What you can get for $1

                                                                       Busy Breasts                                                       

      I was told by my breast surgeon that I have busy breasts. And they are. Constantly running off to meetings and outings with friends. Family engagements and work commitments. Darting this way and that. It’s a miracle they stay attached to my body! But that’s not what she meant. She meant that they are small and fibrous and full of various types of tissues that are hard to image, hard to manage, and at an increased risk of developing breast cancer. I’d rather have the first type of busy breasts. But it’s not up to me. So much is not up to me. I have begun to learn that lesson over the past year. 

Most of my life, I’ve lived in a world where I could count on plans that I’ve made. In fact, I would say that I basked in an arrogance of planning. I loved (and still love) dreaming up plans and finding ways to make them happen. Logistical puzzles and imagined adventures are some of my favorite ways to procrastinate. I had a beautiful, complex, adventurous plan in early 2020 to take my family for an immersion year in Ecuador, where the kids would attend school and Nick and I would study Spanish and pursue various creative and cultural interests. Covid really pulled the rug from under the feet of that plan. I felt like a second semester senior who was told she was not going to graduate. A dog with its tail wrapped all the way between its legs. 

I have enough humility to have quickly realized that during Covid, we have all been  grieving some loss: lost loved ones, lost ability, lost social connections, lost mental health. So, on the spectrum of losses, bagging our travel plans was no biggie. We hunkered down with the rest of the world. We struggled through zoom school. I turned our kitchen into a sourdough bakery, vowing to bake all of our family’s bread for the year. We started the B Flats, our family band. We watched several seasons of Alone and The Great British Baking Show. The kids played on the street like we all did in the 80s. My selfish grief occasionally would creep back in, but I think we were fairly successful morphing the grief and disappointment into gratitude and resilience. 

                                                                         

                

                                      The B flats (missing our ukulele and trumpet players)

                                                                        

                                                                     Homeschool handiwork

                                                                            

        In the fall, we started talking about travel again. At that time, nobody had yet been vaccinated and it was inconceivable to think that we would ever step foot on an airplane again, but we had to start thinking about it because I needed to tell my practice if I intended any upcoming extended absence. It was impossible to predict what the world had in store for us. It felt vulnerable to declare (again!) that we intended to go. But the alternate of letting go of our dream to take a leap of faith as a family was truly devastating. What’s more is that something within me had changed as well. It came into surprisingly clear focus that I needed a break from my practice. 

It’s hard to explain how I can be so fulfilled by and grateful for my job but also know that I need to leave it. It’s also hard that I am leaving many families that I have known for almost 12 years. That’s just about the same age as Sam, my oldest child. So, my first patients are his contemporaries. I see them in their almost adult bodies and am blown away. I remember them as newborns. Even more, I remember their parents in those first days. That deer in the headlights look of all first-time parents. I told them they were going to survive and that it would get easier. That is truly what I got good at as a pediatrician. The simple message of your child is normal and you are doing a good job. 

Deciding to leave my job did not commit us to resuming our S American musings, but it did commit us to making some big changes. “Make plans but hold them lightly” a wise friend said. We booked tickets on miles. For 20k AA miles each, we had business class tickets from Denver to Guayaquil in August. We re-booked the same airbnb that we had originally. We got in contact with the school again. I started obsessively following Ecuadorian Covid numbers. I started to feel excited and hopeful but also very unsure whether this take-two planning would ever come to fruition. I tried not to get attached to these maybe plans. I came up with a million contingency plans. We decided to move ahead with planning but maintain an air of flexibility. 

We never lost sight of the fundamental questions about whether it is safe for us to go. And is it responsible for us to go? These are the questions that kept me up many nights and that I have twisted around and tied in knots in my stomach to the point of feeling ill. Are these selfish dreams going to put us or somebody else at risk? Just because we can get back to traveling and adventuring, does it mean we should? Are friends and family going to judge us for making decisions that they deem irresponsible or selfish? And do I care what other people think or say about us? Should I? We’ve all got this demon’s layer of self doubt within us, no?

I found the lump in March. This is also when we asked the school for a year of absence, started look for house renters, and day by day were committing more and more to being away for a year. I’ve always had fairly lumpy breasts and I knew my routine mammogram was scheduled for the end of the month, so I decided to sit tight. We went on our first trip since Covid and spent two awesome weeks with our family, of which almost all adults were vaccinated. We cooked and hugged and laughed together with a new gratitude for the graceful simplicity of togetherness. Amid this joyful time, every night, I explored my left breast. Made calculating mental notes about the mobility, size, and quality of the mass I felt. Yes, my breasts have always been lumpy, but this was different. It didn’t wax and wane with the rest of the lumps as they went through the nonsensical rhythm of a Mirena “cycle.”

At my mammogram, the tech refused to do the routine study because I mentioned the lump. She called the NP at Planned Parenthood to step up the order to a diagnostic mammogram with ultrasound instead of the routine mammogram. And the study was normal. I tried to feel reassured about this. I wanted to let it go. I reached out to two family doc friends of mine who both recommended seeing a breast surgeon. 

While I waited for the appointment, I signed 700 letters to my families letting them know that I had decided to leave my practice. I cried and laughed with patients and families that I feel I know as well as some of my own extended family. I felt like I was having break up conversations all day long, every day. I questioned my decision over and over again. It takes so long to build a healthy and thriving primary care practice, and here I am choosing to leave. I told my mom that I feel like I just finished building my dream home and decided that it no longer suits me. However, the more I marinated in my decision to leave, the more confident I felt that it was the right decision for me and my family. 

Even with all the uncertainty of the future, deciding to leave felt certain. Partly because it had to. I could not waffle in this decision. Once those letters hit 700 mailboxes around Alaska, there was no changing my mind. But also because it was a brave and vulnerable and necessary decision. My decision to leave was the only path forward in which my family is my first priority. We may not know very much about how the next year will look, but we do know that we get to be together; adventuring and growing together, for better or worse. 

It felt incongruous to be so necessarily certain and definitive about my plans to leave my practice but equally uncertain and flexible about our plans to pursue our year abroad. Just as Alaska’s Covid numbers finally started to remit, Ecuador’s numbers surged. Nick, Sam and I were all fully vaccinated as were all of our adult and teenager friends, and we started to get back to normalish activities and socializing. But Ecuador was going into it’s third lockdown. I nervously watched as the daily cases climbed and their vaccine numbers remained at seemingly less than zero. I started to imagine other potentially safer abroad options: Chile was getting vaccinated and Puerto Rico has the same access as the mainland US. How were we going to make this seemingly impossible choice?

One night, when we had already agreed to rent our house to our good friends but not yet signed a lease, Nick and I sat down to try to figure it out. We were weighing strong personal desire for family adventure and language immersion with personal safety and wellness and community responsibility. We decided that we were comfortable with the very small personal risk that Covid poses to young children and vaccinated healthy teens and adults. We decided that we posed very little risk for others in contact with us as vaccinated adults and good mask wearers. And we both agreed that we still felt like taking a leap of faith. We resolved to go and be as prepared as possible to carry out our original plan, but to maintain as much flexibility as possible, both in planning and in how we think about the adventure. We decided that it was time for our family to make a brave and vulnerable move together, even if we could not quite see the landing. 

The first time I saw the surgeon, she was very reassuring. Small-breasted, athletic women like me always have very lumpy, fibrous breasts, she said. She barely appreciated the lump and told me that it likely had been there forever and I just hadn’t noticed it. Hmmm, I’m pretty sure I have better body awareness than that. I knew it wasn’t there before March and I am really used to the weird normal bumpy cycles that my breasts go through. She told me to return in 3 months. Hmmm. That was in late April and our scheduled departure was July 1. Cue the uncertainty of my future and planning: hasn’t that been the take home message after this Covid year? But with our recently affirmed resolve to go, I would not be able to follow up in 3 months. I tried to embrace her confidence and signed our house rental lease. I supposed that I could get a biopsy in Ecuador if needed (for much cheaper no doubt). 

We all settled into a middle ground of moving ahead with our plans to leave but not attaching too strongly to one version of our time away from Alaska. We enrolled the kids in IDEA homeschool from AK and Nick wrote a beautiful curriculum to loosely mirror the theme studies from Chugach. He consulted teacher friends and familiarized himself with common core standards. It felt like we moved mountains to prepare our home, yurt, cars, and kids for a year away from our home. We lended out mountains of gear, re-homed our hamster, our ancient newt, and our worm farm. We made plans for Mowgli to spend the year with family in Montana. I baked bread and goodies using rice, almond, spelt, and teff flour, wanting to get through our food. 

Through the immense daily list of tasks, I worked. It was exhausting. I tried so hard to stay present, engaged, emotionally available for my patients, especially those whom I know well and who were looking for one last connected visit with me. I knew it would be rough, but I wanted to work to the end of June so it would be simple financially at the office, having worked exactly half of the year. And we wanted to get to Montana for the 4th of July, a holiday that the Montanans celebrate with much more gusto than any Alaskan seems to. Even Matthew (who is from New Zealand) looks forward to the 4th of July like it’s an adult Xmas or something. And I knew I could handle abutting work directly with our departure. A small masochistic part of me enjoys the challenge of jumping directly from being all in one world directly into the next without much time to breathe. But it exhausted me to my core. I may have stopped sleeping for a handful of nights.

Somewhere in those sleepless nights, I realized that I needed to return to the breast surgeon. My nightly self-breast exams assured me that the lump had not changed. However, since my breasts around the lump were in their more deflated state, it seemed more prominent. It was about 6 weeks since my first trip to see her and a week before our scheduled departure from Alaska. The second time she examined me, something changed in her voice. A little less confidence in it’s certainly benign nature. She offered me various ways to image the lump in more detail, but these come with high price tags and vague results. Or she could just biopsy. I choose the needle. 

In the six days between my second visit with the surgeon and the biopsy, we said good-bye. I said good-bye to my book club, dear friends who I had only connected with once outside of the virtual world since Covid started. In September, we met in Jamie’s back yard. At that gathering, we did not touch or share food and I peed in her yard rather than risk going into her house. The good-bye reunion was different. We hugged and shared drinks and food and peed in each other’s toilets like pre-Covid times. We also had a good-bye party thrown by dear friends Annie and Kjerstin. It was well-attended and felt a bit like my wedding: I barely saw Nick all night, had a hard time saying hello and then good-bye to everyone present, and forgot to have a drink. It was amazing. We felt enveloped in love and full of gratitude for our community of friends that feel like family. Why are we leaving again?! 

Last weekend in Hope

                                                                            

Hope Point! Going to miss this crew! Love our Anchorage/Hope extended family
                                                                     

                                       Nothing beats the blissful relaxation of Hope                                             

Through all of these ceremonies and good-byes, through all the last visits with favorite and most difficult patients, through all the packing up and putting on hold our lives, I felt the constant nagging presence of a difficult word.....maybe. Maybe we’re going. Maybe it will be an amazing chance for my family to adventure and grow together. Maybe we will be missed in Anchorage. Because in addition to all the maybes of knowing that plans are to be held lightly due to Covid and letting go of the arrogance of planning (I’m trying, Covid! I’m trying to learn your hard lessons!), I was also coping with the maybe of being in a healthy body. 

In a very unfortunate version of what the world has in store for me over the next year, I am a cancer patient. I have intrusive and disturbing images of myself under the knife, losing my hair, feeling weak and alone and shut out twice (!) from a year abroad. I wondered where I would go through treatment. I assumed I would not know my biopsy results until we had already left and would be in the lower 48. Maybe we would pick up our recently purchased Honda Odyssey and drive it down to Denver. Instead of going backpacking and to amusement parks, I would use it to drive to and from Fitzsimmons where I would undergo radiation and chemo. 

The biopsy was scheduled for Monday, June 28th over my lunch hour. The surgeon is a pro and the procedure was straight forward and mostly pain free. “I hit a vessel, so you’re going to have some bruising and bleeding,” she told me. The nurse held pressure and put on a dressing. I payed and walked back to my office. Sitting at my desk, eating lunch, taking care of refills and calls, I looked down and realized that there was bright red blood soaking through from the dressing and dripping down my shirt. Shit! I rushed into one of my exam rooms, closed the door, quickly took off my shirt and bra, and tried to simultaneously hold pressure on by boob while washing the blood out of my shirt and bra. Usually, I would have had a spare scrub top or T-shirt, but as it was one day until I was done, I had already moved out of my office. I listened for Willow or Jessica and would have drawn them in if I heard either of their voices, but I didn’t. I desperately hoped that nobody else would come in the unlocked exam room. They would have forever been scarred by the image of me, topless and bleeding from my breast. After I had clumsily put together a dressing that I thought could handle a little bit of bleeding, I wrung out my half-rinsed bra and dripping but not bloody shirt and put them back on. I held pressure over the dressing for a moment, composed myself, said a small prayer that somehow the color of my shirt did not change that much in spots where it was wet, and walked out of the exam room. I test drove my situation by walking to the break room to re-heat my lunch. Nobody seemed to know. I closed my office door while I ate and held pressure for 10 more minutes. All afternoon, I worried that I would look down during a patient visit and see blood dripping down my shirt. Luckily, that did not happen. 

The next day, Tuesday, was my last day of work. In most jobs, as you approach the end, you wrap projects and become slowly less busy. In clinical medicine, though, you just keep seeing patients. So, like every other day, my last day in the office was a busy day of patient care. Well checks, colds, anxiety, hip pain. I ordered tests and X-rays that I would never see the results of. I wrote referrals to which I would never hear the answers. My partners will pick up where I left off with my patients: review their tests and read the consult reports. But only I know the decade of history. Only I know how certain families fit together or have fallen apart. All the details that don’t make it in the patient chart. There is a richness and breadth to so many of these relationships that I will never again grasp. 

I painted goodbye cards for my partners and friends

                                                                        

Hard to leave a rock star nurse! Miss you Jess!!

                                                                       

I did not expect to get results that fast. My heart jumped into my throat when I got an email that there was a new result available for me on MyChart through the hospital. I logged on and tried to clear my head and breathe and think positive thoughts while the screen slowly loaded. How would I handle the rest of the day, the next week, the next year if I were to read that I had cancer? I can’t imagine that I could finish out my last day of work with this new bombshell news. Could I get through the good-bye happy hour that was planned for me after work? Would I still get on a plane in two days? Would I continue moving out of my house? The screen loaded. Benign. Lots of other words. Polyglandular. Stromal hyperplasia. Mammillary papilloma. Fibrocystic changes. These are the words of busy breasts. So many words but the first one was the only one that mattered to me. It was an immediate weight lifted from my chest. It felt like I was finally given permission to embrace the joy and excitement of our impending adventure and departure. Huge sigh of relief. 

Biking home after my farewell happy hour. Last minute moving out of my office!

                                                                                

The garage packing scene was daunting

                                                                             

5 readers x 12 months = LOTS of books

                                                                        

The next 36 hours were a flurry of packing and cleaning and weighing bags. Annie, Dave, and Daisy moved in while we hurried to swiffer and sweep. We didn’t think we would meet our baggage limit, but in the end, we checked 10 almost 50lb bags. Our packing was initially organized and well-planned but ended with chaos and mad shoving loose ends like hair cutting scissors and algebra books into whatever bag was a little bit under weight. But we made it. As I write, we are soaring at 30,000ft above the mountain west on our way to Montana, our first stop on our family adventure. We have a van and hopefully a pop up camper waiting for us. We have plans, and we’d like to enjoy them. But we’ve learned from Covid that life is uncertain. We can be flexible and I’d like to think we are up for anything. We are together and I am going to do my best to be present for the ride. 

                                                                        

On our last night in AK we were serenaded by our besties.

The crew

                      Ten 50 lb bags for free! Thank you Alaska Airlines for your generous baggage policy!

Arriving at the starting line felt like a marathon. 

But there is sun on my face

 my partner is by my side

And there is beauty on the horizon.