Call Hierarchy of Needs

Now that I am not on call, all day, every day, I have found there is a certain behavioral pattern emerging on my call days. Something similar to Maslow's "Hierarchy of Needs," if you will.

First Goal - Be able to leave the hospital. You may laugh, but some days it is d*mn near impossible to do. I am always figuring and re-figuring in my head if I am going to be able to go home that night, or if I will wind up being stuck until after office hours the next day.

*First goal bonus if I am able to leave the hospital before my children's bedtime, so much the better to actually *see* them.

Second Goal - Shower at home. This seems like an odd one, I know, but I *hate* to shower in the hospital call room bathroom. It just is not the same, and it also slightly squicks me out. So if I achieve the first goal, I proceed immediately to goal number 2 as soon as I step foot in the door.

Third Goal - Eat. This rule has stayed the same since residency, "eat when you can."

*Third goal bonus if I actually getting to eat with my family or if I am not eating something like Ramen noodles.

Fourth Goal - Spend (somewhat) quality time with family (while obsessively keeping one eye on the computer L&D and ER census for potential roadblocks to goal number five).

*Fourth goal bonus if I am able to tuck my children in for bedtime and maintain a normal evening routine before getting called back to the hospital.

Fifth Goal - Sleep in my own bed. This one is a bit more elusive, as you can imagine.

*Fifth goal bonus if I get to sleep in my own bed *all night long.* (HA HA! Almost never happens.)

**Extra bonus if I get no pages while I am sleeping in said own bed, and wake up the next day frantically checking my pager to be certain the battery hasn't expired. (Again, elusive.)

Let's face it 5/5 goals happens once in a blue (full) moon. If I am able to achieve 4/5 goals, I feel pretty good about my call night. Satisfaction with the night decreases exponentially with each goal not met, naturally. Before I am derided, of course my ultimate and overriding goal is to provide quality care to my patients...and to sleep in my own bed. :)

**Cross -posted at Ob/Gyn Kenobi

MiM Mailbag: Return to medical school?

Dear Mothers in Medicine,

Over the past month or so I have come across your blog and have become so interested in reading all of the wonderful stories and insight that you post. You might wonder how I came across it...well it's a bit of a complex story. After graduating college in 2009 I decided to pursue medical school. I really felt that I wanted to help people and work with children in my future, eventually enter pediatrics (at the same time though, I think I may have just fallen into this track as I had the "premed mindset" for a very long time). I gained acceptance and started medical school July 2011. Yet about a month into starting began to question my decision. Although I loved living on my own, and had a wonderful relationship with my peers and staff, I could not help thinking about my future and if it would really be anything but work-filled. On top of that I was being pushed to my limits, depleted really, and feeling anxiety and bouts of depression. By this past Christmas I decided to take a leave of absence to decide if medicine truly is the right path for me, as everything seemed to be spiraling in the wrong direction.

After being home for about a week now, my mind is more confused than ever. Is the stress/anxiety/depressive feelings something that will get better as school continues and I adjust? When I start practice will I be able to balance my career with family (mind you, having a family and being invested in them has always been my number one priority)? If I leave now, am I going to look back and regret this...but if I don't leave, what kind of impact is this going to have on my future health and family life? Would being a nurse practitioner satisfy me? Do I want to physically endure residency? And am I willing to sacrifice the next 7+ years of my life and give just so much of myself to a career when there are so many other things I yearn to invest my time in as well?

I know that ultimately the decision rests with me. I have tried speaking with others who have been through the same things as myself as well as those in the profession, but am still having a difficult time deciding whether returning to school would be my best option. It has been a difficult decision to even take a break from school as I have always been the overachiever who just pushes through no matter what-yet this was the first time my body made me take more drastic measure and really reevaluate where I'm heading.

Although you may not have the answers to all my questions I'm hoping that some of you might help shed some light on my fears and whether you ever went through any of this thinking. Looking back do you feel that this career has suited you well (family, health, lifestyle, and all other things considered) or would you have done things differently. Any advice would be much appreciated.

Look forward to hearing back from you all!

It's a Stressful Life

During our drive home, my daughter Mel requires a snack. So every day, I have to bring a bag of chips, some crackers, or whatever leftover baked goods were lying around the nursing station for her to nosh on during the ten minute drive home. Sometimes I'll get something extra yummy and I'll be excited to see how happy she is. She even brags about the snack to her friends. "My mommy always has a snack for me in the car."

Yesterday I purchased a little cup of custard for her from the hospital cafeteria. I have always been a fan of custard and I thought she was going to love it. I expected lots of thanks and hugs and a happy drive home.

When Mel got into the car, I presented her with the custard cup. She looked excited and asked me to open it. She took one bite. "I don't like it," she said. "It tastes bad."

I tasted the custard and she was right. It tasted like cardboard.

"Can I have something else?" she asked.

Usually I keep an emergency snack pack of Skittles in my pocket, but I had recently changed coats, so I had nothing else to offer her. "Sorry, honey," I said. "We'll have a snack at home."

"But I'm SO HUNGRY!!!!" she wailed. "I'm going to get a rumbleache!"

"Well, what would you like me to do??" I retorted.

She didn't have an answer, but continued to sob as I strapped Baby into her carseat. I recently purchased a new coat for Baby and overestimated her size, so she's basically floating in this comically large pink coat. And because we're frightened into making the carseat straps ridiculously tight, Baby was screaming by the time I had her secured.

I started the car with both kids crying in the back seat. My blood pressure felt like it was a million over a billion. I considered maybe stopping for fast food on the way back, but really, the only stop I wanted to make was at my OB/GYN to get sterilized.

I don't like stress. Stress stresses me out. While I adore my kids more than anything, it would be so nice to be able to take one shower without someone busting in on me and asking when I'll be done. It would be nice to spend a whole day in bed getting to do whatever I want to do. Something like that feels selfish, even decadent, to me now.

For a brief time, I was trying to do some meditation to help me relax, but in general, I just couldn't find 10 quiet, uninterrupted minutes in my whole day to do it.

The crazy thing is, I don't think I have that much more stress than the average mom. Yes, I work, but lots of moms work. Yes, I have two small kids, but I know lots of working moms who have three or four small kids.

Maybe we're all giant balls of stress. There's this woman I always see at the daycare who comes to pick up her three year old and her twin toddlers, and she always looks so miserable. Is it just a given that when you're a working mom of small kids, you're going to be constantly stressed out? Will I just not be able to relax for another 4-5 years?

final thoughts on last post

As my last post concerned what is arguably the most disturbing aspect of parenthood, perhaps it is appropriate to post, in bookended fashion, on the most joyful.

We brought home our newborn son five days ago. He is healthy and perfect. I am filthy and happy.

I will have to blame poor judgment brought on by the insomnia of manning a 24 hour milk bar for a brief sojourn into the well worn subject matter of writers far more talented by myself.  The death of a child is meaninglessly tragic and unfair and I can't imagine to where or whom one turns for solace. Perhaps the only answer to the question "why" is not truly an answer but a visceral response - to love and love and keep desperately loving the children that we do have. 

I think (and sincerely hope) this is the last time I post on this subject matter. While never forgetting, it is best to move forward and focus on the humor and joy of early parenthood. 

For instance - I am not sure if I should admit this (and again will blame the insomnia) but I was a little shocked by the appearance of my newborn son. His face was purple and squished. Flame colored stork bites stained his upper eye lids and the lower lids were swollen shut by two thick coats of vernix. His nose appeared to have been flattened in order to better accommodate a large crop of infant acne (milia) that sat upon the wide tip. His cheeks sank below the level of his lower jaw, giving the appearance of an edentulous old man. 

The last few days have revealed him to be a reserved little man who doesn't do much in the way of complaining. His emotional range seems to oscillate between boob? and BOOB! I know this range well as I have spent near every waking minute of the last five days staring at him in an almost spellbound fascination. 

I was immediately, and continue to be, deliriously in love. 

Mis-Match

I have a friend, another MiM, who is nothing short of inspiring.

Born in the former Yugoslavia, she was raised in Germany and ultimately went through medical training there. Like all of us, she has stories to tell about her specialty, OB/GYN, that range from hilarious to horrifying. Like us, she has a family - two children, both born in Europe during her medical career. Although training in Germany, as in the US, was demanding, she found the time and courage to return to her home country for a short time during the Balkan War. She worked on casualties in a hospital there while bombs dropped in the distance.

When her husband wanted to accept a job offer in the US about 6 years ago, she didn't hesitate. She dropped everything, including her career, and helped organize the move to a different continent. She supported her children, who didn't speak a word of English at the time they arrived. Since then, their family has thrived. Her son and mine play ice hockey together. We are both now rearing teenagers and commiserating about their lack of frontal lobes!

She did all this thinking that eventually she would resume her career here in the States. To prepare for this, she passed all the USMLE steps and met all the criteria for the match. I remember when, more than 2 years ago, she asked for my help in preparing her personal statement. Having fortunately sailed through my own match as a newly minted American grad, I thought, "Boy, this should be easy - who wouldn't want such a brilliant physician in their program, one with such a broad range of experience?" I'm sure she thought, "I've been through OB/GYN residency, a war, and a move to a different continent - how hard can this be?"

Boy, were we naive.

Since then, my friend has been through two matches without even a single interview. She has done research in an academic GYN lab and is published as a result. She spent a summer in the Himalayas doing medical mission work. Despite everything she tried, she had no success.

I am astonished at what I have learned through her frustrating experience. At the two hospitals where I work, I frequently encounter physicians who are foreign medical graduates (FMG's). Because of this, I assumed there were plenty of opportunities for all comers. Not so.

Speaking to two different residency program directors, I heard the same story. These days, it's all about year of graduation from medical school. If you are more than 2 years out, your application is not even considered. It goes straight to the trash - American or foreign grad.

The other factor is the competitiveness of the market. With the economy in its current miserable state, applications to med school are through the roof. Med schools, seeking extra tuition, are expanding the number of spots available. New med schools are opening in response to the perceived worsening shortage of physicians. However, residencies are not adding positions - they are federally funded, and there is no extra government money for expansions.

This translates into lots of applicants for available residency spots - brand new, shiny American graduates. One program director told me that by 2015, there will be more American med students graduating than there are residency positions to be filled. She said, "At that point, we won't even be looking at Carribean graduates, much less FMG's. If she doesn't find a job by then, she's doomed."

Wow. I had no idea.

We hear a lot in the media these days about the projected national shortage of physicians. We are all concerned about this. How will it affect our jobs? How long will our wait times for new patients become? Who will take care of us when we (or our family members) become ill? How will we divide work with physician extenders?
If this shortage is such a huge problem, why on earth are we shutting out an excellent source of new and yet experienced physicians? There must be hundreds of physicians like my friend, eager to work and already skilled in their fields of expertise. These are intelligent, productive people who will support their communities and pay taxes. If there are not enough residency positions available to accommodate them, why can there not be a parallel program tailored to bringing FMG's into the workplace? Perhaps an apprenticeship model would work...

(I do understand the concerns about FMG's. The American system is different even from Europe's, so it is hard for them to adjust. Language barriers can be significant, even crippling. The quality of FMG's is not consistent, so it is hard to know how much remediation may be necessary on the front end. If a physician has been away from training or practice for too long, the knowledge gap may be large. However, medical training is never easy with any group of students - these concerns are not insurmountable.)

Beyond this, I have concerns about future MiMs in particular. If date of med school graduation is a key factor in residency applications already, this means possibly catastrophic difficulties for women who want to take time off for pregnancies or to care for small children. Admittedly, 2 years is a long time, but it seems to me that even one year off could be considered a serious liability in this competitive climate. Add to that the pressure of student debt. What happens to the med students who cannot match, cannot get a residency position, but owe large amounts? With what means will they pay off that debt?

My talented, courageous friend is the canary in the mine. The difficulties she has experienced with the match process are a harbinger of things to come for many of those who seek to follow in our footsteps.


Encouraging note: My friend is now actively in a preliminary general surgery residency position. We are hoping that this will be the foot in the door that will lead to either a categorical surgery position or a primary care match for her.

Ode to Birth Control

Sometimes people write in to Mothers in Medicine with guest posts, asking, "Should I become a doctor?" Whatever the answer to that question is for you, the truth is that none of us would be doctors and this blog wouldn't even exist if not for one thing:

Birth control.

My great-great-grandmother had ten children. She wasn't so much thinking about whether OB/GYN or family medicine was the right decision for her. I don't know if she worked but she sure wasn't considering a career that involved nearly a decade of intense training. It wouldn't have been possible.

The earliest female physicians such as Elizabeth Blackwell were unmarried and didn't have to worry about children. Most women with any sort of career were unmarried. Being pregnant nonstop and caring for a brood of children makes it very hard to have a career outside the home.

I think it's easy to forget that up until recently, birth control wasn't a given. As recently as the 1960s, many states actually prohibited use of contraception. In 1965, the Supreme Court ruled that a Connecticut law prohibiting the use of contraceptives violated the "right to marital privacy." It wasn't until 1972 that the case of Eisenstadt v. Baird expanded the right to possess and use contraceptives to unmarried couples. That's only 40 years ago!

Think about what your life would be like if birth control wasn't available to you. What would your career be like if you had ten children like Great Great Grammy McFizz? And what if birth control was suddenly taken away from you? How would that affect your career and your family?

So I have to say a great big thank you to birth control. And express my anger that there are people out there, potentially in positions of power, who would like to take it away.

MiM Mailbag: Giving up the baby

Dear MiM,
Has anyone else had to temporarily give up their children in order to facilitate their career in medicine?

I am a junior general surgery resident a few weeks away from delivering my first child. The pregnancy was a surprise, but I am eagerly awaiting the baby. I wrote "I" rather than "we" on purpose- although I am married, my husband lives in another city, some 1500 miles away, where he is at the top of another incredibly demanding, long-hours, "mistress" profession. We did originally live together in intern year, but with my blessing he accepted his current position and moved away. It was shortly thereafter that we found out about the pregnancy.

I have had a dream pregnancy with absolutely no problems- no morning sickness, no cravings, no complications, a total weight gain of 15 lbs, and no stretch marks! My clinical performance has not been affected and I remain passionately committed to surgery- it is absolutely the right specialty for me.

Here's the problem: I have 4 wks of maternity leave. The baby will come in February, which means I return to work in March. My husband will get a month of paternity leave and spend it in my city, which he will take for the second month of the baby's life. This puts us through to April, but I will have 2.5 months of the academic medical year remaining. The hours of a surgical resident, it goes without saying, are not conducive to single parenting- how on earth could I arrange for nannies/ au pairs / daycares to cover 90hr weeks, weekends, night call, unpredictable hours, etc-- especially on a resident's salary? We have no family within 2000 miles, and no family members can take off 2.5 months to be the primary caregiver. So, we have concluded, the only thing to do is to send the baby away to be cared for by relatives, who will love and adore him and give him the 24hr, unconditional attention I cannot.

This arrangement will only be for those three months. I'm starting my gen surg research years in July, and the lab I'm entering will be in my husband's city. So we will all be reunited and normal again after a few months.

We have received a variety of comments on this arrangement, some of which are meant to be helpful ("don't do anything you will regret forever"; "you should sue your hospital;" "why can't you just take a normal 6 month maternity leave."). Many others are to the effect that I am an unfeeling monster who is a defective female and should never have children in the first place. Most people- especially at work- assumed that I would terminate the pregnancy, and were shocked to learn that was unequivocally not on the table. I won't deny that there has been a lot of guilt (my husband, who is unbelievably excited about being a father, feels a great deal of blame) and concerns about emotionally managing the separation, but we truly believe this is what's right for our family and our unborn son.

I was wondering if any other mothers in medicine have had to make a similar choice, and what their coping strategies were? I know, for example, many foreign-trained residents have to leave their children behind when coming to the States for residency. I would really like to hear some stories from people who have "been there," and not to feel so alone.

Thanks very much for the blog- I really enjoy it and its variety of perspectives, particulalrly the advice from the women in long-hours specialties.

Best,
L

In the Air

On December 26th a helicopter went down in Florida, taking the life of a heart transplant surgeon, an organ procurement technician and the pilot. Although the donor heart could not be used, the intended recipient was fine and awaited another donor match.

I heard the news through a text message from my on-call partner, interrupting me two stories into the bedtime routine with my 3 year old son. “A helicopter went down going to get a heart.” The heart transplant community is a small one, this news hit close to home. Often these procurement missions include multiple transplant teams (i.e. heart, lung and abdominal) with young surgeons in training riding along. I often send my fellows or students and have gone myself.

On a rainy night in September I drove along a narrow road on the far side of the airport. I was looking for the private hangar, and once I arrived I pulled into an empty parking lot. There was a dim light on inside so I grabbed my bag and headed for the sliding glass doors. I stood in front of the door and waved my hand but the sensor was not on. I knocked and a handsome man in a flight jacket walked over and let me in. I told him I was part of the transplant team and he looked at me skeptically. I wondered if I should have identified myself as “doctor”. I was the first one there so I sat in the waiting area and helped myself to some coffee and spiked it with hot chocolate.

The last one to arrive was our heart transplant surgeon. With the team complete we carried gear to the awaiting plane. The supplies were placed in the cargo area, but the cooler would ride with the passengers. I lifted it into the cabin, I noticed it was light and empty. As the heart transplant surgeon grabbed it from me his gaze held conspicuously on my belly. Even wearing scrubs I could not conceal the fact that I was five months pregnant. He then climbed out of the plane and practically lifted me up into my seat, he was sure that I did not miss a step.

Once we were strapped and secured into our seats I studied his face and could tell there was something on his mind. I met his glance confidently and smiled slightly. He shook his head, “Do you know how dangerous this is? An entire team from Michigan was lost a few years ago. You know, I am a pilot for fun, and know a lot about aircraft. These guys are good, really good I make sure of that. You must always insist on safe transport. Never go in a prop plane and never let them take you in a helicopter.”

I took in his advice, committing it to memory. As we taxied in the darkness my mind considered the precious cargo including 2 pilots, 2 attending surgeons, 2 fellow surgeons, organ procurement specialist and myself. Then I thought of my patient that we were leaving behind, in the CCU on a balloon pump desperate for a new life. Finally, as we sped down the runway and I felt the first few bumps of flight I placed my hands on my belly and said a little prayer. To the hands of God I give the battle for life, miracle of healing and trust in His protection. The only tragedy that evening was the untimely death of our donor whose family gave the beautiful gift of life.

As the details of the accident in Florida unraveled I learned that I did not know the individuals involved. Not personally. But the event awakened the reality of how close we dance every day on the brink of life and death. Upset, I asked my husband to finish the bedtime routine and retreated to have a short conversation with my colleague. He summed it up perfectly when he said, “This job is humbling…. in so many ways.”

hello!

I spotted a small URL labeled "Mothers In Medicine" about a year ago, linked from the blogroll of a total stranger (as, let's admit it, most of them are...). I was excited for what can be described as only the most obvious reason - I am a physician and a mother and was looking for an online community comprised of other moms battling midnight pages and midday parent-teacher meetings.

It is difficult, for instance, to describe the emotional contortions required to function professionally in the darkest days of someone's life, then go home and play freeze tag and tea party with your children. As there are physicians who choose not to have children and mothers who choose not to work specifically to avoid having to compromise their ability to perform in the respective role of physician or mother, it could stand to reason that those of us who have decided to undertake medicine and motherhood might be doing so to the detriment of both.

And now having actually put into words my greatest insecurity - that as a doctor trying to be a good mom and a mom trying to be a good doctor I am not doing either very well - I have to say that aside from those occasional days when it seems as though I am actually being lit on fire, for the most part I am proud of my ability to do function in the two, sometimes adversarial, roles. 

Or more honestly put-  I am doing the best I can. I try not to think about it more than that as, by virtue of still being a trainee, there is little I can do to reshuffle my priorities. I tell myself that I am, and I hope you feel the same, one of the lucky ones - I have a career that expands my intellect and a family that expand my heart. 

So it has been a pleasure to follow this blog along and occasionally submit a guest post. We don't have the same specific experiences or opinions (although I have yet to read of anyone complaining about working too little...) , but are able to build a camaraderie around the monumental experiences of medicine and motherhood.

It would be ill-advised of me to try to summarize the state of modern motherhood in medicine, so I will just say, it's really good to be here.

(And please forgive all spelling and/or grammatical errors because, as anyone who as seen anything I write knows, I truly cannot edit.)

Guest post: Being a nursing mom on the residency interview road

Editor's note: For companion reading, see my op-ed column "America, get over breastfeeding hangups" from Tuesday's USA TODAY.


I have been blessed to be on maternity-leave since 3 weeks before my due date. My days as a new mommy consist of nursing, diaper changes, cuddling, singing, reading, video chat dates with my distant new mommy friends, sending daily pictures and and videos to my husband and Lil Zo's grandparents, and phone calls with my family. Similar to most other mothers, I chose breastfeeding as the method of feeding our baby in the prenatal period. I knew it was the best thing for Lil Zo, but after consulting several breastfeeding friends, I also knew that it would have its challenges. Thankfully, I delivered at a breastfeeding-friendly hospital and Lil Zo nursed successfully within minutes of our natural delivery. The feeling was bittersweet, I was excited that he’d latched but it was uncomfortable. His latch was perfect but it still hurt for at least a week as my nipples became accustomed to his vigorous sucking. In the neonatal period, he lost a few ounces, but quickly regained them with on-demand (often hourly) nursing for his first few weeks (I am soo glad that phase is over, growth spurts are an entirely other issue).

Now, at 11 weeks old, he and I have had a great time getting into our rhythm and he has even begun taking an occasional bottle from my husband when I am out running errands. Interview season threw a wrench in our well-oiled machine.  The weeks before my interviews began, I looked at my freezer milk stock and began to freak out. How much milk would he need? What would happen if I had to supplement? Would his sitter understand how to prepare the milk? After consulting a very nice woman with the La Leche League, I knew how much milk he would probably need. Thankfully, my family has been able to watch him and I haven’t had to rely on strangers.

Based upon the wonderful advice of the Pediatric Clerkship Coordinator at my home institution, I called each of my interview locations 3 weeks prior to my interviews to inquire about pumping facilities. Pediatrics is awesome!!! Everyone was very helpful and my worries about being a bother were quickly dismissed.  Thankfully my furthest interview was only 4 hours away and my husband was able to accompany me. Armed with my handy Medela Pump in Style and my briefcase, I began each day discussing pumping times with the interview coordinators. Although I wasn’t able to pump every 3 hours as is recommended, I was able to pump in the car on the way to and from the interviews, once in the morning, and once in the afternoon. My time pumping was also a nice chance to reflect on my interview day and have a brief break from smiling incessantly and coming up with impromptu questions. Thankfully, Lil Zo didn’t require any formula and remains an exclusively breastfed baby.

In my humble opinion, UNC Chapel Hill had the best pumping facilities. The Resident Call Suite provided a private room with comfortable chairs, a desk, and a sink. It was nice to be somewhat removed from the main interview location and to not have the Residency Director on the opposite side of a thin wall.  I am indebted to the many Attendings that I affectionately referred to as my “Pumping Godmothers” (note: I did this in my head and would never, ever tell them) who let me know that they too had had to pump during interviews, training, and now daily as they provided the optimal nutrition to their newborns.

Now that I’ve completed my first full days of pumping, I realize how difficult it must be for full-time working mothers especially during residency. What has your experience been? Are there any breastfeeding medical students, residents, or attendings who were able to exclusively breastfeed through the 1 year mark?


Mommabee is an upperclass Medical Student at a mid-Atlantic medical school who is interested in community-based Pediatrics and has a background in public health. Lil Zo is her first child.

Love of Reading

I've loved to read ever since I was a kid. When I was eight years old, I discovered The Baby-sitters Club, which I'm embarrassed to admit sucked me in and got me reading regularly. In grade school, I read like crazy.... kids books, adult books, whatever someone recommended to me and I could get my hands on. One time I read three library books in one day. It was my passion.

As I got to high school and both my school workload and my social life picked up, I didn't read as much. In college, I mostly read the books I was assigned in class. (Some of which were great... that's how I discovered Jane Eyre.)

When I got to medical school, I made a conscious decision: I wasn't going to read for fun anymore. I felt that if I was reading something, it ought to be related to my medical education. So I quit reading for eight years. It didn't feel like that big a sacrifice because I hadn't read something I really enjoyed in a while.

Then in my last year of residency, KC asked if any of us could review a book for this blog. I volunteered, and when I read the book, I remembered how much I used to enjoy reading. So I started up again.

Recently, I was reading an article about a woman who read a book a day for a year. This is not something I could ever do, for many, many reasons. Just reading the article brought on a bit of an eyestrain headache (I take frequent breaks to avoid this). But I was inspired by this woman's quest, and how her love of reading inspired a love of reading in her children. My daughter recently observed me reading and said, "How come you're not saying the words out loud?" Then she seized my book and pretended to read it herself. (This is why I don't own a Kindle.)

There's truly nothing like getting lost in a good book. Unfortunately, I've had to wade through some junk, but it's worth it for the good ones. I also joined a book club that's inspired me to read some stuff I wouldn't have read otherwise (e.g. The Help, best book of the year).

I haven't exactly read 365 books a year, but I've been keeping a reading list linked off my blog and it looks like I've read 43 books this year. I always keep a book next to me for when the baby falls asleep while nursing. If reading is something you love, you can always make time for it.

The 20 Stages of Pregnancy

1: Disbelief
"How did what we did that other night create a human life? Is that possible?"

2: Panic
"OMG, how am I going to manage a whole other person?"

3: Denial
"I'll bet my period will come any day now. 30% of pregnancies end in miscarriage."

4: Panic 2
"Oh no! I'm spotting! What if I lose the baby??!!"

5: Fatigue
"I'm so tired all the time. How am I going to manage a whole other person?"

6: Discovery
"Maternity clothes are so cute! Even I look good in them. And I love my Bella Band."

7: Emerging love:
"Aw, she's hiccupping. That's so cute. I love her."

8: Acceptance
"Pregnancy isn't bad at all! I kind of like it! And I get to eat everything I want!"

9: Anxiety:
"Oh god, I'm gaining too much weight. I need to stop eating everything I want."

10: Panic 3:
"I don't feel the baby moving. When I last feel her move? Oh god, oh god. I'm going to press on my stomach and bother her till she moves."

11: Weariness
"For the millionth time, it's a girl, and yes, I AM tired. Should I wear a sign on my chest?"

12: Disgust:
"Look at my giant belly. Nobody will ever find me attractive again."

13: Living it up:
"Let's go out to dinner since we won't be able to do it once the baby comes. Let's see a movie too. An R-rated movie."

14: Dread:
"I won't be able to do anything once the baby comes. This is so depressing. Why did I destroy my life this way? Things were so good before."

15: Cuteness overload
"Lookit these teeny baby clothes! So cute! I can't believe I'm going to have something teeny enough to fit into these teeny clothes!"

16: Fear:
"What if I need a C-section? What if the epidural doesn't wear off? Labor is going to hurt a lot, isn't it?"

17: Weariness 2:
"This baby needs to come out of me RIGHT NOW. I literally can't stand it another minute. I'm going to have sex, eat a jalapeno, and jump up and down till I give birth."

18: Nesting:
"OK, I'm finished cleaning the entire house, assembling the crib, and painting the baby's room. Now I'm going to finish writing my novel."

19: Acceptance 2
"You know what? Whatever happens, I'm good. The baby can come any time she likes."

20: Panic 4:
"Oh no, I'm going into labor! I'm not ready! This is going to HURT!!!!"

Oh, No! Mr. Elf!

I am sure you have heard of the Elf on the Shelf, haven't you? I have, and have been avoiding him for years. I first heard of him from my sister in Atlanta - the book/concept was published in Georgia, I believe, a few years ago - it took that state by storm. I vaguely understood the concept - that there was a tiny elf that moved around in the middle of the night, occasionally causing mischief and mayhem ("The boys were so surprised to find cereal all over the floor! Underwear on the Christmas tree!"). He reported back to Santa about how the kids were behaving. Kids were not allowed to touch him, only adults, or the magic would be gone. I am sure I am partially murdering the concept, having not read the book myself. To me it sounded like one other thing to have to worry about doing during the Christmas season, as if there wasn't already enough.

Then, this fall, at the kids new school, the author of Elf on the Shelf paid a visit one day. I got advance notice in the kid's folders with an order form. They were so excited, I would have been Scrooge not to have gotten them each one ("There has to be one at Dad's house, too!"). So I buckled, bowing to the marketing genius of the mother-daughter traveling team.

I struggled the first few days of December, but the kids were enamored. "Let's call him Fisbee!" At first I just moved him around at night and the kids delighted in who could find him first in the morning. But they wondered about the mischief, so I concocted various ways to make him devilish in the middle of the night. He made a mess with the cat food. He sprinkled glitter on the dining room table and hung from the chandelier. Despite their enthusiasm, they became a little scared, I think. Ce-silly took to closing her bedroom door at night, citing her fear of Fisbee walking around in the night while she was sleeping. Jack worried that the elf would abscond with his favorite possession, his itouch. I reassured them both, and wondered aloud if I should send the elf back to the North Pole. "No, mom, he's scary but he's really cool." Jack started to invent mischief based on his morning observations - "Look, he broke an ornament!" I replied, "No, dear, I don't think he is mean, I think that was our cat, Katybell. It was an accident."

I think a lot of parents use the idea of the Elf on the Shelf in an Orwellian Big Brother fashion, but my parents never did this to us with Santa, and I was reluctant to do the same. I believe one should be good for the benefit of fellow mankind, not to appease someone in fear of retribution or punishment. Ce-Silly took to writing messages to our Fisbee at night, and I responded in early morning fog, feeling like I was becoming her best elf friend or on an elf date. "What is your favorite food? What is your favorite color? Do you have a girlfriend? Will you please be 'notty' every night - Don't worry, I won't let my mom get mad at you." I resisted the temptation to reply with broccoli and black soot, cheerily proclaiming peppermints and eggnog and bright red - answers I thought would be popular with the kids. I told her I was too young to have a girlfriend. I told her of course I knew her classroom elf Pinecone and her library elf Snowflake - we all went to elf school together, and she was delighted to tell her friends the next day.

My "notty" (Ce-silly's adorable spelling) ideas were fading fast, so I was delighted one day to get a text from a friend of an elf making a snow angel. That morning, I covered the breakfast table with flour and left Fisbee in the middle, making a beautiful flour angel. The kids were so excited they took pictures with their itouches. I think Jack took 50 while I was cooking breakfast. That's when I decided this was worth it. It was making our lives fun. That day, I googled Elf on the Shelf ideas and was flooded with pictures on the internet of elven antics, for which I was eternally grateful. Elves battling superhero figures with marshmallows over Lego forts. I think I botched that one a little - maybe it was because we are from the South and my kids don't know about snowball fights or maybe it was because I used a tissue box and a snowman decoration instead of Legos and action figures, but they still enjoyed eating morning marshmallows. There were also elves ditching the stockings and putting underwear on the hangers - they got a big kick out of that one. Thank goodness for the internet.

One early morning I was staging a scene I had seen online of an elf fishing out of the toilet with a candy cane, ribbon, and goldfish. I was sure the crackers would dissolve into an unrecognizable shape by the time the kids got up in a couple of hours, so I grabbed a plastic witch finger left over from Halloween and tied it to the ribbon instead, to float in the toilet. While I was staging my "notty" scene, the elf fell into the toilet. Suddenly I was reminded of that old Saturday Night Live skit - Mr. Bill. "Oh No!" Since then, I have been staging "notty" tragicomedies in my head for Mr. Elf - getting singed in the fireplace while roasting marshmallows, electrocuted while watering the Christmas tree, it is getting a little ridiculous, actually. And a little black for elementary school children, but perfect, I decided, for lulling sullen teenagers out of their self-absorbed miserable states. I've got a few years of scenario dreaming on my side for that one. In the meantime, Merry Christmas to all and I would love to hear any elf suggestions, G-rated for the present or otherwise for the future. Whether you partake in this madness or not, all comments are welcome.

Welcome to Career Topic Week

Welcome to Career Topic Week on Mothers in Medicine! Posts by our regular contributors and readers on specialty choice will be scheduled to post throughout the week. Thanks for reading.

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Pediatrics is kids and family

How could I have almost passed up the opportunity to post on topic week about a family friendly career? Perhaps because this week I baked for the kids’ school pot luck and bought gifts for their amazing after school counselors and am working on a grand rounds and revising and resubmitting a paper and tweaking the students’ syllabus and conducting meetings with…

All that, and yet pediatrics, the career, is kids and their families. And as such it could not be more supportive of pediatricians raising theirs. Lots of opportunities for part time work, though I have remained full time with enough of “protected” time for non-clinical but otherwise scholarly work, where much of the flexibility is built in.

I aim to be a serious academic and medical educator (albeit still with appropriate levity with my pediatric patients) but at my own pace. After a few “wins” (first grant, first publication, first leadership role) you can pace yourself, pick and choose things (still say yes to almost everything but learn to say an occasional no) in academia. And grow to be a mentor to others.

And all the while my pediatric colleagues have to understand things like pumping, breastfeeding, being called to get your son from daycare, fevers, falls, school performances, and sports events because this is the stuff of outpatient pediatrics. It happens in our lives as mothers (and fathers) in medicine as it happens in the lives of our patients. When I returned from parental leave after 16 weeks the second time around, squeezing in pumping and speeding to daycare pickups, I reassured my boss that that was the last baby for me, and he told me to have as many as I wanted. That was a breath of fresh air (and the legal thing to say), and it was sincere. I continue to have all my patients as “my kids” plus the two of my own, and that is the right number for me in my very full time pediatric parenting career/life.

I think a side benefit of pediatrics as family friendly is it helps in child rearing. You learn the tips, the things we parents struggle with, you read the latest on development, and you can even draw upon your job when you minimize your kids’ screen time, ensure they brush their teeth, buckle up, among other less obvious things. I have nearly said to my children, “If your parents weren’t pediatricians then maybe you could eat that hotdog while playing with matches and then take a ride in the front seat, but….” Furthermore, my children hear me take call by phone some evenings or weekends for our outpatient community-based academic pediatric practice and have nearly become mini-pediatricians themselves. Even though they’ll probably be a rock star (say, Elvis) and an artist (she who draws mostly mermaids).

I didn’t choose pediatrics because I thought it would be family friendly, but much to my joy and satisfaction, in most cases it can be and has been.