Debt Free: It Can Be Done

President Barack Obama was on Late Night with Jimmy Fallon back in April 2012. I watched him slow jam the news with Fallon and talk about student loans during his interview. On the show, the President says he and the First Lady paid off their student loans eight years ago. Only eight years ago? I said to myself. I couldn't believe it. It was refreshing to watch our President speak so openly about his debt. It encouraged me to know he paid it off only recently, and that he was unashamed in talking about it.

I graduated from medical school in 2004 with over $100,000 worth of debt. A physician colleague of mine had almost half a million in debt she combined with her husband, also a doctor. My own debt included mostly student loans, but also included a car loan, and many credit cards. When I met my husband, he was taken aback by my debt, but he wasn't especially surprised. It is expensive to go to school, even a public medical school as I did, in America.

My husband and I paid off our student loans and various debt one year after we married, six years after I graduated from medical school. I could not have done it without him. I met him during the last year of my medical residency. He was really the inspiration for our becoming debt-free. One of the first things he told me while we were dating was that he would be happy never to use a credit card again. That really lit a fire in me and made me love him more than I already did. We were on the same page, but he was more forthright about his goals. He was the most likely of the two of us to make it happen.

After 4 years of internship and residency, my salary as a real doctor shot up and it was tempting not to spend all that new money I was bringing in. There were many times I threw little tantrums unbecoming for a woman my age over things I wanted to buy, but had to wait on and save up for. I wanted them now. I deserved them, god dammit, after all the training I went through. It isn't fair, I'd say to my beleaguered husband. All my doctor friends drive nice cars and live in homes with yards and more than one bathroom. Why do we still live in a one bedroom apartment and take the subway? I would come down eventually from my angry tirade. It usually happened once a month but less frequently as I noticed our debt shrinking.

We started our debt-free saga by putting together our debts in a chart, listing them from smallest amount owed to largest. This made me feel guilty since most of the debt was mine, but we were stronger together than separately attacking our individual debts on our own. We planned to pay the smallest debts first. I tried paying off debt in order of interest rate, but the psychological benefit of paying off a smaller debt first, even if it was only $50, was encouraging. After a debt was paid, we would cross it off the list. We would pay off all minimum payments due for all debt each month, and set aside as much as we could from our take home income to pay off the smallest debt first. After the first debt was paid off, the money we would have taken to pay off that minimum payment due would snowball into the next debt owed on the list.

We told everyone we knew what we were doing. This put some people off. Not everyone likes to talk about money. Our families were supportive. My family reacted first by saying, "Why would you want to pay off your debt? Don't you want a house?" But I felt strongly about what we were doing. We listened to money-minded podcasts warning us most of our support network would find it strange we were living on less than half of what we took home and putting it toward our debt every month. Though he is not religious, my husband listened religiously to The Dave Ramsey Show, and I listened to The Suze Orman Show for motivation and inspiration. I also read a book by Kimberly Palmer (who writes for U.S. News and World Report about money and finance) which was helpful because the author and I are around the same age.

My husband put together a poster on which he drew a rocket made of squares. Each square represented $100 worth of debt paid. We would fill in a square with a colored marker for each debt paid. I saw that rocket poster every day. It was taped to the door of our coat closet, so it was impossible to ignore.

Once we got to the top of our rocket ship, I colored in the last square as my husband took a picture. It was truly a wonderful feeling. An enormous weight lifted off, and a hard lesson was burned into my consciousness. I don't use credit cards now and probably never will again. We still take the subway and live in a one bedroom apartment, but we're happier and debt-free for it.

Sick Day

My daughter spent the weekend in mountainous, majestic New Hampshire with her ebullient Gram and Grampa. She came back happy, well-fed, and vocal. She showed me a couple of new tricks. She loves to stand, though she can't stand up alone yet, and she likes to get up on all fours. She lifts her belly off the ground, rocking back and forth. It's only a matter of time before she starts crawling full-force. She turns 9 months old next week.

Unfortunately, once she got back, she was sneezing and coughing up a storm. A few hours later, so was I. Ugh. Poco started daycare at 12 weeks old, and since then, she and I, and occasionally my husband, will get beat down by a cold or stomach bug or random fever or all three every 2-6 weeks.I hardly ever call in sick, though I tell my patients with similar symptoms to do as I say, not as I do. I don't know why I don't call in sick more often. It's not as though my work doesn't understand the weakening effects of illness. Perhaps it's a pride thing. Perhaps I feel bad cancelling a day of patients who have been waiting to see me.

I have a couple of doctor friends who are the same way, in that we could be dying or feel like we are, and we will still show up to work. I know it's idiotic. Why would I show up and spread my germs around, not only to patients, but to my colleagues? Sometimes, we just have to work. I have many patients who don't call in sick, either. If they get a cold, this is usually what they have: a runny nose, facial congestion, ear popping, post nasal drip causing a cough, especially at night, and general fatigue. The fatigue is likely due to the fact that when you sleep with a stuffy nose, you're just not getting as much oxygen and you don't sleep as deeply. This is how I feel right now.

What do I do for my common cold? It's come down to a science, since I've had it so many times in the last 6 months. I drink lots of water. I love hot herbal caffeine-free tea with honey and lemon, if my throat can stand it. Then I sleep as much as I can. If' I'm at work, I have a water bottle on my desk. I wear a mask and wash my hands frequently. I usually will take a combination of an anti-histamine and decongestant to help me breath easier. This can be Claritin-D, Zyrtec-D, or Allegra-D. I take generics, but I list the brand names here because that's how they are most commonly known.

At the end of the work day, I'm usually beat. I skip the gym. I do not go the gym if I'm sick. I don't get anything out of it, and I feel absolutely crappy if I do go. I get to bed early. That's key. I'm not getting quality sleep, so I need as much of it as I can get. A lot of times, the post nasal drip will make me cough like crazy if I lie down flat, so I raise my head with 2-3 pillows. I will also take a Benadryl to help with nasal stuffiness and post nasal drip. If I have a fever, I don't go to work. That's a new rule for me. My mind gets fuzzy if I'm febrile, and I don't trust myself to make medical decisions when I'm mildly delirious.

My daughter is in the middle of her mid-morning nap, and so far, I don't hear much coughing from her. As for me, I'm waiting for Fexofenadine-D [Allegra-D] to kick in as I boil more water for tea. Perhaps this will only be a 24 hour bug.

Poco's First Yard Sale

Until this past weekend, I only went to other people’s yard sales to browse, bargain, and occasionally buy. My neighborhood moms group held its annual spring yard sale and I gladly signed up to sell various items collecting dust in my home. I also thought the sale would be a great way to meet other moms and interact with the people in my neighborhood. There’s something about having a baby that makes me want to settle in one place. I’ve lived in a lot of beautiful cities conducive for settling,but I didn’t seem to fit in or they didn’t fit me. 

I brought Poco with me to the yard sale. She tends to be observant and quiet in noisy public spaces where there are a lot of new faces for her to smile at. For the first 30 minutes, I set up “shop” and put prices on items, cleaned an old vase, and made my allotted yard sale table look as pleasing as I could with index cards, sharpie markers, tape, and strategically placed items. For example, I put the baby stuff together in one corner so that perhaps people would buy more than one baby item at a time. While I was doing this, I didn’t even notice Poco was there. She was quiet but alert in her stroller. A couple of buyers asked me jokingly—I think—“How much for the baby?” Our assigned table sat at the entrance of the church basement where the yard sale was taking place, so everyone saw us as they entered and exited. 

My first buyer was a pleasant and very pregnant young womanwho said she needed an infant carrier. She told me her story about finding the right carrier and how many carriers she already owned. We talked babycarriers like old pros, but I wondered if she was trying toengage me to lower the price on the carrier or if shejust wanted talk. I felt guilty for thinking the latter, especially when she boughtthe carrier in the end and didn’t negotiate.

The baby items sold quickly, leaving the more grown-up items on the table. My shoes, skirts, scarves, gloves, and a random towel rack from IKEA were keeping each other company at the end. An older mother and her adult son bought my jewelry box, vase, and a 12 piece set of china in one swoop. No boxes or bags needed. They hauled those items out like it was moving day. It was interesting the way her son bought the items. He saw his mother eye-ing the vase, and without asking me or looking at me, he said, “Hey, Ma, I just bought you that vase.” I wasn’t offended; it was sort of funny. He later paid for it.

Another lady looked at an unopened cat litter box wicker cover (retail: I have no idea) with a price tag clearly marked “$20” and then asked me how much I really wanted for it. I really wanted $20, but I also really really wanted it out of my basement, so I said $15. She hesitated. I mentioned that I never used it and that the box top was still glued together. She bought the cover in the end, which was unexpected. I underestimated people’s love for their pets. I was even able to sell my cat’s old hair brushes to a nice lady after we talked about our cats.

Cat lady: “See, my cat has very long hair. Will this work?”

Me: “I’m almost certain it will. It’s called the Furminator.It uses static cling, I think, to get the loose hair out.”

Cat lady: “Why are you selling it, then?”

Me: “Well, my cat died. She was very old.”

(Four strangers looking at my table stop, look up at me, and gasp. For real.)

Nice stranger who loves cats: “Oh, I’m so sorry. That is so hard, losing a pet.”

Me: “Yeah, it was really hard. Much harder than I thought it would be, you know? I got really attached to her.”

Nice stranger #2 who loves cats: “How old was she?”

Me: “She was 14 and a half. It was time.”

(The group seemed to sigh collectively.)

Cat lady: “So, how much for the 2 brushes?”

Me: “5 dollars.”

Cat lady: “I’ll take them.”

I was never a fan of bargaining until I decided to buy a car about 6 years ago. My sister and I read an online “How-To” book on negotiating for your first car. Our mother loves negotiating when she shops for a car, and we didn’t know how she did it with such confidence. I used to be so uncomfortable when having to confront a salesperson and calmly ask them if they wanted to sell me something for less than it was marked. My face would flush and my heart would beat rapidly. But it made me upset to read a study that showed minorities and women tend to pay the most for cars, whereas white males pay the least. This is not because minorities and women don’t like to bargain. Car dealers simply tend to quote them the higher mark-up price. This is from a study written by Ian Ayres and Peter Siegelman, “Race and Gender Discrimination in Bargaining for a New Car,” published in The American Economic Review in June1995.  

I used to hate bargaining, but I wanted a car for a fair and decent price, which I did end up getting. At the yard sale, I felt completely comfortable negotiating a fair price with interested buyers. And it didn’t hurt that I was wearing my cute, smiling daughter while meeting new people in our neighborhood. I felt at home.

Rainy Day Weekend

While Saturday's weather was gleefully sunny, Sunday was a turnaround. Rain and wind sang my family and me to sleep and we woke to clouds and horizontal rain pecking at our windows. My 8-month-old daughter didn't seem fazed. Waking at her usual time of 6AM, weekend or not, she talked loudly and pleasantly to herself, pushing her pacifiers through her crib bars onto the hardwood floor, waking my husband and me. We call her Lil Poco because she is small for her age, but lately, she's been catching up.

We were planning to take Poco to the Esplanade, but the weather was crappy. There were definitely household items we "needed" from the local IKEA, but planning a trip to IKEA always accompanies in me a sense of shame, excess, and consumerist waste, so I saved that for the next day, which I happened to have off. Instead, we visited the Museum of Fine Arts in Boston. It was our daughter's first visit to a museum of any kind.

You may be thinking, What is she doing bringing baby to a museum? That's what I thought, when I was young and childless and encountered screaming children with their tired parents in otherwise tranquil art museums and galleries. I took a chance. Fortunately, we brought a reverent version of Poco who seemed fascinated by color and lights and people. This isn't how she is every day, but at the MFA, she was relatively peaceful. She didn't throw up on anything that I was aware of. I don't know if she liked the art, but my husband and I did.

We headed straight for the new wing which presented mostly American art in a stunningly beautiful way. I loved showing my daughter portraits of Paul Revere and George Washington. There were a lot of works by John Singleton Copley. Then we walked over to the Contemporary Art section. I especially liked explaining to Poco the story of Lilith as we showed her a sculpture depicting Adam's first wife. She did not seem to feel one way or another about Lilith, but she liked touching a long glittery curtain of gold beads that may or may not have been an exhibit unto itself. I love watching her face as she ponders a thing completely new to her. Watching her watching something else transforms me.

I expected the MFA to be crowded due to the rain, but it wasn't. It may have been a combination of the high price of admission and the fact that it was Sunday, it was raining, and most people would stay in. I know I would, but I guess I've changed.

Marathon Monday 2012

Over a decade ago, I remember reading about a woman who won the Boston Marathon. By the end of her run, she had blood and stool draining down her leg. I was a runner at the time, but I had never run a marathon, nor had the thought entered my mind. I had no idea what would happen to a person that they would be OK with having their own body fluids stuck to them while running.

Last year, I went to a continuing medical education conference sponsored by the Brigham where they presented a patient case of a marathon runner who stopped getting her periods. The focus of the case was more on her hormone abnormality, but the doctor presenting the case mentioned, in passing, she would get the runs, you know, when she would run marathons. Then, the doctor moved onto the next topic as health care professionals around me nodded, Yes, the runs. They happen when you’re running a marathon, of course.

Thinking back on my own clinical experience, I have heard patients tell me about similar symptoms of gastrointestinal distress with intense running or exercise, and this often improved on its own.

After reviewing the literature on a basic PubMed search, I found that lower gastrointestinal tract symptoms do occur frequently in runners, specifically bowel urgency, diarrhea, and even rectal bleeding. These symptoms can be accompanied by nausea, vomiting, and abdominal cramping. There are several thoughts on why this occurs. The more obvious explanation seems to be the extreme amount of stress placed on the human body would cause it to combust internally. Or, that would be my first thought. But to be more scientific about it, some have proposed the following as explanations for runners’ trots: electrolyte imbalance, autonomic nervous system stimulation, ischemia, and just plain trauma. There have been cases of rectal bleeding with intense workouts, related to hemorrhagic gastritis. These can be treated with over the counter medications like Ranitidine, also known as Zantac. However, like with any case of rectal bleeding that comes into my office, I take it seriously and do a full evaluation. Most cases of diarrhea with running are benign, but you’re not wrong to call your doctor’s office and ask questions if it doesn’t get better with taking a break from your workout regimen.

With temperatures creeping into the 80’s today and the less elite runners starting later this morning, we may see more blood and poop on the marathon route than we have in the past. We may see more serious medical conditions, too. I hope more runners will opt to defer to next year, or if they go ahead and start, to stop or slow down and rest when their bodies tell them to. I’m not sure how likely this will happen in marathoners, though. My marathoner patients tend to be high achieving, no matter the cost. The mind is much stronger than the body. I will often tell them to slow down if they are injured, but I know better than to expect they will listen. They will need to reach their decision on their own, and when they do, I’ll be there to support them.

I am no marathon runner. I did go running outside this weekend with my now 8-month-old infant daughter, but for 30 minutes. We ran in the morning when it was a breezy 60 degrees, and by the end, I was burning up. By the way, only one of us had any kind of incontinence that day, and it wasn’t me. She slept through it.

Couch to 5K: Discussing BMI with my patients and myself

It's one thing to tell patients they should exercise regularly. It's another thing to do it yourself. A recent study showed that doctors who were overweight or obese were less likely to talk with their patients about weight. I read this study and noted the same behavior in myself. When I was thinner, I had no problem bringing up body mass index with patients. But lately, I'm reluctant to do so, because it sounds ridiculous coming from me, with the way I look. Granted, I had a baby last summer, but that was last summer. There's a statute of limitations on how long the baby weight should stick around.

As much as it feels awkward, I do bring up body mass index at the end of every physical exam, especially if the patient does not have a normal BMI. The medical assistant weighs my patients before the exam. If the number bothers patients, they may bring it up before the office visit starts. Most times, they do not bring it up at all. I know they know, and they know I know. They wait for me to bring it up. Usually when I do, they are relieved that I did, and then we start talking. I'm often able to engage them most on this topic. It's a tough topic! I don't have any magic pill or diet or exercise routine to recommend, but I do like to encourage patients who have already modified their lifestyle, to keep going. I encourage them tell me what they like about exercise and how it makes them feel. I'm their cheerleader.

I used to think back pain limited my ability to exercise. A few years ago, a horse threw me while I was riding in the Andes mountains. The horse and I did not get along leading up to my fall, but he was the only way up and down the mountain. Since then, I've had intermittent chronic low back pain. I stopped running outside on pavement, because I thought it caused my back pain to flare up. I used to run in Rock Creek Park in Bethesda, MD every day after work. The scenery was enlightening and beautiful, and I maintained a reasonable BMI. But I stopped when my back started to ache again. I went to the gym instead and worked out on the more forgiving elliptical machine. Now, it's spring in Boston, and I want to run outside. How do I reconcile my love of running with my poor aching back?

I went to a few Pilates classes last year. One Pilates instructor told me that my back hurt after I went running because my pelvic and abdominal muscles were weak. What?! No health care provider ever told me that, or did they? Did someone mention it, and I just didn't hear it? I'm supposed to know better. Of course, that makes sense for me as a doctor to say it to patient, but not for me to say it to myself. I needed self-realization. I looked on the Internet for folks who had back pain with running. I found an article wasn't exactly about that, but did reinvigorate my desire to run again.

http://news.harvard.edu/gazette/story/2012/04/chasing-down-a-better-way-to-run/

One of my patients told me he lost weight by using an iPhone app called "Couch-to-5K." I looked at the app and gave it a try. My back seized up in a tightening bind the day after my run. I stretched out my back and legs before, during, and after the next run. I shifted my weight during my run onto the balls of my feet, instead of my heels. I stretched more. I felt better. My back didn't hurt while I was running, only afterward. Could it be my posture? (Yes.) Are my core and leg muscles tight and weak? (Yes.) Was I trying to diagnose myself again? (Ummm, yes.)

I'm not sure what the answer is to my back or my running, but I've been running outside again for the last week, and I've been OK. It's possible to exercise and feel great. I feel less guilty advocating exercise to patients, and I can empathize with where they might be if they are dealing with injury or pain.