Mandatory meeting...CHILDCARE PROVIDED

I have posted before about how much I love my job.  I am honored to work with so many amazing people.  Quite recently a revolutionary change has occurred for our late departmental meetings…childcare is provided (as well as dinner).  Such a simple offering means SO much. These special surgeon kid playtimes are now one of the highlights of my daughter’s social calendar!

Below I have posted (with permission) the beautiful and inspiring blog post of our amazing Clerkship Coordinator after the first childcare night. I am so proud of us.  I am so proud of who my daughter (the 6 year old described below) is becoming.  I am proud of this department, of my profession and the future that we are creating for our girls as Mothers in Medicine…

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From the blog of JP -

When I was a kid, about 25 years ago, I overheard my mother repeating a riddle that had been told to her. In short, a young boy and his father were in a car accident. The father died immediately upon impact. The boy was rushed to the hospital. Once in the OR, the surgeon stands over the boy and simply declares, "I cannot operate on this child. He is my son." So the riddle goes, if the father was killed in the accident, how on Earth is this possible? Keep in mind, the riddle is at least 25 years old.

I listened as folks stumbled over themselves with the most absurd answers, "The dad hadn’t really died." "The surgeon was the boy’s step-father!" "The father was not his biological one and the surgeon must have been the boy’s sperm donor." The answers came and went and when the person finally threw their hands up in defeat, the person telling the riddle simply replied, "It was the Mom! The boy's mother was the surgeon!" Gasped responses immediately followed; these gasps were made as if to imply extreme bewilderment that a woman, A MOTHER, could be a surgeon. Nonetheless, the folks on the receiving end of the riddle felt embarrassed for not offering the most overlooked obvious answer even if they could not fathom a female with a scalpel.

Fast forward 25 years, I just spent my evening at work doing arts and crafts with two children of surgeon faculty members so that said parents could engage in an after-hours faculty meeting.  I brought all of my craft items from home so the young girls could make various winter holiday crafts. At one point I noticed one of the girls (6 in age) was making a gingerbread man. I quickly praised her on her great artistry, "Hey! That’s a great gingerbread man!" I pointed out. "That's not a gingerbread man!" she quickly declared. I was caught completely off guard. Y'all. I'm telling you. It was a gingerbread man!  Before I could ask her what it was (since I was so offensively incorrect), she proudly exclaimed, "It’s a gingerbread GIRL!" Immediately, a grin washed over my face. I'd only met this child within the hour. Our time was consumed with learning each other's nicknames, teacher's names and favorite colors. Feminism 101 had yet to make it to our arts and crafts agenda. I wanted to high five her. I wanted to spin around in circles and dance giddily in only the way excited 6 year old girls do. But instead, I nodded, and told her it was the most amazing gingerbread girl I'd ever seen.

Within the next hour, the other little girl (8 in age) casually announced that she was creating a top hat for her snow woman. SNOW WOMAN! Did I hear her correctly? Snow woman!! Yes! And she'd said so, so nonchalantly. It's as if Frosty the Snowman wasn't the first... the only...the standard! “Every snowwoman needs a top hat!” I replied.

If I'd told that 25 year old riddle, now, to both of these young girls, they would have quickly and without hesitation answered that the boy's surgeon was obviously his mother. I am confident of this.

It was in that moment, and for the rest of the evening, I stood proud; proud of the progress women had made in the last 25-30 years. Proud to have been able to witness, in my lifetime, such dramatic change, albeit long overdue and with still so much progress yet to be had. I was proud to be a female working in surgery education. I was proud to work for a team with so many female surgeons. I was proud to work under the leadership of a successful woman, whom not only was a General Surgeon, but also the Program Director of the General Surgery Residency program.  I was proud to work for and with a group of smart and successful women who greatly value their profession and equally, their role as a mother. I was proud that these young girls were exemplifying everything I’d known to be true as a child, but always felt so disconnected with. Perception was no longer reality. The reality had finally become perception! These mothers, these brilliant successful female surgeons, they are paving the way for the next generation of gingerbread girls and snow women to achieve greatness.

This is how we lift each other up. We create an environment in which we welcome one another's children so that we and they grow enlightened, encouraged, educated, inspired and excited by possibilities. We embrace the difficult balance. My God, the balance is difficult. We dispose of the box that which we were placed in and we become assertive in our ideas of becoming both brilliant and successful professionals as well as invested mothers. And it doesn't just begin and end with women, my friends. We must embrace our professional fathers as well! We are only as good as our counterparts. Our strengths are magnified when we surround ourselves with other strong, confident and supportive human beings.

I am grateful to be able to contribute to their (our) mission.

In the dark quiet of the last day of 2016

Oh, no. Not a New Year's Resolution post. Who needs another "Live healthier, Be a better doctor, Be a better mom" post?

Well, I do.

Genmedmom here.

It's 6:30 in the morning on Saturday, December 31st, 2016, and I'm sitting typing in the quiet dark of our house. No one is stirring except for our two big spoiled cats, who relentlessly knocked things off of my nightstand until I got up.

You know how you get really busy, barely any downtime to even answer the texts from old friends, never mind call them, and all the very small spaces in your life are stuffed with overflow tasks, like making shopping lists on your phone on the train, and never going up or down your stairs without having something in your arms that needs to go up or down, like dirty laundry down and folded clean stuff up, empty tea mugs down and toilet paper rolls from the basement up, wrapped gifts down and unwrapped stuff up, so many goddamned toys and factory-new clothes and the boxes, tissue and gift bags that you can't bear to toss that will clutter your home until next year too, and even with your superior physician multitasking skills you realize you're screwing up, like forgetting to RSVP for that thing and being late paying that bill and getting lame last-minute crap for the important staff member you totally spaced out, and then even the doctor stuff starts slipping (which is always last to go, right?) like that you promised to personally get back to your longtime dear patient on a result that wasn't critical but it was important to HER and you totally intended to check that on the holiday weekend and simply send her a quick message through the online portal and you just did not do it.

Then the kids get sick, and you get sick, and any delusion of control you had goes down the toilet with the first bowl of vomit. Your Christmas agenda: poof.

Barf.

But life marches on and there's still things to do and when everyone is (mostly) better you try to keep going, get yourself and the family to rescheduled gatherings and pick up where you left off with the gifts and the cards and the outings for school vacation. Maybe you start losing track of what's really important and what's just life and lose your cool, show your frustration, yell at your kids when the situation just doesn't merit a freakout. No one is running towards a busy street or about to drink drain cleaner, they're just jumping on the couch and throwing pillows and wrestling and, well, not listening to you when you order them to get their shoes on because you're late or pick up that banana peel and take it to the trash or SETTLE DOWN already. And when they react to your red-faced temper with sass and disrespect, maybe you throw the remote control across the living room and when it lands on the hardwood with an unexpected clatter, your kids stare at you with a sad, silent combination of shock and wonder and fear that you hope you never see again.

You know you're out of balance and that this is not right and this is not you.

So in the dark quiet of a holiday weekend morning when, miraculously, there is no event planned nor pressing task nor other thing of perceived great import, you sit and breathe and resolve:

This year, I will live healthier, be a better doctor, be a better mom. I will do this by uncluttering my headspace. I will leave the little breathing spaces empty. For breathing. I will remain thoughtfully committed to my medical practice and remember the high standards I hold for myself. I will love my family, my children,  always reflecting on how blessed we are, how much we have and enjoy in this very difficult modern world. I will pray for those who are struggling and suffering, every day, I will not forget them.

Happy New Year and God Bless.

How Do You Do It All? (i.e. The Art of Being Imperfectly Perfect)

Genmedmom here. 

Let’s face it: working moms have alot on their plate. A patient recently complained to me how guilty she felt because she couldn’t be a perfect mother, wife, accountant, and friend, all at the same time. If she felt really good and strong in one area, she was slipping in another. “No matter how much I try, I’m a failure!” she declared. 

Okay, look, despite the expectations on us, no one can achieve perfection 100% of the time. No one is going to excel in all of the areas of their life always. But we can manage. We can do our myriad jobs well enough. And we can be happy. 

On a weekly basis, I usually manage: four clinic sessions a week (approximately twenty hours seeing patients), one morning precepting in the firstyear medical students’ interviewing and communications course, co-parenting our two school-aged kids (with lots of family help), regular blogging on three separate blogs, kids’ dinner/ bathtime/ bedtime virtually every night, about three good workouts per week, church and big family dinner on Sundays. 

Is it all done perfectly? Hell, no. I wish I could get to all the patient phone calls, emails and lab results every week. It would be great if I could do the reading before the medical school course. Our kids are late with homework probably at least once per week. We never seem to know what's going on at school until the last minute. My blog posts often have typos, and could have used a little more editing. My workouts are sometimes really short. We don't get to church or have family dinner every Sunday.

But I can say this: We fit in what we need to fit in. We do what we feel needs to be done. It's not perfect, but, for us, it is. Imperfectly perfect. We, as a family, are happy.

I am often asked “Geez, how do you do it all?” 

Well, if what you're aiming for is happiness rather than perfection, then I’ve thought about this. It will be different for everyone, but generally, I suggest: 

Identify your time-wasters and eliminate them. What time-consuming things in your life do not help you to achieve your goals, and do not serve a healthy purpose? For me, that’s television. I do not watch television unless there is a really good reason. I’ll watch a Disney movie with the kids once in awhile, all snuggled on the couch. And, of course, once a week our whole family watches my husband’s football team play. Other than that? No sitcoms, no news, no movies. Social media can also easily become a time-sucker, so I limit that to my train commute.

Hire cleaners, if you can. Yes, we all know that we are capable of cleaning. But how much is your time worth? You are an M.D., and if you were paid by the hour, you would earn $100, at minimum. Multiply that by a thousand- no, a million- and that’s how much your hour is worth to your kids. Though we couldn’t afford it when we just started out, as soon as we could, we hired a cleaning service. They are worth every penny.

Order anything online that can be ordered online. We have groceries, pet supplies, clothes, shoes, furniture, books, et cetera delivered right to our front door. 

Stay local. Need to run an errand? If possible, avoid driving time, and support local businesses to boot. 

Schedule carefully. There are so many options for kids’ activities around us. It would be very easy to slip into driving-everyone-all-over-the-place-for-this-or-that-thing. We were forced to hold back quite a bit, as our son with autism doesn’t handle a busy schedule very well, and doesn’t do drop-off events at all. So, we have a music teacher who meets them in my mom’s home after school one day. And we choose family activities like hikes, trips to the farmer’s market, and scouting (Boy Scouts), rather than kids-only classes like dance and tae kwon do. We’ve realized that this quieter, easier, more familiar approach results in less hustle and bustle, and doubles as “family time”. 

Identify toxic relationships and avoid them. Okay, I'm wandering into therapeutic territory here, but the truth is, people who make us feel bad are a real drain on our precious time and energy. Conflict and negativity are distracting. We can't be our best selves now if we're re-living an argument or re-thinking that weird conversation from yesterday. If there's a person around who consistently brings conflict and negativity into my day, I avoid them as much as possible. Likewise, if there are good, psychologically solid people who support me and boost my mood, then hey, I want to spend more time with them.

Keep reasonable goals. I’m not striving for crazy achievements in any area. I’d like to take good care of my patients, be a solid teacher for my students, raise emotionally well-adjusted kids, keep on writing until it goes somewhere, stay as healthy as possible, and be actively engaged in our community. Like I said, it's not perfect, but, for us, it is. Imperfectly perfect. We, as a family, are happy.

What about other mom-docs? How do you "do it all?" What do you do to save time? How do you keep you and your families happy?

[Watching our friends get] Married... with [our] Children

Let's bring the boys to the wedding, we said.

It will be fun, we said.

We were so cocky. Bean had been to several weddings and loved to dance, we reasoned. And Teeny, though young, was just so chill that it wouldn't be a big deal. An outdoor, afternoon wedding of a laid-back couple with tons of family medicine and pediatrics residents in attendance. It would be like a weekend away without needing to pay for a baby-sitter. What could be more perfect?

We rented a house through Airbnb so that we would have plenty of space and the boys would have their own rooms. We beat traffic on the way there and spent the next morning exploring the cute town. We stumbled upon a farmers' market and ate ice cream for lunch. The boys even went down for a pre-wedding nap.

On the way to the wedding, we talked about how we would need to be very quiet. (We had no illusions that we would actually sit down for the ceremony, but planned to watch from a safe distance.) As we rounded the side of the beautiful inn where the festivities were being held, the bride was just starting to walk down the grassy aisle to the strumming of a guitar. Bean pointed to the musician and began shouting, "Man playing 'tar!!!!!"

We retreated. A staff member inside kindly pointed out a large picture window overlooking the lawn where we could watch without disrupting things.

At that point Teeny let us know that he was hungry, so I settled into an armchair in the corner to nurse him. My husband headed to the window with Bean, but there was a problem: the parlor of the inn was filled with so many nice things and Bean needed to investigate all of them. There was a large birdcage containing actual birds and a stone fireplace and so many trays of seashells and trinkets and shiny objects. In other words, it was a room we had no business entering.

"We really need to rethink whether we bring the boys to weddings," my husband noted a few minutes later in a tone that struck me as irritable, though he adamantly denies having felt annoyed. I sighed and internally (or maybe externally) rolled my eyes. We were in another state and the celebration that we had traveled here to attend had just begun. There could be no second thoughts.

As soon as Teeny had finished nursing, my husband pounced. "My turn to hold him!" he exclaimed, which was code for it's your turn to chase the toddler. But Bean was in great spirits, happily occupied by tracing the contours of the stone fireplace with the car key that my husband had handed him to play with. I relaxed a bit and began to really take in the gorgeous setting. On the other side of the fireplace, I noticed a basket filled with books and a plush stuffed lobster. As Bean began to edge too close to the hurricane jars lining the hearth, I lifted him up, intending to plop him down by the [unbreakable] lobster. While in the air, he started to protest: "Hold key! Hold key! Hold key!"

Which is what he says when he wants to hold something that he is not holding.

I looked down at his empty hands. "Key? Where's the key, Bean?" I asked in an urgent whisper, not wanting my husband to hear. "Bean, what did you do with the key?"

"Hold key!!" he wailed, and I left his side, hurricane jars be damned, to retrace my steps, scouring the floor.

"What does he mean, 'hold key'?" my husband asked, because of course he was right there and had heard and now realized the predicament.

"Don't worry, I'm sure it's here - " CRASH!!!!!! 

I spun around, expecting to find my family covered in shards of glass. My husband, with Teeny in his arms, had sprung to action trying to find the key, but in doing so had knocked over an end table. An end table that had held a glass dish of beautiful, fragile seashells.

Of course that was the moment that the inn's manager entered the room.

"I'm so sorry! We're so sorry!" my husband yelled, frantically gathering shells in one hand while cradling Teeny in his other arm. 

"Hold key! Hold key!" Bean continued to wail.

"Just let us know how much we owe," my husband huffed, still scrambling to scoop bits up off the floor. "And also, we're missing a car key."

Outside, the ceremony came to a close. The bridal party and guests began to make their way back up the lawn toward the inn. Having already crawled along the floor to peer under the couch, I stood up and spied the key nestled behind a throw pillow. Somehow the glass and shells and whatever else were picked up off the floor. My husband and I gathered our things and, each taking a child, stepped out onto the back porch where guests were now mingling over cocktails. In the kind of frustrated yet silent agreement that comes from more than a decade and a half as a couple, we parted ways, each joining a separate section of the throng.  

By the time dinner started, Teeny was napping contentedly on my shoulder and Bean had begun to make his presence known on the dance floor. We had caught up with old friends and made new introductions around the table. And for the rest of the night, our family was happy and smiling.

I had thought that some time would need to pass before we could speak of - and certainly before we could laugh about - the scene at the inn. But as he pulled our car out of the parking lot at the end of the night (well, the end of the night for a family with small children), my husband grinned. "Well that will make quite a story."

Since that time, I have referred to it as "The Wedding Where We Almost Got Divorced," though he swears it was never that serious and he was never that annoyed. And as for bringing the boys to weddings? We haven't done it again. 

At least not yet.

Summer Book Recommendations

Ah, summer. There's nothing like the joy of sitting with an iced tea and a book on the deck... or waiting in the dentist's waiting room reading tiny print from a reading app on your phone.

1. Vaccinated by Paul Offit. It was completely fascinating to learn about the early days of immunization. Even if you've learned the science before, reading about the social context is so interesting.

2. Overdiagnosed by H. Gilbert Welch. This book changed the way I look at my practice, every day. Welch is an epidemiologist and explains the principles in a very accessible way.

3. Crazy Like Us: The Globalization of the American Psyche, by Ethan Watters. A must-read, especially if you work in mental health. I see a lot of refugee and newcomer patients, and do some element of cross-cultural mental health most every day. It's challenging because our entire mental health assessment is rooted in the culture in which it was created, and the very definitions of mental illness vary so widely in different contexts.

4. When Breath Becomes Air by Paul Kalanithi. I know you are hearing about it everywhere. It is beautifully written and helped me reflect on medicine in a different way. "But if I did not know what I wanted, I had learned something, something not found in Hippocrates, Maimonides, or Osler: the physician's duty is not to stave off death or to return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence."

I was on a female memoir kick last year, and thoroughly enjoyed the following:

5. Julia Child's My Life in France. Transport yourself to France and witness the early days of her love affair with French cuisine.

6. Nora Ephron's books of essays, I Feel Bad About My Neck and I Remember Nothing were, of course, hilarious.

7. Laughing All the Way to the Mosque by Zarqa Nawaz. Zarqa Nawaz is the creator of the TV show Little Mosque on the Prairie. She diverted from her parents' expectation for her of a career in medicine and found her way to journalism and the arts instead. As a fellow Canadian Muslim woman, I loved hearing her always-funny perspective on issues she faced along the way.

8. I Was a Really Good Mom Before I Had Kids by Trisha Ashworth and Amy Nobile. A down-to-earth book about the real issues we face every day as mothers, I found it totally affirming to read.

Fiction:

9. On Beauty by Zadie Smith. "And so it happened again, the daily miracle whereby interiority opens out and brings to bloom the million-petalled flower of being here, in the world, with other people. Neither as hard as she had thought it might be nor as easy as it appeared". Filled with breathtaking passages but also dry humour and wit, On Beauty was captivating.

10. Everybody Has Everything by Katrina Onstad. Following years of infertility, a young professional couple takes guardianship of a young child when their friends suffer a terrible accident. The struggles of being thrust into parenthood of a unique sort; with the same truth that we all live with - the uncertain future.

What books would you recommend?

All of the ways I forget

I had my 90-day evaluation in my new position today. I left the clinic I was working in, one overrun by burnout and toxic management, in order to remember why I went into medicine at all. I love my patients and this work, but I love my family more. I now work 3 days a week in health care administration and quality improvement. I sleep well at night now that the main cause of my insomnia has ended. My family is happier. My evaluation went very well.

Immediately after my meeting, my husband reached out and said he needed to talk. I needed to talk too. He is finishing his dissertation this week, we just bought a new house, and my parents came in town for the weekend. We have been passing like ships in the night. Both busy and not really checking in enough. With moments of hugs and kisses and simple appreciation. But overall, we haven’t been checking in frequently enough and we definitely haven’t been having the weekly meetings that are my bookends at work.

I feel lonely. He feels unappreciated. Why didn’t I offer to help with his appendices? Why didn’t I read the chapter he asked me to read so many months ago (honestly, he gave it to me and I forget and he never mentioned it again until today and now I feel like dirt). He feels that my work has taken priority in our family for years (medical school, residency, the toxic job took so much of our family’s energy just to stay afloat). And now I’m studying for my Boards again after I failed them last year (more about that later, I have a lot to say about it but it's so raw and traumatizing). And he’s finishing his dissertation and starting his first job as a professor at the state university.

When we get busy I forget that my marriage needs check-ins, scheduled ones, on purpose because they are priorities. And when we are busy, we both have to go the extra mile to make sure that my needs, his needs, and our family’s needs are met.

And I’m sitting here at work, dragging my feet because at home I am reminded of all the ways I forget. I need to go home and start remembering again. And I need to be gentle with myself because we are juggling plates and though many of them are scuffed up I pray that none of them are smashed and destroyed. I’m going to head home now in order to remember that I love him immensely. And loves me. And we can't forget.

On Five Year Plans

This is a throw-back to a MiM post back in 2013 that really resonated with me at the time, and still does, in which T writes about someone asking her, "Do you have a five year plan?"

When asked this recently, I fumbled. Actually, I tossed back the answer, asking the asker to mentor me through getting such a plan. It wasn’t even someone who knew me well and it had been asked in a fairly casual way. Regardless, I was not able to answer the question. But if I were to answer it, the answer would be, “No I do not.”

The comments that followed included other MiMs stating that they too did not have five year plans. People cited living in the present, and checking in periodically to ensure satisfaction and fulfillment, but not necessarily a structured plan. Others did have plans, which they found informed their present-day decisions. I was on maternity leave with my first when I read this post, and was feeling very unmoored. I felt that I should have a very clear path of where I wanted to go in my career.

I remember being asked the same question by a male faculty member during my first week of medical school. I fumbled too, as I entered medical school interested in family medicine but open to possibilities. My surgeon-keener classmate piped in with his plan for surgical specialty x, making me feel even more self-conscious. In retrospect, I don't blame myself one bit. I think some people do well with a well-defined, honed-in focus. Others, like myself, find the goals harder to identify; my priorities have to emerge - they can't be easily forced out.

I have broad goals - community contribution through medicine and beyond, strong faith and family, a healthy lifestyle. I have diverse interests; one is health equity, which has led me to refugee health. Various other interests have led me to different projects over the years.

I do find it helpful to have short-term career priorities; a necessary honing-in to avoid over-commitment and burnout. Dr. Mamta Gautam, the Canadian physician wellness expert, tells physicians that as people who have plenty of interest and enthusiasm about many things, there will always be more interesting things that we want to do, more than we could possibly have time for. So, it is a matter of choosing and narrowing down options.

Right now, I'm focusing on clinical work, local refugee health coordination efforts, and writing - both here, and on a blog aimed at patients. I supervise learners periodically, but have flexibility. There have been other tempting opportunities recently, but I have declined them in order to preserve family and self care time. Personally, I need regular downtime. I schedule a day off every month, sometimes more. I need some "empty space" on the horizon in my calendar, which can involve self care time, and sometimes catch-up work and projects. With two young kids, I've found the regular days off invaluable for recharging.

With the births of my two children, the last four years have been full of transitions. I think motherhood fits naturally with evolving priorities and goals. I look forward to more changing priorities over time. And I'm still OK with not having a five-year plan.

"Why didn't you just go to medical school?"

I'm guessing this is a common question posed to ARNPs/PAs, and one I figured I'd take a moment to answer personally, because I find it irksome. Well, I didn't go (or even apply) because....I didn't want to be a doctor!  I don't think it's a compliment to ask an RN/NP/PA that question, but I'm thinking it's meant to be one (i.e. you're really smart, you could've learned more/done more). But the question presumes that becoming a doctor is The Best Option for those interested in a professional graduate level healthcare career (and that the smartest people in medicine are always the doctors).  But becoming a doctor is one of several medical career options out there, and it's not always The Best One for everyone. So for this post I'm going to recount how I got to ARNPLand, given other possible paths-and how a key factor in going to ARNPLand was motherhood. Doctors are awesome (duh), but not all of us are destined for DoctorLand--for a variety of reasons.

My undergrad education was in liberal arts, which was interesting but frankly not very useful at all (a classic tale). I worked in social work right after I got my degree, and worked in social work/corrections for a while...but I wanted a job where I could DO things, and PROBLEM solve and really FIX things. And not be stuck at a desk all day long shoving paper around.

I knew that I wanted a job where I could do the following:

• Be a big nerd, and be in an environment where nerdiness was celebrated 

  

  What a cute ARNP!

• Fix things or people (or both)
• Make a good living, i.e. to support a family of at least two kids. Oh crap, we have three now; we've debated selling one but the kid market is in a slump. And yes, the third pregnancy was planned. And yes, we had an OB ask us this. We changed doctors. Think about that question for a moment...Anyway, my goal wasn't to be rich but to have enough. Comfortable enough to be like the Cleavers (well, the interracial lesbian family suburban version). Ah, but "enough" is so subjective, isn't it?

The Cleavers, "then"..

The Cleavers, "now"

• Be a mom who could go to choir performances, be home for dinner most nights, have dinner with my mom, go out to dinner with my wife, walk my kids to school sometimes,  have time to email my twins' teacher about schoolwork (and kvetch about common core math, that is a whole different post...), cook dinner on my off days, and so on. 
• Be able to have kids closer to 30, not 35 or 40 (I had twins at 29--overachiever!!). 
• Completely gross out my kids and wife with graphic descriptions of medical procedures, bodily fluids, and so on. 
• I wanted to be able to say nonchalantly, "It's just a flesh wound!" (please click HERE if you understand that allusion...you're welcome!)
• Pay $800 in student loans per month. Actually, this is a heck of a deal-ask a physician (or a lawyer). Gotta pay to play, right?
• Crap my pants as I mumble  confidently say the the words "Call a FREAKING code !!!" as I run to the room, after the RN calls me and I hear the words "EKG changes" and I see the heart rate go from 120--100--90--70--50 in 5 seconds on the tele monitor, while my amygdala fires repeatedly and my brain says "ARGHHHHH!! You totally know what to do, breathe...". Begin CPR....
• Have an unlimited supply of graham crackers to sneak from the nutrition room when the charge nurses aren't around to notice (and peanut butter, oh MAN, that stuff is good).

I also took into consideration how much I'd be able to see my kids, day to day--it was important to me to be around as much as possible...consistency. In some subspecialties (that involve years upon years of fellowship), fellows put in so many hours that it's a real challenge to balance the demands of motherhood and work--and year after year they face these dueling demands--and hats off to these women for taking it on! I see fellows in particular who FaceTime their kids nightly, because they're rarely home in time to say goodnight--especially those with young preschoolers. And sure, it's temporary--because kids grow up, stay up later, and so on--and fellows finish their programs. And fellows do have days off, of course, during which they can love their kids (in person) to pieces. But for me, I wanted more of the day to day mom stuff. The stuff that makes me crazy and the stuff I love.

My point is---to each her own. I have as much respect for the mother who is a general surgeon as I do for the mother who stays home full time. And really, it's great that those of us in medicine can FaceTime now to say goodnight to our kids so that we can maintain the daily connection despite our wacky schedules; I used to do it frequently when my twins were toddlers--I'd leave for work before they were up and get home after they were asleep. It was hard, we missed each other a lot. And it was a lot of extra work for my wife when I was gone, as she'd get through multiple 13-14 hr days on her own. So for any woman who is embarking on a medical career it's incredibly important to consider how one's choice of career will affect one's ability to parent in a way that works best for you, for years.  It's a huge, huge consideration. It's a years long balancing act--how on earth are you going to mix these two awesome things (motherhood and medicine) together successfully and keep your kids alive (and your patients)?! 

I needed the work:life balance that I thought an ARNP career could best provide, and I was concerned that I wouldn't have been able to find had I chosen medical school. Or, I suppose that I could have found it eventually, but I would have had to put off having kids for several years--and I didn't want to do that, for many reasons. I couldn't be the kind of mom that I want/wanted to be had I chosen a different career path. And what about the difference in salary, you might ask? The money is great, I think. The starting ARNP salary in outpatient oncology around here is about 100k. Inpatient oncology at private hospitals around here? Around 130k. That's enough for me, enough for my family to live well. So I'll never be The Boss, I'll never be famous, but it's enough--I'm home over half the month (I work 10-12 12hr days a month), I often pick up the kids from school, I have the time to make dinner frequently (and lunches for school, ugh), I have a challenging/brain stretching/ emotionally taxing job and it's all enough. Score.

So this is my corner in the medical world, and I'm happy in it. And frankly, ALL of us are awesome for making our lives work-however we get it done. So here's a toast to getting by with FaceTime, nannies, dads, moms, friends, support groups, childcare centers, vodka martinis, grandparents, Munchery/Pizza Hut/Whole Foods/Amazon Fresh--we're getting it done--mothering AND medicine.


Later,

ZebraARNP

More Important Than Your Marriage, or Lessons from Old TV Shows

I've been re-watching The West Wing lately - my Netflix version of re-reading a favorite novel, which I also do frequently. In the episode Five Votes Down, early in the first season, Leo (the Chief of Staff to President Josiah Bartlet) forgets his anniversary and comes home at 2:00 AM in the midst of a crisis with Congress. The next day he sends his wife a pearl choker and plans a catered dinner, but it's too late. His wife has packed her bags and has a taxi waiting.

Jenny: I can't do this anymore. This is crazy. I don't want to live like this. I just can't.
Leo: I'm sorry about the anniversary. I just...
Jenny: It's not the anniversary. It's everything. It's the whole thing.
Leo: This is the most important thing I'll ever do, Jenny. I have to do it well.
Jenny: It's not more important than your marriage.

We all know what the right answer is here, don't we? We do. Leo knows, too - but instead he gives her the honest answer.

Leo: [emphatically] It is more important than my marriage right now. These few years, while I'm doing this, yes, it's more important than my marriage. 

Every time I watch it, this scene brings me to tears. This time, though, I watched it while I was doing the dishes at 10:30 at night on a day when I'd missed dinner with my family because I was at work until nearly 8:00 PM. That's not unprecedented; I'm lucky that it doesn't happen very often. One of the reasons we put off having kids was that I knew I would have a hard time leaving work at work during residency to be fully present for a small child. Sam was in graduate school at the same time and it was even more difficult for him. For many years, I was Jenny in that scene - I was afraid to ask Sam if his work was more important than our marriage. I was afraid he would say it was.

And now? Now I am almost always home for dinner, but I know I'm preoccupied with stress about work and thoughts about patients. I have to say "no" to my kid every third Saturday because I'm on call and I can't commit to whatever it is she wants me to do. There are a lot of mornings when I don't hear what's said to me because I'm in a fog from multiple overnight calls. Am I behaving as if my work is more important than my marriage? If I were answering honestly, how would I answer that question?

Overall, of course I would say my marriage is more important. Sam and Eve are the center of my life; I adore them and I want to be with them. I want them to be able to depend on me. In any one moment, though, I make choices that clearly put my work first, and those moments add up.

There's an episode of M*A*S*H in which the members of the 4077th invite their families to a party in NYC. Hawkeye assumes his dad won't leave, because he won't want to leave his patients. The elder Dr. Pierce writes back that of course he will go; "Yes, I'm attached to the patients I've brought into this world, but I'm more attached to the son I brought into this world." Hawkeye, brushing away tears, says "Funny, I always thought they came first."

I don't want my daughter to grow up thinking my patients come first. I want to show Sam and Eve now, in the moment, that they are important to me. And I want - I need - to keep the sense of myself that is only satisfied when I'm doing my work the way I know it needs to be done. Is my work more important than my marriage? No...and yes.

The DC public school lottery struggle is real!

I will paraphrase my mommy friend C when she said “we literally have spent hundreds of hours on this”.

We moved back to DC June 2015 and since then have spent hours and hours touring and talking about schools. My husband O and I are both products of public education - we know it has many challenges and limitations but we are both committed to having our son Zo in a public school that all children have access to. We were extremely blessed in North Carolina to find our outstanding Spanish-immersion daycare. We never ever ever worried about him while he was there. We hope things will work out with public school, but thankfully being a doctor-mom, private school is a viable option.

WHAT WE ARE WORKING WITH:

Flash forward to public school in DC and we have had issues with lack of supervision in the bathroom for the preschoolers, lack of vision, organization, and communication from the administration, teachers who rely too heavily on strict discipline and quiet, homework for preschoolers, and the disorganized and understaffed aftercare that we promptly pulled him out of. What we have loved about Zo’s school - that he really likes it, the Principal Mr. L (he is truly wonderful, so committed to the students and parents), meeting wonderful families and making new friends, the beautiful playground, being a Parent-Teacher Organization parent (I feel like I’m becoming my mom every time I attend a meeting), and the overwhelming majority of his teachers.

MOVING FORWARD:

In early April we find out the results of this year’s lottery. For those who don’t know about DC public schools - there are public schools and separate public charter schools. Some participate in the common lottery and others have separate application processes. All super confusing and overwhelming unless you live in an awesome neighborhood with in-bound preference which we don’t. We based our rankings on a private session with Educational Consultant EV Downey (I still shake my head writing this cuz’ who thought you’d need to pay someone to figure out where to send your kindergartener but I quickly realized there were way too many schools I didn’t know about and I am all about tapping into my resources so we went ahead and paid her and it was well worth it), hours and hours spent touring schools in our preferred neighborhoods, countless conversations with each other, friends, and school administrators. There are so many different schools. So many different neighborhoods (drop off process and location is of prime importance in DC), school buildings with very diverse architecture, philosophies, discipline plans, and aftercare programs. So many different “vibes”.

A few of my favorites (in alphabetic order):

- Capital City, a well-established charter school with the most perfect natural outdoor space and great reputation. Too far out of our preferred neighborhoods, but if I could it would have been in my top three

- DC Bilingual, a well-established Spanish-immersion charter school. In a really nice building, but they might have to find a new site next year. Ranked low for us as not knowing where the school building will be was a deal-breaker for us.

- Mundo Verde, a Spanish-immersion charter school focused on environmental justice and study of world cultures. We love their vision.

- Two Rivers, we preferred the Young Campus as its closer to our preferred neighborhoods and O really liked the Principal

- Tyler, a public school with a Spanish-immersion and arts program that O loved

- Van Ness, newly renovated and reopened public school in Navy Yard (prettiest public school I’ve ever seen though in need of a new playground; which I hear is in the works)

Life in between my notes

Instead of doing notes this weekend I:

• made a fall collage with Zo using leaves and clippings from free magazines
• went on a date night with the hubby during which we ate amazing food and had delicious lavender mojitos and then both almost fell asleep during the movie (don’t go see the new 007: Spectre, it sucked!) and remarked countless times how we wish we had just stayed home and caught up on the Walking Dead
• caught up on the Walking Dead with the hubby. (spoiler: Glenn no!!! and geeze how does Rick run soo far in those cowboy boots and tight black jeans, I’d have blisters and chaffed thighs!)
• listened to Oprah and Deepak’s day 6 and 7 morning meditations. It’s beautiful but I don’t quite know how to pronounce the meditations.
• washed clothes and then folded them with Zo. Who knew 4 year olds were such excellent folders?!?
• made amazing pumpkin chili (check out http://www.popsugar.com/food/Pumpkin-Chili-Recipe-35890481)
• am thankful that after finishing this post I’m just going to go to bed and it’s only 10:21pm and I’ll start the note writing again tomorrow morning at 5am. Only 38 to go!

10 lessons learned in 10 years of Private Practice

This summer marked two major milestones in my life: My 40th birthday and 10 years in practice. Both have prompted some serious reflection on my part. As I thought about the most significant lessons I've learned over the years, I realized some were grasped the hard way and others came from great advice (some of which I got from this blog). For those of you in residency or just getting your ears wet in practice, here's a bit of what I've learned, hopefully it might help a little.

1. Make friends

When I first started practice I would often ask senior physicians what advice they would have for a new kid starting out and I was surprised to hear from several colleagues (male and female ): make time for your friends outside medicine. Several remarked that the felt lonely and isolated as they got older having devoted most of their effort to their career with what little time they had left over to their families.

Quality friendships require the one thing I hold the most precious: time. However, thanks to this early advice, over the years I have been very purposeful about making an effort to make time for relationships. Now I have a community of close friends who truly enrich my life and offer me a reprieve from the drama of the medical community. This year I unexpectedly lost my father and I'm not sure how I would of have survived without the support of my girlfriends.

2. The sky is not falling

Since the day I started medical school in 2001 I have heard how the sky is falling. Managed care, EMR, meaningful use, ICD 10 these were all going to send us to the poor house and ruin medicine. Yes, they have caused me some headaches and I may not make as much money as doctors did in the glory days, but I still can pay my bills, take care of my patients and enjoy my job. (see #10)

3. Lean in (but don't fall in the damn lake and drown)

I hate self help books, but if you haven't yet read Lean In then stop reading this post and go to Amazon right now and buy it. In medicine many committees may feel like pointless wastes of time. I would encouraged you to attempt to find one you can be passionate about and get involved. (If not "passionate" than at least one that doesn't make you want to bang your head against the wall out of desperate boredom) By being willing to say "yes" and giving a little bit of your time to get involved in the processes of your organization, you can learn a lot about hospital administration and make valuable networking connections.

I can always find time for a least one committee, but sometimes I can get a little carried away with my ambitious projects. Recently, I found myself on 4 major committees (all volunteer) at my hospital. That was a little too much. I'm still learning to find the balance between leaning in and falling in.

4. I can't please everyone

In medicine, there is a lot of emphasis on patient satisfaction. It's not enough to provide good care, you must be nice as well so the you and the hospital get good grades on our score cards. That's not to mention internet ranking sites, blogs and facebook. If someone hasn't written something nasty about you that wasn't true, then you haven't been doing this long enough.

Of course, we all want to be liked, but in medicine, sometimes you have to be the bad guy. At the end of the day you must be kind and compassionate to all your patients. They will not always like you and that's OK.

5. Know my stuff

Some of the best advice I got as a resident was that you can't know everything, but the key is to know your bread and butter conditions, learn what's normal, know your emergencies and you can look up everything else. I remind myself of this advice when I begin to feel overwhelmed with keeping up to date in my field. I focus on knowing the basics inside and out and keeping references handy.

6. Find my own version of work life balance

To me my work life balance is a combination of having a fantastic SAHD husband, living 8 minutes from my office/hospital and the flexibility of being my own boss in private practice. When I first started practice I would frequently fret during slow office weeks that I would never make my overheard and equally fret during busy office weeks that my children would grow up never seeing their mother. I slowly learned to enjoy the slow season and embrace the fact that the busy season would help me pay my kids tuition.

{In my opinion no one has ever explained work-life balance better than FreshMD right here on this blog.}

7. Be kind

Be kind. Treat the janitor with the same respect you treat the CEO. Treat the cokehead patient with the same care you would your best friend.

Especially in surgical specialties practitioners tend to yell and pitch fits to get their way. I've seen nurses chewed out for pulling the wrong size gloves for a doctor. To be a confident, respected female physician you do not have to be a bitch. The only excuse for yelling is emergent situations where patient safety is being compromised. I'm not saying to be a pushover, but you can be assertive without being mean. When you are characterized by levelheaded kindness, your true complaints will be taken much more seriously by your supervisors.

8. My kids will not be scarred for life because I missed a few bedtimes

I've missed a lot of bedtimes over the years. I still hate the fact that I have to miss out on important events in the lives of my littles because of my job. But at age 11 and 6, they are doing fine and I can already see that the missed bedtimes are harder on me than them. And I promise all you resident mamas out there: LIFE DOES GET BETTER!

9. Have a financial plan

Again, I hate reading non fiction, but one of the best financial book I have read is The Millionaire Next Door. The title is rather misleading, seeming to be yet another "get rich quick" book, but the actual point of the book is to learn to live well below your means and focus on avoiding the traps of debt. I wish I had read it as a resident.

10. I love my calling

There will be rough days. Patients will die, you will get sued, many nights you won't sleep but through all the crap, try your hardest to focus on the times you made a difference. Don't let yourself become a bitter and filled with self pity. This isn't a job we have, but a calling. Concentrate on the moments you saved a life, provided comfort to the grieving, eased someone's pain and changed their lives. If you find the grey cloud of negativity hovering for too long, then make a way to cut back your schedule and refuel your soul.


I'm not vain enough to believe that what's worked for me, will be the answer to all. I tried to leave out all the obvious things like eating your broccoli, exercising and maintaining your marriage. Hopefully even if my advice doesn't apply that much to you, it may make you pause and think.


Anybody else have some lessons to share?

This child and his sensitive skin

It all started out as a little papule on his left buttocks. In the middle of a busy week of relatives visiting and make-up clinic days, what started out as a small papule morphed into something worse. Zo has had exceedingly sensitive skin since he was 1 years old. Hyperkeratotic plaques behind his knees that sprout up in the span of 2 days if he isn’t slathered in a thick mixture of shea butter and petroleum jelly twice a day. Diffusely itchy maculopapular rashes if we miss his nightly dose of cetirizine. That type of sensitive skin.

I thought I had things under control. But I didn’t.

Monday - I see a little papule on his left buttocks. I put on a thin layer of triamcinolone 0.025% on it. Later that night, I see a few more papules. I put him in the bathtub and then put on more triamcinolone and begin our twice a day ritual for exacerbations.

Tuesday - I see more papules. He is itchy. Is that a ring? Nahhh, I’ll just step up the emollients.

Wednesday - I return home and notice him scratching. How was swimming? His response, “it was fun” as he continues to scratch. Bathtime. Is that a 2 centimeter scaling ring-lesion?!? Oh goodness! He’s got tinea!!! I don’t have time to get clotrimazole and I forget to text my hubby what medicine to get from the pharmacy.

Thursday - satellite lesions. After clinic I run to the local CVS and wait in line for 15 minutes to purchase clotrimazole and by the time I arrive home he's asleep. That peaceful sleep where you know not to interrupt them or all hell will break loose so I let him sleep as I fret about his tinea outbreak.

Friday morning - we begin twice a day clotrimazole use.

Weekend - more lesions. Lower back, posterior and anterior thigh. Areas I won't mention for fear of him one day reading this. But seriously who knew tinea could spread so quickly and that toddlers can get jock itch! Major fail!!! Quick consult to my doctor friends with pictures of all of the lesions minus his groin. Definitely tinea. Definitely spreading; it’s all of the summer camp fun and splash park play dates. Primary care friend KJ says just go ahead and suck it up and put him on griseofulvin too, it’s already too out of hand and you'll stop it before it spreads to his scalp.

And just like that, I have written my first prescription for my son. Too ashamed and time-pressed to bring him in to my new clinic for tinea corporis. I knew the liquid wouldn’t go well as he is now 16 kilograms and our last go round with amoxicillin ended in us making daily smoothies. Based on my calculations, he could do one-half of a 500mg tablet daily - and after all of the pill swallowing for kids I observed due to an awesome program one of my co-residents did, I knew what to do.

Tuesday - I took him to the pharmacy to get him excited about his new medicine to help with his itchy parts. He shook the bottle to a nice beat and did a happy dance. We got home and I cut the pill. Hubby says “shouldn’t you crush this, it’s huge.” I say “nawww, we’ve got this.” Equipped with 1 tablespoon of honey and half of the pill, I say, “okay, you’ve got to swallow this without crunching it up.” Zo smiles, says okay and then hubby offers him some extra water and then VOILA!!! My almost four-year-old swallowed his first pill!!! Proud doctor-mommy moment in the midst of a crazy week.

How I Studied For The Boards...

Genmedmom here.

I saw Mommabee's September 1 post asking for practical advice about how to study for the boards, and I felt compelled to post the link to an article I wrote on this very topic! This was written for the New England Journal of Medicine Knowledge+ blog as a humorous, but essentially accurate personal account: I Studied For The Internal Medicine Boards On The Stairmaster

What in the world?!?

I was supposed to be much farther along in my studying goals and there are 6 weeks until my pediatric boards and every week I realize how much further off track I am.

I thought my schedule was “made for” studying. Four-day work week with Fridays off. And then my clinic closed for 2 days and I’m making up those days on my off days because I don’t have enough comp time yet.

And then the fancy, super detailed Google calendar study plans that I worked so hard on are being utterly obliterated. The first 2 weeks I was solid, but that was when my patient load was only at 50%. Then when I got up to 75% things got real. And now that I have a full patient load there is literally not enough time in the day to sleep, eat, see patients, work on notes, call patients back, read consult notes, spend at least a few hours with my family, and finish the notes that I didn’t get done earlier in the day.

I hadn’t even realized I had gotten to the 6 week mark until one of my study partners mentioned it. What in the world?!? She said “it’s time to go to PICU hours?” And she’s totally right. Something has to give and I don’t have $2,265 nor the time to retake these Peds boards. My husband is super supportive and tells me to take the time that I need but after so many years of missing out on tons of family related activities it just breaks my heart to be at this coffee shop doing Med Study questions on a beautiful Sunday morning while my family is at the park but hey - it’s going down!!! (well right after I write this pity-party of a blog post)

I’ve got this, right?!? I just remember how grumpy I was during the PICU because of the sleep deprivation. At least I don’t have to calculate TPN (total parenteral nutrition) or ventilator settings.

Alright ladies - I need your support. Your encouragement. What did you do? (I scratched that because I have all of the resources I plan on using and don't really want general info about how you studied cuz' we all study differently and I know me - I'm all about practice questions). How did you do it? How did you balance it? Did you study as much as you'd planned? Did you get up at 5am? When did you do your notes? When did you study?