Ship 'em off!

When I made a post last week about fellowship, I was surprised by one commenter who suggested the idea of living apart for a year while I did a fellowship. Either my daughter could come out with me and I could manage as a single parent (eep!) or she could stay with my husband and I could just visit on odd holidays.

Now I've lived apart from my husband for periods of time and it was not fun, but it was doable. But living apart from my child is a totally different ballgame.

I know the commenter meant no offense in this statement, and the truth is, women do this. I know of a few female residents who have sent their babies to live in their home country with the grandparents while they furthered their careers. I don't judge these women but it's not something I would ever remotely consider.

In my daughter's entire life, I have only been away from her for one single night. (Not easy to manage as a resident!) My husband has only been away from her for a handful of nights. For either of us, it is painful to even contemplate a year spent apart. I can do a fellowship in ten years from now if I want, but AGE TWO is only going to happen once. I'd never forgive myself if I missed out on it.... or if I put my husband in a position where he was forced to either give up his job or miss out on it.

For me, feminism does not necessarily equate with always getting my way in terms of career.

Mother of the patient, part II

Since our last visit to the ER less than a month ago, we have been to the doctor's for my son several times. First it was the acute visit follow-up, then his routine well-child visit along with associated vaccines, and then this week, another acute visit for allergies.

I had been noticing him rubbing his eyes a lot, often with the appearance of allergic shiners, rubbing his nose, and the occasional rapid-fire sneeze sequence. My poor boy, one day, was itching his eye so much that it became swollen and red and I feared he would gouge out a layer of his cornea with his thumb. He couldn't sleep due to the itching, crying while standing at the crib rail, itching his eye. Even after I came in and rocked him to sleep, holding him, he continued to rub his eyes in between soft snores.

Of course it was the weekend. Everything only happens during the weekend.

So early this week, I took him in for a visit at the Pediatric Clinic.

We saw a resident. This time, I did not say anything about being a physician, but it must have been in the chart because he knew. I got the sense that he did not have much experience with toddlers with allergies. I sat patiently while he read Up to Date and consulted his Harriet Lane. He presented the options of just treating symptomatically with Zyrtec, skin testing via an Allergy consult, and performing a RAST screen on a blood sample. I was leaning towards some kind of testing; it seemed more logical to me to identify potential triggers and to try to eliminate them as much as possible rather than blindly treating with medications indefinitely.

But, I also wanted to know what his attending's experience was with this and trusted his/her guidance on this. Plus, I wasn't too familiar with the different sensitivities, specificities of the various tests. He went to go discuss our case.

I have to say I was a bit disappointed that the attending never came in to introduce herself or talk to us. Instead the resident just came back and said she thought we should just treat with zyrtec and that skin testing, in the absence of planned immunotherapy, was pointless. She thought allergy testing was way too aggressive, at least that's what I heard second-hand.

I left feeling kind of dissatisfied with the whole experience. With not seeing an actual attending. With a management course I wasn't 100% on board with.

But, after talking it over with my husband and doctor friends, I decided to push for the allergy testing, at least the RAST as a primary screen. I didn't want to commit my son to medication long-term without knowing the causes.

I called and left a message for the resident who did not call me back until I left a second message. (Was I just a pain in the butt physician parent that had to be avoided?) I think I nicely stated my concerns about not knowing my son's triggers and he ordered the RAST right then.

Today, I took my son to get his blood drawn. So, he's never had blood drawn outside of routine newborn tests and it's been a long while since my peds rotation...I failed to remember how traumatic getting blood from a 15 month old can be.

There were 2 adults holding him down while another poked him with a butterfly needle in his right antecubital. Oh, how he cried and struggled and looked at me as if I betrayed him. I kept kissing his forehead and wiping the beads of sweat on the bridge of his nose and his face. They could only get a few cc's from the right and had to switch to the left. At one point, I was ready to call the whole thing off. No more. But I also didn't want to have to do this again.

I suddenly appreciated how this might be the aggressive approach.

Just a few hours later, I was holding him while at the store. He kept raising his shirt and itching. Detergent? I set him down and lifted up his shirt. Red patches, scattered, maybe where he was itching. Yes, definitely a rash. I showed my husband. It was looking more urticarial by the second, yes, definitely the beginning of hives. He looked otherwise well. No trouble breathing. Not feeling ill but itching.

My heart started to race. I had benadryl in the diaper bag, just in case (ever since Tempeh's post actually). Our plans for the afternoon took an immediate detour back home, keeping a close eye on him during the 15 minute car ride for any clinical changes.

Husband: He's itching his leg.

Me: His right leg?

Husband: Yes.

Me: He always itches his right leg. That's where his worst eczema patch is.

At home, I stripped him down to his diaper. I gasped.

Huge urticarial welts covered his back. HUGE. Just the sight of them on his soft baby skin made me cringe. What did he eat? We grabbed packages to read the ingredients. Got on the internet and did rapid searching. I thought back to earlier this week when our nanny gave him some green beans in a peanut sauce that made me hyperventilate when I discovered it, despite our instructions not to give him nuts or shellfish.

The hives melted away within 15 minutes of taking the benadryl. I, however, am on perma-edge. I still don't know what he ate that did it - nothing new. Cheese and Ritz crackers right before.

Suddenly, I'm glad we got the blood test. Maybe it was the right decision after all.

To Get to the Other Side

There are times in life when everything seems to fall right in to place, and then, there are times like now. I can see the shimmering oasis of a new life, just on the horizon. A better call schedule, closer to family and friends, a chance to work in a collegial (not competitive) environment, more time with my precious kids and husband, and a chance to grow as a physician. Between the oasis and where I stand, however, is a treacherous, rock-filled, rapid river, swirling and threatening my ability to ever reach the opposite shore.

Obstacle #1 - Our house is on the market, and we have shown it at least a dozen times. Yet, despite positive overall feedback, not a single offer. I don't mean to boast, but our house is a beautiful house. I love it. I was ready to buy it the second I walked through the front door, and I can't believe that everyone else that sees it doesn't feel the same way. We never thought we would have to sell this house. Maybe we should have thought about selling it before we bought it. If we don't sell before we move, we'll have a hefty house payment, along with any rent payment we need to pay in Newville. This alone will be a financial strain.

Obstacle #2 - Mr. Whoo has yet to find a job, nor procure an interview in Newville. Granted, he has only starting looking in earnest recently. However, he is looking for work in the finance world, which isn't the best place to be seeking employment given the current state of our economy. We have been fortunate that he was able to quit his job last fall when our family really needed it, but now we worry that the employment gap may cause an impetus with new employers. Plus, without an additional income after the move, there will be more financial strain on our family. (See Obstacle #1)

Obstacle #3 - My current place of employment is not letting me go without a fight. There have been veiled and outright threats of lawsuits and damages and liabilities for me leaving earlier than my contract had mandated. There is also the matter of giving back a portion of student loans paid by the hospital. The fact that we would have to pay back was not unexpected, however, the amount that we calculated is about half of what the hospital estimates. We are procuring the services of a contract negotiator and a lawyer, who seem to believe we have a case for inducement, but I'm having angina just thinking of it. Not to mention the fact that, if the hospital's calculations are correct, they want us to pay up in less than 2 months. Add more financial liability to the swirly, cold, and fast water.

Obstacle #4 - Emotionally, I am wrung out. I am completely exhausted, and barely hanging on by my fingernails to make it to the date I indicated I was leaving. Being on call, continuously, with only 4 days off per month (plus vacation time), has left me completely burnt out. I find it hard to drag myself to work and muster compassion for my patients. They deserve better than the doctor I am right now. My health, mental and physical, is suffering. The remainder of my contract is a mere six months, and by finishing it out, I can alleviate much of the financial burden of the above obstacles...for the price of my very sanity. I want to cry just thinking of it.

So, I sit here on the bank, pining for the oasis, and unsure how to navigate the obstacles that lie before me. Oddly, I am reminded of the "old school" computer game, "The Oregon Trail." When faced with a river, you can try to ford the river, float the river, or hire someone else to help you across. Right now, I am pining desperately for someone to throw me a life line, or at the very least, a strategy for surviving these treacherous waters. The best advice I can relate to our readers is to know what you are getting in to before you sign a contract. There is no such thing as a perfect job, and if it seems too good to be true, it, in all likelihood, *is* too good to be true. Caveat emptor...and pass the caulk.

*cross posted at Ob/Gyn Kenobi

There's a reason they call them "fellows"....

This is going to be a bit of a rant, so apologies in advance...

I've made no secret of the fact that I'm not terribly enamored with the field of medicine or being a doctor, but I've managed to actually find a specialty that I love. And within that specialty, there's a subspecialty that I'm very interested in. I've been nerdishly dreaming about a one-year fellowship for a while now, but it's beginning to look like that dream isn't going to be able to come true for me.

I'm not going to get into the details of my own situation, because "it's complicated" (like my younger brother's Facebook relationship status). But I am going to make a really broad generalization and say that it's really rough for a woman with a child to do a fellowship. Granted, some women do it. I know because I see female fellows with pictures of babies on the back of their IDs so I'm guessing they're mothers (unless the photo came with the ID badge). But it's rough.

Here's why:

Fellowships tend to be competitive. So unless you're doing a fellowship nobody wants, like, in rectal exams, you have to be geographically flexible. (There's no such fellowship, by the way. Didn't mean to get anyone's hopes up.)

Being geographically flexible means possibly uprooting yourself to do the fellowship. It's not quite as big a deal to camp out in Whereverland for a year if you're a single person, but it feels a lot more selfish to force your spouse and child to move with you. To give up your home, your daycare/nanny, your spouse's job, etc.

For a man with a family, it can be just as hard, but I'm going to go out on a sexist limb and say that it's harder for a woman for a couple of reasons:

1) There are a lot of men who are totally cool with being stay at home dads and I salute them. But most men aren't. In this economy, it's not easy to find a job and there's a chance your spouse could be unemployed indefinitely if he gives up his job. For a lot of men, this would be a huge blow for their self esteem, possibly one that's unacceptable and would result in marital discord. For women, less so, in general.*

2) I think a lot of women tend to feel that their career takes a back seat to their husband's career and their family's needs. For me, the thought of uprooting my family for my own selfish career aspirations just feels really wrong. I can't do it.

So that's that. My nerdy dream, up in flames. Sigh.


*I am making a bunch of broad generalizations. Please don't throw something at me if you are an exception.

Medical training and marriage

At the park today, I was talking to another parent I know who is not in the medical profession (for the sake of ease, let's call him Fred). Since Fred knows I'm a doctor, he mentioned he had been watching a TV show on NOVA that followed 7 Harvard-educated doctors over 21 years.

Fred told me that he was amazed by both the hard work that these people put into their careers but also by the way their relationships were ripped apart by their professions. He said all but one of the doctors ended up divorced.

I always felt that med school brought my boyfriend (now husband) and I closer. He was actually a much better boyfriend when I was stressed out and upset--he was incredible at calming me down. If I hadn't been dating him during my surgery and ICU rotations, I might never have discovered what a perfect match he was for me. And he learned that I was willing to put my relationship before my career.

For this reason, I tell med students who are concerned about relationships that med school is actually a great test. After all, with all the stress of my 3rd year clerkships and internship, the hardest year in our marriage was probably the first year after our daughter was born. I've heard that's common. Wouldn't you rather know your relationship stands up to stress BEFORE you have a child?

Yes, a lot of long term relationships fall apart during medical training. But 50% of marriages in the general population fail anyway, so clearly a lot of people are getting married who aren't right for each other. Perhaps medical training just hastens the inevitable.

ASS-U-ME

So you probably all know the old saying about what happens when you assume, but just in case anyone is coming late to the game, I'll remind you: when you assume, you make an ass out of u and me. Nowhere is this truer than in medicine.

My 5 year-old son has a life-threatening allergy to eggs and peanuts. His allergist told us ominously a few years ago, "Kids with known peanut allergies have a life-threatening event every 4 years on average." Ever since then, we have been holding our breath, thinking that we are past due. We have been extraordinarily cautious since learning about his food allergies when he was only 4 months old. We have no peanut-containing products in our house ever, period, and have eggs at home, but keep them far from my son and cook with them only under very controlled situations (since his egg allergy is less severe). He attends a "peanut-free preschool." We have Benadryl and Epipens in every bag and car and never leave home without them, even to go for a walk down the street. We have stopped flying airlines that serve peanuts. Everyone in his life, from family members to friends to our nanny to his preschool teachers, knows that we have to read the labels on every food every time. Most of them are far more conscientious about this issue than I would likely ever have been before it touched my own life, and many have gone to great lengths to learn where to buy or how to prepare foods for him safely.

My son's preschool teacher is one of the most endearingly over-cautious individuals of the bunch. She will often dash outside on mornings when I am dropping him off to make sure that the candy they will be using for the buttons on a snowman is safe for him, even though the ingredients are literally "sugar and Blue #4". Our nanny is also meticulous about keeping him safe, having chased after me more than once when I left his Epipen behind as I headed out to the car with him, and having noticed that the same cookies we have been buying every week for 2 years, which have always been safe, now say "May contain peanuts". I really don't worry about his safety when he is in their care, and they are pretty much the only two adults I ever leave him alone with for any length of time as a result.

Yesterday was the 4th birthday of one of my son's preschool classmates, Anna. Unbeknownst to me, Anna's mother had asked their teacher weeks ago if she could bring cupcakes. The teacher told her no, not unless they were made without eggs. Apparently she also inquired about bringing in a variety pack of mini candy bars, which his teacher also rejected not only because of his allergy, but the fact that the preschool is officially peanut-free and many of those would surely contain peanuts. Anna's mother, determined not to give up, went to Costco and bought a big container of gourmet jellybeans, which she divided into little snack sacks for each of the kids and sent to preschool in Anna's backpack. Their teacher helped Anna to pass them out to each of the children, including my son, at the end of class.

I am in clinic on Wednesdays, so our nanny picks up my son. When she got there, he had his head down on the table and said he didn't feel well. She noticed that his bag of jellybeans was mostly full, unusual for my son who is a sweet fanatic. He had eaten only a couple of them, he told her, since he felt kind of sick to his stomach. But then he asked to be able to stay and play with his friends in the adjacent play area, so she forgot about it. After playing for awhile, he came back to his goodie bag and ate a few more jellybeans. Within 5 minutes, he was complaining of nausea and saying he needed to put his head down. Noting that his "nausea" coincidentally occurred as they were being asked to clean up, she didn't make much of it. By the time they got back to our house, less than 2 miles away, he was coughing and wheezing, complaining that his throat was tight, and dry-heaving. She promptly gave him Benadryl and called my cell phone, Epipen in hand. By the time I answered 3 rings later, his face was noticeably swollen. She knew he was having an allergic reaction, but to what, she said, she had no idea. He hadn't eaten anything that should have peanuts or eggs.

When I talked to my son about what had happened later that day and asked him what he thought had made him sick, he said without so much as a pause: "those speckled jellybeans I ate at Anna's party". When I asked him how he knew, he said, "the package didn't have any words on it, which means there could always be peanuts," a rule I have repeated over and over to him for the last 5 years of his life. At least he has been listening.

Ultimately with treatment, my son was fine, but how on earth did this happen? My son is extraordinarily aware of the seriousness of his allergies and routinely surprises me with his own cautiousness about foods that didn't come from our home. He was in the care of multiple people who know him, love him, and are frankly paranoid of messing this up. I called his preschool teacher later that day, quite distraught, to tell her what had happened and to let her know that he was fine, in case she had already heard through the grapevine. She had and had immediately called Anna's mother, who checked the label of the jellybean container and confirmed what I already knew: peanuts, plainly listed among the ingredients. In fact, one of the gourmet jellybean flavors was PB&J.

It turns out that Anna's mother JUST ASSUMED that jellybeans would be safe, so she never actually thought to read the label or bring the original container to preschool. Understandable. Who would suspect jellybeans might have peanuts in them? I wouldn't. His preschool teacher JUST ASSUMED that Anna's mother must have checked the label since she had asked so many questions about which foods were safe to bring to school for Anna's birthday, so she never actually asked her whether the jellybeans were definitely peanut- and egg-free. Understandable. Anna has been in preschool with my son for months, and his allergies were widely known in the class. My son JUST ASSUMED the jellybeans were safe since Anna had brought them, and his teacher had handed them to him, so he never actually asked. Understandable since he is just beginning to read and has learned he must rely on a few trusted adults, one of whom is his teacher, to tell him if a food is safe for him to eat. Our nanny JUST ASSUMED that the jellybeans must be okay for him since a friend's parent had brought them and his teacher had let him start eating them, so she never actually asked to see a list of ingredients. And our nanny JUST ASSUMED that, because he had already eaten some and was apparently okay that, when he began demonstrating the earliest signs and symptoms of anaphylaxis, which she knows very well, it could not have been the jellybeans.

This could all have been prevented had anyone NOT JUST ASSUMED. This is why two OR nurses count sponges at the end of a case, to make sure none get left inside a patient. This is why two oncology nurses independently verify the chemotherapy dose the medical oncologist has written before giving it. This is why the blood bank requires that the nurse check the hospital bracelet of the patient she has been caring for all week and match it to the name on the bag of red cells before starting the infusion. These policies realize explicitly that when you assume, it is only a matter of time before you make an ass out of u and me. And if you're a health care worker, you might kill someone in the process, too.

As I tried to think of medical examples for this post, I was struck by one thing. All of the ones that quickly came to mind involved nurses. The reality is that, on this issue, they are light years ahead of doctors, who may have historically been too proud to acknowledge their potential for error...and who in many cases remain so. The attention recently given to the alarming prevalence of medical errors has led to some positive changes in physician behavior, such as surgeons initialing the correct side of surgery while a patient is still awake before a planned amputation or joint replacement, for example. But we still have a long, long way to go before these double-checks are built into every important medical decision. And finally, let us remember that all of these practices arose from the terrible tragedies of patients, most victims of health care workers JUST ASSUMING.

If you are a medical student or a nurse or a physician in training, there is a lot of unspoken pressure to just assume that someone "superior" knows what he or she is doing and not to question that person. If you are that someone "superior," there can be a lot of unspoken pressure to appear to know what you are doing and not stop to question yourself. Please, for everyone's sake, don't assume anything. Stop to question. I can promise you that it is only a matter of time before your questioning will save someone's life.

Love and Wonder in a Carcass

I got out of work unexpectedly early yesterday and went for a walk with my husband around our peaceful neighborhood.  The weather was sunny and cool - glorious, really.  It's about time we started seeing days like this in New England.

Just as we were coming back around the block toward our house, my husband spotted something on a neighbor's lawn.  It was a tiny skull of some sort attached to a vertebral column with some ribs still connected to it.  The remains of a small animal picked clean of all its flesh, its dry bones curled almost into a fetal position.

I immediately went to get my camera and find my son, who was watching some of the neighborhood boys shoot hoops in a nearby driveway.

"Where are we going, Mommy?"

"I want to show you something.  It's a mystery.  The skull and spinal column of a small animal.  I'd like your opinion on what it might be."

At this, my son acquired more of a spring in his step as he followed me to the grassy area where I had first seen the bones.

"Cool."

He put his baseball cards in his pocket and knelt on the sidewalk to look at the specimen.  "It could be a chipmunk," he suggested.

"That's not a bad idea," I said.  "It's certainly about the right size.  Shape of the head seems right too."

"Or maybe a bird?"

"Possible.  I don't know enough about the skeletal anatomy of birds versus mammals to be sure, come to think of it, though I'm thinkin' mammal."

We looked at the skull from different angles, and I noticed in the concave hollow of the base of the skull a very similar architecture to what I remembered about the base of the human skull. There was even a recognizable foramen magnum leading like a secret portal to the vertebral column.  

"Hey, look at that," I whispered to myself.

"What?"  my son asked.

"Our skulls are not that different on the inside from this little animal's.  They're engineered so similarly.  Amazing."

I said I would go back to our house to find my anatomy book.  As I got to the door I heard one of the neighborhood boys ask my son why his mom had brought him down the road, then heard my son explain about the "cool" animal bones and invite them all to look. I had a brief mental picture of a group of neighborhood boys gazing intently at the little skeleton on the grass, and I smiled at the possibility.

"Honey, have you seen my Netter?" I called as I entered the house.

"I think it's at the bottom of a whole pile of your medical books upstairs."

I rummaged through various piles of books and finally found it - an old friend from medical school, still with me after all these years.  I went back outside to where the boys were shooting hoops and called my son over.  I turned to the page showing the inside of the base of the skull.

"See?  Remember how the animal's skull had these depressions in the bone, just like this, like someone scooped out part of the inside of a bowl?  Our skulls are the same."  By this time three or four other boys had gathered around to look.  I was delighted with their curiosity.

I was pleased to hear, too, that they had been debating the identity of the animal.  A boy my son's age had suggested a mouse.  "There are some mice on B Street, so maybe there are some over there too."  I agreed it was a reasonable suggestion.  Another, older boy proudly put forward his hypothesis:  "It's probably a baby squirrel eaten by a crow.  They fall out of the trees a lot."  This sounded eminently plausible to me as well.

I closed the book and started for home again.  "I'll see you there for dinner," I said to my son.

My time with him had cast a glow inside me.  It was as if the afternoon sunlight had managed to get through even there, to places unseen, and turn what was dark into gold.  The little hollow of a dead creature's bone held our closeness like a cup.  A tiny chalice pouring out wonder.  A passage through death and mystery to blessed life.

[Cross-posted at Notes of an Anesthesioboist.]

Mothering

Relationships with our mothers can be complicated, and mine is no exception. Our past 12 months have been challenging owing to illnesses, schedules and the 600 mile distance between our homes. Through the help of a wonderful therapist, I understand the dynamic between myself and my mother – intellectually – but the emotional part still struggles to keep up. The funny thing about therapy is that it helps me understand the past but not how to navigate aspects of the future.

For example, my father recently left me a message on Facebook (of all places!) that my mother was going to have a bone marrow biopsy for a chronically low platelet count. Based on fuzzy memories of my heme-onc rotations, bone marrow biopsy = cancer until proven otherwise. I google chronic thrombocytopenia looking for answers and a differential. That’s the default setting on my brain – back to logic & science & evidence. I also pick up the phone.

“Hi, Mom. How are you?”

“I’m fine. I’m supposed to have this test tomorrow in the hematologist’s office.”

From the tone of her voice, I can tell she’s on the verge of being unhinged by the test – not the potential diagnosis – although to her credit she’s been through early breast cancer (DCIS) & a course of radiation.

“Dr. Bone Marrow is very reassuring that the test is not a big deal.”

“Mom, you need to ask for Versed & lots of it.”

Flashback to standing at the bedside in the wards of the Navy Hospital. My face is hot as the blood is rushing to my toes in sympathy for the 6’5” man who is howling as the team of physicians are drilling into his pelvic bone. Flash back number two is in the OR with our heme-onc attending as they are putting his 8 year old patient with ALL to sleep. He readies the biopsy tray with classical music tinkling in the back ground.

“You don’t need to be pain.” (Thus my reason for being in therapy in the first place: the complicated dance of daughter nurturing mother. Once again the choreography takes off before I’ve even got my shoes on. )

“How do you spell that drug?” She asks.

“V-E-R-S-E-D.”

“OK, I’ll ask.”

She leaves me a message the next day thanking me. She and her doctor have decided to schedule the procedure in the interventional radiology suite with conscious sedation. She’s still somewhat unhinged by this. She wants to know more about conscious sedation. This time our exchange is mid-day by e-mail.

MWAS@gmail: It will be like your colonoscopy. Probably some Versed and monitoring.

MOM@gmail: OK. They have me scheduled for Friday with the radiologist.

MWAS@gmail: Talk to you later. Love you, Mom.

Post procedure was anti-climactic. She did well, and had glowing things to say for the radiologist and his nurse. With my father on the phone, some more piece of her puzzle slide into place. Mom’s been losing weight unintentionally for several months. She also has a low white cell count. She feels fine, otherwise. We all dance around the big C - and it leaves me wondering if that’s mom and dad’s doing or the doctors until they have a diagnosis. Intellectual mind whirrs through the differential: leukemia – maybe a chronic form like CML, viral infection (that’s the pediatrician in me), or some type of autoimmune problem like rheumatoid arthritis which runs in our family. There could be other reasons, but my adult medicine is rusty and inexperienced.

Emotional mind is reeling. Oh Crap! (and several other expletives) As much as I want just intellectual mind to deal with this, the therapy that’s trying hard to integrate the two aspects intervenes. I feel lost – not sure who is supposed to show up – the intellectual nurturer or the emotional daughter in need of her own nurturing but afraid to ask. To be continued….

My aptitude for family medicine: poor, apparently

I did the University of Virginia medical specialty aptitude test purely for sport recently and was startled to learn that of 36 medical specialties, the one I am least suited for is family medicine.

I'm not surprised that family medicine did not rank first. I chose it only partially because of any natural inclination toward it, and mostly because the training and practice of it meshed best with other priorities in my life, particularly raising a family. What did take me aback was that it occupied the very last spot on the list.

Pathology and radiology ranked at the top.

From time to time I flirt with the idea of returning to residency, but what it comes down to is that I would rank my current job satisfaction as a family physician at a 9/10. Is a chance at boosting that to a perfect score worth three more years of residency, a massive reorganization of family roles, a significant reduction in my time spent with the kids and a hefty kick in the pocketbook? I don't know.

William Maxwell, fiction editor of the New Yorker from 1936 to 1975, said upon retirement: "For nearly forty years I have shaved with pleasure in the thought that I was about to come to this job." How I love that quote. What a gift, such perfect happiness with one's work.

Of course, while he was shaving his wife Emmy was likely frying up the breakfast bacon, readying their daughters for school, preparing for a day of housework and granting him the enviable ability to be single-minded.

That is what I find most difficult about mixing medicine and motherhood: the diffusion of focus.

My work in refugee medicine is profoundly rewarding; raising three little ones even more so. The two have proven to be compatible. And yet at some point the efforts put into one require sacrifices made of the other. There simply are not enough hours in the day for me to invest what I wish I could into both spheres. I have erred on the side of mothering, and while I do good work at the clinic, my career trajectory has been modest.

I say this cheerfully. So far, I don't regret any decisions I've made. And every day presents an opportunity for new and different choices. Maybe one day, when the kids are a little older, I'll alter my career track or return to residency.

But for now, and maybe forever, a 9/10 is good enough.

(Cross-posted at my personal blog.)

Hello, unemployment!

In less than three months, I will be graduating from residency.

I can't tell you how much I've been waiting for this over the last four years, especially the last two years since I had my daughter. I didn't get to take as much maternity leave as I would have liked and all I could think about was how wonderful it would be to have a few months off with my baby. About a year ago, I made a list of all the things I wanted to do when I graduated. I lost the list, but I think "healthy cooking class" was on it somewhere.

Now my dream of finishing residency is so close that I can touch it. And instead of being thrilled, all I can think about is that I wish I had a job lined up. I wish I were doing a fellowship. Anything.

Part of it is that being unemployed is no longer cute or funny now that the economy is in the crapper. Not finding work is a real fear for me. I waited longer than my colleagues and continue to not look aggressively because I'm making a big geographical move after residency and interviewing would be difficult and pricey. So instead, I sit and worry.

I'm hoping the job situation isn't as bad as I fear. After all, I get daily calls from recruiters.... SIX of them emailed me last week to wish me a Happy Doctors Day, whatever that is. I just need one person to give me a chance. I'm not picky. My back up plan is to simultaneously apply for fellowships, since at least I'm only competing with graduating residents for those spots.

I just wish I could enjoy this break that I've been waiting for so long.

once is enough, apparently

Very recently, my son did what most of us all do eventually. He peed in the potty. In an effort to encourage him to continue with this exciting new development, I gave him a gentle prompt. Before tub this evening, I asked him if he wanted to pee in the potty, and he said "that's okay, I already peed in the potty yesterday."

Finding my net

My husband deployed 3 weeks ago today. Before he left, I said a silent prayer that the following 3 things would not happen while he was gone:

1. Sudden demise of a major, cannot-live-without-it household appliance
2. Vomiting illness
3. An ER visit for me or my kids

In those 3 weeks, we have had 2 distinct vomiting illnesses tear through the entire household. One of them, in my 3 yr old, was severe enough that we wound up in the hospital with a very scary clinical situation: dehydration, distended tender belly, anion gap metabolic acidosis, elevated LFTs, and alarming lethargy. Fortunately, after lots of fluids and antibiotics, she is now back to normal. Oh, and did I mention that our washing machine began a slow, spiral of death within 12 hrs of my hubby's departure and ultimately took its last breath in the midst of wave two of vom-a-rama, leaving me to wash about 2 dozen loads of vomit-soaked bedding and clothes in total in our tub, wring them in the washer (which would still spin until close to the end), and then dry them...ALL NIGHT LONG on more than one occasion.

Deployment is really not going so well for us. Or so I thought.

But today, I had a fantastic day. Why? I bought a new washing machine over the weekend, and I did four loads of laundry today. Ordinarily, that would not be cause for celebration, but today I felt like whistling a little tune as I watched our clothes gyrating around. Even they looked happy in there. I could have sworn my sweater was flirting with my jeans. And no one vomited. In fact, no one has vomited for 4 days now. And, although I was in a hospital today and my clinic ran hours late, I was on the right side of the stethoscope. Amazing how a little badness can make a whole lot of ordinary look pretty fantastic.

But the real reason that I am feeling on top of the world is that I have found my safety net when I was beginning to think I was flying without one. In the midst of illness and household crises,not to mention general deployment sadness, we were invited to dinner by other Navy families (thanks, KC!) and preschool families we didn't know especially well before. I had acquaintances who heard about what was going on show up unannounced at our door, asking to take our vomit-soaked laundry to their house to wash and dry and return it to our home (!). I watched in awe as our clearly exhausted nanny stepped up with a smile and came to the ER after working a full day with vomiting kids to take my non-sick kids home for dinner and bed so that I could focus on taking care of my desperately sick one without guilt or distraction. And I had busy family members volunteer to drop everything and get in the car or on a plane to come to us as fast as modern transportation would allow if I said the word. Suddenly, I feel strangely lucky that my husband is deployed. Surely these kindhearted, generous friends and acquaintances and relatives were out there all along, and I could have seen them if I had looked hard and long enough, but it took deployment and all the minor crises that ensued to bring them into focus for me. It has dawned on me how much a little nugget of goodness can resonate with someone who is in a crisis, however defined.

Today in clinic, I saw an elderly woman with newly-diagnosed metastatic breast cancer. Through a series of unfortunate self-fulfilling medical prophecies, including misreading of a CT scan and erroneous interpretation of pathology slides, she had been told that her cancer was widely metastatic, required urgent, very aggressive chemotherapy, and that she would almost certainly die within 6 months regardless. I had the distinct pleasure of telling her that while she does have metastatic cancer, it involves only a few spots on her bones, appears biologically quite indolent, and should be easily treated with one pill a day that won't cause nausea or hair loss or any of the things she fears terribly. As she teared up for the first time, about 30 minutes into our visit, I took her hands and said, "Listen to me. It is far more likely that you will die WITH this cancer than OF it. You are going to live for many years to come." It was one of those moments that every cancer patient coming to a large medical institution for a second opinion (and every oncologist seeing such a patient) silently dreams and prays will come to pass, but which very seldom does. Today, she and I shared a moment of joy that was like nothing I have ever experienced in my life except at a birth. In a way, it was a kind of birth. It was her life, unwittingly stolen by a devastating comedy of medical errors, being dusted off and handed back to her. At the end of our visit, she said to me, "I have had people coming out of the woodwork since this diagnosis making such offers of help to me and my husband...you wouldn't even believe it, if I told you some of stories. And now, I feel on top of the world even though you confirmed I have metastatic cancer. Who would have thought such bad news could sound so great? Weird. I know that probably doesn't make sense to you at all."

Actually, today, it makes perfect sense.

Vote for a future colleague! Vote for love!

Mothers in Medicine, our help is needed. Kirby is a MS3 who is a dedicated reader of this blog. She and her fiancee are finalists for a free wedding...but needs votes to win! You can read about their story and vote on the right sidebar for "Kirby and David" at the website. It takes only a minute to vote but could mean making the dreams come true for a future mother in medicine. Voting ends the morning of Sunday, April 5.

I just voted. It took me all of 0.2 seconds.

Good luck, Kirby and David! You'll have to promise to post pictures of the wedding here if you win.

Mother of the patient

I thought maybe my 14-month old son woke up on the wrong side of the crib from his afternoon nap. He wasn't acting like himself. He had no appetite. He was burning up. And he was breathing noisily. I had thought he was getting better from his cold that started several days ago but now he looked sick.

I took out my stethoscope and listened to his lungs. Coarse breath sounds, rhonchi, and wheezes. It sounded awful in there. In my little baby boy. My sweet, angel of a boy. It seemed so wrong that such sounds would be coming from his lungs.

I grabbed his sister's albuterol inhaler and spacer and gave him a couple of puffs. Which did nothing appreciable to his breathing. He also wasn't the most compliant of patients.

It was Sunday afternoon. Of course. It would be the ER. Now, or in the middle of the night, I thought.

I made the executive decision to have him be evaluated in the ER. We should go. Now.

At the front desk, I insisted to be the one to fill out the triage paperwork (as opposed to my husband, not in lieu of the nurse!) Reason for coming: wheezing, tachypnea, fever. I needed to "sell" him as someone who needed to be a priority. I needed them to know I knew.

Rectal temperature in triage: 102.9 F. Pulse 180s. O2 sat 93% (!) RR 42/min (!)

It wasn't very busy and we got into a room right away. They set up a neb for him right away and had me administer it to him, knowing that I was a physician.

JL did NOT like the nuisance mist machine all up in his business all the time and fought it sadly, crying, twisting. I watched as the nebulized mist battled his thumb that was firmly planted in his mouth. He was burning in my hands.

I told the ER physician right away that I was an internist. We needed to be on the same page. Because of that, her way of dealing with me changed, giving me a lot more power in the physician-parent relationship. She told me her thoughts, but then wanted mine, and ultimately left certain choices up to me. X-ray or not (no). Antibiotics are not (yes). I couldn't bear the thought of his little body soaking of radiation - and for what? To definitely know he had a pneumonia? Would I be satisfied if it was negative to not give him antibiotics (no)? But, I worried about some focus of bacterial infection since he was getting better from his cold and then turned for the worse. Bloodwork or not (no). Ceftriaxone IM x 1 (no).

I appreciated having the chance to weigh in so heavily, although I do wonder if I was completely clinically "on" given my duress having a sick child in my arms. Not any sick child. My sick child. But we decided this would be our management. He would be given an acute follow-up appointment in the peds clinic the next morning.

At the follow-up, the pediatrician examined his ears and saw a very clear-cut ear infection in his right ear. This was never done in the ER. I had wondered to myself if someone was going to look in his ears for the sake of completeness, and even entertained the idea of taking a look myself with the otoscope in the room, but quickly brushed the thought aside when JL had pried open the red biohazard container of the floor exposing some kind of urine hat. Plus, the ER physician didn't think it was necessary.

Perhaps I led the ER physician down a diagnostic pathway due to my own suspicions, and maybe coming from me, was persuasive enough not to veer her too far off that path. I know how to give a compelling story for whatever process I think is going on. Isn't this only natural? But, I'm wondering whether she would have done exactly the same with a parent who wasn't a physician. Would she have been more complete? Would she run more tests?

Anyway, JL is doing better, on antibiotics. He's defeveresced but still with a "junky" chest exam. His antibiotic dose was increased since apparently the dosage is higher for an ear infection than pneumonia (wow, peds was that long ago).

And I'm left wondering how much I help and how much I complicate when it comes to the health of my own children. I hope it's heavily weighted towards the former.

No, Mom, Billy DOESN'T want to stay for dinner

While sitting at the dinner table, someone brought up maggots (I know! – but such is life with two boys of a certain age; disgusting subjects at dinner are the usual fare alongside the main course). Eldest quickly mentioned how skeeved he would be if a maggot were to touch him. Of course, I had to jump in with all of the medical uses for maggots, especially when used to treat decubitus ulcers or other poorly healing wounds. I casually discussed the role the maggots played in debriding the dead tissue and how most patients would likely consider maggot therapy rather than dismissing it out of hand, especially if faced with a potential amputation. I buttered a slice of bread as I chatted about how maggots stayed away from healthy flesh; concentrating on my broccoli, I failed to recognize how quiet my dinner companions had become. As I started in on the medical uses of leeches, I looked up from my plate to see three faces staring at me in horror. Mouths agape, eyes wide, silverware down; my family finally burst out as one: “That’s revolting!”

Er, yes, I guess some might view it as such. Apparently it’s time to brush up on my sense of acceptable dinner conversation, which has at this point been warped by too much discussion around the themes of farts, boogers, loogies and the occasion poop.

Baseball, anyone?