MOC, SAMs, and CME, Oh My!

Maintenance of Certification is a veritable alphabet soup.

I vowed not to blog for a couple of weeks, because I have lots of SAMs to catch up on at night by December 31st. Self-assessment modules, that is. You see, in the age of MOC, it is not enough just to go to conferences and perform the CME (Continuing Medical Education) that has been required by pathologists throughout the ages. I was part of the lucky class to be the first group required to participate in MOC. Maybe in other fields MOC has already been in place, but in pathology it just started four years ago. So now, as a part of CME, we have to find and purchase activities that mandate a pre and post test. Not only that, but we also have to get peer reviews and prove that we are part of a QA/QC (quality assurance and control) activity at our hospital. I haven't figured out exactly how to do that yet, but as the head of microbiology I do attend the QA/QC meetings once a month so I am hoping that will do.

Luckily, SAMs were waived for the first three years, because they were not well set up or readily available. I spent about three hours on the computer last week searching for, and paying for SAMs activities. I have to read 10 journal articles from a respected path journal and pay (did I already mention the pay?) to take pre and post tests.

I was sharing my finds with my co-hort who is a year behind me today, and lamenting over the fact that each module took at least half, if not all of the hour of credit that I received at the end of the testing. Aside from conferences, I am used to these CME activities that my group participates in taking a mere fraction of the time rewards doled out. You know - 20-30 minutes for 5 hours. Another one takes about an hour for 10 hour credits. Now I need to spend about an hour a night to get all caught up by the deadline. Don't get me wrong - I think keeping up with one's field is paramount to being a good professional, I just resent being forced to do it someone else's way and document it meticulously. For me, it takes the fun out of it.

I am currently collecting documents for Phase 2 of reporting. I completed Phase 1 a couple of years after passing my general boards. I had a heart-stopping moment this summer when I received a call from the American Board of Pathology. It was August - I had just sold my house, had six weeks to find another, and was facing the same time frame until my divorce trial. The intercom went off in my office.

"Dr. Shyder, you have a call from someone from the American Board of Pathology. Do you want me to put them through?"

"What? The American Board of Pathology?" At first I thought surely it is a hoax to get me to talk to some salesman. But if it was a trick, it was a new one. I asked her to put them through.

"Dr. Shyder, this is so-and-so from the American Board of Pathology. You were supposed to report MOC for your fellowship at the end of January. We have been trying to get in touch with you by e-mail for months."

"Oh my gosh! I've had a rough year. I'm usually really good at keeping up with these things, I promise. What does this mean? Is my fellowship license in jeopardy?"

She seemed amused, but reassuring. "No, we just need to update your professional e-mail address." I had accidentally given them .edu instead of .org. "Then you have to fill out a form requesting combined MOC reporting for your fellowship and your general boards, fax it to us, and nothing will be due until the end of the year."

Whew.

Anyone else have any MOC headaches to share? I'm not looking forward to the board-like exam in six years to continue my AP/CP (anatomic and clinical pathology) board certification. Luckily I do it all at my job - I can't imagine how hard it would be if I had settled into a national lab job reading only GI biopsies or pap smears. But still - combined boards was hard enough when I had just completed my residency and was used to stuffing massive quantities of numerical and graphic facts into my brain like what platelet aggregation patterns flag Von Willebrand's disease vs. aspirin effect and the numerical likelihood of a unit of blood containing different transmissible diseases. Now, if asked to interpret these tests or dole out this information, I can just look that stuff up - I've got it at my fingertips. I sure hope the MOC boards are open book.

Ode to Mulan

I hate the movie Beauty and the Beast.

We recently retrieved the movie from the jaws of the Disney Vault. I think I liked it the first time I saw it, when I was a kid, but this time it just left a bad taste in my mouth. The music is good, I suppose. But Belle is so annoying. What a horrible role model for girls. Here is a woman who is "smart" because she reads books about princesses falling in love, and has absolutely no aspirations of her own to accomplish anything.

Yes, she wants to leave the town she lives in. And true, she doesn't want to marry the arrogant jackass. But the joyous ending for her is just falling in love with some guy who isn't an arrogant jackass (anymore). Who appears to only like her because she's pretty. Plus she does nothing to help him when he's fighting the bad guy... aside from loving him, I guess.

My daughter has a bit of an obsession with the Disney princesses, as evidenced by the drawings on her underwear, so I can't help but notice that all the movies are like that. Ariel and Jasmine are spoiled little brats. Cinderella falls in love with a guy so generic that he doesn't even have a name and is merely defined by being "charming." It's kind of sickening.

That said, I love Mulan.

We just rewatched it as travel entertainment, and each time, I like Mulan better. If you've never seen the movie, it's about a Chinese girl who poses as a male soldier so that her ailing father is spared joining the army. She completely kicks ass as a soldier and there is only passing mention of her romantic interest in her commander.

But you know what I really love about that movie? Not that Mulan kicks ass, but I love how in the beginning, she sucks at everything. She is terrible at every part of training, and her only comfort is that everyone else is equally terrible. I totally relate to Mulan! Granted, she gets really good within the span of a two minute training montage, but I still like her for it. And I love that she continues to doubt herself until she finally gains confidence in the last sequence.

I think it's such a great movie to show to young girls. Every time my daughter watches it, I want to yell, "Isn't she awesome??!"

Does anyone have any other examples of movies we can show our daughters to inspire them not to turn into whiny brats ogling some handsome prince?

I am Tired but Addicted

I started medical school at 28 with 3 little kids who were 5, 3, and 10 months at that time. I had energy to take care of home, husband, kids and study. I made it through residency with a few more gray hairs but was for the most part enjoyable. I had avoided the more strenuous and time consuming residencies because I wanted a family life, which I have truly loved. Then I paid back my time to the US Air Force and life got a little more stressful.

I am not sure if it was the lovely combat boots, the ever changing rules, the fact that I did not have control of my time or travels or the facing a young mother who was about to leave her young infant for a year long deployment. This takes a lot of “brain and heart” energy that I sometimes do not want to expend. I find myself feeling guilty over this but my husband, kids, family and friends need me to be “fully there” also and at times I am just emotionally and mentally spent.

Now as a civilian a typical day may consist of dealing with a depressed cancer patient and their stressed family members, a concerned mother worrying about her obese child, a middle aged woman with vaginal bleeding after menopause, a hypertensive diabetic patient with an oh by the way I have chest pain, or the patient who has lost their job and will soon be homeless and the list goes on and on. Between discussing odd symptoms, rashes, patient comments with colleagues, pouring through online and print resources and cramming the newest medications in my brain…guess what…I am worried about my patients and exhausted at the end of the day.

My weekends take me away to a place without the stresses of patients’ needs but amazingly enough my thoughts always go back to a patient or two. I find myself thinking of a new strategy to combat their hypertension, a positive word I can say to the worried mom, or make a mental note to call a patient on Monday morning to see what the specialist said. So, even though I am tired I cannot pull myself away from the things I love…family, friends and medicine.

I have yet to decide if this line of work is healthy for me but it certainly is addicting and for the most part enjoyable. I certainly pray a lot more these days than I did when I was younger with fewer responsibilities and more energy. I have learned and changed so much from my patients I can’t imagine who I would be otherwise. So as I walk through my day I must remember to take a deep breath, and enjoy these patient doctor moments because I will never be the same.

Thanksgiving Is For the Birds

As a child, I was the pickiest eater on the planet. My seven year old daughter, Sicily, rivals me.

I hated Thanksgiving - large family gatherings with tons of pressure to eat foods that freaked me out. I did not like turkey (still don't, much). I didn't like mashed potatoes. The combination of sweet potatoes and marshmallows was and is nauseating, to me. I couldn't touch green beans with almonds and fried onions. Any form of vegetable casserole scared me. The only cranberry relish I have ever enjoyed, and this just came with adulthood, had a boatload of jalapenos involved. The only pie I have ever craved had the words key lime in front of it - no pecan, sweet potato, or pumpkin for me - they were and still are as frightening as the vegetable casserole. Stuffing smelled good, but the inevitable discovery of a stray caraway seed in the sausage or a sliver of green onion ruined the appeal and I was left with the one food on the entire smorgasbord I was able to stomach - the roll. With lots of butter, of course.

As I grew older I learned to place a variety of foods on my plate and sample each one to the point of politeness, but have never stuffed myself to the fullness that seems to embody the holiday. Watching sports for the rest of the day? Yuck. I'd rather clean out a toilet with my bare hands.

So you can imagine my delight during the summer vacation Russian Roulette scramble when, for the first time in my three years of private practice, I missed out on Christmas week, New Year's week, and even Spring Break. Thanksgiving was still open, and loomed over my head for a couple of rounds until I finally decided, why not? My kids are in private school, so Monday and Tuesday were just daycare - an opportunity ripe for spending one on one days with each of them while the other got to play with their friends. When you are a single mom, one on one time is a lot harder to come by, and the kids ache for it.

So here we are - a few days into my week off of my most detested holiday of the year. And surprise! We've had a blast. The kids loved picking out their afternoon activities - mornings I engaged them in running errands with me. On Monday Jack was a perfect gentleman helping me out with groceries and dry cleaner clothes. He's really stepped up in the last few months and enjoys being the helper in the house - one afternoon when I first moved to the new house a couple of months ago I was cooking dinner and turned around to find him consulting the picture instructions for putting together a vacuum cleaner I just bought. He amazed me by getting all the small parts in the right place and plugging it in for a test drive without any cries for help.

After our errands we went to buy new shoes and finished the afternoon at the movies. Sicily's day on Tuesday was equally productive - we spent the morning getting together bags from the attic boxes for Goodwill and the afternoon shopping for tiny Christmas trinkets for her and Jack's classmates. Managed to squeeze in a little shopping for her - there was a 40% off sale at her favorite store.

My ex has the kids for Thanksgiving this year - it's all spelled out in the divorce papers. I worry a little about Sicily weathering the food pressures on her own but at seven she's already got more backbone than I ever had at thirteen. So I think she'll be OK. We've got a fabulous brunch filled with all their favorite foods at my Mom and Dad's on Friday, and full weekend plans with friends.

Thanksgiving. My big holiday this year. The most detested *gasp* turns good. Who knew?

Happy Thanksgiving!

Cry baby

In a previous post, I make a comment about how I sometimes (frequently) feel tearful when I'm on call. At the risk of putting myself out there, I'll admit I've definitely cried on call before. A few of the events that have pushed me over the edge:

--My senior resident telling me at the end of my 30 hour call that even though I was off duty, she expected me to go watch my patient get a colonoscopy. ("It might be painful, but you better go because it's worth it for your education!")

--Spending 14 straight hours rounding on 70 patients on a Saturday and finally getting home, only to immediately get called back to the hospital for chest pain the patient had been having all day and decided not to tell me about.

--After an entire afternoon of coding a patient multiple times and finally agreeing it was hopeless, when the nurse said, "The patient's daughter wants to hold his hand as he goes."

After a while, I got a little better at holding it in till I got to my car, where I'd really let loose.

When I mentioned my frequent tears in a previous post, I think a few people may have called me "emotionally unstable" in the comments or something along those lines. All I have to say to that if that's the case, there are a hell of a lot of emotionally unstable med students and residents out there.

Of the residents and med students I've worked with, I've gotten to see a lot of them cry. In my intern year ICU rotation, I saw practically every female resident working there cry at some point. My senior resident cried when she realized the next morning that she missed a pneumothorax (wouldn't have mattered). She also cried when the coroner yelled at her post-call for incorrectly declaring a patient. I even saw the "badass" senior resident on the team crying one afternoon.

In med school... wow, it happened a lot. After exams, before exams, just randomly in the locker room. I remember during my surgery clerkship, we were having a workshop on tying knots, and one student was having trouble with her knots and burst into tears. I still remember what she said: "I don't even feel that sad. I'm just SO TIRED."

I guess my point is that you shouldn't be made to feel like an emotionally screwed up freak if you cry at some point (or multiple points) in your medical training (or beyond). Unless, of course, you're a man and you cry. Then you're weird.

(I have never once seen a male resident or med student cry before. I wonder why that is. Do they just not feel it or are they better at holding it in?)

Guys Do It All the Time

When I first saw him, I’m pretty sure I let out an audible gasp.

It was love at first sight.

As I approached, I began to get goose bumps.

Could I really be thinking, what I was thinking.

Married, Doctor-moms, in their mid-thirties shouldn’t do such irresponsible things.

But, I couldn’t help it, it just felt so right.

Then his intoxicating scent hit me….a perfect blend of leather and new car smell.

As, I sank into those beautifully stitched seats and took my first test drive, I was officially smitten. He cornered like he was on rails and his torque sent my stomach into a tail spin.

Then I had to break the news to my husband.

Honey, I’m buying a new Camero. A ruby red Camero with leather seats and a kick-ass radio.

Really my husband says? That doesn’t really seem like you?

I know. That‘s why I want it.

Don’t you want a Honda Odessy like all your friends?

No.

We already have an SUV for hauling the kids, so my car essentially drives me back and forth to work which is only 5 miles. I was not even considering buying a new car until mine literally got washed away in a natural disaster*, giving me only days to find a new one. In the past I’ve always carefully researched for months which slightly used car was the proper choice, then proceeded drove it forever. This time, I didn’t have the luxury of months to pour over Consumer Reports, so I just went with my gut.

In the grand scheme of things its not that big of deal what car you drive, so why not have fun with it?. Really, in the words of Mindy McCready, “Guys Do it All the Time.” Most of the Orthopods at my hospital buy a new European sports cars every few years. I spent about a third as much. Hey, I’m just doing my part to help stimulate the economy.

Let me just say that our relationship has flourished. I LOVE my car. It’s a fun escape from my real world. For 15 minutes twice a day , I am no longer a suburban soccer mom, I am the cool kid; the race car driver; the rock star; maybe even the homecoming queen. I am one with the road. I find myself taking the scenic route home , soaking in the sights. Enjoying the purr of the motor as I drive through the country side.

So, I have a new man in my life. Perhaps I am having a little midlife crisis as my mom has suggested.

I don’t really care though, cause my new car is Bitchin’.

*In all seriousness, please take a minute to look through the pictures in this link. Though, mostly ignored by the national media, the Mayday Flood of 2010 was absolutely terrifying to live through.

MiM Mailbag: Post-bac pre-med programs for mom of 3

Hello,

  My name is Crystal and I am currently an undergraduate student at UCLA. I have 3 daughters, 6, 4 and 8 months. I also have a husband. I will be graduating in June 2011 with a double major in Anthropology and African American Studies.

  As a "career changer," I am currently looking for the best pre-medicine post-bac program that will lead me to pursue medical school. I have a deep passion for medicine and currently I cannot find ANYONE who could help me (even here at UCLA). I feel very lost going through this process right now, because to most people that I have talked to (especially counselors), my situation is very unique.

    We currently reside in the family housing at UCLA and my children attend the day care/school here as well. I guess my problem is that I am trying to find a program that offers acommodations to families (housing, preschool, scholarships/financial aid etc...)

  I came across a few post-bac programs (Drew, USC, Temple, Harvard) that I think would be a good fit for me, but I am trying to make sure I can find one that will ultimately be good for my family as well. I don't mind relocating. I just need some direction, especially because I have a family, I will be making this choice for them as well.

Do you know of any resources that could help me with finding the right program?

Thank you very much. Your website inspires me a lot. I had no idea that there were so many women going through the same exact thing that I am facing right now.


Crystal

Homecoming Queen

Some weeks being a pathologist is like being the coolest girl in school. All the docs, guys and girls alike, hang on your every word. They call repeatedly, stop by your office, ask your advice on how to get the most out of their specimen to get the diagnosis for the patient, and actually listen and bend over backwards to follow.

On no rotation is this more true than cytology. Interventional radiology and ancillary techniques developed in the last decade or so - all have been created to maximize knowledge yield from a minimal amount of tissue. Yep, that's my fellowship trained specialty. I'm proud.

It's also stressful, because you want your advice to work. So do they. It becomes frustrating when it doesn't.

A few months back, I was on cytology and I got a CSF (cerebrospinal fluid) specimen. The patient had a diagnosis of lymphoma, and I saw some atypical lymphoid cells on the SurePath preparation. Tried to run flow cytometry, but cell yield was QNS (quantity not sufficient) to assess the phenotype and prove clonality. I showed it around to a couple of colleagues and they laughed (in fun, of course - we all are elitist about our own areas of expertise). You see, some pathologists think cytology is like voodoo. Smoke and mirrors. "I can name that tune on three notes. I can diagnose that cancer on three cells. No you can't. Yes I can." Every couple of days I got more CSF, two to five milliliters, and every time I got the same complaint from my flow techs. "Not enough cells." Damn it. I saw the radiology. The patient had a diagnosis of lymphoma, and the meninges were lighting up like a Christmas tree, signaling CNS (central nervous system) spread. I knew it was there, I think the oncologists wanted an diagnosis so they could do intrathecal treatment (I'm a pathologist, not a clinician, so don't call me out here), but we weren't getting anywhere.

A couple of weeks later, back on the same rotation, I was saddened to learn the oncologists were still trying to get the diagnosis to no avail. I called one of them up. "Skip cytology. Skip hematology. We've seen the cells, they're scanty but weird, we know what they look like. Draw off more CSF and put it all in for flow." I was trying to get more bang for the buck.

The flow techs were by now jaded and skeptical after weeks of QNS. My hematology trained colleague was scoffing at me. So I was excited when the flow tech popped her head in my office one afternoon and handed me a blue folder. "They're positive for B-cell clonality." Me, the oncologist, hell the PATIENT got their diagnosis so they could begin treatment. I felt like dancing with my microscope.

This week was one of those weeks. I was the most popular girl in high school. My courtiers weren't jocks and stoners - but breast specialty radiologists, oncologists, neurosurgeons, thoracic surgeons, and pulmonologists. My phone never stopped ringing, and some doctors were hand delivering patient specimens to my office. Luckily this week, every effort (sometimes thrice attempted) ultimately yielded good results, and the excitement in each doctor's voice as I relayed the diagnosis gained from their efforts was palpable. They were all giddy with success, armed with knowledge to begin treating their patients. I was heady with the challenge of making tough calls, silently wishing for more straightforward cases, but thriving on each diagnostic dilemma. Poring over my books. Searching for articles on PubMed. Consulting with my colleagues. Thank goodness every week isn't as tough as this one, but I do enjoy them every once in a while.

Who says pathology is boring?? I'm finally the Homecoming Queen. Now I just need a date.

In the Comfort Zone

There are few things I enjoy more than talking about the spine and the brain.

Therefore, it stands to reason that I enjoyed our state neurosurgical society meeting last weekend. I don't like big national meetings, being an introvert at heart. Our state meeting, however, is small; this makes for a more intimate atmosphere and more outspoken dialogue. Colleagues from across the state can exchange ideas, new techniques, and opinions. We also discuss issues of importance to us locally, such as our lack of a motorcycle helmet law (UGH!).

I generally come away from these meetings with a new idea or two to implement in my practice. I fear becoming a "dinosaur," stuck in the rut of old techniques and outdated technology. My patients deserve my best efforts to stay current, as difficult as that sometimes is. Looking back at the last 9 years, I think I've done a pretty good job with keeping up to date, particularly as related to the spine (my professional passion).

This weekend, I sat in that chilly conference room second-guessing myself.

My colleagues are astonishing. One academic cerebrovascular surgeon showed a video depicting the results of the new non-profit organization he founded recently. Neurosurgeons travel to East Africa in groups to train local doctors in basic and emergency neurosurgery. He envisions such a training network all over Africa, bringing ongoing lifesaving care to thousands. They operate on brain tumors without microscopes, power drills, even electric lights. And the outcomes are remarkably good.

Another colleague, a skull base specialist, presented a series of "eyebrow craniotomies" in which he removes tumors through a single eyebrow incision and an endoscope. It's hard to get less invasive than that. Yet another brought me up to date on the neurophysiology of consciousness and the two biological definitions of time, all over dinner.

I had looked forward to seeing the only other woman neurosurgeon in our state, but she wasn't there. She was in another state doing a fellowship in interventional neuroradiology, learning to coil aneurysms. She already has a fellowship in neurotrauma, and she is laying the groundwork for a new residency program at her hospital system.

Driving back across the state, I tried to envision how my colleagues do all these marvelous things. I don't know how they find the time and energy. I admit that I struggle just to keep juggling all the basic balls: raising a kid, running a practice, taking care of a house and husband, the things we all do as routine. I am doing my dead-level best to just stay current in my field. Professionally, I am inspired by all the possibilities out there; I would love, for instance, to learn to do an eyebrow craniotomy. I probably should learn. Practically, I can't imagine taking time for more training or an overseas mission trip, or anything on top of my current load. I understand Bilbo Baggins when he said, "I feel thin, sort of stretched, like butter scraped over too much bread."

So, this week, despite my glimpse of the shining frontier, I feel myself inevitably settling back into my comfort zone. My familiar routines embrace me like a warm, cozy bed. Just as it's hard to get out of bed in the early dark, it's so hard to contemplate changing the patterns of my practice and my life in a dramatic way. I'm actually alarmed at how much harder it is as the years go by. Maybe it's time to push myself out of the zone and see how much more I can do.

On the other hand, perhaps it's wiser to stick with what I do best, as opposed to scraping myself over even more bread. How important do you think it is to keep stepping out of the comfort zone?

Fee for advice

I used to love my daughter's first pediatrics practice. Then they went and totally BETRAYED us. (Sort of.)

Some background:

I'm not one of those mothers who calls the pediatrician for nothing. I would say that in Melly's first year of life, I called a total of twice, one of which was for simultaneous fever of 102, diarrhea, vomiting, and bilateral ear infections. (For the record, I had to beg for an appointment that time, which the nurse only grudgingly gave me. Should have been a warning.)

When Melly was about two, she woke up one Sunday morning and one of her eyes was swollen. This had never happened to her before and I was concerned, so I called the pediatrician's office. I was met with the following message:

Due to the high cost of after hours phone calls, all calls to the advice nurse after regular business hours will be charged a $20 fee.

At the time, I was a resident and my husband was a student. I thought about the $20 and decided her eye didn't look that bad and decided not to pay the $20.

I can understand why they might do this. Even if you're not a physician, if you've ever read Dr. Grumpy's blog, you'd see the ridiculous, trivial, non-urgent things people call about in the middle of the night. I bet parents are even worse than neurology patients.

But I also think it was horribly unfair. I can understand charging parents who call excessively a copay, but I don't feel like it's fair to put a parent in the position of deciding if their kid's swollen eye is worth the $20. And what if my kid had a health problem that required more monitoring? Would I just be screwed and have to keep paying $20 every time my kid got sick and I wasn't sure whether to go to the ER?

I've used two different pediatrics practices since then and neither charged a fee for after-hours advice.

What do you think? As physicians or mother or patients, do you think it's wrong to charge for after-hours nursing advice?

Nightmare on Nanny Street

Things had been going well, as well as could possibly be expected, ever since my husband moved down to N.C. a few months ago. My dramatic post about becoming a single parent seemed almost silly in retrospect, since here I was, having a ton of help and support all the time, between my parents, my in-laws, my husband on almost every weekend (yes, driving the 6-8 hours each way), and our live-in nanny. Yes, I pulled more double bedtime duty than I had been accustomed to M-F, but it was hardly the hardship I imagined.

Tempeh, who has been through multiple deployments, and who is quite possibly The most supportive friend in the history of supportive friends and who has made offers weekly to help in some tangible way, joked a couple of months ago that I was overdue for a major appliance failing, a fate that befalls almost every newly-alone spouse of a deployed servicemember.

My appliances, thankfully, are all in good working order (I am furiously knocking on wood right now), but my once-rock-solid nanny situation disintegrated before my eyes.

I will save you all the gory details, but even before the sordid events that unfolded over the course of a couple of months, we had certain reservations about her as a childcare provider. Namely, that while she was perfect for an infant: loving, warm, patient, calm, she was highly ineffective with a toddler and a kindergartener:  entirely passive, indulgent, and without a limit-setting bone in her body. Yet, we were willing to ride it out until the new baby came in a few months and her primary focus would be, again, a newborn. The older two kids would be at school all day.

But, then, the sordid events happened, involving a quite-possibly mentally unstable boyfriend to nanny who would not stay away from our house or our children despite our many requests, and to top it all off, reports from the school that she and said boyfriend picked up our  two-year-old son from half-day pre-school and put him in boyfriend's car, without a car seat and sitting on her lap in the front passenger seat.

Stress? Yes, hello, it's me again. This all went down on my birthday, of all days, and right before a month for me that included 3 work conferences, including 5 presentations and being attending on wards.

We fired her immediately. My parents moved in temporarily. It was all very sad since she had been with us for over 2 years and was very much a part of our family. She had taken care of my son since he was 9 months old and he was/is very attached to her. When she moved out, she cried and hugged me for at least 10 minutes straight, telling me how very sorry she was and how I was like a daughter to her.

This has all highlighted for me how tenuous having a nanny can be. Great one minute. Disastrous the next. I can't tell you how many times my husband and I have told each other how lucky we were to have had our nanny over the past 2 years. Up until recently, it was truly great and made our lives many times over easier. And now, we're/I'm starting all over again. No one is going to be perfect, I know. But, it's scary how far from perfect they can be.

Sick Days

Recently, there was a post I ran across on Kevin M.D. that argued that doctors who are sick should just stay home, for their patients.

I'd post the link, but it was a while back, and I don't feel like searching for it.

Calling in sick is antithesis to our profession. I know of neurosurgery and anesthesia residents, dehydrated and drained from GI illnesses, who hook up their veins to a bag of normal saline to keep working through the night. As a pathologist I thought - lucky that they had the resources and know how to be able to do that.

I called in sick once during residency - it was the night before my rotation at the State Crime Lab. I had been up all night vomiting due to God knows what bug and remember laying on the bathroom floor at one point with my arms drawn up in a semi-state of paralysis, probably induced by a dearth of electrolytes. I could not face my first Monday morning of bodies swarming with blowflies - knew instinctively that it was a bad idea. I felt horribly guilty, and showed up on Tuesday apologizing profusely.

Although I have been sick in my three years in private practice (I have two kids - they bring home lots of bugs), I haven't once called in. This decision probably caused illnesses that might have lasted a few days with some good old fashioned R&R to drag on for a couple of weeks unchecked, but there was really no precedent that I could find making "calling in sick" acceptable. Not that I begrudge this aspect of the M.D. work ethic - it had been set up in residency and even on clinical wards as a medical student.

To be fair, a pathologist doesn't really see patients that often, and I think the crux of the article I read had to do with not exposing your patients to the bugs you yourself are suffering from. But it made me curious. The only partner I know (of my 13) who has called in sick in the last three years was in the ER with perforated appendicitis. And one of my senior partners once went to the ER with heart issues, but we all covered him for a few hours and he was back at the end of the day to finish his work.

So I wonder - how many people out there feel justified in taking sick days? Have you ever taken one? If you are a clinician, or anyone in the medical field, how do you feel about exposing your patients to your own illnesses?

Working weekends

I don't like working weekends.

Well, who does, right? I mean, there are probably a few people who like it for some reason. But I'm guessing most people don't enjoy working weekends.

But I really, really don't like working weekends. When I have to get up to work on the weekend, I usually spend much of my time at work on the brink of tears, accompanied by a steady stream of resentment toward all the people who don't have to work that day. Then I usually come down with a cold the next day. So I feel like I might dislike working weekends more than average, but I could be wrong. That could be average.

Sometimes weekends on call aren't as painful as regular days. But sometimes they're much more painful. Sometimes they involve rounding on every patient on everyone's service with an attending who doesn't seem to understand that weekend rounds are for emergent issues only and judiciously uses the phrase, "Is there anything else?"

I suppose that there are several jobs that also involve working weekends (policeman? chef?), but there are also many that don't. My husband, for example, has never worked a weekend. And he has a good job with a good salary.

It bothers me that becoming a physician requires this commitment of working weekends, at least during training (which, as we all know, lasts for freaking ever). Especially when you have young children at home, this requirement ranges from annoying to heartbreaking. I'm sure lots of people will comment and say that they have a job that doesn't require any weekend responsibilities, but I don't think that's the norm for physicians. People get sick 7 days a week.

There's a part of me that wonders if you're the kind of person who really, really hates working weekends, and really, really hates waking up early, if maybe you shouldn't consider a different career based on that alone? Sometimes I wonder if I should have.

Maybe I Need to Clarify

I feel the need to defend my daughter here, before I expose her. And I get the chance to boast a little.

When I went to her second grade parent-teacher conference a couple of weeks ago, I learned she made the honor roll. Here are a few other things the teacher said,

"Your daughter is very smart."

"She is a leader, not a follower."

"Boy can she tell a story! She will go on and on, and if she's not done before recess she'll come back in and pick right back up where she stopped. Her level of detail and vocabulary are impeccable for her age. She's going to be a great writer."

"Your daughter and son are some of the sweetest children in the entire school."

OK, I'll stop. But when you've been through all we've been through in the last year, and believe me - the sibling infighting does increase a little during rough roads, and it takes extra effort to try to keep everyone level and sane during all the change surrounding divorce. So to get this level of praise was extra rewarding, and relieving.

I was going through my daughter's weekly work that comes home every Tuesday just now. I always learn amazing things - like that she knows what the word antonym means and can apply it on worksheet questions or that she is getting more complex understanding of math word problems. This week, on one section of a worksheet she had to choose verbs from a word bank and fill them in to sentences with missing verbs. Here's one mix up she encountered that made me laugh out loud:

Mom examines us home after school.

My doctor drove me carefully when I have a checkup.

I guess she's got the whole mom/doctor thing mashed up in her head. What on earth do I do that makes her feel examined? Sure, I scrutinize her bumps and rashes at night on occasion, but that's at her request after bedtime is long over - I think it's one of those "what can I think of to continue to engage mom as long as I possibly can" tactics. Or is she thinking of my incessant and sometimes pleading questions about her day and how it went and "tell me something good" and "tell me something bad." I'm not always so insistent but I just love hearing about her day, and try to create questions around bedtime and dinnertime to get her going. Maybe she feels overly scrutinized. But isn't that what we mom's do? Hold up the magnifying glass under the bright sun and hope your kid's head doesn't start smoking?

She's quite healthy and with her mom and dad both being doctors, she hardly ever goes to one. So she was probably really stumped on that one.

Anyway, I can't wait for breakfast. I'm thinking maybe I need to clarify.

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