Are we there yet?

I have 3 kids ages 1-5. I have taken 4 flights alone with said 3 kids in the last month, so I find myself attempting to answer "Are we there yet?" often lately. But guess what? I'm actually the one who has been asking it and not just because I was READY to get off that plane (though I was READY to get off that plane, too). My husband I are struggling with our future childbearing plans. With 3 kids, is our family complete...or not?

Now ordinarily, I'm not a huge fan of the overshare and I wouldn't take these musings to a blog of physician mothers, but it feels relevant here.

My med student brother-in-law and his wife and two little girls were visiting this weekend, so I had to drag out the high chair and the pack n play and all of the baby stuff that is still stowed in our attic. And while I had a little familiar wave of nausea as I watched all of our floor space become occupied by clutter, as it has been for so much of the last 5 years, I also had a little wave of nostalgia. Actually a big wave of nostalgia. We are long overdue for a yard sale to be certain. But am I really ready to give away the bassinet? The baby tub? The smallest baby clothes? The boy baby clothes that I haven't had occasion to pull out since my first child was born 5.5 years ago? I'm not so sure.

My son would love to have a brother (no guarantees there, of course, but as a woman who can't imagine not having a sister, I do give a nod to his desire for a brother). We have the space--two of the kids would have to share a room, which none of them do right now, and I'm sure that would generate discord and some night time awakenings, and we would need to trade one of our cars in for the dreaded minivan--but we have the space. More importantly, though, we have the space in our hearts. We love each of our kids more every time we have another one. I know we would be busier, which unfortunately detracts from the individual time each of our kids get with us, but in exchange, they would get the love and companionship of another sibling, and that counts for a lot. And when my husband and I are long departed from this life, it will count for even more.

So why am I struggling? Well, the truth is that it wears me out to think about having to "start over" yet again at the career. Having to make excuses about being late because the baby kept me up all night and then I slept through my alarm. Having to take breaks from meetings to pump. Having to rush out of clinic and skip tumor board in order to see my baby before he or she goes to bed at an insanely early hour that is currently referred to as "dinner time" otherwise in our household. Having to turn down awesome opportunities and excuse myself from obligations because deadlines or conferences will occur when I am 36 weeks pregnant or when I have a 6 week old. And, most nebulously but maybe most significantly of all, having to prove that I can "still do it" as I had to prove I could still do it when I was pregnant as a first year fellow; when I had two children and therefore two maternity leaves during the course of a 3 year fellowship; when I got pregnant with my third child shortly after starting my new job. Presumably, this time it would be having to prove that I can still do it even though I now have 4 kids since I have been told many apocryphal stories of physician moms who "cut back to part-time when they had their second and then decided it was just too much and quit working after the third." I don't know what happened to them when they had their fourth. Maybe I don't want to know!

There is definitely an assumption at our jobs that we are done since we have 3 kids. I have had multiple colleagues tell me jovially and empathetically, "Hang in there. It's going to be so much easier in another year or so all of your kids are out of diapers!" It is a forgone conclusion that we are done to everyone except us. We have already exceeded the magic number (that would be 2) of kids for the two-physician family. On the other hand, I was recently told by a former med school classmate who also has 3 kids that "3 is the new 2". The question that leads me to is: So, does that make 4 the new 3...or is 4 still 4?

But the bottom line is that I just turned 37 a few days ago, and I have 3 small kids. If I am going to have another, I want to get on with it and soon. I would rather keep going with the diaper stage than have to go back. I don't want to be facing paying for college tuition at the same time I am also trying to retire. I want to be able to do things like go camping and hiking as a family, things that are harder or impossible to do when there is a baby or toddler straggling and holding back the rest of the group. I want to be able to plan days without having to accommodate anyone's nap. And I want to do it while I still have the energy to survive sleepless nights and chase my kids around the yard after a full day of work. So while I am not sure what our decision will be, I think the time we want to make it is soon.

So, are we there yet?

Favoritism

Usually I try not to post twice in a row, but I'm angry about this now.

On my way out the door on my last day of residency, I was chatting with two male junior residents about how much I enjoyed residency and wouldn't even mind if I had another year left. This may be selective amnesia on my part and I probably deserved to be smacked for saying that, but I love my field and I thought (most of) residency was awesome.

However, as I spoke with these junior residents, I got the distinct impression that they thought the only reason I enjoyed residency so much was that the attendings have been favoring me.

They cited the example of an attending that I will call Dr. Smith:

Dr. Smith has a reputation, in general, for favoring female residents. Several (but not all) of the male residents dislike him and say that he gives them a very hard time. A few residents were annoyed that he didn't make me go to the grand rounds that took place once a week at 6AM. Dr. Smith told me: "Fizzy, I know you have a baby and you've got a lot on your plate, so since you're not going into my field, I don't want to push you to do this."

I overheard another resident complaining that Dr. Smith didn't force me to do this once a week afternoon clinic for the undergrad students (note: don't talk shit about someone when they're standing three feet away). It is true that for the first month of our two month rotation, I didn't have to do the student clinic, but the underlying truth was that there was no school that month so there were no patients. The second month, when school was in session, I worked at the clinic. Yet a couple of residents insisted that my month free of the clinic was all because of favoritism.

I worked hard on that rotation to impress Dr. Smith, not by kissing up but by having a strong knowledge base. My shining moment was when I was doing a procedure with Dr. Smith and he was pimping me nonstop through the whole thing. Finally, after about half an hour of pimping, he said to me: "I can't stump you, can I?"

It bothers me that other residents think that I've been favored because I'm a mother. Just because I enjoy residency, it doesn't mean I haven't worked hard. If I've received any favoritism, I'd like to think it's because the attendings know I'm hard worker. I also study my ass off. We had two major exams this year and I got the highest score on both by a large margin.

A friend told me that any time an attending likes a female resident, all the men will say it's because that attending favors women, not because she's actually a good resident. I'm beginning to wonder if that's true.

Graduation

It's official: I've graduated from residency.

We had our graduation dinner last week. I was anxious about it all day and my husband kept asking me why. Somehow it wasn't a good enough explanation that I was scared my two year old daughter would scream her head off during a ceremony attended by professionals in my field that I highly respect.

One other graduating resident had a child and we conspired to sit at the same table, thinking that at least this way, nobody would be able to differentiate one screaming child from another. Right off, things didn't go well when Melly didn't seem to get that she was only supposed to clap when everyone else was clapping. Neither of our girls made it through the ceremony and our husbands had to take them outside. Apparently, her husband said to mine, "So this is what our lives have become."

In general though, I was very proud of how well Melly behaved. As long as there was food in front of her.

I'm proud of myself too. I still think of myself as very very early in my career, but when I see high school kids shadowing our doctors, I realize that I've come very far. They've still got to graduate high school, go through all of college, take the MCATs, go through med school, take Step 1 through 3, do internship, and do residency in order to get to where I am right now.

It was not easy. I am a little ashamed to admit how many times I came close to quitting. There are a lot of people who started med school with me in 2001 that have been lost along the way... they will not be graduating now or ever. There are so many ways to get tripped up on this journey: students who flunked out, switched into other fields, quit to raise children instead, or worse, are no longer with us.

But I made it. I'm licensed to practice medicine and will (hopefully) soon be board certified.

So has anyone warned you not to get sick in July?

Worried

I really, really don't like to post about political topics. Mostly because it is inflammatory, but also because, to me, it is extremely personal. However, based on recent media coverage, and President Obama's recent remarks to the AMA, I feel that I cannot keep silent on this subject. In his recent speech to the AMA, he downplayed the importance of tort reform in decreasing rising medical costs (such as unnecessary, expensive tests, ordered primarily to CYA and keep the lawyers at bay). More disturbing, however, was the notion that, in a "public option" (aka Government-run plan) he would base physician rating and reimbursement based on their personal health outcomes.

So, wait a minute, what's wrong with that? You ask. I mean, it is the doctor's *job* to make you *better,* right? It doesn't seem so horrible...you have a cold, you visit your physician, s/he diagnoses you with a viral infection, you get better, life goes on. But, what about this? As a physician, your patient population is obese. Despite your multiple attempts and counseling and lifestyle change recommendations, your patients continue along their unhealthy lifestyle, becoming even more obese. Guess what? You get a pay cut. Your patient that has smoked a pack a day for 50 years, and laughs in your face at your attempts to counsel smoking cessation develops COPD. Sorry, that is coming out of your hide. You did such a *bad* job of taking care of this patient! Your diabetic patient doesn't fill their medicine for a month, and then comes in to the hospital in frank DKA. *Your* fault for a negative outcome. Then, to add more fun, your ability to order laboratory/imaging tests will be limited (in the interest of keeping costs low), but if you miss out on a diagnosis? Your *fault,* and here come the lawyers for their piece of your livelihood. Where is the personal responsibility?

Who wants to put up with years of rigorous training, difficult study, and mountains of student loan debt only to be stymied in patient *care* at every turn? Surely not our best and brightest. I am worried about the future of our profession. A "public option" (not "free," by the way, more like $62,000 taxpayer dollars per person) for all intents and purposes will likely undercut any private competition (not to mention the tax burdens that will be levied to discourage competition). This will leave us, both patients and physicians, with only one choice. Government Medicine. Just like Government Motors. I don't want to become a government employee. I don't want my health care options to be limited to government employees. I don't even like to spend a day at the DMV!

I do believe that some reform, obviously, is needed, but I think it needs to be more geared to catastrophic coverage. I think we need to go back to fee-for-service health care, even schedule fees on a pro-rated percentage based on income to make health care visits affordable for all. Get rid of insurance for preventative care, labs, and office visits. Competition will then drive the costs down naturally. We, as physicians, can stop shuffling through piles of insurance paperwork and prior auths and get back to doing that which we were trained to do. Something that we love to do....take care of patients! Personally, I feel that "free" = "of little value." I believe we need to give people back a financial stake in their health care, and, perhaps, when they are financially vested in staying healthy, then they will value their health, and their health care providers, once again. Until then, I jump through a few more hoops to get my patients the care they need, and I worry about the future of our profession, and our nation.

Elizabeth Blackwell is rolling in her grave

When I was in grade school, we did a one week segment on human biology. What I remember about grade school human biology was that our teacher would write a bunch of information on the blackboard and we'd copy it down and then memorize it. By the way, did anyone else really really hate copying things verbatim from the blackboard? It seemed like something we had to do an awful lot.

At the end of the one week, we would select three pieces of paper from a bag of questions, and we'd have to answer those questions in front of the whole class. If we got all three questions right, we'd win a prize. For the girls, the prize was a book about Elizabeth Blackwell, the first female doctor. I had like four of them by the end of grade school.

(FYI: I remember one of the questions was, How many bones are there in the human body? I no longer know the answer to that question. I was smarter when I was six than I am now.)

Anyway, fast forward fifteen years into the future. I am at a med school interview and I get asked a really dumb question by the interviewer: "If you could have dinner with any person, living or dead, who would it be?"

That's such a stupid question. Honestly, if I could have dinner with any person, living or dead, it would probably be my husband. I like having dinner with my husband. If I were having dinner with, like, George Washington, I'd probably be really nervous. And creeped out, because he's dead. I'm sure I wouldn't enjoy the meal very much.

(A better question would have been, if I could FIGHT any person living or dead, who would it be? I'd fight Ghandi.)

So I had no clue what to say, but I remembered that Elizabeth Blackwell book, so I said, "Elizabeth Blackwell. Because she's also a woman in medicine and she understands the obstacles we have to overcome."

Oh man, good answer, Fizzy! Except for the fact that I've spent the last nine years kind of feeling like a tool for saying that. I mean, it was just the lamest, most untrue answer I could have given. I don't actually want to have dinner with Elizabeth Blackwell. I was just trying to come up with an answer that would impress the interviewer. (Although actually, maybe it would be fun to talk to her about arrogant male doctors.)

The worst part is, that med school went and rejected me.

MiM mailbag: NP or MD?

I am a 30 yo woman who finally got up the nerve to pursue medical school after dreaming/obsessing about it for 15+ yrs. I'm planning to start a post-bacc program next May. But now that I'm 30, I've realized that I do want to have kids, soon, and I don't want to miss the most exciting years of their lives. Although becoming a Nurse Practitioner has never been a goal of mine, I'm wondering if you Mom MDs think it would be worth it to settle for a career as an NP in order to have more time to spend with my kids. Thoughts?

When EBM is not enough...

I recently had my third child (he's 7 weeks today) and he's a boy - which is a new experience since my two others are girls. Among the various new challenges (which include changing diapers - I've managed to get sprayed on more than one occasion) one unanticipated challenge is what to do with the vaccination schedule? Since my 2 older children are girls, I didn't really worry about autism - but now that I have a son, I find others are asking what I will do?

Well, I started to answer this question with my EBM skills - I looked up the evidence to support any change in the normal practice and of course, there is no good evidence right now. However, now that I have engaged my many Mom friends on this topic, I have heard many, many anecdotes of parents who are sure that a known case of autisum was related to the vaccines given all at once.

Next week, my little one is schedule to get 5 vaccines at once - 4 injected and 1 oral. With all due respect to EBM, while there's no good evidence to support any interventions, I've decided to give the vaccines over 2 visits, probably 1-2 weeks apart. I figure there's little to lose and possibly something to gain? At the very least I wont' have to sit there and watch him scream 4 times - on the other hand, I'll have to take a crying baby home on 2 different days...

Any thoughts on this issue?

Playing nice

Recently, we've been teaching Melly to be nice.

Some of the kids at her day care were hitting and we were shocked to discover that she was one of the perpetrators. So we took it upon ourselves to train her not to hit.

Me: "Melly, don't hit the babies. The babies are your friends."

Melly: "Fwends."

Me: "So what are you going to do with the babies?"

Melly: "Hit the babies." (Repeat x 100)

But we were eventually successful and now the day care is reporting that she gently pats the other babies and says that they are her "fwends." We have successfully trained our daughter to be nice.

Now it's my turn.

It's not that I'm not nice. I'm nice enough. But when Melly woke me up at 5:30AM and I've just seen 15 back pain patients that morning and now I'm on #16, it's hard to keep a smile plastered on my face. Especially when patient #16 showed up 20 minutes late and now I'm going to have two minutes for lunch.

(I tend to get really irritable when I think I'm going to miss lunch. I hate the fact that it's totally acceptable in our field to have zero lunch break in a day. Sometimes my morning clinic ends later than my afternoon clinic, so I have negative lunch. I guess that means I'm supposed to throw up?)

My new resolution to be nicer comes from a recent visit to my youngish female primary care physician, who was clearly running an hour late and doing my physical exam during a time when most people would be eating lunch. Yet through our visit, she kept the brightest, most cheerful smile on her face. She was so nice, I wanted to hug her. And I'm not such an awesome patient to warrant that kind of niceness.

Obviously, it's great to be a master diagnostician, but I am most impressed with doctors who can exhibit that kind of unconditional, overwhelming niceness. (Especially in a field where there are, let's face it, a lot of assholes.) My PCP is a physician mother as well and I'm sure she has all sorts of stress in her life, but I wouldn't have known it from looking at her. When I look at my PCP, I think to myself, "She is a born doctor."

When I meet a doctor like that, I resolve to walk into every patient's room with a huge smile on my face. It generally lasts for about a day, sometimes less. Sometimes I can only smile through my first patient. Still, I'm working on it. If my two year old daughter can be nice, I can too.

My golden anniversary

When I realized that this was to be my 50th post on this blog, I decided I want to make it good. (Not my usual crap, right?) I asked around for advice and got some suggestions that were good, possibly topics for future posts, but didn't quite have the WOW! factor I wanted. I wanted to make a post that was not just interesting, but.... SHOCKING.

So here goes:

When I joined this blog back in its infancy, one year ago, I had an ulterior motive. The truth was that I felt that going into medicine was a huge mistake for any woman who wanted to become a mother. And I was determined to share that opinion.

Anyone who has read some of my earlier posts would know that I came dangerously close to blurting out that opinion on several occasions, but I always just barely stopped short and ended with some cheesy phrase like, "But it's all worth it." I didn't say what I truly felt because I was scared. I knew this opinion would not be popular. Nobody wants to hear that a woman shouldn't follow her career aspirations just because she wants to have a family. And moreover, I was embarrassed to admit that after seven grueling years of training and 100's of thousands of dollars in tuition, I had major regrets. But I felt that it was important and needed to be said.

(Maybe that's why I've written so much. I'm like the guy who buys twenty unneeded items at the newsstand, hoping the one issue of Playboy goes unnoticed.)

A year later, I still haven't made a definitive post warning mothers-to-be not to go into medicine. But not because I'm chicken anymore; it's because reading these entries over the course of the year has actually changed my mind. Hearing about all these female physicians (both the bloggers and the commenters) who love being mothers in medicine has inspired me. I'm changed. If you guys love it, then I'm optimistic that I can too. Maybe I'm just giddy about graduating residency, but I no longer feel a dire need to tell young female pre-meds to run before it's too late.

So I guess for my 50th post, I'd like to say thanks. Thanks to everyone who posted or commented about how being a physician mama is a gift that only a few of us get to experience. I needed that.

once I get through May (June, July, August...)

It's Monday morning, hope y'all had a great weekend. I did, but the weekends haven't been a problem, relaxing with Husband, Just Five, and Almost Three, as silly and lovable as they all are. Work-wise, though, I've noticed a trend I've fallen into all too often of late. I find I'll have a lot on my plate, usually professionally (sometimes personally) and so I say to myself calmly, if I can just get through May, then I'll have a lot less to do. I'll just get through all these deadlines that have crept up on me for early, mid, and late May, and then I'll be set. But of course, then June rolls around and I have yet more decisions to make, work to get started on, tasks to complete, things to prepare... They are things I enjoy, usually, but a lot of things nonetheless!

Well, when I had my little fender bender last Monday (no one was hurt, kids not in the car) I had an all to harsh reminder that it was time to slow down, literally and figuratively. Might not have been my fault, after all, in an accident you don't intentionally bump into another car, maybe it bumped into you. Who knows? Then, get this, after the accident and exchanging information and seeing that every one's okay, and taking care of all those necessary details, I got back in my car, drove to my morning meeting, walked in a few minutes late apologizing that I had an unexpected delay, and proceeded to lead the meeting for which I'd set the agenda. Only afterwards did I share what had happened with a trusted colleague, and then with my mom (with whom I cried on the phone) and had already called my ever so supportive ("It could happen to any of us") husband.

So, I've decided to slow down, this month, now, today. You?