Finding my sport

In Iowa in the 60’s and early 70’s opportunities for organized sports for girls were limited. In small high schools, half-court basketball was available for girls. Three players per team on each end of the court. One end of court playing offense and the other playing defense. It was apparently felt that girls were not strong enough to play full court basketball. This actually became a part of the messaging used against approval of the Equal Rights Amendment in Iowa in the 70’s. The ERA would make half-court basketball for women illegal. As we now know, girls and women are quite capable of playing both offense and defense and running up and down the full court.

In was the second of 5 kids (boy, me, boy, boy, girl). My brothers were year round athletes and I was reasonably uncoordinated. There was track and field and volleyball for girls in my high school which did not have girls basketball. I did shot put and went out for volleyball for a couple of seasons but fitness was not prioritized. Going out for a walk for fitness was not a part of the farming mentality. In retrospect I have reflected on this believe this is in part due to the the fact that generations ago, farming was very physically challenging for the men in the fields and the women doing house/gardening and or field activities. There was always work to do and except for Sunday for church and family, there was. no down time. Everything you did must have a purpose and that belief was embedded in my psyche. During my decade in NYC where we did not have a car, I found myself resistant to walking for exercise or pleasure, but I could walk for long distances for a purpose. We would pick a movie theater two-five miles away and walk there and back, etc. The distance was not the problem, I needed a purpose. I have gotten over this to a reasonable degree.

I am tall and “big boned”. I always felt “fat” in part due to comments by my older brother and his friends and in part because Twiggy was the new icon during my junior high years. I gained a lot of weight during pregnancy and was on many popular diets in the world throughout my adulthood. I did successfully lose 40 pounds in my mid-thirties but fairly quickly put in back on because it was through calorie control alone.

On one fateful day in August 2017, a friend and mentor who had become a huge fitness advocate post retirement told me I should join a group she was putting together to celebrate her 80th birthday. Her celebration was to cycle the 444 mile Natchez Trace (Nashville to Natchez, MS) in October 2018 – 14 months from then. I had just started to work with a personal trainer as I was now over 60 and had the time and resources to prepare for growing older. I said yes. I hadn’t been on a bike in 40 years. I went to a bike store and decided to start with a hybrid. I was very nervous about drop handle bars and thin tires. I know from exercise cycles that I had problems with perineal/labial numbness after riding 15-30 minutes and this was a challenge on my bike as well. On my third saddle (seat) I found one that did not cause problems and worked my way up to riding 40 miles. In August of 2018, 2 months before the start of the big Natchez ride, I decided I was ready for a road bike. I felt very secure on my new bike and it was a more efficient ride that I felt would be better for the days where we would ride 40-70 miles. The “saddle-soreness” resurfaced and I knew I didn’t have it right when we started the 9 day trip so I took 2 saddles with me and alternated. A couple fo days I had to end a bit early because of pain, but I did log 400 of the 444 miles.

It appears saddle technology and options have improved significantly in the past several years. I really appreciate this recent article https://www.bicycling.com/health-nutrition/a35982610/bike-seat-pain-saddle-sores-women/ I have a saddle that works well enough for now, but may explore some of these newer designs. Training for the Natchez ride was a BIG GOAL and I while I continued building strength with my trainer, I did not know if I was going to be able to ride for 9 consecutive days – if I could keep up with the rest of the group that while older were fit and experienced cyclists and skiers.

Fortunately, I did not slow the group down and I discovered that I loved cycling – I found my sport. I have continued cycling regularly since the big trip. Thanks to Team 444 for supporting me during the BIG ride and showing me that age is irrelevant to enjoyment of sport and staying fit. It is never too late to find your sport.

The day I became a feminist

In 1987 I arrived at my new job as the first woman urologist in Seattle (actually the first woman urologist north of Los Angeles and west of the Mississippi). I found a great private practice that wanted me to focus on taking care of women and invested in the specialized equipment to allow me to build my practice. I noticed that the receptionist would say the first available appointment for Dr. G is in 4 weeks but Dr. Bavendam is new to our practice and HER first appointment is later this week. Women were delighted to have a woman urologist and it was a rare men that decided to wait to see a man. Male referring physicians were the most hesitant about their male patients seeing a woman urologist but there were enough women physicians to build my practice quickly.

Many of were initial women patients were incredibly complicated. They had already had all of the standard treatments – the same ones I had to offer and were either not better or worse. The women expected me, as a women to have better treatment options. I had little I could do except take very detailed histories and work to unravel their stories. Many of these women had been told they were hysterical and/or that their symptoms were all in their heads. When a cause for their symptoms can not be found or women do not respond to the usual treatments, the norm at that time was to blame the woman rather than recognize our lack of knowledge about the problems and potential new treatments. Some women were undergoing weekly or monthly painful dilations of the urethra having been told that if they didn’t keep coming in, their urethra would close up. Women had painful, emotionally draining stories that I found distressing to listen to and document. I went through a box of tissues a week. I got a humorous tissue box cover that was prominent on by desk that helped break the tension when emotions took over. With some of the stories, I also needed to use the tissue.

I was angry at my fellow urologists. I looked for any source of information that would help me offer something new. I went to a text book that I had received during residency (perhaps 3 years previously) and found a chapter on Female Urology. I started reading until I found this section:

My world stopped for a few seconds and I became a feminist in those moments. You might have thought I considered myself a feminist during medical school and residency but I hadn’t really taken time to think about it. I was in rural Iowa in the 60’s as feminism emerged. There was little discussion on the topic. No one ever told me I shouldn’t go to medical school. Becoming a urologist was novel. I had 3 brothers so it was easy to be one “of the boys” at the beginning. I had an unplanned pregnancy during my first year of residency. I spent the rest of residency feeling guilty and trying not make waves. I was grateful that I was allowed to finished residency on time in spite of taking 6 weeks off after delivery with some additional time later for postpartum depression. I did not have the capacity to consider feminist principles until the day I read this statement.

That statement provided the context for me to better understand the experiences the women were reporting. Hurting women with dilation of the urethra and putting liquid silver nitrate in the bladder was what many urologists had been trained to do. In the absence of any other options, the practice persisted. My plan to find a better way to care for women with urologic problems went into overdrive. I started practicing patient-centered, individualized care before those concepts existed. Each woman became her own puzzle to solve and together we developed an approach to care that was based on education, behavioral change and rehabilitative strategies. I used medication and surgery when I thought there would help. First and foremost, I did my best to explain why I was recommending treatments and what aspect of their condition I thought each treatment would help. I did everything that I could to “not hurt them”.

From that point forward, I have never passed up an opportunity to act like a feminist because I finally understood I was one.

Health Care Insurance – The core of my freedom to take risks

It is so gratifying that a few individuals have commented on my first post. It makes it easier to write this one. First and foremost in every decision about change in employment I made was the availability of a good group health plan. I was not free to consider leaving the government until I qualified for retirement from the government which includes continuing with the same health care coverage. As I have always been employed by big employers with good plans, I really didn’t understand the complexities of being insured with personal plans. I had a bit of understanding from the years I spent delivering health care when individuals wanted to schedule surgery at the end of the year after they had used up their deductible and the uninsured who literally earned $2 too much per month to qualify for Medicaid but did not have enough money to afford private insurance that would cover preexisting conditions. I have 2 examples that were very impactful on my understanding.

A young woman who was on Medicaid and food stamps needed a surgery to use a segment of intestine to enlarge her bladder. This was several decades ago and at that time the standard of care was to do 3 days of clear liquids with laxatives to clean out the intestine prior to surgery. She received all of the standard written instructions. During her surgery, she became incredibly unstable and we had to stop the surgery and close up the incision – the first and only time this ever happened to me. She later told me that because her food stamps would not cover food for her kids and the clear liquids (apple juice, jello, popsicles) for her, she just bought their food and drank only a bit of water during her bowel prep. While I don’t know for sure that this was the cause of the problems during surgery, when it came time to reschedule the surgery, I gave her plenty of cash to buy the clear liquids and the surgery went very well the second time. From that time forward, I was much more careful about trying to respectfully determine if patients had the resources to comply with what I was asking of them. For someone living on the streets, it is obvious that they many have difficulty complying with treatment to similar situations exist for persons that have stable housing. Difficult choices have to be made. Fortunately there is increasing awareness and research being done to understand these social determinants of health.

The second example is related to my helping my son and soon to be wife find adequate health care coverage. There were healthy, self-employed musicians in there mid-twenties. Up do this time when I heard someone say they were saving to have a child, I really thought they were getting a head start funds for daycare or college. I had no idea that in the private personal insurance world, affordable policies excluded pregnancy coverage for young women unless they purchased the pregnancy rider at the beginning which may be years before pregnancy. You would not be allowed to purchase the rider at a later time. How unfair!!!!

When I was practicing medicine, I was subject to the sound bites about how horrible single payer systems were and while I didn’t necessarily believe it, I didn’t have/take the time to inform myself. When I was practicing in Seattle, I would occasionally see persons from Canada who would come because they were upset about the waiting time for an elective surgery.

I have subsequently taken time to learn more and am a huge supporter of a single payer system. Health care cannot possibly be affordable if private insurance is allowed to insure the healthiest and make huge profits while public funders are left to cover the most unhealthy. There needs to be one risk pool. The owner of the single risk pool does not have to be the government, but it is hard to imagine a private entity being willing to do it if their profits will be less. In my mind, we need a government-based single risk pool to cover health care delivery.

My career path was through larger employer based health insurance benefits which I knew was important, but did not fully appreciate until very recently was at the core of my being able to take the risks that I did. It also is one of the many aspects of my privilege.

These will get shorter over time as I have less time to write but this is fun.

Today is the first day on my path to joy

Yesterday I worked for the National Institutes of Health. Today I am no longer a “fed”. The sense of freedom this brings me is immense – thus the title of my blog – Unleashed. The “necessary” constraints of being a fed were particularly onerous for me. I have “necessary” in quotes as I am unclear how necessary many of the constraints are, but more about that over time. I am initiating this blog as one way to use my authentic voice which has been stifled during my 8 years and 5 months as a member of the Executive Branch of the federal government. I have tremendous respect for all of my colleagues who continue in federal service.

Who am I? I am a woman who uses the pronouns she/her/hers. I grew up in rural Iowa in a family of where men were farmers and women were teachers. I decided to become a physician and urologic surgeon in the early 80’s. I got married in medical school and pregnant during my first year of residency at the University of Iowa. I am a mother and no longer a wife. I decided to specialize in women’s urologic conditions and following specialized training in Los Angeles I was in a private practice for 2 years in Seattle, followed by 8 years on faculty at the University of Washington. I moved to Philadelphia and spent 5 years on the faculty at what is now Drexel Med in Philadelphia. In 2001, I realized the incentives in health care delivery were not consistent with how I wanted to provide care for women and I decided to pursue an opportunity in the pharmaceutical industry. I thought this would be a 2-3 year detour to learn new skills that I would bring back to medical school administration but it turned into 10 years of constant learning and growing. From Pharma I decided to accept a position in the National Institute of Diabetes and Digestive and Kidney Diseases with a specific goal of starting research that would lead to the promotion of bladder health in women. I achieved this goal. The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium in now in its 6th year. ]https://plusconsortium.umn.edu

How did I get from bladder health to lower urinary tract symptoms (LUTS)? LUTS are the symptoms or experiences ( for example, frequent peeing, urgent need to pee, leaking of pee and pain or discomfort with peeing) that occur with bladder conditions such as bladder infection or UTI, overactive bladder (OAB), urinary incontinence (UI) or interstitial cystitis/bladder pain syndrome (IC/BPS). While the ultimate goal of PLUS is promotion of bladder health in women, the established area of research is prevention science. So within a government organization funded to support research, the road to promotion of bladder health is through prevention research. Thus the PLUS consortium will gather the science to support prevention of LUTS and assoicated conditions that will lead to promotion of a healthy bladder. Much more to come about this topic in the future.

My view of the world is shaped by these various experiences and more. While I thought being a kindergarten teacher like my mother was too much responsibility and chose to be a physician instead, I am an educator and mentor at my core and ultimately understood that what women needed most was information, support and respect – the foundation for empowerment. Thus I have chosen the tagline for my musings: Women. Health. Empowerment.