24/7

Mamapop had a great discussion Thursday about feminism, and how it applies to politics, specifically Sarah Palin. Feminist is not one of the labels I apply to myself (like juliaink). Just don’t consider myself a pioneer in moving the cause of women forward. I also don’t tag myself as a political animal. However, this election has me fired up because I feel that the items the media has picked up and discussed are issues in my back yard.

As women in medicine and specifically mothers in medicine, we have a unique perspective. My occupation is 24/7. I share call with other physicians, now, although I was once a solo practitioner. The ownership part of my practice is still there seven days a week and requires maintenance whether it is employee reviews I need to write, maintenance of the facilities or just a late night security call. Being a physician is a 24/7 job whether I’m on call or not – and I suspect it may be that way for my fellow MIM writers. Have you fielded a phone call from a worried neighbor or family member because you have MD or DO (or RN, PA, NP) after you name?

Mothering, Fathering and Parenting are also 24/7 jobs. Even with my two healthy children, the balance is precarious and dynamic. I can only imagine what adding intense media coverage, decision making for 300+ million citizens, and overlapping passport stamps would do to my stress level. It’s not that the VP (or presidency, for that matter) job isn’t compatible with parenthood. It is. I’m not sure the job that will require 110% focus seven days a week (or at least this is what I expect out of elected leaders ) is balanceable with children that need their parents as much as 2 of the 5 Palin kids will need their parents in the coming months.

Childbearing in Surgical Residency

My intent was not to make such a serious posting, but I did not succeed.

After 8 years of surgical residency and fellowship, I am happy to report that our lives are returning to some sort of “relative normalcy.” Stress the word “relative” as most would not describe it anything close to “normal.” Life as a junior staff surgeon involves frequent call, occasional emergencies, and the ability to pick up slack for my senior partners. But my life now carries with it innumerably greater amounts of flexibility than life as a resident or fellow.

I now have a small teaching group of 2 female medical students in their first year of medical school. They “shadow” me in clinic or the operating room once a week. Although both are interested in what I do as a surgeon, inevitably they are most curious about my decisions and experiences with childbearing and family life. I tell them about training. I tell them that it is hard but that family life and motherhood are great and well worth it.

It was harder than what I tell them, especially as most of my training was before 80-hours and “80-hours” is often still theoretical in surgical training. All medical training is difficult, but surgical training is perhaps the hardest. Finding the balance between family life and work duties is hard for all surgeons, particularly for women surgeons in training.

The “ethos” of surgery remains principally masculine and rigid. Surgeons are supposed to be particularly strong, not to complain, and to go along with the “status quo”. While this may sound backward and negative, paradoxically in many circumstances I find the first two of these qualities admirable, and I still believe surgery to be one of the most exciting and rewarding career paths that anyone could choose.

As most parents will testify, childbearing is one of the less challenging aspects of parenting. But decisions around childbearing and the time with your newborn are important shaping experiences.

The concept or image of a pregnant surgeon, whether or not in training, is still a foreign one to quite a number of surgeons, some of whom feel free to share their opinions. The decision and process of pregnancy for women residents (I suspect in a number of medical fields) produces anxiety and (both subtle and overt) comments. I have seen female residents leave surgical residency either for another medical specialty or leave medicine entirely as a result of issues surrounding childbearing. Two of my female resident colleagues “decided” to return to work only a few weeks after giving birth because one had been placed on bedrest before giving birth and the other was told two weeks was all the residency program could bear. Female residents that take full time for maternity leave often “owe” additional months (as it might be in other training programs) but also often suffer palpable resentment from fellow residents.

This is, in part, because typically the decision for a female surgical resident to have a child directly impacts the entire training system. And surgery, worse than most other medical sub-specialties, has not found solutions to address these issues. Most surgical training programs suffer from more limited people-power. When one person is not performing optimally or is absent for any reason, the entire team feels it. The call schedule might change from every 3rd night to every 2nd (of course, illegal under current regulations). This issue is perhaps the worst in some of the sub-specialties where the entire training program is composed of a handful of individuals. Interestingly, several of my female friends who have entered small private practices after training also experience similar pressures as childbearing would impact their partners' lives significantly.

Issues of maternity leave, parental leave, and time for other parenting duties in most residency training programs have not been traditionally prioritized. Not surprisingly, fields like surgery which have been slowest to find solutions and to transform their ethos feel much-needed pressure to start making changes -- as women now make up over half of graduating medical school students nationwide.

Personally, I “timed it” well, having my daughter during my years in research during residency. My 4-year-old daughter is beautiful, well-adjusted, and a great kid. And my husband and I have found a satisfactory parenting balance that works. I am extremely lucky, but I would like for my experience to be less of the exception.

Shoes: the other Elephant in the Room

So. There‘s pair of $200 shoes sitting on the floor of my closet.

They are beautiful. The smell of their leather sends chills down my spine.

When I tried them on in the store, I actually felt giddy. I’ve put them on twice…. But if I wear them outside the house I can’t take them back, so I haven’t yet.

I tell my self I deserve them. All those long nights at the hospital and hard work should be rewarded. Really, I don’t need them. My closets are full. I’m blessed. Truth is: time is money. As we prepare to hopefully adopt baby # 2, I see each purchase as time. The less I spend, the more time I’ll be able to take off to spend with the new baby when it comes. (No announcements yet but I'll keep you posted.)

I own my own practice. I’m one of 4 partners. My overhead is killer. My malpractice premium alone could buy one fancy Lexus. I do well, as long as I’m working. Taking much time off leaves me seeing red for a few months. Last year when I had to take my boards, I didn’t get a paycheck for 2 months. I accept this because it gives me complete control of my schedule. My partners are great. We get along personally and professionally remarkably well. We are all moms and we cover for each other a lot. Financially though, we “eat what we kill”. We work as little or as much as we want, take equal call, and pay equal overhead. Overhead includes salary, FICA/taxes, and benefits for two dozen employees.

I try to remind my self that the more money I spend, the more I have to work, the more time I spend away from my family. So I think the other elephant in the room is money. At least for me, since I’m the breadwinner in my family. It‘s physically painful to write out a check every 3 months for $15,000 and mail it to uncle SAM. It’s hard not to also see this as time stolen away.

I was looking at everyone’s profile in our group and it seems that myself and perhaps MWAS are the only Physician’s in private practice. Is anyone else self employed? Are taxes less obvious when you’re an employee and it just gets deducted. Is malpractice less obscene when some else foots the bill?

I don’t plan to vote with my pocketbook. I actually don’t plan to vote. (My state is so red even Gore couldn't take it.) But as I said, time is money. Every dollar more I pay in taxes and malpractice is less time spent with my family. Since the Dems came a little too close to having a malpractice lawyer on the ticket, and because I am both a corportaion and nearly "rich" some have promised to increase my tax burden, twice (don't tell my staff, but we could have to cut back). So yeah, I’m eyeing the Dems with more than a little suspicion.

Gottogo. Need to return some shoes.

The Elephant in the Room

I, like many women, and perhaps like physicians in general, am averse to political activism. Medical problems have, or we are taught to think they have, right answers. Controversy and disagreement are uncomfortable to us, implying that our judgment or knowledge is somehow at fault. Even the formal exercise of an M and M conference does not help us recognize and accept legitimate differences; at the end of the disagreement, the pathologist is there to provide the single right answer. And as women, we want to make others feel accepted and comfortable. So I am reluctant to take a political position in this blog. Some of my best friends, etc....

I am not about to rant on either candidate, but I do want to share my dismay at some of the health care issues that are going to be affected by the outcome of the next election. A friend of mine in Hawaii wrote to me that blue cross/blue shield in her state requires women to pay higher premiums than men--and gets away with it! Yes, women have expenses related to reproductive care that men don't, and yes, we live longer. But the whole idea of health insurance is to spread risk fairly through a population. Differential pricing by gender implies that men are the true representatives of the population and women somehow deviant from the norm (despite being an absolute majority). This stands the very edifice of health insurance on its head.

Beyond reproductive health care services like abortion and contraception, adequate insurance for the elderly, including nursing and other support services, are also "women's issues." When insurance fails to cover services, it is typically women--wives and daughters--who pick up the responsibilties of caregiving. When insurance does not pay for services for children, it is mothers who step in fill the vacuum. Now that women are more productive in work outside the home, the economic costs of us having to cut back our own work to become caregivers are huge, and rarely acknowledged.

The underlying problem is one of state/federal conflict, not necessarily Democratic/Republican differences. The regulation of private health insurance is a state rather than a federal function. Many insurance companies have budgets--and therefore political clout--larger than the state governments that regulate them. Only the federal government is large enough and strong enough to rein in the rogue health insurance industry. Personalities and records aside, this mother in medicine is going to vote for the candidate who believes in using the power of government to regulate crucial service institutions directly, not through byzantine manipulations of the tax code. Three guesses as to who that will be.

Girl Bonding 101: Moving Beyond Netter

I am in a state of slow, silent, ever-evolving panic.

I just looked over at my 10-year-old daughter (soon to be 11), and for a second I saw a young woman sitting in the armchair. Or at least, a young pre-woman. Ack.

She has shot up several inches and a couple of shoe sizes this year. I feel like she goes up one Tanner stage every week or so. Her face has gradually acquired subtle, more mature angles, and let’s not even talk about the rest…

She builds sand castles at the beach and sleeps with her teddy bear. But she also notices attractive young actors or singers, and her comprehension of the nuances of flirtation is accelerating at an alarming rate. She is bubbly and all smiles and hugs one moment, irate and scowling the next, at the slightest provocation. She can still enjoy Sponge Bob, but she can also start to discuss American politics and social issues. I am amazed and thrilled and in awe and totally distressed.

I want to tell her pituitary axis: whoa! Slow down! Childhood’s short enough! But it’s useless.

It’s time to have THE TALK.

No, not that talk. We had that talk when she was eight, because the kids at school were already disseminating all sorts of sketchy information about reproduction and childbirth. I told her I was okay with her discussing reproduction and childbirth but I wanted her to have the right information – and who better than her doctor-mom to provide it, right?

Now, I am sure there are lots of people out there who can describe the “right way” and “wrong way” to handle sex education. I myself got “educated” in a bit of an unusual way. I was in a book store when I was five and saw a book entitled Where Babies Come From, or something like that, illustrated with some cartoon-like illustrations. I had been reading for about a year. I picked up the book, learned the facts of life, and, bored out of my mind, put the book back on the shelf. My mom was a little surprised, I think, when, after she expressed doubt that I actually knew about intercourse, I explained the process to her fairly accurately. It was only later that the more abstract concepts came within reach.

When my daughter asked me where babies come from, I said, “Cells, of course. Remember how I told you all our bodies are made of little, tiny things called cells? Babies start out as little clumps of cells inside their mothers and grow bigger and bigger with time. The parts of the body develop as our cells make more cells.”

That explanation satisfied her for a while, but then the inevitable came: “How do the cells get inside the mommy? And is it true that mommies push the baby out through where they pee?” That was the part the kids at school were talking about.

That was the part that made me thankful I'd hung on to my Netter Atlas of Anatomy from medical school. I sat my daughter down between my husband and me and we explained the relevant mechanics of reproduction step by step. I explained a little bit about menstrual cycles. I drew simple diagrams of female internal organs and used Netter as a supplement. Last but not least, my husband and I both expressed our personal values regarding the place of sexuality in the context of human relationships. As our daughter listened I felt proud, because she seemed to be listening so thoughtfully.

Lately, though, now that she’s a little older, she has acquired a kind of embarrassed reluctance to discuss “woman stuff.” When she was eight we could almost sense a certain pride in her at being entrusted with these more “adult” concepts. Today, however, she’d really rather not talk about them. But I feel I have to get us talking about them, not only to reinforce the idea that it’s okay for us to talk and for her to have questions, but also to make sure she doesn’t feel anxious or uncertain or ill-informed. Sometimes it seems like it's almost easier to get patients to open up about personal things.

I wanted to have the talk about menarche. I think it’s imminent at this point. But how to create a level of comfort about the subject? And to make sure we’re prepared, together, before the moment arrives? I want her to feel good about growing up, to celebrate each milestone instead of dreading or being unpleasantly surprised by it.

The other night an opportunity arose. I don’t quite remember how. But the subject came up, and I asked her if she had any questions about periods.

“No,” she answered emphatically, casting her eyes down. I could almost hear her mortified mental voice asking me, Please don’t give me an awkward, long-winded lecture; please don’t start looking for “ins;” and please, whatever you do, don’t ask me if I’m sure about not having any questions.
“Are you sure?” I asked, stupidly. So predictable.

Then I started to babble. I told her she could always come to me if she felt unsure or worried about something. I told her it wasn’t at all scary to get a period if you knew what to expect. I told her I would go with her to the drug store when the time came to look at the options in terms of supplies.

Then it happened. I got my “in.”

“Actually, that’s the part I wasn’t sure about,” she said, looking up again.

“What’s that, honey?”

“The supplies part. I don’t exactly understand how they work.”

Relief! She had given me a concrete way to nurture and support her! Hallelujah! I launched into an enthused discussion - not, I hoped, an awkward, long-winded lecture - about the pros and cons of various types of supplies, demystifying the “anatomy” and mechanics of each with appropriate exhibits. I explained what I liked and didn’t like about each option.

Sometimes, whether it’s a patient or a beloved child, it can be so tough to talk about so-called “sensitive” issues. And somehow it can be much easier to be direct with total strangers. “Are you sexually active?” we ask during a comprehensive medical history. “With one partner or more than one? Male or female?” I can do all that "doctor stuff" without batting an eyelash, but somehow when it comes to the mother-stuff of making sure my daughter’s emotionally okay, or figuring out if I’m asking too much or too little, saying too much or too little, I feel much less certain that I’m doing an adequate job. There’s no Netter Atlas of Parenting, after all.

I guess I just have to take my cues from her.

Photo: reusable menstrual pad with Kokopelli motif from Wikipedia article on the history of sanitary napkins

Link of interest, for the historically inclined: Museum of Menstruation

Guest Post: Vigilance 101

Several decades ago I began medical school as one of five women in my class. Medical school was followed by internship/residency at a tough city hospital in the days before 80 hour work week restrictions. So I considered myself a non-pampered full-fledged member of the medical profession. But after fellowship finished I was elated with the offer of a half-time job at a university clinic. The hours would prove perfect for raising young children. Of course, half time in medicine means 50% pay for at least 75% time. I worked 5 days per week, 6 hours each day, straight through lunch, so I could finish the workload and get home at a reasonable time. Outside of the regular clinic hours I was also responsible for any of my patients that were hospitalized and for every other week 24/7 on-call. But it was all tolerable because of the flexibility. I essentially job-shared with a near retirement age physician who had raised a large family and he was welcoming of my bringing children to work on the occasional school holiday or child care emergency day.

My rude awakening was the chance spotting of a young male physician at the shopping mall one mid-week afternoon.

“Hi – are you on vacation this week?”

“No – Wednesdays are my discretionary time”

“Discretionary time???????”

“Yes – the day I don’t see patients. It’s the time I write my book, review residency training curriculum, do phone conferences…”

OK, I calculate. He’s my age, same amount of training, hired by the same university division. I work 5 days x 6 hours = 30 hours in clinic for 50% pay. He works 4 days x 8 hours = 32 hours in clinic for 100% pay. I did register a complaint which did nothing but label me troublemaker, but I was attached enough to my work hours that I didn’t pursue legal action. (That’s another story for when children were older).

Fast forward to August 3, 2008, The Outlook Section of The Washington Post. There’s an op-ed article by a physician bemoaning the current state of patient care in primary care medicine. No argument, primary care medicine is dying for a variety of economic reasons. But wait – our author has an answer. He claims there’s a “silver lining” in that many more women are entering medicine. Women tend to migrate to primary care fields, and they are documented to spend more time with patients even if they don’t get paid more. So there we go – cheap, undervalued labor is still with us!


Dr. Nana is a private practice internist in a suburb of a large east coast city. She has a physician son, a medical student son, and a physician daughter-in-law. Besides her clinical work, she is active in political action/legislative lobbying/educational efforts to preserve the practice of medicine, which is currently under assault on multiple fronts.

Mothering a med student

Pathmom has been off the air for many weeks, primarily due to the addition of a full time med student last month. I have a healthy amount of respect for med students (we were all students once), and this one was particularly bright and appeared to have the requisite "good eye" that any successful pathologist must have. So in the title of this blog, I don't want to sound pandering or condescending in any way, but there was an incident that I found particularly memorable, and worthy of sharing.

This young woman had a 4 month old baby girl at home. She came back from maternity leave and went straight into her general surgery rotations. Her medical school was in the habit of "farming out" students to community groups across the metro area (and even the country) for their clinical rotations. The two surgeons she rotated with were geographically close, but had a reputation for inappropriate behavior.

"K", as I will refer to her, had an initial interest in surgery, but she was fully cured of that in the process of her rotation. Apart from being bad-tempered and complaining vocally about having to have med students at all, these surgeons were apparently openly misogynistic. They reduced one female med student to tears by verbal abuse, got cited for making "inappropriate remarks" to another, and told "K" directly that the only way they would ever hire a woman was if she had a hysterectomy.

The last incident really burned me, but I was more appalled by the way "K" told me about it, almost like she was waiting for me to chuckle or at least smile.

"Are you serious? They said that to you?"

"Well, these guys are pretty old school."

"Old school, nothing! That's an extremely offensive remark!"

I had that bewildered sense of reacting very strongly to something that appeared to have no effect on someone that I would consider more or less a peer, based on age and being the mother of a small child. I explained that you can't change individuals, but that she should not take that comment as something either acceptable or amusing. I also thoroughly derided her medical school for allowing students to be with these physicians (apparently, options are rather on the slim side). Despite having quite strong opinions about many and varied things, I actually do not "soap box" very often. This, however, did ignite a spark. The term "flipped out" sums it up nicely.

I couldn't help but wonder if it was her upbringing or just a lack of social aptitude that made her fail to realize the abhorrent nature of that comment (and, yes, I am intentionally leaving out the option that I was just plain over-reacting).

I also couldn't help waxing philosophical about the whole incident. Obviously, this blog is built around the notion that mothers in medicine are worthy and capable members of the medical field. We are also, frankly, necessary to the system. If every "mother in medicine" were to disappear from the profession, and if only those women who were indeed sans uterus were allowed to practice, what then? Not so great for aging baby boomers, that's for darn sure.

This student was convinced that surgery was not an option for her - and maybe it wasn't her path for other reasons - but these horrid surgeons certainly made it clear that she wasn't a candidate based on who she was. "Of course you can be a surgeon!" I explained to her that my sister-in-law is a practicing general surgeon, and has had two girls and plans to have more. I also pointed out that 3 of the 6 general surgeons at my hospital were women, all of whom had small kids. That being the case, I had already melded her mind towards the utterly cool and completely irresistible field of pathology, so I believe it's unlikely she will do anything else (path props).

Frankly, mothers in medicine typifies a scenario that all professional women of this era face: creating the reality of how working moms fit into the American workforce in the 21st century. We're living at a time when there is no "norm" for working mothers, and the expectations and experiences are supremely varied. Some moms get months of maternity leave with full pay; others get paltry weeks (or even days) and pro-rated salaries. Some moms have to take leaves of absence; others invoke FMLA. But we are an increasingly powerful and valuable voice in the professional community, and I believe the situation for working moms reflects that more with every passing year (a generation ago, my mother in law and her female residency colleagues had to sign contracts with their programs explicitly stating they would not get pregnant - they did anyway). We are more involved in making our own reality today than ever before, and I believe that what we want to be and how we want to practice are out there waiting for us, be we single, married, pregnant, or toting around that mysterious black bag with the plastic suction devices on it. And if there are still the remnant neanderthals who feel that the possession of fully function female parts excludes someone from consideration, they are, of course, free to limit themselves thusly while the rest of the world spins ahead with diverse, talented, and dedicated mothers in tow.

Four Months

I came back to residency from my maternity leave when Melly was two months old. By the time she was four months old, I had gotten the hang of things, but it was still rough. Sleep was a frequent issue and between taking care of her and doing night call for work, I was constantly tired. I wrote this one night:

Melly seems to have developed severe separation anxiety in the past week. Leaving her for 5 seconds, or even just putting her in a bassinet, makes her cry. She's cried herself to sleep the past 4 or 5 nights because no matter how late I stay up with her she never wants to be left in her crib alone. I feel terrible.

I was also breastfeeding, so my entire existence seemed to revolve around the boobs. I was always looking for an opportunity to sneak off with my pump. By the end of the day, I was nearly desperate to get home so that I could be "emptied out". It was all I could think about, aside from her tiny little face.

As wonderful as that time was, new baby and all, it was very hard. Very very hard. I felt like I was being pushed to the edge of my limits, keeping things together only by some miracle. But yesterday I realized that as difficult as it was for me when she was four months old, it could have been worse.

At least I wasn't running for Vice President of the United States.

(Or is residency harder?)

Worms

The kids know that I'll check out their cuts or scrapes on a routine basis, and I've been known to pull out more than a few chunks of bothersome ear wax when asked. So it doesn't usually surprise me when one will pull me aside and ask for my "professional opinion". The other day was an exception:

“Mom, can you look at worms with your magic* otoscope?” Youngest casually posed the question one morning.

“Yes, of course,” I began to respond. Then his question sunk in. “Um, honey, why do you want to look at worms?” With mild disgust, I pictured some juicy night crawler on the sidewalk that he wanted to look at more closely.

“Can you look at the worms in my head?”

“WHAT?!” Take a deep breath, I told myself. Surely this isn’t what you think.
“Youngest dear, you don’t have worms in your head,” I stated, with far more confidence than I felt.

“I have one of those song worms in my head and it’s making me crazy. I thought maybe you could see it with your otoscope and get it out,” he replied calmly, starting to walk away.

Song worms? Song worms? What the heck is a song worm? I wondered. Then it hit me – he had an EARWORM that was tormenting him. Starting to laugh, I followed him and pulled him in for a hug.

“Even with my magic otoscope, I can’t get out ear worms. You just have to let them die a natural death. Sometimes, if you’re lucky, you can pass them along to someone else. What song is bugging you?”

And now, Miley Cyrus’s “The Seven Things I Hate About You” has given an ear worm in my brain new life…

A

*Magic because it only turns on when a child blows gently on it – with a little help from Mom’s fingers on the rotary switch. And for more on worms, check out the post here.

A Body in Motion

In my younger days, I was a veritable whirlwind of activity. "The busier, the better!" was my personal little motto. I did feel as though the more that I had to do, the more that I could get done. In high school I juggled studying, cheerleading (yes, I was a cheerleader, hush), multiple extracurricular clubs, honor classes, a 20 hour a week job, and a steady boyfriend with relative ease. Every minute was scheduled to the hilt. Every weekend was planned in advance. I buzzed from one activity to another like a frenetic hummingbird, and honestly, thrived on the pressure of keeping it all going. Granted, all of my activities were very self-centered. I did what made me happy. I didn't have to worry about cooking or doing a lot of chores or taking care of anyone else but myself. The money I earned went for fun stuff, gas for the car, and clothes. I did get to sleep all night every night, and exercised very regularly and would periodically skip lunch to keep my (I imagined) plump 112 pound figure in check.

In college, it was more of the same; harder classes in a biology major, more studying, way more partying, leadership positions in extracurricular activities and my sorority (again, hush), the (required) volunteer work and physician shadowing in preparation for applying to medical school, and a long distance relationship. I bemoaned the woe of having 8 am classes, keeping me only able to go out 4 times a week instead of 6. When I found I had gained the dreaded "freshman fifteen," I dutifully trudged to the gym every afternoon after my 3 pm class, and found the will power to decline dessert with my meals. I lived in the sorority house where meals were cooked three times a day during the week, there was a housekeeper, and my idea of shopping was sneaking in a box (yes, I said box) of contraband wine to hide under the bed and drink with my roommate on the balcony. "A body in motion tends to stay in motion!" I would chirp, and be on my merry little way, padding my resume for medical school applications.

In medical school, things got a lot harder. The classes weren't easy any more. I actually had to go and study, a lot more than I ever had. I was living on my own for the first time in a really big city. I doing all of the chores, laundry, cooking for myself (lots of ramens, rice, and pasta), shopping for myself, and really starting to live like a responsible adult. All of the sudden, all of the extra stuff just wasn't so appealing. I dodged requests to join the AMA, and AMSA, and more volunteer work, and med school committees. I was too busy! I joined the note service for the benefit of not having to take notes during class, but dreaded my transcriptions. It was all I could do to keep my clothes clean, my brain plugged in, and my fledgling relationship thriving. I still made an effort to get to the gym, but the nearest one was a 30-45 minute drive in traffic both ways. This coupled with the pasta, after exam parties, and late night study snacking packed on about 20 pounds. In the last year of medical school, I planned a wedding, got married, interviewed for residency, matched, moved across the country, and bought a house. All of the sudden, I didn't feel like I could do it all.

Then came residency, the mother ship of having no healthy life at all. No sleep, terrible eating habits, 120 hour work weeks, and the *pressure* of being a neophyte physician. Hobbies outside of surviving residency? Surely you jest! It was all I could do to stay awake long enough to speak briefly with my new husband, eat a piece of pizza (cooking just didn't happen any more), and maybe occasionally bathe. Fortunately for me, the 80 hour work week was passed 2 years into residency. I celebrated my new found "time off" by getting pregnant...immediately. Then it was triple the laundry, triple the chores, and triple the responsibility. I began to lose who I was, other than doctor, mother, and wife. I stopped taking care of myself, in order to get everything else done. I was constantly in motion, and constantly wishing to rest. During this time an additional 50 pounds of weight crept on gradually, then not so gradually.

So here I am now, still working ridiculous hours. Still eating like I did when I was in medical school and residency. Still not quite keeping up with the chores. The focus of my life has completely shifted from myself to everyone else *but* me! I stop to look around, and I realize that with as much motion as I have experienced in my life, I have been standing still for years. During a recent interview, someone asked me what I did for "fun" when I wasn't working, and I couldn't come up with a good answer! Um, reading? Blogging? Trying not to pass out whilst my children crawl all over me in the evenings after work? I was shocked to realize that I am not really living, I am merely surviving. In all of my constant motion, that once started out so self-centered, I have lost contact with what exactly it is that I would *want* to do, should I have the time.

I want to cultivate in my children a love of something that makes them uniquely them, be it sports or music or dance or chess or reading. I realize that it is my responsibility to be an example for them, and I don't want my legacy to be only a strong work ethic and keeping very slightly ahead of chaos. I want my children to live in motion, like I got to do, once upon a time. I now realize that to help them live in motion, I've got to find a way to get some rest.

How do you take care of you, and still take care of your families and patients? I welcome your advice.

Enjoy the moment

Having spent a few weeks off with my kids this month I feel renewed.

It has been an interesting time - My kids are 3yrs and 22mos so not quite independent, rather being with them is quite tiring. And while I still have to escort my 3 year old to her room several times a night, and my 22-month old has started having night-terrors...I feel ironically refreshed and rested.

It's because spending time with the kids requires me to be in the moment. They require my attention physically and emotionally.

Throughout my work day, I am usually multi-processing. Driving to and from work I am carefully planning how to use my time effeciently. While in a room with a patient, I am busy trying to cram their agenda in with mine while simultaneously typing their note. In between patients I'm usually checking labs while keeping a window open for my two email accounts...my usual routine is hardly restfull.

I'm not sure I need to do so much multi-processing, but from the time I spent this month at home with the kids, I am reminded of how important it is to enjoy and stay in the moment. I also feel blessed to have children to share these moments with.

What If?

In Eat, Pray, Love Elizabeth Gilbert introduces us to her goons, Depression and Loneliness. They follow her through Rome and Italy as she begins her journey back to herself. I have thugs, too – the What Ifs? They’re a nebulous group of wanderers that pop up as uninvited guests to my thought party.

As a physician they appear as I’m trying to decide how to treat a febrile infant with no source for the fever. “What if,” they poke, “this baby is septic? Will the parents call for more advice, treatment?” “Will this child die in the night?”

“What if the eight-year old that hit his head on the basketball court has a subdural hematoma? What if I miss this serious diagnosis? What if I get sued?” They love to spin tornado-like into larger and larger scenarios of doom. Rarely, they bring news of good. There’s no “What if you catch this hip click before it becomes avascular necrosis of the femoral head and needs a hip replacement when this patient is 25 years old?" There’s no “What if you’ve caught this MRSA before it’s an admission to the hospital?”

They bleed into life as a mother, too, where they take advantage of my sympathy and relative novice state as the parent of a grade- schooler and tween. Never having charted this particular course in parenthood – and it’s very different being a parent and having experience and being a physician and having book-knowledge – is perfect fodder for these thugs.

“What if being too tired to read to Harry tonight makes him feel unloved, unintelligent, uninteresting – take your pick? What if my slightly overweight sons don't hit that growth spurt just right to put their body mass indexes into a normal range? What if someone takes my social and easy-going seven-year old? Who will I call? Where do I look first? What would he do?”

Neurosis is part of my hard drive. I was born to worry about something and these goons know that. A good day for them is when they spin me so tightly that I spook when someone drops a pencil or my husband sticks his head into my office to say hello. Sometimes the What Ifs bring their cousins the What’s Next and Whys. Newspaper trivia about lame lawsuits and pediatric listservs feed their hungry mouths, but they’re always starving for more. Sleep deprivation is a neon open sign to my goons, and if they can catch me just right, What Ifs can keep me up all night with their myriad possibilities.

Lexapro is weak garlic to the What If bloodsuckers that leach my energy. Gilbert’s kept her vampires at bay with Wellbutrin. Breathing exercises and meditation return me to now from La La Future Land where these ding-a-lings prefer to inhabit. Running, walking and exercise also repel the monsters that dwell in my head. Maybe they hate body odor and running shoes. Experience locks the door on the What Ifs cage using reason and common sense as arsenal for the grenades they lob at my head.

Do you know the What ifs?

I feel sorry for you

Last night we went out to dinner with a friend of my husband as well as his girlfriend. Both members of this couple were graduate students and didn't have any kids yet.

If you were to construct a Responsibility Scale to rate the obligations that various people have in their lives, I would say that being a medical resident with children would fall on the higher end and being a childless grad student would fall on the low end. The very very low end. Like, zero.

Naturally, the topic of my own career came up. When the friend discovered that I'm a resident, his first response was, "Wow, that must be REALLY HARD."

Then he added: "You must be EXHAUSTED."

Well, yes. It is hard and I am exhausted. But regardless of the hard truth of that statement, I absolutely hate it when people say that to me. Maybe in this case we could blame it on the fact that Melly had just thrown like five consecutive tantrums (damn teething), but it seems like that's the universal response I get whenever someone hears that I'm both a resident and a mother: sympathy.

I don't want sympathy. Not unless it comes with an offer of babysitting.

Sometimes I question my reasons for going to med school and if they were the right ones, but I have to say, I'm pretty sure I didn't go so that people would feel sorry for me. And I know I didn't get pregnant so that people would comment on how absolutely horrific and miserable my life must be.

Just once, when I tell someone about my job and my child, I wish they would say to me: "Wow, I'm so jealous of you. You have a wonderful, fulfilling career, and you have a beautiful daughter."

(And not be sarcastic when they say it.)

Normal Incompetence

This blog is useful. Yes indeedy. Because all of you, I'm sure, will understand the emotion behind this post.

I can run a code. I could, if forced to, put in a chest tube, intubate, throw in a central line. I've delivered over 100 babies and I've taken care of countless numbers of people in the ICU. I can and do coordinate the care of patients when they are circling the drain. I can and do make life and death decisions every single day.

But put me in the room with my 4-year-old and I'm weak. He throws a tantrum (or eight) and I break. I yell. I threaten. I have no control over him, and no control over myself. I've never hurt him, but that's because I put myself in time out when things get really bad.

Yes, I occasionally lock myself in the bathroom to get away from my son.

Today, while sitting on the toilet in my locked bathroom, I thought, "What am I doing bringing another child into our family?"

_______________________________

After I typed the above, my phone rang. It was my adoption coordinator. I think perhaps God dialed the phone for her. I told her about my day and my feeling of utter incompetence. And then I wept on the phone with this woman who has the power to make our adoption happen or not.

She said I'm normal. She said she's glad to hear that I'm scared and feeling overwhelmed. The adoptive parents who have it all together, she said, terrify her. Like the mother I want to be, she soothed me with her kind words and lifted my spirits.

I'm normal. Incompetent, but normal.

So I went to peek in on Son, who is asleep in my bed. Angelic. I lay next to him and he snuggled in, his hot breath brushing against my neck.

And as I type the second half of this post, I'm starting to feel better.

Normal, if you will.

The Speech I Never Gave

Being on a medical school faculty, I have just listened to a slew of speeches welcoming the new students. Everyone from older students to the dean exhorted the students to be diligent, caring, dedicated and so on, and tried to capture the transformation that occurs between layman and doctor. The students all seemed overwhelmed, being told medicine would be a rewarding but all consuming life. While the speakers honored the families from whom the students came, none said anything to reassure them that their future lives might include families of their own. I listened with the ears of the lonely single woman I was on my first day of medical school, and I felt the mixture of aspiration and despair the dean’s vision evoked.

As my family has observed, I always want to be the bride at every wedding and the corpse at every wake. Sitting there, I tried to think what I would want to tell the students, especially the incoming women, about what lies ahead. I suspect a more feminine image of devotion and change might have been of comfort to them. After all, they are joining a profession, not a convent or a monastery.

Becoming a doctor, I would have said, is a lot like becoming a mother. When you imagine it, based on the images of motherhood that surround you, the vicarious experience of friends or family, and your own experience as a child, you imagine the change occurs suddenly and thoroughly. The baby is placed in your arms, you expect to be flooded with tenderness, to know what to do in every circumstance, and to have the respect of those around you. In fact, the process is gradual. The day you find out you are carrying a child is like the day you get your medical school acceptance letter. The child grows in your mind and occupies many different roles before it ever becomes a flesh and blood reality. How many different specialties did we practice in our heads, before we put on our first white jacket and tried to find a comfortable place to stash the stethoscope? Delivering the baby, like the first day in anatomy lab, doesn’t suddenly make you a mom, or a doctor, not the way you imagined it would. It takes time, sleepless nights, anxious days, moments of profound resentment and moments of even greater tenderness before you fall in love with this child, a love that evolves and changes as the child becomes more and more complex and separate from you. As with medicine, the more fully you embrace this new focal point in your life, the more your inner sense of self changes. Various milestones—the child’s smile, the end of your first period of exams—mark progress toward your new self, but the real transformation occurs privately. It can be sudden—the day someone calls you mommy, or doctor, and you don’t jump. More often, it is retrospective. You look back and realize that somewhere in the past few weeks, months or years, you have become what you and others have expected for so long—still yourself, yet profoundly and irrevocably other than what you were the day you first began to dream.

Do not be afraid, I would have said to them. The sacrifices you will be making will not be more than you can bear, and the rewards will be more than you can imagine.