PM&R: The Holy Grail?

Hi, kids! I'll be tackling two questions today:

My name is Brittany, and I am a third year medical student obsessing daily about what kind of doctor I should be. I struggle daily because I have loved mostly all of my clinical experiences thus far and could truly see myself in a variety of different fields. All around me my classmates are making decisions about career choices, and it just does not seem like an easy choice to me! Considering family life and how it will factor into whatever choice I make makes the decision even more difficult.

So, my question is how did you choose the specialty you went into? Was there a moment or a series of choices or did it just make sense? How much did family factor into this decision?

I realize that everyone says, "do what you love and you'll be alright." However, I love medicine as a whole and different specialties for various reasons, sometimes completely unrelated--there are other factors that influence this decision, and I am curious how others dealt with them.

And more specifically:

My name is Alli and I'm an MS 3 who is in search of the holy grail in medicine-- a profession that provides both financial stability and flexibility. Here's my story: I live with my boyfriend, and future fiance, on Long Island and as I get deeper into looking into residency I am petrified. I love my boyfriend, and want nothing more to have a family (why didn't I want to be a math teacher again??) but I'm really concerned, not only about juggling being a mother and wife with being a doctor, but about finances. I am SO in debt and my boyfriend is a firefighter and doesn't make much money, meaning I would be the primary breadwinner (shudder). Is there a medical field that exists that would allow me to provide for my family while also being a dedicated wife/mother? Don't get me wrong, I'm not trying to get out of working hard and I honestly love what I do. I'm just afraid that years later I will burn out and realize that I wasn't there for my family and that I could have made just as much money doing something else. I have already ruled out certain specialties that I have an interest in because I'm afraid they demand too much (i.e. surgery, ob/gyn) and others because while they might be low key they don't have enough financial stability (i.e peds). I honestly love pediatrics, and was considering it up until I discovered physiatry. Physiatry is a great field, and certainly a strong second choice. I was just wondering your thoughts on my situation, if you have any input about physiatry programs in NY and physiatry salaries in general for a future Mother in Medicine.

OK, since I just blew a bunch of space posting those questions, I'm going to cut right to the chase and be brutally frank here:

For many graduating med students, lifestyle matters. A lot. When we applied to med school, we all had a convincing story about how we want to help people, blah blah blah. And maybe at the time, we meant it. Or at least, some of us did. But when it comes time to decide what specialty we want to do for the rest of our lives, other things become more important than just "helping people" and generally doing good. We've all got loans, rent, children or potential children, future alimony payments, etc., so money is important. And many of us have gone through waking up at 4AM for surgery rotations (on Saturday! horrors!) and decided that's not so much for us.

I'm going to continue to be brutally frank. Get ready:

I don't like to work that hard. I don't particularly like to wake up at 4AM. In fact, even 7AM is a bit early for me. And that whole going to work on weekends thing? Not a fan. Or staying up the entire night on call? Also, not my favorite thing. When I was entrenched in my third year of med school, I realized that I desperately wanted a 9 to 5 type of job. Lots of people have 9 to 5 jobs. Why not me? Why?? Why did I have to suffer through 3+ years of a horrible lifestyle in residency just to possibly have an equally busy practice after residency? I had already worked SO HARD in med school. It wasn't fair. IT WASN'T FAIR DAMMIT!

There were specialties out there that could have catered to the lifestyle I wanted. Dermatology residents have it pretty good. But my grades weren't good enough for that. My grades were good enough for radiology perhaps, if I was willing to go anywhere. But I wasn't. I was following my husband where he wanted to go for his career. (Yes, I was one of THOSE women.)

The brutal frankness continues below...

If you want an eas(ier) lifestyle during residency and your options are limited by your grades and/or geography, there are two options: psychiatry and PM&R.

Psychiatry: Everyone knows what a psychiatrist is. I know this, because people accidentally call me a psychiatrist about five times a day. In any case, psychiatry wasn't for me. I won't get into the reasons, but I was pretty sure about that.

So that left PM&R, which stands for either Physical Medicine & Rehabilitation or Plenty of Money & Relaxation, depending on who you talk to. I did a rotation as a med student, expected to be bored, but actually really liked it. I did my residency in PM&R and it was.... easy. It was rare that I had to wake up before 7AM. I got home most days around 5PM. I spent maybe one or two nights in the hospital during my entire residency. I had a life like a normal human being. Amazing.

The field itself is a hodgepodge of different things. One day you're directing the care of a 24 year old with a new spinal cord injury, the next day you're treating a 60 year old stroke patient. I injected a lot of knees, shoulders, and spines. I performed hundreds of electromyography studies. I got to see young patients who couldn't run two marathons next week because of knee pain. I did acupuncture as part of my residency. I worked races. I had fun.

Even though I was a mother for most of my residency, I was still able to be a great resident. I knew my shit, I was responsible, I was enthusiastic (and I was also modest). I was able to fulfill all my work responsibilities and beyond, had free time to study, time to spend with my daughter, and even *gasp* time for myself. In most other residencies, I would have had to sacrifice something.

On graduation, there were definitely job opportunities, although you may have to be a little flexible about geography. Also, for people interested in research, PM&R is wide open, especially compared with older fields. Now for the salary: according to the Medical Group Management Association's Physician Compensation and Production Survey in 2007, the median salary for physiatrists after 1-2 years in practice is $213,701. A lot of my class ended up doing one year fellowship to specialize in Pain, which commands a much higher salary.

The worst thing about the field is that nobody knows what I do. Even my parents don't know. I mean, nobody here is writing a post called "What is a Pediatrician?" It gets tired to keep explaining to patients what a physiatrist is, especially since the answer requires a few paragraphs.

Let me be totally clear though:

Do NOT do PM&R just because it's easy. We hate it when med students say that and it's always a big mistake to go that route. PM&R is a really fun field with lots of procedures and a chance to really develop relationships with your patients. It's got a good lifestyle, which is something I love about it, but is only one of many things I love about the field. If you work in a field you love, you'll never work a day in your life. (I never really could have been a dermatologist.)

Also, please check out my FAQ on PM&R.

Tips for Surviving Call during Pregnancy

Great timing for Q&A week! I just found out last week that I'll be a new mom in November, making me an official mother in medicine! I've been reading the blog for a while, because I love hearing what all of you have to say about your lives. Here's my question: What tips would you give for surviving residency while pregnant, especially 30-hour calls (without caffeine)?

From a future mom and Family Medicine resident in the midwest

Congratulations on your pregnancy! I know that being pregnant during such a difficult time as residency seems daunting, but you can (and will) survive! Overnight call is never fun, but with a few small changes, you can get through a 24-30 hour call with relatively minimal discomfort.

Survival Tip #1 - Bring lots of snacks to work with you. As a resident, especially on call, you often have an erratic schedule, and sometimes it is difficult to eat at regular intervals. If you are fortunate enough to avoid severe nausea in the morning, then try to eat before you leave the house. Pack your pockets with snacks that are portable, like protein bars (Z.one bars are really good, more crunchy than chewy, and covered with chocolate. Yum!), hulled sunflower seeds mixed with dried cranberries or raisins, or even the standard peanut butter crackers. Having something on your stomach at all times will help stave off nausea and fatigue.

Survival Tip #2- Some caffeine is still ok! No, really! I am not sure how much caffeine you have been consuming prior to pregnancy, but a small amount (150 mg-300 mg) of daily caffeine has been shown to be safe in pregnancy. The official March of Dimes recommendation, I believe, is 200 mg or less. One (regular) cup of coffee or 2 caffeinated sodas per day should definitely fall well within the safe range, not to mention the occasional chocolate fix (so needed on certain call days).

Survival Tip #3 - Learn how to prioritize your duties while on call. It is likely that you already do this to a certain degree. Do the most physically strenuous tasks (procedures, lines, rounding) as early as you can in the call day, when you have the most energy. Try to chunk as many things as you can on a single floor, and "gravity round" (start at the top of the hospital and go down floor by floor). Don't be ashamed to use the elevator, but by going down steps, you can get a little physical activity without straining yourself. Do your best to anticipate any additional orders (nausea medications, sleep aids, pain medicine, diet orders, etc.) that may be needed throughout the day and write them while you are on the floor, saving yourself middle of the night phone calls for Tylenol during the 2 hours that you may have been resting! Another thing you can try is to do quick PM rounds. Alternatively, call and talk to the nursing staff, floor by floor, asking about any issues that may need to be addressed prior to trying to lie down, thus avoiding the "sit on bed, pager goes off" phenomenon to the best of your ability.

Survival Tip #4 - Stay hydrated. I know it is hard to do, and even more annoying when you have to stop working and actually *use the bathroom* on occasion, but trust me, adequate hydration can stave off multiple discomforts of pregnancy and decrease the development of more serious complications like pre-term contractions. Have a bottle of water accessible throughout the day, and refill it often.

Survival Tip #5 - Don't stand when you can sit, don't sit when you can lie down. Rest as much as humanly possible, even if it is just the short time between one clinic patient and the next. Go to the call room and lie down on the call bed instead of sitting around and chatting at the nurses' station, even if you don't sleep, you will be much better rested and prepared for that inevitable page from the ER at 3 am.

Survival Tip #6 - Bring your meds with you. If you are one of the less fortunate ones (like me) who happens to be plagued with persistent nausea/vomiting throughout the pregnancy, Zof.ran will likely be your very best friend. Bring it to work with you, along with Tyle.nol, Sud.afed, Zan.tac, Tum.s, and your pre-natal vitamins. It will help you to avoid having to get IM shots of Zof.ran from the nursing staff or walking around with an IV (both happened to yours truly) for fluids.

Survival Tip #7 - Utilize any support that you have. I'm not sure if in your program you take solo call, or if you have a junior person and a senior person on call at the same time. If the latter is the case, then utilize your support person to their fullest potential (if they are amenable, that is). Try to "divide and conquer" tasks instead of tackling them together. If you are the senior, then trust your junior to do good work without you hanging over their shoulder. If you are the junior resident, don't be afraid to ask the senior for help if you feel you are in over your head.

Survival Tip #8 - It's ok to whine....but don't whine about your pregnancy discomforts to your co-residents or to the nursing staff. Call your husband or your best friend, or compose a long, whiny email and then delete it if you must. It is normal to feel whiny when you are pregnant, but it may ultimately foster unwanted and unpleasant feelings in your co-workers if you vocalize these feelings. It saddens me to have to write this tip, but this is a mistake that I made in my pregnancy that came back to bite me. Sympathy is not always rampant in the medical community, so try not to seek it there, and you will not be disappointed.

Survival Tip #9 - Be aware of your limits. As you progress in your pregnancy, you should not be lifting more than 20-25 pounds, nor should you be feeling more than 4 contractions in an hour. Don't push your body's limits in order to be a "super resident." It is ok to ask for help if you need it, and don't ignore the warning signs that something may be wrong. Often, we as physicians will push aside our own physical discomforts and keep on working. Don't ignore serious signs like contractions, shortness of breath, headaches, excessive swelling, or increasing abdominal pain.

Survival Tip #10 - When you go home, do nothing else but take care of yourself and your needs. If you need to go home and sleep for 10 hours, then do it, dishes and housework be damned. Celebrate the fact that, in spite of being up all night, you have this time catch up on sleep. When the baby arrives, your call shift will never truly be over. Luckily, in many ways, motherhood is infinitely more rewarding! I wish you all of the best as you enter this exciting new time in your life, you can do this.

Playing doctor

This week, I got to have one of my best experiences ever as a physician: I got to teach the kids about being a doctor at Melly's daycare!

I have literally been waiting for this moment for 25 years, since my own father came to my school and taught my classmates about being a doctor. And it was every bit as fun as I hoped it would be. I dressed the kids up in masks and caps with rubber gloves, let them use my stethoscope to listen to each other's chests, let them pump up my sphygmomanometer, and checked knee jerk reflexes on every one of them.

It was a hit. The kids were shooting their hands up to volunteer. I kept a dozen kids ages two through four captivated for 45 minutes, and when the teacher broke it up for snack time, the kids were crowding around me for more. I loved hearing the other kids saying to my daughter, "I didn't know your mommy was a doctor!"

It made me happy that I have a career that seems so fun to little kids. If I were, say, an investment banker, I'm not sure what I could have done. I wonder if I converted any of the kids to wannabe doctors.

And today they made me a card to say thank you.

P.S. Good luck to everyone on Match Day! Apparently, there's a very scientific method to assure everything works out OK.

Stat Pap

This week, I was rotating on EV cytology. EV means "extra-vaginal." I always wondered why my group doesn't call it NG (non-gyn) like the rest of the world, so I don't have the word "vagina" in my rotating service. EV cytology is anything other than pap smears. Fluids, fine needle aspirates, ultrasound-guided thyroid biopsies, and CT-guided biopsies.

The only exception is when there is a "stat" pap smear. Stat pap smears don't come up very often - they are usually done in the OR when the surgeon sees a fungating mass on the cervix or something, and wants to confirm cancer prior to his or her surgical removal.

Earlier in the week, the head of cytology came into my office.

"I've got a stat pap. I think I need to explain it to you, it's kind of confusing."

She told me that a patient received a diagnosis of High Grade Squamous Intraepithelial Lesion (HGSIL) a week earlier. All paps these days also get molecular HPV (Human Papillomavirus - that is the virus that causes cervical cancer) testing - the wave of the present and future. The molecular testing for high risk HPV types came back negative. I've been in practice for almost three years now, and that is a first for me. The molecular always backs up our diagnoses. She's got a lot more experience than me, so I asked her, "Has this ever happened before?" She shook her head like she couldn't remember a time, and said, "Not often."

I said, "Do you have the pap there? Why is it stat?"

"The OB referred it to someone else, and the new clinician wants to know why the results don't match up. We, of course, would check this ourselves, but they are already aware of the mismatch and want it resolved quickly."

My first question was, "Who reviewed the original pap?" I didn't want to step on any toes. If it was me who reviewed it, I would want to be in on the problem, and I would want to be part of the solution. I saw the pathologist's name, and looked up at the schedule. He was off this week. Darn it. Oh well, I could fix this without him.

I looked at the pap smear while she was standing there. All of the techs had already reviewed it, and all were on the fence between HGSIL and ASC-H (atypical squamous cells of undetermined significance-cannot rule out a high grade lesion). As I moved the slide up and down on the stage, I immediately saw the problem.

Usually, when we see high grade lesions, it is pretty easy because there is a lot of low grade, raisinoid nuclear change in the background, and there are clumps of ugly, hyperchromatic cells with irregular nuclear borders - classic high grade lesions. Here, I saw a few single cells that I learned in fellowship were called "litigation cells." Easy to miss (and subsequently get slammed with a lawsuit because you've got to pay attention to every cell) - because there is no low grade change in the background, no clumps, just rare single cells with really ugly nuclei.

"OK, I see why he called it high grade. In retrospect, in light of the molecular, we could go back and change it to ASC-H, if the OB wants us to do that to triage the patient for proper treatment and follow-up. But first, let's call the molecular company (we currently send these out) and ask them to repeat the hybridization studies. When you call them, find out how often this happens and if there is an explanation - I know there are some rare strains of high grade HPV that aren't covered in their assay. Let's find out what they are, and if we can test for them."

She agreed, and called me later in the day. "The company is going to repeat the qualitative hybridization assay and also run concurrent quantitative PCR studies, which should be more sensitive. They'll call us with the results."

I worried over calling the clinician. I worried over having to change a colleague's diagnosis. I showed the pap to another cytopathologist, didn't give her any of the history so she wouldn't be biased, and she basically agreed with me and the techs. "I'm on the fence. Could go either way." It was easier for us all to be hedge-y in light of the molecular. Those few cells were darn scary.

The cytotech called me the next day. "PCR came back positive. They think it is a rare high risk strain. The diagnosis stands fine, and we will just release the report to the clinician."

Whew. It feels good to make the right call, so the patient can get the right treatment.

Bradley Method for Life *

At 3 am this morning I stood by my laboring patient's bed. I know her very well. Her heart's desire was to have a natural childbirth. She was 6 cm and progressing well. She looked at me after her contraction.... "Doctor, How much LONGER will this Take.... I can't do this for hours!"

I encouraged her, you don't have to make it for hours. Just make it through the next contraction. Then will think about the one after that. Relax in between. Breathe.

Two hours later she delivered a beautiful baby girl naturally. Tears of joy rolled down her face.

Tonight as I finally drove home, after a full day at the office, my mind raced. I miss my kids, deadlines and responsibilities are looming everywhere. How on earth am I going to make it through the stress of the next few weeks. I am currently back in survival mode. I haven't been here in a while and its not pleasant.

I will make it, though. One day at a time. One patient at a time. I'll try to find moments in between to go to my happy place. Perhaps when it gets really bad, I'll get in the 'knee chest position' and moan or perhaps soak in the tub..... but I will make it.


*I am not an expert on the Bradley Method, though I am a fan.

Announcing Next Topic Week March 22-26: Q & A

Our next topic week is going to be in a couple of weeks, with a theme of Questions & Answers. We invite all readers to submit questions - either specifically for one our our regular MiM contributors, general questions that one of us will try to answer, or questions directed at the greater MiM community.

What do you want to know?

We hope this will a fun Topic Week to get to know our contributors better, involve you, the readers, more, and answer any burning (or not so burning) questions you may have for mothers in medicine.

Please feel free to submit your questions starting now at mothersinmedicine@gmail.com. You can also submit questions via our Facebook page or on Twitter (@motherinmed).

Hope you will join in and submit something! Include a short one-line bio (anonymously, if you prefer), for example: Izzy is a surgical resident in the Pacific Northwest.

If you are new to the blog, check out our prior Topic Weeks and Topic Days in the sidebar, under Labels.
For all those students about to find out where they are matching: check out Match Day Topic Day from last year.

Thanks for reading and making this such a wonderful online community.

The brutal nanny hunt

Tomorrow morning my nanny starts and this is not something I take for granted.

I had a nanny for almost five years, she now wants to only work part-time so three months ago, I went about looking for a replacement. Yes, amazingly, it has taken me three months to find a nanny.

There are so many things about this search that were painful. Amazingly, despite the slump in the economy, experienced and affordable nannies are hard to come by.

In our area, the cost is crazy - most nannies value themselves on their hourly rate, feeling that they are entitled to at least $15/hour. Well, that's fine except that they also want all the benefits of being on salary - like vacation, sick leave, personal days, health benefits etc...for my husband who runs his own company, this drives him crazy because because we are paying more per hour than his (more formally educated) office manager and this 'hourly' rate that nannies use doesn't include the 'true' cost to us - the real baseline is $17/hour since we have to pay social security and unemployment on top....(painful since these are all AFTER tax dollars).

The second most painful thing was finding the right person. I hired one lady who I thought was perfect, and she didn't show up for work the first day because of something 'personal'.

Then I hired another lady who was cheaper, a little less experience but willing to work longer days and she just had no instincts about caring for a baby (mine is now 10 months). Plus, she was missing her own two kids while working long days so that didn't last but a week.

Third, I hired a 25year old student who was taking classes on the weekend. I was really excited about her because she was young, energetic and would live with us so we would have the flexibility of having her babysit in the evening. So we moved all 3 of our kids into one room to accommodate her (yes, I really thought I could manage with all 3 in one room...). The second day she was watching TV, on email while my baby was sitting under the table. The next day my Mom came to check in on them and she was barefoot in the garage, trying to adjust the stroller while she had the baby PROPPED UP on a box...ultimately she confessed that she had no time to babysit and we both agreed it was not a good fit.

The fourth lady seemed amazing on the phone but it turned out she had NO filter. When she came over for the first time, she expressed many opinions including inappropriate commentary about my kids in front of them. She also only provided references from five years prior and didn't show up to her second day on trial because she thought it would be ok....when I called her to tell her she didn't get the job she really let her words sneak out of her mind and I was reassured that I made the right decision.

Finally, we found our current nanny who has been with one family for the last 8 years- she's wonderful. We found her from a teacher at the preschool.

I must have interviewed over 30 ladies on the phone and brought 20 ladies home over the last few months. I bought subscriptions to all the nanny websites and as good as their services are, the nanny I loved came from a personal reference...which in the final analysis is really the best way to find a caregiver.

For anyone who's interested, Here are the sites I used:

enannysource.com - good listings, good sample documents to use

care.com - utlimately the best site I found, I got a lot of responses from this site and found the spectrum of young and mature

sittercity.com - found most of them to be quite young and a lot of people who just want part time work

sulekha.com - the indian classified ads, people willing to work for good rates, good hours but most want cash

Others include: dcurbanmom.com; whitehousenannies.com

I would be happy to share many more pearls from the nanny hunt for anyone who's interested. For now, I'm just enjoying all the free time I have!

MiM Mailbag: Self-entitled?

Editorial note: We received an anonymous comment this past week to a post that was published about a year ago on this blog (Fizzy's I hate boys). I debated whether or not to publish this as a MiM Mailbag since it has the potential to become an inflammatory discussion that would ultimately not be constructive. However, the comment presents challenging views that many women face when having children during training (and sometimes beyond); a thoughtful and respectful discussion about the issues raised could further understanding by all. So, feel free to join in, but please keep comments constructive and respectful so we can have an intelligent discussion. Thanks.


I am not really sure why all of you self-entitled people in medical school and residency, think that it is actually an acceptable time to be having children at all.

Your absence put a huge burden on the remainder of your class, and your constant need to leave early to "be with the kids", "take care of sick kids", etc. just highlights the fact that maybe you should have chosen a career more inline with what you percieve to be an ideal life - like being a PA, nurse, etc.

The ultimate problem lies in the people who seems to "want it all", but feel they are "special" and don't need to sacrifice anything. Because some of us don't want children doesn't mean that we should supercompensate for those that do. Not everyone was meant to be a doctor, and if other people started using similar excuses in would certainly raise eyebrows - eg: I NEED to go on frequent climbing trips because it is consistent with my world view of life and you OWE it to me.

Basically just entitlement by another name, but not overly surprising in this society.

Attachment

When I was pregnant with my son (now 15 months) I sat down with Dr. Sears' book. I probably did not fully grasp the true philosophy of attachment parenting. What I do remember is one statement in an early chapter that disturbed me at the time and haunted me since.

I remember reading that mothers who work full time and take time off for maternity leave have a high risk of attaching poorly to their babies. That instead of completely focusing on the role of mother they instead are preparing for the day they will leave the child. Preoccupied with their career they are unable to be fully responsive to the needs of the child.

I am sure many reader's blood is boiling right now. Now if I have mis-quoted Dr. Sears I apologize, but even if I did my real point is this: I think about this all of the time. When my son was a newborn and would not nurse, my sleep deprived hormone toxicated brain determined it must be because I planned to pump when returning to work. When he did beautifully with the transition to day care, I figured he didn't really miss me. When he runs to daddy when tired, I take it as further evidence of my shortcoming.

This is working mommy guilt and as a Mother in Medicine I did not invent it. Upon reflection I think overcoming this thinking is a unique challenge for the following reasons. First, I sacrificed a remarkable amount of sleep, happiness and personal well being to become a cardiologist. The idea that I could continue to sacrifice in a way that I would later regret is a true possibility. Second, in reality if I had to choose either my career OR motherhood it is not 100% that I would have chosen motherhood. This is perhaps difficult to explain but I feel like my work is a calling that I was born to do and is my mission in life. Finally, I am a master organizer/ planner. Indeed I was pre-occupied during maternity leave planning my return to work. But only because of my deep respect for how challenging it was going to be- and my desire to arrange help so that I could enjoy my son (an hopefully not kill anyone in my mommy-head state).

So I put this out there to share how my consideration of attachment parenting led to a judgment that is difficult to shake. The challenge to be a mother, as a full time physician, as a perfectionist, as a woman committed to caring when it seems no philosophy can be easily applied to my reality.

What's your major, baby?

For some reason, people are always shocked to find out I was a math major in college. My math ability, which was embarrassingly nerdy when I was going to competitions with the math team in high school, has amazingly become something that makes me interesting now that I'm a physician. (Which is why I bring it up as much as possible. I like to be interesting!)

My husband was a math major too, so between the two of us, we're expecting our daughter to have no less than 800 in math on the SATs. I mean, you can actually get one wrong and still get an 800. So there's no excuse!**

It's not clear to me why math majors are so rare in medical school. I think I was the only one in my class. By far the most common majors were biology, chemistry, biochemistry, and psychology. But to me, math makes sense too, at least as much as psychology. Because I was good in math, I breezed through physics and chemistry. Mathematical thinking even helped in o-chem. It was only in biology that my refusal to actually memorize anything that I couldn't work out from scratch became a liability. That and, you know, in all of medical school. (I'm kidding. Thanks to my math ability, I have a perfect understanding of acid-base status.)

People sometimes ask me if with my math background, I ever considered a career in finance. I didn't, not even for a second. The truth is, a lot of the careers that are very math-heavy (finance, actuary, engineer) seemed very boring to me.

So my question of the day is: what was your major before you ended up in med school? And if it was something crazy, like I don't know, Celtic Folklore, how did you reconcile that with your future career?


**Before the hatemail pours in, I just want to clarify that I'm joking about this. Any score above 700 would be totally fine.

The Journal Backlog

I recently experienced an epiphany. In my office I keep a stack of journals (most still in the plastic wrapping) that I plan to read. Instead of reading I cultivate this neat pile, that is about to sprout into a daughter stack.

Then I did the math:

Journal American College of Cardiology (one/week = 4/month)
Journal Heart and Lung Transplant (one/month)
Journal Cardiac Failure (one/month)
---------------------------------------------------------------
Six journals/ month or 1.5 journals per week!

Epiphany: unless I ACTUALLY read at least one journal per week the pile will continue to grow.

Despite the new clarity I have yet to read or recycle.

It true Mother in Medicine fashion, and in the spirit of full disclosure, I present another pile. In my kitchen, of parenting magazines. Nestled neatly next to my stand mixer (which I am proud to report has been used quite frequently lately).

Men suck too!

Dr. Whoo most recently made a post on the cattiness of females in the workplace, which I found to be very much on the mark. I applaud her for saying what a lot of us were thinking.

However, I was a little disturbed by the enthusiasm of the people who agreed that women are awful to work with and they'd rather work in an mostly-male environment. Seriously? I feel compelled to point out: men suck too.

One of the commenters mentioned watching a movie about a landmark sexual harassment lawsuit and that "after the protagonist complains to management about the fact that some guy decided to ejaculate in her work locker, the other women give her the cold shoulder and tell her what a bitch she's being." I agree the other women were awful for giving that poor woman the cold shoulder. But let's put things in perspective. At least the women didn't ejaculate in her locker. If I had a choice between working with a woman who doesn't talk to me and a man who masturbates in my locker, I'd choose the former. (Go women!)

Of all the attendings I've worked with over the years, probably the biggest ten egos have belonged to men. The biggest gunner jerk in my med school class was a guy. Men can be lazy, they can be assholes, and they often HATE being bossed around by women. A lot of men don't respect their female colleagues. The worst experience I had with a nurse was not a female nurse being catty to me, but rather a male nurse who sexually harassed me.

When I started my residency, the program was mostly men. If you think I was reveling in cattiness-free bliss, you are wrong. Let me assure you, it was not pleasant being a pregnant female in a boys club. I sat there listening to them joking about females they met while going out drinking over the weekend, knuckle-punching each other, and generally making me feel left out. It was obvious the only way I'd feel more welcome was to grow a penis. And don't even get me started on my experience in orthopedic surgery rotations during med school.

I've worked with a lot of men who have been wonderful and also with a lot of jerks. Ditto with women. But when it's a woman, I guess I feel more disappointed in them. Because I feel like we should stick together. That's part of why I love this blog. Because it's a group of mothers in medicine, supporting each other.

In summary, I 100% agree with Dr. Whoo. But I want to point out that we shouldn't go around idealizing men because they ain't so great either.

Own Worst Enemy

Sometimes I wonder, as a person who has very few "girlfriends" and who tends to gravitate more toward men for friendship, how I ended up in a profession where I am constantly surrounded by women. (Maybe it is because men are whiny babies when they are sick, and I have little tolerance for it. That, or prostate exams. *shudder*) I think I tend to want to avoid the drama that inevitably comes along with close female friendships. I've been burned one too many times, I guess. I've been mortally wounded time and again by women who were supposed to be my closest friends, often for nebulous reasons. We've touched many times along the same topic since the inception of this blog, yet I see the theme being returned time and again, *women* keep women down.

I see this every day in my profession (and, more recently, the blogosphere), where women judge other women's birth choices, from the kind of pain relief they choose to the kind of provider that attends them. Female physicians still don't command the same respect as male physicians, primarily from the predominantly female staff. Stay-at-home moms are aghast at working moms for "abandoning" their children; working mothers "look down" on stay-at-home mothers for not pursuing their own career. Breast-feeders sneer smugly at the bottle-feeders. Women judge other women based on their clothes, their handbags, their hairstyles, weight, and personal grooming (can you *believe* she doesn't *wax*??) It is so pervasive that we automatically apologize for not being precisely groomed. (I can't tell you how many women have apologized to *me* for not shaving their legs prior to an appointment! As an aside, I neither notice nor do I care.) As a happily married woman, I find myself angsting over letting my highlights grow out too long, or running to the hospital with no make-up on. My husband does not care about make-up, and he doesn't have a clue about highlights. I'm not looking to hook-up at the hospital, so why do I care? Because, inevitably, I will get the standard, "Oh, you look so *tired.* Are you sick?" or the snide, "Growing out your highlights, hmmm?" These comments do not come from men.

This extends to the political arena, where any woman that ascends to a position of prominence is viciously and ruthlessly attacked, scrutinized, and her family life nitpicked and torn apart (the phenomenon is bi-partisan, see Hillary Clinton or Sarah Palin). The worst perpetrators of this are not the male commentators. It is the female commentators who render the harshest blows with a glint of evil satisfaction in their eye. Even so-called "feminists" are just as inflexible and intolerant of any woman that does not share their point of view as any conservative male evangelist. I've had women, who (prior to a certain post that tweaked a nerve) proclaimed to *love* my blog, flounce noisily with a searing comment from my blog for simply expressing an opinion that differs from their own (totally within their prerogative, but baffling nonetheless). I'm not saying that I'm not just as guilty of this behavior as anyone else. I am woman, hear me snark. If you don't have anything nice to say, come sit next to me, ad infinitum. I have sinned as well.

My question is: Why?

Why do we do our best, intentionally or unintentionally, to tear other women down? Historically we are supposed to be the collaborative gender, working together for the greater good of our families, villages, etc. So why, now that we have more opportunities than ever, are we snapping at one another's heels? What exactly has feminism done for women from a sociological point of view? Are we jealous? Insecure? Afraid there isn't enough to go around or that it will be suddenly snatched away? More importantly, what can we do to change it? What do *you* think?

Tracking Patients

This morning, I dropped my kids off to school early at 6:30 a.m. Luckily, there is a teacher available to help me out when I have to go to a more rural hospital or cover early frozens or a conference. Fortunately, I only have to do it about once or twice a month.

I was covering breast conference for my partner, who is on vacation. The last time I covered it for her was a year ago, when she went to the Rio Carnival on a cruise (jealous!) for her honeymoon. I love covering this monthly conference because it reminds me, in an attenuated version, of the hardcore weekly breast conference I covered at my training university during my fellowship year. Geneticists, medical oncologists, radiation oncologists, radiologists, mammographers, case coordinators, surgical oncologists, PET experts and oh yeah, pathologists -- all gathering in one room to pow-wow about the patients. Going over cases. Discussing new treatments. Asking questions. Challenging each other (hopefully in a tame fashion - it doesn't always work out this way depending in personalities involved).

Today we began by discussing an incredibly rare breast cancer, and I was happily surprised that only two years out of residency I had the same experience with this type of cancer as surgeons and medical oncologists ten and twenty years my senior. So my contribution to the discussion, based on my reading, was substantial. We presented one other case, a sad one about a young girl that was just diagnosed with a high grade breast cancer - after she finished lactating she noticed a lump that didn't go away. Lactational change, to a pathologist, is usually a sight that generates a big sigh of relief when peering in the scope, because 99.9% of the time it means the lesion is benign. Then there are the exceptions. They make your gut twist. They generate nausea. Even though you know what you are looking at, you show it to a partner because you are staring at the age, and thinking about the young nursing mother and what she is about to go through, and you desperately want your partner to tell you that you are hallucinating.

I remember when I was a nursing mother I read nursing texts obsessively in attempt to prevent stories I heard from my friend who attended La Leche League. She would call me and tell me somewhat comical ones, like the girl who brought to the table her issue of being unable to find a bikini because her baby would only nurse on one side and therefore one breast was a G (do those really exist?) and the other was a C. As a new nursing mother, despite my symmetrical breasts, I was impressed (thinking of my flabby stomach) that she was even considering going out in a bikini at all that summer. Then my friend would tell me horror stories, like the girl that ignored a lump and developed an abscess and sepsis and had to have surgery and quit nursing. I went to my OB/GYN once, obsessed over something I felt in my breast that in retrospect was probably fibrocystic changes. I was convinced it was the seed of the abscess that was plotting to doom my nursing efforts. When my OB palpated my breast, she looked at me quizzically. "Um, Gizabeth, I'm not sure I really feel anything? But if you want me to pull out the ultrasound, I'll be happy too." I smiled and blushed with relief and embarrassment. "No Cindy. If you think I'm crazy, that makes me happy. I'd rather be crazy about this, than right."

There were two other patients to present in breast conference, but the radiation oncologist generated a lively discussion about a new treatment, and everyone joined in, burning up the rest of the hour. Back in fellowship when I was doing weekly conferences, I was annoyed when this happened, because I had usually spent an extra couple of hours the night before taking pictures of cases to put in a power point - other pathologist's cases (I was doing a cytology fellowship) -while my own breasts swelled up like melons, aching for the relief of going home to my nursing son. All my work seemed like such a wasted effort. But now I was the relief pathologist, no longer nursing, and the discussion meant a lot more to me with my own experience of signing out breast cases. Of course we always strive for accuracy and perfection in our reports, but it is nice to sit in the room with treating physicians and learn the direct implications of your words. The all powerful ones that you put on the patient's permanent record. Grade III. 2.5 cm. Posterior/superior margin positive for malignancy. Micrometastasis to the sentinel lymph node. Estrogen receptor positive. Progesterone receptor negative. Her-2-neu positive.

So I sat back contentedly and listened, so I might learn something. At one point, the radiation oncologist and a breast surgeon (one that I have always admired tremendously) got into a discussion about a particular patient. The radiation oncologist began discussing her, and how she treated her. She turned to the breast surgeon.

"That was your patient, right? I'm surprised she is still alive. She made it longer that I would have expected."

The breast surgeon reached into a tiny notebook in front of her and pulled out a square of newspaper, showing it to the radiation oncologist. An obituary. Everyone remained stoic.

The radiation oncologist said, "Oh. When did that happen?"

"February 3rd."

"Not that long ago, then."

The discussion moved on, and everyone slowly began to gather up their breakfast trash to throw away and head to their respective clinics, OR's, radiology caves, and lab offices. As a pathologist I have so many cases, and bounce around on so many different rotations, that I don't get follow-up unless I serendipitously come across a patient for a second time on a new case. Then I get to catch up on what has happened between then and now. I can't imagine being a treating cancer surgeon or oncologist, and keeping up with my patients by scanning the obits. Cutting them out meticulously, and keeping them in a notebook, as a reminder of how that patient ended up. Maybe to affect how you might treat a similar case differently, next time. Or maybe just to remember your patient.

Guest post: Advice to a mom starting her pre med

A classmate of mine introduced me to a friend of hers who is a mother of three, is starting her pre reqs to apply to medical school, and is interested in ob/gyn. She connected us via a social networking site, and I wrote down came to mind as far as advice:

I haven’t found the mom thing to be a big obstacle for me in medical school. I learned how to juggle and prioritize my time when I became a mother.

Of course, I only have two kids, and I heard the transition from 2 to 3 can be a little rough. How old are they? Mine are 5 and 10, so they are both potty trained (whew!) and can both understand when mommy needs to study. Not that they won’t interrupt me, but still.

I was a little nervous about doing my post bacc pre reqs as an older student and a mother. I felt a little lonely in those classes, but I was pleasantly surprised when I got to medical school. There were other mothers and other older students there – one of my closest friends is a grandmother, and she found time to work 40 hours a week while in med school (I don’t recommend it, but she did. And she still does on her rotations).

I obviously don’t have the time nor the inclination to party as hard as many of my classmates. Nor do I get my nails done or go to the gym. But, I managed to be incredibly active in extracurricular activities in medical school. I found time to be involved in things that interested me (I was president of the ob/gyn club, for example, and helped run the Vagina Monologues and ran the HIV testing clinic) because I wouldn’t enjoy medical school otherwise. And, I could always give them up if I wasn’t happy with my grades, which I was.

What helped me:

1. Juggle and balance. I would go to school, try to make and eat dinner with my family, and then study in the later evenings when the kids were in bed and on weekends after spending breakfast with the family. That schedule worked for me.

2. During my pre med, I only took part time classes, but I was also working full time. Looking back, I wish I took out loans and did the school thing full time. My life course might have been different, since I got into ob/gyn late in my premed, but still, it was a longer journey than it had to be.

3. Find friends who know what’s going on and use them. (Not use them use them, but you know what I mean.) I am not the best person when it comes to knowing what paperwork is due when, etc. So, I find an organized, friendly classmate who is good at staying on top of this stuff, and remember to ask them for help when I need it. It’s also good to have a phone number or two in case a family issue comes up and you miss something.

I did not do this enough in my pre med, and entered the application process woefully underprepared. Do your research, ask for help if you aren’t informed. I didn’t have time to do all the pre med extra curricular stuff since I was working full time and my kids were younger. I blew it my first application round, because of stupid stuff (I didn’t wear a suit to my first interview. I wore professional clothes, like I would to a business interview. Wrong. Stood out like a sore sore thumb).

4. Don’t overestimate or underestimate the understanding of your classmates, professors or administrators when it comes to your kids. Some people who you think will be understanding won’t, and may treat it like a weakness. Some people who you wouldn’t expect to be an ally at all will surprise you. Don’t be afraid to bring up the kids, but don’t act like you automatically deserve a break or special treatment. If you try as hard as you can to be as good (or even better) than the childless students, you will hopefully get the support you need when you do need an accommodation.

5. Don’t put your education last in your house. I sometimes find myself having standards for myself as a parent that may be too high. For example, I love making home made valentines with my kids, and despise the commercial ones with the cartoon characters on them. Well, this year I had a major research presentation due this past Friday, and was working on it Thursday night when I realized that my younger son had to do the Valentine’s Day exchange Friday since the holiday occurred over the weekend. My husband bought some Batman valentines, I gritted my teeth and got over it.

6. Quality time is OK sometimes, as opposed to quantity time. I ave myself permission to leave the house to study if I had to, when shutting myself in a bedroom wasn’t working. I didn’t do it too much, but one day a week or so, more during board review, with strategic kid bonding time scheduled in, worked for me.

7. Remember, it could be worse. You could be looking for a husband and trying to plan kids during your residency.

8. As for ob/gyn, I wouldn’t obsess about a specialty now, but I am a huge fan of ob/gyn. Any specialty can be challenging, time wise. Neurosurgeries take 6 hours or more a piece. I talked to an ophthalmologist who loves her practice as a mom now, but she had a grueling residency, with three babies at home (she had twins during her residency!)

Hope that was helpful. Please feel free to contact me whenever you need to.

*****

Please feel free to add advice!


Mom TFH is one of the oldest people at her medical school. The other students learn from her various valuable life experieces: as a pizza delivery driver, a Denny's waitress, an art major, a health food store manager, a purple haired punk, a natural supplement researcher, a midwifery student, and a mother. She has two boys and a public elementary school PE coach. Going to med school just didn't keep her away from them enough, so she is doing a dual degree (D.O./M.P.H.), is the president of the ob/gyn interest club, and is now doing a preclinical research fellowship before starting rotations in July.