I react to them. I'm trying to figure out what those differences might be because that is how I'll be able to get back to work, by correcting or modifying one of those things or another. We all have this same short-term disability policy that allows us to take up to 6 months off. By taking advantage of this, I have made the work harder for the rest of the providers at my office, which puts them at increased risk of burnout. And what about all the other people in the world who are struggling so much to get by, with not enough money, or not enough support for raising their children? They don't get to just turn off the world and take a break. Why do I deserve to have this time?

I opened the email app on my phone yesterday, which contains both my personal and work email, as well as my calendar. I continue to get messages specifically for me, asking me to do something or other by next week. As soon as someone enters my address into the "To:" line, a warning pops up displaying my out of office message. Everyone should be able to see that I am on medical leave before the message is even sent. Maybe I need to change my OOO message to say "I am on medical leave due to burnout and am unable to respond to any administrative or clinical requests." Then I get mad, because why is that necessary? I am trying to not look at my email and not respond because if I continue to respond to things, then it sends the message that I'm actually available. And the whole point of this leave is that I'm NOT actually available. I guess I have to imagine that I had a heart attack or something and really not let myself do things. I'm having trouble figuring out where the line is. In the meantime, things keep coming in, and one thing I really need to do is delete the thousands of emails sitting in my account, many unread.

Another thing I'm trying to balance is what I'm teaching my sons. They both want to stop doing things when they get hard. They look at a math problem, say they can't do it, and flounce into a chair. This is not the work ethic I want to instill in them and I try and try to encourage them to look at problems from different directions before giving up. When I look at my leave from the perspective of a 10 or 12 year old boy, I wonder if it looks to them like deciding a problem is too hard and giving up. I don't believe that is actually what they think - the message I've gotten from them so far was really mature, that they are sorry things got so hard for me and glad I'll be home more. But this voice in my brain wonders if I should have kept pushing, to show them how important it is. Again, though, they really have no way of seeing what exactly I was pushing through. They just saw me coming home late, tired, not wanting to engage with them - and that isn't what I want either.

This morning, Thing 2 announced that he didn't think he could go to school. The assessment from his parents - one a family doctor and the other also an allergy sufferer - is that this was nasal congestion due to plants waking up in the spring. One does not stay home from school for allergic rhinitis. It was not that simple, however. He is physically unable to blow his nose so he swallows mucus, and had a stomachache. I gave him medicine, tried to get him to breathe in some steam (he proclaimed that this hurt too much), and lay him on his stomach and rubbed his back to see if his nose would clear. Finally I told him he had to go to school, and he proclaimed, "I'M NOT GOING." He was less than pleased when he heard that this meant I'd be taking him for an acute visit at our family doctor's office, and that we'd better have tried everything we had available, which meant I was giving him some Flonase. He submitted to this harsh treatment and then was ready for breakfast - ate an English muffin and 3 pieces of bacon. This is leaving me again questioning all of my decisions. He's not really sick as far as I can tell, so he should go to school. He says he couldn't concentrate yesterday because of his nose, so he shouldn't go. He might be pushing the line to try to get some time with me, and I shouldn't give in to that, so he should go. My work has been hard on all of us, and he really probably needs more mommy time, so he shouldn't go. Bottom line is that he's staying home, I canceled my plans to hike with a friend this afternoon, I'm taking him to see the NP, we'll have some time together, he'll go to school tomorrow, and it will be okay.

I'll need to reread this later and try to break some of it down, explore it more. There's so much rolling around in my head. Right now, though, I need to make my smoothie and squeeze in a little yoga before taking Thing 2 to his visit. The robins and blackbirds are singing their joy at the changing seasons while snow falls from the sky - springtime in Vermont.

Irony or Inevitable Consequence?

2017 was, objectively, the best year of my career to date. I was promoted to Associate Professor and the residents voted me Teacher of the Year. I put together a two day conference on integrating behavioral health and primary care. In the fall, I learned that I was chosen to be one of the FACES of our medical center. I also received a large grant to fund our new educational and clinical program that will integrate reproductive health care into our primary care office, a project I have been working toward for years.

Today I started a medical leave to recover from burnout.

I am a dedicated, hardworking, intelligent, caring, empathic person. This makes me a great family doctor. It also means that I have poured everything I have into my work. If something comes to me that needs to be done, and I know that I could do it and it would be helpful for someone, I want to do it. I have done a lot of good for a lot of my patients, and also for the residents and medical students I have taught. I have great working relationships with colleagues in my department and across the medical center. The practice of medicine energizes me. I can come home every day and know that at least one thing I did made a difference for someone.

BUT! In between the office visits and the professional conversations and the teaching, I am haunted by the other, hidden work of medicine. People call or send an electronic message to ask questions or to get medications renewed, and much of this can't be managed by front office or nursing staff, and comes to me for review and advice. Every test I order means a result comes to me, and someone wants to know that result. If my patient sees a specialist or goes to the emergency room or is admitted to the hospital, I get copies of the notes and results from those visits, sometimes in duplicate. Some of these include important information I need to follow-up on or tests I should order, so I need to look at them carefully. If someone on blood thinners is going to have a dental procedure, the dentist's office calls to ask me what to do to prevent bleeding. All of this and more comes into my InBasket in the electronic health record. I try to address it during my administrative time, but those hours get broken up by meetings and errands. When I'm seeing patients, I am present in the office so in theory I could respond quickly, but my focus is on the people who were scheduled for visits. When I finish with one the next is waiting to be seen, and I don't want to extend their wait longer than I have to. Then I open the InBasket at the end of the day and am confronted with all the things people wanted me to do that I didn't do. Sometimes they have called back several times asking why I haven't done whatever it was yet. No matter which task I choose to address, I didn't look at something else that was important to a different person.

I am a good doctor, a great doctor, yet every day I feel like a failure.

I've been trying different strategies to manage this work over the last several years. I use timed periods of work followed by timed periods of rest, or I set an intention for which folder I will clear out. I have been able to keep on top of things for a period of time, then I spend a week working 70 to 90 hours as the supervising physician in the hospital, and the outpatient work is neglected. Often I would just about have caught back up when my next hospital week came around again. I increased the frequency of visits with my therapist, and started seeing my psychiatrist more regularly. We adjusted medications, adding a stimulant to improve concentration (though I never met criteria for attention deficit disorder before my 40s) and a benzodiazepine to manage my near constant anxiety. I appreciate the value of these classes of medicine but I have seen them cause so many problems in my patients that I was hesitant to take the prescribed dose and took half of each pill, first just when I thought it would be most useful, then every Monday through Friday. Each day, I swallowed my stimulant and my anxiolytic with the same swig of water and wondered what I was doing.

I worked hard to maximize self-care. Since January 4, 2018, there have been four days when I did not meditate. Two were because I was delivering babies, one was the day I got a new phone and couldn't access the app, and the fourth I sat down to my practice at 11:47 pm and when I finished realized I'd chosen a 15 minute session instead of the usual 10-12, so it counted for the following day. I found ways to exercise almost every day, even if only for 10-15 minutes. I chose to prioritize going to bed over getting more work done. I found my mental clarity improved dramatically, at least when I was face to face with patients. I was better able to appreciate what they were telling me even while typing the narrative, and felt at the top of my game when we talked together about what might be causing their symptoms, and how we should proceed. At the same time, the administrative work felt harder and harder. My brain would jump to anything other than the InBasket tasks in front of me. Email became completely impossible - I couldn't even justify the time to delete the garbage that comes in every day, because if I was going to be sitting at the computer I needed to be responding to the things that my patients needed, but my brain just wouldn't do it.

I had this experience to a certain extent during my second year of medical school. In college, I could study for hours at a time, and it was worth it, because the effort I put in resulted in measurable success. I scored 100% on organic chemistry tests, and at graduation my GPA was in the top 5 students in the College of Arts & Sciences. In medical school, my techniques no longer worked. It was no longer possible for me to achieve such a high level of mastery. I made it through, and felt a lot better once I was in the clinical years. I knew residency would be hard, and each rotation was a new challenge, but no matter how difficult it was, I knew that this would pass in a few weeks. I could do anything for a finite amount of time. Now, there is no final hurdle to overcome with a last big push. It feels like constant hurdles, one after the other or one on top of the other, and the strength of my pushes seems to be weakening.

In my 13 years of clinical practice, there have been a lot of different challenges, but I have always somehow turned it around. This time, it isn't getting better. My psychiatrist suggested a leave a month or two ago and it seemed ridiculous, impossible. Last week he mentioned it again, and coincidentally I was seeing my family doctor and my therapist the same week. I thought through the possibility of reducing work hours, but less clinical time would just leave me with more administrative time, which was the part that was making me crazy. I decided to meet with our medical group's physician relations specialist to review the specific things I was having trouble with, and found myself crying for most of our 90 minute meeting. When she told me the process of taking a leave, it seemed so simple, and it just felt obvious that I needed to proceed.

I did not and do not like the idea of burdening my practice partners and our office staff with the additional work of caring for my patients. I have always been able to do whatever needed to be done - but I guess it's true that we all have a limit. I'm hoping to make good use of a couple months without clinical or teaching responsibilities. Maybe writing about it will help me recover. In the meantime, I have to find a safe place for this little beast, because eventually I'll need to turn it on again.

A glorious wedding

My brother got married this past weekend. I am still floating on the energy of this incredible event. Katie is the executive producer at an event organizing company in Manhattan, and Eric produces parties driven by whimsy in Brooklyn as a hobby, fueled on the energy of friendships he and Katie have made over years of living around the world and attending Burning Man. To create a wedding festival suitable for their life, they found a summer camp in the Catskills that hosts events when camp isn't in session, and about 250 people converged to share in their joy.

We weren't able to leave Vermont until the late afternoon so we didn't get to see the signs along the way.

I knit desperately for the entire 6 hour trip. We stopped at Golden Corral because the kids wanted to eat there. It will be okay with me if we never go to another Golden Corral again. They liked the chocolate fountain, though.

We arrived at 10 pm, after the pig roast but before the campfire hangout.

There were greeters waiting at the gate with brochures with a camp map and schedule of activities, on which they marked our assigned cabin. Everyone had a button waiting for them with their first name, color-coordinated based on their relation to the bride and groom. We were also provided with plastic cups with the couple's crest (yep, they made a crest) labeled with our names to use for drinks, and ear plugs, though we found the cabins were so quiet we didn't need these.

I was still knitting my shawl and bound off around 1 am, went back to the cabin and blocked it out as quietly as possible. Yes, I brought mats and pins. The next morning I made the tassels over coffee.

They had asked everyone to dress in their favorite colors - you may still be able to see the instructions at boltfest2017.com. The result was amazing.

We were greeted with bags labeled with our names, instructed not to open them until we were instructed to do so.

You can see my shawl in this photo, just above Katherine's arm.

Also here's me and my mom.

Eric and the rest of us in the close family entered to Ceremony by New Order.
Then we all sang A Little Respect by New Order together. Mary Ellen helped us. That's Scotty, the officiant, on the right. He had an ID tag labeled CLERGY so no one would be confused.

Katie came in to Music for a Found Harmonium by Penguin Cafe Orchestra. She's actually that beautiful. Every day.

Lauren read I am much too alone in this world, yet not alone by Rainer Maria Rilke. She read it twice so it could settle in.

Their vows started and ended with the same words and were more individual in between, and both promised to join together to build friendship, community, art, and love.

The rings were delivered by drone. I am not kidding.

We also sang The Crane Wife 3 by the Decemberists and Manchester by Kishi Bashi.
Katie and Eric were adorned with capes.

We were then instructed to open our little red bags, in which was a cape, in our favorite color. They knew our favorite colors because it was a question when we RSVPed via Google Forms.

Much rejoicing!

We went down the hill for drinks and tacos. Dad led the way playing his bagpipes.

That kid on the right in orange pants? He's mine.

Here's the crest:

My parents' speeches were just perfect. My mom was so funny and my dad blew everyone away with his philosophizing, and spontaneous quotation of more Rilke. This is Dad in his kilt, with his friend Amy.

And me and Eric with our lovely parents. I had replaced my shawl with the cape as it was too warm for that much alpaca. (Miranda Lace, yum!)

Then there was an afternoon of hanging out by the lake and dancing.

Also streamers!

My other kid is the one wearing the Vans with green laces. When they reunite with their second cousins from Mississippi, it is like they were never parted!

Dinner was hot dogs and burgers, and blue bug juice! It felt like camp.
Saturday night dance party was 18+. Katie wore her shawl and was stunning as always!

It is knit in SpaceCadet Luna (cobweb) and the pattern will be released on Ravelry at some point in 2017 ...

My speech was during this part, and it was well-received, though of course I didn't manage to say everything I meant to say, or everything I felt. I was dead on my feet and had to go back to my bunk, sadly, before the party moved to a mysterious woodland location to continue all night.

There were so many DJs at this party. My brother's set started at 4 am and greeted the sunrise. He has a great aesthetic for sunrise.

Turns out their capes glowed. GLOWED.

People took off gradually over the morning on Sunday. We were among the first, because we had to get back to Vermont for Will's All Star baseball practice. It is Thursday and I still want to be back there. I am so blessed to have Katie as a sister and to be among this amazing group of people. Thank you Eric and Katie for touching so many lives. You make the world better every day.

Photos collected from various sources: camp photographer, Facebook, other family and friends. Everyone is awesome.

Alpine Adventure: Day 1

In which we ascend to base camp
Uneventful flight to Zurich and the international entry process went smoothly. I had been looking forward to the Swiss rail system and I was not disappointed. The app I downloaded ahead of time generated the next 5 possible itineraries, each indicating the platform for the train, and linking to a progress bar of the train along the station route. Every connection involved getting off of one train and walking to another platform to get on the waiting train which then left within 5 minutes. It was unbelievable.

We were anticipating a shared room with twin beds and were amazed to find ourselves assigned to a 3 bedroom apartment with a patio overlooking Murren, the valley, and the Eiger and neighboring peaks. Here's a panorama from our deck:

From left to right, the peaks are:
Eiger (pointy)
Mönch
Then the ridge without snow is Lauberhorn.
Just behind that is Jungfrau, the one just under the clouds.
The center of the photo is a long ridge leading to Breithorn (rounded).
There is another rounded peak just to the left of the ridge on the right, which is Tschingelhorn.
Then the ridge just behind the patio with umbrellas leads up to Gspaltenhorn, a cute mitten shaped peak.

We walked to Grimmelwald, about 45 min on a paved path. Tiny village. We took the cable car back up to Murren for fun. The cable cars are loaded with tourists traveling up to the summit of Schilthorn, where there is a rotating restaurant which was featured as "Piz Gloria" in my favorite Bond film, On Her Majesty's Secret Service. We're going up today, the hard way.

With the train ride I nearly finished my Oscillo scarf. Just the cast off to do and it looks like I won't need the second skein of yarn. Now I have an extra 100g of Aurora ... What a problem! Not sure what I'll do with it as it's a rather distinctive colorway. I think it might be nice combined with a semisolid in Pure Joy.

We have "half board" at our hotels, which means breakfast and dinner are included. We sat on the sunny panoramic patio (with the umbrellas on the right in the photo above). They have a huge a la carte menu but I was pretty happy to not have to choose. Our set menu was a lovely salad with fresh strawberries, mozzarella, basil - fresh and delicious; roasted wild boar medallions and mushroom risotto; and caramel pudding.

We were fighting to stay awake all afternoon and evening. I made it til 9 then thought I'd just finish the last rows of the scarf. An episode of Outlander helped carry me to 10.

Alpine Adventure: Day 0

In which I earn my vacation
June 26 I went for a great bike ride. When I got home I took a nap and I woke up sick. This virus really wiped me out and I took naps whenever I could, all week long, and canceled one of my clinic sessions. I needed to rest as much as I could for my week on inpatient service.

My call for our maternity care group started at 8 am on Friday morning 7/1. I needed to go to the hospital straight from work because we thought we were going to put our laboring patient on pitocin. She ended up not needing it but I stayed to manage things until her own doctor got there, and worked on catching up with notes from the week. By the time I was relieved it was midnight and as I wanted to be in for sign out on Saturday morning, I slept in the hospital.

It was a busy Saturday on service, July 2 so the intern was brand new and the second year was acting as the solo senior for the first time. Labor intensive. I got home for dinner then in the evening answered a call from a patient with contractions. She didn't sound too uncomfortable so I decided that while she was getting to the hospital I would take a shower, as I hadn't changed my clothes in 24 hours. I got out and was drying off when L&D paged that she was fully dilated. Because I was officially in charge I headed on in even though there was no way I would make it. They paged me along the way as the baby was born and the placenta followed. Happily my friend who was on as the obstetrics attending was able to supervise my resident, and it was a great experience for him to do the delivery so independently. I tidied up loose ends but then it was midnight again so I slept at the hospital, again.

Another busy day Sunday and I was paged about obstetrics again Sunday night, though I didn't have to go in. Monday was July 4 and I was still on maternity call until 8 am Tuesday, and responsible for the hospital service until 5 pm. I calculated that this put me as the responsible attending on call for maternity and/or inpatient for 105 hours straight (8 am Friday until 5 pm Tuesday). And still Wednesday through Friday I was rounding. I did a good job getting all the notes signed but it required staying up until 12 or 2 am every night. I averaged 5 hours sleep I think.

I had a nice restful weekend. Then a busy week with lots of extra time in the office so I could get some patients in before my vacation.

In the category of really, really stupid, I was again on maternity call starting Friday 7/15 and hospital attending for the weekend. A friend had asked for coverage so she could go out of town for her son's birthday and I agreed so I could trade for a weekend I wanted to be off in January. I knew it was right before I was leaving so we agreed to trade off on Sunday night. But I hadn't thought about how my family might want me around for the weekend before I left them for 9 days. Also I forgot that it was my own son's birthday on Friday. Idiot. I again had to go straight to L&D from work because I was responsible for a patient who broke her water at 22 1/2 weeks. I had already arranged for the high-risk obstetrics service to take over her care, but again I needed to go in to be present. I had a good talk with her - lovely lady who has had a really hard time, and although I'd never met her before, I was glad to be able to support her on behalf of her own doctor. Then home for cake which was delayed for me.

As I was lying down to sleep Friday night the resident called me about a woman coming in, just to let me know. He was being so responsible, knowing that we expect them to call us about all pregnant women who call, but hadn't heard the part where if they have decided to evaluate them on L&D they don't have to call us until they have done the assessment. Then an hour later I was paged by a colleague who wanted to know about a test result. Then another call to let me know the patient's water was indeed broken and she was getting admitted. Then at 3:00 a call about a decrease in the fetal heart rate, so I needed to go right in. I stayed up getting work done and watching the strip, got sign out on the hospital patients, then back to L&D. I had tried to call the patient's doctor all night without response, so I figured she must be out of town. She got to complete dilation and started pushing. At the same time, another colleague's patient was undergoing induction. Things had been going okay and at the last check she was 4 cm. We were working with Patient 1 and giving her lots of coaching, she was doing fine - then the nurses asked for us to check Patient 2 - and she was complete with visible hair. So we left Patient 1 with her nurse, zipped over to Patient 2, did a lot of careful support so she wouldn't tear. I called her doc but there was no way she could get in in time. Patient 2 pushed out a 9 lb 10.5 ounce baby in about 20 minutes with no trauma and we were able to get right back to Patient 1 for more support. Then I heard from Patient 1's doctor who had been sleeping in a tent with her kids so didn't get my pages and texts. By this point there was no reason for her to come in either. Patient 1 started having some more low heart rate and we started talking about a vacuum delivery and called the peds team. But then just when she thought she couldn't do it anymore she turned the corner and had a great delivery. Two babies in less than an hour!

During that exciting hour another patient arrived in early labor and she had a prior cesarean section so needed lots of monitoring because of the extra risks. I was able to get my adult patients managed then back up to L&D to watch Patient 3. Her doctor couldn't come in because her husband was away and she didn't have child care. At 11 pm I lay down for a nap, got update calls from the resident every hour or so, things really stalled out but my brain was so fried so I let him manage things. Then there started to be some heart rate issues so I got out of bed and went out to assess, we were finally ready to push. This was a kind of scary second stage because the heart rate kept going down and our monitors weren't working well. But happily we had yet another nice delivery and healthy baby.

Back to the call room for 5 hours of sleep before another day of medicine service. Then hometown for dinner, signed out to my friend at 8, got my bag packed, hung out with the fam, took a shower. Alarm at 3:30 and cab at 4:20, flight at 6:10 am. Now I am spending the day in Atlanta until our 5:45 pm flight to Zurich! I managed to devote 3 hours to getting work done so I am in great shape and now I can KNIT.

Projects I brought:
Beekeeper's Quilt - plan to continue a puff a day. I did two today because I didn't manage any the last two days. I still owe myself one for today.
Featherweight (wip) - Posh Yarn Bryony Lace
Oscillo (wip) - SpaceCadet Aurora
Everyday Shawl (casting on now) - SpaceCadet Oriana and Celeste - gradient mini skeins from Sept and Oct 2015
La Jefa - SpaceCadet Thebe
Tucked - (Vi)Laines BFL DK
Wide Ribbed Beanie - Swan's Island DK

Express Lane by Diane Mulholland - KAL

Hello PL!
I started the socks with a video pretty much of each of the 6 rows. Here are some things I learned:
- it's pretty hard to see the stitches with the yarn I'm using, I think
- I needed to do gauge math.

I realized once I was in the 6-8 row range that the toe was going to be HUGE. This is because I ignored my gauge swatch. Rookie mistake. I'm still going to put up the videos, since I took the time, and because maybe they're helpful. But I frogged and will start over with the right number of stitches. I might also do a mini piece with a yarn that is easier to see.

Gauge math:
Pattern gauge is 36st per 4"
My swatch is 30st/41r per 4" on 2.5 mm needles and the fabric feels good to me so I don't want to do another swatch on smaller needles.
My foot is about 9" circumference, 9" x 36st/4" = 81 st in pattern gauge - not sure how much negative ease is recommended for this pattern. The L size has 64 st around, 64st x 4"/36st = 7.1", 2" negative ease seems like more than enough so I'll follow the L instructions.
The L instructions say to CO 32.
32st x 4"/36st x 30st/4" = 26.67 st so I can CO 26 or 27 st
Once in the round pattern has 64st x 4"/36st x 30st/4" = 53.3 st
twice 26 is 52, a little tighter
twice 27 is 54 which is pretty close to what I want so I'll CO 27 even though it's an odd number.

Oh you didn't check your gauge? Then you have homework before you start!
1. read this article
2. knit and measure your gauge swatch

My usual strategy is to CO half again as many sts as the pattern says will be 4" - this makes a 6" swatch. So for this pattern, 36 + 36/2 = 36 + 18 = 54, but I like multiples of 5 so I'd CO 55. Then I'd knit garter stitch for a few rows (3 or 4 ridges), then I carry on with 4-5 st of garter stitch at the beginning and end, and when I'm about square I do the symmetrical number of garter stitches. Then I bind off, measure, wash the swatch, and measure again. I have a sweet little pile of gauge swatches that are something like 6" square that eventually might be an interesting quilt ... someday.

This project illustrates how I have taught myself so much knitting. I started in and thought things were awkward but figured I was following the pattern so it was okay. Then I got to the "complete toe" section and it didn't work at all. I frogged and started over with my new knowledge and then something clicked and I figured out how it worked. Lots and trial and error but I learn a lot from all my mistakes.

Here is me figuring it out for real:

Then as I worked more to get to the toe completion part it started to get a lot more comfortable so I think it might be valuable to watch this toe part before starting.

And this is unzipping the provisional cast on and preparing to knit in the round. I picked up with the other end of the same needle. Don't do this! My needles were going in opposite directions when I was done!