Dreams, Stevie Nicks and me.

Now here you go again, you say
You want your freedom
Well who am I to keep you down
It’s only right that you should
Play the way you feel it
But listen carefully to the sound…

–Dreams, written by Stevie Nicks



I have always loved the Fleetwood Mac song “Dreams”. I was a kid when it came out and had no idea what the song was about (the star-crossed romance of Stevie Nicks and Lindsey Buckingham), but it moved me nonetheless. The first strains of the song with the evocative drums and bass elicit a sense memory even before the fabulous Stevie starts to sing.


I woke up thinking about that song this morning. But it was different from my sense memory. I thought about it in light of “listening carefully” to my dreams. For the past week since I got back from an international panel of geriatric psychiatrists in Berlin I have been having vivid and elaborate dreams that are hard to ignore. Perhaps jetlag. Perhaps more.


While I am not a psychoanalyst, I love to “listen” to my dreams. I believe that dreams represent our brains trying to problem solve while we sleep. I often find that my dreams give me a perspective on some aspect of my life I didn’t see or notice while awake.


In the first dream that I had earlier this week, I am in my house but I find several rooms that I somehow didn’t realize that we had. The rooms are really interesting and compelling. While they are not to my taste, I begin to think about all the ways that I could remodel the rooms, and use them in my daily life. In the dream, I have a slight sense of “how is it that I never realized we had these extra rooms”, but not in a self-critical way.


I woke from that dream and didn’t have to think too much about what it might mean. I stepped down from a leadership role a year ago to pursue my research on improving care for dementia behavior more full time. This has been extremely rewarding. And yet. Something is missing. I have “extra rooms” or skills that I am not using.


I put the dream aside and carried on with my week. It was a busy one, filled with all the emails I triaged while in Berlin, two grants that I am working on, a clinic day full of patients, and three mentees who needed my direction and advice. But my dreams decided to make their point again and vividly.


Last night I dreamt that I was fishing in a muddy river. I immediately caught a relatively nice sized fish and put it away as a keeper. Not satisfied with just one fish, I went to put more bait on my fishing pole and discovered that the worms were extremely tangled. I worked and worked but couldn’t get them untangled. These worms were real sons of b*tches and keep retangling themselves as soon as I got them untangled. I decided to create a “work around” and just affix the entire mass of worms to my fishing line. I put the line into the water and waded into the river. I was getting mud on my clothes but somehow didn’t care. It was then that the worms began to take over, They began to pull the pole, and then me, the way that they wanted to go instead of what they were supposed to be doing. I decided that the only way to proceed was to cut the line and let those loathsome worms do what they were going to do. I walked away alone, happy to be done with the worms, but knowing that I would need to find another line.


I woke up from this one feeling refreshed and thinking of this line from Dreams:

“When the rain washes you clean…you’ll know, you’ll know”


I won’t get into what the worms represent exactly, but as you can imagine they are the most annoying, difficult and stressful parts of my job.


In some sense, the role of dreams may be to bust through our denial and our defenses to ‘not want to think’ about difficult things. The ‘dream factory’ goes to work and says let’s present this to her in a weird and unexpected way that will really make her think and wonder and pay attention. “Finding another line” is what I need do. Stay tuned.


I am curious if readers have had this type of “aha” moment from their dreams. Did you change course? What were the outcomes?


Rotten Tomatoes for Docs?!

Here is my new head shot for work. Like it? I do. It’s pretty nice. Thanks again to Jen Geer Photography for making the process fun, quick and easy.

My new headshot. Thanks Jen!

My new headshot. Thanks Jen!

This post really isn’t about my headshot, but that’s how my day started. I had asked our Department IT guy to switch out my old headshot for the new one and then Googled myself to make sure the switches had been made on various Department, Program and UM Health System websites.


Here’s where the story gets interesting. They say not to Google yourself, and it’s probably pretty good advice. Here’s what I found:


Ok. Let’s see here. There’s our Program website, there’s the Health System website, there’s a news piece about some of my research, there’s the HealthGrades.com website where I have a 1-star listing, there’s ResearchGate—HOLD UP. I have a one-star (out of five) listing on something called HealthGrades.com?


God help me, but I couldn’t resist. Click.


Here is what I saw next:


So apparently, a reviewer gave me one star (e.g. THE WORST) in EVERY SINGLE CATEGORY. Ok, I say to myself, let’s look at the categories: trust, explaining medical conditions, listening, spending the appropriate amount of time with patients. Per this reviewer, I am THE WORST in all of them. Hmmm.


Ok, what are the other categories? Looks like these are for my facility and staff. Let’s see what the reviewer said….oh, looks like we are ALSO THE WORST in terms of scheduling, cleanliness and friendliness.


As a person, I admit, my first thought is, “who hates me this much?”. My second thought is, this person is seriously disgruntled with me. Am I really so untrustworthy? Such a crappy explainer of medical conditions? Have my fingers in my ears when patients talk? Give them the bum’s rush out of my office? (that last one is kind of funny, because if anything, my clinic runs late because I tend to go over time with people, especially if they are in crisis).


But let’s forget about me for a moment. Our wonderful clinic staff who specialize in the care of older adults are really the MOST UNFRIENDLY? Our beautiful pristine facility is really the LEAST CLEAN clinic this person has ever been to?


Our beautiful facility.

Our beautiful facility.

Because I do mostly research these days, I see a pretty limited number of patients, most of whom I have seen for years. Would someone who thinks I am the WORST DOCTOR EVER really keep coming back to see me? Year after year? My patients also tend to be a pretty outspoken lot. A patient once commented pretty openly about my very dark toe nail polish color. And by “commented”, I mean to say she blurted out: “Dr. Kales, your toenails look like sh*t!” (and brought me a beautiful pink shade of Opi at the next visit).

One of my favorite pieces of constructive criticism.

One of my favorite pieces of constructive criticism.

So, not exactly a group of shrinking violets. And I love them for it.


After my morning of personal research, here are thoughts on physician ratings (and take them for what they are worth, because apparently, I may be the WORST doctor ever).

  • Anyone can write a rating of a physician. Whether they have ever seen that physician or not. So my review could have been written by a neighbor who doesn’t like how barky my 2 dogs are (and they really are pretty barky, but I’m working on it).
  • This applies to positive ratings as well. I could get my mom, who may be my biggest cheerleader, to write one (hey, maybe that’s not such a bad idea? I kid. I kid).
  • Speaking of my mom, when she read a draft of this post, she said “the person probably thought that a ‘one’ was the best and just made a mistake…I am eighty-one years old and pretty smart, but sometimes I get confused with these kind of ratings”. First of all, let me just say, I LOVE YOU MOM! But second, that is a valid point.
  • Even if written by a real patient, physicians, unlike hotels on TripAdvisor, can’t really address the bad ones because of privacy.
  • Ratings CAN be really useful, IF they are valid. We use them for rating lots of “products” like hotels (TripAdvisor), books (Amazon) and cars (ConsumerReports). But, because of the issues I note above, we probably need to think of new and more creative ways of measuring physician quality that are easily accessible to the public. I would also note that typically for products, you need to write something about what happened and not just do a numeric “drive-by” (e.g. I have to say how my hotel experience was in words not just in numbers for TripAdvisor).
  • Constructive criticism is really valuable. I wouldn’t be in the world of research, where I literally get 3 kicks in the teeth for every pat on the back in grant and paper reviews, if I didn’t have a pretty thick skin. But the difference here is that the academic kicks in the teeth actually come with good thoughts and ideas about how to make the ‘product’ better. As a clinician, I would love to get the same.


  • In sum, I encourage you to tell your physician how he or she is doing (or how their nail polish looks). But when you do it, like my patient who brought me a nail polish color she liked better, tell them how they can improve or how you could be more satisfied. Or to put it more plainly, don’t just tell them they stink, tell them how they can stink less.PePeLePew-1


New School, Old School

2011.10.14_LEGOLANDMEDIADAY_001.jpgOur eldest daughter Tasia starts school at the University of Michigan in about 2 weeks. This summer has been a blur of getting ready. And by getting ready, I mean materially, but more so emotionally. It has been like a mini-roller coaster ride as we experience each related milestone. Orientation: “Did I do it too late? Who will be there? Will they like me?”. Class scheduling: “Mom! The psych class I wanted is full! Will this other one be ok?”. Dorm assignment: “Oh no! they put me at Bursley and not on main campus!”. And, less often, but underlying it all:  “I am really going to miss you seeing you guys every day”.


And of course, I have had my own separation issues too. Our family is a pretty tight unit, and while Tasia will be here in the same town (thank you God), she will not be HERE. I will miss our nightly meetups before bed when we talk and compare notes about our days while she snuggles our dog Sasha. I will miss her snappy wittiness. I will miss her luminous face in the mornings. I will miss her chasing her 11-year old brother around the house to try to snag an extra hug from him to his protest. I will even miss her nonsensical bickering with her 15 year old sister over bathroom time.


I will miss everything about her being here, in this house, with us. This is a two-way street.


Flying back from a conference in Boston this summer, a toddler “flirted” with me and other passengers over the seat as we waited to get off the plane. Without even processing it consciously, I suddenly found my eyes swimming with tears. What the hell? As I thought about it, I realized that Tasia used to do the same thing when she was that age. My husband Pat dubbed it “fishing for customers”. And of course, the next thought was that it seemed like only yesterday that Tasia was fishing for customers, and now she is about to go to college.


To manage my own feelings, it seems like I have adopted a “no-nonsense” “just the facts” approach at times. Mary Poppins-pish posh-style.  “Oh, it’s going to be fine” I say. “Oh c’mon, you are going to love it” I say. I even said (after talking to a colleague and good friend) “So and so’s daughter is really excited about college, not anxious at all”. No wonder Tasia told me the other day “I get that you are a really good researcher, but sometimes I question how good a therapist you are”. My Mary Poppins persona said “Well, Tasia, I am not YOUR therapist “. Pish posh! But really, it gets hard to be “therapeutic” when you are experiencing the loss too.

mary-poppins-el-capitan-theatre (1)

But there has been some fun too as we “get ready”. I love to shop. I love to shop with Tasia. And there has been a lot of associated dorm room shopping. She and her lovely best friend and soon to be roommate Dany decided early on that the colors of the room would be aqua and salmon. Sounds great, but do you have any idea how hard it is to find the right shade of salmon? (“Um…no…that’s peach mom!”). We have worn out the route to Bed Bath and Beyond, my kids laughing as I never seem to be able to find that ubiquitous 20% off coupon when I need it. A trip to IKEA was a huge success, but I largely credit that to Dany’s Ukranian-born mom, a beautiful and petite woman who maneuvered us deftly through the store with military precision.

The IKEA gang

The IKEA gang

Along our summer journey, I have also experienced some wistfulness about my own college experience that prompted me to think about one of my favorite movies, Old School. In the movie, Will Ferrell, Luke Wilson and Vince Vaughn find their lives at a crossroads in their thirties and decide to experience a “college do-over” and form their own frathouse on a college campus. The college fun without the college classes. The thought has definitely occurred to me that I would “do so well” at college if I could go back now. Not the class part (I did pretty well there the first time) but the fun part. I was an anxious homesick kid and it definitely impacted my freshman year. Now? With all of my adult toolbox? I could totally manage it!


But that’s life, right? We don’t get do-overs. The trick is to try to do the best you can. And of course, everything—and perhaps, especially- the mistakes, warts and disappointments can sometimes lead to the best opportunities and outcomes. Tasia and I were talking about my own freshman experience the other night before bed (while snuggling Sasha), and she said “So, what are you complaining about? You turned out pretty well.”. Nice. That girl might make a good therapist someday.


So, we will do the best we can and savor what we have and hopefully what is coming.



Giving Voice to the Silent Sisterhood


I don’t talk about it a lot and I have certainly never written about it. “It” is that twelve years ago, we lost a baby sometime between 16 and 20 weeks of pregnancy. I still feel a stab of pain as I type that.


Life has moved on, but that loss will always be with me. I was inspired to write this after I read a post by Facebook founder Mark Zuckerberg as well as a blog about miscarriage on the always excellent website The Mighty. In announcing his wife’s pregnancy, Zuckerberg mentioned that he and his wife had endured a number of miscarriages and wrote about the need to bring pregnancy loss into the open. Indeed, miscarriage is a truly “silent sisterhood” including members of all ages, races, faiths and beliefs. But few people talk about it. So, here goes.


I got pregnant in 2003 after a trip to Hawaii. My husband and I were a bit overwhelmed by the thought of a third child when we already had two girls (at that time aged 6 and 3), but we were pretty stoked. Our kids are our life, and the more the merrier. The fact that I got pregnant while on Maui was pretty magical.


My third pregnancy was not different in any way than the first two, in fact, when I got pregnant that time, I was actually in better physical shape than prior to the others. Despite the typical pregnancy accoutrements like morning sickness and fatigue, things sailed pretty smoothly, until suddenly, they didn’t. I will never forget sitting in my office at the VA Hospital and getting “the call” from my doctor at 20 weeks. As I sat frozen in my office chair, he told me that one of the measures on my triple test was markedly elevated. Something was “very wrong”. I didn’t sleep at all that night. Terrifying thoughts.


The next day, my husband and I went to the OB’s office. The drive felt like a death march. And when we got there, there was no heartbeat. What happened after that was a blur, but I recall we were sent for a confirmatory ultrasound at UM hospital. Our baby looked perfect, but was no longer with us. Numbness set in.


We went home and we watched a rented Margaret Cho standup video to distract ourselves. It didn’t work. Our doctor called and explained that it was likely our baby had died sometime between our 16 week checkup when there was a strong heartbeat, and 20 weeks.  The measure on the triple test was so elevated because our baby was already gone. Somehow my body hadn’t gotten the “message” and I hadn’t miscarried on my own. I would need to have a “procedure” to do what my body hadn’t done.


We dropped our kids off at my parents and told them some lie. We were not ready to tell them. As the “procedure” started, the resident laughed and joked with the nurse assisting. In fact, I clearly recall her saying jokingly “Oh, I am such a retard sometimes!”. I also recall wanting to jump off the table and throttle her, but being sedated and beyond paralyzed by grief, it was not in my capabilities at the time. To say we were treated with insensitivity as if the loss was “nothing” would be accurate. After the procedure, care staff said some brief platitudes, “sorry for your loss” etc, but that was it. We were given a small pamphlet-like book called “Empty Arms”. I read, reread and highlighted that book like it was my new Bible.


In the hazy, painful days that followed, a remarkable thing happened. My “silent sisters” came out of the woodwork one by one, calling, visiting, writing and taking me out to lunch. They each had their own stories of loss that were sadly powerful. My own mother and grandmother (“YiaYia”) each revealed their own losses to me. Tears still came to these women’s eyes as they told me their stories. For my YiaYia, this was 60+ years after the fact, but she still teared up in talking about the daughter she had lost. And in every case, they had “moved on” but somewhere, “it” was still with them. I drew strength from them. Particularly as a part of me viewed the miscarriage as a sign that my previously healthy body had failed me in some way. I was not alone. I was not defective.


About a month after the procedure (sorry, I have a difficult time typing D&C for some reason), we got a letter from a pathologist. They couldn’t figure out what had “gone wrong” but wanted to console us on the loss of our “baby boy”. I can see myself standing by the mailbox as I read those words. It will never leave me. Thankfully, I had two lively and loving little girls whom we loved a little extra hard that day and pretty much every day that followed.


The acute pain receded. Things did get better. I would like to note that the platitude/misstatement “you can always have another” (along with the even worse “it’s a blessing, something must have been very wrong” or “it’s Nature’s way”) while well-meaning, was never helpful. What was helpful? Family, love, friendship, faith, time and most of all the sisterhood (and brotherhood for my husband).


Six months later we found ourselves trying again. Our son Theodore (Greek for “gift from God”) was born in August of 2004, a year and a couple of months after we lost our first son. I have never felt that Theo replaced our loss, but somehow he did make our lives measurably better.


Every time I go to church, I light a candle for the son that we lost and feel that connection. One very positive thing the UM hospital has is called “The Walk to Remember” where a huge group of people who have experienced pregnancy or infancy loss walk together, culminating in a tree planting ceremony. Over the years, we have attended this several times and it is very healing.


I only hope that by more people (women or men) sharing their own losses and stories that we can make miscarriage something less hidden and help others to feel less alone.

Dr. Kales Goes to Green Acres

MV5BMTczMTQ1ODg3N15BMl5BanBnXkFtZTcwMTQ2NTQ4NA@@._V1_SX214_AL_Do you remember the show Green Acres? It was in reruns when I was a kid. The premise was that a New York lawyer (Eddie Albert) drags his protesting socialite wife (Eva Gavor) to a rural farm outside of the  town of “Hooterville”. Hilarity ensues.

It occurred to me the other day that, in some ways, I am the Eva Gabor character in my marriage. Not in being high maintenance or really rich, but being in a “mixed marriage”. You see, my husband is from a family raised in Nebraska and Idaho. They have a rustic family cabin in the Boise National Forest near the Sawtooth Mountains of Idaho that is like Mecca to them. There is no electricity (gas lights only!), no cell phone service, and certainly no wifi.

The Gibson Family Cabin, Boise National Forest

The Gibson Family Cabin, Boise National Forest

In contrast, both of my parents were raised in a city (Detroit) and the dominant culture in my family is that of being Greek-American. Once when he was in his residency at UCLA, my father, goaded by a colleague, went camping and HATED it. He never went again. When I told my dad that my husband and I were going camping shortly after getting married, he said with horror in his voice: “and after you cook the food, WHAT are you going to DO there?”. A famous family story tells of my husband early in our relationship meeting my dad and asking him if he liked fishing. My dad replied with two words “Too pastoral”. My mom, although not Greek, also came from more recent (Polish) immigrant stock and always said “my idea of camping is checking into the Hilton and ordering room service”. For some immigrant families, it seems, the idea of camping and getting out into the “great outdoors” seems ridiculous. I mean, didn’t the family leave the old country to get away from having to gather wood and cook over a fire?

While over the years I have grown to appreciate the outdoors (certainly more than my parents), I still struggle with some aspects of the ‘rustic’ experience. Let me list my top 5: 1) Bugs (and especially those %^&%$@! deer fly that populate the cabin—they hurt like a mother trucker when they bite. And they seem to love me a bit more than others); 2) no blowdryer (I have very temperamental bangs that curl every which way when airdried); 3) being unplugged (with three current federal grants as principle investigator, I like to stay on top of things); 4) “doing nothing” (I start to get itchy and feel like I am being indulgent and lazy); and 5) feeling isolated from civilization (I begin to crave contact with people, even annoying people).


%^&%$@! Deerfly

So when this year, my husband proposed a two-week vacation at the family cabin in Idaho (again, no electricity or wifi), I was a little bit trepidatious. In addition to my addiction to checking email and in with “work” multiple times per day. I also have two teen girls (aged 18 and 15) who are constantly on their smartphones (Instagram, Snapchat, etc). I have a 10 year old boy who loves playing computer games on the Ipad. What would happen? But like the Eva Gabor character, I decided that love won out. We had spent last summer’s vacation in England and Ireland on my sabbatical, most of it in cities. We would go to the cabin in Idaho for two weeks (a la Eva in Hooterville), come hell or high water.

So how did it turn out? Well, I am not going to say it was easy. I definitely had some Eva Gabor moments of being a “city girl” (two highlights: sliding down a huge log in a jeans miniskirt on a hike and landing into a pricker bush and being popped out of the raft on our white water trip and getting fully submerged into the Payette River). Oh and also? Those deer flies are still sons of a %^$#$.

Me having a moment in the Payette River. I am under that helmet on the left.

Me having a moment in the Payette River. I am under that helmet on the left.

However, going “off the grid” and “offline” for the most part was a gift. Yes, I came back to Ann Arbor and was confronted by about a thousand emails (literally). But none of those was truly urgent. And in return, the family: played cards, read books, hiked, went white-water rafting, had conversations that lasted more than five minutes, watched humming birds, listened to family stories/legends/tall-tales, cooked amazing food, looked at the stars, fished, and slept REALLY well. Idaho is a gorgeous (largely undiscovered—shhhhh) place.


At Stanley Lake with Pat and Theo.


Outside Stanley Idaho #nofilter

Outside Stanley Idaho #nofilter

One of MANY hummingbirds at the Cabin. Sometimes there were 5 at the feeder.

One of MANY hummingbirds at the Cabin. Sometimes there were 5 at the feeder.

I also thought of a way to manage my (likely genetic) need to be busy and productive. As I talked to Pat’s grandmother, dad and aunt and uncle, I began to gain an appreciation for the role this cabin (in the family since 1961) has played in holding the family together. Through death, divorces, moves and other life changes, this cabin has represented “home” to this family. Without realizing it, I created a little anthropology project for myself, taking notes on what they told me about the history of the cabin and the tchotchkes/treasures it holds within itself. Pat’s grandmother Helen, who more than anyone, has kept the flame of the fire of the cabin “lit”, has stories to tell. At 98, Helen continues to amaze. She drove and volunteered at St. Vincent’s into her 90’s. Although in recent years, she has slowed down and her memory is less sharp, she remains the pillar of the family, weathering each and every ebb and flow with aplomb.

My family with Grandma Helen Gibson, the 98-year old matriarch of the Gibson family

My family with Grandma Helen Gibson, the 98-year old matriarch of the Gibson family

I decided to catalogue what I found at the cabin and began to ask her about each item. The joy in Helen’s face as she told me what she remembered was priceless, and this knowledge will make these objects and experiences even more meaningful and connected for the next generations.

Grandpa Hoot's chair. We found out from Grandma Helen that he had it recovered with this 70's vintage covering.

Grandpa Hoot’s chair. We found out from Grandma Helen that he had it recovered with this 70’s vintage covering.

I have returned from Green Acres refreshed and awakened, glad to have been there…and glad to be back.