Thursday, May 30, 2013

Size matters.

So I recently came upon this post discussing the existence of weight-related bias in the medical profession, and was...sadly, not terribly surprised. In medical school alone, I've seen countless instances of body-shaming and downright hatefulness related to people's (usually patients') size, including a discussion of childhood obesity that somehow devolved--while led by an attending physician I otherwise greatly admire--into a youtube-comments-worthy, riffing free-for-all on the themes of "Why can't fat people just not eat fatty fat all day," "God, why are fat people so gross?" and "If they weren't so lazy and would just exercise..." Interestingly, now that I think about it, my medical school class of 125 had...5 people I can think of who might qualify as 'obese' (ie, BMI >30, which is totally arbitrary, but whatever). That's 4% of my class, as opposed to 36% of Americans as a whole. Not drawing any conclusions (cough, education and socioeconomic status, cough) just...thinking.

 It was around the time that someone suggested drawing attention to a child's obesity at every single office visit (to 'inspire them to change,' of course) that I started getting truly angry. I stuck my hand in the air.
"Don't you think," I said, "That's somewhat shaming for the kid? Don't you think it's overdoing it to mention size not just once a year at physicals but during every visit for every runny nose and earache? Don't you think these kids are already aware that they're fat? Don't you think their peers already remind them every day?"
"Well, if shame acts as a motivator..." Her voice trailed off and she smiled.
"No," I said, "Shame is an awful motivator. Shame doesn't lead to healthy changes. Ok, I hear you, more than a third of American youth are overweight or obese. But you know what? Between a quarter and a half of young women in the USA have disordered eating patterns--or outright eating disorders--that put them at much greater physical and emotional risk. And do you know what drives eating disorders? Shame."
And then I sat down and tried not to look at anyone, because I could tell my voice had gotten a little growl-y at the end and I didn't want to be known as 'the girl who flipped her shit during that obesity talk'...but it was already too late. In hindsight, I'm kind of proud of it.

College was a rough time for me, body-wise. I started college weighing 170 lbs, which for my height put me--just barely--in the 'obese' BMI category (the vagaries and vicissitudes of BMI is a topic for a whole different post). I also had some rip-roaring bulimia going on, for which I sought help at the Student Health Center. However, because of my weight, my eating disorder wasn't deemed 'serious.' It wasn't until it morphed from bulimia to anorexia, and I dropped 70 lbs in the space of a year, that I was suddenly granted the label of someone with a 'real' eating disorder. I remember very distinctly coming back to school August of my sophomore year and seeing my physician at Student Health for the first time in several months. At the time I was in the low-normal BMI range, and creeping ever-downward.
"Look," she said to me, suddenly very stern, "You're at a normal weight now. A little low, even. You can stop doing this now."
As if everything that had come before had been legitimized. As if it were OK to starve myself and purge and overexercise while I was "overweight" (because everyone knows fat people can't have 'real' eating disorders). As if an iffy weight-loss technique suddenly became pathological when I crossed that magical line of 'healthy' BMI. As if self-loathing and body hatred and abject despair over what I saw in the mirror were totally fine, even expected--as long as I was fat.

I've heard doctors mock their obese patients in private, and I've heard them rake patients over the coals for their weight face-to-face (mostly the former, thank God--for the patients' sake). Which is sad, really, for a lot of reasons--but primarily because doctors are DOCTORS--professionals with a duty to do no harm and provide the best possible care, which doesn't include shaming. Shame, as mentioned previously, is a terrible motivator. How on earth is telling someone that their body is ugly and disgusting and unacceptable supposed to motivate them to take care of it? People don't take care of things they hate.

I'm not saying physicians shouldn't discuss weight with their patients--far from it. There are certain health problems that are more common among overweight/obese folks, and losing weight can sometimes help clear them up. It would be foolish at best and malpractice at worst not to tell an overweight patient with PCOS that losing weight could help her improve her fertility. The same goes for patients with diabetes, or osteoarthritis, or high blood pressure. However, focusing on weight as the sole metric of a person's health is not only myopic, it can be counterproductive. There are numerous studies that indicate focusing on behaviors instead--increasing intake of produce and whole grains, getting more exercise, reducing stress--is more effective in improving outcomes.

Para ejemplo: a relative of mine makes occasional attempts to lose weight. He's what would be called, somewhat melodramatically, 'morbidly obese.' It all starts well--he'll begin eating more fruits and vegetables, checking his portion sizes, and getting more exercise. For a few weeks, or even months, this 'works,' in that he loses weight. He starts feeling more energetic and less depressed. Then the numbers on the scale plateau, and because that's the only thing he and his doctor focus on (rather than how his new regimen makes him feel, rather than the fact that his blood sugar and blood pressure are improving, rather than the fact that his stamina has grown by leaps and bounds), he gets discouraged and impatient...and he stops. What was an opportunity for him to feel stronger, healthier and happier gets derailed because people (himself included--it's hard not to do as 50-odd years of socialization have trained you) are only looking at the numbers.

People aren't numbers. They're people.

Friday, May 24, 2013

Things Medical School Has Taught Me

Sorry for the long interlude without a post--things have been busy, what with the graduating and commencementing. And now that med school is all over, and I is officially a doctor, I thought I'd post a few of the things I've learned in the last five years--some technical in nature, some more to do with matters of the heart. A quick run-down, in no particular order.

1. To quote an anesthesiologist colleague, "It's pretty hard to kill a breathing patient." That's why the ACLS algorithm (Advanced Cardiac Life Support, for those wondering about the abbreviation--don't feel bad, I had to look it up myself) goes Airway, Breathing, Circulation. I don't know why, but I find this oddly comforting--as long as they're breathing, and you keep them breathing, things are (relatively speaking) pretty good. Which leads into our next point--

2. What doctors mean when they say someone's "sick" and what everyone else means are COMPLETELY different--and it varies a little bit from specialty to specialty. From what I've gathered from ER and surgery/trauma folk, their "sick" means "this person is going to die within the next hour unless someone does something." Internal medicine folk are a little more liberal with it, and as long as someone's basically OK at baseline (ie, doesn't have kidney failure, heart failure, diabetes, AND hypertension), someone can have a pretty gnarly pneumonia or acute liver failure and still not be "sick." Psychiatrists' "sick" has more to do with whether someone's talking to people who aren't there and smearing feces on walls.

3. Speaking of feces. One of the main things I learned during my time on labor and delivery is that, while childbirth is a beautiful, natural, ethereal experience in theory, in practice there is a lot of grunting and screaming and, now that I think about it, literally every secretion the female body is capable of producing. This is not a soft-filter Lifetime Very Special Event with gentle lilting flute music in the background. There is sweat and blood and vomit and feces and don't even get me started on meconium. And there's nothing wrong with that, because pushing another human being out of your body is miraculously awesome and I think entitles you to do pretty much whatever while it's happening. It also taught me that, while I do want kids, I think I probably want my wife to have them, or that if I do any child bearing, I want an epidural early (like, the beginning of the third trimester would be nice).

4. Also from my time in OB/Gyn land: lots of women are allergic to something in Always pads, and Kotex (or another non-Always brand) will often work better, and by 'better' I mean 'not cause a painful, itchy rash in the lady regions.' Also, there is no reason to douche, ever, and most of the products sold for 'feminine refreshment' (I don't understand--does my vagina want a glass of lemonade?) actually make things worse by mucking up the natural pH balance and allowing yeasts, unhealthy bacteria and other interlopers to set up shop. I don't completely understand why anyone thinks women's bodies are supposed to smell like a summer's eve or a spring morning or a dog day afternoon, but they aren't. If things are getting kind of...malodorous in the region, you don't need to be spraying Febreze down there, you need to go to the doctor. If things smell just fine, you don't need to be fancying things up with new car smell anyway.

5. As for psychiatry, I've learned a ton, but the most interesting is that ECT is actually not a scary, mediaeval procedure. In fact, it's one of the safest and most effective procedures in all of medicine, especially for people who are seriously depressed and who need a quick response to treatment. For out of control psychosis, Haldol can be like a magical elixir. For folks with dementia, unfortunately, medications like Namenda and Aricept do virtually nothing. Also: for people with pretty much any mood or anxiety disorder, a companion animal (in conjunction with an SSRI or mood stabilizer, of course) can be just what the doctor ordered. If my cat hadn't come to me with a name, I probably would have named her Zoloft--Zoe for short, of course.

6. To quote an internal medicine colleague, "Often the shortest road between despair and hope is a good night's sleep." This is true not just for overworked, hyper-stressed interns and medical students, but for everyone.

7. Drinking caffeine in little bits throughout the day is more effective at keeping you awake and functional than chugging a large coffee all in one go. Eating a little protein snack will also help you stay alert. Avoid processed carbs like the plague. At least for me, a bag of Cheez-Its from the vending machine might as well be cheddar-flavored Ambien.

8. Never pass up a chance to eat, sleep or pee. It may not come again for a while. As for sleep, I learned during my surgery rotation that it is most definitely possible to fall asleep standing up--and during rounds, no less. In fact, it's probably easier than falling asleep in a call room bed (which is often only a bed in the loosest possible sense of the word). I'm sorry to disappoint all you Grey's Anatomy fans, but call rooms are approximately as romantic as that Motel 6 out by the highway, with the added possibility that someone could come in the door at any moment. I can't imagine anyone ever having sex there. Then again, I can't imagine anyone having sex in a hospital room, but I've definitely heard of patients who have managed it.

9. On a more serious note, it's OK to cry with patients sometimes. It's OK to cry with colleagues sometimes. And sometimes it's OK to find the nearest bathroom, lock yourself in a stall and have a good sob. I've done all of these things, and from what I've gathered, so have a lot of other doctors (especially the crying in the bathroom).

10. Everyone wants to feel heard and to feel validated. "Tell me more about that," "I can understand why you feel that way," and "I hear what you're saying" will almost never go amiss. This isn't only true for patients--it works with families, with other healthcare professionals, hell, even with yourself.

Wednesday, May 08, 2013

Things that Piss Me Off, Part...Whatever

Well, it looks like it's time for another installment of TTPMO.

Number one, the word 'feminazi.' I thought it was just a Rush Limbaughism, and didn't imagine that any reasonable, non-MRA person would use it (the MRA is a whole different bag of crazy to be addressed in a different post, because I could go on for days and gurl, who has time?). However, in recent weeks I've heard several people use it--including some people I previously regarded as sane--and was all like, what the ENTIRE f*ck? Here's the deal. I'd like it if women could be paid the same as men are for doing the same work. I'd like it if the legislative bodies in this country were actually representative of the people they, y'know, represent (that means 50% ladies and 28% minorities--a far cry from what we have now). I'd like it if women could have access to safe, legal medical procedures without de jure and de facto interference. I'd like not to live in a culture where 1 in 4 women are sexually assaulted. I'd like not to live in a culture where more than half of teenage girls are fasting, overexercising, vomiting or using laxatives to lose weight. This list of 'demands' is SO OBVIOUSLY equivalent to enacting a plan for world domination through brute military force, including the denigration of broad swaths of humanity as 'sub-human' and the murder of more than 12 million men, women and children. See how those two are totally alike, you guys? Oh, wait, NO.Those aren't apples and oranges; they're dental floss and Siberian tigers. As a feminist and a person of Jewish ancestry, just the word 'feminazi' pisses me off in no fewer than seventeen different ways. Knock it off, plz.

 The Paleo diet craze. Hey, guess what? You know the foods that make up the majority of the 'Paleo Diet'--veggies like asparagus, avocado, eggplant, and tomatoes, or that grass-fed beef? Cavemen--sorry, cavePEOPLE, cavefolk, whatever--didn't have any of that, at least not in the form we know now. The idea that eating grain or dairy is a bad call because our bodies haven't had time to 'adapt' to it is BS too. You know what made us the species we are today, with our big brains and machines and iPads? The fact that we figured out the whole agriculture thing, and along with it, began selectively breeding wild varieties of plants and animals to make bigger, stronger, tastier varieties that were easier to harvest. We made aurochs into cows and wild grasses into the wheat we know today. Actually, domesticating wheat was kind of a big deal.  Wheat enabled the development of city-states in the Fertile Crescent (commonly known as the birthplace of civilization) by being easy to grow in quantity, and easy to store. If you hate on wheat for no good reason (ie, without celiac disease or something), you are saying you hate civilization as a whole. Why do you hate civilization?
I don't really get the Paleo nostalgia anyway. It seems like a throwback to the Iron John/primal scream days of the 70s. Cavefolk didn't live very long--the average Cro-Magnon's life expectancy was 30, on account of the mammoth-gorings and semi-starvation and Paleosyphilis, which is like regular syphilis only bigger and with tusks. The women were squeezing out little ones (Honey, which name do you like best? Ugg, Ogg or Madisynn?) until they died in childbirth or dropped of exhaustion. So did Cro-Magnons get heart disease? No, something else generally killed them first. If you want to eat a ton of veggies and fruits and lean meats, go nuts, but realize that you're probably going to miss those complex carbohydrates when the time comes to hit the CrossFit box.

Somewhat relatedly, the anti-gluten business makes me nuts. Yes, there are people who can't/shouldn't have gluten in their diets--they have celiac disease, and gluten literally makes them sick (an overzealous immune response damages their intestinal lining in response to gluten). How common is celiac disease, and other medically recognized forms of gluten sensitivity? Less than 1% of Americans suffer from it. Yet a recent survey showed 30% of Americans are trying to "avoid/cut back on" gluten. First of all, if you genuinely believe you have celiac disease, YOU CAN'T JUST 'CUT BACK.' THAT'S NOT HOW THIS S$%@ WORKS. I have a friend with legit, diagnosed-by-biopsy celiac disease, and if she eats a salad that has had croutons on it--even if she picks them off--girlfriend gets sick. If I sound annoyed, it's nothing to the anger L can summon for gluten-avoidance dilettantes.
"I feel like most of the time it's just a weight-loss thing to them," she says. "When they're on the wagon, they avoid bread and whatever, and say really self-righteously, 'Oh, I can't, I'm gluten-free,' but if there's pizza or pasta and it looks divine and they really want it, they dig right in, and for the next thirty minutes gluten-free goes out the window. I can't do that. Screw them, seriously. And then at restaurants when I say I need to know if the food is gluten-free, waiters assume a little gluten is OK because they think I'm one of those asshats, and then I have diarrhea and stomach cramps for a week. Screw them so hard."

 Leaving aside L's anger, I'd say the 29% of folks who are trying to go gluten-free and don't have celiac are doing it either for weight loss/to cover up some sort of eating pathology (I've known quite a few people with eating disorders who hid behind the gluten-free thing, which seems to be the newest iteration of the vegetarian/vegan 'excuse' a lot of ED patients used during the 90s and early 2000s), because there's a sort of social cache in doing it (Gwyneth Paltrow is gluten-free! Ditto Miranda Kerr and Victoria Beckham! PS--None of these women, as far as I've been able to find, suffer from celiac disease, and have all received attention for what might be termed 'extreme dieting behaviors.' See what I meant about the eating pathology thing?), or out of some misguided idea that it's "healthier." Sure, eating your way through an entire baguette and a dozen cookies every day isn't particularly good for you--but that's a refined flour and sugar issue, not a gluten issue.

 I don't know, it just smacks of a particular brand of bougie food-purity snobbery to me. It reminds me of a woman I saw once at the health-food coop in Ithaca. She was standing in front of me in the bakery, examining the vegan baked goods. I was waiting on a vegan cupcake, salivating at the very thought, and wishing she'd hurry up. "Excuse me," she called shrilly to the bakery attendant. "Those chocolate cupcakes--they're vegan and gluten free, but are they organic?"
"Those aren't," the attendant said apologetically, "But like you said, they are completely vegan and--"
"WHAT is the POINT if they're not ORGANIC?" The woman half-wailed, half-yelled.
Then she swooped out and I got my cupcake, so whatevs, but Jesus tap-dancing Christ, woman--pull your head out of your patchouli-scented, tightly-clenched ass and eat a damn cupcake.

Here ends the ranting.

Thursday, May 02, 2013

Oh Sh*t...I'm Racist.

So, intersectional feminism for the win. I've recently felt...called to start doing some anti-racism work both within myself and within the city I live in. Now, when I started (ie, when I picked up a ginormous training manual and supplemental readings for Dismantling Racism training from one of the women in my church who has done a lot more work on this issue), I thought, "Oh, f'sho, this'll be easy...after all, I'm totally not racist."

Yeah, except no.

Then I read Peggy McIntosh's ovaric (it's a feminist equivalent of seminal--deal) article White Privilege: Unpacking the Invisible Knapsack, and it Changed. My. Freaking. Life. Reading it was like having Angela Davis and Gloria Steinem spin-kick down the door to my soul. It draws parallels between feminist work (uncovering and combating male privilege), with which I am intimately familiar, and anti-racist work (uncovering and combating white privilege), with which I am less so. I'd heard the term 'white privilege' before, of course, but I'd never thought deeply about it.

 See, I'm conscious of the fact that being white in the USA in 2013 still confers advantages on me that people of color don't enjoy, not least the fact that I don't have to think about race if I don't want to. After all, I'm white, what is regarded in the USA as the 'default' race in much the same way as male is thought of as the 'default' gender. It renders my race invisible to me: I don't have to self-identify specifically as white because in the majority of spaces in which I find myself, I am read as a person, or a woman--not specifically as a white woman. This is not something that can be said for people of color. To quote a bit from McIntosh's article, I was taught to see racism only in individual acts of meanness, not in invisible systems conferring dominance on my group. Privilege accrues in big ways--there are still parts of the Deep South I wouldn't like to drive through if I were African-American, and there are few people of color in corporate offices and Congress. It shows up in small ways, too: Band-Aids match my skin well, I can get my hair cut anywhere, and most grocery stores have the food of my people (being Midwestern, the quintessential Food of My People is casserole).

To use a minor example, the beginning of the Dismantling Racism training manual is taken up by a bunch of articles on the history of slavery and racism in the colonial Episcopal Church. I'll be honest; modern history is not my super-favorite thing. My period of historical interest starts in about the year 400 CE and goes backwards to about 12000 BCE. Babylon, Sumer, the Indus River Valley, ancient India and Egypt and Greece; that's my jam. My mind started to wander as I read about this convocation and that historic church and this congregational schism. "I could just skip this," I thought. And then it occurred to me that I know a ton about colonial history from the white point of view--even from the white Episcopalian point of view, because that was part of the inquirer's class I took before I was confirmed in the Church--but absolutely jack about the role of people of color during that period.

 Growing up, I didn't have the option of not learning White History, or White Church History, because they weren't called that. They were called History, period, shut up and learn them. And so, I chastised myself, it would be kind of shitty to have spent all that time learning about Samuel Seabury and Philander Chase (yes, his name was Philander and he was a priest--shame on you for laughing), and then decide that, now that I had a choice, I didn't want to read about Absalom Jones and Richard Allen. Absalom Jones, BTW, was a total badass who was not only the first African-American ordained to the priesthood but who also founded his own parish, bought his own and his wife's freedom from slavery, and petitioned Congress for the amendment of the Fugitive Slave Act.

What's been most helpful, for me, is to draw parallels between male privilege and white privilege--to basically swap the words out in my head when I'm thinking of situations. Then I try to think and act in ways, as a member of the dominant 'racial' group (the fallacy of race as anything but socially constructed is a topic for a whole different post) that I wish men would act in response to male privilege and racism. The metaphor/comparison doesn't hold in every case, but it makes it easier for me to wrap my head around, at least at this early stage while I'm still learning.

For instance.
At the VERY least, I wish dudes would acknowledge that sexism and male privilege still exist. There IS a legit, for-real, problem. It's not just women imagining things while on their monthlies. Men still get paid more than women. Men are still more likely to be hired for high-paying/prestigious jobs than women. The vast majority of elected officials are men. Yet, there are still people who insist that we live in a 'post-feminist' world, and that sexism is no longer an issue (tell that to the residency director who asked me, during my interview, if I planned to have kids. I thought about saying I'd probably have my wife do it...). People say these things out of ignorance at best and assholery at worst. Similarly...
People of color are paid less than whites. Whites are more likely to be hired for high-paying/prestigious jobs. The vast majority of elected officials are white. Trying to decry the existence of white privilege (eg, white people who bitch about affirmative action; I have a relative who once said, in complete and utter seriousness, "These days white men are the most oppressed people around"), or saying something Pollyannish-but-idiotic like "We have a Black President now, so racism must be dead!" is ridiculous.

There is a phenomenon known in (mostly third-wave) feminist groups as mansplaining. It's when a man steps into a women's space to tell them "what's really going on," with a condescending, patronizing attitude and the assumption that everyone must want to hear his opinion. Having been thus enlightened, he imagines, the women will then go and get his words tattooed on their eyelids, or pre-order their gravestones with his words as epitaph. I especially hate when dudes mansplain feminist issues to me, or tell me how I should feel. Guess what? Not every conversation is about you. I understand that you have grown up in a society that taught you everyone waits for your proclamations with baited breath just because you have a penis. That is male privilege.
Similarly, (often well-meaning) white people whitesplain. We've been raised to believe our words have more inherent worth--that everyone wants to hear them--just because we're kind of melanin-deficient. It's our job to minister to the melanized. Guess what? Not every conversation is about us, white people. Especially when discussing racial issues, we should listen at least twice as much as we talk. STFU sometimes is what I'm trying to say here.

I wish feminist guys would call their friends out when they say or do sexist stuff. Your pal harasses some woman? Tell him it's not cool. He uses the word 'sluts' or 'bitches' to describe women? Nip that ish in the bud.
Thus, we white folk have to call each other out on racist bullshit, even--maybe especially--if it's not meant maliciously. We need to be aware. Friends don't let friends fall into frothy-mouthed jingoistic frenzies over "illegal immigration". Friends don't let friends listen to Rush Limbaugh, or tell racist jokes, or say that Cuba Gooding Jr. is 'so articulate' (mostly because he's not. I've never forgiven him for Snow Dogs). Hell, I have to call MYSELF out sometimes--when I automatically assume the African-American teenager on the Metro with two kids is a teen mom rather than babysitting younger siblings, or when a young Black man comes into the ER with a gunshot wound and I assume he's part of a gang. I have to stop and say, "Dammit, brain, knock it off," because living in the US for twenty-odd years has filled my brain with prejudices and racist attitudes (though I'd say this is probably also true for...well, everyone else).

We have to be the change we want to see. Yeah, I realize that is a major contender for the gold in the Trite Slogan Olympics. It's also true.

 

Wednesday, May 01, 2013

Living ethically, from soup to nuts

There are some decisions that are obviously ethical in nature.
Some are mundane and readily apparent: more than once I've come out of the grocery store and realized that the cashier (and I) both forgot about the case of Diet Coke I had stashed under the cart. That's simple; just run back in and pay. Sometimes things get a little thornier, especially in professional situations. If I'm on call at the hospital and admit a man I know from church--and in the process find out that he's having an affair-- it would be unethical to disclose this to anyone else, even his wife. What do I say if she's my best friend? What do I say if she comes to me later, in a situation completely unrelated to his treatment, and confesses she's afraid he's cheating?

Other decisions are less straightforwardly ethical--but I've come to appreciate that, in fact, every decision I make is important and has effects that extend beyond me to the world at large. The global community is currently more densely interconnected than it has been at any other point in history. Everything from the clothes I wear to the way I get to work to the things I eat and drink matters--to me, to my neighborhood, to the planet.

I wake up in the morning and have a cup of coffee. Do I have conventional coffee or fair trade? Is it worth it to me to pay twice as much for coffee that is produced humanely (ie, not on coffee growing plantations that are the agricultural equivalent of sweatshops)? Do I spring for shadegrown too and help protect the rainforest? What do I have for breakfast?

Then I put on my clothes, which I bought at a thrift store (true facts--I buy 90% of my clothing at thrift stores) both to save money and to avoid contributing to corporations that use sweatshop labor. Sweatshop labor is ubiquitous, and it's not just the bailiwick of the Walmart or Kohls brands as you might expect (triple word score for squeezing 'ubiquitous' and 'bailiwick' into one sentence--up top!). H&M, Wet Seal and Forever 21 are able to offer clothing-ish products at bargain-basement prices because they 'employ' children in Bangladesh and Vietnam--and do a brisk business, likely because the majority of people aren't aware of their use of sweatshop labor (I'd like to believe that no one, if made aware of these companies' labor practices, would prioritize inexpensive clothes over human suffering). However, I reserve particular ire for the Gap family of brands: Gap, Old Navy, and Banana Republic. I can't buy a pair of chinos that was made by an eight year old, no matter how cute and cheap they are. Ditto for my running shoes: the only ones I can wear are New Balance, because Nike, Adidas, Saucony and ASICS all use sweatshop labor (which bums me out, because I love Nike's pro-woman marketing campaigns).

Then I walk to work (or bike, if I'm in a major hurry--ie, I woke up late, again). I try to take the Metro or other public transportation when I can, since the car I have at my disposal is an enormous twenty-year old gas guzzler that kills a piece of Al Gore's soul every time I start it. I want to get a Prius but, y'know, money. I don't have it.

When I get to the hospital (and every few hours thereafter) I have a diet Coke. Tap water in a reusable bottle would be more ecologically and socially friendly--and friendlier to my wallet--but I am for-real, hard-core addicted to diet Coke. Sadly, there's an entire page on wikipedia devoted to criticisms of Coca-Cola, from its suppression of trade unions to ecological and human-rights abuses...so that's a big FAIL on my part.

For lunch, I have leftovers--I have doubts about the quality of the food in the cafeteria, both from a sustainable-sourcing perspective and from a nutritional perspective. There's the whole processed foods vs 'natural,' trying to find local foods, getting organic vs. conventional.

I go for a run in the park after work's over, wearing the aforementioned New Balance sneakers, then come home and shower. I have to use Cetaphil cleanser because I have crazy sensitive skin that gets all eczematous and nasty if I look at a bar of regular soap or body wash--Cetaphil is literally the only thing that works for me. Galderma Labs, the makers of Cetaphil, do test on animals--which sucks, but as Cetaphil is technically classified as a drug, the FDA requires it to undergo animal testing. FAIL for me, though I'd really say it's a FAIL for my skin (I can't really help it). However, when it comes to washing my hair and using lotions and cosmetics, I'm super careful to use only products that haven't been tested on little bunnies and guinea pigs. PETA has a good list of cruelty-free beauty products that's updated regularly; I may not agree with a lot of PETA's tactics, particularly 'liberating' laboratory animals that then have nowhere to go, and advertising campaigns that aim to save animals by throwing women under the bus, but I trust them on this. My personal favorite brands include Zum (Indigo Wild), a natural beauty product line that was started in Kansas City and makes an utterly delicious-smelling Frankincense and Myrrh body oil, Burt's Bees for makeup, which is kind of spendy but worth it as it doesn't make my skin revolt, and LUSH products, which are often organic and always smell mouth-wateringly good (scent is a big deal for me).

I screw around doing...whatever until bedtime, then take my meds which are made by big, shadowy, ethically questionable pharmaceutical companies (which I will continue doing until I'm somehow able to compound sertraline and valproate myself, on account of they keep me--comment se dit?-- not crazy).

Point being: Every action has consequences, and while it's not always feasible to avoid making a decision that has inadvertently crappy results, we can at least make an effort to be aware of the ramifications of what we do, from coffee in the morning to bedding down at night.