Guest post: Happy Father's Day

Confession time. Despite a paucity of evidence, I once lured my unsuspecting husband and daughter into the bathroom and told them to strip. I handed my husband a tube of 5% permethrin cream and proceeded to apply the same cream to our daughter and myself. My husband, well-acquainted with my neurotic behavior, laughed, shook his head in mild disbelief, then willingly obliged. “Jeez”, he muttered under his breath “I give you a car, and you give me scabies” (a reference to our recently purchased vehicle). My decision to call in three scripts for permethrin was based on two intensely pruritic hands and one overactive imagination. My lips were also swollen, but despite repeating over and over in my head, “You have an allergy, not scabies”, the heebie jeebies were welling into a tornado of anxiety that was wrecking havoc on my paralyzed little brain.

My husband puts up with a lot of crap being married to a doctor. And although I would like to think of my neurosis as merely an occupational hazard, I suspect it was likely a preexisting condition, exacerbated by the daily exposure to other people’s illnesses. I am forced to recognize that this career, and the ways in which it has dictated my behavior, can be a hardship on my non-physician husband.

In addition to not having me committed over the permethrin incident, in this first year of my fellowship my husband has shouldered a disproportionate amount of child-related care and chores. When I left for work last Saturday morning, my daughter was naked in the bathtub, in the throes of a wicked GI virus. My husband was at her side, cleaning and comforting her. I wasn’t worried that she critically ill as she had just been eating and running around earlier in the morning, but I still felt horribly guilty for leaving my family at this moment.

And while I am almost certain my husband didn’t mind, much less resented, my departure, I do wonder if he fully appreciated the extent of his parental participation when he married a female physician. Did he know that he would be in charge of daily school lunches, drop-offs, and pick-ups? That he would know the pediatrician better than his physician-wife? I can’t imagine that he did as I didn’t predict (nor wanted) it myself.

Although I recognized how very fortunate I am in my marriage, I sincerely hope that amongst this group of mommy-MDs, I am not unique in the depth of support my husband provides me in my career and our child in my all-too-frequent absence.

So ladies, in celebration of the men whose lives might have been a whole lot simpler had they just married someone, uh, less interesting.... I’d like to say: thank you.

Happy Father’s Day

s

s is a hematology/oncology fellow in California. She lives with her husband and 2 year old daughter. She blogs at www.theredhumor.com

Don't Give Up on Women in Medicine

The Mary Elizabeth Garrett Room lies off a busy corridor on the main floor of Johns Hopkins Hospital. As a medical student and later an internal medicine resident at Johns Hopkins, I often treated the small women’s lounge and adjoining locker room as a sanctuary amid my hectic days and nights of studying and call. Its namesake, a philanthropist who was one of the wealthiest women in the US in the late 1800s, used her financial power to provide opportunities for women to gain independence and autonomy.  She and her friends offered to raise a badly needed $100,000 for the endowment of the Johns Hopkins School of Medicine if the trustees agreed to admit women on the same basis as men.  The rest, for future women in medicine, was history.

In her New York Times opinion-editorial  “Don’t Quit This Day Job” (June 12, 2011), anesthesiologist Dr. Karen Sibert argues that women physicians, who increasingly work part-time or leave clinical medicine altogether to find better balance between work and family life, have a moral obligation to practice medicine full-time. She rightly points out that there are limited medical school and residency slots in the face of a growing physician shortage, particularly in the primary care fields that attract women in high numbers. However, Dr. Sibert’s envisioned ideal would be a great loss to patients and the profession, and a major step backwards for women in medicine.

Historically, the practice of medicine had required a selfless devotion to the profession at the cost of personal and family life.  Turn of the 19^th century legendary physician Sir William Osler is credited for saying, “Medicine is a jealous mistress; she will be satisfied with nothing less.” These roots are evident in the harsh training environment that prevailed for so many years, requiring super-human work hours, rare days off, and expectations to work through personal illness. Slowly, medicine professional culture has made progress, realizing that the care of its members—in all senses of that word—helps physicians (men and women) lead more balanced, healthier, happier lives and helps patients by improving the quality and safety of their healthcare experience through physician work-hours restrictions.

For women physicians, who continue to perform the lion’s share of household duties and child-rearing despite a more progressive society towards the division of household labor, this has meant the increasing availability of part-time positions, job-sharing, and other creative solutions to allow them to continue practicing medicine while fulfilling commitments at home. Achieving work-life balance means greater satisfaction for one’s career and keeps women (and men) physicians in medicine. Indeed, it is this flexibility that is possible in certain specialties such as primary care, dermatology and radiology that makes medicine an attractive career for many women, despite the years of difficult training and medical school debt.

We are, after all, talking about a profession that is built around caregiving, with the parallels between caring for patients and families undeniable.  Women physicians spend more time with their patients, up to 10% more, and have been shown to have a distinct style of doctoring from their male counterparts: more encouraging, supportive and patient-centered. The contributions of part-time women physicians are no less in quality to the lives of their patients; shouldn’t such devotion to caregiving at work and home be traits encouraged in physicians? 

Invoking the predicted physician work shortage as a reason why women physicians should not work part-time or leave clinical medicine places undue guilt and blame on them.  The main factors driving up physician demand is the growth and aging of the US population and health care reform.  While women physicians do work fewer patient care hours compared to men, what kind of profession would we have if women who might decide to work part-time later were denied admission?  More reasonable (and humane) answers to the physician shortage lies in lifting the residency training caps to train needed physicians and creating new models to increase efficient use of the existing workforce.

Besides, women (and also men), who choose to spend a portion of their medical careers working part-time or who take an extended leave, may return to full-time work at a later time, for example, after their children reach a certain age. Thus, there is a need for effective physician-reentry programs that help prepare any previously trained physician to return to the workforce, providing education and re-training as well as portals to reenter medicine.

Let’s not forget about the men. Besides early to mid-career women, men approaching retirement age are the other fastest growing segment choosing to join the part-time physician workforce. Survey data show that today’s medical students and residents, both men and women, say achieving a balance between their work and professional lives will be the most important factor when establishing a fulfilling career in medicine. Medicine mistresses are going out of style all-around, much to the dismay of the medical henchmen: Burnout, Stress and Dissatisfaction.

To be sure, medicine is a public good. Federal dollars support physician training, and certainly, it is imperative that medical school admissions committees select applicants, male and female, who show a strong commitment to medicine. Yet after training, men as well as women may decide not to practice clinical medicine. Is it more problematic when the reason is because a woman wants to raise a family versus a man who takes a job with a consulting firm? I hope not. These are difficult personal decisions, emphasis on personal.  Like everyone else, doctors need to make decisions for the health of themselves and their families. Life happens.

I am a mother, and I am physician.  These two roles are complementary in more ways than they are not. The increase in flexibility for women physicians in recent times has been a boon to those of us who have found a calling in medicine but do not want to sacrifice having a full family life. Isn’t that what Mary Elizabeth Garrett had in mind as well? Independence and autonomy for women to practice what they love, to be empowered by having choices.

Katherine Chretien is founder/editor of www.mothersinmedicine.com.

Rites of Passage

There are the ones you get excited about. Turning 16 – the freedom gained from driving a car. Turning 21 – finally being able to drink legally. And there are the not-so-exciting ones.

When I went to my OB for the first time in few years a couple of weeks ago for a routine check-up, as I was leaving, she said, “Oh, Gizabeth. We need to schedule you for a screening mammogram.” She must be mistaken, I thought. I am eternal youth. I am 37. I informed her of this, and she said, “Screenings are recommended between the ages 35 and 40.” Hitting this particular mile marker is a little depressing.

You might think, since I am a doctor and all, that I had an actual clue about the process of getting a mammogram. I didn’t. Although I spent a week on radiology, quickly determining that me sitting in a dark room for a job might not work since I always wanted to fall asleep, and a week on breast oncology surgery, I have never witnessed a mammogram. I saw one of the breast radiology specialists describe it once, using her hands and her own breast to illustrate (through her clothing), when answering an oncologist’s question about the orientation difference between looking at a mammogram and MRI, but I still didn’t really get it. What would it be like? Since no one other than myself has touched my breasts (for self-breast exams and washing, of course, this is a G rated article, well maybe PG) for quite some time, I even wondered if it might be a little exciting. I was a little relieved, for my own sanity, to discover that it was not – far from it, in fact. I know many reading this have had a mammogram, but for those who have not, let me describe it to you.

They called me back into a cubicle to put on a paper gown. There was an advertisement on the wall claiming that if you went back to the front desk to pay an extra few bucks you could get this foam pad that was statistically proven to make the mammogram experience more comfortable. What about a mammogram experience requires a foam pad, I wondered, since there were no visuals or an explanation provided? Was it something to lay your head upon? I decided not to ask. I was going to go in cold turkey. I’m pretty tough. There was also an instruction card asking you to remove deodorant or powder from your breasts with baby wipes provided. Who puts deodorant or powder on their breasts? Is this something I missed in adolescent hygiene?

I was escorted into a dark room and saw what reminded me a little of a giant vertical George Foreman grill, minus the ridges, at about breast level. It was on a large post and could be manipulated up and down as well as rotate back and forth. The thankfully female tech looked at my breasts. “I think we need to switch out the tray.” She pulled off a large tray underneath the metal sandwich, I mean breast press, and reached down to the bottom rung of a shelf, grabbing a much smaller tray (haha, for the runts, I thought). One at a time, she used her hands to manipulate my breasts into very stretchy shapes I did not know were possible and squished them tightly between the metal plates, which she was closing in on my breast with electronic manipulation. All the while I was being instructed to “angle your head back this way,” “No, wrap this arm around the top of the machine that way,” and “push your shoulder back a little more” and I was oddly reminded of yearly school pictures. At one point she said “No, put your arm over here, I don’t want this to be awkward for you.” I laughed out loud, and told her, “I know you do this many times a day, but there is nothing to me about this situation could not be called awkward.” She smiled, “I guess you are right.”

She was nice. We chatted about kids and concerts throughout the process. When she had each breast sufficiently pan-caked to her preference, she instructed me to hold my breath so she could take a picture. When we were done, she said, “Do you mind if I get a picture of your left breast again? I didn’t get the nipple in profile and it is so much better that way.” I looked up at the radiographic images she had put on a light box, and gasped internally. I see these all the time in conference, but they were mine, and they looked so beautiful. I wanted to ask if I could take one home with me, but that would sound weird, and it’s not like it’s something you can just frame or display on the fridge and not get questions. The one with the nipple profile did look much better – the side without a nipple looked a little malformed, so I agreed.

I got called back for additional images the next day – luckily I was prepared by learning from a friend that this is common, not to worry – they just need to get a really good baseline to establish any asymmetry as most likely benign, and I was glad for her reassurance. But this did not help me from having a tiny panic attack in the waiting room cubicle once again – still did not buy the foam cushion, but at least I understood it now – because I have so much to live for, these days. So I was relieved when after more mammograms and then an ultrasound exam the radiologist, who seemed very surprised to see me as his patient – the name change is still throwing people off – assured me that everything looked all right. “We’ll see you in three years.” Whew.

Finding Balance

Life has a funny way of reminding you daily that you are not in charge. You walk into work after a full night's sleep, thanks to my ear plugs because hubby snores. (Don't tell him I told you!) My energy is positive and I am ready to conquer the day. Then I proceed to look through the files of the patients on my schedule and then I realize there are a few chronic pain patients, crabby COPD patient with new CHF that refuses to go to a specialist, and on and on it goes. I feel the wind go out of my sails and I lean back in my chair trying to decide how to move my mood to a more positive state. Then I take a little mental mini vacay to a winning lottery ticket. Yep, it works every time.

Then after an exhausting day at work, going home to make dinner, started and folded more laundry, discussed the day with the family as we played "Apples to Apples" (Fun game if you have older kiddos.) I soon realized that I really am very vulnerable to my circumstances. Dealing with difficult patients...frustration and fatigue sets in...fun game with the family...happiness and energy abounds. Geez, this is sad realization my mood is so easily shifted. Maybe it is hormonal or maybe I just don't like not being in control...ahh...that is it.

I am a control freak. Yes, type A personality to the core. See when I go on my mental vacations I am in control and decide my fate. In real life, not so much. Not sure how turned into this over the years. Certainly not genetic as my mom is a peace maker and sweetheart and my biological dad never stuck around to change or be in control of anything.

I guess when I figure out how to solve this little personality disorder I will probably become a wealthy person. Any thoughts?

The Massage

For special occasions, my husband likes to get me creative presents. No chocolates and roses from this guy. He claims it's because I don't like chocolates or roses, but I do actually like chocolates and would be fine with receiving them as a present (not so much roses). Some creative presents he's gotten me have included a membership to the Lobster of the Month Club and a hammock for our tiny one bedroom apartment:



(Unfortunately, the hammock came to life during the night and tried to bring us back to its home planet. We had to destroy it with fire, its only weakness.)

Last year, he bought me a gift certificate for a massage at a spa. Sounds like a great gift, right? Unfortunately, I've never had a massage before and I'm a little bit terrified of them, mostly because I vasovagal kind of easily. When I was having a one on one yoga demo session, the instructor did some kind of massage-like manipulation and I almost fainted, and felt lousy the rest of the day. The same thing happened when an osteopath in my class did some kind of manipulation on my shoulders.

So I traded the massage for a pedicure and a wax, and I was happy. Yes, I preferred having hair yanked out of me by the root rather than get a massage.

I guess I didn't emphasize to my husband my feelings about massage because this year for our anniversary, he again bought me a gift certificate for a highly rated spa in our area. Except this time it was a spa that basically ONLY does massage and variations on massage. And it's a $200 gift certificate, so it's not like I can just toss it. I have to get a massage.

I feel a little stupid about the whole thing, because really, what woman wouldn't want a massage at a nice spa? But I'm seriously worried about fainting during the experience or something along those lines. And isn't part of the fun of a massage looking forward to it? I feel like this is going to become a self-fulfilling prophesy.

So here I am, dreading a massage (and also playing the world's tiniest violin).

Guest post: Top 5 Unexpected Discoveries While on Leave of Absence

As a rising 4th-year medical student, I took an extended maternity leave after giving birth to my youngest daughter, Starlight (for many reasons, mostly practical ones, but some sentimental).  While the obvious reasons (a proper recovery, extended breastfeeding, family quantity time) were readily apparent, there were a few unexpected discoveries on the way:

1. Making new friends, and keeping the old. During medical school, and especially during the in-hospital clerkships, my life choices were made for me: either school or family, often in that order.  There was little room for anything else, especially not friends.  (Have you been friends with a medical student?  They are never around, and if they are, they are talking about exams or sneaking peeks from flash cards.  And planning get-togethers? Forget it--they're at the mercy of the next clerkship schedule.)  So a few months into my leave, when someone asked to set up a play date after a La Leche meeting, I was dumbfounded.  That there are other people out there who can relate to me outside of my profession and are willing to rehabilitate me back into the world of non-familial human attachment, was--and still is--a wondrous thing.  I am forever grateful for those friends who ask to socialize despite my terrible track record at reciprocation.

2. Time to....think.  Don't get me wrong, in school I was thinking all the time.  But the thinking that came with school was strictly medical (normal pressure hydrocephalus or early dementia with BPH?).  Left to my own devices, I started to think about my medical thinking (metadiagnosing?) and how I was taught.  I reflected on what I would do for a career, what kind of thinking I liked to do.  I read JAMA for fun, and went to a writing workshop for medical students.  I feel...more resolute now, more introspective.

3. Hobbies.  While I didn't revive my favorite hobbies with nearly the gusto I intended, it was nice to dabble in them here and there, even if it meant that time-intensive knitting was replaced with beadwork, or jogging was replaced with chasing kids in a park.

4. Kids--they grow!  Once Starlight was born, I lived in this fog of sleep-deprived, perpetual kid-tending.  Starlight never slept more than 40 minutes at a time, and she constantly needed to nurse.  Unlike Sunshine, she wanted to be held all the time.  Sunshine (my oldest daughter), being barely two, still needed intensive mothering--I was clothing her, diapering her, and cutting her food in little pieces.  She couldn't be left alone more than a few seconds.  It didn't occur to me then that this state of being might be temporary.  Over the last few months, I've watched Starlight nap longer, learn to explore on her own, and try all sorts of finger foods.  Sunshine can now put her own clothes on, play quietly by herself, and use the potty.  This was definitely one of my favorite discoveries.

5. I'm the same person I always was.  When I started my leave, I had grand ideas of remembering everyone's birthday with personalized cards, preparing elaborate dinners, and finishing all sorts of household projects.  The truth is I'm not an apple-pie mom.  I'm a doctor-mom, and if my heart and my mind are ever not with my family, they are with medicine.  My house never got to immaculate status these last months, but it matters more to me that I was able to tutor medical students and perform experiments.  My cooking will never make anyone's life a little better (Mr. Scrub can probably attest to this), but hopefully my skill and empathy as a physician will.

Tomorrow is my first day back.  I should be wistful (and probably fearful), but right now I'm full of anticipation.  New lithium AA in my pager, and a fresh set of bound notecards to pair with my pocket reference book. 

The air is hardly crisp, and the leaves are far from turning, but back to school, here I come!

-scrubmama

Reverse Sexism in OB/GYN

From the moment I was accepted to medical school, I began to get unsolicited advice about which specialty I should choose. The most common recommendation was OB/GYN. “Female OB’s are in such demand!” I was told on a regular basis. However,I had ZERO interest in becoming one of THOSE women. As I began my rotations, I realized that there was more to the specialty than pap smears and stereotypes. In time I embraced it as my calling.

The year I graduated (2005), 75% of OB/GYN residents nationwide were women. I don’t know today’s numbers, but some recent journal editorials have brought attention to the fact that there are fewer and men going into OB. As more and more practices are marketing themselves as “women only,” some male OB’s are beginning to cry, “Foul!” To some extent they are right.

When I made my appointment for my very first pap smear, I called every female doctor in our town, only to find them all on a 6 month waiting list for new patients. I begrudgingly went to see my male FP, and he was fantastic… well as fantastic as the person giving you a pap smear can be (not THAT fantastic). Some of the kindest and most compassionate OB/GYNs I know are male. Many of my mentors in residency were older male physicians, who would really take the time to teach, while the female attendings often hurried home to their families.

At the end of the day, when starting with a new physician, a lot of women just feel more comfortable with a female OB/GYN. I am part of an all female practice, and honestly that is beneficial to getting new patients in the door. A significant majority of our obstetrics patients will ask to confirm that there is no possibility of a male physician delivering them. I answer in the affirmative, but the answer makes me a little uncomfortable. "I prefer to see a woman because you KNOW what I'm going through" they will often tell me. As women, the ‘been there, done that factor’ can cut both ways. Yes, I do get pap smears and understand the discomfort of putting my junk in the literal spot light every year. I also worked 12 hours the days I delivered my baby, and find it hard to muster up compassion for the multiple complaints of my term pregnant patient who work a part time desk job.

Being a MIM is not easy, but honestly in my field it is an advantage. Is it in yours? These men are saying the current situation in OB is rife with discrimination. What do you think?

Home vs. Hospital Birth

When a woman I know in real life or online tells me they are interested in giving birth at home, I am never entirely sure how to react.

While I am a physician, I'm not an obstetrician or pediatrician or someone who works regularly with childbearing age women. When it comes to the statistics and research about home vs. hospital birth, I know very little. All I can really offer to an expecting mother is anecdotes from my brief experience on L&D. I can share a story about a severe postpartum hemorrhage that might not have made it to the hospital from home, or the newborn with unexpected heart problems whose life was saved only by immediate medical care. Based on that experience, I would never consider giving birth at home or advising anyone else to do it. But anecdotes don't equal evidence-based recommendations.

In contrast, a lot of women having home births have done tons of research on the topic. Something I recently discovered is that some women who are pro-homebirth not only feel that it's safer to give birth at home, but that this is an undisputed fact supported by solid medical evidence.

There are probably women who read and write on this blog who know the evidence back and forth, but I'm not one of those women.... which is why I'm writing this post. I am not entirely sure what to make of women who proclaim that they're giving birth at home because it's safer, then try to convince others to do the same. Yet I feel like as a physician, I have to speak out on behalf of my profession.

The readers of this blog are generally medical professionals of one kind of another, or at least people who likely respect physicians. So I ask this specific community for the sake of my own (and the readers') curiosity and knowledge: what are your thoughts on home vs. hospital births?

Triggers

The first time it happened I was an intern. I was starting the first day of a week of vacation after a 6 month straight spell of no vacation and few full weekends. I had just finished one of our more demanding services and had been up until 1am finishing up notes. I woke up late Monday morning - after the sun was up - and got in the shower. It was a bright, beautiful sunny day! Then, about 5 minutes into this glorious long shower I started BAWLING!!!! Just the day before I heard about a patient that I’d taken care of off and on all year - she had died in hospice earlier that week. She was a patient who I got to know well. I got to know her family. I was devastated but never really felt it because I was just way to busy. Well, five minutes into my vacation shower I started to feel it. I started to think of all the patients who had died - oncology patients who fought hard to the end, sick kids in the PICU, bad trauma patients, EVERYTHING!!! I cried for like an hour! Then I got myself together, and went out for breakfast.

Well, this morning, I was driving to work. I had just dropped my super cute daughter off at daycare and I was having a good morning. Then, on npr there was a story about poet Dean Young who had just received a heart transplant. In the interview he talks about what it means to receive a heart from someone - in his case a 22 year old college student - and suddenly I start crying. A patient I took care of died over a year ago suddenly and very dramatically after being totally stable from his heart transplant. It was a heart I helped procure. He was one of the kindest patients I had ever had. He was young and so happy about the new life he was about to begin. I had a hard time with his death last year but I thought it was behind me. However, here I was, in my car, crying for this patient. I knew I needed to write about this, the thought of writing it out is part of what got me to stop crying so that I could get out of my car and go to work. How do we deal with the crushing losses we are a part of? How do we stay human and also stay sane?

When Your Patient Can't Get Pregnant- And You Are

Now that I am again expecting, I am wondering how to approach potentially difficult clinical situations in my Internal Medicine practice. It’s too early right now for my pregnancy to be obvious, but I know that it will soon be very obvious to my patients who are struggling with infertility issues or pregnancy losses. Not only that, but I am struggling with my own emotions when I counsel patients through miscarriages or pregnancy complications.

Last pregnancy, when I walked into the exam room at 6 months to see my patient with a cough, it was painfully, massively obvious that I was pregnant. This patient is a lovely woman, about 42 years old. She and her husband had been trying to conceive for several years. She had tried Clomid, in utero insemination (IUI), and several cycles of in vitro fertilization (IVF). They had used up their infertility treatment insurance benefits and a large chunk of savings on the project. We had spoken of her issues before, and I had provided referrals for her to a new fertility center, to try again. But that day, she was only in for her cough.

When I was at 6 months, almost anyone who saw me commented on my pregnancy. Patients would almost invariably enthusiastically ask: A query as to how it was going, how I was feeling, did I know if it was a boy or a girl, etc. I welcomed this banter and enjoyed the opportunity to chat with patients, as most times the banter led to some memories from the patient on their own pregnancies, or expressions of hopes for future pregnancies, or descriptions of beloved nieces and nephews or grandchildren. In short, a pleasant time was generally had by all.

But this patient was clearly pained by my state, and the visit was strained to the max. As soon as I walked into the room, she seemed shocked, silenced, and took some time to get composed. It did not occur to me right away what the issue might be, so I asked her some questions about her illness. The visit progressed, I took care of her cough, but she never once commented or said anything about my state. She kept looking at me as if I had somehow betrayed her. She fairly fled the room at the end of the visit, clutching her prescriptions. I felt terrible.

Afterwards, I asked colleagues how I could have handled this better. It had seemed as if there was an elephant in the room- and at my size, there literally WAS an elephant in the room. They suggested that I acknowledge the elephant, say something like, “It’s possible that my state is upsetting to you right now, and it’s no problem at all for me to find another provider to care for you, if you like” type of thing. I think that with this pregnancy, I’ll be more sensitive to these situations, and likely offer something like that. I’m curious as to what other providers do, especially the OBs, who much encounter these situations far more often than I do.

Now, I am 9 weeks along. I’m exhausted, emotional, and a tad nauseated, but other than being various shades of green during exams, I don’t think anyone would know that I was pregnant. However, it comes up for me, on my end, with the emotions I have in caring for my patients who are having pregnancy issues. Two weeks ago, I counseled one patient through an early miscarriage. She had had a hard time getting pregnant, and the loss was such an overwhelming disappointment to her and her husband. I couldn’t help imagining what it would be like for me, for us, to go through the same thing; as a result, it was difficult for me to contain my own tears in front of them.

I have another wonderful young patient who is struggling with a complicated early pregnancy, right now. She has numerous health issues, and hers is a very much desired pregnancy that has been a long time in the trying. Our LMPs were close to the same date. She does not know that. My pregnancy has progressed pretty normally thus far; hers has been fraught with vaginal bleeding and erratic HCG levels; an early ultrasound showed a small gestational sac with no heartbeat, and she was counseled to hope for the best, but prepare for the worst. This week she has had more vaginal bleeding, and a followup ultrasound showed a fetus, alive, with a heartbeat, albeit a slow heartbeat. She was again counseled to hope for the best, but prepare for a possible miscarriage. I cannot imagine the limbo she must be in. I worry that I will run into her at the OB’s, as we both are going to the same OB office for care. I wonder what I will say, or what I should say, what I need to say.

How do other physicians cope with these difficult situations? I do not believe that a complete dissociation into professional identity is possible here. These issues hit the deepest emotional, irrational parts of us. For so many women, being pregnant or trying to get pregnant can represent a whole future; hope and loss, life and death, and is life-CHANGING, regardless of the outcomes.

What do people do?

Is There a Doctor in the House?

Last week, I had a kid-free weekend coming up. Trying to decide how to spend my time, I googled volunteer opportunities in Little Rock, AR. I came across a website called volunteermatch.com, or something like that, and signed in to look for opportunities.

There were lots of chances to mentor kids, or host exchange students, but I have two kids of my own that I am currently trying to mentor, so I am reluctant at this point to take any others on. It seemed serendipitous that a big event was happening on Saturday, called Take Steps for Crohn's and colitis. They were looking for 50 volunteers to help set up. My brother has Crohn's disease - he is in Boston. I decided to go for it. I e-mailed the coordinator, explaining that I was a physician and touting my personal interest in helping out. She e-mailed me back.

"We had a nurse running the First Aid tent, but she had to back out due to family obligations. Could you man the tent between three and seven o'clock?"

I cursed the fact that I told her I was a physician. I am a pathologist, for crying out loud. I could do someone's autopsy, if they died? I was counting on setting up tents, or maybe hanging up balloons, but running the First Aid tent? Yikes.

I decided well, maybe I'm a pathologist, but I'm also a mom. I don't keep up with my ACLS certification, but I am pretty good at bandaging boo-boos. I told her yes, and hurriedly and desperately recruited my friend Ramona Bates, a surgeon, to help.

Ramona and I arrived promptly at 3:00, and despite our attempts to help in whatever capacity, we were relegated to the First Aid tent. There was a plethora of Central High School students doing chalk art and any manual labor that was necessary. I was worried (Ramona was not), but my worries were to no avail. In four hours, we passed out two band-aids - to the same person - one who was trying to protect a blister during the walk. MEMS was present - it seemed a little silly considering the short walk required after the provision of massive amounts of Bar-B-Q, freebies, and pizza, but I was still comforted that if anyone needed a "real doctor," I had back-up in Ramona and MEMS.

As a pathologist, I worry about my little exposure to the "real world" of medicine. Here I am, a bona fide M.D., and what do I have to show for it? Sure, I make a decent living, and am proud of what I do, but why do I have heart palpitations when I am on an airplane and I worry about hearing an overhead announcement, "We have an emergency and we need a doctor - are there any on board?" Will I be able to perform? I was recently discussing this with an OB - she voiced the same concerns. She was on a plane recently where they asked for a doctor, and after realizing she was one of two on board - her and an ENT - they both reluctantly volunteered to help, wondering if they could do anything for a geriatric stroke victim.

I was talking with one of my partners Monday about my weekend volunteer experience. She empathized. She said, "I think we should have a yearly workshop. Call it, "Is There a Doctor in the House?" And we should be updated on how to respond, as M.D.'s, in emergency situations. We were trained to help, and we should keep up the training, so we can perform in these situations.

One Friday night a couple of years ago, I was triaging bone marrows and lymph nodes that were rolling in mercilessly while I was on weekend call. I had just finished a platelet apheresis on a patient with Essential Thrombocytosis. She had been done for a couple of hours, and for all I knew, she was on her way home. I got a call from the dialysis nurse. "She is on the floor, seizing." Shit. I told her to call the heme/onc. He was climbing a local mountain for exercise. I told her to call the on call hospitalist. He told her to call me. As I was rushing upstairs to get labs and try to stabilize her, with my limited microscope medicine, I got a call from an internal medicine doctor. "Her electrolytes are out of whack. We are fixing it. It is all under control."

We are so subspecialized, in medicine, that the very thing we start off trying to be good at (dealing with these emergency situations) we end up being abysmally afraid of. Maybe it is just pathology. I am a general pathologist. I presented three disseminated fungal infections at a hospital-wide Chest Conference today. I did three fine needle aspirations in fast-track ED. I handled two inpatient needles in radiology - making spur of the moment decisions with limited tissue to benefit the patient in the CT scan, under the needle. I feel like I am so much, but also not enough. Does anyone else feel this way, as a doctor?

What do we owe?

I recently had a discussion with fellow residents, their spouses and friends at a dinner party. We ended up discussing the difficulty of balancing family and a surgical career which brought us to a discussion about two recently graduated female residents who both have young children. They both started out residency very similarly. I had the pleasure of working with both of them and they were awesome leaders and had great technical skills. Both were ironically interested in the same very demanding subspecialty and had done everything necessary to secure top fellowships. Then they both had kids during residency. One went on to pursue her very demanding fellowship and is currently doing well and loving her job. The other finished residency and is now a stay at home mom and also very happy. When we brought up these very divergent career paths it started a discussion about what doctors owe society. One person commented that there is a significant societal costs of training a doctor. In addition, there is a surgeon shortage and therefore a responsibility of those trained as surgeons or any type of doctor, to actually practice medicine. I was surprised by the strong feelings about this issue and felt that personal and family decisions are based on more than these large scale societal issues. Yes - the resident that is not currently practicing as a physician represents some loss to the society. But, I didn’t feel she owed anything to society. She worked hard through medical school and 7 years of residency. She took care of many patients during that time and devoted much of her life to it. In my opinion we all have a right to choose.

What do you think?

Guest Post: My biggest fan

My mother is almost inappropriately proud of me. At parties or social gatherings she will announce unsolicited that I am a physician (or was a medical student, or was planning to go to medical school, etc etc). She will go on, to whoever hadn't made an excuse to refill their drink, about whatever particular detail makes me fabulous, the word "doctor" coming up repeatedly. And although I find her rosy accounts to be both flattering and endearing, I have had to pull at her arm and mutter in her ear “Mom, come on” when I sensed our crowd is not interested.

I would of course like to think that my dazzling success, tireless benevolence, and deafening charisma has deemed me worthy of her immoderate praise. But I recognized that part of her pride stems from the fact that until she made a huge mid-life career change (into social work) never derived much pleasure or satisfaction from her own work. She raised my sister and I to “reach for the stars and let the rest shake out where it will”, and with the expectation we would have our own careers, earn our own money, and generally live as independently as possible.

My mom is very bright; however raised in Latin America as part of a family whose hopes and expectations for my mom did not extend beyond that of marrying "well". Her education and personal development were not valued to the same degree as those of her younger brother, who was sent to boarding school in Italy when no satisfactory local school could be identified.

Despite, or perhaps in reaction to, being presented with so few options, she spent her twenties partying in night clubs around the world, working in generally low paying jobs, and becoming engaged to six different men. I find the motley anthology of my mom’s travel and love trysts almost painfully exotic, especially in comparison to how I spent the same decade of my life. She strongly disagrees with my characterization, insisting that she would have spent her twenties very differently if she had known how to get herself on a different course.

Last month my mom lived with me while my husband was out of town and I was on our busiest inpatient ward service. With my pager going off starting at 7am six days a week, I needed help with everything, including but not limited to getting my daughter ready for school, making her lunch, dropping her off, picking her up, dinner, and all the other small tasks that can become monumental when I am on my own.

I am unfortunately now accustomed to the constant distraction of my pager, so it was interesting to see my mother’s frustration grow each time it went off. She watched curiously as I had to leave the dinner table to get on the computer. She worried that I was too tired to work. She wondered aloud how I was suppose to attend to so many people’s needs without being able to meet my own.

Slowly, she started to understand that which I realized soon after my daughter was born - I can still do anything, but I can’t do everything.

Her rudest wakening came during a conversation we had about the upcoming plans to “transition” my daughter from the toddler to the preschool room at her daycare. When my mom inquired as to my “strategy” for said transition, I stared at her blankly before replying that the great plan was to drop her off, as I would any other day, and go to work, again, as I do every other day.

My mom looked at me as if I had just said I was going to kick her out of a moving car on a cold and raining morning, with the hopes that fear and hypothermia would drive her into her new classroom. She immediately started planning a return trip so that she could oversee the "transition".

I would like to think my mother is still proud of me, but as she realizes how much I have missed, and will miss, of my daughter’s early years, she seems less enthusiastic about my choice in career. She has become almost bitter about my inability to be in two places at once, and would like to hold the "male-dominated world of medicine" responsible for this failing.

And now we both wonder to what degree we will encourage my daughter to pursue a similar career pathway. My mom might never have been satisfied with her career, but she was at every soccer game and running event. She was there when I got home from school and on weekend mornings. And she never left in the middle of the night.

I owe a great portion of my accomplishments to my mom, who was always by biggest fan and believed in me when I didn’t believe in myself. But, armed with only the best of intentions and an incomplete view of the consequences, my mom inadvertently overlooked the cost of this success.

With the full appreciation of its benefits and limitations, how I counsel my daughter in this regard remains an unanswered question. I love what I do, but I love my daughter more.

And I think that will be only contribution I can make over that which my mom gave me; do something you find meaningful, but know that nothing will mean as much as your children.


s

s is a Hematology/Oncology fellow in California. She lives with her husband and two-year old daughter. She blogs at http://www.theredhumor.com/

Pregnant in the cath lab

There is no harm in being protective of your unborn child. There is no harm in speaking up for yourself when you have strong feelings about any subject. For heaven sakes we are in a healing profession- we should take care of one another too. We should make a pact- all MiM and MiM followers to steadfastly protect and promote the (physical and mental) well being of our gravid counterparts.

There is potential harm in overstating the risk of x-ray in pregnancy. At least from my perspective. Sorry for additional post Fizzy, I have too much to say for comment section. I really think you are on to something here, and I appreciate this discussion.

First to get this out of the way, there is a major difference between therapeutic (or diagnostic) radiation exposure vs. occupational radiation exposure. All physicians would consider using x-rays to examine or treat a pregnant woman. As long as the benefit outweighs the risk. Do you need dental xrays while pregnant- probably not. You have a serious condition during pregnancy, attempts will be made to use alternative imaging or minimize fetal exposure. The risk to the fetus is based on amount of exposure (may vary based on type of exam) and week of pregnancy. It would be a mistake to x-ray a pregnant woman without considering the fetus (therefore the questions and signs in radiology). Just because there are signs and attempts made to avoid exposure in no way means that it is absolutely contraindicated.

Here as Mothers in Medicine we are discussing occupational exposure. A classic intersection of personal responsibility and professional obligation with undercurrents of gender discrimination. We would all take a bullet (literally) for our children, our own safety/sanity is only a secondary concern. What are we willing to expose our children to- now that is a hot topic.

Fifty percent of Internal Medicine residents are women, yet only 14% of all cardiology fellows and a mere 7% of practicing cardiologists are women. We may be few, but as women in cardiology we are a serious bunch- and are concerned about why more women do not consider careers in cardiology. It is likely women are deciding not to pursue cardiology early- as med students or interns. Concern over lifestyle and radiation exposure during mothering years is likely a key issue.

Tackling the subject head on, two important papers are published in cardiology journals. The first published in JACC in 1998 (http://www.ncbi.nlm.nih.gov/pubmed/9525565) is a consensus statement for radiation safety in the cath lab. This year another consensus statement (http://www.ncbi.nlm.nih.gov/pubmed/21061249 ) was published by a group of women interventional cardiologists (now these are women who I seriously admire). I recommend that you read both if this issue affects you directly.

Here are important points I would like to make:
1. Fizzy's initial post upset me a great deal, it felt like a personal attack (unreasonable I know). I think this points to how intimate and heart wrenching pregnancy related issues can be.

2. Fundamental radiation science: exposure is proportional to energy emitted, inverse to distance from source, and subtracted by protective equipment. When pregnant I wore two layers of lead (my usual apron) in my first trimester then special pregnancy apron (even though it weighed 12 lbs-or maybe a TON) the rest of the time. I never let the fellows control the fluoro pedal and when able always took an extra step away from the camera. On occasion I took it as an excuse to stay far far away from the table, on a stool in the corner where I could rest my feet too, a bonus.

3. When I was a fellow one of my female attendings was pregnant. It really helped me to see her in this role. She gave me the best advice. Meet with the University Radiation Officer- this really helped to balance my fears with what is known about the risk.

4. The female fellows in my current program are not allowed to work in the cath lab during pregnancy. This takes the decision making away from them. I am not 100% behind this, only because it is really hard for them to find coverage for maternity leave already.

5. X ray is not the only source of radiation exposure. I learned from the Radiation Officer that my greatest risk would be during my nuclear cardiology rotation. Patients dosed with isotope emit radiation, and despite high standards areas of radiation can be present in the department. Always wear your badge when reading nucs, do not leave your lunch in the reading room and for heaven sakes do not do injections for stress tests or PETs.

6. The total amount of radiation allowed in pregnancy is 0.5 mSv per month and 5 mSv for entire pregnancy. This is 10% of the amount of radiation defined as negligible by ACOG guidelines (Obstet Gynecol 2004;104:647–651 ). Studies from diagnostic radiology in pregnancy show exposure below 50 mSv is not associated with fetal loss or anomaly. Other population studies suggest that exposure to 100% of the allowed radiation during pregnancy will increase the risk of having a child with congenital anomaly from 4.0% to 4.01%. The chance your child will develop cancer will increase from 0.07% to 0.11%.

7. It is difficult for me to compartmentalize my role as mother and cardiologist. It all runs together in an overwhelming way. Eight weeks pregnant, while taking progesterone for a fetus at risk I was inches away from the camera while doing CPR on a woman while my partner inserted a temporary pacemaker. I had lead on, but had not yet declared my pregnancy and did not yet have a fetal badge. That woman celebrated Mother's Day with her children last weekend. During my 2nd trimester I was exposed to acute viral myocarditis, amazingly 3 times where two of the three patients were killed. Suspected viruses can cause fetal hydrops. The surviving patient was a miracle and my ability to cure him was instrumental. My team knew I had ID consultation and special tests by Employee Health. They did not know I took a "time out" in the call room where I sobbed uncontrollably for 20 minutes.

I carried two pregnancies and worked in the cath lab both times. I checked my fetal badge religiously every month. Under my lead, over 18 months of pregnancy my fetal badge (s) summed total radiation exposure of <0.01 mSv, below the measurable limit, ZERO.

It is probable that women avoid their true calling into cardiology due to concern over the occupational hazard. It is possible those who do pursue cardiology still face additional obstacles based on current maternity policies (I think this is true of most of medicine). My experiences thus far have been challenging, and I hope we can make things better for the next generation.

Okay so you may now jump in to discuss. So let me have it, I imagine being crucified and accused of child endangerment. For the sake of full disclosure in addition to exposing both of my boys to radiation I also ate lunch meat, non-pasteurized cheese and even drank a glass of wine (or two) during my 3rd trimester. And if anyone corrects my writing/ grammar I will kick your ass.

Radiating Yourself in Pregnancy

Last week, I wrote an entry about things that bugged me from my pregnancy during residency. One thing that ended up being a bit of a topic of debate in the comments was the issue of radiation during pregnancy. Basically (in case you didn't read the original post), when I was in my second trimester, an attending asked me to hold a patient's head while they were getting spine X-rays, then seemed shocked when I was reluctant to do so.

I certainly didn't expect all the readers to be on my side, and I wasn't disappointed. A couple of people commented that they didn't understand the big deal, since I would be covered by lead. One person went so far as to say that she would never ever consider covering for a pregnant women who wanted to avoid radiation.

I don't think I'm a weirdo for worrying about radiation during pregnancy. Most attendings never asked me to do such a thing. When we were taking an X-ray at the patient's bedside, they immediately stepped in and ordered me out of the room. On another occasion, when I wasn't pregnant, I went down to hold a patient's head, and the radiology tech grilled me about whether or not I was pregnant, even going so far as to ask if I was on birth control. Another resident in my program had her schedule for the year arranged so she could avoid a radiation-intense rotation during her pregnancy, and I don't think anyone questioned this.

Of course, there isn't a lot of conclusive research about radiation exposure during pregnancy, since it's not like they're going to be doing any double-blinded randomized controlled trials any time soon. An X-ray, I've read, provides about as much exposure as a cross-country plane flight. I spent a minute doing a PubMed search before writing this and it seemed like the only thing they knew for sure is that radiation during pregnancy causes a lot of anxiety in mothers-to-be.

I think it's an important topic for women in medicine though. After all, a lot of fields do have radiation exposure. And a lot of us get pregnant. A friend of mine is currently pregnant and working as a Pain physician, performing injections under fluoroscopy. I know she wanted to get pregnant and deliver prior to that job in order to avoid the radiation exposure, but things didn't work out that way. Sometimes you can't avoid radiation during pregnancy. But if you can, should you make an effort to try?

At the risk of causing an argument in the comments, which y'all know I really hate, I'd like to ask the readers what their feelings are about radiation exposure during pregnancy. Do you think the anxiety is unwarranted? If you were pregnant, would you have held that patient's head during that X-ray (and the 3-4 other times it came up during my pregnancy)? Would you work as a Pain physician doing injections daily with an X-ray machine? Would you agree (or better yet, volunteer) to help a pregnant co-resident who wanted to avoid radiation exposure?