When the G's and P's do not Align

It was 3 a.m. on a Saturday night, midway through my intern year, when the impact of pregnancy loss first slapped me in the face. As intern, I was in charge of doing the paperwork for all those being admitted to the hospital that night. The last patient on my list was a pleasant 50 year old women being admitted for pelvic pain.

In my rush to finish the paperwork and hopefully get an hour of sleep, I began hammering her with my list of questions. I started with, what every good OB/GYN intern starts with, the "G's and P’s". G=Gravida, which stands for the number of pregnancies. P=Parity, which stands for the number of deliveries. Each piece of the gynecological medical record starts with this bit of information. Yes, OB/GYNs start first by judging the ability of your womb to accept and carry a child.

“How many times have you been pregnant?” I ask hurriedly, pencil in hand.

“Only once.. but … he didn’t make it.” She said, her voice shaking, with a single tear quickly wiped from her cheek.

I was taken aback, both by her response and my own. This loss had occurred years ago, yet still stung so deeply. That night I learned to ask this question more tactfully.

A couple years later, I learned another lesson in the pain of pregnancy loss when my own joy of conceiving was quickly mired by seeing blood stained toilet paper. My loss was early, but the pain was deep and real. Time has healed my hurt, but I am frequently reminded of the pain of loss as I am often the bearer of bad news. Sadly, miscarriage is extremely common and something I had dealt with on a regular basis, but I had not truly appreciated the level of loss experienced, until I was on the other side of the stethoscope.

Over the years I learned to look differently at the G’s and P’s on the medical record. My heart will ache when I see a G6P2, realizing the painful reality that the 4 losses must represent. I cannot fathom feeling your heart sink so deep with disappointment, not just once, but 4 times.

October 15 is pregnancy and infant loss day. A time to remember and acknowledge the loss and pain that occurs when the G’s and P’s do not align. For those of you who have have experienced this loss, I cannot say I know how you feel, for everyone processes loss differently. I can say that I acknowledge that your pain is real and I pray that in your journey, you find peace and healing.

-RH+, a 36 yo G2P1011

cross posted at http://thepregnancycompanion.com/

It's a Man's Man's Man's Excuse

I recently finished "I Don't Know How She Does It" by Allison Pearson, about an investment banker trying to juggle motherhood with a busy career. I spent most of the book thinking to myself, "YES! YES! That's EXACTLY how it is!" It actually made me feel better about myself as a working mother because at least I'm not jetting to Milan every weekend.

One of my YES moments when reading the book was when the protagonist was late for work because her nanny didn't show up on time, but she felt like she should use "a man's excuse" instead. Men aren't late because of sick kids or tardy nannies--men are late because of traffic or car trouble. And male bosses respect a man's excuse more than a woman's excuse.

Lately I've been forced to use the "sick kid" excuse a lot and I always hate it. I haven't used it as an excuse to not do work or not show up, but to explain why I'm being extremely efficient, skipping lunch, avoiding small talk, and postponing a few things till the next day. It's embarrassing for me and makes me feel unreliable. Especially when sick kid isn't miraculously better in one day and eventually requires a doctor's visit, then second kid gets sick right after. That's nearly two weeks of having to mumble excuses about sick kids.

It makes me feel like I'm seen as unreliable. It makes me feel like I'm being labeled as "that woman who's always leaving early because her kids are sick." It certainly doesn't make me feel like I'm going to get a raise or promotion any time soon.

But what else can I do?

My (grandmother's) legacy

Of all my family members, the one I'm probably most like is my grandmother on my father's side. Unfortunately, I wasn't that close to her and only realized this years after she died.

My grandmother was a teacher and she loved to write. After her death, my father came across a bunch of clippings from articles she had written for her condo newsletter. If she had been around now, she totally would have been a blogger, I can tell. Her articles were all the sort of "reflections" that make up the typical blog entry.

My father told me he thought it would be a nice tribute to her to bind the articles in some way and distribute this to her relatives. I told him to let me take care of it.

Over the summer, I scanned in her articles, formatted them, and published a 100-page book on Lulu that looks exactly like a real book. Then we distributed copies of her book to all her grandchildren and other relatives.

It brought me great pleasure to do this. I know it's what she would have wanted because it's what I would have wanted. When I blog, I have this fantasy in the back of my mind that my children or even my grandchildren will someday be reading my totally brilliant insights. I was doing it for her, but in a way, I was also doing it for me. If that makes sense.

People who fancy themselves as creative types like to have a legacy of themselves in print. This book is her legacy, even if she never actually knew about it. And here's one of my legacies:

A book of my own

I think it's kind of amazing that companies like Lulu allow people like me and my grandmother to sort of live out our fantasies.

Teddies and Elephants and Tears

Today I had one of those unexpectedly gut-wrenching experiences, as I was waiting for the elevator on one of the medical floors, the one that looks out onto the Helipad.

I’m always amazed that the pilot can land a helicopter full of bustling paramedics and a (usually) severely injured patient on this relatively tiny piece of rooftop. I had finished rounding on our inpatients, and I wasn’t in a hurry to get anywhere, so I walked to the window, and watched.

It was a beautiful clear day, and the large window is fairly close to the landing pad. The helicopter had just landed and the crew was pulling out the stretcher. There was a carseat on it, with a very awake and scared toddler strapped in, clutching a teddy bear. He wasn’t crying; he was craning his head this way and that, looking around, probably for his mom or dad, but it was only uniformed crew members around him. I could even see that his teddy was kind of worn, and lopsided, like it’d been washed. As the crews started wheeling the stretcher towards the doors, the teddy started to fall, and the toddler frantically grasped at it; there was a flash of panic in his already terrified eyes. But a crew member stopped the stretcher and planted the teddy firmly in the boy’s arms, before continuing, and the boy clutched at that teddy for dear life.

In the space of those few seconds, I not only wondered, I wanted to know how hurt the toddler was, or if he’d been airlifted as a precaution, or where his parents were? What happened, how bad was the accident? Were his parents OK?

And I thought of my toddler at home, just starting to get attached to his own Teddy; just starting to realize when we leave and when we come home. Lately he cries around strangers and clings to us… I imagined him in a carseat strapped to a stretcher and airlifted to a rooftop trauma center somewhere. Would a crew member be so kind as to make sure his Teddy didn’t fall out of his arms? And I pretty much almost lost it right there. My eyes blurred with tears, and I would have started bawling, but the “ding” of the elevator arriving made me pull it together.

The elevator doors opened but I still watched as the crew wheeled the baby in the carseat out of sight, my eyes welling with tears.

Then I realized that there was lady standing inside the elevator, waiting for me to get on; I think she was kind of annoyed. I also realized that I looked like I was about to cry. I felt the need to offer some sort of explanation, so as I stepped on, I murmured, “Sorry, the helicopter just landed, and it was a baby.”

“Oh!” she said, her face softening. “Oh, that is very sad, you always wonder what happened…” and when she got off, she smiled and said, “Take care.”

All day the image of the baby in the carseat, the flash of panic, the grasping for teddy, the crew member placing the teddy in his arms… all day this has been with me and all day I have been just on the verge of tears.

And at the end of the day, as I was walking to my car, again thinking of this, and reflecting on how lucky we are, and how anything can happen to us at any time, I saw elephants. I mean, real elephants.

Apparently, the circus is in town, and they were unloading the elephants from the trucks to the stadium. The stadium is right near my parking lot, and I got quite a show: Three elephants marching up the long ramp to the delivery bay, each one holding the tail of the one in front of it with their trunks, so adorable. They weren’t very large elephants, must have been Indian elephants, if I’ve learned anything from Animal planet.

There were many people who had stopped to watch this spectacle, including some moms with babies in strollers. And I again thought of my toddler at home. He would have got such a kick out of this. He loves animals. I teared up again, but this time a smiling-tearing-up.

Someday, I thought, we’ll take him to the circus. That we can do.

I am, too, committed (or maybe I should be)

I’ve been away for a while now, birthing, or perhaps mid-wifing, two books. For me, editing seeps into writing and rewriting for others, to the point where I am not sure whether I wish I’d said that, or I did say that. What on earth was I thinking, involving myself in two projects with competing deadlines, and then volunteering to write an index?

Now that everything is in the uber-editor’s inbox, I can blog again. It feels like when my last child got her driver’s license and could get herself to school on her own, or when my first child finally slept through the night, or the day they all were in school for a full six hours, or the first weekend that they all went to grandma’s, or…

Here is what I didn’t have time to write in May: At graduation, I again heard the speech about putting patients first, sacrificing ourselves to medicine. I could see all the graduating students, especially the women, looking vaguely shifty-eyed, wondering what those exhortations would mean to them and their hopes for a full and balanced life.

I think beyond valuing the contribution of privileged males, medicine suffers from its institutional history. The structures of medicine and medical education are eerily like those of the Catholic Church and the military—institutions in which celibate young men with great physical stamina have the greatest value in perpetuating the institution. I do believe in the value of altruism, selflessness, and commitment—but I also believe these can be expressed in many contexts. When I am in the office, I will do for my patients whatever I can, above and beyond what they pay me to do. When I am on call, I stay late. But I do not think that I am any less of a dedicated professional (a word originally applied to priests) because I also worked part time for many years while my children were younger, pursue hobbies now that they are grown, and comfortably wear many different hats and uniforms, depending on the day.

I wish that just once the graduation speaker would say this out loud—it is, after all, what all of us, men and women, really do and mean in our lives after training.

I Have A Dream...

Writing this post, I am sitting in a luxurious hotel room half a continent away from home. Well, actually, this city was home for six years. It still feels like home, in a strange way, whenever I return and drive around its streets for a day or two. This is so, even though it's been ten years since I left. Ten years...

This was an exciting place to live. I remember driving here in the moving van, young and idealistic, freshly married. I bought my first house here, had our first (and only) child. I learned my craft here, entered the fires of neurosurgical residency. After six years, the crucible decanted me into a busy, thriving private practice in my original hometown. Now, I am part of the storied history of my training program, one of only four women to graduate, one of many well trained neurosurgeons this city has disseminated across the front lines of America's hospitals.

I am proud of my training program and its history, its traditions. I am humbled by and deeply grateful to my mentors here. So, when the news came that my program chairman was retiring this weekend, I immediately rearranged my schedule so that I could be here for the celebration.

This man is one of the great names in neurosurgery. He is technically a master of complex skull base surgery. He has held the most august academic positions, has received international honors. He is, quite simply, one of the most brilliant men I have ever known. And yet, as he said in his speech last night, he feels that his greatest accomplishment is us, his residents.

We all have a dream that we spend a life to pursue. We work, we suffer, we make sacrifices - and we keep dreaming.

He said last night, "It's never been about me. It's been all about the residents, the education. Anybody who does this knows that teaching residents is like raising kids. The people I chose to go through this program are a reflection of me; their success or failure is my responsibility. It's been about teaching the next generation, making sure this program lives up to its tradition of greatness."

We were his dream, us and his own five kids and twelve grandkids.

At dinner, many of us had a toast to make, a story to tell. Mine was about a favorite memory from residency. We had journal club once a week, at 6:00 or 6:30 am, over breakfast. One morning, the topic was sports injuries. We reviewed several articles comparing different sports and the risk of serious neurologic injury in each. Ice hockey, soccer, baseball, basketball were all on the charts, but football was way up high at the top of the list. There was a huge gap between it and the next sport down. We spent 45 minutes seriously discussing the ramifications of this.
Then the room got quiet, and my chairman piped up, not having said anything up to this point. He stated cheerfully, "I like to play football." We stared. "Because I like to hit people!" he finished.

We must have laughed for five minutes!

At the end of telling this story, I mentioned that now I have a 13 year old son who plays football. Every time he takes the field, I think of my chairman and chuckle a little. I finished by stating, "Thank you for being the best possible example. You showed us all that you can be a neurosurgeon and be brilliant... but also be a real person, and a great guy."

We will remember our chairman, who could give the presidential address at the big national meeting and then greet us on a Saturday at the local IHOP, driving up for breakfast in his beat up gray pickup truck. We will remember how he always asked about our families, and how proud he was of the number of babies the residents had.

Cheers, doc, mentor, friend. You deserve all the honor and respect you have gained from us all. Your dream allowed us to realize ours. We will pass it on, and on. My dream will help my son realize his one day, whatever his turns out to be.

We all have a dream, probably more than one. That guy playing blues on his saxophone outside my window right now has one. Mine has been to succeed in the most difficult, and most rewarding, career that I could have imagined; to also succeed in constructing a happy, healthy family. We work, we suffer, we make sacrifices. We hold onto the dream. It may come true, or it may not. But in the end, we will know that we have given it our best.

Blood Bank Halloween

The Blood Bank always has some pretty interesting Halloween decorations. Last year they had gel blood dripping from the top of the main door. This year I was excited to see a bloody hand at the Blood Bank blood product distribution window. The window is kind of like a fast food restaurant window - only it opens bottom to top instead of sliding sideways. I imagine it was designed in the 1960's. This morning when I went to take a photo of it for this blog that was marinating in my head, I was upset to find it missing. I wandered into the blood bank.

"Where is that bloody hand decoration that was in the window?"

A tech responded.

"Someone complained. We put it on the patient specimen refrigerator."

"What? It is fabulous! Who complained?"

"I know. We were upset too. We think that the patients over in fast track ED waiting area, the ones who use the lab bathroom, got upset when walking by it."

"Well, maybe an ED patient might find a bloody hand distasteful. Oh well."

I started to take a picture of the one on the patient specimen fridge. It looked great - the door is glass and you could see all of the bags of blood behind the bloody hand. I worried aloud. "If I take the picture here, well, there are patient names. Someone might see them, if I show the picture."

The tech answered, "I wouldn't worry, they are so small, how would you see them? There is another one on the ProVue, but one of the fingers is detached."

Since this was for the blog, and I think maybe anyone could blow up the patient specimen fridge pic and manage to find a patient name with the technology available these days, I decided it wasn't appropriate. Big possible HIPAA violation. So I wandered over to the ProVue, and took this pic. I love how festive everyone in the lab gets on the holidays.

So now I have to tell a Blood Bank story. As pathologists, we supervise the Blood Bank. One of my partners has a Blood Bank fellowship from Johns Hopkins, so he is the main supervisor, but when we rotate as clinical pathologists on call, we take the calls from every section in the lab. Most calls from the Blood Bank are routine, for example, "We've got a 56 year old man in surgery. We are out of 0 neg. Can we switch him to 0 pos?" "Yes, of course."

Sometimes, though, you've got to play God, which is kind of scary. There are a lot of shortages of blood products, and when multiple clinicians are fighting over products for their patients, ones that we don't have enough of at the moment, we have to decide who needs them the most, and triage appropriately.

The last time I was on call, I got a call from a heme/onc doc. She is lovely and intelligent and gregarious, and passionate about patient care. We were fellows together at the VA, and she often called me to do fine needle aspirations to diagnose follow up lymphoma patients. So we have been a team for a long time, and are on cell phone basis, which is a step above pager basis in the clinician world. I was at The Pizza Joint on a Friday night around 7:30 with my kids when the phone rang. I immediately recognized the number.

"Hey, what's up?"

"I'm so sorry to bother you at dinner, but I've got a big problem. My nurse has been talking to the Blood Bank and they say they are out of platelets - won't have any until 8 a.m. I've got a patient that desperately needs them. Can we call Red Cross? Have some flown in from somewhere? He just got out of surgery and he's bleeding out."

When she said the patient name I immediately knew the history. I had been dealing with him all day with a surgeon, and knew he was pretty critical. "Let me just call the Blood Bank and I will see what I can do. I'll call you back."

I plugged my kids in with my parents and their pizza-slinging, college student, summer sitter extraordinaire, and stepped outside where it was quieter to deal with the problem. Called the Blood Bank, and talked to the head tech.

"Yes, we are out of platelets until tomorrow. But we've got two set up for a patient in the CVICU. And we've got some baby platelets."

"What is the platelet count on the patient in CVICU? Are they actively bleeding?"

"Moderate thrombocytopenia. No bleeding."

"Well, get those platelets for our post-op bleeding patient. And save the baby ones, too, in case we need them."

I knew, especially since my dad is a neonatologist, that most baby platelets are set up on a protocol and given at a certain platelet number in a baby as routine - they could most definitely wait until the next morning at 8 a.m., not being critical, in the vast majority of cases.

I called my heme/onc friend back, and told her what I had managed - that we garnered two units from the guy in CVICU and had some babies if we needed them. She sighed with relief and thanked me. I went back in to The Pizza Joint to finish dinner and pay the bill.

The next morning I was triaging bone marrows and lymph nodes - it was a busy Saturday call. I never get follow-up - but checked on the patient I had emergently triaged platelets to in the EMR (electronic medical record) and was happy to see he was still alive. I also checked on the guy I had stole the platelets from - I would be lying if I didn't tell you I had a tiny anxiety attack in the middle of the night that he actually needed them more than my bleeding guy and my decision had hurt him - but he was stable as well, and now we had more platelets, and everyone who needed them was getting them. My turn to breathe a sigh of relief.

There is a moral here. Give blood products! And please don't be offended by our lab Halloween decorations - we are a very congenial, if a little nerdy, lot. We mean well.

Being Nice

This weekend, I had an unpleasant encounter in the parking lot when I was at the grocery store. I shop at this HUGE strip mall, and there are probably at least a hundred spots right in front of the grocery store. I try to park a bit off the the side so that there won't be lots of people around.

Anyway, I parked off to the side, and there was an empty spot next to me, so I had the back door wide open while I tried to get the baby out of her carseat. So I'm getting her straps open and I hear this honk: a woman was trying to pull into the spot right next to me and she couldn't because I had the door to my car open.

Now the lot was nowhere near full. There were empty spots behind me. There were empty spots across from me. There was absolutely no reason why anyone had to have the spot directly next to mine while I was struggling to get my baby out of the car.

I kind of waved my hand helplessly and closed the door a little bit more. She went into the spot and pulled through to the spot in the next row (which she also could have gotten to by just spending two seconds driving around the row).

And then the woman, who had her window down, yells at me, "That's not very nice, you know."

I yelled back something like, "You have the whole huge lot to park in!"

It was sort of ironic that she said that to me, because I spend my life obsessing over whether I'm nice or not. I want desperately to be nice. I hold doors for people, I always brake to allow people make the difficult left turn out of the McDonald's by my house, I try to give money to charity, and I usually tip more than 20%.

At work, I make a huge effort to be perceived as "nice" by staff and patients. I try to smile a lot at people, even when I'm exhausted and not entirely feeling it. I write "please" and "thank you" in my orders. Whenever a nurse or therapist alerts me about something, I make a big deal out of thanking them. I want people to say, "That Dr. Fizzy is so nice!"

Of course, I worry that the fact that I am always conscious of making an effort means that I'm not genuinely nice. Maybe I'm just faking nice. Making I'm actually a jerk and nobody is fooled by my nice facade.

Or maybe I shouldn't let myself get so riled up by a crazy woman in the parking lot.

Guest post: The Mini-Me

Sometimes, I am jealous of my husband's relationship with our daughter. They play games I don't follow, tell inside jokes, and make up words. Neither cares if the beds are unmade, there is applesauce on her shirt, or if daddy hasn't shaved in weeks. They have the same goofy sense of humor. I have been described as many things in my life, both positive and negative, but "goofy" has never been one of them.

But lately their relationship has been strained by our daughter's insatiable interest in all things "girlie" - princesses, fairies, pink ruffles, dresses, dance shoes, jewelry, etc. My husband threw an adult tantrum when she refused to go to the park with him because she would have to take off her "dance shoes" ballet flats with rhinestones pasted on- a big no-thank-you to my mom....), which are not to be worn outside. We created that rule thinking it would limit her wear of the shoes, never anticipating she would instead opt out of playtime with dad. He threatened to throw out the dance shoes and all her dresses if she did not take them off immediately and come outside. Predictably, she burst into tears. Even though I know he is just upset that he could be losing his best little buddy, I got annoyed at what I judged to be a total over-reaction.

With Halloween coming up, my husband wanted to circumvent the possibility she would insist on dressing up as something he found unbefitting his exceedingly bright daughter. He proactively found and purchased this:

For some very muddled reasons- that I will attempt to clarify here- I think I would be more comfortable if she were to dress up as The Supreme Fairy Queen from the Land of Helpless Dimwits and Antiquated Ideals of Feminine Virtue than wear this outfit out on October 31. The fact that my husband will be out of town, leaving me alone to parade my daughter around the neighborhood dressed up as a mini-me, certainly isn't alleviating my discomfort.

And to be fair, I think I should mention that last year we dressed her up as an astronaut and the year before she was a zookeeper. At age 2 1/2, she takes swim lessons and Spanish classes. Next year we hope to start her in Mandarin and ballet. We have chosen to pay more for what we believe to be a better preschool. In short, we are exactly the sort of middle class people with high parental expectations to which this sort of merchandise is marketed.

So why does this costume make me feel so, well, squeamish?

I guess some of my unease is easily explainable. I know way too many physicians who dislike our profession, a profession that was chosen for them by their parents. I vowed long before I became pregnant that I would never pressure my child to enter medicine. If he or she wanted to go to medical school, they would do so with a more complete understanding of the life of a physician than I had when I made the same decision.

But there is just something about medicine that makes parents think "it will be good for her", just like Mandarin class I suppose, and results in some obedient little children being pushed into a career that is just too demanding when pursued on a parent's behalf. It is perhaps internally inconsistent that I am completely content to be the mom with the vocabulary flashcards but am emotionally tortured by even appearing to pressure my daughter into medicine.

I may not be a perfect parent (and truthfully, some days I am just shooting for "acceptable") but I hope to encourage my daughter to contribute to society in a manner of her choosing that that fulfills her emotionally and intellectually. If that isn't in medicine, than at least she won’t incur as much educational debt as I did.

And we might have found a solution to my mini-me misgivings. She is very excited about the doctor's costume, but wants to be a "dancing doctor". Since my husband will be out of town, I might just let her pair her coat and scrubs with those rhinestone encrusted shoes. And some fairy wings.


s is a heme/onc fellow in California. She blogs at http://www.theredhumor.com/

Dear American Board of Surgery (a rant that may get me in trouble...)

NOTE: The communications manager for the American Board of Surgery responded to the post below with an assurance that the leave policy for medical or maternity has not changed. The quotation below was sent to program directors yesterday which lead to the misinterpretation. I decided not to delete the entire post however because I think it still brings up relevant points about leave during residency. I apologize for any problems caused by the post but I am happy that the issue has been cleared up.

Today, after having a nice conversation with a fellow mom/surgery resident about trying to achieve life balance and how much we are committed to being surgeons, I went back to my desk to find this in my inbox:

“48 Weeks of Full-Time Experience Required. We require all residents to complete 48 weeks of full-time experience in each clinical year. No more than four weeks of time off is allowed per year, regardless of the reason.”

Now this is an amendment to the previous rules that allowed 46 weeks in some years for different reasons - illness, maternity leave, etc. However, apparently the almost exclusively male American Board of Surgery has decided that in 2011, the most progressive move for them is to make surgical residency even harder for women if they are crazy enough to want to have a family! Seriously! I own my choice to be a surgeon. I love it, I can’t imagine myself doing anything else. But I am also 31 years old, and I own my choice to have kids. I will do both, it is hard but it can be done. Women surgeons are a valuable and necessary asset to the practice of surgery and as a result of biology, many of us who would like to have children have to do it during training. I do not apologize for my desire to both be a surgeon and a mom. I will take my call and operate and do whatever. Is it too much to ask that I be given a remotely appropriate amount of maternity leave while forfeiting my vacation and any travel to meetings. Many residents already take less than 6 weeks of maternity leave just because they may have to fly to interviews and only have 5 or 4 weeks remaining. This new rule will leave women with 2 or 3 weeks of maternity leave. We would never ask a patient to perform the tasks we do 2-3 weeks post op. LEAD BY EXAMPLE!

be better, be innovative, be smart, be equitable, be accountable. This is ridiculous. Stop being unrealistic about reality. I will make a great surgeon. So will/do lots of women with kids and people who have to interview for jobs and present at meetings and would also like a week of vacation or who may just once need to stay home with a sick kid so as not to destroy the career of their spouse in order to meet your rules. Grow up ABS. Figure out ways to train surgeons more efficiently. We work 90 hours a week (yes, I said 90, 100, 80, 60 pick your number), we care about our patients, we care about being good surgeons - figure out a way to make that happen with humanity and 2 less weeks.

Childcare: A review

My daughter Mel (I feel she's old enough to have graduated from Melly) has experienced pretty much every kind of daycare environment. We've done it all and here are the fruits of my wisdom:

Nanny:

We found ours on craigslist (I know!) about 2-3 weeks before I had to go back to work after having Mel. I loved her. She cleaned, she was loving, and she didn't charge an arm and a leg (although some do.... the first nanny we interviewed, who had no references, wanted to charge $22/hour). Since we didn't have any other kids in daycare, we were able to shield Mel from germs for most of her first year of life. The nanny prepared all the bottles, and washed them after using them. She cleaned our house, which probably saved our marriage.

The big con is that when you have a nanny, you're at the mercy of her life. Our nanny couldn't work later than 5. Some nannies call in sick a lot. If she suddenly quit, we would have been screwed.


Family Home:

We switched to a family home when Mel was a year old because we needed longer hours than our nanny could provide. A family home is a very small daycare in someone's house, which is (should be) certified. Unlike larger daycares, there are much fewer kids (obviously), they are cheaper, and all the ones I called had no waiting list.

The family home we used had six kids aged two and under, and two adults. Mostly the kids played in a small room and there was a little playground in their backyard. I felt Mel was safe there and although she didn't get as much individual attention, she was older now and the socialization was more important, I thought. Kids who don't start daycare till three years or older seem to adjust poorly, in my experience.

I thought this was an absolutely perfect environment for a one year old baby, aside from the fact that she was sick almost continuously the first three months at the daycare. And so was I. The other con was that the hours were shorter than a large daycare (8:30AM to 6PM) and they closed for two weeks over the winter holidays. If my husband's hours weren't so flexible, we couldn't have managed it.


Small daycare:

After Mel outgrew the family home (and we moved), she went to a small local daycare with about 16 kids ranging from babies to age 4. I liked the closer-knit environment and the fact that I knew the name of every single child in the daycare.

There were several cons to the small daycare. First, the hours were again fairly short (8 to 5:30). Second, we had to prepare all of Mel's lunches (mostly mac and cheese). Third, we were at the mercy of the owner's personal life.... she closed down for three weeks every summer to take a vacation, leaving me to scramble for alternate childcare.

I had mixed feelings about the environment of babies along with older kids. It was nice for Mel, who likes babies. But for the babies, I worried about their safety when exposed to toddlers. And of course, there's tremendous potential for germs.


Large daycare for an older kid:

A year ago, Mel started a large daycare, run by a faceless company. OK, something about the fact that the teachers are constantly holding a large checklist of all the kids doesn't make me feel all warm and fuzzy, but there are definitely benefits to the large daycare. The hours are fantastic... occasionally, I've felt a bit of time pressure, but honestly, it would be pretty bad if I couldn't get to my kids by 6:30 every evening. They pretty much never close, even for blizzards. They provide lunches devised by a nutritionist. And Mel seems to really love it there. For an older kid, it's not even that expensive.

A few months ago, they started her in a kindergarten-type class of ten kids and one teacher, and it's been great for her. Yesterday, she recited The Pledge of Alloogin for me:

"I pledge alloogin to the flag, and to the 'public, al Obama and Erica."

(Sorry, I had to, it was too cute.)


Large daycare for a baby:

A month ago, we started Baby Lem in the same daycare that Mel attends. It's expensive for a baby, and I had my reservations, to be honest. I wanted her to have the same individual attention that Mel had as a baby. Also, I have to label and prepare all her bottles every morning at home and must bring home anything that is unused at the end of the day, which makes me feel like I'm running some kind of chemistry lab.

So far, I have not been unhappy though. Lem is kind of chill in personality, so she's tolerating the environment well. Also, because it's such a large daycare, they have a "baby room" with seven infants and two teachers, and she has her own assigned crib. They're very careful about hygiene: they use plastic gloves when they change diapers, and they don't allow shoes (or toddlers) in the baby room. Every time I come to pick her up, Lem is being held, and there have been only a few times that I've found her crying unattended. And now that we have two kids, I know it's impossible to shield her from germs. I'm not sure if I would have chosen them if Mel wasn't already going there, but I don't feel like it's a bad choice.


So that, in a nutshell, is our experience with childcare. Questions, comments?

Why do I have so much clothing??

This is a photo I took today of my side of the closet:

And this is my husband's side of the closet:

As my husband frequently asks, why do I have so many clothes?? And this doesn't even include all my pants (I have an entire dresser of pants) and non-work shirts. I never buy clothes. OK, I did recently buy maternity clothes, but I didn't have much choice in the matter unless I wanted to come to work with my stomach exposed. But I've gotten rid of those clothes and look how much I still have! Despite the fact that I feel like I wear the same 5-6 shirts over and over.

And worse, every morning I stare into the closet and think to myself that I have nothing to wear. I seriously do that.

Part of the problem is that I like to always pair a sweater with my work shirts because it's a little hard to predict whether the hospital will be freezing or sweltering. (It has nothing to do with the weather outside.) I usually look a lot like this:

So that requires me to have twice as many clothes.

But I suspect the bigger problem is that I can't ever bring myself to throw anything out. I save shirts until they're just about falling apart at the seams because maybe I'll want to wear them again. Or I save shirts that I hate (usually gifts) because I never wore them and I can't bear to get rid of something that's basically brand new. Or maybe one day I'll lose a lot of weight and be able to wear those pants again. It could happen!!

I know I've got to go through my closet and make some hard choices. I just can't seem to bring myself to do it.

Pseudonyms

I've been thinking about posting on this for a bit. Aliases, noms de plume, alter egos. We all have them for some reason.

When I started blogging as Gizabeth Shyder back in the fall of 2008, it was primarily out of fear. Fear of failing, fear of exposing my kids online. I was in a bad marriage and it was just a hell of a lot easier, and more comfortable, to be out there as another person. My real self, shrouded in a name I stole from a geek at Best Buy that set up my new laptop as Gizabeth Scheider. I thought the "y" was a lot cooler. I thought the name was much more interesting than my own. My kids were initially John and Sicily, but have since been changed to their real names, Jack and Cecelia (or Ce-silly, as she prefers to be called).

Within a few months of blogging I was written up in a local medical news rag. I let them use my real name, and answered something like this when I was asked about blogging under a pseudonym. "You are never really anonymous on the web, and I think it is dangerous to think that you are." I believe this wholeheartedly.

A recent comment thread on MiM got me thinking anew about aliases. I have no real judgment about them, unless they are used to talk negatively and scorn patients. Embarrassingly, I have followed some of these blogs, kind of like rubbernecking. I don't always approve but am sometimes entertained. As far as the comment threads, someone I love railed on an anonymous commenter who was full of negativity, recently. The commenter wrote back - basically asking what the heck is different about anonymity and having a pseudonym. Despite their negativity cloaked in anonymity, I thought what an apt observation.

Most of us on MiM are more comfortable writing under pseudonyms, using cute/false names for our kids, and I have never felt that uncomfortable feeling I do when I read about doctors judging patients here. These women are all pretty high quality. The fact that they choose anonymity doesn't detract from their posts, and I see that many choose it for different reasons, some similar to my original ones, some different.

I write about this in hopes of sparking a conversation about aliases. Opinions, and people's reasons for using them. Some women, like Michelle Au who I interviewed this summer, are completely kosher with using their real name (If I had a name as cool as Michelle Au - I would be sharing and spreading all over the web). But many other women are not. I personally see no problem with going either way, as long as you stay within the lines. By that I mean adhere to ethics, as each of us hopefully learned from our parents, and if not picked up in medical school. What do you think?

My personal statement

I just filled out my residency application. Ugh. Here is my personal statement:


At the last postpartum appointment following the birth of my second child, I wasn't worried for his future. I was worried for my own. I had just gotten my MCAT score and started the medical school application process when I became pregnant. I couldn’t decide if I was more elated or upset. I desperately wanted a second child, but my body and circumstances conspired against that desire for years. My seemingly perfect plan of having two children during premed, then entering medical school with them potty trained and ready for elementary school turned into a dream of having an only child and going to medical school.

Now I was holding a new baby, and my medical school application hung in the balance. Although I was happy my family was now complete, I came to medicine as a second career, and I was already an older applicant. I couldn’t imagine putting off school and residency any longer, and I wasn’t sure if I wanted to face the demands of rotations and residency with a toddler at home.

When I told the midwife of my fears, she said, “Why don’t you come to the midwifery school here?” I laughed and immediately refused. I had no interest in obstetrics. I wanted to be an endocrinologist. I thought it would fit my interest in having long term relationships with patients, with lots of opportunities for education during clinical visits.

But, over the next few months, her invitation kept resonating with me. I had loved my prenatal appointments. I read voraciously during my pregnancies, and found the material very interesting. I started the midwifery school when my son was three months old. Two years later, I thought it was the best and worst decision I had ever made.

I found out that I loved everything about medical care of women, especially during pregnancy and birth. I had the continuity and clinic experience I craved. I loved it even when I had been up for a day and a half. I loved it even when there were fluids and meconium and discharge. Yes, I even loved it when the women were screaming. Yet, I was unsatisfied.

The midwives knew it. I would discuss research and evidence. I would read about pregnancy complications that were outside the scope of a midwife’s practice. Although I loved the training, especially the extensive hands on clinical experience, I felt that I meant to be a doctor, not a midwife. I was the first to volunteer to go whenever there was a transfer to a cesarean section. I wanted to be able to do surgeries and advanced procedures. I finally had what I refer to as my “midwife crisis” and left the program to apply to medical school.

Despite being an older student, a working mother, and former midwife student, I was happy to learn I fit in and even excelled at medical school, preclinically and clinically. I was president of the obstetrics and gynecology interest group, and went to every ACOG Annual Clinical Meeting. I had dedication, a work ethic and time management skills earned from my diverse life. I won a research fellowship with a full tuition scholarship, and studied labor and delivery interventions for a year. The fellowship allowed me to work with CDC funded researchers, practitioners around the globe, maternal health care stakeholders, and academics. I also reviewed and contributed to the anniversary edition of Our Bodies, Ourselves, and various medical websites such as KevinMD and Mothers in Medicine, along with getting published in peer-reviewed journals. My hundreds of hours of clinical experience during midwifery training put me way ahead when I started rotations.

I am sure my clinical skills, intellectual capacity and endurance are up to the challenge and that I would be an asset to any obstetrics and gynecology program. I am eagerly awaiting the opportunity to shine. My last baby is now almost seven. My dream did come true - my kids are independent, proud of their mom, and can’t wait for me to be a doctor.

Guest Post: VIMP

When I was a resident on ICU, the staff physician mentioned that his mother needed an ultrasound. He asked the radiologist what the waiting list was like. This was in Montreal, so the answer was something along the lines of "Bad. Who's it for?"

"My mother."

"Oh, your mother! I'll squeeze her in."

"No, that's all right. We can wait our turn like everyone else."

I felt ambivalent, hearing this story. On one hand, I support a one-tier, publicly funded medical system, which is not the majority view among my more verbal friends. On the other hand, I think that if I can assist one of my colleagues in any way, I will do it. Our health care system is so tight and this is one of the last ways we can make it more pleasant for someone ill.

This comes up in the emergency room all the time, of course. I will see a nurse's relative, for example, ahead of the waiting throng, and usually, at my hospitals, this is not such a big deal. We don't have the 14 hour waits. But one day I saw several people ahead of time and I felt uncomfortable about it.

Meanwhile, I kept trucking along until, at 19 weeks of pregnancy, I passed some blood clots.
I woke my husband up and said, "I think I'll go use the bedside ultrasound in emerg. If the baby's okay, I can still make my appointment Montreal." Bedside ultrasound takes approximately zero skill after ten weeks of pregnancy, just to check on the baby.

I felt the baby roll—or was that the beginning of a cramp? After a minute, I felt a kick. And then two more. But then I remembered more about second trimester bleeding.

I woke Matt up again. "I have to get a real ultrasound. In first trimester bleeding, you want to know if the baby is alive. But in second trimester, you have to start looking at the placenta. If it's a placenta previa or an abruptio placenta..." My bleeding was painless. Therefore more likely a previa. Ultrasound was not always diagnostic, but it would definitely help. Me sticking an ultrasound wand on top of my belly was not going to help. I couldn't tell you whether there was a bleed or not.

"You may end up on six months of bedrest," said Matt.

I waited the marginally civilized hour of 6 a.m. to call one of my hospitals. The emergency doctor, who is also my friend, said she could arrange the scan.

I walked in just over an hour later and the nurse looked at my belly and asked, "Are you still bleeding?" So the word had gotten out.

That made it easier for me. I didn't have to explain, just let her take my vitals and breathe in relief when another nurse successfully found the baby's heartbeat with the Doppler. I ended up writing my own ultrasound requisition and paging the tech, who was already with the first patient, but the next slot was free.
The emergency doctor talked to the radiologist, who agreed to call me on my cell phone with the results. And pretty much immediately afterward, the ultrasound tech was ready for me.

And the baby looked good! The placenta was less than 2 cm from the cervical os, so that probably explained the bleeding.

Before lunch, the radiologist called me and said, "The baby looks fine." He wasn't convinced that the placenta was marginal, based on the views he'd seen, but he concluded, "Good news."

This is Very Important Medical Person treatment. Scanned two hours after I called, results another two hours after that.

Is this right? Should I just meekly line up at the ER and wait my turn with the doctor? By then, it would be too late for the 7:45 a.m. open ultrasound slot, so I'd have to wait and see if a spot opened up later that day. Then I'd wait for the radiologist to read the films in order. Then I'd wait for the ER doc to get the results. I'd wait for him to tell me said results, either before or after he called the ob for an interpretation.

I know that's the "right" thing to do, in some people's books. But I don't see the medical system like that. I see it as a resource that I understand and need to maximize. So yes, I could have hung around. But then I'd be one more patient clogging up the system. In and out and we're all happier.

I'm not a star. I don't get the red carpet rolled out for me. Paparazzi don't follow me around and sell my photo for thousands of dollars. But when I need medical treatment, I have doctors and nurses who will help me get it as quickly and pleasantly as possible.

Is that wrong?

-From an e-book by Melissa Yuan-Innes "The Most Unfeeling Doctor in the World and Other True Tales From the Emergency Room."