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"Rape is like the weather. If it's inevitable, relax and enjoy it".

This sentence was uttered in 1990 by Clayton "Claytie" Williams, then Texas gubernatorial candidate. Except he thought the microphone was off. It was not. He lost the race to Ann Richards.

In 2016, candidate Trump was elected to the presidency of the United States of America after bragging, also when he thought microphone was off, of "grabbing them by the pussy".

Apparently raping women had become less unpalatable than making a very insensitive absurd statement about it.  I don't know how the Trump presidency has worked out for you or how you think it's working out for the world but I haven't forgotten that this was a foundation for it: the tolerance and embrace of a person who brags about assaulting women.

So, like many women, now living in a country where saying that goes unpunished and where doing that is in theory now far less punishable than aborting or in some states, miscarrying under circumstances judged to be a woman's responsibility, an embryo that, trust me, is not capable neurologically of pain till about 20 weeks in the womb, consciousness till after birth, a real heart beat till it has a heart around 20 weeks.

We are also living in a world where children die or suffer of preventable poverty, hunger and disease including in the USA. A world and its children current and future which is also impacted large scale by many decisions which are not biologically and ecologically sustainable.  At least not if the goal is really to not hurt or kill children.

But going back to Claytie. I was in an OR the day he lost his gubernatorial bid.

I was a medical student and my attending cardiac surgeon wanted Claytie to win.

I was a medical student in a room full of men: from Russia, China, the USA. They had come to observe my famous attending operate.

Med Students Circa 1990: Plunkett, Preisinger and Glowinski
He wanted another kind of blood that day than the one from his cardiac surgeries: female blood. "So little girl...." (he called me that by the way) what do you think about rape? "  He then proceeded to express that rape was a invention by women without any foundational reality. Sex was enjoyable, hence rape did not exist. Women who were raped were missing an opportunity for joy. He was surgically invasive in his attempt at getting a raise at the female representation in the room.

I started to cry. Which was not ideal in several ways, including my proximity to the patient's open chest. But I had a mask on and it absorbed my tears.

"What's wrong little girl?"

"I. Have. A. Cold." I said with the dead look that those who know me understand as pre-explosive.


This was 29 years ago. This would be less likely to happen in a medical school. Not without consequences.  

What is happening to women rights and safety overall is worse.

By the way, who suffers the most when you hurt women? Oh..Children.
Till Later,
Anne
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I am a working mother and I am a lucky one:

I gave birth to three healthy sons.

I am proud of many former trainees who are doing great things with their careers and are having a positive impact on the world around them. I just heard THREE of them talk today at our annual conference for pediatric providers.

Our freshman in college son brought some of his friends home for a couple days: children by extension. We are rich in children and blessed.

My calendar is full of meetings with young people. Seeking advice, mentorship, conversations, input, connection. I am very lucky.
Lucky Mother, April 1996

I do not have biological daughters but I have almost daughters: trainees, current and former students, friends of my sons. Tomorrow, going to a concert with Nate, the boyfriend of my very first almost daughter Kate (with her real mother for the weekend) and Mike, the husband of one of my medical students from almost 20 years ago.

Yet, lucky one that I am, I did not have maternity leaves when our children were born.

I took vacation time and sick leave. My children all started day care at six weeks, which felt almost insurmountably painful at the time. I wanted to carry them in a pouch. I visited them at daycare, stealing minutes from the work day to nurse them sometimes in the sun, sometimes in a dark corner so as to not offend the sensibility of easily offended people.

I'm a lucky one and had a pumping room during residence. It was called the moo room.  My on-call attending when I thought my waters broke made it clear that my number one priority, before heading to the emergency room, was to ensure coverage by a peer, to make sure that he did not work for me himself.

I'm a lucky one and I spent years paying astronomical sums to daycares and babysitters so I could work when my children were little, so I could bring my kids along on work trips when they were still nursing, so I could honor invitations to places like Cold Spring Harbor or keep speaking engagements.

I'm a lucky one and I did not sleep for years and, at the time, even when the research showed that women are as if not more productive than men over the course of a lifetime, I was evaluated as a young woman without any allowance for the juggling act of motherhood and academic medicine. My h publication index is 19. It's good enough by any standard. For a working mother with a primary educator hat,  three children, a husband with an insanely busy job and no family in town to help...it's more than good and yet, it always felt not enough, like I was under-achieving by the standards of a culture that prides itself on love of science but can't do multivariate math (still can't even if it's a bit better) like appropriately measuring academic productivity during the reproductive years of a woman faculty.

I'm a lucky one that starting four years ago or so, thanks to lucid motivation and an exceptional trainer, I turned around or at least ameliorated several stress related disorders accumulated in a profession were women are twice as likely to die from suicide than women in the general population.

I'm a lucky one in a country where, according to a recent study, women who are mothers feel the most work/life balance stress of all the mothers in the developed countries world. A country where one of the States just made it possible for a woman who has miscarried to be considered a murderer, where maternity leave or early preschool education is not universal and where many mothers and children do not have medical insurance.

I'm a lucky one that for the last decade, when my almost daughters or sons have their own babies, I can give them a gift of compassion, understanding and occasional help. It may help 2% only but it makes a difference.

I'm a lucky one that I have a partner who was not neutral but staunchly supportive about the importance of my contributions in a very underserved profession.

We all know children are the future.

Then, parents, teachers, people who work with children are the future too.
Let's protect it better.
Love and Happy Mother's Day to All,
Anne
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Flyer for UCLA Greenblatt Lecture, May 2019
I just returned this morning (around 2 am) from a wonderful visit to UCLA where I was honored to give the annual Gertrude Greenblatt Memorial Lecture to honor the spirit of Gertrude Greenblatt: passionate and compassionate dedication to education.

I don't need to tell you what an honor it was to be invited.

I should tell you that I met many new wonderful people over the last few days and that if not for serious jet lag and sleep deprivation (up since 7 am after 4 hours of sleep, clinic day and after school special on a science project involving crickets in the Grand Teton national park), I would tell you about more of them.


I'll just tell you about meeting Karen Miotto, a UCLA psychiatrist who directs their Behavioral Wellness Center and their newer physician wellness program.

Here is what she said to me (and I'll look up the precise reference when I'm not falling asleep friends): a study shows that the number one factor cited by medical students as key to their well-being is?

It is the happiness they perceive in their residents or attendings.

Let's unpack:

1-We create neurotoxic environments for our students when our chronic unhappiness is poured in the clinical environments where they learn.
2-There might be many reasons for this. Including the projection that this is the future awaiting them after so many many years of training.

If you needed one more motivation to take care of yourself, your health and your happiness: there it is.
You welcome.
With Love and Till Later,
Anne
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When I was eight, one of my favorite books was StarWolf by Edmond Hamilton.

Nott a brilliant Science Fiction book but I read and reread it.


It makes sense: the hero, like me, was culturally ill-fitting and had to deal with his identity issues.

He was not a Jewish pre-tween with a Polish name living in a country that reminded me my name was not French nor my religion Catholic on a regular basis;  and had a complex WWII History....the hero, Chane was a human adopted by extraterrestrial parents, the so called Star Wolves and he lived on a planet that had no other humans and that was both an awesome and a hostile environment to grow in.

That spoke to me.
Loups Des Etoiles
I actually just dreamt of this book.
In a plane to Los Angeles.

A plane where sleeping or blogging is an excellent choice.

Judge for yourself:  on my immediate left, a young man is watching a TV-MA program, profoundly mortifying the teenager in the middle seat next to him. The teen is sandwiched between nudity watcher and I think his mother---an identity crisis right there too. 

The teen's discomfort is palpable to me in a cringy way. 

I'm not saying anything because my inner Don Quixote has to take breaks or I fizzle.  I am not the world's watcher. At least not for things like that.

In any case...I dreamt of this book probably because Chewbacca died and it's May 4th and May the Fourth be with you etc....My brain went from the Star Wars to the Star Wolves in one short dance step.

Another reason I loved that book was the prescient adventure where (and my memory is very probably distorting this plot) Chane happens on a device that allows for space travel to the furthest confines of the Galaxy. 

Not in a spaceship, no... as a soul traveling like a light particle through the stars, seeing their symphonies and dances etc....going from one place to the other in a wink. The lesson was (again I may be confabulating) that such a device had brought down an entire planet/civilization when people had started traveling in space, leaving their bodies to wither away behind them.

The guy to my right is watching sports on his phone; I'm blogging. The TV-MA watcher is going strong to my left and the teen next to him is furiously absorbing himself in a video game. The mom is playing phone solitaire, oblivious to her son's drama. 

Not space travel but not good for bodies either. Our postures, like my coach Reuben would say...

Back to my nap. and my dreams.

Till Later with Love,

Anne
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Napping Hippopotamus, Copenhagen, Denmark
These days, the so called hand on the door knob question in my clinic is: "So...Doc, what about CBD oil for his/her [insert disorder, usually depression or anxiety or both]....the cousin of my friend swears by it..."

By the way, door on the knob question refers to the question that patients ask just when you are about to end session/leave the room.

In other words, their MOST important question.

So, here's what we say these days.. What WE say since each of my patients has a treatment team that, besides me, includes at least one other, usually younger, doctor -a resident or fellow physician- who contributes to making sure we are up to date in reviewing informative literature.


1-Yes, we know that CBD is very popular. There is an entire industry branding CBD as benign and miraculously helpful.

2-That industry is shaping to be as powerful as the one behind the non-generic drugs we prescribe but with even less oversight/regulation for claims and disclosure of side effects. The preparation is also far less regulated so there is a risk of contamination including by THC which undoubtedly, over time, has been shown in good studies to worsen depression and anxiety.

3-That said, there have been some studies that suggest that CBD might be very slightly helpful for anxiety. Not extremely good studies. At most, for now, they suggest that the anxiolytic effect of
CBD is slight and less than CBT, SSRIs or SNRIs.

4-If a patient in my or another clinic is on a medicine metabolized through the Cytochrome P450 (essentially every SSRI or SNRI though with inter-drug variations in terms of strength of interface with P450) then CBD, which is also cleared by P450 enzymes, can slow the metabolism of SSRI or SNRI and result in toxicity. Serotonin syndrome is no joke.

5-Many CBD industries have become aware of that but are making light of it and claiming, online, their product is nevertheless entirely safe.

6-The last century has seen series of "miracle, entirely safe, drugs": cocaine (seriously fascinating read on Freud's cocaine addiction), morphine (great book by Bulgakov, doc and writer and morphine addict), cigarettes, benzodiazepines, barbiturates. Some drugs, like St. John's Wort, were not that unsafe, compared to the ones previously cited; but NONE were miracles.

7-Studies on stigma show that when it comes to mental disorders, the most stigmatized situation (by the way...this is by non doc patients and docs as patients alike) is the one where they are treated with drugs like SSRIs or TCAs or SNRIs....In other words, drugs that don't feel like there is a "natural" (or more sinister-ly, more addictive) remedy for something that needs a happy ending of "I had this terrible problem and it completely miraculously went away."

The number of narratives about depression being due to diet, etc...is high.  Those narratives are always more triumphant than the "yep, I'm depressed and I take Prozac" ones.  It's not that they are untrue: there are many factors that impact well-being or lead to its opposite, including inflammation factors we are starting to understand better, and diet, activity, brain environment choices etc...are extraordinarily important.

It's clear though that the narrative of depression or anxiety as (for many) chronic conditions which require a number of approaches including at this point in time, for optimal results, prioritizing something as "un-natural" as an SSRI, a TCA or an SNRI" is just not as popular as the idea of CBD or other snake oil.

I do not blame patients.
I would blame myself if I did not know what to say when they ask.
With love and till later,
Anne
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Psych RC Meeting April 2019, Chicago, Illinois
Louise, the Executive Director for the Psychiatry and ACGME Residency Review Committees, is a very intelligent, tactful, diplomatic and wonderful woman.

So, it is entirely possible, even a little likely, that she was stretching the truth when she said that psychiatrists are the most fun and (shhhhh....) her favorite.

You say that to all the Review Committees, right? I tease her. Are you saying that if you had to choose who you'd be stranded with on a desert island, you'd pick the psychiatrists?

Garrulous dinner companions (the putative desert island contingent) are quick to ask why in the world she would want anyone like us on a desert island.

A terrible reality show I explain.  Worse have been funded. Survival on an island: which medical specialty to take with you?

We run with this for a few minutes. Imagining how members of the Surgery Residency Review Committee would build houses, boats etc....while we, the psychiatrists would..... what exactly? Try to engage the local monkeys? look for mushrooms? validate the feelings related to isolation from civilization?

Yeah, Louise jokes, I'd be dying and you guys would make me feel alright about it.


We sign a confidentiality agreement when on boarding as ACGME RC members.

But... this I can say: like many of the best experiences of my professional life, the quality of this privileged experience has to do with the people: my funny, intelligent, passionate about education, perhaps useless on a desert island colleagues and the staff of the ACGME, a model of professionalism and high standards.

So here is to that imaginary island and Louise's choice of companions.
Love and Till Later,
Anne
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The Fractured Buttwhole???
I'm mostly working from home this week, on a spring break with my oldest and youngest sons contaminated by my to do pile that I have not dented enough during my normal work hours.

To each his own: if I don't work some on vacation and a bigger avalanche hits me when I return to work, the stress erases the benefit of vacation so I accept my lot for now. It makes sense if you think about it: working moms are always working anyway so I have years of habituation to rehabilitate from.

So, I'm pleasurably blogging in the living room before attacking that pile for a few hours and my 21 and 16 year olds and two cats are hanging out too. My 21 year old is reading Paris Trout. Our 18 year old is not on Spring break. He had dinner with us last night but went right back to his dorm after. My 16 year old is playing something ridiculous, a game based on Southpark.


There is blood, pooping, hamsters in cavities, ubiquitous flatulence jokes and sounds and those nasal grating voices.


My son is having a blast.


So slowing down for a minute before we get back to the living room and its inglorious happenings: my husband and I resisted getting a game console for the boys for YEARS; till about a year ago.

What happened during these years was straightforward and simple: censoring at home. Playing and sleepovering at friends who owned consoles. We never censored friendships and even if we had done it on the basis of console ownership vs. not, the pickings would have been vanishingly slim.

So, we got a console for the last birthday of our youngest, who is, for his age, eminently reasonable and ethical, wickedly funny (playing cards against humanity since 11-that what happens with two older brothers) and also in the position to live alone with parents for a couple years since his brothers left for college.  So, a consolation prize of sorts. Also we knew we had lost any hope of censoring the exposure and were at the stage of let's see what material he consumes and for how long.

Something like that.

So I have sat, perplex, through fragments of "God of War" and some other game with a cowboy that goes on laconic (him-the women babble more) adventures.

Nothing had prepared me for the Southpark game though.

"What are you doing?" I ask with a slightly anxious pitch as I take in the slightly disturbingly familiar bopping roundness and middle school voices of Southpark characters.
My 16 year old answers: "this is hilarious. The Southpark game. I poop in that game."

My mind does a somersault at the prospect of a game where the characters poop and the attraction this presents. Then, a microsecond later, my mind remembers that a 16 year old teen boy would indeed find this tremendously attractive.

James Baldwin (and I'm mentioning him because to balance this living room situation, we were talking about other things last night at the dinner table including Mr. Baldwin and his contribution to American culture) said: "Love does not begin and end the way we seem to think it does. Love is a battle, love is a war; love is a growing up."  

Well, you could really say that about parenting, of course...parenting is love,  a kind of love.


Till Later,

Anne
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Global Health Week: Reverse Case Competition
on Global Warming, February 28th, 2019
The Water Will Come...It is the title of an acclaimed book by Jeff Goodell . We gave it to one of our sons for his birthday this winter break; he left it behind in his room when he returned to college.

Hence...I know exactly where the book is.  However...I have not read it yet.

When students invited me to participate in a reverse competition panel on Global Warming in Bangladesh, Kyle, the student liaison specifically told me to not study/review/get smarter on this topic which is for sure outside the bounds of my usual knowledge expertise.

I mean I'm a scientist and I've been to Bangladesh but neither is particularly specific.

I obeyed and did not look anything up or read the book I knew where to find exactly in our house.
I wanted to.
I obeyed and did not.
Not because I'm a genius at following rules but because I was too busy with 30 other things.

As to why I would add one thing I know relatively little about to 30 other things: well...here is the truth...I've learned from my life and its unexpected twists, turns and surprises that it is a good idea to say yes to interesting new things in general and figure it out later.  Young people, I'm not taking about jobs here: those should be negotiated a bit and not just for salary. I'm talking about invitations outside your usual boundaries that intrigue and scare you a little.

I will continue being honest: I often do want to kick myself as I'm rushing to something that I said yes to months ago and it is most highly inconvenient the day of.
Nevertheless the rate of regret AFTER is close to zero %.
Not zero...but close (there was just that one disappointing documentary once really.)

So I did not review global warming's impact on Bangladesh's precarious environment and its people but I was thinking about people in general:

1- People who do not believe that global warming is happening and even snicker smugly when we have wildly cold winters...despite the scientific predictions of more erratic weather conditions as a normal correlate of global warming.

2-People who know it is happening but do not think it has anything to do with humans-just normal variation. Not completely unreasonable given our planet's history except for the impressive mountain of evidence related to the impact of human activities on climate.

 and then 3-People who know it is happening and that humans are involved and do not think about it and how this probably includes:
3-a: pessimists who just do not think much can be done so why think about it?
 3-b: people who only care about what happens to them and theirs and consider theirs to  be a very tiny circumscribed group.

I often have imaginary conversations with other people in my head to deal with the intensity of my thoughts. I would drive my family and friends bonkers if I shared all my thoughts so this works more or less.

I was talking to people in category 1 first and asking them (I swear) if they owned a smart phone? Many of them do. Who would you want to make the smart phone for you?  I asked them that in my imaginary dialogue which was over tea and in my sun room by the way.  A team with the technical ability to make the phone? or your grandfather and father who have no idea how to do it but have strong opinions about everything? (Sorry if your grandpa and pa are actually omniscient-i'm generalizing here.)  The same grandfather and father that you parrot when you say that global warming is a joke. You would not buy the smartphone they make; why are you expertifying and internalizing their opinions of scientific evidence?

Then I was talking to people in category 2 and it was a similar conversation: Who do you believe? Your opinionated relatives or a preponderance of experts who have now compiled evidence for decades?

I'm  mad at that group by the way: we could have mitigated the problem more if not for them. I'm not even talking about Category 3 people who pretend to be in Category 2 for political or other reasons and know very well that humans have had and continue to have a destructive impact on the environment that will make our world unrecognizable within decades.

I was talking to them as well, the category 3 people.
Telling the 3-a that giving up guarantees failure and that not giving up does not guarantee success or mitigated failure, I know...but it ups the odds of improvement.

The 3-b, especially those who over-represent people who believe religiously in love of one's brothers and other humans (also plenty of representation in Categories 1 and 2)....I was telling them that everybody they leave behind, children and grand-children alike, will be profoundly affected. Emotionally, socially, psychologically, physically, materially affected. A few will enrich themselves for crisis related opportunities but most will suffer from living in a world where islands and cities sink or have sunk, animals we love have disappeared, coastal areas they love (if only to vacation in) exist no longer.  Their  children and grandchildren may not think fondly or proudly of their family members' behaviors. They will wonder why you did not care. They will know you lived in a wired world where you DID have access to information and that your ignorance or choice to believe implausible sources without appropriate credentials was not excusable. They will likely know that.

Anyway....I don't even like myself in those conversations.  I know too well that being self-righteous back-fires and is annoying as hell. I do know however that I get tired of diplomatic patience and tolerance when the waters are rising. It has not been an effective strategy to protect our world.
I'm just telling you the truth here.

Thank you for reading so far.

So what about the panel? I was "competing" with two internationally known infectious disease doctors (including Dr. Powderly who directs our WashU Institute for Public Health ) and Rupa Patel who has helped implement PrEP protocols around the world, very active with Physicians for Human Rights, and the reason I started going to Bangladesh, Joe Steensma a delightful professor of Practice at the Brown School (check out his Ted Talk here) and Marris Brenn-White a fantastic wild life veterinarian and global health specialist currently at the St. Louis Zoo.

Here is the thing: what we concluded (and the students said we "won" but they may have been generous as they usually are when faculty lend them time and attention) is that to even have a chance to damage-control this upcoming calamity which will affect us all but will affect some of the world's poorest people first (such as the citizens or asylum seekers of Bangladesh) and among those, will affect the most vulnerable first (children, elderly, the handicapped), we needed to at least do this -in addition to of course recognizing some basic threats related to water contamination and its ecological impact and the complex reality of human and animal displacement or disruption on a large scale-:





  •  Understand the marriage of mental health to physical health; addressing these un-dissociably related consequences in silos is a losing proposition;
  • Broadly recognize the breadth and scope of the impact;
  • Know how to work in teams;
  • Re-emphasizing: learn how to work in teams;
  • Know how to ask for input and by whom;
  • Know how to seek expertise outside our own;
  • Recognize our short comings honestly;
  • Know how to communicate because boy.. the communicating is going to get more complicated. For instance, fragile co-habitations in the same country of various ethnicities by allowing each a certain territory: out the window with global warming. 


  • The risk of conflict on a larger scale heretofore unexperienced is high.

    The water will come-we can not afford to ignore it.
    Love and till Later
    Anne
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    Stanford University, February 2019
    Friends from California, Missouri and everywhere... I have some news.

    Jim, my husband, is moving to Palo Alto this summer to head pediatric anesthesia at Stanford. Sammy (our 16 year old) and I supported and encouraged him 150% to step into this position eventhough Sammy, a 10th grader, and I will stay behind in Missouri for two years and a few months to not disrupt his end of high-school. I'm also glad that I have time to help with succession for my job here.

    Sammy said: "I would never even think about getting in the way of anyone's dream job" when we were talking about what that meant for our family.

    We will be living over two households in the next 28 months. 

    It’s exciting and a little scary. 

    I do not have a new job lined up yet. Most days I like that. 

    I wanted to tell everyone I care for in person (and did for most of our fellows) but it's not efficient.  An email seemed weird. I'm not leaving...just stepping into a transition phase.


    I’m counting on you to continue being our tribe in Missouri or California or elsewhere and look forward to seeing you more or at all or to have you visit.  I'm going to want your love and help and ideas as we navigate new waters and go through changes. 

    Thank you.
    Till Later,
    Anne
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    Table 12: Therapeutic Alliance
    Create a diorama, depicting either peer review, the therapeutic alliance or resilience.

    We are at the KTGF annual conference; this year hosted by our wonderful colleagues and friends (Shashank Joshi, one of the co-director sang at our wedding-from the Nozze di Figaro if you are curious...)

    The annual conference is a busy 24 hours, part social, part oral presentations and posters and part games.


    The dioramas' challenge (ideated by the Stanford students in charge of the games' part of the conference) led to gravity defying, recycling of every material available, metaphorical story telling.

    I have to go play, but here is my story for the day: the future of our field is bright.

    Till Later,

    Love-Anne
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