Gestational Diabetes

(Note: I'm posting this story because someone requested it in the comments of my last post. I apologize if it gets long.)

I failed my gestational diabetes screen by two points.

For those of you not familiar with the screen, it’s a test during pregnancy where you drink this horrible, sugar drink and then come in an hour later to get your blood glucose tested. Considering I was seven months pregnant, not showing, and weighed only 116 pounds, I didn’t think there was any chance of my failing the test. I was so overconfident that I had some crackers right before I had the drink, to make it go down easier. (This was allowed, but probably stupid and likely pushed me over the cutoff.)

The cutoff my practice used was 135 and I had a blood sugar of 137. In some practices, a cutoff of 140 is used. And when I looked this up in research studies, in a woman of my age, race, and BMI, it is appropriate to use a cutoff of 140. Or actually, some say the screen isn’t even necessary in the first place in someone like me.

Now if you fail the screen, the next step is a three hour glucose tolerance test. You come in for a fingerstick and if that’s normal, they give you a huge amount of sugar, do a venous draw for blood glucose, then repeat that every hour for three hours. I did not want to do this test.

You are probably thinking to yourself, “Why is she being such a baby? It’s just four blood draws.” That’s exactly what I’d be thinking if someone told me that story, believe me. I’ve had like a billion blood draws in my life and I’ve always thought of it as no big deal… needles don’t bother me.

Except for some unknown reason, my ob/gyn practice gave the most painful blood draws known to man. Now I can deal with short-term pain, no problem, but on two separate occasions of having my blood drawn at this practice, my arm was basically incapacitated. The pain in my biceps was so bad that I was actually awakened during the night due to pain. I could barely move my arm to drive and I had bruises going all the way up to my deltoids. And the pain persisted for over a week. Both times! Their phlebotomist was obviously not the greatest.

So I wasn’t thrilled by the idea of having four of these blood draws in a row at that practice. (The only other place they’d do them was at a hospital a million miles from my office.) My job involves a lot of writing and I was terrified by the idea of my arm being taken out of commission. I was literally in tears at the thought of being unable to function or sleep due to these blood draws--blood draws that I felt were basically unwarranted given the fact that it was so unlikely that I had GD. If I felt the baby were in danger, I’d have done anything, but it seemed more like this test was being done so they could cover their ass.

Anyway, I did try to keep a somewhat open mind. I felt if they had a convincing argument, I’d do the test. I went to my appointment for the 3 hour test at 8:30AM. I did the fasting fingerstick, which was 90. I asked if it would be possible to briefly speak to any OB at the practice about the test before doing it. Immediately the phlebotomy tech looked really put out, and acted like this was a ridiculous request that would take hours to fulfill.

About five minutes later, they miraculously located an OB that was between patients and she came over to talk to me. Except before I even opened my mouth, the doctor’s arms were crossed and she looked really angry at me for taking up 2 minutes of her precious time.

I explained that I was a doctor, that I researched the test myself and that I knew I was extremely low risk. I explained that research showed that with someone my age, race, and weight, testing wasn't indicated at all, or at the very least, a cut-off of 140 was warranted.

Doctor: [snippily] "OUR cut-off is 135."

I then tried to explain to her about how painful the blood draw had been at that office. They clearly went through the vein both times due to the pattern of bruising. I had been awake all night in pain. And then continued to have pain for a week after both times.

Doctor: [snippily] "That's impossible."

So I guess I was lying?

At this point, all I wanted to do was run home crying. Finally, I said I would do the test in fingersticks on my left hand.

Doctor: [snippily] "Fine, so I'm documenting your refusal to do venous draws!"

The phlebotomist was kind of cold to me after that too, possibly since she was the one who gave me the two painful draws. She started ranting about how she didn't know how to document my results. I felt like I had to apologize with every single hourly fingerstick.

I don’t know exactly what the doctor could have done differently. I would have preferred if she gave me an actual explanation of why it was so important for me to have the test, aside from just reiterating the cutoff. Or if she did agree with me the test was unnecessary, she could have nicely explained to me that she had to document a refusal, but admitted that I was very unlikely to get a positive result.

Anyway, three of the four fingersticks weren't even close to the cut-off. The fourth was below the cut-off, but only slightly. I was terrified the entire night that the mean doctor would call me and try to bully me into repeating the test and threaten to kick me out of the practice.

What did end up happening was that I had to call the next day (originally, they promised they’d call me, but apparently they wrote me off) and they got a different OB to speak to me. It wasn't my usual doctor, but it was one I had seen before and liked. He told me that the test was definitively negative. He didn't know what to make of the one borderline number, but said their glucometer tends to run high, and one abnormal value wasn't enough to diagnose GD anyway. He said to me, “I kind of remember from seeing you and from looking at your weight here… you’re pretty tiny, aren’t you? I really don’t think you could have diabetes. That test was probably overkill. Just, you know, eat healthy.”

(I then proceeded to not gain any weight for the next month because I was so nervous about eating carbs, and meat made me ill.)

Even though I guess it worked out in the end, the whole thing left me with a negative feeling about the practice. I felt uncomfortable coming to my visits and I imagined everyone was angry at me. Moreover, guess which OB in the practice was on call the night I went into labor?

So now that it’s all over and I’ve given birth to an average sized baby, you can go ahead and feel free to judge me and tell me that I sacrificed my baby’s health for the sake of avoiding discomfort.

Being a difficult patient

Especially since I'm a doctor myself, I hate being a difficult patient. I want to be the sort of patient who does everything the doctor tells me to do and never complains and is always healthy.

In some sense I've succeeded. As a mother, I don't call the pediatrician's office after hours more than once or twice a year. Aside from making appointments, I only called my OB's office once: while in labor. But I also feel like I should advocate for myself a little bit as a patient, and I worry that sometimes might cause me to be perceived as annoying.

For example:

At my last visit to the OB/GYN, it was noted that I had my last pap smear six months ago. As such, the doctor told me I'd need to come back in six months for my next annual pap.

Now don't get me wrong, I love getting paps. I love having to pay for them out of pocket due to my deductible, I love waiting an hour to get in to see the doctor, and the exam itself is pure enjoyment. I wish I could get them every week. But in actuality, the guidelines from the ACOG say:

Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years

And actually, the last doctor I saw before I moved a couple of years ago was a primary care physician who confirmed that I only needed to get this delightful test every three years.

So now I have two choices: I can either get an inconvenient and expensive test I don't need, or I can be that patient who shows up with the ACOG guidelines in my hand and explains why I'm refusing the exam.

The 4 Stages of EMR Adaption

Stage 1: Naïve anticipation

Last summer, as we began the process of choosing which EMR (electronic medical records) system that we would buy, I was filled with my usual optimism. Despite the naysayers, I was sure that our efficient office would have no trouble adapting from paper charting to computer charting. Above all else, I was convinced that Moi, ‘Ms. Computer Savvy Blogger' would love EMR. In the months leading up to the transition, I began to look condescendingly at our cumbersome paper charts and our 3x5 card tracking system for abnormal labs, as I anticipated their retirement. They seemed quaint relics, like cassette tapes or Ms. Pac-man machines. I could hardly wait for the charts to be replaced by information at my finger tips and the promised fool proof tracking systems that would improve quality, while making my life easier. Though my partners voiced trepidation about what we were to endure, I had little doubt that we would be paper free in just a few months. It would take work and there might be a few hiccups along the way, but I knew that if we put in the time and effort, the transition would go smoothly.

Stage 2: Adaption Angst

We decided on Greenway, a system that was specifically marketed for OB/GYN. Training was scheduled for early November, with the plan to ‘GO LIVE’ the following week. Leading up to our training, I (as self appointed EMR point person) had several conference calls with our trainer. It was during these calls that the first inklings of doubt began to set in.

Every question I posed to our trainer was answered the same way, “Oh, yeah, that is SUPER easy, I’ll show you next week.” Her voice was high pitched and bubbly, like an excited Barbie doll. While I was naïve enough to think that the transition would go well, I was not an idiot. I knew that not every aspect of EMR would be, as she repeatedly intoned to me, “SUPER EASY!”

Training week did not flow well. While we all did manage to learn the basics of charting notes and navigation of the software, any question outside of basic charting was met with a blank stare from our Barbie doll trainer.

“How do we order labs?”

Blank stare.

“How do we track labs?”

Blank stare.

“How do we fax?”

Shrug.

Things weren’t quite so “super easy” anymore.

She abandoned us after a two weeks. That’s when the fun began.

Stage 3: Self Pity/Anger/Denial

While I did learn the EMR fairly quickly, my biggest disappointment came in the realization that it did not make my life any easier. On the contrary, it added at least an hour to my day. Everything just takes longer.

It took us several months to figure out the extremely cumbersome tracking system for labs. I began to look longingly at the 3x5 note card boxes that I had previously scorned. It takes me 14 clicks to sign off a lab, IF ITS NORMAL! While it used to take two seconds to make a quick signature, now it takes 14 clicks. My nurse also has several extra steps involved with routing documents back and forth. If there is an abnormal lab, I then have to open multiple documents to decipher the plan, task it to the correct staff and turn on all the tracking mechanisms.

Home has always been my sanctuary, unless I was on call. Now I find myself leaving work before my charting is completed, so I can attempt to be home for dinner. After the kids are asleep, I dial in to finish charting. Home is no longer a safe haven. I really hate the fact that I can ‘work from home.’

I began to relish the last few paper chart patients. When I would see a paper chart in the door, I would get that giddy excited feeling, like when a patient brings in hot fresh chocolate chip cookies for you at three o’clock on a Friday afternoon. I realized that it is so much easier for me to remember the patient details by leafing through a paper chart, rather than clicking on 17 different documents in the electronic file. Paper charts were nostalgic for me. I would flip through and see the handwriting of previous employees; coffee stains of the day I was running late and the smiley faces I would draw on the lab results when a patient’s cholesterol finally came down or their Chlamydia finally cleared up. Paper charts are full of physical, tangible memories in a way that an electronic file can never be.

I felt betrayed by Miss ‘Super Easy”. Yes, the actual charting was not difficult, but it was time consuming and the orders tracking system was cumbersome. Most importantly, I didn’t HAVE an extra hour in my day for charting.

And did I mention the FOURTEEN CLICKS?

Stage 4: Acceptance

Slowly, things have become slightly better. I will admit that being able to READ everything is very much a benefit (the computer gets bonus points for penmanship!). Also when on call, it is great to be able to pull up charts at home to review the patients history while talking to them. There is no more hunting down prenatal records when someone goes into labor on a weekend. As patients come back for return visits, it definitely gets easier. EMR still adds time to my already packed work day, but slowly I am figuring out how to make it work for me.

It was the following encounter that convinced me that I had to truly accept EMR and stop my grouching about it:

Last week I was seeing a young girl for a check up before she left for college. She was having issues with her birth control pill and wanted to switch.

This is the type of encounter that makes me hate EMR the most. While in the room with the patient, I have to attempt to look through her old chart which is in a zillion different saved files in her new electronic chart. So as I’m clicking on each file, attempting but failing to find the one that tells me which pill she was on before this one, I make some smarmy comment about how I hate my new computer.

“That’s Ok,” she says in a slightly patronizing voice,” My Grammy is a nurse, and she has a hard time learning computer stuff too!”

At this point my jaw literally dropped. It took every ounce of self control to maintain my composure at that moment.

Ummmmm did she just compare me to her GRAMMY? I am 36 years old!

After a few deep breaths I regained my composure, found the file I needed and sent her on her way with a new script. Sent by e-prescribe, of course.

From that day forward I have vowed to never complain about EMR again. Not even the fourteen clicks. No its not perfect, but it is here to stay.

Every time I get frustrated and want to complain, I just take a deep breath, smile and whisper the word, “Grammy.”

Sexual Harassment in the Workplace

I think this is an important topic to discuss, one that is all too often swept under the rug. I recently had an uncomfortable encounter with a clinician in the doctor’s lounge – I work at many hospitals so think I can say this pretty anonymously. He introduced himself, and asked me immediately if I was married. The way he did it – body language and demeanor, mostly - made me physiologically recoil, but I quickly regained my composure.

He continued the “too familiar for someone you have just met” small talk, some of it bordering on inappropriate, until I found a quick exit when another doctor walked in the lounge and said hello to him. I said, “It was nice to meet you.” I turned around, pushed the green exit button, and walked out the door.

When I checked in with my female colleague he had mentioned during the interaction a few days later, it turns out she has had some reportable incidences with him. I could handle occasional randy attendings during residency – most harmless, but some encounters are just plain creepy. My female friend did not report this clinician we both had negative encounters with, but she did at least document them in case she needed to support someone else, as well as confidentially notify the Chief of Staff. We wondered aloud that if he treated his colleagues this way, how must he treat his subordinates. She vowed to draw a tighter line if she had another strange encounter. “I wanted to maintain professionalism at the first incident, but I think I will have to be stronger with my words if it happens again.”

I was bouncing all this off of one of my friends from medical school, and she said, “I had two reportable incidences in medical school. But I didn’t report them. I’m sure I told you. Do you remember them?” I remembered one – the attending that tried to hold her hand in the hallway all the time. Once he lifted her shirt and tickled her belly. Luckily that was toward the end of her rotation, so she didn’t see him again. But I did not remember the other, she never told me.

“I didn’t? Maybe not. Probably because at the time, that fourth year medical student reported that doctor that reached up her skirt and grabbed her leg, and she was being raked over the coals. I didn’t want to be ‘that girl.’”

So tell me, I asked. Turns out, in a late night OR, she was being harassed by a surgeon. While she was placing a Foley catheter, he would say, in front of residents, “It looks like you really know how to handle a piece of meat.” Another time, he was pulling a kidney out of a patient, and referred to its erect-appearing state. “I’ll bet this is exactly the state you like your dick to be in.” She told me over the phone, “That was the point I had to step away from the table and leave the OR. It was too much. My body reacted by burning, and my eyes even got a little teary – not with sadness, but with shock and anger. “

She remembered later to me on the phone that she did bounce that encounter off of someone – her then boyfriend. He encouraged her to report it, and they argued about it. She reasoned that she would be off of the rotation in a week and it would be a non-issue. If she reported it, it would be an eternal issue – one that might affect her career trajectory. Later in the year when another female in the class sought her out about her experience on that rotation – she was having similar issues – my friend assented that it was a problem and felt a measure of guilt in being silent, which may have played a part in the continued abuse. Not your fault, I told her, which she already knew, but still. This type of stuff is a Catch-22. I will be interested to read comments about the situation. I can see both sides of the coin, and we both realize there is no easy answer. There is a right answer - to report. But not an easy one.

My current encounter with the clinician was not reportable, but disturbing. I immediately bounced it off of a lab supervisor, and another one the next day. I don’t like these things to be ignored, as they are all too often. Women (and men, fewer for sure, but I do know that it exists) who are sexually harassed often feel guilty somehow, like it was something they did, and are too embarrassed to discuss the incidence. It is especially tough when you are in a subordinate position, under someone who is grading you. So it continues. Our societal reaction to women who speak up often reinforces our silence. It makes me angry.

I wondered aloud to a male colleague – one that we let into the loop for support - about the women, I know they are out there, that encourage this behavior. This colleague is conventionally handsome, I was certain he had experience in this arena. “Does the fact that some women encourage this type of interaction, out of some sort of need or desire, make these men think they can behave this way to anyone?” He assured me that no, it was still inappropriate. “You should gauge a woman’s reaction, her comfort level, to this type of small talk. If it isn’t there – you back off immediately.” I guess some guys don’t get this. No brain to mouth filter. The charge from the inappropriate interaction is enough for them to continue without reserve. Women can overstep bounds as well. My one reportable incident in medical school, one that I did not report, was perpetrated by a woman.

Both my female colleagues (current and med school friend) and I have pretty wide personal space boundaries around men. I do have a sibling relationship with a man at work I trained with – we have known each other as residents and now partners for over ten years. We can share silly sex stories we read – you know, not personal but Anthony Weiner type stuff that I might not talk about with most men – there is just an incredible comfort level. I am friends with his wife. I am finally starting, with my other male partners, to forge sibling relationships after knowing them for over three years. It takes a lot of time for me.

So I am posting this because I hope that some readers out there that may be in a situation they are uncomfortable with can know that they are not alone. It is OK to speak up. Or walk away. We do not have to tolerate this behavior, in the workplace. My friend and I have discussed our current inappropriate interactions with many male and female colleagues, with details, and have found lots of support. To quote Hillary, it takes a village. We can drive this behavior out of it, together.

I have sought and received the permission of both of my friends mentioned in this article to write this post. They have read it and are comfortable with what I have said. The older incident – ten years past now – contains more details, as it is in the past. The current situation is still too fresh to flesh out online.

Trying not to be "one of those" mothers.

CindyLou, believe it or not, is now 7 (going on 13) and Bean just turned 4 (!). In the days of old, when Mr. Whoo and I were uninitiated to hard-core parenthood and naive to the social rigors that exist in the suburbs, we concocted a wonderful fantasy that each of our children would select 2 different activities completely of their own accord, without pressure from either of us, and while we would always encourage them to finish out a season, we would never be "those parents" who pushed them to be "better, stronger, and faster." Ha. Ha. Ha.

Enter these last few months, where CindyLou chose cheerleading and tumbling (With or without a nudge from her mother? A former cheerleader, who always regretted a lack of formal tumbling training? Ok, probably a little nudge.) Bean chose soccer (pretty much of his own accord, well, that, and the fact that it is pretty much the only organized sport available for boys at age 3). We started out with the best intentions, and really, watching 3 year olds playing soccer is a bit like watching cats being herded on the field. Except, then Bean really started to *get* it, and then he got *really good* (for a three year old). Each game he would score at least a couple of goals, setting his own goal for each game for *at least* five goals per game. Then he achieved that goal, and all of the sudden, Mr. Whoo (assistant coach) felt like he had to take his own son out so other kids had a chance to score. The other parents would ask where or how often we practiced with him (exactly twice, right before the first game and then again right before play-offs), like they were somehow implying that we were driving him to his successes (we were not). It made me uneasy to have that feeling of competitiveness creep anywhere near my sweet 3 year old baby, who was just there to have fun.

Things were no better with CindyLou, sitting behind the glass with the other "gym moms." I did my best to fade into my chair while the other mothers, obviously veterans, systemically analyzed and subsequently ripped apart each girl in the gym, including their own daughters. Despite my best intentions, however, it completely stoked my competitive fire, and made me want to take CindyLou home and drill motions and practice flexibility for hours on end. How dare they judge my babies like that, and, indirectly, how dare they judge *me*? It is a strange new world, the world of competitive extra-curricular activities, where the parents are just as cruel and mean as the kids can be.

Growing up, for me, it wasn't this way. Parents did not hang around at our practices and activities and compare notes. I did tap at 5, piano at 8, softball and cheer in 4th and 5th grade, band (clarinet) in middle school, and cheerleading through middle and high school. Parents were only there for recitals/games. Maybe that made it easier to not be so fiercely competitive. I think this can apply to the academic setting as well, although, to this point, we have had no "real" report cards with As or Bs, just Ms for "meeting criteria." So tell me MiMs, how do you stifle your competitive streak and just keep your cool around other "tiger-like" mothers and fathers? How do we teach our children to be *their* best, without making them feel like they have to be *the* best?

Spoiled?

I was the daughter of a single mom who was also a student, so as a child, I always felt like we were living in poverty. Toys were something I got on my birthday and Christmas, and that was it. So when I was four years old and I saw this set of three identical blond-haired dolls of different sizes at the drug store downstairs, I knew I had no chance of getting it, even though I really, really (really) wanted it.

Then, miracle of miracles, I got the chicken pox and my mother bought me the dolls! It was totally worth being covered in pox to get that toy. I will never forget it.

My daughter is now four years old. She doesn't need to be pox-stricken to get toys. We buy her toys all the freaking time because she wants them and we can easily afford it. And as the only grandchild on both sides, her grandparents shower her with toys.

A couple of weeks ago, I bought a present (a pet shop dollhouse) for the birthday girl at a party we were going to and my daughter saw the present and threw a fit because she wanted it for herself. She even said she'd skip the party if she could keep the present. And in the back of my mind, I thought to myself that it wouldn't be so bad if we bought a second pet shop dollhouse and it would make her SO happy. Then I was disgusted with myself. What have I become that I would even consider such a thing?

That's the problem with being financially comfortable. You can easily afford to buy your child whatever toy they want, and in fact, it's easier to do so than to listen to them scream. It takes real self-restraint to say no. But every time I buy her something, I feel like I'm spoiling her and turning her into a person who doesn't appreciate what she has. There's no way she's going to look back fondly on most of the toys in her room 25 years from now.

Our resolution was to make a sticker chart on the wall, to allow her to earn the present by cleaning her room, brushing her teeth, etc. Since then, she's entirely forgotten about the pet shop dollhouse and now wants something called a pillow pet. (It's a pillow! It's a pet! It's a pillow pet!) But either way, she's going to earn it and maybe that will make it worth more to her.

MiM Mailbag: Third year med school schedule as a mom

Hi Ladies!  I'm an M2, and soon I'll have to put in my schedule request for third year rotations. I know all the theories about the best schedule as it affects your career. But what about your children? 

My son will be two when I start my M3 year, and he's never spent the night away from me (at my school, surgery is the only rotation with overnights). I was thinking about starting with the lightest rotations and working up to surgery last, so my schedule won't vary wildly every few weeks.  But does anyone have any suggestions as far as how it will affect him?  (or just tips on how to maximize our time together?  Or how to ease the transition from him having a mostly stay at home mom to having me be gone a lot more?)

Thanks! 
Sarah

This Won’t Hurt a Bit (and other white lies) - My Education in Medicine and Motherhood – A Book Review

I first heard of Michelle Au on Mothers in Medicine – saw that KC, our fearless leader, admired her blog. As an admirer of KC and all things MiM, I started to follow her blog over a year ago. I was not disappointed. Her mind is incredible, I envy her picture-taking abilities, and she is an endless font of entertainment and wisdom. She’s a hop, skip, and a jump away from my home in Little Rock, AR, and I enjoyed watching her struggles through the ice storm last winter as I flew into her current home Atlanta to visit my brother and sister at the end of their long icy convalescence. She drove to work bravely and safely, I drove to work bravely and safely. I feel a kinship with her.

I’ve been following the acceptance for publication of her first book, and stole away from work one day to buy it at Barnes & Noble toward the beginning of the summer. So when KC posed the question in Big Tent – that is our group discussion area for all the bloggers – “Who would like to read and review Michelle Au’s new book for MiM?” I literally jumped at the chance. “I do! You don’t have to send me a free copy – I’ve already bought it!” And so here we are.

The book is a series of vignettes that takes us through her med school experience, residency with major decision changes, and new path to motherhood. She is brilliantly funny, has enormous emotional wisdom beyond her years, and displays honesty and humility that brings the reader to the center of her journey, rather than preaching from a false ivory tower of medicine.

Art, music, and books are as important to humankind as serving others. They forge a common link by bringing out experience and emotion that we all share. Nowhere is this more real for me than sadness. There is a story in the book – I hate spoilers so I will be generic – about a pediatric patient she encountered in her training. Her description of witnessing a bedside interaction between the patient and two other children brought me to tears – they don’t come easily to me. When I collected my feelings to return to the book, I saw that she too collapsed in sadness at the nursing station, and I felt a strong connection, even though I don’t know her. That is what makes a great book.

I obviously enjoyed the book because since her path is so similar to mine, it brought back many memories from my training. One thing that was remarkable to me was watching her navigate the physician/physician parenting dynamic. She and her husband seem to support each other so well. Physician/physician couples have a higher than average rate of divorce – those who know me here know of my own experience in this arena. I asked her today in an online interview (swoon! I talked to her!) to give advice, which I think applies well to any home situation where both parents are working.

“Well, first of all I'd like to ask your readers to e-mail me any tips that they might have, because even twelve years into our relationship, we're still trying to work these things out. But I'd say that most important thing in a two-physician family is the idea of triage. On the whole, a family with two working physician parents is going to be strapped for time, and quite simply there is not enough time in the day to do all the things you would like to do. So just do the things you need to do and screw the rest. You need to spend enough time with your patients and do a good job at work. You need to feed and clothe and bathe your kids. You need to spend time with your family before bedtime, just goofing around and loving them. Everything else can wait. Triage.”

Love the medical parallel. Triage. Take care of your needs. I went to visit my best friend from med school, who recently had her second child. Her house was an absolute mess, but her family was happy. Taking care of your basic needs is most important when times are tough.

So I hope it’s obvious, I loved the book. Highly recommend. I might even go out on a limb to say that it should be required reading for all women interested in medicine and/or starting a family. I could go on and on, but then I would be telling the story. Of the book. And frankly, I think you should just go out and get a copy and read it. I have no financial interest in saying that. Incidentally, I also discovered in my interview that Michelle loves Chinese soup noodles. And she cannot write while listening to music (me neither!). She is super cool.

Not just us anymore

I had planned to write about my first post baby overnight call which occurred a couple of weeks ago. Long story short, I survived, hubby survived and my little peanut survived. I felt good to be back in the hospital and thankfully it really was like riding a bike, everything came back to me (FYI - I actually can’t ride a bike, but that’s another story). I may still write about it later, because I did gain some nice insights, however, now as I get ready for my next overnight call and a potential procurement call, I decided to write about this new feeling of accountability.

I have one more year left in the lab and I just started taking overnight ICU call twice a month in order to keep my feet wet. Last week I was asked if I would like to to cover some organ procurement calls as well. Initially, I wanted to jump at the opportunity (I’m interested in transplant surgery). However, when thinking about the burden middle of the night procurement puts on my hubby (especially with one car), I decided to table it unless they were really in a bind. Then, I kept thinking about it. And suddenly I was paralyzed about the thought of getting on a random, unregulated jet in the middle of the night with a baby at home. I’ve flown on a number of procurements in the past and I love riding in the jet. I love the free meal we get on the ride over, the much needed nap on the way home, and the urgency of getting organs back to help save someone who has been desperately waiting for them. However, now all I could think of was the danger of these jet journeys. What if I crashed? How could I be so frivolous with my life and safety? Even while on call, I find myself being a LOT more diligent about wearing my PPE and more being careful when putting in lines. A fellow resident is currently suffering on antiretrovirals after being stuck with an open bore needle of an HIV patient - one of my biggest fears. Now, these fears which were sort of trivial, in the background, part of the job fears have moved promptly to the forefront of my mind. I now feel as if I’m not just taking risks for me and my grown adult husband. Now the risks affect my innocent child.

I don’t really know how to deal with this new feeling of accountability. Specific to the risks of being a transplant surgeon (flying and Hep C) I plan to follow one of my husband's suggestions of finding Pauline Chen and asking her! (Yes, he, the non-medical one, knew about Pauline Chen!) I enjoy my work and I fully understood that there were some occupational hazards when I signed up. However, in the meantime, I wonder how others feel about the things we expose ourselves to at work and how that affects our children.

Guest post: Get your boots on

Last week, I was pleasantly surprised to see Sheryl Sandberg, Facebook’s COO, featured in The New Yorker. Considering her TEDWomen talk in December, and her recent commencement speech at Barnard College, she has been front and center in the effort to support women’s success at the very tops of their fields.

For those who can’t access the links, Sandberg’s main points from her TED talk are these:

1. Sit at the table; own your own accomplishments. Studies have shown that for men, success and likability are positively correlated, whereas for women, success and likability are negatively correlated. Women need to attribute their own success to themselves, even though there is a risk of not being liked. In her Barnard speech, she says, “[But] I know that the truth comes out in the end, and I know how to keep my head down and just keep working.”

2. Make your partner a real partner. Women still do twice the housework and three times the childcare as men, even though they also are working outside the home. In homes where responsibility is equally shared, the divorce rate is halved. “It’s a bit counterintuitive, but the most important career decision you’re going to make is whether or not you have a life partner, and who that partner is. If you pick someone who’s willing to share the burdens and the joys of your personal life, you’re going to go further.” (Side note: a recent article in Time magazine notes that women and men work about the same hours in the day, although women work more unpaid hours, i.e. in housekeeping and childcare. This is usually accomplished by the woman scaling back her paid hours.)

3. Don’t leave before you leave. It is so common for women, from the moment they even start thinking about having children, to start leaning back from their careers, sometimes without realizing it. “Keep your foot on the gas pedal until the very day you need to leave…and then make your decision,” says Sandberg.

I watch these videos of Ms. Sandberg, and wish she could have teleported herself through the last decade and shaken some sense back into the old college me. You see, I made the wrong career decision ten years ago, and the only reason was because I didn’t believe in myself. I became a nurse when I really wanted to become a physician. Even ten years ago, there was no question in my mind that I would have made a good physician, and no question in my mind that I would love, adore and provide for my future family. But I still feared becoming a mother in medicine.

So why didn’t I go for it? For years, my pat answer was that I wasn’t sure medicine was for me until I was well into my nursing career. Now that I can finally admit this to myself, I think the real reason went deeper than that. I chose nursing because I was afraid that if I chose medicine, my boyfriend might get cold feet, and I might emotionally damage my future children. I was afraid that medical school rejection could be the ultimate social suicide. I worried that my friends and family might judge me for “choosing career at the expense of my family” and turn their backs when I most needed their village around me. As Sandberg might say, I was simply afraid of not being liked—in the most extreme way.

But ten years later, I do have something else to say, and that is that I did go to medical school, I did marry my college sweetheart, and I do have two happy, well-adjusted children. I am surrounded by friends and family, and I have done well in school. The sky, in fact, has not fallen.

While I am so proud of the above accomplishments, I still find at times I still revert to my old ways. I apologize for everything—for taking 20 minutes to pump breastmilk on clerkships, for passing off daycare duty to my husband, for not knowing when I will get home. But here’s the kicker: I don’t actually feel bad about any of the above, and I don’t think anyone in my family even expects me to feel bad. They know it comes with the job. What I feel bad about is that I should feel bad and I don’t. It’s as if I’ve been conditioned to believe that worry is synonymous with love, and that constantly shortchanging myself is penance for wanting children.

This, to me, is the fundamental problem of women today. It seems like we have no faith in our social or professional supports to help us get done what we need to get done. We’d rather hide behind the façade of martyrdom than find a way to get what we need—and then we tell the next generation “I gave up my career because you can’t be a good doctor and a good mother” or “I had to work 100 hours per week, and that is the only way you can deserve this job.” And so we saddle the next generation of mothers in medicine with the baggage of choosing either success or likability. Again.

What if we women did something radical instead? What if we thought long and hard about what we really want and actually asked for it proudly? Maybe that means finally having “the talk” with your significant other. Maybe it means keeping the kids in daycare one more hour to get something important done. Maybe it means daring to ask for part time—or partner. Maybe it means saving your apologies for when you have actually done something wrong (and, ahem, it is not wrong to have a career and a family).

When I think of the two most radical things I have done in my life—applying early decision to medical school with a marginal MCAT score and asking the cute guy in my dorm to come swing dancing with me, I realize that they are two accomplishments of which I am most proud, because those risks have given me a thousand-fold return. What if, when it came to big decisions, we honored our id as much as we do our superegos? What if we not only made radical decisions but celebrated other women who dared to do the same?

I was a child in the 1980s, and the message to little girls was “you can be anything you want to be.” I still believe that. But I think our daughters need a stronger message: “You can be anything you want to be, on your own terms, and you deserve to be happy.” And when we live out this message, it won’t be in an aggressive, cold-hearted way, but rather our way—with kindness, creativity and collaboration.

I just got back from a U2 concert, and my ears are still ringing. The turning point in the concert for me was watching four men singing at the tops of their lungs:

“You don’t know
you don’t get it, do you?
You don’t know how beautiful you are!”

So ladies, strap on your boots. We are a new generation of mothers, and we are proud to have it all, and share with each other in our successes.

-scrubmama
mamascrub @ gmail-dot-com

******

So now it’s your turn, anonymous or otherwise: Tell me one way in which you have shortchanged yourself. Now tell me one way you might do something radical. What would you do if you knew you could not fail?

MiM Mailbag: Considering a medical career later in life

Mothers in Medicine:

I just stumbled upon your blog in my quest for information about later careers in medicine.  I have been considering a transition to nursing.  I am 32 years old, have never been married and haven't been a mother at this point.  However, I was wondering if you might have any information or resource suggestions regarding preparing and applying to medical school later in life.  While I am interested in nursing, I did not realize medical school could potentially be an option, that older candidates could be considered, and I would love to find more information about how women are doing this.

Thank you for any guidance you might provide - this blog is great!

B

Boards. Tomorrow. Ack.

Sorry I have been incommunicado, but I am taking my Step II CK tomorrow.



Wish me luck.

Practical advice for nursing mothers

When you announce on the internet that you're nursing your baby and need advice, women are only too happy to give it to you. However, I've noticed that the women most likely to give advice, the ones who frequent the breastfeeding communities, are the so called "boob nazis." They feel so strongly that breast is best, that even an ounce of formula is criminal. For example, a new mother I know was just "dropped" by her online breastfeeding mentor because she confessed that she started giving her newborn one small bottle of formula at night (for the sake of her sanity).

To me, this seems crazy! If you believe so strongly in breastfeeding, isn't it better to encourage women to at least do it part of the time, rather than reprimanding them for taking measures to make it more doable? I've gotten some ridiculously useless advice from women who refused to compromise their breastfeeding ideals. (i.e. When I started giving my daughter solids, I was advised to have her reverse her sleep cycle to spend most of the night awake so she could nurse during this time. Seriously??)

With that in mind, I'd like to offer some practical tips and advice for breastfeeding and pumping, coming from a working mother who believes strongly in breastfeeding but is not a "boob nazi." You can take this advice with a grain of salt, because this is just based on my own personal experiences:

1) Breastfeeding is actually not that easy. I was amazed how challenging it was the first week. Your nipples hurt, the nursing itself hurts, you get dehydrated, and you never seem to have enough milk. Don't give up after just one week. It gets way easier. Promise.

2) One (or even more than one) bottle of formula will probably not result in terminal nipple confusion or a sharp decrease in supply. Due to an ABO mismatch between me and my husband, we produce very jaundiced babies. They got bottles in the hospital. No evil resulted.

3) You are not a horrible person if you allow your partner to give the baby a bottle at night so that you can get a few consecutive hours of sleep and feel human. I resisted this for as long as I could with my older daughter and finally gave in when my health started suffering. It actually ended up being wonderful because it made my husband feel closer to the baby and more comfortable taking care of her.

4) You don't need to have five gallons of frozen milk stored up when you go back to work. If you do: awesome. But if you don't, it's not the end of the universe. Due to a variety of reasons, I had absolutely no stored breast milk when I returned to residency. Despite this lack of foresight and my daughter's monstrous appetite, she didn't get any formula at all for the first three months I was back at work. Obviously it would have been better if I had planned ahead, but I'm just saying that you can make it work.

5) Expect to hate pumping. I have yet to meet a woman who didn't find pumping really depressing.

6) If you're having a hard time pumping during your maternity leave, try pumping first thing in the morning every morning. Your supply will be highest then and the pumping will be most successful. Nurse one breast, pump the other. One 5 ounce bag of milk every morning for 11 weeks will give you about 400 ounces of milk, even if you don't pump any other time.

7) If you work standard hours at your job (Monday through Friday with most weekends off), your supply will probably decrease as the week goes on and be highest on Monday. Take advantage of this by pumping like crazy on Mondays and over the weekend. I used to nurse on Monday morning AND pump out 10 ounces.

8) Keep well hydrated.

9) If you feel you can't breastfeed and your baby gets formula, your baby will still be healthy and absolutely nobody will judge you except for a few nut jobs on the internet. When I was an intern, a graduating resident told me she couldn't make breastfeeding work because of her hem/onc fellowship. That woman was an awesome resident, a wonderful person, and I bet anything she is a great mother. If nursing is going to make you tired, cranky, and unhappy, and you hate it and are only doing it out of guilt... well, I just don't think it's something worth feeling guilty about.

Anyway, that's all I've got for now, but feel free to add your own practical advice. Hopefully, this will help some new moms or mothers-to-be.

Guest post:: Trying to conceive

Twice a day, during my typical 5am - 7pm style day, I sneak away to the bathroom with a little sealed packet.  In that little packet is a small white test strip.  I have a small plastic cup in my hand.  You can buy these little packets online -- 50 of them for about $10.  I  pee in the little cup and dip the stick, waiting to see what lines develop.  One dark line and one lighter line; nope, no LH surge.  Still not ovulating.  Then I wonder, for the hundredth time: is it my irregular schedule?  Is it the q3 call, even though it's home call, still tends to extend my work hours to the 80/week boundary?  Is it the stress of running an Orthopaedic Surgery trauma service?  Is it my complete lack of sleep?  I bury the little stick in the trash, hoping nobody notices it, and I rinse out the cup, dry it off and palm it, heading back to clinic.

I'm disappointed again today.  I do this twice a day -- looking for my LH surge, looking for a sign that I'm ovulating.  On my OR days, it's harder to test in that daytime window.  I usually manage at least one pee-in-a-cup time a day, though.  My cycles aren't regular enough for me to just count calendar days.  My basal body temperature pattern isn't consistent enough just to test around "expected ovulation" time.

When the two lines are the same color, I'll get home at around 7 or 8pm and try to coax some energy into my body in order to get some lovin' from my husband and work on this conception business.  Small windows in time where gettin' busy really matters.  Small windows of time in my life where I want to catch up on sleep.  In the 6 months we've been trying, there have only been one or two cycles where I was pretty sure I had an LH surge and I ovulated.  After those cycles, it was hard not to get hopes up.  Each time, blood in the underwear heralding menstruation left me disappointed.

Each morning, around 5am, I take my basal body temperature before getting out of bed.  All the temperature/charting folks say 3 hours minimum of uninterrupted, good sleep are necessary for a reliable basal body temperature measurement.  HA!  Have they ever met a surgery resident before?  My chart looks like a saw blade ... up down up down up down ... it's no wonder I can't figure out whether or not I've ovulated.  My OB/Gyn doesn't really know what to make of my temperature charts.  He tells me: "Sure, I'd love to say 'get more regular sleep,' or 'try for a more normal schedule,' or 'work on your stress levels,' but I was a resident once, too, and I know how ridiculous that sounds to you.  He's right - if I had a "normal" job, or a "normal" life, those would be reasonable suggestions.  I do what I can with the life I've chosen.

All of this is difficult, even though I've been off hormonal birth control and we've only been officially "trying" for about six months.  What compounds the difficulty, though, is that all this has to be kept under wraps.  Most women who start down the path of trying to conceive are, understandably, quiet about their journey, unless they have a kindred soul (who may also be trying) with whom to share their experiences.  Being a surgical resident just adds another level to the need for secrecy.

In my program right now, there are several male residents whose wives are pregnant.  All of those announcements were met with a lot of "way to go, man!"  "Congratulations!  When's she due?"  "Not much longer until she'll want #2, eh?  Too bad we've got residents' salaries!"  In my program, we average one woman for every 5 or 6 men -- and that's actually a good number, for an Ortho program.  There have been two women before me who had children during residency, and one woman in the class below me.  When they got pregnant, there were significantly fewer "YEAH!  Way to go!  Congrats"-type responses.  Instead, it was a whole helluva lot of "how much time are you taking off?"  "Wait, you're due during a rotation where you're q3 call -- who is going to cover your call?"  "We're going to have to book down that clinic for a month, aren't we?"  And while they were away on maternity leave - most of them took 4-6 weeks - there was definitely a fair amount of grumbling.  I found myself defensive for them: "If this were YOUR WIFE, I'll bet you'd be fighting for every single day of her leave," I'd tell the complainers.  The double standard still gets me.

And so I continue to sneak away to pee in my cup and look for signs that I might be ovulating, despite this ridiculous schedule and stress I put on my body, my mind and my spirit.  I'll deal with the double standard when I get to that point; right now, I'd just like to see two lines of the same color, and my husband and I will keep hoping.

-I'm an orthopaedic surgery resident on the west coast. No children yet.

Safe Landings

A couple of weeks ago, the kids and I went to Florida with some friends. It was an amazing trip. I didn't get to do a vacation with the kids last year - was so busy with divorce and house selling that it didn't happen. I realized, after this trip, how much we all really needed the break from life.

We flew into Destin/Ft. Walton Beach late on a Saturday night. While standing in line for a rental car to drive 2.5 hours to our final destination, the kids were running around the baggage claim area burning off energy. There was a big display of brochures advertising various activities next to the rental car desk. Cecelia (8), oops I mean Ce-silly - she asked me to change her blog name to a pet name her second grade teacher called her - picked up one on parasailing.

"Mom! I've always wanted to do this! Please can we parasail?"

Me, yawning. "Um, OK maybe? Let me look into it tomorrow." I still had the drive in front of me - unknown territory in the dark - and was a little anxious. I was thinking parasailing? Really? How had she even heard of this? I did it once back when I was 15 or so, but hadn't thought about it much since then.

We arrived safely around 2:30 in the morning and had a magical week with friends and lots of kids. Ce-silly was relentless about the parasailing thing throughout the week. On Wednesday I finally picked up the brochure. It advertised that kids 6 and up could participate, which put Jack (6) into play, if he was willing. More enticingly, we could all ride together. I called the place in Destin and they said they would reserve us a spot at 9:45 on Saturday morning, leaving us plenty of time to parasail and catch lunch before our return flight to Little Rock. Everyone else drove, so it would just be us three. Catch was to convince Jack.

"No way, Mom. I'm not doing that."

I explained the process to him, told him I had done it and he would love it.

"What if the rope breaks?"

"I'm pretty sure the rope won't break. Haven't really heard of that happening. I think you will be fine, but it is up to you. You can stay on the boat if you want, and I will sit with you."

Ce-silly has amazing lawyer-like powers of convincing and negotiation, and by Saturday, Jack was game. We boarded the speed boat and headed out of the bay to the open ocean. We listened to the instructions of the guides and got to watch a couple of people go before us and return safely, so Jack was excited when it was finally our turn. We harnessed up and sat on the front of the boat.

As the boat sped up, the rope loosened and carried us 800 feet up into the air. It was surprisingly quiet up there - I was in the middle of Jack and Ce-silly. Much quieter than on the boat where the motor competed with the 1980's music. Seagulls and pelicans flew by. We watched a plane carrying a bank advertisement in the distance. Jack turned to me in amazement.

"Mom, this is my dream! My flying dream. You made it come true. Thank you so much. I love you."

My heart melted all over my thorax, despite the fact that I worried I had peaked him out at age 6, and it would be all downhill from here. I noticed that his hands were clenched on the ropes.

"Jack, you can relax your hands, if you want. Sit back into the seat. You will be fine. Did you notice down below, how the sun is shining all sparkly on the water? It looks like diamonds, doesn't it?"

He nodded in assent. Ce-silly said, "Mom, I have to pee. I wonder what it would be like to pee 800 feet in the air?"

I laughed and told her - "Well if you have to, I understand. But hold it if you can - we'll find a bathroom as soon as we get off the boat."

"OK, I think I can hold it. Mom, you know what? This is the best 10 minutes of my life. Only I wish it was a little faster - might be more exciting."

Just then the boat slowed us down and dipped our toes into the water before taking off and carrying us back into the air. Ce-silly got her thrill.

We landed safely on the boat and snuggled up happily to watch the last two rides. Both kids and I were sitting serenely, dazzled by the experience. Maybe we'll go again next year. I had to pay $20 bucks for photo service, but for once, I was on the other side of the camera.

Here's to safe landings for everyone.