Not-So-Secret #25: Well Dad, Well Baby

The last patient I saw on Friday was less than two pounds when she was born. Delivered 3.5 months early, she spent nearly that much time in the neonatal ICU, overcoming life threatening issues that preemies face- a bleed in her head, a gut that started to die off, lungs that were not ready to breathe air.

Now at 9 months old, she was nothing short of a miracle- already doing all the things that full term babies her age were doing, without the luxury of spending the third trimester inside.

Her dad brought her into clinic that day- I hadn’t seen him since visiting with the family early on in the NICU. As I marveled at all of her amazing accomplishments- eating solid foods; pulling to stand; saying mama and dada! I watched her dad force a smile.

“I can’t help but notice that you seem really quiet today- how are you feeling?” I asked.

Looking down at the ground, he told me that ever since his daughter came home from the NICU, he had been feeling worse than he had ever felt before- having headaches and chest pain nearly every day; not sleeping or eating; overwhelmed at work and at home. A week ago, he had such extreme chest pain that he went to the emergency room, thinking that he was having a heart attack. When all of the tests came back negative, the ER doc asked if the chest pain could be related to something else- stress at home? Anxiety? Depression?


He paused. “I didn’t even think that was even possible. But after she said that, all of this started to make sense…I felt this way when I was a kid. And I’m feeling it all again now, with mine.”

We talked some more. He had no thoughts of self harm or harm to others. He already made an appointment to see his primary care provider. He talked about it with his partner, and she supports him, 100 percent.

Postpartum depression is very real, and can happen in all parents, moms and dads. While feeling emotional after a child arrives is common, the symptoms of postpartum depression are more persistent and severe. Postpartum depression not only affects parents, but their children as well- feeding difficulties, language delay, behavioral issues- all can result from untreated parental depression and can have lasting effects.

There’s a lot we can do to help:

Recognize: All parents can suffer from postpartum depression. Symptoms may include: feelings of sadness or depressed mood; change in appetite; difficulty with sleep; feelings of worthlessness; loss of interest in activities; inability to bond with the baby. Postpartum depression can start from a few weeks up to a year after the baby is born. Remember, continuing to feel down after baby is born is not normal.

Ask: If you are concerned about a friend or family member, please ask. Your baby’s pediatrician will ask too: the Edinburgh Postnatal Depression Scale is a useful screen for postpartum depression that should be administered to parents at their child’s well visits in the first six months of life.

Support: Parents with postpartum depression do better when they are supported by their social network and their medical providers- offer it however you can.



Earls MF, Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032–1039

Not-So-Secret #28: You Can Save A Life

June 1-7th is National CPR and AED Awareness Week— a great reminder that you can save a life with CPR.

Cardiac arrest is a leading cause of death in the US. Timely CPR can double or triple the survival rate from cardiac arrest. In the community AND in the medical setting, high quality, effective CPR is the key to a successful resuscitation.

Hands- Only CPR is CPR with compressions only, and in the community, it has been shown to be as effective as conventional CPR. If you see an adolescent or adult suddenly collapse, there are 2 simple steps to follow:

– Call 911

– Push hard and fast in the center of the chest

You should push hard and fast at a rate of 100-120 beats per minute. When I teach CPR in the hospital, we tell students do compressions to a song like “Stayin’ Alive” by the Bee Gees, but there are a lot of other songs to CPR to that may suit your fancy:

– “Fly” by Nicki Minaj
– “Float On” by Modest Mouse
– “One Touch” by LCD Soundsystem
– “I Will Survive” by Gloria Gaynor

(“Stayin’ Alive” and “I Will Survive” seem particularly appropriate, don’t you think?)

Learn more at the American Heart Association website:

And remember- You can do it! #CPRsaveslives


Not-So-Secret Secret #57: I Worry About My Patients

First it was the 9 month old losing weight. Then it was the family who suddenly became homeless and had nowhere to go. By the end of the week, it was the boy whose mom was being deported.

My thoughts often turn to my patients. Will the baby get enough to eat? Where is that family sleeping tonight? Will that little boy, a boy who is the same age as my son, ever get to see his mama again?

Sometimes I can’t help but worry.  Food security. Affordable housing. Immigration policy. These are not just concepts for political debate— this is a hungry child, too hungry to concentrate at school; a new mom and her baby with no place to live; a preschooler whose parent is suddenly far away, in a place he has never seen or will ever know. I cannot ignore that all of this affects people that I’m connected to.  These are children and families that I care about, and in the face of these big issues, I feel small.

So I do what I can. I take time with the families I am privileged to care for. I give my patients full attention. I listen with an open heart and work to understand. I offer guidance however I can. I support however I can.

Sometimes that is all I can do. And it’s a good start.


Not-So-Secret Secret #43: Let It Land: Great For Gratitude (Not So Good For Dodgeball)

Mother’s Day and Dodgeball made me think about writing this blog post. First, a belated word on Mother’s Day: It was lovely. A day filled with sweet gestures and thanks. But in my typical self-effacing fashion, I spent much of it deflecting the appreciation:

Thanks for everything you do! Don’t worry about it. Your family is lucky to have you! It’s no problem. And from my son: Thank you for having me! What, only 5 hours of pushing when I couldn’t feel my legs? It’s no big deal.

I realize that my usual way of dealing with gratitude is a lot like the way my kid plays dodgeball. How so? My son, when he plays dodgeball, he absolutely loves to dodge. And that’s pretty much it. There’s no throwing and certainly no catching, just getting out of the way. And that’s exactly what I do with thanks: dodge at all costs. You thank me for helping you with a project? I’ll shimmy to the right! Praise me for a job well done? I’ll dive roll to the side! If you’re a patient and you thank me for caring, I’ll pull out a big move– maybe even do a super-jump flying split to avoid those kind words (I saw my son do that move during a game and it was impressive).

It feels immodest to accept praise. And I question if I really deserve it– part of me feels like I can always do better. But in all my dodging and deflection, I don’t allow myself validation– to realize the meaning of what I do, and genuinely feel good about it.

So I’m trying something new– I’m letting it land. Letting gratitude land. I’m moving away from my dodgeball strategy and allowing myself to be noticed, and opening up to appreciation. If you’re a dodger like me, this isn’t easy, but a simple “thank you” is a great place to begin.

Let me know if this works for you.


Not-So-Secret Secret #64: Work-Life Balance Is Not a Perfect…Balance

This past week my husband was away in Singapore for work. Without him around to help steer, the family ship went a little off course– there were more mac and cheese dinners and late bedtimes than I care to admit. And dessert. And screen time. In fact, I think my son had the most consecutive screen time ever under my watch– 5 hours of straight up sedentary, eyes glazed over, uninterrupted movie viewing.

As a family, we are already pretty lean when it comes to child care. And, not to make excuses, with a full time work schedule and no other resources up my sleeve, I did resort to screen-as-babysitter on that Saturday, as I did my best to finish up notes, make calls, do reading, see patients, and keep an eye on my kid on the tablet. Thank goodness The Lego Movie is still awesome on third (and a half) viewing.

I wonder if I could have done this differently. Maybe I should have tried harder to find someone to cover clinic for me so I could spend time with my son. Or pushed myself to finish all my notes during the day, in between seeing patients. Or maybe I should have prepped for teaching while the kiddo was asleep, instead of watching old episodes of Flight of the Conchords over (and over) again.  But would that be better? Would I be a happier person; a more present doctor; and a more loving mother? I am not sure about that.

For me, work-life balance is about understanding that I am making a choice about my family and work, and accepting the decisions that I make. It’s not about knocking myself down when things don’t go quite as planned, but allowing myself to feel good when things go right (I see lots of patients AND get my kid to school dressed in non-pajamas- yay). It’s knowing that quality time with my family can be little things- the sweet conversations in the car, laughs over dinner, a good book shared together.  And realizing that self-care doesn’t have to be profound journal writing, massages or morning meditation- if it’s watching Jemaine Clement sing “Bret You’ve Got It Goin’ On” for the millionth time, so be it.

I’m becoming okay with the work-life balance that I’ve struck as a working mom, and I hope you are too.


Secret #74 There’s A Wild Child In All Of Us

I loved Lena’s last post! I too have cried at work, and I didn’t even have a good reason. There are just days when the tears need to come, and I am forever grateful for the understanding souls I work with who hold space for me to have my moment. That is the greatest gift I have been given, and one I hope to give to my colleagues and my patients.


A few days ago as I was playing with my 5 year old niece, she confidently sat down in the middle of an ant hill. I looked at her beautiful flowered dress and bare legs and tried to get her to stand up. She resisted, insisting that her friends, the black ants, didn’t bite and that it was okay for her to be in their midst.

“The ants are just running around because they are afraid of you!” She explained. They crawled over her legs and arms, while she gently reassured them that I was not a monster, but a new friend. Each one was named Claudia, she explained to me. They all looked the same, so they had the same name.

I marveled at her confidence and comfort in the dirt and compared it to my immediate desire to get her up so she wouldn’t muss her dress. “What has happened to me?” I thought. I used to be the kid that couldn’t stay clean, and now I have morphed into the clean dress enforcer.

I spend a lot of time in my clinic talking to parents about the need to get their kids outside. In our hectic, scheduled days, we have lost the time to spend endless hours and afternoons in the sunshine. Neighborhood parks are often so far away we need to drive to them, and parents are reluctant to let kids be outside by themselves. Free range parenting has become controversial.

What are we losing with this change in lifestyle?

A lot, actually.

A recent study in Asian children showed that adding an hour of outdoor playtime a day drastically reduced the incidence of myopia in kids. Meaning your mom was right! Staring at a TV screen all day will break your eyes. Going outside can actually fix them (or at least make it much less likely that you’ll need glasses)!

In his book, Nature Deficit Disorder, Richard Louv draws the connection between depression, adhd, and obesity to our disconnection from nature and the drastic reduction in outside play time. Rather than looking at too much screen time or too many classes, Dr. Louv points out that the problem is too little time outside for unstructured play. This loss of connection with the deep truth that each of us is part of an ecosystem with a myriad of miracles around us at any given moment is the root of dissatisfaction. How can we be happy when we don’t understand where we fit in the world?

I do not think this problem is just in kids. When I spend less time outside, I lose my way. My priority is in getting the next cup of coffee, sending my next email, finishing my next chart. Each of these tasks becomes a goal that I pursue with single-minded intensity. I am very good at completing them. As I trained to become a pediatrician, I thought that my close association with people, bearing witness to their struggle with illness and in health, would provide the perspective to keep me grounded. Somewhere along the way, as I sat with families in fluorescently lighted hospital hallways, I realized it was not enough.

When I spend time away from nature, I lose my ability to create perspective. Each small task becomes the next most important thing, and I stop paying attention to what really matters.

I miss out on the joy of sitting down amidst a hundred new tiny friends and calmly introducing them to a new friendly giant.

Not-So-Secret Secret #68: Doctors Cry Sometimes Too.

My baby was a crier. In the first months of his life, there were days when the crying felt endless- hour after hour of red in the face, screaming and bawling and breathlessness, hair and clothes soaked with tears. No amount of nursing or holding or diaper changes or naps ever seemed to do the trick. 

My clinical self knew about the newborn cry curve, that the amount and intensity of newborn crying naturally increases in the first weeks of life, and gradually decreases by 3 months of life. I tried to reassure myself. This is normal and healthy.

But my emotional self was a different story– I felt, well… sad. As if I was doing everything wrong, that I was failing him. I was doing a bad job and somehow he was telling me that.

A particularly harrowing day my guy cried for nearly 4 hours straight. We tried to go for a car ride (he was not having that car seat); I tried to nurse and cuddle and hug. I read somewhere that turning the lights off and on may do the trick…our house looked like a makeshift disco, but apparently my baby was in a crying mood, not a dancing mood.

He cried himself to sleep that night, and between the overnight nursings, my tossing and turning and worrying and (my) crying, I got 2 hours of sleep before it was time to get up again. Somehow I got it together enough drop my child off at daycare and head into work to see a full day’s worth of clinic patients.

I tried hard to put on a good face for my families– they have concerns of their own, they don’t need to be bothered with mine, I reasoned.

My last patient of the day was a babe about the same age as my son. She was her mom’s first baby. Her mom looked exhausted, just like me. As her mom began to apologize for being late– the babe had been crying all night and day and they tried their best to get here on time but they are just so tired– I felt my long held back tears rolling down my face. Thoughts of my crying baby, my sleepless nights, my feelings of self doubt again filled my head. I couldn’t control the emotions any longer.

I cried for a while in that exam room, face buried in my hands, trying desperately to put every tear back from where it came. I was ashamed that I had broken down at work. Between the tears, I stammered out my own apology: “I’m so sorry, I don’t know what happened, I guess it’s been a long day, my baby didn’t sleep either, I…”

I looked across the room to see the kindest face looking back at me.

“Being a mom is hard, isn’t it?” She knew.

Many tears and tissues later, we finished the visit. The babe was wonderful and healthy– her mom was happy to hear that. Before they left, the babe’s mom said, “Dr. Kuo, we’ll get through this together, right?”

Right– together.


Not-So-Secret Secret #17: There’s a Good Reason Why Your Doctor is Late.

I hate being late. I’m the one at the airport two hours before the flight (more time to stretch my legs before taking off!). I’m the first person to come to the party (and if I’m way too early, I’ll wait in the car until I’m just a little early).

Same goes when I am in clinic. I want to be on time to see you. I want to address your concerns in a thorough and timely manner. I respect your time. So when I show up in the exam room after your appointment time, what just happened there?

I thought a lot about this today. I was pretty late for my last patient—almost by a half an hour, sorry to say. Where did the time go? The minutes and hours were filled with urgent phone calls with other providers and patients; visits that needed more time than we had; concerns that needed attention sooner rather than later– on top of an already full schedule. Here’s a snippet:

7:40 am: Get to work after dropping the kiddo off at preschool.  My first patient is not until 8:20, and I like to start early and set myself up for success– organize my desk, listen to my voicemail, clean my stethoscope, look at my schedule, turn on KEXP. (John in the Morning is the perfect soundtrack for a good day.)

8:05 am: Just started to look at the chart of a complicated patient scheduled later today when I get a call– it’s a psychiatrist I have been playing phone tag with for the past 2 weeks.  I have to answer this. I put my chart review on hold.

8:40 am: Still on the phone with the psychiatrist when my medical assistant knocks on the office door. My 8:20 patient just arrived. She’s already 20 minutes late, and with the additional 10 minutes it’ll take to get her vitals, I’ll be 30 minutes late (and my day hasn’t even started!). I agree to see her– she took 2 buses to get to clinic and doesn’t have any other free time to bring her kiddo to the office.

9:05 am:  Finishing up with my first patient– thankfully the visit was relatively uncomplicated, giving me some time to catch up and see my 8:40 patient, not too late.

9:10 am: While I am in the exam room, my pager goes off. I glance at the message while pulling up the growth chart for the little one here for her well visit. Looks like an urgent lab result for a patient I saw in the nursery over the weekend. The babe was still working on feeding, and her bilirubin level was just on the cusp of being too high. Should I answer the page right now or finish up with my visit? I decide to finish up with my current visit first—hopefully the lab tech will stay close to the phone for the next few minutes.

9:17 am: Out of the exam room, placing orders for vaccines for one patient while calling back the lab about another patient. The baby from the weekend has jaundice and needs to be hospitalized. The family is primarily Spanish speaking, so I’ll need to call a phone translator first in order to explain the lab results and the need for hospitalization to the family. My 9 am patient is already roomed and ready to go. It’s one of my patients with chronic complex medical needs. I really need our time together to be uninterrupted, so I ask the nurse to complete all of the routine screenings before I am in the room—this will be more efficient for the visit, and also buy me some time so I can admit the baby to the hospital.

9:32 am: On a phone call with the Spanish interpreter, the baby’s mom, hospital admitting, the hospitalist team, and myself. Mom has a great understanding of what is going on with the baby and agrees with the need for admission. The RN pops into my office– all of the screenings are done for my patient here in the clinic, and the vaccines have been consented to and done as well. I give my nurse a thumbs up and quickly glance at the clock. It’s more than 30 minutes past my patient’s appointment time, and still I have to finish the admission, and then see my clinic patient who is here. On top of that, the 2 cups of coffee I had this morning are coming back to haunt me—I have to pee. Really badly. We don’t have a staff bathroom in the clinic (it’s for patients only), which means I have to go to the other side of the building to empty my bladder. Time wise, this translates to 5 minutes of walking, 5 minutes of pee-ing, and another 5 minutes of walking. That’s 15 minutes that I don’t have right now. I guess my urinary needs have to wait—maybe I should schedule voiding time at the end of the day??

So what does all of this mean, for you as a patient? First of all, I hope my little schedule expose helps you realize that there is probably good intention behind why your provider is late. We are trying our darndest to address everyone’s needs. Secondly, I hope this glimpse into a busy day helps you find ways to get your medical needs addressed in an efficient yet thorough manner. Here are a few of my thoughts:

Schedule medical appointments at the start of the day or right after lunch: Unless an emergency crops up, you are likely to be seen right away.

Come to your appointment on time:  Or better yet, come early. In a busy practice, every step of the process takes time, and every bit of time counts. We ask our patients to come 10-15 minutes early- that way, all the necessary registration, paperwork, and rooming (which usually includes taking vitals, growth measurements, and answering historical questions) is done before the actual scheduled time.

Find ways other than an appointment to get your medical needs met:  In the era of internet connectivity, many providers have the capability of communicating with their patients via email or electronic messaging. Ask your provider about it. Oftentimes I find that this a great way to communicate about non-urgent needs. I can also let my patients know if I think an appointment is needed.

Come to your appointment organized:  I love lists. When patients make lists of questions, then I feel confident that we are addressing the most pressing issues.

Talk to your provider:  Let him or her know your concerns. We care about you, and we want to make things better.


Not-So-Secret Secret #41 Take good care of yourself.

Whether in doctoring or parenting, we all need to take good care of ourselves in order to have the capacity to show up to our own lives. That might mean trying to find time to sleep and exercise with a new baby in the house, or finding time to eat when you are on a 30 hour shift at the hospital as an intern.  In stressful times, it can be easy to feel overwhelmed by life.
When the back of my neck starts to hurt, and my heart rate picks up, I think back to the last time I slept for more than 6 hours, or went for a run. At 40 years old, I have learned to think a bit before I put my hand in the candy jar, and instead of getting a cup of coffee, I occasionally try to walk outside for a few minutes instead.  Don’t worry, I hit up the candy jar and coffee pot on a regular basis too, but I’m trying to pay attention to what helps me feel better for an hour or a day, not what distracts me from reality for a few seconds.

So…tips for new parents (and all of us)
-Ask your friends for help. Especially with a newborn, it is easy to feel overwhelmed and alone with a new soul needing you, your boob, and your attention. So call in your friends and family to come over and do your laundry, vacuum your house, take you on a walk, or hold your baby while you take a shower.
-Make a short list of things that calm you and bring you joy. For me, it is five minutes sitting in the sun, a 20 minute yoga practice, and sleep. Find a way to do those things. It will often require asking for help.
-Wash your hands. All of the time. It will keep you and your baby healthy which will allow much more time for all of the above. As a doctor, I wash my hands religiously at work. I don’t get sick from working in clinic, but bring a toddler to my house and I will be sniffling in a few days. All those loves and slobbery toys get me sick every time. I can’t say it enough. Handwashing!
-Feel the love. Make a list of the people you can count on. Family, friends, husband, colleagues. Bring those people to mind when you feel overwhelmed. Call them.
-Read about post partum depression. Having a baby is hard on both parents. And the horomone roller coaster as your body recovers from birth can be a wild ride. Your pediatrician and obstetrician will have the information about local resources and support groups. Postpartum International at is also a good place to find support.


Not-So-Secret Secret #52: Breastfeeding is Hard Work.

I’m just coming off a weekend working in the newborn nursery, and these days there’s a lot of talk about breastfeeding. My hospital is in the process of becoming “Baby Friendly”, which means that the medical center is taking big steps to encourage the best way to feed that little one– with breast milk.

And it make good sense– the “delivery system” is built into us mamas; the nutrition is optimal (human milk for human babes, right?); and through antibodies in breast milk, babies get protection from certain diseases that they can’t build on their own just yet.

Now, don’t get me wrong– breastfeeding is awesome and I’ll be the first one to jump in and say that. But in all of our talk about the virtues of nursing, we often neglect to mention just how HARD it really is. It takes practice. And commitment. And it’s painful. Learning to breastfeed was harder than taking my medical boards. Really.

When I was pregnant with my little guy, I thought that breastfeeding would be a snap– moms have been doing this for centuries, right? Babies have built in reflexes to make them eat– what could possibly be hard about it? It would be like in the movies (if there were movies about nursing)– I would deliver my newborn (sans pain medication of course); within minutes he would immediately latch on; I would magically have gallons of colostrum. And all of this would happen with a warm glow of sunlight shining behind both of us– a halo, if you will. And my hair would not be messed up.

But what really went down was this: I was in active labor for 3 days (no kidding); I pushed for 5 hours (no kidding). I had to have a C-section and went on to have a postpartum hemorrhage with a uterine clot that had to be manually extracted (again, no kidding). So needless to say, there was no immediate latch, there was no magical let down, and there was no shining sunlight– I was in an operating room in Portland in the fall, for Pete’s sake. And most certainly, my hair was seriously messed up.

What I did have was an amazing nursery nurse who made it her priority to get that kid on the boob, in the recovery room no less, and even when I felt too tired and worn out to do anything. (I had the chance to watch her in action with a mom and baby this weekend, and she has mad skills!). My great husband kept us on track with the nursing schedule and kept ME on track with my own eating schedule. My lactation consultant’s constant support helped me realize we were doing a good job even when I felt like we weren’t. To me, this is what “Baby Friendly” means– in whatever way possible, supporting moms and babes through the feeding tough patches in order to ensure long term success.

A few tips to get things off to a good start:

— Breastfeed early and often. Having the baby latch on in the first hour after delivery, while he or she is still awake and active, is the first step to establishing nursing. Feeding often, up to 8-12 times a day, not only helps establish milk supply, but also helps mamas read hunger cues better.

— Lactation consultants are your best friends. They are there to help you make good decisions about feeding, and are often a part of a nursery care team. Definitely take advantage of their amazing knowledge and skills.

— Ask for help, and take it whenever and however you can get it. If having your father-in-law do a Target run buys you some time to rest between feedings, so be it. More support for the cause!

— Resist the urge to offer the bottle early on. Breast feeding is all about supply and demand– once the demand (the baby) is gone, the supply dwindles as well. Protect that supply!

— Pumping can help build and maintain supply. After the first couple of weeks, starting a pumping schedule can help establish a stash of milk and also increase demand by a little bit. Remember, when you first start out pumping, you may not get very much out– this doesn’t mean that your not making milk. Rather, your body has to make more supply to keep up with the new demand (pumping). So, more milk down the line.

— Be good to yourself. Eat well, laugh a lot, snuggle with that baby. And remember, no matter what happens, if you are trying to breast feed, you are doing a good job already.

— Lena