Opportunity Costs

As a trained economist before I started training to be a doctor, I often think in terms of “rational decision making.” In economics, all of the basic models are based on free markets and rational decision making. One key component of making rational decisions is determining the opportunity costs of one decision versus another. After picking up my daughter from daycare yesterday, I (for some odd reason) started thinking about opportunity costs and the difficulty of actually quantifying it in real life - if only I could assign a real value to what I give up with the decisions I make.

Other people may not have such a hard time with this. My husband and I actually started hanging out because I took 30 minutes to make a vending machine selection. I headed down to the basement with a definitive plan to buy twizzlers, but once I realized that this particular vending machine also had sour straws (a blast from the past), I simply could not decide if buying twizzlers was really worth giving up sour straws. As I agonized over this very important decision, my future husband had time to sort two loads of clothes, put them in the machine and wait to add fabric softener. When he saw I was still standing in front of the vending machine, he asked if I was okay, suggested sour straws, and the rest is history! Obviously, my inability to assign a value to sour straws has little consequence in real life, in fact it worked to my advantage since I got a husband out of it. However, when it comes to big decisions I am often paralyzed in trying to decide if my decisions are worth what I lose.

I can’t decide what specialty to pursue, I can’t assign value to the time I will give up with the additional training or the additional demands of one specialty over another. I can’t decide if I honestly think I can finish my surgical residency or is the cost of the time I will lose with my daughter too great. I can’t decide when and if I should have more kids. I can’t decide if my husband should really go for that higher paying job in a city 2 hours away, and I know there is no need to make all of these decisions all at once, but I can’t stop thinking about what I’m giving up.

Nurses and Female Doctors

Can nurses and female doctors be friends?

That is, nurses and female doctors who work together? Can they be good friends? Outside of the hospital setting?

I think the answer may be no. I wish it were yes. But I'm pretty sure it's no.

Where I work, most of the doctors are older. The nurses are younger, closer to my age, a lot are in the same stage of life in terms of having kids, etc. And there are many that I really like and I sense that they like me. We chat in a friendly way and have a sociable relationship. But I feel like there's this WALL between us that will keep us from ever being real friends. My tip-off is that they all call me Dr. Fizzy, despite the fact that I have asked several to call me by my first name. The only ones who call me by my first name are.... the MALE nurses.

Of course, for male doctors, I think it's a different ball game. Because they can flirt. I don't know how many male doctors have become friends with the nurses they worked with, but I bet there are plenty that have started dating.

Or am I wrong?

Kindness

by FreshMD

Last spring, my experience as physician, mother and patient intersected through a calamitous pregnancy loss. A few weeks ago (days after I delivered my daughter), my reflections on those events were published in CMAJ. As on-line access requires sign-in, I requested permission to post the entire article here. As always, details of patient encounters have been modified to preserve confidentiality. My physician gave his consent for publication.


An Eritrean couple first saw me at the refugee clinic four months ago in crisis with an unplanned pregnancy. "It is good now," he says today, gesturing at his wife's belly. "We are happy." It is their last prenatal visit before being transferred to an obstetrician. He says a little speech, thanking me for what I've done, the support and the kindness. "You helped us when we were new in the country, in trouble." I feel professional gratification that they were satisfied with my services, and tell them with sincere emphasis that it was my pleasure! to care for them. As I usher them out the door I've already forgotten their gratitude.

"That was a beautiful speech," says the nurse after they leave. "My patients in Uganda used to do that all the time." I look at her, and I think, Yes, yes it was beautiful. I've heard these speeches before, though, thanking me for kindness, and I feel embarrassed that I'm thanked for dispensing something that cost me nothing: no education, no honing of skill, no effort. I'd rather be thanked for diagnostic prowess or a deftly-performed procedure. But I extend kindness to patients habitually, with an extra measure when I have nothing else to offer.

* * * * *

Seated in my doctor's office, I'm in the chair tucked right next to his desk. This is the first visit that I haven't sat casually on the exam table with my legs dangling over the side, the first time I haven't popped in for something routine like a vaccination or contraception or a prenatal visit, where we talk shop and I ask about his daughter, a medical school classmate. This time, I'm here to follow up a disastrous ending to a second-trimester pregnancy. He knocks on the door, steps in, gives me a long, sober look as he slowly closes the door, sits down. He sits in silence. I can't look at him. Finally I force myself to talk, exhausted, crying, despairing and he listens. He leans over his desk, arms folded on it, looking down. Eventually I look at him, at his solemn white-bearded face, and I note that he is flushed. His eyes are damp. And I realize that he is moved by my distress, and I am completely taken aback.

Over the next few weeks, I think back to our encounter repeatedly. The memory of him sitting there, seemingly with all the time in the world, fully present, saying little but moved by my situation, is an enormous comfort. His kindness is more dear to me than anything he's done for our family over the years, even his delivery of my daughter.

I see him in follow-up two weeks later. The visit is such a solace that I am certain I am being extended divine kindness; my doctor is the unwitting priest. What a profession! What power! I imagine, longingly, that I could only extend the same to my patients.

And I realize with horror that this kindness which has impacted me so profoundly is the very one that I use unthinkingly in my own practice, that I dismiss as a personality trait, a last resort for patients for whom I have no medical therapy to recommend. I feel I have been wielding something powerful without any respect for it.

* * * * *

Back at work, I determine to be conscious of what I give to patients, and to receive what they return to me. An elderly Congolese patient with severe osteoarthritis has found a French-speaking family physician near her home. She makes a short, thankful speech, and this time I don't dismiss the gratitude as grossly disproportionate to what I've done for her. "Every visit, I felt better just to see you," she says. She hugs me; I feel very slight. She presses her cheek against mine and I can feel and smell her hair. "Don't forget me," she says through the interpreter. "Come visit my home."

* * * * *

Weeks later, I see my doctor again. I'm doing much better, and he seems mystified as to why I've come. I wanted to check in, I explain. I can see him trying to figure out what I really want from him, thinking we're doing the doctor-doctor visit dance, where he must guess the investigation, referral or prescription I have in mind. He offers a medication, and I decline. He offers a different one, but I don't want any medications. He asks again why I've come. He has no idea, I realize, no idea how therapeutic his presence is. I don't want to alarm him, so I don't give him the simplest answer: that all I needed, quite literally, was to see the doctor.

With your head held high

I heard a phrase today that I will remember for a lifetime. It has given me inspiration in my struggle to achieve a perfect balance between parenting and working GUILT-FREE.

Grand Rounds today was given by a very accomplished woman (and Mom). Faculty at Harvard Medical School. She's affected national policy and changed the course of a major public health issue. What struck me was her introduction. One of the first comments was that one of her first employers, while reluctant to hire her only part-time, soon realized that even her part-time work, amounted to a dozen others working full time. (I nodded when I heard this because I often feel I'm efficient and use this rationale to justify my part-time work as well.

Her introduction was 15 minutes long as her introducer took us through her career path and mentioned all her accomplishments along the way. When finally at the end, we were all anxious to get on with the show, the introducer continued, "I can't end an introduction about this remarkable woman without telling you about her family. She has 3 amazing children who are all incredible human beings. They are all adults now and have all gone on to college. Until all 3 children went to college, she worked part-time. And the remarkable thing about her, is that every day that she left work early, she did so with her head held high. She made it clear to those around her that raising her family was as important as her work."

I love that last line - I often feel like I have to sneak out the back door when I leave early to be with the kids. Today I decided that I need to hold my head up high more often at work. I am a confident woman in the many hats I wear at work, but when it comes to leaving early, I am quiet, almost sneaky, hold my breath and only relax when I'm finally home with the kids...it doesn't need to be like that. I felt an enormous amount of pride and excitement to hear this woman's introduction today. It was a clear articulation of the woman I want to be. Proud to be both Mom and Doctor. That's the introduction I want to earn 15 years from now.

Art vs. Science

beep…… beep……beep…..

The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. The nurse looks at me anxiously, waiting for instruction on what to do next. Glancing past her, I see she has all the supplies in the room to prepare for a cesarean section.

This is the patient’s* third pregnancy. The first two pregnancies culminated in beautiful 'Kodak moment' vaginal deliveries. However, this labor was not going quite as dictated by the birth plan...

Earlier that day, she had started her labor with a bradycardia, where the baby's heart rate had dropped to the 70's for several minutes. Luckily, it resolved nicely when we changed mom's position. The baby’s heart rate becam reassuring, showing signs of adequate oxygen and health. Her labor had progressed quite well until 8 cm at which point the baby’s heart rate tracing began to have late decelerations, which can be an indication of poor oxygenation. We rolled her onto her left side and applied oxygen, but despite our efforts, the decels worsened. With the next cervical exam, there was only a small amount of cervix remaining (“anterior lip”). The cervix is essentially like a very tight turtle neck that the baby's head has to squeeze through as it passes through the birth canal, with only the strength of the uterine contractions and gravity to help it escape. I placed her in 'knee- chest' position, hoping that gravity and physics might help dissolve the anterior lip of the cervix. I rechecked her and found that my attempts to convince her cervix to dilate were not working.

Time. How much time do I have to get this baby out? Assessing a baby during labor is like taking care of someone in the ICU with only one vital sign. No physical exam, no pulse OX, no stethoscope, just a 1 lead EKG to make your diagnosis. In obstetrics, we have only the fetal heart rate tracing and can infer limited information from it. There are a number of fetal heart rate patterns that can tell us the baby is healthy. Most of the “bad” patterns are not very accurate. Around 97%of the time even though the tracing looks “bad” the baby is still OK… but there’s no way to know for sure. Studies suggest that it takes up to 30 minutes of decreased oxygenation to lead to brain damage.

I look to my patient, knowing that she wants a vaginal delivery very strongly but she also has put her trust in me to help her have a safe delivery and a healthy child. I look at the clock, and see the pattern has been questionable for about 20 minutes. I need this baby out in 10 minutes or less.

Do I take her to the OR? Do I try to have her push?

If she pushes through the lip, I’m the hero for helping her achieving the much desired vaginal delivery. If it doesn’t work, we may have to rush the delivery and do a stat c-section.

I search the fetal heart rate tracing for one sign of reassurance. Come on give me something I can hang my hat on: an acceleration or some variability. I know the patient can do this vaginally if only we could buy her some time. The tracing, however gives me no reassurance.

Let’s try to push one time, I tell the patient. If you can’t bring the baby close enough to deliver were going back for a cesarean section.

The OR team begins to set up. I position her at the angle I think gives her the best shot at pushing past the anterior lip of the cervix.

With the push, the multiparous cervix dissolves and I feel the baby entering deeper into the birth canal.Yes, I think internally, this is going to work. As the contraction finishes, the head retreates back up into the pelvis and the cervix reappears. Crap.

beep…… beep……beep…..

The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. I meet the nurses anxious gaze. The art of obstetrics has failed me and now the science of it is pounding in my ear drum telling me that time is up. I have to call a stat section or the risk to harm to the baby will quickly climb above the risk of cesarean section to the mom.

The moment I call it, the room becomes well-oiled chaos. As we sprint to the OR, I wonder to myself if maybe we should have tried one more push? But on arrival to the OR the nurse rechecks the heart beat, finding it still in the 60s.

Moments later I pull a screaming healthy baby girl through a low transverse uterine incision. The cord had been wrapped tightly around the shoulders, preventing her descent. The baby comes out screaming, filling her lungs with much needed oxygen and quickly turning a healthy shade of pink. The mom cries gentle tears of relief.

Later in the waiting room, I let the family know mom and baby are fine.

I await their reaction.

The dad thanks me, with tears in his eyes.

These are the hardest calls to make. I had mere moments to decide the fate of this precious woman and her child. In this situation, the safest thing for the mother was a vaginal delivery whereas the safest thing for the baby was a cesarean section. I try my best to use the science available to balance the pendulum of mother's and baby's safety to achieve a healthy delivery for both. In the end, that's what matters most.

Photo credit to: www.amandamcnealphotography.com

*All patients examples are either used with the patient's permission or are a fictitious conglomerate of multiple patient encounters.

Also posted at ThePregnancyCompanion.com

A Little Encouragement

I often feel like the odd man out. Here, I'm the wanna-be doctor mom. At school, I'm the 27 year old sophomore who has been married for almost ten years and has two kids. At the kids' events, I'm the young mom, 27 with a 9 and 6 year old (I'm often mistaken for the big sister). In parenting circles, I'm the mom with a medically-needy kid...nobody else is dealing with tube feeds, a half dozen specialists, bi-weekly therapies, and med schedules. With friends, I'm usually the odd one out on all accounts...our friends are just starting to get married for the most part, they are childless, and they are out of school. Sometimes I feel like I've done everything in reverse. I graduated at 16, got married at 17, had my first child at 18...I didn't figure out who I was or what I wanted to do until much, much later in life, and of course even that isn't typical or easy. When you stick out all the time, it is easy to feel like you aren't doing anything right. It is tough to be a premed student/mother of both a typical and atypical kid/wife/volunteer/friend/human and there is a lot of juggling involved. At times I wonder if I'm crazy to even be attempting this, but then a well-timed bit of encouragement helps restore my faith in this endeavor and my ability to see it through.

Math isn't my subject. It never has been. In grade school, math was the only subject I was allowed to make B's in. I chose my major based on the fact I only have to go up to Cal I...not Cal III like some other science majors. However, I made a 110 on the first exam in PreCal this semester AND my professor sought me out during class to try to poach me for the math department! She told me about a math major premed she knew who went on to do very well and now works in medical modeling. She said, "Not everyone is so gifted in math, you know!" I never thought I'd hear something like that!

I'm taking Cancer Biology this semester. It is a special topic class, which means it is a higher level course and it isn't always on the schedule. The hard pre-reqs are Bio I and II and Chem I and II, but on the first day, the professor said, "If you haven't taken Biochem and Genetics, you should definitely think about dropping." I haven't had either, but I stuck it out. We had our first exam a few weeks ago, a comprehensive midterm. I made 303 neon notecards for it and studied a lot. The night before the exam, we had tickets to the Rodeo. The kids really wanted to go and I didn't want to disappoint them, but I knew the exam was going to be tough. I studied very hard that week and opted to go to the Rodeo with the family the night before the exam. After we got home, I hit the books again and everyone else went to bed. The next day in class, I was the first one done with the exam (which was mostly short answer and essay, no multiple choice). I re-read my exam a few times and submitted it. I hate being the first one done...did I do really well or really poorly? Ack! The following class period, the professor handed back exams. She pulled me aside and said, "You're the one who finished in 45 minutes, right? And you got an A?! That is the best use of time I have ever seen!" Then she said, "Aren't you the one who emailed me about your daughter having pneumonia a couple of weeks back?" I nodded and she went on to say, "And you're doing all of this with kids at home? I'm so impressed at how well you are balancing everything!" That kind of recognition felt really amazing, especially because prepping for that exam and spending time with the family had been a bit of a balancing act.

I went out to dinner with my best friend (who is also my sister-in-law) last week, and she said, "I always use you as an example all of the time when I'm talking to people." I looked at her quizzically and ask, "What kind of example?" She said, "When I'm talking to people and they say they can't do something for any reason...like they are unexpectedly pregnant and can't finish school or whatever. I tell them about you and how you didn't to things in the 'right' or 'normal' way, but that you are premed now and doing really well with everything." That might be the highest praise, because it came from someone who knows me almost as well as I know myself.

It is amazing the effect a few encouraging words can have on your outlook and commitment. I hope that at whatever stage of this game you are at, you have people cheering you on and helping you see how well you are doing in the various aspects of your life. If there is one thing I've learned, it is that this kind of life is a circus and all the MiMs I know are extremely gifted jugglers. We all deserve a round of applause every now and then.

- Posted using BlogPress from my iPad

Health Tricks from a Working Mom

Both my husband and I have out of control cholesterol. Out of control good, that is. We've both had ours checked in the last two years and been surprised at the results. My HDL is 80, and while I can't remember the LDL and triglycerides offhand, both were in the 60s or 70s.

My husband's cholesterol surprised me more. He reported to me that his LDL was 39. He's not a physician, so I assumed he got confused and was telling me his HDL because I have literally never seen an LDL that low. But then he showed me the paper and he was right. (His HDL was only 47 though, which he took as a personal offense since he says he eats a lot of peanut butter.) It's weird because neither of us really "deserve" to have good cholesterol based on the way we eat and (to be entirely frank) look, but I guess we're young and have good genes. (At least, good cholesterol genes. The rest is still suspect.)

Sort of the same way doing well on a test makes you want to study more, having good cholesterol makes me want to eat healthier. My husband and I are far from being health nuts. Very far. We've gotten better in the last few years, since my schedule has allowed me to do more home cooking, but we still get fast food probably twice a week. And the fast food isn't, like, a grilled chicken sandwich. My husband gets the Angus bacon burger with approximately 10 million calories, although I get the Southern Style chicken sandwich with only 5 million calories. And other times when we eat out at a restaurant, it isn't healthy stuff either. Although this is way better than in residency, when my personal food pyramid probably would have allotted a large space for the vending machine.

I do try to cook as much as possible. I figure anything I make at home, even the stuff that comes out of a box, is better than eating out. Even TV dinners, which are probably the equivalent of chugging from a salt shaker, are better than eating out, because the portions are way smaller. Whenever I eat out, I usually end up feeling nauseatingly full, whereas I rarely feel that way from home cooking.

These are my extremely easy, working mom strategies to try to be healthier:

1) I buy big bags of frozen vegetables, mainly broccoli, corn, peas, and carrots. Whatever I cook, no matter what it is, I dump a bunch of vegetables in it, and then add less of everything else (i.e. meat, pasta). I'm sure frozen veggies aren't as good as fresh, but I'm not Susie Homemaker and I just don't have time to chop fresh vegetables like I used to do when I was an MS4 (that was the most free time I will ever have in my life again until I retire). I figure even if the veggies have zero nutritional value, they at least take up space and make us eat less of the other stuff.

2) I only use olive oil. It's the only oil in my house. I use it place of any other oil that's been called for in a recipe and there have been no major consequences. I sometimes use it in place of butter, but that's been a little less successful.

3) I buy whole grain rice and bread. My daughter will only eat white rice and bread, but you can buy whole grain white rice and bread, and if you're a trusting sort, you can believe that's just as healthy as the brown stuff. (We compared the ingredients once and it was pretty close, actually.)

4) I drink only water. When I gave up soft drinks a few years ago, I instantly lost like five pounds without making any other changes. The only drink we have in our house right now is milk. I even get water in place of a soft drink at fast food restaurants.

So those are my easy strategies for trying to be healthier. What are yours?

Will pee for M&M's

My 2-year-old son is learning to pee on the potty. When I ask him if he would like to go to the bathroom, and he shouts M&Ms!! In our small community you will find a similar response from all toddlers, it is nearly universal. A behavior modification tactic, the children are offered candy as a reward. At our house it is one for sitting on the potty, two for peeing and three for poop... although we have not had any "poops" yet.

To the best of my knowledge this stems from a popular pediatrician group that many families use. It was the doctor that suggested this positive reinforcement system- of course with the reminder to always brush your teeth!

This has me thinking about how our practices influence the populations that we serve. Especially when it comes to non-evidence based measures, where personal style has an influence and regional preferences may exist. I can think of a couple of examples from Cardiology. For one stress testing. When selecting an exercise or pharmacologic stress you may choose your imaging modality. Depending on the strengths of your lab you may favor echocardiography or nuclear imaging. Personally I prefer stress echo because you can look at the valves and diastolic function (sans radiation), but you must have a great tech who can skillfully scan the patient as they hop off the treadmill. Another example is the management of acute MI (heart attack). Depending on where you live the standard may be primary PCI (going to the cath lab) or if you are in a rural area thrombolytics (clot busters). Also when in training the way we were taught seemed like the obvious and natural way- but then when emerging into practice there were some real surprises.

As far as I know (the little-people docs out there can set me straight!) the M&M potty training protocol has not been subjected to a randomized controlled trial. It probably just worked for my pediatricians kids- and so will it for the rest of us.

Now for the next challenge, his teacher says that he is ready for underwear at school. So our bag is packed for Monday- Elmo undies and extra pants for accidents!

Doctors Want a Life: A GOOD THING

The New York Times has an article up titled “More Physicians Say No To Endless Workdays” (April 2 2011), which features an emergency room physician, the daughter and granddaughter of long-time practicing family physicians. She had originally planned to go into practice with her father in her small hometown, but for several reasons decided to go into ER instead, and after she had twins, she took a salaried position as a part-time ER doc.

Basically, the author explores this cultural shift in medicine: more and more, doctors are turning away from regular practice and more towards part-time or shift work. More and more, doctors want to be able to go home at night, with no risk of being called in, or called, at all. Doctors want a family life, and this may be linked to the fact that more doctors than ever before are women, and moms.

The article is interesting and timely- but what is more interesting to me, and sometimes, frankly, disturbing, are the comments.

The comments attached to an article like this are a window into the room where our patients are talking.

Some comments were supportive of the trend, and they say things like “I say YAY! Good for docs, good for us! I'd rather be seen, whether in an ER or a clinic, by someone who is not overwhelmed, not heading towards burnout, someone who can still love their job because they have time to have a life.” But others says things like, “If an individual who has chosen a medical career as a physician is unhappy with the number of hours s/he must work, I would suggest changing to a position where family time is valued, say as a greeter at a Walmart”.

The opinions range from positive to brutal. One person described the young woman in the article as belonging to “a cadre of physicians who have little interest in putting patients needs before their own.”

Ouch, THAT stung. If I’m a primary care doc and I work part- time, and I value my family and my baby, does that somehow signify that I don’t care about my patients, that I don’t belong in medicine? Could it possibly mean that medicine needs me, needs moms and our viewpoints and experiences? Could it signify that I provide better care, because I have balance and can be present with my patients?

I wanted so much to grab a sympathetic doc and discuss this article, and the way these comments made me feel. And I realized, that’s Mothers in Medicine.

Here is the link to the article and the 51 comments. I want to read YOUR comments!

The Snake and the Pussycat

Not too long ago, I blogged about my family’s about one year old Florida Kingsnake, Spotty Dangerous (Cecelia wanted to call him Spotty, Jack wanted to call him Dangerous, so we combined the two). He was about the only pet I could handle acquiring last year during the time of great upheaval, and he has provided an endless source of comfort and companionship to my kids, in addition to spending a week in my daughter’s second grade classroom. I can only imagine if I was an 8 year old girl handling a snake in front of my class – surely she wowed the elementary school, almost as much as when she dressed up in front of the entire school as Billy in How to Eat Fried Worms for her character book report last month.

So I wasn’t too pleased when I received a phone call from my ex a couple of weeks ago explaining that when he went to pick up the kids from my sitter, Spotty was missing.

“Surely he is in the dragon,” I said. “He can get so far down in that Chinese dragon we bought him for Christmas that you wouldn’t even know he was there. Did you check the dragon? He must be in there, he was there this morning. I haven’t opened the cage since I fed him four days ago.”

He wasn’t in the dragon. Nor was he under his water bowl. Damn it. I wasn’t really up for getting Spotty III (Spotty II quickly replaced Spotty I at the old house when my ex left the top off of the cage one day - kids don't know about that), but my brother and I built this amazing terrarium stand over Christmas – what was I supposed to do with it? I just had to find Spotty.

I went to the local pet store on Saturday for advice. “Your snake got out? This time of year, he will probably look for someplace cold and dark. Look for a good hiding place.” Great. That describes about half my house. In a couple of weeks when the leaves grow on the trees my house won’t see the sun until fall. Since Spotty lives in my bedroom, I figured he was around there somewhere – searched high and low, in drawers and cabinets, under the mattress, to no avail. I problem solved with a friend over the weekend – despite warnings from my cat’s adopted shelter about the incompatibility of cats and snakes, we reasoned that if Spotty had to stretch to eat baby mice there was no way he could hurt Katybell.

I was thrilled when I stepped into my shower Sunday morning and saw the characteristic mouse hair-filled feces. It meant Spotty was alive, and around, and that he had been looking for water, probably. My excitement led to renewed energy for a search, which was unfortunately not fruitful. I was upset when the kids came home from their Dad’s Sunday evening and I had no good news. I told them the shower story, and my daughter said, “Don’t worry, mom. I’m sure he will turn up.”

Tuesday evening as I was reading my son his chapter from Harry Potter, my daughter called excitedly from my bedroom. “Mom! Katybell found Spotty! Katybell found Spotty! Hurry and come!” Cecelia explained that she was trying to get Katybell to snuggle in bed with her, but the cat was distracted by something in my room. Cecelia followed her, and found her sniffing in a space between the walls underneath the pocket door to my bathroom. Cecelia barely saw Spotty’s head disappear into the space. Jack grabbed a flashlight and we peeked in the narrow space – sure enough, Spotty was curled up inside.

There was much laughing and dancing and hugging – I’ll spare you too much cheese, but we were ecstatic that this family member, the one that had weathered us through our big life transition, generated school science reports, and provided overall slithery comfort throughout the year, was safe. I ran to the freezer to pull out a mouse to thaw. “He’s got to be starving,” I told the kids. “He was supposed to eat the day before he disappeared, but I ran out of mice.”

After the mouse thawed, I dangled it in front of the small space for about thirty minutes until Spotty finally caught its scent. I called to my son, and instructed him to cover the space once I lured Spotty out – he is well over a foot and a half by now – so he wouldn’t disappear back into the wall with his food. When he had the mouse halfway devoured, thus rendering him completely distracted, I scooped him up and put him safely back into his cage.

Thank goodness for our cat – no one else in the house has the proper perspective and I am sure Spotty would have gone unnoticed without her keen senses. I had already planned to leave my porch door open for a couple of hours, weather permitting – I was worried Spotty might die somewhere and start to smell, and would rather him escape to the back yard than perish in our home. No more worries, now – all’s well that ends well.

Delivered of a baby girl

by FreshMD

I gave birth to a baby girl four weeks ago.

This is where the statistics go, the measurements and time of birth, precise - to the gram, to the minute.

What I really want to tell, though, are those other details. That my semi-retired doctor came up from a day at his cabin digging a garden for raspberry canes, for his last delivery. The warm blankets piled on me postpartum, white flannel with pink and blue stripes, the softness gone after hundreds of launderings - how they reminded me so strongly of both nights on call in the same hospital and my previous deliveries. The nevi simplex on my newborn daughter's eyelids, symmetrical flames, perfect.

Raspberry canes? Those are just the hormones talking, said my girlfriend flatly. So maybe it is. What does it matter what gives that magnification to the incidental facts around her birth? I'm still sifting through the experience, letting the details settle. I don't have any perspective yet, and I'm hardly coherent. And that's why, although I expected to post about her within days, I haven't.

Here's what I can tell you:

Her name is Ilia Tove. Yes, I realize the name has all sorts of possibilities for medical bastardization.* I proposed the name Imogen but that struck my software husband as sounding like a photo app. Ilia is the female variant of Elijah, and means 'My God is the Lord.'

Several times the entire family has spontaneously migrated to her room, forming an admiring semi-circle around her crib. Her siblings adore her. "Hey Ilia!" said my six-year-old the first time he met her, waving his hands gently in her face. "Dynamite!" and his fingers burst apart in a soft explosion. The four-year-old imitates her Moro reflex perfectly. And my nine-year-old has been poring over my baby books: "Mom! Did you know that in a few months you can mash up a banana and feed it to her?"

Her first week she attended three show-and-tells. "She breastfeeds," my son told his Grade 1 class. "She breastfeeds breast milk. From my mom's breasts." He patted my right breast for good measure. "All her life, my mom's body has been saving all the milk she ever drank to feed this baby," he went on knowledgeably. "It even saved all the milk my mom drank as a little girl."

And me? I feel rich. Three daughters and a son. I don't take it for granted for a moment.

Before I left the hospital the public health liaison took a history from me and asked after my occupation. "I'm a family doctor at a refugee clinic," I said, and I was almost startled to hear myself say it, as if I'd suddenly remembered it. I turned away as tears came. Hormones and lack of sleep, yes; and a sudden brief nostalgia for a life that seemed to have very rapidly receded. Most of all, though, the grateful realization, as I sat cross-legged in the hospital bed with my infant daughter in my lap, considering my work, that I have this - and I have that, too.


*cilia, milia, ill, iliac, ileum, ileus . . .

Pager Anxiety*

I was on call for 7 days starting last Friday. My mother watched Babyboy all day until I got home from work close to 7 pm. My husband was traveling. Mom and I had a bowl of soup together, and then she went home. I was thankful knowing she would be on duty for me Saturday and Sunday so I could go in and round on my patients. Babyboy and I set about our usual Friday night routine: he sat on my bed supported by pillows as I got my pajamas on; then we did tummy-time for a bit and sang songs for a bit. As soon as he started to rub his eyes, I darkened his lights, set Sleep Sheep on “rainfall”, and gave him a warm milkie bottle. And as per usual, he conked out.
Time for Mommy to conk out. I set my pager on the bedside table, turned out the light, and nestled down for the night. Then, “Bip!” the pager went off. I startled and turned the lights back on and fussed with my glasses and looked at the page text: an urgent page from someone with a sore throat. Sigh. I got up, logged into the computer, pulled up the patient’s chart and called her. A young new mom, her baby is in daycare and is on his 3^rd course of antibiotics for an ear infection. Now she’s had a very sore throat and fever over 101 and difficulty swallowing. She knows she should have come into the office, but between work and the baby, she couldn’t. She’s miserable, she’s pretty sure this is Strep, can I help her? Sure. We chatted, she was very gracious, and I felt good to be able to help her out. I called in her Amoxicillin and that was that.
I again set the pager down on the bedside table, turned out the light, and settled down to try to sleep. But how could I sleep when I kept worrying and fretting that the pager would go off again?
Sigh. This has been an ongoing issue since residency. As a resident, when you’re on call, you’re in the hospital, often covering more than one service. As an example, when I was on Pediatrics call, I sometimes would cover two floors: toddler and school age. Back then, each floor had their own pager. Then there was the clinic pager. This in addition to my own personal pager. So it was not abnormal to be wearing 4 pagers. I had to double-knot my scrub bottoms so they stayed up with all these pagers clipped to my waist. It was a feat to use the bathroom and not lose one down the toilet!
And they beeped. A lot. I remember being on call one overnight at a satellite hospital. I was the resident covering the Peds ward, admissions, and backup for labor and delivery. I was paired with an intern who was thankfully a smart and cool-headed guy. For most of the night, we were working with a newly admitted teenager in diabetic ketoacidosis. The teen was on an insulin drip, and their blood sugars, electrolytes and acid/base balance had to be watched carefully. We were being paged so often about the teen that we decided to just stay up there. But, BEEP! A code in the ER! An 8 year old in status epilepticus. We ran and got there at the same time as the on-call anesthesiologist. We decided to sedate and intubate the boy, give as much Valium and other antiepileptics as we could and call for transport to the Main hospital. Then, BEEP! we were STAT paged to a delivery. The resident covering Neonatal was already in a delivery, and there was another imminent delivery that required Peds presence: premature TWINS. They were 32 weeks, which is little but not too too little. They would need to be in the NICU (Neonatal intensive care) for a few weeks, but they were fine. The whole time there were numerous other pages: issues with the admitted children on the ward, beep beep beep; some new admissions to go and see, beep beep. We split up to try to cover it all.
That was a pretty bad night on pediatrics, but it wasn’t abnormal. Medicine codes were much more common, and arguably worse, because people died more often. The medicine code pager, which went off if there was an adult in cardiac or respiratory arrest somewhere in the hospital, had the loudest, most obnoxious sound: “REE-OO-REE-OO-REEEEE”. If I’m in my hospital now, and someone’s pager is set to that tone, I get so uncomfortable. I want to run, or hit them.
I now have my pager set to a sound that isn’t at all like the ones I had in residency. It’s a little “Bip!”, almost a chirp, really. And it never means I have to run anywhere. I only need to be able to pick up the phone and talk, and think. But when that thing goes off, I might as well be back on the floors again. I’m like a returned soldier from ‘Nam, man. Just a tad PTSD.
There was even one holiday weekend, a Fourth of July, where my office was closed on a Friday. I was on call starting that morning. It was a beautiful day, sunny and warm. But the pager went off every five minutes for the whole day. I was planted at my desk, fielding calls, reading charts, looking up answers, trying to keep track of all the issues. The calls piled up. People were annoyed that the office was closed, and that I took so long to get back to them. I went into a full-fledged panic attack at one point. I can now tell my patients with panic attacks that I really do know what a panic attack feels like.
And so, a week ago Friday, there I was, in bed and trying to sleep, in the safety and comfort of my own bedroom, and I couldn’t sleep, after just one benign page. I even started drifting off to sleep, and hallucinated that the pager beeped. I woke up and turned the lights on and stared, but there was no blinking callback number, no message.
I finally fell asleep. Then, at 4:30 a.m., “Bip!” From the deepest sleep, I startled, turned the light on, fumbled with my glasses, and looked at the message. An urgent call for nausea, vomiting. I sighed, pulled myself up and to the computer, and dialed. The lady had school-aged children. She couldn’t keep anything down. I talked to her husband. We agreed that he would take her into the emergency room. I called the emergency room to let them know she was on her way and that I suspected Norovirus, that she would likely need IV fluids. I typed a brief note. I went back to bed.
Two hours later, I was still awake.
*originally posted at generallymedicine.com March 19, 2011

The Mother Load

When I was pregnant with my first child I was a sponge for advice. Every mother I met would be inundated with questions about labor, best diapers, breast feeding or formula, best car seat, and on and on. I am sure many of those poor mothers were glad to see me waddle away.

Now on the other end of the spectrum I find myself giving advice to pregnant moms to be about child rearing and discipline. I am discussing with older parents how to teach kids to respect parental authority, deal with teens who are sexually active, kids being bullied, kids on drugs and often how to communicate with their children. It seems many parents these days are either afraid to discipline their children for fear of “not being their friend or hurting their feelings” or are indifferent to their behavior. I find this very concerning. Am I the only one noticing this trend in America?

I recently read some reviews of Amy Chua’s book, “Battle Hymn of the Tiger Mother." It is a memoir written by an American born Chinese mother of two teen girls. Tiger Mother is Amy Chua's own assessment of herself as she was born in the Chinese year of the tiger. She is a strict disciplinarian who micromanages all aspects of her children's lives which may include calling them "garbage", rejecting hand crafted birthday cards or forcing a 7 year-old child to practice at the piano hour upon hour without a bathroom break. She states that this was how she was raised by her Chinese immigrant parents. Her goal is to prepare her children for the harsh world reality. It is tough out there and you need to be prepared.

I certainly do not agree with her harsh and humiliating tactics but she does point out that in our western culture we are raising a generation of weak children who are indulged for the sake of their self esteem. We have lost sight of the fact that children need to learn from failures, solve difficult problems, that there are rules, and that they will be held responsible for their actions. America is back sliding but are we helpless to stop it?

I would hope not. I can only challenge each of us as mothers and physicians who can influence parents and children alike to put forth the energy to change the culture we have developed. Do we want to put our future into hands of adults who expect life to be handed to them on a fluffy pillow to soften their falls? We are doing ourselves, our children and country a disservice if we don’t encourage families to focus on staying together, push parenting with the goal of responsible adults even if it means some discomfort now, and being honest with our children that our country needs strong, creative, hard-working adults to fix the many problems we have created. Will you join me?

Is There Intelligent Life on Mars?

To continue Fizzy's dating theme, I thought I'd follow up with this.

It has been over a year since my separation and six months since my divorce. Both my brother and sister have been urging me to get on match.com for months - my happily married sister's good friend at work had luck there and my younger brother (26) in law school had luck. "Giz," they told me over the phone, "It's cool to get on match.com now! Everybody does it!" But they are both in Atlanta - way more cosmopolitan than Little Rock, Arkansas. So I have been highly skeptical. And not ready. Still not ready, but sometimes I think for me just getting into something - even a friendship - slowly, might be an important step, based upon my history.

So Friday night, after dinner with a friend and a couple of glasses of wine, I took the plunge.

No most of you happily married mom's out there have no need to get on match.com, so I'll tell you a little about the premise. You set up a profile, with photos and interests, not unlike Facebook. You have a profile page, with a header (It's what everyone reads first - sum yourself up in a simple sentence that will grab someone! - puke) and a ridiculous amount of space to tell who you are and who you are looking for. They give you enough room to write two essays. I wrote two short paragraphs. Anyone who wants to know more, I decided, could find out in a message.

There are three ways to communicate with someone - instant message, message, and winks. The winks show a small picture of the person winking at you with a link to their profile. They tell you to "wink back or send him a message." The next morning, I had a bunch of winks. I was deflated. The winks annoyed me right away. What the hell does a person do with a wink? And some of the people winking so completely grossed me out that I wanted to close out my profile and hand back over the sixty bucks I paid for three months. I sent a message to one person that winked, trying to find out about the winks ("Are they like a poke on Facebook," I asked? Not that I've ever poked anyone) and the ensuing brief exchange of conversation was so abysmal that I vowed never to respond to a wink again - Tenet #1.

Then there are all the strange messages. I don't know why many guys think it is perfectly appropriate to approach a girl they do not know with text message abbreviations. I don't even understand half of the text message abbreviations. Tenet #2 - do not respond to messages written in text slang.

Tenet #3 was formed quickly - do not respond to anyone who comes up with a tag name pairing their first name with the suffix -tacular. The tag name is the anonymous name you use that goes with your profile. I'll leave you to imagine the possible variations. Use your spouses or boyfriends name, for instance. Or mine. "Hello, I'm Giztacular."

Unfortunately (or not), my three tenets have severely limited my interactions on the site, which I can only manage to check for a few minutes anyway, after blogs and Facebook, at night. Oh well. Nothing ventured, nothing gained.

I called my law school brother for support (who has been dating a smart gorgeous girl he met there for a couple of months) on Sunday night telling him I was completely disgusted, felt like I had been approached by a bunch of drunk rednecks at a bar all weekend (text abbreviations are kind of like slurring, after all) and wanted to close out the profile. He said, "It's work, Giz. You've got to laugh at all that, or you'll never get past it. You should have seen this lady twice my age in fishnets and bright red lipstick following me for days. There's a block function. If it gets too intense, use it. It's all anon, anyway. Edit your profile. Take your time. It will take a couple of weeks to get comfortable there, anyway."

I also got advice, strangely but happily, from my ex when I called to talk to the kids Saturday morning. He has apparently been on since last summer, and has had a few relationships. I did not tell him I was on - he had already seen me there. He told me to get a couple of things off of my profile that might identify me. He talked about some missteps he had that cracked me up. He cathartically described the women he dated, briefly, as if he had been holding back for a long time out of respect for me and my presence on the dating site released him. Then he wished me luck and offered to watch the kids if I ever needed help babysitting. Wow. What a difference a year makes.

Yesterday afternoon I got my first intelligent message. I came home, ran, went to get the kids, tucked them in, and decided to blog about this crazy embarrassing experience over the last few days. Now I think I'll send a friendly message back. It's nice to know there might be intelligent life on Mars, after all.

Breast pump outrage!

Breastfeeding is one of those issues that can be extremely controversial among mothers (dads don't seem to care so much). For the record, I think breastfeeding is a woman's choice. If a mother feels for whatever reason she can't do it, I don't think we should chastise her. It's horrible that some women will approach a mother feeding her baby a bottle in public, and feel a need to comment to this stranger that the baby should be getting breastmilk. If you've ever approached a stranger and said something like that or given any sort of unsolicited parenting advice, you're nuts and should mind your own business. Just so you know.

That said, I think breastfeeding is wonderful. Both for the health benefits and the bonding. I think that we should provide every possible resource (finances, time, moral support) to make it easier for women to give their babies breastmilk.

Recently a woman at work told me that her insurance company had paid for her breast pump. Then she gave away that pump to a friend and they paid for a SECOND breast pump for her next child. I was impressed. I thought it was incredibly forward-thinking of insurance companies to pay for breast pumps.

Because I might hypothetically need one someday in the future, I decided to call my insurance company to ask if they would cover a breast pump. The answer was no, which wasn't a big shock. But what really surprised me was when the woman on the phone added, "Unless it's medically indicated."

Of course, I had to ask, "What do you mean by 'medically indicated'?"

"Well, if the baby is premature or has an abnormal sucking reflex," the woman told me.

After thinking about this a bit, I found it kind of disturbing. Basically, they're admitting that breastmilk is important and beneficial for babies, because they're providing the pump for women who can't nurse the natural way. They're saying that if a baby can't nurse directly from the breast because they're premature or have an abnormal sucking reflex, they want the baby to still have that breastmilk because it's SO important.

But if the woman can't nurse directly from the breast because she has to go back to work... well, those ladies are on their own.

There are some states in the U.S. where you get 12 weeks of family leave time that's unpaid, but at least your job is guaranteed. After that, you can lose your job. In other states, you can get short term disability to pay for those 12 weeks of leave. But that just means you have a three month baby when you get back to work. So are insurance companies saying that it's not "medically indicated" for three month old babies to get breastmilk? And I think many people reading this blog who live in the U.S. probably took far less than 12 weeks. (I did.)

I think that kind of stinks. Insurance companies pay for preventive care, vaccines, etc. But for some reason, they won't pay for a relatively modestly priced breast pump to facilitate a newborn getting breastmilk from their working mother. Seriously, could this country be any less supportive of breastfeeding? I think all women who manage to do it, especially when they have to go back to work, deserve a round of applause.