A Little Gift To Take To Work

We just returned from a week's family vacation. The kids have been off from school, and Hubby has been off from work, so, we've all been together 24/7.

I have afternoon clinic on Mondays, and we dilly-dallied away the early Monday morning.

Finally, reluctantly, I packed my lunch bag, kissed Hubby and the kids goodbye, and set off on foot for the train.

My three-and-a-half-year-old daughter called out to me from an upstairs window: "Mommy! Mommy! MOMMY!"

I looked up from the driveway and yelled back, "Yes, honey?"

"Will you do me a favor, after work?" She says "favor" like "fay-vow" and "work" like "wowk".

"Of course, Honey! What is it you'd like?"

With adorable preschooler excitement, she stammered out, as loudly as she could: "Will you- will you- will you... I mean, after work, will you... please just come home?"

Oh, so, so adorable. So simple. I melted, I promised I would come home, directly home, and I kissed her on the head.

I kept remembering her sweet little three-year-old voice saying, begging, …will you please just come home?, and it kept me smiling all day long in clinic.

Book Review: Burning The Short White Coat by Eve Shvidler, M.D.

I love reading books written by other doctors. Especially when I actually have time to read them. When I read the P.R. blurb on OB/GYN Eve Shvidler's Burning The Short White Coat: A Story Of Becoming A Woman Doctor, I knew I HAD to make time to read this book:

"What happens when Sex and the City meets Grey's Anatomy?… A medical chick-lit novel, Burning The Short White Coat exposes the personal battles that single women must overcome in balancing a demanding profession and the desire to find a trusting and loving relationship…"

I've been waiting my whole life for the female House of God. I was very excited to know: Could this be it?

Well, not quite. But, this light read is definitely engaging, funny, and fun.

The story follows relatable Elle Gallagher (and BFFs) through four years of medical school, and much romance. The action of the prologue draws in the reader (Overnight call! Crash c-section!). The first chapter, "The Gross Lab", is so gross, it's great. I was having formaldehyde flashbacks, myself. There are such nice touches here: the dissection of the penis by the retired surgeon is worth the price of admission.

But, the issues that plague this book also begin here: spelling and grammatical errors. Lots of them.

Now, I also write for publication, and I hate when some reader expresses extreme annoyance over a couple of typos. But there are ALOT of typos, misspellings, and incomplete sentences throughout this book, so many that even I was extremely annoyed. If I wasn't almost at the end of the book, I would have put it down at "introidus". Which appears twice. These errors make the book read more like a rough draft.

There is also heavy use of clichés, which I can forgive because at the same time, there is also plenty of fresh, unique material.

The chapter titled "Psych" is a fascinating little story-within-a-story featuring one of the creepiest cases I've ever heard. If what is described really happened, that's crazy disturbing. If it didn't, that's crazy good imagination.

One surprise for me is that my favorite character in this book isn't one of the female protagonists at all, it's the slightly immature but lovable surgeon Samy. We all know that attendings who hang out with medical students… well, that's just wrong. But this guy, he's complex, and he has some great lines. His advice to Elle on booty call vs. relationship girls is right on, and I'm not sure I've seen it done so well in a book that wasn't intended for teenagers.

The best part by far, though, was the chapter titled "Good Vibrations". I believe I had a similar hilarious conversation with my medical school BFFs. I would never have dared to write about it, though. I'm impressed!

In the end, I thoroughly enjoyed what was overall a refreshing, real-deal, feminine take on the modern medical school experience. (Yes, people, med students DO party that hard.) I just wish someone had run a spell check and an editor's eye over the text prior to publication.

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Hot off the presses! Addendum! As of 6/27/15 I have just heard from the author that she had already realized there were many errors in the original manuscript, and she put the whole thing through a copyediting process. There will be a new release in about 2 weeks from now, sans errors.

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As an aside, I have to say, the author's blog on Wordpress (https://burningtheshortwhitecoat.wordpress.com) is VERY good reading. Her articles and essays are enormously informative and entertaining. Moms in the audience, do yourselves a favor and read her post Where's My Orgasm from June 8, 2015.

How Much Do You Share With Your Patients?

Genmedmom here.

In my practice, there are two kinds of doctors. There are those who don't display even one personal photo in their exam rooms, and then, there are those that do. Me? I proudly display a collage of recent kids' photos. Occasionally, a photo will include me and/or Hubby, or our cats.

I've found that the photos can "break the ice", meaning serve as benign fodder for a softer, friendlier discussion in an otherwise sterile, somewhat scary environment.

Let's face it: a bleachy-smelling standard-hospital-grade exam room, where the cold speculum and bristly Pap brushes are laid right out on the chux, is not a fun place to be sitting twiddling your thumbs. No People magazine can change that.

How do I know this? Hey, I have a doctor, too.

What I've personally experienced is that decorations or photos can help to create a warmer, more inviting environment. I'll immediately feel like this provider is confident enough to share of themselves; that they're open to connect with me as a fellow human being.

The exam rooms that don't feature any kind of personal touch may as well be alien spaceship exam rooms: What part of me is going to get probed?

The worst exam rooms I've encountered are at my GYN's office: almost completely tiled without any objects left out in view whatsoever. I feel like a lobster in a pound. They may get high marks from OSHA and The Joint Commission, but I sit there increasingly uneasy, freezing in my flimsy paper gown. Even our dentist does better job with environmental emotional regulation.

Our pediatrician wins the prize for personal adornments. He's got family photos, his kids' artwork, obviously his choice of decorations (all sports-themed), and entertaining items like books and toys strewn all about. Not only am I made to feel more at ease, but my kids are, as well.

Of course, items and photos invite questions and conversation. I think this is good, and I tend to be very open and honest with my patients. Hey, I'm querying them deeply about their relationships, jobs, bad habits, fertility plans, and private parts. These are all topics that are socially prohibited in usual, out-of-the-doctor's-office conversation. I can at least share that my kids are in preschool and my husband works for the Patriots.

Some patients ask more, and I have real conversations with these folks. My general rules of thumb are: no personal chit-chat until the patient's issues and concerns are addressed. No shooting the breeze when I'm running behind. No sharing of my own medical issues. (Well, I'll sometimes share that I used to smoke cigarettes and that it was hard for me to quit, too.)

In seven years of practicing in this style, I haven't had anyone complain that I waste their time or overshare. My colleagues can tell you that I run on time, more or less. (More than most.) At this point, my regular patients excitedly ask for updates as soon as I walk in the door. How are the kids, how old are they now? Still have those huge cats? What does your husband thank about Deflategate?

Obviously, I'm all for sharing. heck, I blog.

What do other docs think?

A Teaching Moment

Genmedmom here. This was going to be a sweet little post about a teaching experience from my clinic yesterday. A patient presented with a classic clinical finding, and I knew that one of the other providers had a few students with them. So I asked the patient if I could bring in a student or two, and she cheerfully assented. It's been a very long time since I was involved in clinical instruction, and I enjoyed it.

I searched the web for a photo image or clip art to accompany this piece, something that illustrated a female doctor teaching medicine to students. I typed in all sorts of search phrases, but the vast majority of clipart or stock photos clearly depicting a doctor instructing medical students showed male doctors- and often with a lovely nurse standing by.

The best approximation of a female teaching physician that I could find was this (*and, this image is totally copyright of Disney Junior):

I mean, it's a good thing that Doc McStuffins exists, and that this image and the DVD it advertises exist. Not to imply a commercial plug; I must emphasize, I have no financial disclosures here! I just love the example she sets for little girls, all the pink and purple notwithstanding. She's a doctor, and her mom is too. They're African-american. The show is a hit. It's awesome.

So, why was this the only image I can find of a female doctor actively teaching medicine to students? This was mind-boggling to me. I needed to understand. I needed data to interpret; it's just my research fellowship training.

And I found data. According to the Kaiser Foundation, there are 893,851 practicing physicians in the United States, and 32% of those are women. The American Association of Medical Colleges (AAMC) has published a detailed breakdown of U.S. medical faculty, by rank, sex, race/ethnicity and specialty. Per their data for 2014 (which can be found at The AAMC website Reports page):


Of the 155,089 total U.S. medical faculty, 62% are male and 31% are female.

Of those that are at the higher ranks, as in professor or associate professor, 72% are male and 28% are female.

The breakdown by race/ ethnicity is frankly depressing, and I didn't even want to figure it out. For those of you that enjoy crunching numbers, have at it- there's tons of other good data in there as well.

It's clear that we need more women physician role models and teachers of medicine. So, what are the obstacles?

Well, in my case.... When I started by current position at a major academic medical center, I was involved in a medical school course geared towards fostering empathy and communication skills. I think every med school has these now, Patient/Doctor/Society type courses. But then I became pregnant with Babyboy, and realized I would be out on maternity leave for a chunk of the next session, so I never signed back up. Now, with two very young kids and enough to balance as it is, I'm not sure I want to take on the added responsibility of teaching...Not just right now.

I know my kids will get older, and I hope to get involved with teaching again someday. Likewise with medical volunteer work. I'm half Latina, I speak Spanish, and I've lived and worked in Latin America. At some point, I'd like to get re-involved in that work, as well as be a mentor for Latina students...Someday.

Meantime, I very much enjoyed interacting with our students over a case of erythema multiforme this week.

I'm curious what the doctor-moms out there think of these numbers. Do we need more female physicians teaching medicine? How about female minority physicians teaching medicine? And what do others think about Doc McStuffins?

Up Against The Boards

Genmedmom here.

It's been ten years since I graduated from residency. I was Med/Peds and not quite sure what I was going to do with my life. So, I took both the Pediatrics and Internal Medicine board exams, within two months of each other. I know I studied, but I don't remember feeling overwhelmed by the material or flummoxed by the practice questions. I was a resident and then a research fellow, so I'm sure I didn't have oodles of free time. Both exams were sit-down, pencil-and-paper, highly regulated, proctored, and extremely lengthy affairs. But, somehow, I passed both tests, with minimal pain. (I'm not saying I passed with the highest scores, but hey, all you need to do is pass.)

Fast forward. I've been a Medicine attending for six years, and I'm due to re-take the medicine boards. I've registered and paid and I've got a date: April 15th.

But this time around, I am struggling. Yes, I have two little kids, and may be sleeping even less than I was as a resident. Yes, I'm purely outpatient and far, far removed from acute, inpatient care. There are scads of specialists in my large, teaching hospital- based clinic, and we frequently refer patients for alot of management issues.

But I'm only studying for the Internal Medicine boards, and I've been in practice for six years. You'd think I'd be more comfortable with this material.

Now, I like to study. I'm a dork that way. In my practice, I look stuff up all the time. I earned three hundred CME credits in the course of a year just by looking things up on our favorite medical search engine (yes, you can earn CME credits that way, if you register and then print out the report). So I figured, boards, no problem.

I got the study books and the audio material in November. I read when I can (after the kids have gone to bed, or late on a weekday workday) and listen to the most BORING medicine lectures during my commute.

But, I'm just struggling. I've reviewed a fraction of the total material. I'm getting killed on the practice questions. There are huge gaps in my knowledge, that is clear.

So I'm trying to get my head around this. The re-cert is about 8 hours of testing, now done electronically in testing centers around the country. Looks like a few hundred questions, from these basic areas:

Cardiovascular Medicine
Dermatology
Endocrinology & Metabolism
Gastroenterology & Hepatology
General Internal Medicine
Hematology & Oncology
Infectious Disease
Nephrology
Neurology
Pulmonary & Critical Care Medicine
Rheumatology

There is alot of potential question material under each discipline. At this point, I won't be able to review it all, to ABSORB all the material. I don't have time.

So I'm cramming questions. I'm doing 25-question blocks, and studying the answers, trying to learn patterns, what are they likely to ask about.

The overall pass rate for the October 2014 Internal Medicine board exam was reported as 72%... Ugh. The pass rates have been steadily declining over the past decade. Why? This is, apparently, a matter of much lively debate. In one fun article from the NEJM website, several hypotheses are presented. One conspiracy-theory hypothesis purports that the people that write the exam and charge us to take it have made it harder so that they can charge us to take it more times. Like, it's a money-maker. Other hypotheses include that we're losing the ability to study effectively, because we CAN look everything up on medical search engines... Oh.

So, I hired a sitter to get me 100% protected time on Saturday afternoons; I registered for a boards review course next week; I slashed my clinic hours to two hours per session for the three weeks leading up to the exam; and I limited my time writing blog posts to about thirty minutes a week total (ha!) so I can CRAM.

How does everyone else study for their boards?

Do Female Physicians Need Female Chaperones?

Genmedmom here.

Our department is considering a policy that would require female chaperones to monitor every pelvic exam. This would include pelvic exams performed by female providers.

As a primary care women's health doc who performs pelvic exams every day, I felt vaguely insulted by this.

But, as both a female physician as well as patient, I understand the reasoning behind this potential policy. In our department's case, it was apparently proposed in response to a complaint involving a female physician; we have no idea what the issue was. Of course, historically there have been cases where there was abuse of the doctor/ patient relationship in this context. Also, cases of perceived abuse. To have an official "observer" present can help to prevent any abuse, or false claims.

My own OB/GYN office uses chaperones. But it always strikes me as odd and impractical. My own OB/GYN is an excellent physician with superior bedside manner who has overseen both of my pregnancies; she even guided me safely through a VBAC. But even she has to leave the exam room and go fetch a medical assistant, who may have never met me and is not involved with my case, so that they can stand there and observe what is basic, routine office care. I've considered requesting that she NOT go fetch the superfluous eyeballs, as I think it's kind of weird, and it would save time, too. But I haven't wanted to rock the boat.

So, as I have myself experienced, having an additional person present for this exam can also in and of itself be uncomfortable, and can make routine medical care feel weird. It may not help many women to feel more comfortable at all.

Are there things we providers can incorporate into practice that can help minimize discomfort and prevent abuse, or perceived abuse?

I really try to help patients through what is generally considered, at the very least, an uncomfortable and awkward examination. For many women, a pelvic exam can even be a traumatic experience, either physically due to atrophy or inflammation, or psychologically due to past rape or sexual abuse.

I think there's some basic things that we can do to help women feel more comfortable and in control when a pelvic exam is necessary. These include explaining why we are doing the exam and what we are looking for before we even start. Does she need a Pap smear, or STD screening, or both? Is she complaining of pain during sex, abnormal discharge, abnormal bleeding? Is there a strong family history of GYN cancers? Is there a family or personal history of melanoma? Then we'll discuss whether the exam will include a speculum exam, or a bimanual exam, or just an external exam, and why. Not everyone always have to do have all of these.

It's important that the patient knows what's going on at all times. I think it's better if the back of the exam table is slightly elevated and the paper drape is pushed down, so that the patient can easily see the provider. I also try to explain everything I'm doing in real time. I don't even touch the patient in that area at all, without saying what I'm doing and why immediately beforehand. I'll hold the plastic speculum up, and explain that it's the same diameter as most regular tampons, that we use plenty of lubrication with this, and it's usually cold. I tend to talk through the entire procedure, Rachel Ray-esque. Often I'll suggest yoga breathing, letting the pelvic muscles and buttocks relax.

In some cases, urinary incontinence is a problem. If Kegel exercises may help, I ask women if they know how to do these. Then, I either test their Kegel, or ask if they want to learn this. What I've seen is that many women who think they're doing a good Kegel squeeze will actually be tightening their buttocks, or simply tilting the pelvis. So I add pelvic floor physical therapy here: a lesson in isolating the pelvic floor muscles, and a test to see if the patient is able to do a decent Kegel. I think if someone walked in as I'm saying "Squeeze!" they'd wonder what was going on. But since Kegel exercises are effective for preventing and treating urinary incontinence, we'd better make sure patients can do them before we recommend them.

Sometimes, a patient is extremely uncomfortable with some part of the pelvic exam. Then, the exam must be halted. I usually pull the drape back down and discuss, ask if they would like to try again, or hold off. I really don't think a provider can proceed in those cases without a time-out and discussion. It's okay, and sometimes absolutely necessary, to just skip the exam. It can be rescheduled; special arrangements can be made as well, as in cases of extreme physical or psychological discomfort, such as exam under anesthesia.

I've had patients tell me that the pelvic exam "really wasn't that bad", or even that they learned something useful. I take this as positive feedback! I'm sure I can do better; we all can. I'd be interested to know what techniques other providers have found to be useful.

If we are required to institute this female-chaperone-for-pelvic-exams policy, it would mean significant logistical hassle. In our office, we work one-on-one with the medical assistants, and several are male. Would the guys need to be let go, transferred to other practices? In addition, our medical assistants perform the phlebotomies on the patients they've checked in. Were this policy to be put in place, we would need to reorganize our whole system, and likely need to adjust the operating budget to include additional staff. And, of course, if we're required to go fetch a chaperone before every pelvic exam, that will add time to all of those patient visits. Either we'll all run even more behind, or we'll have to restructure our scheduling, and likely need to institute longer days for us and our staff, to accommodate. Again, this could mean a budget problem.

In summary, I don't think that requiring a chaperone to stand there and observe every single pelvic exam is a good idea.
But, I'm very curious what women physicians think about this, both as providers and as patients.

What better place to ask, then the physician-mom blog? What's the vote: Yay or nay?

For those docs that perform pelvic exams, what have you incorporated into your practice to help women feel more comfortable and in control?

-Genmedmom

I Don't Know How To Dress Myself

And I know I'm not the only one...

I was thrilled to see a physician-mom address this in the Atlantic: The Clothes Make The Doctor, by Anna Reisman. In this thoughtful and humorous piece, she describes how she met with a potential new primary care doc, and was put off by the sharp-dressed woman's stiletto heels and expensive suit. She then explores how physicians should ideally dress, and thus, present themselves.

She hit on a perennial topic of discussion and debate amongst my colleagues, both male and female. Male colleagues bemoan that they are expected to wear a collared dress shirt and tie, day in and day out. But female colleagues complain that they have no real "dress code", and thus, no guidance, on how to dress for patient care.

In my office, which is an all-female practice, the "work uniform" runs the gamut from: clean and pressed white coat over smart dress suits and heels, to dress suits and sensible shoes without the white coat, to business-casual with or without the white coat, and then, to me.

I'm usually in whatever Bargain Basement Clearance Store pants with less-dirty knit top and scuffed sensible shoes I can match when I get dressed in the dark at 5:30 a.m, with a reasonably clean white coat pulled over it all, like a disguise. I can't remember the last time I ironed anything; I think it stretches back a decade or more. I buy all permanent press or knit clothing. If something needs to be dry-cleaned, it's a once-a-year piece. Sweaters, slacks, scarves- they all must go into the washer and dryer, or be relegated forever to the back of the closet. This all is, I feel, most practical. Who has time to fuss over clothes?

I also LOVE a bargain. And while there are women who can browse Nordstrom Rack or Marshall's or TJ Maxx and put together respectable, even snazzy, professional outfits, I am not one of them.

Still, I can't let go of my old habits. In medical school, we had an informal group of women about the same size who met occasionally to "swap": everyone brought a bag of clothes they didn't want, all higher-quality stuff, and we had a party as we tried on each other's stuff. Everyone left with a "new" item, and the leftovers went to charity. If someone I knew suggested this today, I would so totally be there!

I even found my wedding dress, a 100% silk designer ball gown with an impressive train, for $250.00 at the Filene's Basement Run Of The Brides Traveling Sale, back in 2008. I considered it the find of the century, a total coup, and I told anyone who seemed like they cared how much I had spent.

I still have had no qualms with rooting through school fundraising secondhand clothing sales, and leaving with large bags of the clothes of people who are probably my neighbors.

I think some of my reticence on spending money on clothes stems from the fact that I've gone up and down ten sizes within the last five years. Yes, there were two pregnancies in there, but the ballooning waistline was not due to gravidity. It was due to the fact that I gained an unbelievable amount of weight with each pregnancy, on the order of sixty pounds, EACH TIME. Three months after my second baby, my daughter, was born, I realized that I had even GAINED weight while breastfeeding. My BMI was over 30. I was OBESE.

Then, with a two-year-long concerted effort at a low-carb diet and exercise when I could get it in, I lost fifty pounds. Babygirl is now almost three years old, and I've kept the weight off for almost a year.

Despite being back to my pre-pregnancy weight and size for this long, my closet is still filled with a mishmosh of sizes, and alot of "more comfortable" pieces, like Ponte slacks (read: knit pants). A friend and colleague recently pointed out to me, in a humorous way, that Ponte slacks are in the same category as yoga pants. Meaning, not acceptable work attire.

Unfortunately, in order to dress well, one needs two things: Time, and Style sense.

I know I will never have the time or inclination to study fashion magazines or follow style blogs. And for some reason, when I see someone who I think is dressed really well, meaning, how I'd LIKE to dress, I can't seem to replicate their look (probably because of my clothing care learning disability.)

But, I still want to look like a real, respectable, clean, practical yet SOMEWHAT stylish physician. Someone who is aware that it's almost 2015, but who is also willing to kneel down on the exam room floor to look at a patient's diabetic foot ulcer.

I know, I know. Time to grow up, learn how to iron, make the dry cleaners a regular weekly errand.

I also need a personal shopper. I have seen this mentioned on prior MiM posts (that I cannot locate right now), and people have suggested Macy's, as they offer those services free of charge. Of course, to take advantage of that requires several things: Making an appointment, taking some time, and investing in attire.

Sigh. With two children under age five, a working husband who travels alot, and boards study on the agenda every day, these things are not likely to happen anytime soon.

Tomorrow will dawn, and I will likely be pulling on a wool blend turtleneck, my black slacks with a little elastic in the waist, and Danskos.

But I will be comfy...

-Genmedmom

How Do You Discipline Your Kids- In Public?

Genmedmom here.

Last week, on my usual Thursday off, I was on kids' dropoff and pickup duty, and I had a very difficult time with pickup.

Both kids are in preschool: Babygirl, almost age 3, loves her Bright Horizons daycare/ preschool, and Babyboy, age 4, is becoming more fond of his public Special Ed preschool program, as his teacher has really connected with him. Getting them up/ fed/ dressed/ out the door is always a bit of a challenge, but manageable.

Pickups, however, are getting dangerous. And not just for me, but also for my mother, who is most often on pickup duty.

Given the timing of school dismissal, we need to pick up Babyboy first, and then swing by Babygirl's school. Since you can't leave a four-year-old in a car by themselves, he has to come in with us to retrieve his sister. For the past month or so, once inside, Babyboy finds something he wants to play with in her classroom, and won't leave. He gets obsessed with completing whatever project he's invented, like lining up the construction toys or building something with Legos. I get it, he's autistic, and tends to have these sort of OCD-like moments. If you try to stop him before he's done with whatever it is he's determined to do, he throws himself on the floor in a tantrum. A loud violent tantrum. Even when he doesn't engage in something in the classroom, when it's time to leave, he gets wild, and runs away down the hallways, laughing at me when I call to him.

Babygirl is also now commonly protesting leaving, and has thrown herself on the floor, or also run away, giggling.

All of this is totally disruptive. Not only for the kids in her classroom, but for everyone in the whole school, as my kids scream and shriek and wreak havoc. Heads pop out of doorways, teachers checking on us, kids asking what's going on. If I yell, I'm just contributing to the mayhem.

Last week was the worst for me. It was him running away, and her tantruming. We were in the hallway, me kneeling on the floor trying to dress Babygirl to go outside, as she rolled around screeching, fighting me. I gave up on forcing her into rain gear (it was pouring) and hoisted her up, flailing and screaming. Meanwhile, Babyboy was running up and down the hallways, throwing himself on the carpet and rolling around, laughing defiantly. I had to chase down my son, grab his arm, and struggle out of the building. This was while carrying Babygirl, her lunchbox, raincoat, and backback.

I lost the backpack somewhere (and didn't realize until we got home), probably when I opened the heavy door. I had to let go of Babyboy in order to open it, and as soon as I did, Babyboy bolted out, across the driveway, and into the parking lot. In the rain.

There were no cars coming at that moment, thank God. But I yelled and yelled: Get back here! You hold mommy's hand in the parking lot! It was a safety issue. I had to get him and us out of the driveway and the parking area, and into the car. I yelled, I threatened, but he would not cooperate. Then Babygirl hurled herself down and I had to wrestle her back up, while attempting to run after a defiantly giggling Babyboy. The more I yelled, the worse he got. I caught him, and fairly dragged him to the car.

Finally, I jammed Babygirl into her seat and buckled her in- safe at least! And threatened to do the same for Babyboy. He got in his seat.

I was fairly shaking by the time I got into my seat. My throat hurt from yelling so much. It was so embarassing... What do the teachers think? What do other parents think?

"You both were very bad today," I admonished. I wasn't sure what else to do. They're in the car, so can't do a time-out. I'm not sure a delayed time-out would be helpful. I think spanking solves nothing, and would look awful in public as well!

They've been much the same for my mother all this week. So me, my husband, and mother have talked about this. We're struck with the difference between the kids when they're together, and when they're apart. One-on-one, they're little angels. Barring hunger or naptime, when it's just one by themselves, they're model citizens.

And, occasionally, they're OK together. I've taken both kids to restaurants, just me and them, and they've been wonderful. Random elderly women have complimented us: "Good as gold!" "So nice to see such good behavior!"

We can't figure out why Babygirl's school pickup has become such a trigger for terrible behavior. Sibling rivalry, like, they're competing for attention? Normal toddler/ preschooler defiance, like,as their sense of self forms and they're establishing independence?

We have consulted with a child psychologist in the past, and we will again. But I know there's alot of experience out there. Anyone else sometimes struggle to control their kids in public? What sort of discipline tactics work?

Genmedmom

Would You Care For A Patient With Ebola?

Genmedmom here.

Last week, a patient with risk factors for Ebola exposure, and who had medical issues, walked into our office.

Kudos to our N.P., who handled this very well. Upon learning of the potential exposure, she called infectious disease at our hospital, and they walked her through the appropriate screening interview questions. It took awhile, but she was able to determine that this patient was extremely low-risk for direct contact with the Ebola virus, and was not exhibiting any suspect symptoms. She was given the all-clear by infectious disease, and proceeded to take care of the patient.

Of course, this drove home very quickly the fact that any of us could be called upon to make a similar evaluation at amy time. I know I opened our hospital-issued Ebola risk stratification and action guidelines and read them over several times.

All day and on the long drive home, I imagined what I would do.

My first instinct was: Of course I would step in and help, no matter what any patient had or may have. I'm a healthcare provider. That's my job.

But.

There are now two nurses who contracted Ebola through caring for an infected patient in Dallas, despite knowing the diagnosis and wearing all the recommended protective gear. This is a virus with a 40 to 50% case fatality rate (now reported as closer to 70% in West Africa, due to lack of resources and care).

I'm a mother to two very special little kids. Could I justify knowingly exposing myself to a highly contagious virus with a grim fatality rate?

I went back and forth in my mind.

There are many healthcare workers in this country... But my kids only have one mom.

On the other hand, I do think that nurses and nurses' aides are at far greater risk of exposure, due to the inherent nature of their jobs and the mode of transmission of the virus. Now that I am an outpatient attending, I am rarely exposed to patients' body fluids.

But.

It only takes one, tiny exposure.

Of course, we have had a providers' meeting about this, and we did review our office protocol again. If needed, we have the "moon suits" and a designated isolation room. We have all the phone numbers to call to arrange transport of a suspected case. We have solid resources, so unlike our counterparts in West Africa. My heart goes out to them and to all the poor people suffering with this. We are lucky over here.

But.

I don't know much about donning layers of protective gear. I would likely screw it up. It only takes one, tiny exposure.

How would I then limit contact with my family, not get too close with my kids, for twenty-one days? I'm always clearing noses, changing diapers, wiping binkies... it would be near-impossible, and nerve-racking.

Ugh.

I don't know what I will do, given the choice.

I know that many hospitals are compiling lists of volunteers, staff who are willing to care for patients with Ebola, including aides, nurses, physicians.... I understand that most of these lists are pretty short. I have no idea what our hospitals' list looks like. I know I am not on it.

I am very curious what others have thought about this, especially the hospitalists and nurses out there, who would likely have more direct and frequent contact with a case should one come in.

Healthcare provider-moms, what are your thoughts?

And if you haven't thought about it, you should....


--Genmedmom, also at www.generallymedicine.com

Why Is Residency So Harmful? (And What Can We Do About It?)

Genmedmom here.

I'd like to thank "J the intern" for her post on physician depression and suicide on 9/9/14, as it prompted me to read Pranay Sinha's excellent New York Times Op-Ed piece "Why Do Doctors Commit Suicide?" He discusses what may have contributed to two recent intern suicides, namely, the shock of graduating from well-supported medical student to overburdened resident drowning in the macho medical culture. He describes his early intern year as "marked by severe fatigue, numerous clinical errors [], a constant and haunting fear of hurting my patients, and an inescapable sense of inadequacy."

Ah, yes. Residency.

In the comments to J the intern's post, OMDG brings up as additional factor to consider: "the elephant in the room... sometimes doctors treat each other like garbage".

Yup, I agree with that one, too. No one is more cruel to the suffering than the suffering. Many of my own emotional injury during training was at the hands of my colleagues. But, I know that I lashed out as well. We all hurt each other. I'd like to expound on that, if I may.

I well remember being humiliated on rounds, Monday-morning quarterbacked by someone fresh and showered. I cringe as I recall snapping at my intern for waking me up to check on a patient she was worried about. I'd been snapped at in a similar way as an intern. I remember with sinking stomach the disdain and sarcasm I received when I tried to teach a medical student a very simple procedure, and then couldn't do it myself. I still get angry when I think about the patients who suffered as my residents tried to teach me paracentesis, central line insertions, lumbar puncture- and failed on their attempts. I know my anger showed then. When our colleagues rotating at a small outside hospital transferred a sick patient to us in the emergency room, and it turned out to be a case of lab error, no pathology, there was derision all-around: "They dropped us a turkey, guys." When I was worried about a sick patient and called for an ICU consult, the ICU resident came, and told me I could handle it. "Don't be a wuss. Be a real doctor."

The cruelty towards women was pervasive. A pregnant resident had an early miscarriage. Still bleeding, she asked to be excused from her outpatient clinic. The chief, a woman, said no. "Just think of it like your period," she said.

A colleague went out on maternity leave six weeks early, for premature labor. Another resident was pulled from an outpatient elective to cover the rest of her rotation on the floors. The resident who was pulled was very resentful, angry to tears. "Why the f-- would anyone want to have a baby during residency? Why?" Another answered, "I'll never understand it. It's so selfish."

It's well-known that medical training erodes empathy. It took years for me to recover from residency, to feel like I could even begin to take care of people again. Literally. I did a research fellowship for three years, in large part because I couldn't imagine returning to clinical practice.

But, why did I feel this way, when my residency program was well- regarded, with many opportunities to share, reflect, even write? Why were so many of us injured and angered by our experience? So many of us recall their training with a shudder, vowing "I wouldn't revisit those years for all the money in the world."

That's just not right. How can we change it?

Open discussions confronting the cruelty of medical training may help. As a medical student, I was rotating on surgery. A rural hospital transferred a very sick patient to us, someone who had been misdiagnosed and suffered greatly. As the case was reported on rounds, there was loud derision and disgust expressed towards the rural docs. But one senior surgeon, someone so intimidating and revered that just a movement of his hand silenced the crowd, quietly admonished:

"There's no point in criticizing. Your fellow physician took the same oath you did. Assume that they tried, and that they feel terribly. We have all made mistakes, and we will all make many more. Don't waste your time on judgment."

End of that discussion, and it made an impression on me. Don't waste your time on judgment. I think, as teachers, we need to stand up and say that, and live that. Be real doctors.

We also need to dismantle that confusing paradigm of training: You are here to learn, but you should already know how to do it. Sinha also illustrates this in his essay. You were a coddled student in June, and then the doctor in July. You feel like you're supposed to know it all, because everyone is acting like they do know it all. Everyone's got a front. To ask for help is to be weak.

I remember very early in training, asking how, exactly, to write a prescription. I'd never written one before.

Oh, the rolling of eyes, the quick snappish explanation. I was so upset, I didn't catch it all. I spied on other people writing prescriptions and copied them. Seriously, how the heck are you supposed to know how to write a prescription if no one's really taught you?

How are you supposed to know how to be a doctor, if no one's really taught you?

I'm interested to hear what others' experiences have been, good and bad, with an eye towards practical suggestions. How do you think medical training be reformed?

Taking Care Of Ourselves

Genmedmom here.

A patient of mine recently asked me how my kids are, and what cute things were they doing nowadays? I'm very open about my family with all of my patients. They've seen me huge and pregnant, and they've seen my colleagues during my maternity leaves. My kids' photos hang in my exam room. We often trade parenting experiences as part of the visit.

So, I was not at all put off by her asking about my kids. Her visit was over anyways, and we were only making small talk as we wrapped it up. I described how Babyboy is a little engineer, always building and figuring things out, and that Babygirl is full of sass and song, teasting and challenging and singing all day long. She laughed and said a few things about her kids, how they were all grown up, how she missed their little days, but didn't miss how hard it had been.

"Make sure you take care of yourself," she said, suddenly not laughing anymore. It was a bit abrupt, this serious turn of mood.

"I mean you need to take the time for care for you, because you need to replenish your strength, to be able to care for your kids. Exercise, salon time, friends time, it's really important. You need to do that." She was beseeching me.

"Uh, okay, yes, I know what you mean, absolutely..." We were moving towards the door.

She stopped, and said, quietly: "No, really, I can see how tired you are. You're really, really tired. Remember to take care of you. I need you to, too!" Here she smiled, and the door opened and she was gone, leaving me unusually flustered, standing there for a few seconds, wondering what next.

I know I carried on with my clinic, and then went home, and did the dinner/ bathtime/ bedtime routine with my kids. I know I crammed in some mail opening, bill pay, and reading. I know that sleep was likely disrupted by something... If not one of the kids (usually Babygirl) then the cats, or this nagging cough I've had. I know I am really, really tired.

Now, I have alot of help from a wonderful husband and my untiring mother. I do get to exercise twice a week. I write, which is therapeutic. Hubby and I sit down for dinner every night that he's not traveling, and we have family dinners every week. I don't shop much, or see friends that often, and I can't remember the last time I went to a salon.

I honestly can't tell if I'm taking care of myself enough or not. I think I am. But if patients see me as exhausted, drained, that's not good. I'm not sure how much more time I can carve out for "down time" things, and I'm not sure I feel that strongly about making that happen.

What do others do to take care of themselves? How much down time do you need?

I Spanked My Kid.

Genmedmom here.

I spanked my oldest last Wednesday. Twice. He's only four, he's autistic, and I hadn't seen him all day. I am such a jerk.

My day had started at five a.m. I had several extremely complicated and sick patients and several extremely complicated phone calls and a load of logistical paperwork and an inpatient to see and it was downpouring when I left work and I had to walk a mile to my car and the afternoon rush-hour traffic was standstill in the tunnel and I was forced to breathe car exhaust and I felt sick all the way to Nana's house blah blah blah.

I had been truly looking forward to seeing my little man and my little bug. But all the way to my mother's house (she picks the kids up from school/ daycare), all I was thinking was that I had to get the kids rounded up and in my car and back home for baths and bedtime, and I wasn't sure what time Hubby was coming home. I was stressed that I might be solo for the whole night-night routine (Panic!!!!)

When I got there, Babyboy had a poop and a terrible diaper rash, and he didn't want to be changed, so he twisted and turned, and he started grabbing things and throwing them at me, including poop-covered baby wipes, and I yelled STOP IT and swatted him on his butt. Then five minutes later he shoved a throw pillow at my infant niece, and I yelled THAT'S IT and I spanked him.

Now I feel terrible.

I've yelled and spanked before, and it always makes me feel like the most ineffective, inept, stupid, bad mommy. I intend to avoid this primordial parenting technique. But when I'm exhausted, and I can't seem to get control of my kids, I just get so frustrated and angry, and I can't seem to access any of the more advanced parenting skills I've read about.

And, spanking works. In the very short term. Very, very short term. Babyboy stopped throwing poopie wipes the first time, and he stopped shoving pillows the second time. But he cried and wailed for Nana, who never loses it and is always calm.

So, obviously not a great parenting tactic. And if my colleagues and patients saw me lose it and get physical over poopie wipes and pillows, I would be mortified.

The best book on parenting an autistic child that I have encountered so far has several wonderful lessons and suggestions on this very topic. I've dog-eared the pages and read them several times.

The book is Ten Things Every Child With Autism Wishes You Knew by Ellen Notbohm (Future Horizons, 2012), and chapter 9, "Identify What Triggers My Meltdowns" is applicable to any parent of any child who ever throws a tantrum for any reason.

She writes: "If you react with anger and frustration to your child or student's meltdowns, you're modeling the very behavior you want him or her to change. It's incumbent upon you as an adult, at all times and in every situation, to refrain from responding in kind. Be your own behavior detective. Figure out what triggers your own boiling point and interrupt the episode before you reach that point. When your thermostat zooms skyward, better to temorarily remove yourself from that situation."

In my case, Babyboy may have been overstimulated, and then protesting. There were many family members in the house and in the room; I had just arrived; the television was on; it was stormy outside... and I was pinning him down to the unpleasant and even painful task of a diaper change. When he acted out, I could have held in all my frustration, got the poop reasonably cleaned up, and put Babyboy in time-out in another room, away from everyone. That may have avoided the second outburst and spanking.

Of course, there are many people who feel that spanking is acceptable parenting behavior, and Ellen Notbohm has these questions for those folks:

"Consider:

Does spanking follow careful weighing of alternative responses and a reasoned decision that, yes, striking someone one-quarter our size is logical, provides a good example for them to follow, and will produce the desired long-term result? Can we be sure that it teaches the child what she did wrong?

Does it give her the knowledge and skills to correct the behavior? Or does spanking spring from aggravation, wrath and desperation?

Does it foster respect and understanding, or humiliation and bewilderment? Does it enhance the child's ability to trust us? Is it a behavior we want the child to emulate?"

Of course, this all makes perfect, clear, sane sense. And I've read it, and I get it. But in the moment, I haven't been able to consistently refrain from yelling and spanking. And I'd like to.

I think the real answer is in identifying Babyboy's triggers and trying to avoid them. In my case that day, there was an even better potential solution: I could have taken him to another, quiet room to change his diaper, and, after a bit of cuddly mommy time, I could have given him some control over the process, a job to do, like handing me the wipes or unfolding his clean diaper.

That response would have been ideal. It would have required some thoughtfulness, some space, some time.

As Ellen Notbohm writes, "Many will be the wearying moment when the root cause of your child's meltdown won't be immediately evident. There may never be a time in your life when it's more incumbent upon you to become a detective, that is, to ascertain, become aware of, diagnose, discover, expose, ferret out..."

As a physician, I am so accustomed to multitasking, problem-solving, wasting no time, get the job done... With Babyboy I need to slow down, breathe, and think. Study him, and anticipate the acting out, the outbursts, the tantrums, and steer around, or make them disappear. I do think it's possible...

Has anyone else out there had any similar experiences/ got any suggestions to share?

What Does "Lean In" Mean? Whatever You Want It To.

Genmedmom here. You'd think that as a doctor and a mother and a blogger with a focus on work-life balance, that I'd have been psyched to read Sheryl Sandberg's Lean In. Truthfully, I dreaded reading it.

I figured I'd have to read it sooner or later, given what I do, and I wasn't looking forward to it at all. From the bits and pieces I'd heard about it, I assumed that it must be a pushy, finger-wagging manifesto designed to make me feel more guilty that I already felt.

But I felt guilty NOT reading it. So one day, when I ordered a bunch of books on Autism (our son is autistic) and a few Barbara Brown Taylor essay collections, I also ordered Lean In. It sat on my bedside table for about a month. The other books got read (I read a lot), but Sheryl's smiling face looked up at me night after night, book closed, waiting.

Finally, one night, after the kids were down and charts were done and my brain needed some book reading for an hour or so, I realized I had nothing else to read but smiling Sheryl. I very reluctantly opened it...

And she had me at the second paragraph of the introduction.

She describes how she gained seventy pounds in her first pregnancy, and suffered from brutal nausea the whole time; how she struggled with simply walking, and realized that Google needed to have pregnancy parking close to the building, for all pregnant employees. So she made it happen. Wow.

Flashback to my pregnancies, where I gained, yes, seventy pounds, and felt awful, and struggled with simply walking... Like many employees of my big city hospital, I park at a garage about a mile away, and walk in. For my first pregnancy, my manager gave me a handful of parking passes that I used in the last ten days. That was great, but it was the last ten days, and there weren't any for my second pregnancy. I remember waddling painfully to and fro...

The point of her sharing the anecdote is to illustrate that she didn't realize how helpful pregnancy parking would be until she experienced it for herself. She wondered how no one brought it up before:

"The other pregnant women must have suffered in silence, not wanting to ask for special treatment. Or maybe they lacked the confidence and seniority to demand that the problem be fixed. Having one pregnant woman at the top- even one who looked like a whale- made the difference".

The book continues in this style, outlining the significant challenges women face in today's workplace, dotted with personal anecdotes and shared stories, humor, and problem-solving suggestions. There's plenty of data, but it's not boring. I was surprised at the praise, validation and encouragement for women at all angles of leaning in, including those who work part-time or stay at home. There is very little by way of exhortation; actually, I had to search for anything:

"I have written this book to encourage women to dream big, forge a path through the obstacles, and achieve their full potential. I am hoping that each woman will set her own goals and reach for them with gusto."

I actually enjoyed this book, and strongly recommend it to any woman considering a career in anything.

So, why did I dread reading it? Why did a book described everywhere as "an inspiring call to action" sit gathering dust on my bedside table for a month?

Well, as an internist who works part-time and mother of two young children, I've been exhorted, invalidated, even attacked. So, I assumed Sandberg's book would be another attack. It's not every day, but I'm sure I'm not the only part-time physician who has encountered this, the face-scrunching and "So, how does THAT work?" or a "Don't your patients get frustrated that you're not fully available?" kind of thing.

The attack most famous came from a senior female physician. I remember how sick I felt when I read anesthesiologist Karen Sibert's Op-Ed "Don't Quit This Day Job" in the New York Times (June 2011). In this essay, she doesn't just frown upon women working part-time in medicine: she crushes them. Worse, she crushes the aspirations of those considering medicine as a career:

"I recently spoke with a college student who asked me if anesthesiology is a good field for women. She didn’t want to hear that my days are unpredictable because serious operations can take a long time and emergency surgery often needs to be done at night. What she really wanted to know was if my working life was consistent with her rosy vision of limited work hours and raising children. I doubt that she welcomed my parting advice: If you want to be a doctor, be a doctor....You can’t have it all."

The death blow, however, was to people like me,

"Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work."

The... what do you call this? It wasn't an implication or an accusation, it was a sound dismissal of MY life's work. I have a small panel of patients, commensurate to my four clinical sessions per week. I work in a warm, nurturing environment, in a group practice of all part-time female internists. We have excellent clinical support staff. We enjoy great flexibility in our hours. We also are also regularly evaluated and rated by our patients, as well as our hospital, on various criteria ranging from patient satisfaction surveys to outcomes data comparisons between practices, and we perform extremely well.

I also have two small children, ages two and three, a working husband who is a wonderful partner, and family close by. I'm almost always home for dinner, and enjoy most weekends with my family. Yes, we carry pagers and are on call for ourselves Monday through Friday, with weekend calls shared, and there are occasional calls at less opportune times (bathtime, bedtime..). And, with the advent of the patient portal, where patients can communicate with providers online (kind of like email), they can send me a message basically anytime. But overall, clashes between work and family are few and far between.

My gut sense is that what I have going works. Most of my patients are working women, and I'm open and chatty about being a working mom (can you tell?). My kids' photos are up in my exam room, regularly updated, and patients eagerly ask about them, just as I inquire about their families. We trade stories. I receive solidly positive feedback from patients and colleagues alike. (I feel weird putting it on paper, all this positivity, but isn't that what we women do, is downplay our achievements?)

THIS is my "leaning in". I do not aspire to be a department chair, to publish in the peer-reviewed literature (though I have), or to have my own office with puffy leather chairs. I have made the considerable achievements of graduating from medical school, surviving residency, and thriving in a highly regarded primary care practice. I want to be a good doctor and a good mother (and to write about it!) I believe that you CAN have all this, because I do.

That is the beauty of the message from Sheryl Sandberg: "leaning in" isn't a one-size-fits-all formula. As in the quote above, she hopes that women set their own goals and reach for them.

Sandberg also talks about how women need to help other women achieve their goals. I agree with that, and it starts with pregnancy parking! It also includes calmly ignoring even senior female docs like Karen Sibert when they try to force a one-size-fits-all, my-way-or-the-highway approach onto a career path as variable and malleable as medicine. Sandberg discusses the phenomenon of senior women not only being unhelpful, but even hindering the progress of the up-and-coming women:

"Critics have scoffed at me for trusting that once women are in power, that they will help one another, since that has not always been the case. I'm willing to take that bet. The first wave of women who ascended to leadership positions were few and far between, and to survive, many focused more on fitting in than on helping others. The current wave of female leadership in increasingly willing to speak up. The more women attain positions of power, the less pressure there will be to conform, and the more they will do for other women."

So, read the book, and either make your way up, or reach a hand down. Set goals and "lean in" any way you choose, because only you know what is right for you, and if it's right for you, it's all right.

And I'm interested to hear what others think of smiling Sheryl's book.

Jack Of All Trades, Master Of None

(Patient accounts have been altered so as to protect their privacy and identity)

When I walked into my internal medicine practice office yesterday morning at 6:30 a.m., I was surprised to see only three patients on my schedule. Then I remembered there was a major winter storm forecast, and no one was sure how bad we were going to get hit. By the time the early administrative staff was arriving at 7:30 a.m., patients had realized the storm was basically just alot of wind, and they started calling. And booking. The 8 a.m. slot filled, then the 8:20, soon all the rest... I had an almost-full schedule in no time. And it was almost all "urgent care".

I love urgent care. It's so nice to take a break from the "comprehensive annual exam". Or at least, the way I approach those... I tend to obsess over missing something, and so I take the annual exam as an opportunity to comb through the patient's chart, and attempt to make appropriate note of every past, present, and possible future health issue. Plus, this is my big chance to catch up with folks on their Real Lives. So, What do you do when you're not sitting on my exam table in a johnny? Of course, folks come in with their own agendas, the lists of questions jotted down on the backs of envelopes or in the iPhone. Some docs shut all that down, citing "This is your preventive health time only!" which is ridiculous. So, the issues are addressed. Then there's the vaccines review, and lab ordering... These may or may not be straightforward, and more often than not involve additional discussion. My physical exams always run overtime.

So, a day of mostly urgent visits, those single-issue problem visits that can be serious, but at least, straightforward, are a welcome change.

On the other hand, these days highlight what is beautiful, difficult, and terrifying about primary care specialties like internal medicine:

1. You're supposed to know everything about everything.

2. Because we're trained to be always thinking about the Whole Patient- Nothing is ever straightforward.

First patient. The check in sheet states "Cough". Ha, easy. Well, not so much. The cough was undertreated asthma in the setting of a mild cold. But his blood pressure was very elevated. And a quick perusal of the chart showed, this was someone who hadn't been in for a couple of years. Turns out this was someone who had extreme doctor anxiety and alot of issues that needed more fine-tuning. So the visit turned into counseling and negotiations. I set up a followup appointment with the actual primary care and sent my note... Hoping the guy comes back.

Now, running fifteen minutes behind, next patient. "Rash". This is only easy if it's Shingles... and it was. But, the patient is a healthcare provider. And they wanted to know- needed to know- know all the occupational health issues around Shingles. Did they need to notify all the patients they had seen in the past day? How long did they need to be out of work? Did my recommendation around that differ from our hospital's occupational health policy? I wanted to be able to provide a modicum of accurate counseling in all of these areas. I spent some time with her researching the guidelines and then asked her to contact both her supervisor and occupational health for the rest. Then she needed a note. We wrestled over how to phrase it. I hit "print". The printer wouldn't print. Had to run to another computer. Time ticking away.

Then done with that, I had to check my clinical messages (our in-office messaging, where the secretaries and nurses send me anything from patient phone or email queries, VNA concerns, controlled substance medication requests, or abnormal lab or radiology results). I need to quickly scan the list and make sure there is nothing requiring urgent attention. Then deal with those. Someone emailed about their ankle sprain. Nurse: They just want X-rays ordered. Can we do that? Me: Not really, please have them make an appointment. Et cetera.

Then, my email. There's several more emails for me in a now-massive email chain regarding one patient of mine. She has a large team of specialists; her case is complicated; she may need to be admitted, and I would need to arrange that. I read quickly and make sure no one has asked me to do anything yet. I know the specialists probably roll their eyes at my questions. I haven't treated many cases of what she has. I have to read up every time she has labs. But she comes to me, and I'm doing the best I can.

Now hopelessly behind. Next patient: STD screening. Ha, easy! Not. Upon questioning, she tells me one of her partners is a recovering IV drug user. I deliver alot of counseling around this, do a pelvic exam with cultures, send for bloodwork and arrange more followup with bloodwork in two months.

Next: Elderly patient with shortness of breath. She was pretty sick. She told me she had almost passed out in the waiting room. Long and short of it, this person was too sick for my office. But, she resisted my emergency room suggestion. We went into negotiations. I called the emergency room to expedite. We waited for a wheelchair. I typed up my assessment and impression so the emergency docs would have it. Why take the time to chart, when the next patient is waiting? I felt like I needed to present at least a reasonable hypothesis for her condition, as well as defend my decision to send her to the emergency room. I delved more into her chart. Why do her lungs sound like a freight train screeching to a halt? Asthma in someone who's never had asthma? COPD is someone who's never smoked? Pneumonia more likely. Pulmonary edema, maybe.... Type it up. Hit "finalize."

Next: Wrist pain in a guy who does martial arts. I had to do a quick review of the possibilities. Refresh myself on the exam findings in occult scaphoid fracture. Then look up what type of immobilizing brace to prescribe while that is being ruled out. Then the printer didn't work again.

Next: Lovely lady with- finally! A very straightforward issue. Simple. I took care of it and was ready to wrap it up, when, she wanted my opinion on the new blood thinners. She's on Coumadin for atrial fibrillation, for stroke prevention. These new blood thinners are advertised on T.V. The cardiologists are prescribing them right and left. I have never prescribed these. I look it up, with her right there, and review some of the major pros and cons. There's no testing to see if someone is on too low or too high of a dose. That's nice. But, they aren't as readily reversible, so if someone has a car accident or a bleeding ulcer, they may bleed to death more easily than otherwise. Basically, that's what I told her, adding that we can also ask her cardiologist about it. No, she said, I like to know my numbers.

Next, next and next. There was a physical exam in there, and a few more not-so-straightforward urgent care visits. That was it. Nine Patients, and a barrage of clinical messages and emails. I was starving, and I had to pee. I peed, ate something at my desk, and delved into charting, billing, and all the messages/ emails, as well as the arrangements to be made for that very sick patient. I checked in with the emergency room on the lady I had sent in- she was to be admitted. Ha. I knew she was sick.

Mixed in there, I check in with home. I'm thinking about my kids. On my personal email, there are messages back and forth about our autistic son who's had some issues at his special education preschool. School aversion, we don't know why. It's getting better, with a good and patient teacher. But, I worry I'm not doing enough reading and research on autism, that we're not doing enough behavioral work at home. So I got on Amazon and researched, ordered some books.

At the end of the day, I wonder why I'm so fried.

Is it a good, or a bad thing, to be in a job where your mind has to hop, skip and jump and WORK from case to case and even within a case? We see everything and anything, and we're expected to counsel on even more. That, plus the balance with home life, taking care of a family...

Is it a good thing to be a Jack of all trades, Master of none?

-posted by Genmedmom (generallymedicine.com)

Docs, do you prescribe for your kids?

Genmedmom here. I did a bad, bad thing this weekend.

Both of my kids, Babyboy age 3.5 and Babygirl age 2, have had upper respiratory boogery junkiness for weeks. Both are in some sort of school, hence, they're both sick all the time. We deal with that; it's to be expected. They were either sent home or kept out of school all last week with boogery junky coughs. Saturday: they were pretty good, on the mend, even! Sunday: horrible.

Babyboy woke up very early Sunday morning complaining of a tummyache. Then, ear pain. Then, he started vomiting. He'd hold his right ear, howling and whining, then vomit. He's had ear infections before, and this is his presentation. Prolonged congestion, followed by malaise and tummyache, followed by ear pain and vomiting.

It was kind of scary as he did something I haven't seen him do before- he was grimacing, crying, holding his right ear with one hand, and then hitting the couch with the other hand. Like, hitting the couch with the pain.

Usually, I am a stickler about bringing my own kids to their own doctor to be evaluated for anything. Yes, I am Med/Peds trained, and I passed the Pedi boards, um, ugh, nine years ago.... but no, I do not practice Peds. I hate examining my own kids; I don't have the heart to hold down anyone's head to try to look in their ears.

But.

It was Sunday. It was really, really cold out. Babyboy was absolutely miserable. And it was so, so obvious that he had an ear infection. I knew that if I called his Pedi's office, they would (probably correctly) recommend some sort of eval. On a weekday or Saturday, they are awesome about making same-day appointments happen. But on a Sunday, it's going to mean a ride into the city and a looong wait in a crowded waiting room full of kids sicker than mine.

So, I made a diagnosis. I did examine him, sort of. I listened to his heart, normal. Lungs, clear. I felt his tummy, soft. I tried to look in his ears. He screamed and pulled away. I waited until he dozed off and tried to look in his ears: He screamed and pulled away. He's not that protective of his ears generally, so I figured that was further sign of ear discomfort.

I did talk it over with another doctor, an experienced GP turned oncologist turned internist, who was our own default emergency pediatrician growing up. That would be my dad, still in solo practice after all these years. And, I got a second opinion from a very well-trained internist who happens to work at my same hospital...That would be my brother. And the diagnosis was further confirmed by our informally-trained healthcare provider, my mother, who said something like, "They're been sick for weeks. Get them on some antibiotics already." It was my dad who called in the Amoxicillin, though I figured out the dosing.

Babyboy got some Ibuprofen and Amoxicillin and slept on the couch most of the day... When he woke up around 3 pm, he sat up, rubbed his eyes, hopped down onto the floor and started playing Legos. "Can I have juice?" he asked. Ha.

I felt guilty, though. Was I wrong to diagnose and treat my own kid?

Then, more horrible. Babygirl was a bit off all day. She didn't eat well. She fell asleep pretty early at 6 pm.

Then, around 8 pm, she awoke, screaming. We tried rocking her, tried to soothe her, but she kept screaming this shrill, high scream, kicking her legs in convulsive spurts.

And holding her left ear. Actually she was sticking her finger in her left ear, digging at it, like she was trying to get something out of it. We got Ibuprofen into her and waited for it to kick in. Minutes ticked by and still she was sreaming, convulsively kicking, digging at her ear, screaming, kicking, then "Mama mama mama aaaaaah!" It was pretty awful. I was trying to think what to do. We didn't have any Auralgan... The last time I asked our pediatrician about it, he said he discouraged its use, and told us to use Ibuprofen or Tylenol instead. I thought about... Ciprodex.

Back in the old days, like, when I was a resident, the standard prescription for an ear infection was oral antibiotics plus something like Ciprodex, an antibiotic/ steroid ear drop. Research then showed that the drops didn't do much for otitis media, so the dual prescription fell out of favor. Except with my dad, who had called it in along with the Amoxicillin. So, Hubby ran to get the bottle, and out of sheer desperation, with a sweating, almost crazy with pain Babygirl writhing in my lap, I squirted a good amount of the room-temperature drops into her left ear canal.

She startled, screamed some more, still holding the ear, then, slowly, relaxed. Whimpered, cried out a few more times, then fell alseep.

Hubby and I looked at each other like, Okay? Is that it? I tried to think how the drops might have worked so well, so quickly. I didn't expect the anti-inflammatory effect to take so fast. But perhaps they did nothing more than equalize the pressure in her ear. If the tympanic membrane was bulging out, some warm fluid might have helped ease some of the distension. After all, as my mom pointed out later, an old remedy for an earache used to be warm olive oil poured into the ear canal.

Or maybe the Ibuprofen kicked in. Or maybe she had exhausted herself. At any rate, she had been insanely flailing with pain for almost 20 minutes, and now, was resting quietly. We were so glad. I was almost in tears, actually.

Then we went and pushed our luck. We had two big fresh bottles of Amoxicillin for Babyboy (with alot extra, as the pharmacist had told us to discard the leftover half bottle). We logicked it out: this is also likely an ear infection, let's get her some antibiotics as well. So, I calculated her dose, and tried to slip some into her mouth with a syringe. The first two mls went fine. She sort of gulped and took it.

The last 3 mls didn't go so well. She gagged, and then vomited all over. Ugh.

She fell back asleep and we decided to let well enough alone. She was awake several more times during the night, and we did eventually get both Ibuprofen and antibiotics into her. This morning, she is cheerful.

So both kids are now committed to a full 10-day course of Amoxicillin for ear infections, and neither has seen an actual practicing pediatrician.

So am I a bad, bad mommy? Or will the rest of you 'fess up that you've done the same in similar situations?

How Has Medicine Changed Me?

KC suggested this topic, and I have had to think and think about it. How HAS medicine changed me? 

As an uber-idealistic practically socialist gunner med student, I had a vision of myself in the future as a doctor completely devoted to the poor and disenfranchised of the world. I was going to work for Doctors Without Borders or something like that. I was going to deliver skilled medical care with aplomb, to the suffering and forgotten. My vision was pretty vague, but definitely included basic field hospitals, palm trees and grateful patients.

I held onto this vision well into residency, shrugging off questions about how I would finance my dream, seeing as I paid for med school with loans, and would end up about $120,000 in the hole, before interest.I shrugged off those questions, figuring where there was a will, there was a way. I did every international elective I could. I ended up in crazy places (and I have many crazy stories) from Guatemala, Nicaragua, Peru, Ecuador, Sri Lanka...

As the end of residency approached, along with those ever-increasing loan statements, I started looking for a job in my dream field, which was, in my head, basically "International Health". Of course most medical jobs in this area don't pay much; and though many allow loan payback deferment, the interest still mounts... I considered going for an infectious diseases fellowship, but I had signed on for Primary Care loans, and would take a penalty if I broke my commitment to primary care.

I tried some things; I did work in HIV research and thought about pushing that work into something more... international. I struggled. I got kind of depressed, trying to reconcile my vision with the reality of life, and finances.

But then, something else was happening. I was in my mid-thirties, and I was starting to have other visions... Visions of family. Of settling down, raising kids, of community, of stability.

There was a transition, a positive one, and I ended up here, in a very nice suburban home, with my wonderful rock-stable husband and two healthy kids, working in a small practice at a respected academic institution, providing primary care to decidedly American patients. I'm really very happy.

A lovely patient of mine, someone who has faced many medical adversities, told me once that "it's the kindness of caregivers that gives a person courage." I do try to remember that, even when faced with an angry patient... Be kind. It matters, whether it's with first-world or third-world patients.

So, I try to be kind. And it's all good. What's so funny is that I feel like I'm a nicer person now than I was when I was supposedly devoted to saving the world...I seriously think that's how medicine has changed me. It's made me a nicer person, though not in the way I anticipated it would.

Book Review: The Devil Wears Scrubs by Freida McFadden

I love to read books written by other doctors. I think doctoring can be kind of isolating sometimes, but reading about the experiences of our colleagues can be so... validating.

This book, which was written by Mothers in Medicine blogger Fizzy McFizz under the second pen name Freida McFadden, is a humorous account of an intern's first month in an internal medicine residency. It's light, it's a quick read, and it really is funny.

The story follows newly minted Dr. Jane McGill as she tries to figure out how to survive and thrive on the floors at a county-style hospital, with little to no instruction or guidance on what, exactly, to do (sound familiar?), and all the while being picked on by a seemingly sadistic senior resident. The senior, however, has a human side as well, and a few good lessons to teach.

While this fun little book is fiction, I get the sense that it's House Of God-style fiction, meaning, alot of it is likely sort of true. I don't know this, I'm just guessing, and it made the book so much more interesting to me, as this intern's experience is largely miserable, and it reminded me of my own miserable intern experience (and I blogged about those memories in a post titled "How a fun little book dredged up buried memories of my intern year" ).

I was again reminded of this book at a recent medical conference, a Virginia Mason seminar (all about running a more humane, efficient practice) and one of the speakers was describing how setting basic work protocols and standards is so key to a positively functional work environment. She asked us how we can expect people to do tasks if they have no formal instruction in how to do them, saying: "Asking people to do things that they have not been trained to do is an exercise in frustration: theirs, and yours. Most people want to do a good job, and if you repeatedly put them in a position where they are likely to fail, they become demoralized, angry, and difficult."

I sat there thinking: Well, that's medical residency in a nutshell.

And Dr. McGill's experience in this book exemplify this: An experience so miserable, it's funny.

The book is available on Amazon.com, here is a link.

The Opiate Epidemic And Us

Our 25-year-old nephew passed away last week.  He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.

His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.

When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.

We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.

There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or  left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).

Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew.  In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time  dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.

Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.

Because we are in an epidemic.

All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.

Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.

Opiates are extremely physically addictive. And lives are crushed by addiction.

Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.

Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.

Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.

In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.

I'm curious to hear what are the thoughts and experiences of other physicians on this issue...

I Care About You, But I Hate What You're Doing: The Internal Struggles of a Primary Care Doctor

Gizabeth, a pathologist, just wrote about needing to maintain a "poker face" when she did a patient's biopsy, because she knew the diagnosis was metastatic cancer, and she knew it wasn't the right time or place to deliver that diagnosis.

This hit on something I've been struggling with for some time, now, and what I suspect many doctors struggle with (unless they've become completely detached):

Over these past five years as an internal medicine attending, there have been patients who have broken my heart, who have made choices I strongly disagreed with. Of course, as long as the choices are legal and not harming anyone but themselves, they can do that, and the point of my writing about these cases is not to debate these choices. It is to learn how to manage my emotions as both a physician and as a thinking, feeling human being.

How do other doctors deal in the immediate moment, and then in the long-term, when a patient follows a path you believe is wrong?

 I'm thinking of several cases (all details obscured or altered to protect true identities):

Several years ago, I took care of lovely, vibrant, fifty-ish year old woman, who in addition to living extremely healthfully, also saw a holistic provider. One appointment with me, we reviewed some test results that suggested she had cancer. I arranged for immediate referral to a wonderful specialist. The specialist confirmed cancer, and outlined a reasonable treatment plan that involved surgery and chemotherapy. About a week later, the specialist sent me a note that the patient declined all of it, and instead chose her holistic provider's plan of herbal remedies.

I was horrified. I called the patient and asked her if this was true. She said yes, that she thought of cutting and chemotherapy as worse than cancer, and would take her chances with the herbal tinctures, powders, teas, cleanses and energy healing offered by her holistic provider.


What would other doctors say to that?

I said, something along the lines that I respected her decision, but felt that I, as her primary care doctor, needed to inform her that she was choosing untested and unproven treatments, treatments that were not likely to help her at all. She said she would take her chances, and we hung up. That was the last I ever heard of her.

The above case is actually a combination of a few similar cases... It's not unusual for patients to turn down the 'Western medicine' treatment plan. Again, of course, the choice is the patient's, that is not debatable. What I struggle with is my own feelings. Because I know that when this situation comes up, when I KNOW the "Western Medicine' plan, though imperfect, is the patient's best shot at extending their life and quality of life, I know my heart beats like crazy, my palms sweat, and I have to work very hard to control myself, to NOT stand up and scream: "ARE YOU CRAZY?? You're planning on taking all kinds of potentially toxic and useless herbal crap when you have access to the best treatments in the world for this, and suffering people in every developing country would give anything to be here in YOUR place with the chance YOU have at a cure, and YOU are turning it down???"

Then, there's the opposite scenario.

I once took care of a lovely and also quite seriously ill man. He was extremely elderly and debilitated, with some dementia, enough dementia that all of his finances and logistics were managed by family members, though with enough insight and judgment to contribute to his own medical decisions. He had a terminal cancer diagnosis, on top of multiple medical problems, making his care quite complex. He was feisty at times. He had been asked to consider his palliative care and hospice care options on several occasions, and always became quite angry, usually ending up by shouting things like "I'm not going to let you kill me!".

He was admitted for serious, life-threatening complications related to his cancer. It was very likely that he would end up on life support without a chance of any meaningful recovery. He was asked again if he would consider hospice/ comfort care. He refused. His family, who had power of attorney, chose to abide by his wishes. He ended up near cardiac arrest and was sedated and intubated, and stayed in the intensive care unit on a ventilator for a very long time before he passed away, without ever having regained conciousness.

I don't need to tell many people in healthcare that this scenario is so common, I've seen in many many times. It plays out every day. It's just as heartbreaking to me, to see someone choose the cold, often prolonged ICU death, when they could have had the chance to go a homey hospice - or even home!- with the comfort of a morphine drip, holding hands with family members all around them, saying goodbyes or telling stories, until a naturally peaceful end.

Again, the choice is the patient's. But how do you deal with seeing this over and over again, trying to convince yet another human being that the choice they are making really, really sucks?

There are many other situations where my heart breaks. I hesitate to write about it, such a huge can of worms is the subject of abortion. It's with a heavy sigh that I even type this, as I know it stirs strong feelings and stronger words, pro- and anti-, either way. My point in writing is, again, not to debate the choice. In this country, thank God, the choice is up to the woman.

But I struggle, sometimes, to contain my own emotions when I am counseling a patient through her options.

I am pro-choice, and do believe that someone needs to provide safe pregnancy termination services to those who choose that. But at this stage of my life, I am personally, for my own self, pro-life. I did not choose to have any early risk assessment in my pregnancies, despite my own advanced maternal age. It wouldn't have changed mine nor my husband's decision; we agreed to carry on with any chromosomally imperfect fetus. We had even agreed to carry on with a pregnancy if it happened before we were married. We agreed that we have the financial resources and family support to care for a child, any child.

So, I struggle when I am counseling women who, like me, are financially stable, partnered, educated... who, in short, I perceive as having the resources available to care for a child, any child, special needs or not... and yet, they choose to terminate a pregnancy. In the room with them, I am professional; I smile kindly; I hand them the list of termination clinics; I counsel on birth control; I often see them after a procedure for followup.

But it is not uncommon that I tear up. I often need some space after one of these sessions to recover before I can go into the next patient's room. And I take it home with me. It makes me very, very sad.


How do other doctors deal with this? Especially, doctors who are mothers?

So many situations in medicine can affect us. We are all different in our beliefs and actions... But there must be situations that affect all of you, as healthcare providers. What are they? What touches you, and what do you do about it?

No Good Deed Goes Unpunished...

For a long time now, I've been feeling like I need to start giving back. You know: volunteering time, helping people, at least THINKING about others (who aren't my patients or my family). Not like I have alot of free time, as a primary care doc, mother of two little kids, loving wife, and caretaker for two large spoiled cats...

But, it's like a weight, a constant nagging wagging finger saying "YOU ARE SO FORTUNATE. WHAT ABOUT THE REST OF THE WORLD?"

I don't think doctoring counts, either, because it's my job. I try to be caring, and I try to go above and beyond (within reason), and I like my job, but it doesn't count. I get paid to do this.

Yeah, we go to church, but that doesn't count either, as we get more out of church than we give. I really, honestly, or perhaps predictably, don't do a hell of alot for others.

Not to get all religious on people, but honestly, my family, we're blessed. Or, you could also very agnostically say, we're very lucky. We have so much: good education, jobs, beautiful healthy children, a safe home and plenty to eat. Last time I prayed, I thanked God for all that we have, and promised to TRY to do more for others. TRY.

So this week, when my elderly neighbor called us out of the blue to say hi, I ended up asking her if she needed anything, like, say, a trip to the grocery store? She can't drive anymore, and as I chatted with her, it occured to me that our neighbors who usually take her food shopping are away on vacation. I suspected that her call was a way of reaching out for help.

She jumped at my offer, said she hadn't had some basics in some time, and we agreed that I would swing by and pick her up after work, yesterday. I offered up my offer to God as proof that Hey, I'm trying!

Well, yesterday I barely got out of clinic in time to make it to her house at the appointed hour. Then there were torrential downpours and flash floods... The sky dumped on me as I ran to my car, and of course I was wearing a long skirt, and the hem got soaked, and then it got all caught up around my legs, and then I tripped and slipped and cut my heel against a curb. I made it to my car, but only to sit in a massive traffic jam as one lane of the expressway was closed due to flooding. It was the worst traffic jam I had ever been in. I called my husband to say I would be late and asked him to call our neighbor.

Long story short, I was over an hour late to her house, and I saw her tiny, frail face peeking out through the lacy curtain on her front door window. I called out my apologies.

Not to worry, she said, I expected traffic would be bad with all this rain!

I (of course) had to pee, but she was all set to leave, and I was too late to go use my bathroom, and too embarassed to ask to use her bathroom. As she fretted with her umbrella and her house key, I decided to just deal with it.

I noticed that she had done her hair neatly, put on lipstick, and a nice blouse with a flowered brooch at the neck... This may have been her first foray out of the house in some time.

We got to the strip mall where her favorite small grocery store is, and she asked if she could also stop at the pharmacy there as well... Of course I said yes, and we agreed to meet up at the cash registers at the small grocery next door.

I figured I would be moving faster than she, so I dawdled and lingered over the fruits and vegetables. I checked out the gourmet chocolates and the imported Italian foods in jars. I tried not to think about how badly I had to pee, and thought about asking to use the grocery's bathroom, but then was worried it would be gross, or that my neighbor would come looking for me in the interim.

Time passed. I called my husband to let him know I would be even later than expected. I decided to check out with my groceries and put them in the car and then go looking for lovely neighbor.

I found her in the salad bar aisle, packing up this petite salad in an itsy little container, and she couldn't get the top on. I helped her and accompanied her on the rest of her shop. She actually needed help with alot of things, with reaching up to get things higher up on the shelves, to lifting a bag of discounted corn on the cob, to picking out appropriate sweet potatoes and finding the bread she likes (she can't see that well). We realized that we both love vanilla soy milk. I realized that life must be very hard for her, and my heart went out to her (even as my bladder was about to burst).

We made our way to checkout and then to the car and then to home, and I helped her with her bags. She said Thanks, I really appreciated your asking if I needed groceries, since I didn't have bread, and if I at least have bread, I feel so much better...

She has no family nearby to help her, and is completely reliant on neighbors and folks from her church. Again, I thanked God for all that we have, and especially for our family.
I made it home, and finally, after big hugs to my kids and a peck on the cheek for patient hubby, I got to thankfully, and gloriously, pee. I thanked God for that, too.
Next stops: our town's food pantry and the local animal shelter...