Guest Post: Why It’s All Worthwhile (or What Keeps Me Going)

(I am posting this as a followup to Gizabeth’s excellent, thought-provoking “Disillusionment” post. I wrote this anecdote awhile back but decided to post it now, since it illustrates so perfectly what “keeps me going” and why I’m not disillusioned despite all the difficulties we face. - gcs15)

“Make a Joyful Noise unto the Lord”

In October 2007, the ER called me for yet another emergency. A thin, elderly man lay on the stretcher with his anxious wife at his side. “He’s been more and more confused, Doctor. This is just not like him!” she said. Sure enough, on examination, he had no focal deficits, but he was clearly disoriented. No history of trauma, no blood thinners, just chronic treatment for myelodysplasia (which was stable). His CT scan showed the reason for his confusion: a large subdural hematoma extending over the entire right hemisphere of his brain. Yet another elderly patient with a subdural.

I took him to the OR emergently that night. I removed a large window of bone from his skull and opened the tense, bluish dura. A large blood clot lay on top of his angry-looking cortex; once the hemorrhage had been removed, his brain began to gently reexpand. Successful surgery, but how would things go over the next few days? So many irritated, elderly brains begin to seize postop. The mortality rate for subdural hematoma is 50%. This is one reason many budding physicians avoid neurosurgery; we see a lot of terribly sick patients, and a lot of them don’t get back to a functional life.

Back in the ICU, the nurses told me, “We’ve been getting a lot of phone calls about this patient! How did he do?” Evidently, he was a Ph.D., a professor emeritus of fine arts at Bob Jones University, beloved by hundreds of students and alumni around the country. He conducted their orchestra and had been composing all kinds of opera and classical music for more than 50 years. His children was all bright and successful, some of them accomplished vocalists. In short, my patient was a brilliant, artistic man.

His first 2 days postop were encouraging. He began to eat and joke a little. I transferred him to the floor and gave a sigh of relief. That evening, however, the nurses called me. “He’s not looking so good.” When I arrived at the bedside, he was minimally responsive, pale and diaphoretic. A workup, including a CT head, was suggestive of infection. I transferred him back to the ICU and aspirated fluid from his wound; clearly he had developed meningitis. I started him on IV antibiotics and began to really worry.

He was very sick for a long time, but he recovered and actually did very well. I got to know him and his family a little during his illness. They were delightful, cultured people with a great sense of humor. The first time I saw him stand up, I realized he was at least 6’6”! We talked about his passion for music and his love of God, among other things. I told him, “When you are completely recovered, and you are ready to conduct again, let me know. I want to come.” He laughed and promised. Privately, I wasn’t sure that would ever happen, after what his brain had been through.

About 2 months after he left the hospital, he came back to my office. “What do you think about this spot?” he asked, pointing to his head. The wound was infected again. Over the next few weeks, he had 2 more surgeries and IV antibiotics to remove the bone flap, clear the recurrent infection, and implant an artificial custom-made bone flap in the defect. Finally, finally, he was better, this time for good.

The months went by, then a year; no news from him. I thought of him every so often, hoping that his cognitive function was still improving. By this time, he was 78 or 79 years old.

Just before Christmas 2009, my phone rang at home. “Hello, Doctor! Remember me?” Of course I did! “Remember my promise? I am conducting Samson et Dalila in March, and I want to know how many tickets you need.” What a wonderful Christmas present!

So my husband and I took my 12-year-old son with us to my friend’s opera that weekend in March. I can’t remember ever enjoying opera so much. It was stunning. A cast of 200, including 3 nationally acclaimed guest performers, and a wonderful orchestra took a simple Bible story and cast a spell that lasted 3 hours. As the stars of the show escorted my patient onto the stage at the end for a long standing ovation, the supertitle proclaimed, “This will be the final major performance of his career.” I stood with his family in the audience, hoping my eyes wouldn’t overflow.

I could feel in the thunder of applause the impact he had made on so many of his students, and the love and respect they have for him. I could feel the force of his personality and the persistence that brought him back to his baton at almost 80 years old. And I could hear clearly the Almighty whispering to him, “Well done, good and faithful servant.”

Professor, I was blessed to have played a tiny supporting role. Bravo, and bravo!


About my patient: Dr. Dwight Gustafson was the longest-serving Academic Dean in the history of Bob Jones University. Samson et Dalila took 2 years of intensive preparation and rehearsal; it was the biggest such production done at BJU in the last 20 years. Dr. Gus says of his illness and recovery, “Through it all, I kept saying to everyone, ‘God is good at all times.’” I continue to be inspired by his faith and his example. This is printed with his permission.

Disillusionment

When I went into medicine, I had clear goals in mind. Helping people. A stable income to provide for a family. I grew up under the spotlight of my father, who is a neonatologist, and lived in awe of his work. I remember being in restaurants with my dad - people would come up to him reverently and sing his praises (to his obvious embarrassment). Talk about their son or daughter that he had taken care of, and fill him in on how they were doing now. Once, in a small town in college, I was filling out a check at a convenient store. The clerk recognized my last name as the same one as the doctor that saved their premature baby. "Your dad is amazing. It must have been wonderful growing up with a father like that - one who hung the moon."

So although my path was a little wayward, I found myself starting medical school at 23 years old - not too bad after taking three years post college doing B.A. level psychiatric jobs and taking pre-med requisites. I thought I might be a psychiatrist, but quickly changed my mind because I worried about the burnout I might experience taking on the burden of other's emotional and mental issues. Then I decided to be an ophthalmologist, but changed my mind at the last minute - fall of senior year. This is why. I was on a month away rotation in a different state, and worked closely with an ophthalmologist at the general clinic. She was elegant, razor-sharp, and efficient. I watched her manage the clinics with grace and ease - quickly entering and exiting each room, performing eye exams, dictating notes for the chart. She took me out to lunch. Here is what she said.

"Don't do it. Did you see how many patients I plowed through? It's like that every day - you have to see more and more. Some days I squeeze in 60 or 70. It didn't used to be this way. Did you see me get to talk to a single patient?"

I didn't.

"The techs do all the talking. I don't get to know them at all. I'm like a machine, getting briefed by the techs and looking at their eyes. It's all I get to do. Then I tell the techs what to write in the chart, and have to rush to the next room. Job satisfaction is nil."

My best friend in medical school ended up going into ophthalmology - I'm going to take my kids to visit her this weekend. She works in a small town, and seems to have good patient interactions, but her job is not without its challenges. Overall, she seems happy.

I am reminded of another experience my third year when I was considering orthopedic surgery. I had the grades, and the strength to manipulate the hardware. I was surrounded by encouraging attendings, but they and the residents were all male. I asked if anyone knew any female orthopedic surgeons I could talk to. One of the attendings gave me the name of a woman that rotated once a month from a practice in a smaller town. I called her. She was in her early 50's. Here is what she said:

"I made great sacrifices, for my family, in order to do what I did in my career. If I had to choose all over again, I would choose differently."

The one girl I knew who went into ortho, she was a year above me - bailed for radiology as soon as she started a family.

I encountered a lot of frustration on the pediatric wards when I rotated. The pediatric residents, especially those in the SICU, liked to stay up late talking about how hard they worked and how little money they would get in return, when all was said and done. Massive debts, burnout, and destined for salaries that barely scraped the bottom of the physician barrel. Many residents in the primary care fields appear to share this sentiment.

I was watching a film tonight that my friend Ramona Bates shared with me called "The Vanishing Oath." It messed up in the middle (I think it was my player Ramona), but what I saw was this. An ER doc who sacrificed for many years to study - missing important life events of family and friends along the way - and is now overworked and bogged down in bureaucracy. He feels he has no time to spend with his patients from all the charting and hospital hoops he encounters. A few years out of med school, having barely made a dent in all of his debt, he is ready to get out - or at least take a big sabbatical. I need to give it another shot so I can do a proper review, but the little I saw inspired this post.

I work in the field of pathology. I do have a little patient interaction, but most of my work does not involve patients. I love my job - wouldn't trade it for the world. I have become somewhat disillusioned by how much of a money game it is between hospitals and doctors. I spent a day in a special session of legislature last year, watching a battle, and that was an eye-opener. I am also disillusioned by the lack of teamwork involved. Dr. Gawande said it better than I can in a med school graduation speech at Yale called The Velluvial Matrix that I read earlier this week. It's not that we don't try to work as a team, the system is just set up against us. And it really is our job to figure out how to fix that.

Sometimes when I get really angry and jaded I try to remember that little girl that sat in awe of her dad, through all those chance encounters with the parents of the many babies he helped that would not otherwise have lived. Now I'm doing my own part - although somewhat more behind the scenes. I love calling doctors and telling them the results of their procedures so they can move on to treat the patient. This week, I got to help an enigma of a young girl being treated for a brain tumor with fever and neutropenia. The pulmonologist was so happy when I called to tell her there was pneumocystis all over the GMS (fungal) stain. Something to treat. A cardiothoracic surgeon called me three times, hanging on my assessment of a CT-guided lung biopsy. When I finally called him late in the day to tell him that yes, me and my partner agreed we could name that cancer on three cells so he did not need to proceed to mediastinoscopy - he was overjoyed. One less procedure, and one more step toward treatment. Every day I get to supply a big piece of the puzzle that can help the clinicians move on. That is extremely satisfying.

So my question (after blogging way too much) is - what were your goals when you started medicine? And how have you been disillusioned along the way? What keeps you going?

Guest Post: Pregnant, in surgical training

We recently received this anonymous comment to an older post on childbearing in surgical residency and thought this might open the discussion back up.

Ok. So I am pregnant and in training after practicing for a while. My boss knows, but the rest of the team does not (I am not showing yet).
I am due after I finish my training so my issues are more financial and how to look for a job with a big belly. Also any leave I take it will be just detrimental to me, since I will not be making any money.

I look around the group of surgeons and trainees (100% male) and I feel like I am doing something against that whole environment..

I try to keep in my mind that in order to society to continue, women have to have babies. It is not like we are choosing to take a vacation for months or something.

As for the programs I do believe they should hire locum tenans people to cover for that period of time. For guys may sound unfair, but their mothers and wives were pregnant one day.

I use to be amazed by the residents that only took a month or two off, but now I am contemplating just taking a month off because I cannot afford to take more.

I think a lot of the negative thoughts are in our mind and we just have to shake them off.

As for the right time, I still think its best in training because you have a system of coverage. In practice you will book cases and not know if you will be well enough to finish it.

I had to scrub out twice in 3 months , but I was assisting a surgeon so I just asked the scrub nurse to help out and came right back.

I guess is also improtant to keep in mind that all these people around us will go away from our lives at some point, but your baby will be with you for a long time and if something goes wrong, it will be hard to forgive yourself if you think you havent done what was right for your kid.

As my husband says, we are not in control afterall. At some point we have to give it up to the Boss- God

MiM Mailbag: Question from a student

Hi:

I've seen people submit questions to your blog, so I thought I'd ask one myself!

I recently started reading this blog, and I love hearing such a real perspective on medicine.  I'm a grad student, and my plan has always been to apply to med school.  All my pre-reqs, MCAT, etc. are complete.  However, a discussion with a dental student recently got me thinking about dentistry.  My main concern with medicine has been the lifestyle and strain on family.  Not to say that dentists have it easy, but I get the impression that they generally have more manageable schedules.  Of course, I would need to find the same passion for dentistry that I have for medicine.  But I'm curious if any of you considered any other health professions.  Would a career in health care with a friendlier lifestyle still fulfill you?

This blog is such a great resource.  Thank you all for your insightful writing!

Take care,
A

Comic Relief

Our hospital recently bought new scrubs. They reminded me of an incident that occurred shortly after starting my intern year.

My chief resident was late for morning rounds by a few minutes and in quite a foul mood when she arrived. We interns we too afraid to ask what the issue was, but later I heard her venting to a fellow chief.

Evidently her 10 year old son had asked a simple question, "Mom what color are your scrubs going to be now that you are a chief?"

"What do you mean?" she had inquired.

"Well when you were an intern you had scrubs with an orange belt, then second year you got promoted to the brown. Third year you got the red belt. So what color do you get as a 4th year?"

It was at this point that I looked closer at the badge. I saw the much thinner face on her badge that was taken her intern year and realized why she was so upset.

explanation: The drawstring colors are the sizes of the scrubs orange = small; brown = medium; red = large

Fear

I am scared.

Next week I'm going to be starting my first Real Doctor job. After nine blissful years of getting to look over my shoulder, I am going to be on my own, trusted to make my own decisions.

I probably shouldn't be scared. First of all, I did have some attending privileges as a fellow, so this isn't entirely new for me. In fact, much of the time during fellowship, the attending presence kind of annoyed me. I feel ready to make my own decisions.

Second of all, it's not like I'm being released into the OR with a scalpel. My job as a rehab consultant is not the kind where I'm likely to be making any life or death decisions. Harming a patient in any serious way would be challenging, even if I were totally incompetent (which I don't think I am).

Third of all, I won't be in private practice by myself. There will be tons of other senior physicians around that I can ask for advice if need be.

Still, I'm scared. For all the same reasons I was scared on my first day of high school:

What if nobody likes me?

What if I'm not any good at it?

What if I hate it?

What if I'm overwhelmed with work?

What if they steal my lunch money? (Unlikely, but not outside the realm of possibility.)

On my last day of fellowship, they threw a pizza party for me, gave me a card that everyone signed, along with a gift card. I felt so loved. I started to wonder why I'm striking out on my own when I could stay a fellow for another year if I wanted. I know I had really good reasons: (lack of) money, the lack of a future in my fellowship (hiring freeze), a chance for a secure permanent position elsewhere. But I can't help but doubt myself. And be scared.

July Decisions

It’s early July and newly minted interns and residents are gracing the hallowed halls of hospitals across the country. Not only do these intrepid souls have to cram every possible byte of data into their sleep-deprived craniums, maintain their patients and respond to pimping questions from attendings, they need to decide what they will call themselves at the end of their training.

General surgery is easy – when you’re done, you’re a surgeon. No one really has any questions about that. But what if you chose Orthopedic Surgery? When you’re finished, will you refer to yourself as an “Orthopod” (which brings up visions of a scary armor-plated vector to some), or an “Orthopedist” (which, strangely, some individuals seem to confuse with a Podiatrist)? Adjacent to the surgeons are the anesthesiologists – will you (should you) really tell someone you “Pass Gas” for a living?

Then there’s the pronunciation factor. If you choose to go into Obstetrics and Gynecology, will you practice O-B-JIN when you’re done, or are you going to practice O-B-GUY-nee? If you follow in our beloved Fizzy’s footsteps and specialize in Physical Medicine and Rehabilitation, will you be a fiz-EYE-a-trist or a Fizzy-AT-trist? (And when you examine the bony structure of your patients, are you looking at the SKEL-a-tal system or the ska-LEE-tal system? Perhaps it depends on whether you had any British instructors…)

Perhaps most confusing of all, those who choose general internal medicine – will you be an Internist? Will you practice Internal Medicine, I.M. or “Medicine”? Family Practitioners don’t have it much easier – too often, they’re considered Generalists or General Practitioners and the time they spent in training is ignored.

Some specialties don’t seem to have issues with confusing acronyms. The only time anyone had any questions about my field of Neurology was when he misheard my response to “What type of doctor are you?” as “An Urologist” rather than “A Neurologist”. Physicians who specialize in Pulmonology, Cardiology and even Proctology rarely receive questions about what they do – most people outside of the medical world know what those names mean. And I’m happy that some specialties maintain their formality: Would you really want to see a Hematologist/Oncologist who refers to herself as a “H-ONC”? (Is “QUACK” the logical next step if that were to occur?)

Medical school and Match Day are memories for those in training by this point, but the hard work is really just beginning. The title “Doctor” is a given – how will it be modified?

A

Guest Post: When medicine gets personal (Part 1)

My journey in medicine has been somewhat semiotic; an ebb and flow journey that has been almost entirely governed by signs. My journey in medicine would seem to be predetermined and there have been many signposts to guide me along the way.

Some call it fate.

Upon hearing my story you might call it bad luck.

Or maybe it’s ‘just the way the cookie crumbles’.

I? I believe I have been blessed.

***

Once upon a fairy tale, I wanted to be a vet. As a little girl all I wanted to be was a vet – I loved animals and the arduous training schedule appealed to my über type A alter-ego. My decision to ‘bat for the other team’ and pursue a career of experimentation on humans came later, much later.

In fact it wasn’t until my final years in high school that I decided I wanted to be a doctor. Cardio-thoracic inspired. It came to me like a cosmic ray, complete with visions of fame of wealth, and probably the standard quo but ubiquitous desire to ‘help people’. I can’t really remember, but I concede that visions of a leather interior Marilyn Monaro did dance in my head!

What? You don’t know what a Monaro is?!

Troglodytes!

Puh-lease!!! I would have looked HOT in a Marilyn Monaro! The wind blowing through my hair...

In reality, today? Today I drive something Toyota-esque, fitted with child restraints, with the occasional projectile vomit from the backseat breezing by my head. NOT exactly what I envisioned!

***

As a naïve and self-absorbed pre-med, I had my life all planned out and I never, not for an instant, thought it would ever go otherwise. My entire life I had always been successful, the top of my class, and I was a stranger to failure. I was arrogant, it’s fair to say, but I had my healthy aspirations to ‘do good’ too.

I grew up in a family which was entirely devoted to community work and the advocacy of social causes. My parents in fact spent more time helping people than they spent taking care of themselves. I wanted to help people too, but medicine was also going to be my way of doing a little better for myself than my parents had. I was a zealous surgeon-wannabe, with just the right amount of arrogance and pride to dream of saving the world.

We all, I believe, want to help people and it’s a big part, hopefully the BIGGEST part, of why we pursue medicine as a career. The desire to help people is quintessentially pre-med, almost every medical school applicant pulls the line ‘I want to help people’, but some mean it more than others. This desire, however, means very little until you have something to back it up with, something to serve as personal motivation. Something.... that can take that desire to change the world and turn it into the desire to be the change that you want to see in the world. Ghandi knows best! After doctors of course ;)

***

I was knocked from my pedestal early on. The ink was barely dry on my medical school applications when the phone rang and I heard the news that my older brother, a long-term mental health patient, had taken his life. In the dark of the night, amid the reclusive bushland of Australia, he had drunken himself into a stupor, taped a hose to the exhaust and, piping carbon monoxide into his car, put an end to his life. It was not his first attempt, but it was his last. And the sound of the telephone ringing can still send a chill up my spine.

I attended my brother’s funeral just 10 days before I was to sit the final exams that were to determine my entrance into medical school. Standing before his open casket I was impressed with the life-like pinkness to his skin, his face looked almost flushed, full of energy and vitality. Today I understand this as a direct consequence of the CO poisoning, but at the time it seemed in stark contrast with the coldness and rigidity of his hands. I know what his hands felt like purely by accident as I was too terrified of the presentation of death before me to touch him. But, as I tried to slip a note into/under his hands as they lay cupped on his chest, my fingers brushed his with a sensation that I will never forget, and I met death. His was a death that could have been prevented, and in that instant as our fingers brushed, his with so much left undone, mine with so much yet to do, I also met myself and I found my reason to be a doctor.

The note? The note was a simple declaration that I would become a doctor, in his honour, and I’d have better faith in, and care for, my patients than that which was afforded to him.

I had found my personal motivation, my reason to ‘help people’, but I was still yet to encounter my Ghandi moment.

This was just signpost 1.

(To be continued)


DSM-IV 299

DSM-IV 299 hails from Australia where she is currently a fulltime mother to Ocean Boy (4), Mini Me (coming up 3) and Freckles (18 months). Now aspiring to a specialist career in developmental paediatrics, having once graced the diseased halls of sexual medicine until one day her life collided with a rainbow... more revealed in Part 2.

Guilty Pleasures

OK. So divorce sucks. But there are some good things. Yes, I miss my kids this July 4th holiday weekend - can't remember having one without them. They are at the beach with their dad. Crabbing and having a good old time. Luckily their dad's cousins are posting mobile uploads on FB, so I am getting to see them, and talking to them on the phone.

Guilty pleasures:

1. Walking around the house, kidless, in my underwear until noon.

2. Brunching and shopping with my mentor Dr. Styles - gifting lunch and being gifted wine and facial products.

3. Exercising whenever the hell I want, at my leisure. And I need to exercise, cause the food/parties are over the top indulgent.

4. Finished the second season of Breaking Bad last night after wandering across my street to watch the firework show downtown on the river with my neighbors (we have a nice view through a clearing in the woods). When your kids are away, life degenerates to college days. Watching TV until way past midnight. Making nachos at 11:00 p.m. It gets quite ridiculous, knowing you won't be up at the crack of dawn cooking eggs and making cinnamon rolls -you find all kinds of rationalizations for one more episode. Thank goodness I have work to get me back up on Tuesday.

5. My spotted king snake, Spotty Dangerous, has become an important source of emotional nourishment, during this time. He also likes Breaking Bad. And the new blue light I bought him for night time. He crawls around on my hand while I wander about the house. I'm glad I got him in the split. Dog, schmog. The importance of mammals is way overrated.

6. You all have kids, right? When is the last time you have taken a long, uninterrupted shower? Ha! I guessed right. Not in the last few years. It's quite nice.

7. That string bikini I bought through Victoria's Secret last year? The one I've been afraid to wear because it might not hold up in the pool while I was: Playing categories, riding the airplane/crocodile floats, and having pool races with my kids? Well, it's safe when the kids are gone. I can just read my novel on a raft to my heart's content and relax in the knowledge that my 5 year old isn't around to accidentally pull those strings. (Yes, I am only brave enough to wear it at my mom and dad's pool with no one else around, and I think there is more of me that is tan than there has been in 10 years).

8. Zoning out on the floor of the bathroom and cleaning drawers. That hand cream I saved from that Arbonne party from ten years ago? The stretch mark prevention cream I bought for long ago pregnancies that I forgot to apply? The stretch mark reducing cream I bought after pregnancies that I applied maybe once when the box recommends a strict routine (who can stick to a strict routine when taking care of a two year old and nursing a newborn?)? The feminine hygiene products I have not needed since I got my IUD four years ago (what am I waiting for, Sicily's first menarche? Doesn't she deserve a new box of tampons/pads for that? Scary to think that will actually be coming up in 4-6 years). Just chunk it.

9. Having uninterrupted conversations at extended family and friend holiday gatherings.

10. Heading to an adult movie tonight with my good friends (histotech and gross room assistant) from work.

Yeah, divorce is tough. But I'd be remiss to not revel in the good stuff. The alone time. The facial time. The movie time. The coffee time. The wine time. The not being a mother time is oh so much sweeter when you are one. Hope everyone else is having a wonderful holiday weekend, with lots of independence!

Letting go

While I was walking home from a "lunch date" with my daughter yesterday, I inexplicably started to get pissed off about the fact that I never had a baby shower. I don’t know what set me off. There are a lot of babies in my neighborhood, so maybe that was it.

As a pregnant person, I was just starting out a new residency thousands of miles from my family and where I went to med school and college. I didn’t have many (any) friends nearby, at least not female friends. There were only a couple of other female residents in my program. I have no sisters. So really, I didn’t expect to have a shower. No problem. I got some presents independent of a shower.

Then a year later, another female resident (let’s call her Tina) in my class got pregnant. One of the (female) attendings at my residency, one who had actually been my attending when I was about five months pregnant, said to another female resident, "We should plan Tina a baby shower."

The other resident told me about this and I flew into an absolute rage. I was SO angry that this attending would show such blatant favoritism. Also, it was embarrassing for me. Moreover, Tina had tons of friends and family in the area and surely had her own shower planned. I said I was going to boycott any attending-planned shower, I was that angry. But the shower never ended up taking place, possibly because someone clued the attending in to the fact that I was angry, or possibly because most of the residents didn’t like Tina very much. (I liked Tina, but I was still furious about the shower.)

Anyway, after getting extremely worked up over this and planning out a whole MiM entry in my head, I thought to myself, "Why am I still angry about this? It happened YEARS ago!"

I’m still angry about other things too:

I’m still angry at the senior resident who verbally abused me during my first ward month as an intern (For examples, read some of my cruel resident stories). I’m still angry at the co-intern who gave me shit about taking a night off when I had a threatened miscarriage. I’m still angry at this gunner med student who stole my first delivery on OB/GYN. I’m still angry at the attending who was so slow on the weekend that I was rounding for 14 hours in a row on a Saturday. I’m still angry about... too much.

This week, my medical training comes to an end. Four years of med school, a year of internship, three years of residency, and a year of fellowship. Obviously, I’m never going to forget all the miserable moments, but maybe I can try to stop being so angry about them. Maybe I can finally let go of that anger. Maybe I can focus on the good memories, of which there are also many.

Dear medical training: You suck sometimes, but I forgive you.

Besides, I’m sure I’ll find all new stuff to get pissed off about next year.

Divorce

It's not for everyone. I don't advocate it. I certainly, in my Disney princess fairy tale happy ending view of life and marriage, never dreamed it would happen to me. I really don't know many people who have been divorced - a couple of friends, maybe. My parents have been happily married for almost 40 years and that is just how I thought this was all supposed to work - especially having two kids, now ages 7 and 5.

I sat down with my Mom a year and a half ago and said, coming from a walled up, stressed out, angry, confused place, "I want out." She gave me one of the best pieces of advice I have ever received, "Go to counseling. For six months to a year. If not for this relationship, for your next one. You'll keep repeating the same mistakes over and over unless you work on yourself and your marriage." So I did that - spent over a year in counseling and six months in marriage counseling. I can't say I regret the time one bit. I am still in divorce, and even though we hadn't been working for a long time, I tried as hard as I could. I think if I had exploded without all the work, I would have many regrets. I owed it to myself, and my kids.

So here I am plugging along this alien path of divorce. I'm learning so much - hiring lawyers. Answering interrogatories. Doing house inventories. Learning the custody lingo, as well as child support and alimony terminology. Taking transparenting (Yes! The actually call it that!) classes. My ex and I, while not really on a friendly basis, are doing a great job of co-parenting the kids over the summer, and we are very good at being cordial. It was tough giving up five whole weeks with the kids, but I've now got two under my belt and the second was a hell of a lot easier than the first.

I'm not sure really what the point of this blog is other than to talk about my experience, so far, and open the table for future discussion. I haven't made my divorce a secret - it is obvious in my comments and I think I may have alluded to it in a past blog. A couple of months ago someone asked me to write about going through divorce and I was so stressed out and worried over emotionally supporting my kids that I couldn't imagine talking about it. But now I think I'm ready.

Here's the toughest part - Sicily, my 7 year old, is in that age (thank god I took the transparenting class right off the bat) group that likes to play "Parent Trap." She is constantly trying to get us back together, and that is so heartbreaking to watch, even though I look back on my marriage and see that even at 3 and 4 she was trying to get us together, so this is not so different from then, only more out in the open. Here are some particularly painful examples:

"Mom, I'm going to have Dad bake you a cake for Mother's Day so you get back together." She got him to do it. That girl has amazing powers.

"When is Christmas? What I want from Santa is for you and Daddy to get back together. Can we start calling Santa now?"

"If you didn't have to work would you be going to the beach with us and Daddy?"

I know she is just trying to wrap her seven year old brain around all of this, but ugghh. Luckily she has a few key players in her life that have been children of divorce, and they have offered incredible support. I'm glad she has examples of those who have been there and have turned out OK - not to belittle their experience, I am sure it was hard.

John is of a different age - one of magical thinking. He is just 5, and his adjustment has been quite different. He doesn't talk about it as much, and at first I made the mistake of thinking that it was easier for him. I talked to a friend who has a mother with her masters in childhood development, and she said that girls usually come out better because they talk a lot more, and boys shut down. I started paying more attention, and I've had to troubleshoot some fear, separation anxiety, and stuffing emotions issues that were much more subtle, but I think that he is doing pretty well, overall. Kids struggle with divorce. But they also struggle in marriage. Attentive parenting is what matters the most.

I know marriage is hard. I've seen lots of people struggle and hit highs and lows (including my own parents). I think that if you do get married, you should try to work through the low points. I believe in those vows - but I also reluctantly, slowly, finally admitted that sometimes two people just don't work. I'm starting my life over at almost 37 years old, with two beautiful children. There's nothing to regret - and lots to look forward to. I am a pathologist who is about to be a partner in 4 months. I can support myself and my kids. I can afford good childcare and help, and am getting a lot more vacation that I've ever had. When I make partner, I will have the flexibility to cut back more if I need to while my kids are young. I'm in a great place. But it is still tough.

Becoming a single parent

A couple of months before my son was born 2 1/2 years ago, we were notified that my husband, an active duty member of the Navy, was getting deployed to Iraq. His date of departure was exactly one week after my due date. To any wife or family member of a service member, this would be difficult news - a loved one going into a war zone. But, to me, 8-months pregnant, insanely emotional, and mother to a then-2 1/2 year old already, it was devastating. I was terrified, almost paralyzed, with fear for his safety. But also, how could I handle being a single parent for 14 months?(!) How would I cover the many weekends I have to work on the wards? How would I keep my sanity and not go into a serious postpartum depressive funk? I didn't have postpartum depression with our first, thankfully, but the utter despair I experienced in the weeks and days leading up to his planned departure--I had never experienced anything quite like that before. That darkness was almost unbearable.

Then, a miracle happened. He didn't end up going. We found out 4 days after our son was born, 3 days before he was scheduled to leave. It had nothing to do with us just having a child, of course, but we were thankful nonetheless. Our family would stay together.

And it's been wonderful. A gift to be together. Yet, I had almost forgotten how easy it is to take things for granted.

In less than a month, my husband is moving to North Carolina for the next two years for his next military assignment. And we've decided that the kids and I will stay in DC. Which means, I will essentially become a single parent for the next two years.

The common response: Why don't you just all move down?

Well, it's complicated. The main factors:

- We have little to no support in the form of family or friends there. There's a good chance he could get deployed and be away for up to a year, and then me and the kids would still be alone but now with no help. Here, we have family, friends, great child care, a great school. At least here, the kids will have some stability.

-I love my job. I don't want to give it up, have to find a (most likely) less-satisfying one, and then have to find a job back here in 2 years. My career is exactly where I want it right now. I'm also the larger breadwinner, and we're more dependent on my salary to pay the mortgage, the bills, etc.

It is not an easy decision. It's going to be hard for everyone. I worry especially about our 5-year old daughter who is Daddy's girl, and I hope, hope, hope this turns out to be just a small blip in our overall happy family trajectory. And, of course, I worry about missing my husband - my best friend and love of my life. (I also worry about going insane from the stresses of single parenting but hopefully blogging will be therapeutic. See Tempeh's amazing grace through multiple deployments.)

So, we'll make the best out of it. We'll do weekends here or there. We'll Skype. I know we'll get through it together.

I have also learned, from Tempeh, that I'll need to lean on people to help. Which involves getting over the silly hang-up of having to ask for help.

I'm working on that.

But, something also dawned on me: I'm thankful to even have a choice to stay behind. As an independent woman, as a mother in medicine, I have a choice. A career I'm passionate about. A family I adore. It means certain sacrifices for sure, but it also means the chance to be fulfilled in multiple aspects of life. Yes, I'll always be dealing with finding balance, negotiating.

But, I'm still glad for the choice.

Looking older

I've always looked young, and received countless remarks to the same as a medical student. The comments were made in a marveling or appreciative way, but as a novice struggling to project confidence and professionalism, I didn't find them helpful.

Aged 24. I am radiating something here, but it's not life experience.

Of course, it became much more tolerable a few years later when I was twenty-eight and being taken for twenty-two. And then I had three children, and I'd been in practice a few years, and comments on my age trailed off. One day last year a patient said to me, "You must be about my age - from 1974?" and I was shocked that he had nailed it. Shortly after, for the first time ever, I asked my hairdresser for a cut that would take a few years off. Now I have bangs.

Then last month my patient, a widowed Iraqi refugee with three teenaged daughters, asked me through the interpreter, "As a woman, how do you be strong, but kind and loving and forgiving at the same time?" She looked at me expectantly; she wanted an answer. And I recognized that this was less a patient asking a question of her doctor, and more a woman asking a question of another woman. I was moved that she would think I had any advice to give her. I am fifteen years her junior and certain that my life has not required the strength and forgiveness of me that hers has asked of her.

As I offered my ideas on the subject, I wondered whether the twenty-five-year-old me - ten years ago - would have had anything to say. I doubt it. In fact, I seriously doubt that anyone would have asked my fresh-faced self such a question in residency or early practice.

It is a rare moment when I acknowledge that there may be advantages to not being or looking twenty-two. If my aging suggests to patients that I have lived even a little, and have learned something from it, I am grateful for it.

Aged 35. Zoom in for crow's feet, dark smudges under eyes and four white hairs in those bangs.

And bringing up the rear...

Ok, so in honor of our birthday here at MiM, I thought it would only be fitting that I chip in my tribute about a week or so late. Though I have been repeatedly accused of making readers cry on this blog, and in fact my favorite posts admittedly DO fall into the category of tear-jerkers, I'm not completely a one trick pony. Occasionally I find comedy in the intersection of medicine and mothering, and here's my proof. If I should be known for anything on this blog, it would have to be lateness. Every topic day/topic week, I am dead last to contribute if I manage to contribute at all. Usually it comes at about midnight on day #7, but since it's our birthday, I thought I would sleep in and make my contribution a whole week or so late. Happy Birthday, MiM! And many more!

Damn you, Facebook!!!

I'm not a huge fan of Facebook. I have an account because everyone I know has an account and I didn't want to be completely left out. I have something along the lines of 100 friends, most of whom friended me first (I swear!). I have never played Farmville and I don't even know what it is, beyond that I think it has something to do with, like, building a farm?

My main use for Facebook is finding out which of my (former) friends and classmates are getting married or having babies. That's pretty much it. And I don't even have to friend someone to do that! Because as we all know, the first thing a woman does when she's in a serious relationship is to put the guy in her profile photo. And as soon as she has a baby, the guy is removed and now the baby is in the profile photo (+/- the actual woman).

So I've got a long list of friends who now have husbands and/or babies featured in their profile photos. But lately I've been noticing a small but growing trend: TWO babies.

It all started a few weeks ago. Facebook suggested a friend for me and I noticed from her profile photo that she was holding two babies (both of whom were younger than mine). When I knew her in med school, she had zero babies. She had deleted "pediatrician" from her employment and written "stay at home mom."

And then yesterday, I noticed that yet another former classmate had added a second baby to her profile photo. And this woman was going to be a freaking SURGEON, not exactly the type who pops out lots of babies. In fact, she's probably just about finished with her surgery residency (or not, considering she broke it up with two babies).

I couldn't help but notice that both of this woman's babies were also younger than my three year old. And suddenly, I felt an immense pressure. Women don't have one child and wait a long time to have a second. They bang 'em out fast: baby, another baby, another baby, bam, bam, bam. Every single woman I know who was pregnant at the same time as me or shortly after now has another baby or is pregnant. All the kids in my daughter's daycare have siblings and she wants a brother or sister. I feel like everyone is looking at me and wondering, "Where is #2?"

I've written about this on here before. I obsess over it unhealthily. It's awful.

But the thing is, I don't want a second child right now. I know I don't. I think about how sick I was when I was pregnant and I don't want that right now. I think about how newborns wake up to cry all the time and I don't want that. We have no diapers in our home right now and I love it. I finally have time to read fiction, exercise (a little), and cook dinner every night. I like not having to hand my salary over to a nanny. I'm starting a new job soon and I want to be at my best, not vomiting and exhausted like I was when I started residency. I don't want my first year on the job to contain a maternity leave. I miss breastfeeding, but I don't miss feeling chained to that awful pump. Yes, I find newborns cute, but not achingly so. When I hold them, I usually want to give them back pretty quickly. I find my preschooler much more fun and interesting than a newborn. And she's such an easy kid, who gets sweeter and more fun every day. (Our latest game is competing who loves who more. She loves me a thousand million. I love her a million billion, which she swears is less than a thousand million.)

I do want another child. But not now.

Yet I feel like I'm on a clock. I don't want my kids to be too far apart in age. Four years is good, five is okay, six is pushing it, seven and they'll never be friends. And then I worry that they won't want to do any of the same activities because they'll be too far apart. Also, I don't want to wait until I'm too old and at risk for infertility. (I'm 30. Well, almost 31. Damn birthdays just keep coming.)

Sigh. Why do I have such stupid worries? Why can I never just sit back and enjoy life?