I am 22 years post partum and still worried about mood

I just came back from a research conference put on by the Marce society on the topic of perinatal mood disorders. It was great—the science is growing rapidly, and there are lots of clinical programs that are trying to promote recognition and treatment for women across the social spectrum, here and around the world. The human genome project is really bearing fruit.

Even as I got fired up (again) on this subject, I felt my usual sorrow and frustration that most pediatricians and obstetricians don’t screen for these disorders, even though they see the women (and their fetuses and then children) at risk, repeatedly. Today, many more obstetricians and pediatricians are now mothers themselves. Yet the demographic change in those professions doesn’t seem to compensate for the dis-incentives, blindspots, and confusion that discourage psychosocial pregnancy care.

I hope I am wrong, and that this area has just become so routine that my younger colleagues address it well and take it for granted. Is it?

PS: PLEASE VOTE ON NOV 2

scary doctors?

...for Halloween, that is. Anyone's kid dressing up as a doctor? Girl (6) is choosing to be a veterinarian (close!) and boy (4) is choosing to be a, well, Michael Jackson (who shall we say, had enough doctors). Any Halloween plans? We happily hay-rode and picked and carved our pumpkins way too early, kept them inside on the countertop safe from squirrels, hence the mildew and caving in on themselves, before we donated them, alas, to said squirrels. All in advance of 10-31.

Socks on Stairs

by Dr. Shoes

(The latest in patient educational materials, written after one too many such injuries came through my office...)


I like my socks.
I have 12 pairs.
I wear my socks
Upon the stairs.

1 step, 2 steps...
That's not all!
3 steps... Oops!
I slip and fall.

Bump! Bump! Bump!
I bang my head.
Thump! Thump! Thump!
Ouch! "Help," I said.

I wish my socks
Were not so slick.
My low back hurts.
I'm feeling sick.

I have to see
My surgeon now.
My spine's messed up.
Those socks, that's how

I hurt myself.
I couldn't wait
To put on shoes.
Now I'm prostrate

Upon the floor
Below the stairs.
My vertebrae
Will need repairs.

Be more cautious
Than I have been.
Those socks on stairs
Will do you in!

Join me in my journey to 50K!

So once again, November is almost upon us and once again, it is almost time for National Novel Writing Month (NaNoWriMo)!

In case you didn't read my post last year, NaNoWriMo is "a novel-writing program for everyone who has thought fleetingly about writing a novel but has been scared away by the time and effort involved." Yes, you too can write a novel that will never be read by anyone ever.

I think it's especially aimed at us workin' folk, who are too busy to write most of the time. This kind of forces you to sit down and write. And it's FUN. All the cool kids are doing it, including yours truly.

I would love to have more "writing buddies" so that we could have some fun competition. If you want to friend me, go here to read my brilliant title and the compelling description I wrote.

I "won" (= finished 50K words) last year, but this year is going to be a much bigger challenge. First, I've got a real job instead of a "research" "fellowship". Second, I'm losing an entire weekend to a conference. Third, Thanksgiving is gone because I'm going to relatives. And fourth... well, you don't need to hear my whole life story, but trust me, I've got stuff going on. But I'm determined to stagger in at the finish line.

Will Fizzy succeed? Can a mother/physician write 50K words in a month? Friend me to find out!

AWOL: Waiting for baby

I left work four days ago. Standing waiting for the elevator I felt tears well up in my eyes. Pushing back the emotion I turned my thoughts away from reflection and toward my next move.

A 38 week and 4 day little boy. Inside my uterus threatening to make his big arrival. Oh the places this little guy has gone (conferences in distance cities, organ procurement midnight travels) things he has seen (dying patients, miracle recoveries) and the drama overheard (dying great-grandmother, father unexpectedly unemployed). I could feel the strain of the pregnancy. In my hips and pelvis. On my mind. Being the wholesome expectant mother was inconsistent with my reality of 12 hour work days, two week blocks of call and Saturday and Sunday rounds.

It was time for me to move on. To move away from my office. To enter the parking garage and drive away. To pick up my two year old at day care in the middle of the afternoon. To arrive home in time to make dinner.

Really I had made it. Worked beyond emotional and physical pain. Accomplished professional milestones that I felt would justify my absence for maternity leave. But on that day instead of high fives on my way out- I felt a strong sense of disappointment. Despite all that I had done. Despite my sacrifices of health and happiness. To my (mostly male) colleagues at the end of that day I was still leaving. Taking a three month "vacation" where my work would need to be done by someone else.

Is it simply a scenario of wanting the cake and to eat it too? (And let me tell you I have indulged in my share of cake eating over the past nine months.) Honestly it would have been my preference to continue working up until my due date. To ease out of the most grueling work and ease into my transition home. Ultimately I had to call it quits. I needed a physical separation. I needed a vacation.

In my first days home I completed my patient charting, painted/organized the nursery, caught a matinee and napped in the mid-morning (and afternoon). It has been an active process of turning off my role as doctor, grappling with this guilt of desertion. What I have been able to do is sit and find my voice (hence the blogging). A week ago I feared that labor would come too early- leaving me to scramble and find a replacement for my hospital duties. Now I find myself, thank goodness waiting patiently, staring over at an empty bassinet as I type.

What I also found is strength. Strength that I was using every day, but somehow managing only to get by. Following a day at work too exhausted to climb the stairs to bed and overwhelmed to the point of tears. Now physical strength to attend a fall festival and join the family for a hike in the woods. Emotional strength to participate in the hospice care of my grandmother occurring five states away. Finding myself in the quiet and recognizing that there is plenty of me for this baby, my son and my husband.

Yes I do have a problem with work/ life balance. Partially to blame is my chosen specialty, but also to blame my own ambition. Achieving a sustainable effort is something I will continue to pursue- but for the time being I am the wholesome expectant mother. Hmmm, I wonder if there will be time for a pre-natal massage before my OB visit tomorrow afternoon?

Maternalism

I attended medical school from 1996 to 2000. At that time HMOs were on the rise, Google was being born and a strong emphasis was placed on patient autonomy. Although no one recognized it at the time, we would become the next generation of physicians. We had already been advised by old wise doctors to choose another profession. That we would never make any money. That MDs were no longer respected by society, and everyone (insurance companies, litigators) were out to get them.

We enrolled in med school anyway. We would become the physicians that knew nothing other than evidence based medicine, that would trade in our pharmacopias for epocrates, and see a work hours revolution change how patients are cared for in the hospital.

As an impressionable first year medical student I had a wonderful course called Medical Humanities. In a series of lectures we explored the philosophy of doctoring, and received our assignment. To preserve our humanism despite the rigors of training. To see each patient as an individual. To ask open ended questions. To respect cultural and racial diversity. To evolve beyond the paternalistic model and embrace the world where the patient is a partner.

I took this assignment on as a mission, reminding myself as years went by that smart and skilled was only part of the equation. That acting patient and compassionate was ultimately important. Years later I find myself in a field caring for extraordinarily ill patients, where astronomical efforts are made to save a life. Where more often than not this falls short and the best we can offer is a good death.

Over time I sense something that is just not right. It began with overwhelming frustration as a patient arrived with a ream of "medical information" downloaded from the Internet. Later it turned to disbelief as I found that my patient who cannot afford their rent is buying $100 per month of vitamins and supplements. As I find myself explaining why their information and supplements are bunk I find myself tip toeing in order not to offend and alienate. With so many new sources of medical information I think perhaps the grumpy old physician was on to something, the role of the physician has changed. Not necessarily a lack of respect toward doctors, but certainly a fair dose of skepticism that perhaps is deserved.

In my opinion the partnership model became derailed as the physician embraced the evidence and at the same time grew fearful of litigation. Informed consent then became central to the patient- physician relationship, a legal document. The conversation turned to odds of this and that, alternatives A and B, and finally the decision is up to you. The physician no longer answers the age old question, "If I were your mother/ child/ spouse what would you tell me to do?" Instead the doctor deflects a personal stake in the matter and ensures that in case of a bad outcome it will all be supported by the evidence, guidelines and paperwork.

Emerging from my medical training I began to feel an alienation at the bedside of my sick and dying patients. Witnessing their struggle with fear and uncertainty I felt like the care was falling short. The paces of a typical hospitalization includes selection of the proper evaluation, declaration of the correct diagnosis, and the discussion of treatment (with risks and benefits)- by the book. All of this done with the physician as the advisor and patient as a partner. When tackling the toughest issues- for instance at the end of life this series of discussions and decisions became just too much.

Grandma is too ill to speak for herself and there is a 80% chance that she will die. Would you like for us to do? Continue to try to save her? Should we treat the renal failure/ pneumonia/ UTI? Place a feeding tube? Continue lab work? Continue IV fluids? Turn off the ventilator?

My attempts to impartially advise and educate about all options grew in conflict with an urge to protect. To comfort. To spare whatever suffering could be spared for the patient and their family. But to step in and dictate what should/ could be done would be adopting the age old Paternalism we were raised to leave behind.

Perhaps there is a better way. May I be bold and call it "Maternalism". A way to provide compassionate care and resume part of the burden that we were taught to deflect. Partnering not as an equal but as a nurturer and comforter. For dying Grandma, first to help the family understand the situation, then to articulate what Grandma would have wanted. If that is go down fighting, they get a fight. But prevent the fight gone awry where Grandma suffers years as a vegetable with a feeding tube. If Grandma wanted to die naturally, then we allow nature to take its course. But spare the family from the agonizing series of discussions, where the family feels that at each step they are actively bringing the death of their loved one.

I find myself in a struggle to practice with excellence but also to sleep at night. Perhaps what we need is a sound clinical trial- or perhaps a meta-analysis to investigate the most effective role of the physician- in the post-Paternalistic era?

The Newest Angel

The OR was hushed on Friday.

Normally, it is a loud, busy place. The staff and surgeons are almost like a big family; we chat with each other and banter cheerfully with patients to help get their minds off the imminent ordeal of surgery. Chaplains pray with patients and families. Sometimes there are disagreements, as in any workplace. But everyone cares about everyone else.

Because of that caring, it was hushed. Instead of talking, people touched hands or embraced. The chaplain's prayers could be heard more clearly than usual.

Thursday night, a colleague's daughter had died. She was 4 years old.

She had been diagnosed with a childhood cancer over a year ago. We had followed her progress through treatment on a Web page her family set up. At first, we thought things would be fine; so many children can be cured these days. The survival rates were encouraging. Her dad, a talented young surgical subspecialist, carried on as usual after the initial shock.

Then the cancer spread. It stopped responding to treatment. One morning we came in to find her dad's cases cancelled at the last minute. Word spread surreptitiously: "She's had complications, and she's comatose now. It's not looking good." In the following weeks, hope slowly evaporated.

Strange; we all live with the presence of death every day. Patients code in the hospital. We make critical decisions about patient management; we do brain death exams and organ harvests. We live with its inevitability and yet find ways to go on. How unexpected, then, the pain when it happens to one of us, even when we know it's lurking just around the corner. No matter how much we know, we are never prepared for its intimacy when it comes. When it's a child, it's so much worse.


This is why I couldn't do pediatric neurosurgery. They see the worst of the worst; head injuries, abused children irretrievably damaged, malignant brain tumors that can't be cured. When I did that rotation in residency, my son was 18 months old. I couldn't help superimposing his face on patients about his age. It was unspeakably difficult. Admittedly, it can be very rewarding, because children do have such amazing capacity for healing. But many don't, and they broke my heart. I have such respect for those who can do this work, and for pediatric oncologists, too.

There must be a way to offer comfort to parents who have lost a child like this. I still don't know what it is. All I can do right now is hug my own son, smell his hair, and watch him sleep as if he were small again. I'll go back to the OR this week wishing I could repair my colleague's wounds like those of my patients. I'll be thinking about his daughter's Web page, purged of all the news of suffering.

Last Friday morning, that page had just one sentence: "There is no cancer in Heaven." Seeing that, we knew the newest angel had arrived.

Being judgmental

In my last two posts, a handful of people felt that I was being judgmental. My official reply to that, I suppose, would be: "Wah wah wah."

Meaning this: We ALL get judged all the time. For everything. Whether people mean it or not. Do women get judged more than men? Possibly. Do female physicians get judged more than non-physicians? Actually, I doubt it. And no matter how much you protest that you do not judge others, we ALL do it.

One person commented that we "must be supportive of all women." Supportive of all women? What about a female patient who comes into our clinic pregnant and drinking vodka? Obviously we wouldn't support this decision just because she's a woman. I know that seems like an extreme example, but there are lots of crunchy internet moms who think giving your baby formula is just as bad as guzzling vodka during pregnancy. We judge any decision that we don't agree with, that we think is potentially harmful.

So after that lengthy introduction, I'd like to present some actual REAL judgments passed upon me over the last several years by family, friends, and nosy people on the internet:

You should go to medical school. You're never going to be happy if you don't.

Why are you going to medical school? You're going to be in debt forever.

You're going to sleep now? The final is tomorrow! Are you really done studying?

How are you going to do well on your exam if you don't get any sleep?

You're going to do a residency in internal medicine? You're going to be miserable and never make any money.

If you drop out of internal medicine, you'll never find a new residency.

If you do PM&R, there won't be any jobs for you when you graduate. And what IS PM&R anyway?

You shouldn't have a baby in residency! You're going to be exhausted!

You should have all your babies before residency ends because the coverage is better.

If you get an epidural, you won't be able to feel your labor and you'll end up getting a C-section.

Don't try natural labor. You're just going to end up begging for the epidural and by then, it'll be too late.

Don't give your baby a bottle too early! She'll get nipple confusion!

If you wait too long to give your baby a bottle, she'll refuse to take it.

You let your husband give your baby formula so that you could sleep? You're a terrible mother. I don't care that you had a fever of 102 and had just come back from the ER.

You have to swaddle your baby or else she'll never sleep.

Stop swaddling your baby, you monster!*

Everyone does a fellowship after residency.

If you do a fellowship, you're wasting your time.

Having a second baby will quadruple your work, so make sure you're ready for that.

If you don't have your kids two years apart, they won't be friends.

I could probably think of more, but I think you get the idea.

The point I'd like to make though is not that we should all try to be less judgmental and more supportive of each other, because let's face it, that's never ever going to happen. The one thing I've learned though is that you must try to be happy with your own choices. The judgments that really hurt me were the ones where I wasn't sure I was doing the right thing and already felt guilty about it (i.e. giving formula).

So while it would be great if we could all support each other, what I'm really trying to say is that we should try to support ourselves.


*This is my absolute favorite. I posted a video of my two month old daughter in a Miracle Blanket on youtube just for my parents and in-laws to see (because she was making sucking motions in her sleep and it was cute). I thought it was unsearchable, but somehow some nosy woman found it and started yelling at us for swaddling her.

Jumping in...

Thanks, KC, for inviting me to officially join MiM!

I've been following along for a couple of years, occasionally putting in my two cents' worth. It's exciting to be joining in as a regular contributor. This is an amazing group of women, all great writers with a lot of stories to tell. I look forward to being a part of it all.

Guest post: New mom in an unsupportive environment

Today is day two for me. Day two, that is, of returning to work leaving behind my 5 week old infant daughter.  I am a 34 year old surgery intern, wife of a new work-at-home-dad and mom of one.  I was allowed to take my vacation weeks as "maternity leave" in order to avoid becoming behind in my program; however, a late baby and an unforeseen c-section caused me to have to take another 2 weeks off unpaid.  I knew this was going to be difficult. "How difficult" remains to be answered.  The all-male administration/faculty/senior residents of my program have barely acknowledged the situation aside from the program director's half-joking comment, "Don't you dare have any more."

Right now I'm on a lax 2-week radiology rotation consisting of half-day lectures but on November 1st, I return to the surgery department for 2 months of Q3 30 hour call.  Board exams are in January.  It's beyond daunting to even think of it right now.

After a struggle to establish successful breastfeeding with my baby, we have finally done it! But now I'm facing going back to work in an unsupportive environment. I questioned the possibility of pumping at work (very loosely suggested the topic to the head admin) and was told I could probably pump in the bathroom. I really don't think I'll be able to sneak off to do it anyway, but the fact that there is really no place to do it at this facility besides a dirty bathroom is even more frustrating.  I've been torn up over making the decision to try to pump some or to just switch to formula.

As I have not met anyone who has had a baby during intern year, let alone in surgery, I would love to meet anyone who has been in a similar position.  Even other moms in surgery practice.
Anyway, this has been a very emotionally draining and physically exhausting month "off".  My medical school debt load is so insanely large that I could never fathom taking time off or not pursuing the paths I have taken so far.  So, here I go...

My Experience With Infertility, Part 2

I felt like my first post hadn't pissed everyone off sufficiently, so I've decided to take things a step further. I mentioned this internet discussion to my mother (who is not just a Mother in Medicine, but also a Mother of a Mother in Medicine), and she wanted to share her story. With KC's permission, I'm posting what she wrote to me below. Get ready to flame because the people who didn't like the first post are going to HATE this one:

I got pregnant for the first time after three nervous tries when I was just 29. I went to my doctor and I remember him saying when my pregnancy test was positive, "You saved us a lot of trouble." I was to find out just how much trouble less than ten years later.

My husband wanted to have another baby right away, but I was never satisfied with my career as a teacher so I decided to instead go back to medical school first. I assumed the myth that if you can have the first child, you have all the time in the world to have the second. This was wrong, wrong, wrong. Not only does fertility decline 50% from age 35 to 40, but I didn’t count on other unforeseen things like my first husband leaving me when I was 33. At this point I was in a sheer panic to find someone else fast and have a second child.

The infertility spiral began slowly. I was remarried at 38 and immediately even before formally getting married, tried to get pregnant again. At first I was really excited about trying and finally having a new baby, now that I had a new husband and had a stable job as an attending physician. This time when I didn’t get pregnant on the first try, I went back to the same doctor and he started doing tests. I had to have an x-ray of my tubes which initially showed that my tubes were blocked. I had to then have a surgical procedure which showed that they actually were not blocked. I had several other tests and each month would go by and I wasn’t pregnant. Finally after what seemed like forever, I started getting injected with a massively potent drug called perganol which not only did not work, but left me with a disabling tinnitus that cut my infertility treatments short. The tinnitus was so bad that I couldn't sleep and nearly lost my job as a result. As if that was not enough, the perganol caused me to get uterine cancer about 15 years later.

I became miserable and bitter and the worst part about it was that it all didn’t have to happen if I didn’t just wait too long for no reason at all. I wasn't infertile when I was 29. What was I doing that was so important that I had no time to have a second baby? What about my work was so important that I had to do that instead of having a second baby? There is no job on earth that is worth giving up having a baby. I was horribly envious watching all the women on the street pregnant and with baby carriages wheeling young babies. It got so that I couldn’t watch people on TV who were pregnant, even if they were dead and in reruns like Lucille Ball. I could not go to any family functions or have anything to do with anyone who had more than one child, which was practically everyone.

I hated knowing that there was no way my daughter would even think of having a baby herself until she was done with medical school. I just worried that she would have to go through all the misery and dangerous treatment that I went through. If there was one good thing that came out of my infertility, it was hoping that she would learn from my mistakes.

In answer to your questions, she was serious about the Lucille Ball thing. She has been really bitter about this for the last 20 years and this is really how she talks. Perhaps you can now understand how much I want to avoid turning out that bitter and angry.

Guest post: The "art " of medicine and getting along with others

There is a reason why people often say “the art of medicine.”  It’s not just the fact that so much of what we do is based on culture and habit rather than science, but also the fact that there is a lot of finesse when it comes to relationships as a doctor.  Oh sure, we know all about patient-doctor relationships and its importance.  There are a lot of studies about it, and most medical schools spend time teaching students how to break bad news and so on.  But what about doctor-doctor relationships?  In the years since leaving residency, I feel like I have left a bubble and been deposited face-first onto a cold hard sidewalk, and have had to learn to pick myself up, dust off the grime and scrapes and keep walking.  I’ve had to learn the hard way how to get along with my colleagues.

I trained at a major academic institution, where residents would impress attendings and each other with detailed discussions about scientific studies and their merits and flaws.  Over a few years, we all become indoctrinated with the importance of evidence based medicine and more than that, the fact that it was the gold standard of practicing medicine.  There’s a sense that practicing according to evidence is the RIGHT way, and everything else is morally reprehensible.

Fast forward then to my first job out of residency.  I was in a small rural community in a group practice with a nurse practitioner whose husband was her supervising physician.  After a few months of working there, I started becoming really incensed at some of the practices she had, which to me, were questionable in some instances, and in others, outright harmful.  They were not supported by any kind of scientific evidence, and in some cases, even actively discouraged by the evidence.  I printed out guidelines and papers for this nurse practitioner to review, and in return, she gave me a book written by a layman which supported her practices.  Feeling helpless and outraged, I vented to other staff members and was ultimately confronted by her husband, who called me rigid and inflexible for not being able to accept that there were different ways to practice medicine.  They threatened to fire me, and “demoted” me to a separate office location in another part of the medical building.

 I did apologize to the nurse practitioner just to make peace, but have always maintained that her practices are wrong and detrimental to patients.  I have even contemplated reporting her to the board of nursing and him to the medical board, but have been afraid of repercussions (which is a separate discussion in and of itself).  I established my own patient base and kept my practice separate from hers.  With that separation, I was able to regain a sense of sanity.

After a period of time, I was finally able to move to a new job.  In this new job, I work with a couple of physicians who do some things that are not evidence based, although it’s nowhere to the degree that the prior nurse practitioner does.  I had a run in with one of the physicians who got very upset when we had a disagreement over a patient management issue.  Not wanting a repeat performance from my former job, I apologized to him for any hurt feelings, reiterated that we should have the freedom to practice the way we want, and stated that I wanted to have a separation in our patient population.  He was pacified, and the relationship was repaired.

At the end of the day, I realize that there really is an “art” to mastering relationships.  At the heart of being a physician is this fundamental conflict.  On one hand, we are supposed to tell patients what to do, because quitting smoking is the right thing to do, getting a flu shot is the right thing to do, going for the stress test is the right thing to do.  On the other hand, we are supposed to maintain an encouraging and positive relationship with patients when they don’t follow our recommendations, and we are supposed to respect their choices.  It can be hard to let go of the sense of what’s right and overlook that in treatment of the patient.

In the same way, when it’s been drummed into your head that practicing evidence based medicine is the right thing to do, it can be hard to accept other physicians disregarding that tenet.  It’s like what a young woman physician said to me about another physician, “I hate to tell him that he’s wrong, but… well, he is!”

Regardless of our position on evidence based medicine, we still need to be able to work together and get along.  We need to be able to depend on each other for backup and allow for differences in practice styles without getting too upset about other doctors not practicing according to guidelines or evidence.  After all, we’re not perfect ourselves and have to constantly strive to improve our own knowledge and habits.   

 Have you had conflicts with your colleagues about patient management issues?  How do you resolve it?  Do you think being a woman or being young has any impact on this?

- Kelly 

My Experience with Infertility

Susan Sarandon had a child with Tim Robbins at age 46.

You might ask why I know such a thing. Believe me, I'm not some kind of encyclopedia of what celebrities had kids at what ages. But in 1992, when Susan Sarandon was 46 and give birth to a son, my mother was 42 and trying to get pregnant for the last three years.

I don't know if you've ever known someone having problems with infertility. Or if you have, you may not have lived with them. It's pretty painful. When my mother found out Susan Sarandon was pregnant, she cried. Cried! Let me tell you, there are a lot of people in this world procreating... probably, like, millions... and it's really difficult to shield your mother from all of them. We weren't even allowed to watch television shows involving fictional pregnancies or babies.

It went on for years. Years of pregnancy tests, ovulation kits, fertility drugs, and mostly just a lot of crying. And eventually, she really was too old and then there was the "trying to adopt" era, which came with its own set of heartbreaks.

I had my daughter when I was 27 and was probably the youngest of all my friends and colleagues to have a baby. Although interestingly, that was still above the average age to have a first child in this country. But then again, that includes people living in huts in Wyoming, where I don't think birth control has been invented yet. (Kidding!) In any case, I felt a little awkward at times having a baby so early. Some of my friends thought I was nuts. And now, almost four years later, some of them STILL haven't gotten started on their first.

The thing is, when you've watched someone so close to you go through the heartbreak of infertility month after month, it's really hard to wait for something you know you really want. I knew I had to be a mother, that my life would seem empty if I didn't get to experience that, so how could I do anything to risk that not happening? And I did wait for quite a while. It's not like I got knocked up in high school... I made it through my entire intern year.

That's why I feel a bit perplexed when I see my female friends waiting through all of med school then all of residency, and even though they're married and in their early or even mid thirties, they still continue to wait. And the truth is, I'm sure they're all going to get pregnant. People seem to get pregnant pretty easily. But then again, what if you're the one person who can't and you didn't even start trying till age 35? I had a talk about this with an OB/GYN attending and she said that most of her female co-residents decided to wait until after residency to conceive and some were less successful than others.

That's why, despite the fact that I'm only 31 and in many ways I like my life how it is, I feel compelled to start thinking about having a second baby sooner rather than later. My husband tells me I'm being silly, but if I know I want a second, then how could I risk not having it?

Note: This is my 100th post on MiM. Definitely a sign I've got too much time on my hands.

Seriously, I wanna know...

Who do your children consult for minor medical problems? Who "doctors" the scratches, sniffles, and bug bites?

MiM Mailbag: Need some help (urgently)

Dear Mothers in Medicine,
I need your help. I am in a sudden mid-training crisis and after years of being absolutely sure of what step comes next… I now have choices and that leaves me in a panic. I’ve been reading this blog for about a year now and I respect and enjoy reading the posts that go up. So I need your help in the form of unbiased opinions about what to do with my life.

I’m an internal medicine resident in my second year, with a 19-month-old son and a loving husband. I’ve been interested in Endocrine casually for a while now but recently I’ve decided that I would like to specialize in it. The unfair thing is that the match application for fellowship occurs in December of the second year of residency… for a spot after the third year is over. So after the whirlwind of intern year, it seems like this crossroads comes up way too quickly. This is also the time that my program sends out the call for Chief Medical Resident applications (there are 4 chiefs every year for my program), again, for the year just after I graduate. I’ve been asked twice by one of the associate program directors to apply for CMR, which is both flattering and shocking to me. I want to stay at my current program for fellowship, but this is a year when 5 of my colleagues also are applying for Endo and 2 out of the 3 spots have already been promised to people. Basically, no reason to apply for the match this year. I’ve been told that if I did do CMR that I would be guaranteed a spot when I was done. I literally have to make a decision in 2 days (deadline for CMR). So I made pro/con list (or, sort of a stream of consciousness) for the jobs that I’m considering.

Endocrine Fellowship +/- Chief Medical Resident vs. Primary Care Internal Medicine

Endo...

Pro: Focused on limited problem set - thyroid, pituitary, diabetes, PCOS... Overall nice colleagues. Maybe a little better salary than primary care... Don't have to deal with musculoskeletal issues or runny noses. Get to potentially see some really crazy pathology and treat thyroid cancer.

Con: Have to apply for fellowship, including a personal statement, letters of recommendation, trying to start and somehow make sense of a research project. Being stuck in a fellowship for 2 more years while not making a full salary. Possibly having to end up doing primary care anyway after 2 years of training (the market in my area of the state is completely saturated and full time endocrine jobs are extremely hard to come by from what I’ve been told).

Primary care...

Pro: Tons of jobs available. Weekends off, no more overnight call in-house EVER. Making a decent salary in less than 2 years. Happier husband. Potentially really nice patient-doctor relationships with the sane and reasonable patients.

Con: The overwhelming amount of follow up labs, etc. MSK complaints that I never know what to do with. The fear of missing a big diagnosis. The awful gyn complaints (though I think outside the VA where my continuity clinic is at, internal medicine primary care is probably a lot less gyn since women usually have their yearly pap by an OB/Gyn).

Chief Medical Resident. This is an esteemed position that comes as a bitter-sweet combination of administrative work, no clinical time, teaching, politics, and pretty much an 8-5 M-F schedule, and a few more bucks than a regular resident. It would be one more year past my 3 years of residency and would essentially guarantee a spot in my institution's Endocrine fellowship after I'm done. On my curriculum vitae it would be a plus for any future job application. What's one more year out of my life? Well, I think I'm hesitant for two reasons: 1) my husband is not a fan of making 1/2 the salary of an attending for one more year of delay to a real job 2) I don't want to have to deal with all the politics and new ACGME rules that are coming down the pike, i.e. the new rules of interns only working 16 hrs in a row (which is ridiculous, but I'm sure all the new interns for next year are happy about that). I think I would be a good chief and I've always liked mentoring along my younger colleagues (mainly medical students, at this point), teaching, realizing that I actually do know some medicine.

Here’s the rub… My husband has been in his career for 10 years. He is making great money… but he hates his job. He has stuck by me for years now… moved with me to medical school, moved back for residency, supporting me through the overwhelming debt I have from medical school and college, being the primary caretaker for our son last year when I was an intern. He would like nothing better than for me to finish IM residency, get a job in Primary Care, and start having a regular salary and consistent schedule. He’s sure, now more than ever, that he needs to change his career drastically for the sake of his happiness. I want this for him too. After all, he has been supporting me this whole time… when is it his turn? How long can he wait? We will both be in our late 30’s by the time I am really done if I continue onto fellowship.

So. Here I am. I feel like there are a few ways this could play out… and any of them I would find a way to be happy. That’s just who I am. That’s what makes this decision so tough… In any of these, I think I could be happy.

1. Primary care – as a career

2. Primary care for 4-5 years, then apply for Endocrine fellowship - my fear is that I become too comfortable in my current salary/job and just bag the whole idea of going back to training

3. Chief year, then Endocrine fellowship directly after – this is what I would choose in the alternate reality where I’m not a wife or a mom

Any comments or ideas I would greatly appreciate!

NiqueKee