snarky

I try not to be snarky about things in which I have no formal training. Homeopathic, complementary, alternative, and untested (excluding clinical trials, of course) therapies fall into that category. Sometimes this is difficult as I have encountered many patients who have lost the last of their time and money on such treatments.  Or as in the case of Dr. Burzynski, who, over 30 years from his discover of "antineoplastons", still has yet to publish data from a randomized, controlled study in a peer-reviewed journal (And it might be mentioned, also threatened to sue a 17 year old who blogged critically of his purported cancer therapy. Say what you will about pharmaceutical companies, but they don't generally go around suing high schoolers for defamation.)

Given what I have to offer is literally a form a poison, I do understand why patients ask for more "natural" remedies. And their inquiry is not entirely without merit if you consider that some of our most commonly used drugs, like the vinca alkaloids, were derived from plants. However, despite this "natural" origin, no one would categorize vinblastine as anything other than standard, and thus toxic, chemotherapy.  And one that has proven its efficacy in clinical trials. I try to work with patients on this issue - explain that I do not object if the patients wants to incorporate a diet high in vitamin C or the occasional coffee ground enemas into standard chemotherapy, on the condition that the patient tells me what additional therapies they are trying and that the patient understands there is a possibility the alternative (or "complementary") therapy could adversely interact with their chemo in ways I cannot predict.

I am on maternity leave right now, so it is perhaps strange that I have spent the morning googling Dr. Burzynski (although truthfully quite helpful as I really do get asked about the Burzynski Clinic often). I started thinking about this issue when I noticed the tag on the "Mother's Milk" tea I have been drinking two or three times a day -

That says "Traditional Medicinals". My first reaction was "Oh no you don't. It's me, being a practitioner of "westernized" medicine, that is the "traditional" one here. You, my homeopathic tea, are the "alternative". In my world, tea is no more medicinal than the vinca alkaloids are natural. And for the record I don't talk to my tea.

I started drinking this tea "just because", and more as novelty than because I worried about my milk supply. That being said, in the last few weeks my milk has been "coming in" more frequently than I remember it doing when I was nursing my daughter. I really don't know how proven a galactagogue fenugreek is, but in my case (the worst kind of evidence - anecdotal...) it certainly seems to be working.

And so I find myself in the odd position of feeling both snarky towards the makers of this "medicinal" tea and yet not able to go an hour without the need to nurse or pump. Of course, the answer could be as simple as it just works, although I would feel better about recommending it should its efficacy be proven in a randomized trail published in a peer-review journal.

yet another posting on career vs. family

A few months ago I was having a not-so-great day on the Transplant service. The not-so-great aspect of this day had been brought about by the need to discharge a single patient after his allogeneic stem cell transplant. Having to discharge a patient after allo stem cell transplant is both the most mind-numbing and complicated role of the fellow on the BMT service as it can involve the need to coordinate home health, home blood draws, line care, monitoring of drug levels, home antibiotics, home TPN, outpatient medication, PT/OT equipment, transportation, clinic follow up, and a lot of patient teaching.  In fact, no discharge would be complete without an irate call from the discharge planner about some order I entered incorrectly.

While although important, this isn't very satisfying work and I was already a tad annoyed by some of the inevitable “complications” that had arose. I was trying to hide this annoyance and get through attending rounds quickly when my attending turned to me and mentioned that there was a grant proposal meeting regarding a clinical trial our institution was trying to get off the ground. It was this afternoon and I should definitely go.

My annoyance deepened.  Oh sure Dr. Attending. With about ten thousand little BS issues I have to resolve in the next two hours, I definitely want to go to your grant proposal meeting. Wonderful.

He mentioned the trial would involve the use of autogenetic stem cell transplant in patients with HIV-related recurrent lymphoma with the goal of curing the recurrent lymphoma and eradicating the HIV.

Now he had my attention.

Although I complain about the fellow’s role on the BMT service, I actually find transplant fascinating and have considered extending my fellowship for additional BMT training.  And while it might sound strange, I also find HIV fascinating and for a brief period considered ID just so that I could study and treat HIV (the fact that all the ID peeps I know get to do some wild traveling might have contributed to my interest).

A corner of medicine that involved both? Here, at our institution? I was definitely interested.

The meeting was between the clinical transplant staff and the basic science team. It started with the members of the lab explaining each step in the development of the vector carrying the gene for HIV resistance and how it would be introduced into the patient’s stem cells. I don’t want to embarrass myself by pretending I could follow all of the molecular biology, but followed enough to become very excited by this project that bore more resemblance to science fiction than any clinical experience I had ever had.  My attending then took over and explained what they proposed would happen to the patients who received the genetically modified stem cells.

I’ve worked on a lot of dead-end and/or boring research projects. In fact, I’ve never been part of a project that really piqued my curiosity, although some have been better than others. I had certainly never felt as excited by any project as I was sitting in that dark conference room.

I wanted in. I wouldn’t care what menial task it was, although I did start to envision what it would be like to write the first manuscript of a paper on curative HIV therapy.

My unborn son thumped me and reality set in. It is not a bad reality, but it is this – I almost certainly not staying at my current institution when I am done with training, and this project is still years away from inception. This is not because I don’t want to stay– and sitting in that room I really wanted to – but because we need to move closer to family when I am done here. I am actually very fortunate in that, my husband, who has followed me three times during my training, wants to move to the town in which I grew up and I have promised both him and my family that we will relocate as soon as I complete my fellowship.

I have also already decided against additional BMT fellowship training, which would almost certainly be required of any MD who wanted to be a part of this project. I have multiple reasons for this decision, including the need for a job with regular hours (please!), the need to start paying back my loans, the obvious financial needs of our expanding family, and again, the need to relocate. I like transplant, but I don’t feel as though it is something I absolutely have to do in order to feel intellectually and professionally satisfied. 

But I can’t pretend part of me doesn’t want to go after this. After all, I started med school when I was almost 22, I am now 31, so what is just a few more years of bad hours and worse pay for the chance (and it is really just a chance…) to be a part of something huge?  Maybe this isn’t the time – after I have almost a decade invested in my training- to start passing up opportunities.  

But that wistful, sometimes nagging, line of thinking hasn’t dominated my decision-making and, at least right now, I am very comfortable with the current plan as it is in place. 

This has become a much much longer post than I had intended and I worry I might have lost some of you along the way. This is unfortunate because part of my reason for posting it is to get feedback from those of you who have faced similar decisions. To be clear, I really don’t think I will regret the decision to move and forgo the very remote possibility of being part of this project, but it is the idea of slamming doors now, so early in my career, that is unsettling.

Thoughts?

final thoughts on last post

As my last post concerned what is arguably the most disturbing aspect of parenthood, perhaps it is appropriate to post, in bookended fashion, on the most joyful.

We brought home our newborn son five days ago. He is healthy and perfect. I am filthy and happy.

I will have to blame poor judgment brought on by the insomnia of manning a 24 hour milk bar for a brief sojourn into the well worn subject matter of writers far more talented by myself.  The death of a child is meaninglessly tragic and unfair and I can't imagine to where or whom one turns for solace. Perhaps the only answer to the question "why" is not truly an answer but a visceral response - to love and love and keep desperately loving the children that we do have. 

I think (and sincerely hope) this is the last time I post on this subject matter. While never forgetting, it is best to move forward and focus on the humor and joy of early parenthood. 

For instance - I am not sure if I should admit this (and again will blame the insomnia) but I was a little shocked by the appearance of my newborn son. His face was purple and squished. Flame colored stork bites stained his upper eye lids and the lower lids were swollen shut by two thick coats of vernix. His nose appeared to have been flattened in order to better accommodate a large crop of infant acne (milia) that sat upon the wide tip. His cheeks sank below the level of his lower jaw, giving the appearance of an edentulous old man. 

The last few days have revealed him to be a reserved little man who doesn't do much in the way of complaining. His emotional range seems to oscillate between boob? and BOOB! I know this range well as I have spent near every waking minute of the last five days staring at him in an almost spellbound fascination. 

I was immediately, and continue to be, deliriously in love. 

hello!

I spotted a small URL labeled "Mothers In Medicine" about a year ago, linked from the blogroll of a total stranger (as, let's admit it, most of them are...). I was excited for what can be described as only the most obvious reason - I am a physician and a mother and was looking for an online community comprised of other moms battling midnight pages and midday parent-teacher meetings.

It is difficult, for instance, to describe the emotional contortions required to function professionally in the darkest days of someone's life, then go home and play freeze tag and tea party with your children. As there are physicians who choose not to have children and mothers who choose not to work specifically to avoid having to compromise their ability to perform in the respective role of physician or mother, it could stand to reason that those of us who have decided to undertake medicine and motherhood might be doing so to the detriment of both.

And now having actually put into words my greatest insecurity - that as a doctor trying to be a good mom and a mom trying to be a good doctor I am not doing either very well - I have to say that aside from those occasional days when it seems as though I am actually being lit on fire, for the most part I am proud of my ability to do function in the two, sometimes adversarial, roles. 

Or more honestly put-  I am doing the best I can. I try not to think about it more than that as, by virtue of still being a trainee, there is little I can do to reshuffle my priorities. I tell myself that I am, and I hope you feel the same, one of the lucky ones - I have a career that expands my intellect and a family that expand my heart. 

So it has been a pleasure to follow this blog along and occasionally submit a guest post. We don't have the same specific experiences or opinions (although I have yet to read of anyone complaining about working too little...) , but are able to build a camaraderie around the monumental experiences of medicine and motherhood.

It would be ill-advised of me to try to summarize the state of modern motherhood in medicine, so I will just say, it's really good to be here.

(And please forgive all spelling and/or grammatical errors because, as anyone who as seen anything I write knows, I truly cannot edit.)