Orienting Hemorrhoids?

Last week I was covering our cytology rotation, which can be very demanding.  There are a lot of diagnostic radiology needles.  We are also responsible for junk surgicals, as we nickname them - gallbladders, tonsils, breast reductions, hemorrhoids.  We call them junk because they are easy to look at and sign out, most being very routine cases with only one or two slides.  Occasionally there is a surprise tough case (gangrenous toe chock full of melanoma, for example) but overall they go quick.

One day I had a tray full of hemorrhoids.  They are usually easy cases, normal sign out being "Dilated submucosal vessels, consistent with hemorrhoids."  You have to check out the overlying epithelium to make sure there is no dysplasia, being ever vigilant.  Some breast reductions have carcinoma in situ.  It happens.  Some hemorrhoids have overlying HPV (Human Papillomavirus) changes.  Whenever I have a surprise like this, I generally contact the clinician.

I usually have a hemorrhoid or two, but a whole tray?  I spoke to a friend.  "Either the surgeons are having a blue light special or there is an epidemic of which I am unaware."  I have written of hemorrhoids in the past.  Gangrenous hemorrhoids, to be exact.  I won't rehash that in this post, but you can read about it here, if you want. I thought that was the most interesting hemorrhoid case I would ever see, but then I came across one that was oriented.

Orientation is necessary in pathology for many cancer cases.  Here's a good example.  In all breast excisional biopsies, the techs will ink the margins according to the surgeon's marks.  Sometimes the surgeons use long and short pieces of thread tied to the tissue.  "Long superior, short lateral."  Since a breast biopsy looks like a technicolor version of a lump of scrambled eggs, this is helpful to us in the gross room.  The tech inks the margins according to the surgeon's notes, and describes it to us in their gross description.  "Black anterior, blue lateral/posterior, green medial/posterior,"  for example.  That way, when we see the slide the next day, if the cancer is plowing into a margin, we can see the green ink and note it in our report (invasive carcinoma transected at the medial/posterior margin) so the surgeon can go back and get a clear margin.

But I was very surprised to see a case of oriented hemorrhoids, my first.  There were three different specimens.  The first two were "left hemorrhoid" and "right hemorrhoid."  Left and right hemorrhoids?  Are you the surgeon looking at the person?  Is the person supine or prone?  Or are you the sitting person?  And the third one was the kicker.  "Left posterior hemorrhoid."  Really, posterior?  Aren't all hemorrhoids posterior?

And why does a hemorrhoid need to be oriented?  If you don't get a clear margin on an invasive cancer, sure, you need to know, because it can recur.  But a hemorrhoid transected?  I imagined a transected hemorrhoid, dangerously spreading and growing out a patient's ears.  Ha ha.  Doesn't happen.

So I'm wondering if any surgeons out there can enlighten me.  Or maybe it was the surgeon's joke on me.  In any instance, I enjoyed wondering why on Earth a hemorrhoid needed to be oriented.

Dear Moms, How do you cope?

I'm currently doing the dreaded stint as the chief resident in the burn unit.  Its a particularly grueling rotation, lots of getting called in from home, crazy sick patients and lots of terribly sad stories.  It is taking an emotional toll on me, and I've been missing out on seeing by little peanut.  For the first time since I've come back from the lab I've gone two full days without seeing her.  I have cried a record number of times after countless family meetings at the end of hours of doing everything we could.  Thankfully, I've had a fabulous and amazing team of interns, nurses, chaplains, social workers and support staff to be on this journey with me.  However, despite the support, the one thing I haven't managed to cope with very well is the non-accidental injuries.

I have always found child abuse unbelievable horrifying, but as a mom, my horror about this has reached new levels.  In particular, a recent child I operated on, who is very similar in many ways to my own, has left me having nightmares every day in which I see her injuries on my precious daughter.  I wake up gasping and anxious and immediately go hug my daughter or go to her room and stare at her while she sleeps.  I've talked to other moms with similar experiences, a pregnant NICU fellow fighting the nightmares about her unborn child mirroring the illnesses she saw each day, the burn unit nurse manager who I sat and chatted with in her office about how this unit makes you so hypervigilant about protecting your kids, but the one thing we fail to come up with is a solution.  How do you make the nightmares stop?  I even talked to my own mom, who doesn't need to be in medicine to understand the disturbing fear a parent feels anytime they see another child harmed.  (My mom is awesome by the way, just want to throw that out there because she is my greatest mentor as I navigate this crazy journey of motherhood!)

So, tomorrow I will go to the spa, and try and lose my thoughts and replace them with relaxing calm.  I will continue to listen to my mindful meditation CD's as I drive home from a particularly horrifying day of work.  I will continue to delight in my beautiful, amazing blessing of a child each moment I see her.  And, I will pray for the beautiful children who have endured hurt and pain and pray that they someday receive the love they deserve.

Selah.

MiM Mail: 2 countries, 2 doctors, 1 baby girl

Hello fellow doctors,

I stumbled across your blog while searching for resources for single moms who also happen to be resident physicians. Currently, my girlfriend (Dr. B) and I are in a somewhat unique condition and I was wondering if anyone out there had any similar experiences and any advice for us.

Our situation is as follows: my girlfriend and I both graduated from an offshore medical school this past June. Neither of us are from the US and I actually attended medical school on scholarship from my country's government. In return, I am supposed to give them 4 years of service following graduation and as such, I did not bother to apply for the match in my 4th year since I planned to go home and fulfill my obligation. My girlfriend, who is from a different country and who has no such obligation to return to her homeland, obtained a residency position in a small Ob/Gyn program (only 3 interns/year) in New Jersey where she is currently halfway through her intern year. 

During our 4th year of medical school, we became pregnant unexpectedly and despite the challenges we both faced in the future we decided to keep the baby and this past August, only 40 days into her internship, Dr. B gave birth to our beautiful daughter Princess Peach. Unsure of what she was entitled to in terms of maternity leave for residents and how it would affect her ability to finish her residency on time, Dr. B took 2 weeks vacation following the birth of Peach which served as her maternity leave. Before she began her residency, I had decided to defer the start of my service in my home country to January 2013 in order to be free to care for Peach while mom continued to work, with the thought that I would take Peach with me back to my country since I would have family to help support me in taking care of her since Dr. B does not have that kind of support here in NJ. Her hospital doesn't offer childcare either so that is not an available option.

As such, since August I've been Dr. Daddio, stay-at-home father, which has been an absolute blast to be honest. I had no idea I had the capacity to love someone as much as I love my daughter and I cherish all the time we have together, even more so when her mom actually has a little free time to spend with us. However, as we near the end of the year, my time here is drawing to an end and Dr. B is freaking out at the thought of Peach and I leaving her here alone. She is already guilt-ridden about the very little time she gets to spend with Peach and she is dreading the day when Peach is no longer here for her to hold and kiss and love when she gets home from the hospital. As a result she is reconsidering letting Peach go home with me, however neither of us can see any feasible alternative. At this time, we cannot afford to pay for the kind of flexible care that Peach would need which would also accommodate Dr. B's crazy work schedule.  Our apartment, which we share with Dr. B's full-time student brother, is not big enough to accommodate a live-in nanny either. The situation in my home country is less than ideal as well since I would also have to be working crazy hours as an intern, and I am unsure of who among my family and friends can realistically take care of Peach while I work, but at least I would have options there that Dr. B doesn't have here in NJ. One option is to let Dr. B's mother and grandmother take care of Peach in their home country but neither of us wants our daughter to grow up without either of her parents.

So here's the conundrum: I have to leave the country for 3 reasons (a. to fulfill my contractual obligations with my government; b. my visa only allows me to stay up to 6 months at a time; and c. my brother's wedding on January 1st), so there's no chance for me to stay here beyond the end of the year. Currently, Peach and I are booked to leave at the end of December but I know at any time Dr. B can change her mind and say that she won't let Peach go with me. If Peach leaves with me as planned, Dr. B won't see her again until the end of March when she takes her next vacation. As far as I can see there is no ideal situation for the foreseeable future as we both have commitments to work in 2 different countries for at least the next 4 years and although we are committed to each other and to our daughter, it will take at least that long for us to be a nuclear family unit again after I leave. This prospect is daunting to say the least! Neither of us want to be away from the other or from Peach, but our situation necessitates the separation. I'd like to explore the option of Peach splitting her time between the US with her mom and my country but that would have to be after we have saved enough money to afford to pay a carer regularly.

Does anyone out there have any experience in such a situation where both parents are doctors and one has to live and work far away from the other? Are there any options for childcare that I am missing? What advice can you guys offer us as we prepare to face this extreme parenting and relationship challenge?

Thank you for your blog and any and all comments are appreciated.

Sincerely,

Dr. Daddio

Clerkship Preference

In light of my post last week, about people with special considerations (i.e. kids) getting preference for the holidays, I wanted to post this story. A version of this was originally on my personal blog:

During second year of med school, most schools have a lottery to decide on what the third year rotations will be, both the order and where we would have those rotations. There were four main hospitals we rotated through, two of which were nearby and two of which were about an hour and half away.

Prior to our 3rd year clerkship lottery, we voted on special considerations for the clerkship lottery. Basically, students emailed in their special needs, and an email was sent to the class with the anonymous requests and we could vote on them. These were some of the requests I remember:

--A few students who had children asked for all their rotations at one particular hospital so they wouldn't have to move around.

--A couple of students asked for an elective during a certain month so they could get married.

--Two male students asked for an elective month during their wives' due dates

--One student asked for an elective month when his father was having cancer surgery

--One student asked for rotations at a certain location because she only had one car and she carpooled with her husband

Out of our class of 100+ students, 12 anonymously asked for special considerations. Out of the 12, 10 passed through majority class vote. (Notably, the car one didn't pass, the one with kids/births did.) I actually voted yes for all of them, mostly because I felt if they believed it was important enough to get special consideration, they cared about it a lot.

Anyway, the day after we found out which requests passed, one woman in our class sent out the following email:

This is ridiculous! Many of those reasons were absolutely silly. What was the percent of votes needed to pass this anyway? I can't believe the votes passed with those stupid reasons these students gave.

Because for one thing, if your parents are ill, get a visiting nurse, since there is nothing you can do while you are studying anyway. Secondly, all these people that want to take care of their family or assist with their wife's pregnancy or take care of the children or see your children and all that... well, we all have loved ones we would like to see as often as possible, but because we chose such a demanding profession, we simply don't necessarily have that luxury. We just make it work without having to subject our colleagues to it. If it matters so much, have your family member move to where you are or you can commute or hire a baby sitter that can pick your children up from school.

I easily could have said something equally lame, but I sacrificed and let people with more important reasons have their say. But all these crazy reasons, I tell you, is unfair to the class as a whole and it is especially unfair to people that had good reasons but took the initiative to find solutions to their issues.

We generally all thought this particular person was being extremely selfish. What do you think?

Role Reversal

I was once at a pancake breakfast for my kid's school.  Cesilly was 5, Jack was 3.  Jack was in a dance class, pre-Taekwondo and Boy Scouts.  I was feeling pretty savvy, my son in a dance class!  How liberal and against the grain.  He had to wear a uniform for the performance - a black suit with a spangly sparkly bow tie.  He looked like a flim-flam man.  I was a little confused by the attire.  I wandered over to another mom to ask her about the logistics.  She was a gyn-onc at the University - a transplant who was trained in California.  Her son was my son's age, her daughter the same age as mine's.  I didn't know her well, but was itching for companionship, especially from another doc/mom.  I walked up to her and took a deep breath.  Wanting to be her friend.

"So what are they supposed to wear for the recital?  Do you know?"

She looked at me, puzzled.  "I have no idea.  My husband takes care of all of that."

I think he was a stay at home dad, or at least had a very flexible laid back job.  I had gathered that much, from observing them over the past few months at the school.  I also saw them at the grocery store on Sundays, all of them, the entire family shopping together, while I was on my own doing the weekly shopping.  I admired that about them.

My reaction to her statement was complex.  I was awed that she gave up those duties to her husband, and also jealous that he was available enough to take charge in that arena.  I also felt angry at her, probably projected anger redirected away from myself.  Angry at her for not knowing about the mundane details of the children's lives, since that was my primary role in our family at the time.  I was a resident, busy with work and two small children, and I would have never imagined relinquishing that knowledge or responsibility to my husband.  It would not have worked, in our relationship.

I am divorced, two plus years now.  My ex and I get along better now that we are co-parents, and not married.  He is remarried to a wonderful woman who has taken the role as stepmother to my children, not stepmonster.  She calls my kids her "bonus children," and read such a beautiful passage to them at her wedding last March, about there being room in her and their hearts for everyone, that I got teary.  As my daughter Cesilly said at breakfast one day, "Mom, Dad sure does some things really well.  He picks good women.  He picked you, and he picked Miss Rachel."  I laughed.  I agree.  I love Miss Rachel, and so do my kids.  I maintain a respectful distance, but will be eternally grateful for the structure and emotional support she provides to their household.  My marriage issues are water under the bridge.  But there was definitely a large gap in childcare division back then, me taking on most of it.  I don't think this is uncommon, especially when the children are young.

My primary reason for writing this blog is about roles and delegations in marriage, traditional and otherwise.  Did I have any right for feeling judgmental about the gyn/onc's lack of knowledge about her son's dance outfit for the recital?  Or was it all a reflection of my own situation?  Would I have reacted the same way if she were a man, and he didn't know?  I could not have imagined approaching any father at the pancake breakfast to ask about dance recital outfits.  Part of my frustration in my own marriage was the one-sidedness of it all - I saw other friends whose husbands were much more involved in the day to day of the kid's lives.  I take some responsibility for this, in retrospect.  If I had a stay-at-home dad back then, and not a physician husband, would it have been so weird to me that she had no clue?

My kids have moved on to two different schools since that pancake breakfast.  The gyn/onc and I earnestly tried to make some play dates, but I am sure the readers in medicine can guess how that worked out - busy lives move forward without much room for pause.  I last saw the gyn/onc a couple of years ago at the grocery store.  She was expressing frustration with her academic career, the challenges of it, and I listened sympathetically.  Told her about Mothers In Medicine, it being such a great outlet and community for me.  I haven't seen her since.  I sometimes wonder if she is still at the University, or if she has found another job.  I hope she is happy in her career and life.  I don't feel as judgmental of her now as I did back then.  Maybe that speaks well of where I am now in life.  I guess it ultimately takes a working balance in a relationship to make it all work, no matter how the roles play out in the end.  As long as everyone is happy and on the same page, that is what matters more than individual responsibility.

I am curious to hear about how other women, all women - working and stay-at-home, negotiate these treacherous waters in their relationships.

Some days I’m envious of my Acting Intern

I used to be you. Well rested. On top of things. Bright-eyed. Now I’m the sometimes harried Intern with lots of patients, experiencing lots of sign out and cross-covering. Now I’m the Intern with the baby and husband who you look at and say “wow, I just don’t know how you do it, that’s soo much!” while you run out to your weekly exercise class while I finish my umpteenth note and go home for bath time, dishes, and a glass of wine.

I’m the one with the mommy pouch that won’t allow me to wear the cute new fashion trends (who am I kidding, I can’t even afford those trends) and the hair that needs to be done. I’m the stressed Intern with the significant student loan debt and monthly loan payments. I don’t tell you that if I made just a tiny bit less I’d qualify for public welfare benefits. I’m the one with the job that matters so much that I constantly check and recheck my orders. It hit me hard Day 1, I write the orders and they get done. I get the pages and notifications and make split-moment decisions. I am part of the Code Team. I affect lives. I affect health care costs.

I used to be you, the Medical Student, but now I’m the Intern, I’m Doctor Bee. I used to be scared but not this scared. I used to be tired but not this tired. I used to be happy, but not this happy (in a wickedly complex, exhilarating yet scary all while being fulfilled kind of way). Sometimes I am so envious of you, but more often than not, I’m happy to be exactly where I am.

Holiday privileges

Here's a question for the ages:

Should employees with children be given preference in terms of not having to work holidays?

I say yes.

And I say this as someone who will be working on Black Friday. And I worked most holidays during residency without complaining. Before I had kids, I actually offered to work holidays so that other people who had family in the area (I didn't) could be with them. After I had kids, I still worked most holidays without complaining.

The only time I ever asked for preference was when I discovered a couple of weeks before the fact that our daycare was closed for two weeks for the Christmas holidays, and there were just a couple of days when my husband couldn't get out of work, and our usual babysitter was out of town. Basically, I had no options, and my program was super nice about accommodating me, so I appreciated that.

I can see how one might argue against this. After all, just because you don't have kids, it doesn't mean you have no family. And while I agree with this, I do have a few arguments for why I think people with kids should get preference:

1) Schools and daycares are likely closed for holidays and nannies go on vacation, so finding childcare becomes a nightmare. I wouldn't want anyone to put their kids in a potentially unsafe situation just so I could have a holiday off.

2) If a person has school-age children, holidays may be the ONLY time the kids can go on a trip to see family members, since you can't pull them out of school.

3) Holidays are important to everyone, but nobody finds holidays as magical as kids, so I think it's worth it to make it special for them. And they actually probably like seeing their relatives.

Maybe if someone has a big family Christmas event every year that means the world to them and it's a thousand miles away so they have to take off several days to go... well, fine. But frankly, I don't think that many adults feel that way. Most probably appreciate having work as an excuse to get out of the Christmas events.

Personally, I don't care as much, since my husband is usually able to take off days when I can't, and my family is very willing to visit me, rather than vice versa. But I know that's not the situation for everyone.

MiM Mail: Ready to quit

Hello to whoever might be reading this,

I am a 2nd year Peds resident in a grueling program, and I have 10 month old baby.  N'er the twain shall meet.  But they did and they are, and that is why I am burnt out.  I am a zombie from sleep deprivation; being on call q 1 is beyond my capabilities.  And my heart isn't in the residency program like it was a few short 11 months ago, but once my son was born all I want to do is be a mom.  I don't think I want to be a doctor anymore, but I can't decipher between not wanting to be a resident anymore vs not wanting to be a doctor anymore. Oh, and I'm 300k in debt. So I can't quit.  But I want to.  I'm away from my son so much sometimes I forget what he feels like. 

 

I'm hanging on here but the thread is stretching thin.  I envision, mostly when I'm post-call like I am today, walking into the program directors office and saying, "I quit."  It feels good.

 

Anyone been in this predicament?  Any suggestions? I love this online community and often read it while at work or right before going to bed to check in with all you fabulous other women doing the combo of medicine and parenthood.

 

Thanks everyone.

I Hate the Library

I love to read.

I have ever since I was a kid. Obviously, I don't have as much time to read these days as I used to, but I've read a good number of books this year. I've found if you really like doing something, you can always make time for it.

Back when I was a mother of one, I used to get most of my books from the library. I used to enjoy browsing through the shelves and seeing what appealed to me. Now that I have a toddler, I haven't been able to make time for that, plus I'm terrified of her destroying a library book. So I haven't been to the library in a while.

Last weekend, however, I got bored and decided to take my kids there.

As some of you who read my personal blog know, I have some issues with the library. But since our local library has an entire floor dedicated to kids, I figured that we at least wouldn't get shushed.

When we arrived, my older daughter Mel was thrilled to discover that there was a train set for her to play with (because you don't actually go to the library to look at BOOKS). She started playing with it while I flipped through books with my toddler. I must have turned away for, oh, sixty seconds.... and the entire train set had been dismantled!

Me: "What did you do???"

Mel: "I'm going to rebuild it!"

OK, well, I don't want to stifle her creativity, right? So rebuild away!

Except she wasn't quite done rebuilding by the time she got bored. I think it ended up being more complicated than she thought it would be to fit everything together, and she couldn't do it. She went about ten feet away to the young readers section and started pulling out books.

"I'm going to read these!" she announced.

And of course, my toddler followed her and we all read books together. Yay for encouraging reading!

Except about ten minutes later, a family of three came into the children's area. It was a mom, a dad, and a girl of about three or four. The mom looked at the area where I was sitting with my kids, where we had a few discarded books strewn about (which I was TOTALLY going to pick up when we were done), and says, "Oh my god, what happened here?"

I didn't say anything, just kept reading and focusing on my kids.

Then they go over to the train set, and now the woman is almost screaming, "OH MY GOD, WHAT A MESS! WHAT HAPPENED?!!!"

Then the couple starts discussing what a travesty this is. The dad especially seems really upset that the train set has been dismantled. He actually sits down and starts grumbling to himself while attempting to put it back together. And I hear the mom say loudly to him, "Can you believe this? I'd like to shame her into cleaning it up!"

Now you don't have to believe me, but I was TOTALLY going to make Mel clean it up before we left. I mean, I was still right there. And when I've got two small kids with me all by myself, it's not the easiest thing to not leave a tornado behind you everywhere you go. Even if I wanted to, I couldn't have put that train set back together without both my kids vanishing on me. And to be honest, they didn't even know it was me who made that mess in the first place.

I fully expected them to come up to me eventually and confront me, but apparently, they just wanted to passive aggressively talk about me behind my back. Still, it upset me, so they did their job.

Is it possible for me to bring my kids to the library without some library patron yelling at me and making me feel like never coming back?

MiM Mail: Taking a year off from medical school for baby

Hi ladies!

I'm a long time reader/ asker and I've got another question for you guys. I'm an M3 with a 2 1/2 year old and am about 5 weeks pregnant with baby number 2.EDD around early July. I had six months off with my first baby and really would have enjoyed having more time. I'm a crunchy kind of mama (attachment parenting, breastfeeding, etc) and I know how I feel when my baby is new and tiny, and I'm certain I'll want lots of time with this baby too.

So, I'm considering taking a year off when the baby gets here, between 3rd and 4th year. I'm not certain I'll ask for it, or even if I'll get it, but I'm wanting to know what I'm getting into if I go down that path. I'm not sure what I want to do, but right now Emergency Medicine and Internal Medicine are my top two, and we live in the south and I have no Ivy League or academia dreams, so no seriously competitive residencies. Preclinical grades are average, Step 1 was above average, but not shockingly awesome. I don't have any research done yet, and honestly, think that the year would provide some time to boost that aspect of my resume (in addition to making connections in EM, since we don't have much exposure there as M3's). I also think I'll be a much, much better intern with a 2 year old than a 1 year old (and I know, because I have been there!) At my school, M4's essentially have 5 months off, but I'd like more time.

So, has anyone done this? Anyone have thoughts on it?

Onion Skinning

I was at a Halloween party at the kids school on Wednesday, opening sticker packets for a craft.  I noticed a few moms I didn't know, so I wandered over to introduce myself.  It came out that I was a pathologist, and later in the party one of the moms pulled me over to talk in confidence.

"I really hate to bug you about work issues when you are on vacation with your kids.  A significant member of my family was recently diagnosed with probable cancer.  She is incredibly healthy, this is a big shock.  My kids don't know about it yet.  She has had a couple of biopsies, and they can't figure out what it is.  Since you are a pathologist, can you review the slides?  Do you think we need to send it for another consult?  She is in another state being worked up.  We feel so helpless and frustrated!  What do suggest we do?"

I was reminded of a case I had a couple of weeks ago.  Walked into CT - a second biopsy was being attempted on a patient with probable pancreatic cancer.  The radiologist was livid that he did not get the diagnosis on the first attempt.  The biopsy the week previous was called "Atypical."  The tumor marker serum levels were sky high and the radiology was practically diagnostic, but they needed our help to call it and start treatment.  I had a heads up in the morning, and had already reviewed the first biopsy, which was looked at by four pathologists.  It was a tough case.

Sometimes the clinician doesn't get at the heart of the patient's problem the first time the patient presents to the office.  Pathology is the same way.  I don't think people realize this - they think it is all black and white.  We absolutely hate to be wishy-washy, and will often gather our colleagues to try to push the call one way or the other - negative or positive.  I was doing a frozen on a laryngeal biopsy on call a couple of weeks ago.  It was scary and ugly but I couldn't go beyond atypical.  Called a colleague to help and he agreed, so I called the surgeon in the OR and gave him the worst kind of answer - "We don't know."  I was thankful the next day - it turned out to be completely reactive/negative.  It is much easier to look at a piece of tissue that is processed overnight than one that is quickly frozen, sliced and stained for a preliminary answer for the surgeon during the operation.

I told the mom the same story I told the radiologist, in an attempt to assuage their respective fear and anger.  "Sometimes it takes time to get there.  When we have definitive specimen, it is easy.  Once I had a case of a patient with probable lung cancer.  It was exceptionally hard to get the diagnosis.  The pulmonologist did two bronchoscopies with washes and biopsies, and despite seeing the mass, they missed it.  The following week the patient went to CT-guided biopsy twice.  Both times the radiologist missed.  I happened to be on frozen sections the next week, when the patient went to open lung biopsy.  It took the surgeon four frozen sections to get to the bottom of it.  I kept calling it negative, and he was frustrated.  'Giz, I'm standing here staring right at it.  Don't tell me you haven't got good specimen.'  He was speaking to me on the intercom in the OR, I was on the phone by the microscope in the gross room staring at the tissue.  He could see the tumor, as did the pulmonologist and radiologist, but he wasn't grabbing tumor, just reaction around it.  He finally got it on the fourth piece of tissue he sent."  That case was an exception - we can usually diagnose the patient more rapidly.  But sometimes it takes time.

I love the term my partner used once to help me.  She calls it "Evolution of Diagnosis."  I was particularly upset about a muddy specimen.  She said, "Gizabeth, our field requires patience.  It's not always clear from the get go.  It's not a failure on our part if we can't call it right away.  Don't internalize it."  In psychiatry they call this onion skinning.  Peeling the layers away to get to the meat, or the psyche.  The diagnosis.  The answer.  Some onions have thicker skins than others.

I reassured the mom that the doctors would most likely get her family member's diagnosis soon, and gave her my name and number if she had any questions.  Assured her that most pathologists are trained well enough to recognize when they are in their comfort zone, which is 95% of the time, and when they need to send something away to an expert.  I also shared that my kids and I recently lost my mother-in-law, their Nana, to cancer.  Told her about the poem my daughter wrote and read at the funeral.  Empathized about how hard it was for kids to experience loss of that magnitude - mine had to at a much younger age than I ever did.  She thanked me and we served orange ice cream punch.  She and her family are in our thoughts.

The radiologist got good pancreas specimen on his second attempt, and I was able to give a definitive diagnosis to the surgeon the next day so they could cancel the open biopsy and the oncologist could start treatment for the patient.  A lot of times our frustrations and anger, as clinicians and family members, are an expression of the emotion that we have surrounding the stress of getting an answer to alleviate the fear of the unknown for a fellow human being or loved one.  When you can step back and see that objectively, it's a lot easier to let go of it all and focus on the job.  Skinning the onion.  Which is not generally a process that can be performed without burning, stinging and tears.  But the answer is usually well worth the effort.

Guest Post: Five Lessons Learned on Being a Patient

Last summer, I was enjoying a relatively smooth second pregnancy despite my “advanced maternal age.”  It was a warm, sunny Sunday afternoon, closing a (miraculous) full weekend off of clinical shifts.  I lay down to take a little nap; my then-two-year-old daughter climbed into bed next to me. Suddenly – life changed.   I felt a gush of fluid, and knew that I was either bleeding or had broken my water.  To my dismay, it was blood.  A lot of blood.

At that moment, I made the transition that all doctors will make at some point in their life, but which we all fear:  from physician to patient. 

I was now G2P1, EGA 31w2d, with a spontaneous abruption, praying to feel the baby move.   I had no history of trauma, no cocaine use, no history of bleeding disorders.  My husband (who was, luckily, at home) scooped up our daughter and me and drove at what felt like 100mph to the hospital.   I sobbed in fear the whole way.  Thank god, on arrival to the hospital, our little one had a healthy heart rate.  But I was still bleeding, and contracting, and had some cervical dilation.  What followed:  8 long hours of being NPO in fear that I’d need an emergency C-section.  A long discussion with the NICU fellow about prognosis if my little one needed to be delivered that night.  An admission to the labor & delivery floor “just to watch.”  Then a week in the hospital.  Then 2 months on bedrest.   

No one knew why I had spontaneously abrupted, and therefore no one could say if or when the abruption would recur.  Although no large clot had been visualized on my ultrasound, that didn’t mean that my placenta was okay.  I was a nervous wreck, hoping my little one would gestate until he was big enough to avoid the NICU.

Thank goodness, nothing happened over those long 2 months.  I had occasional contractions, occasional spotting, no bright red bleeding.  And 1 week shy of my due date, my son was born, small but healthy.  And I was healthy.  I realize how incredibly lucky I am, and how much tougher things could be.

Still – it was the scariest two months of my life.  And it has changed my way of doctoring.   I walked away from this experience with 5 major lessons for my own practice of doctoring. 

1. Empathize with patients’ and families’ anxiety.

I now understand why people over-interpret their symptoms.  I get why the patient with a history of CABG comes back to the ED every week for twinges of chest pain.  (“What if?.... Last time… I don’t want to be home alone….”)  Often, my primary role as a doctor in the emergency department is to assuage this anxiety, especially if patients have had a long wait prior to being dispo’ed.

2. Be honest about a lack of knowledge, and explain what we can given the limits of our diagnostic/prognostic ability.

I am a physician, and understand medicine!  But I am not an ob/gyn, and have been out of residency for more than a few years.  The only abruption I saw during my training resulted in a stillbirth, so had no practical experience in this diagnosis.  Scarier yet, even among my ob/gyn’s group, management of moderate abruptions differed.  This was scary.  Luckily my personal physician was stellar at making me feel comfortable both with the lack of an evidence base, and with the recommendations she made.

For my patients who are sent home without a diagnosis or clear prognosis, I now try to acknowledge my frustration with this fact, and give an outline of both what I know they do NOT have (e.g. “I am pretty sure your really bad headache isn’t a bleed, or a tumor, but I’m not really sure what’s causing it”) and an outline of when/why they should come back.  I make sure they feel heard, and reassure them, which is often the whole reason they sought medical care in the first place: just to make sure they were okay.

3. Don’t be offended when patients ask for their personal physician when they present to the ED.

In a moment of fear, you want someone you can trust.  I was lucky that my personal ob/gyn was on call the day of my abruption.  I’m not sure how I would have responded to non-evidence-based recommendations had they come from someone other than her.

Now, when patients’ first words on seeing me are: “Have you called my doctor [X] yet?” – I tell them how lucky they are to have such a great doctor as their PCP/cardiologist/whatever, and reassure them that I will work closely with her/him.

4. Give good, thorough discharge instructions.

I left the hospital not understanding exactly what “bedrest” consisted of, and how much I could/could not do, and what would/would not increase my chances of doing well.  I think this was because no one really knows the right answer!  Still, not knowing was very tough for me at first, as I was scared stiff of re-aggravating the abruption.

I now try to be as clear as possible with my patients about what their instructions mean.  (What is “weight bearing as tolerated”?  When can they stop taking Motrin?  At what point should they return to the ED or their PCP?) … .This often involves rewriting or augmenting our computerized discharge instructions, of course.

5a. Acknowledge, and encourage, the use of social supports.

Being sick is scary.  And I wasn’t even physically sick – I was more worried about my fetus!  I can only imagine how difficult life must be for my patients with limited support systems, no money, and fear of losing their job if they stay out of work.  I know how tough it is for people to ask for help, but I encourage them to do so, for their own sake.

5b. Encourage the exploration of online support groups – Especially for chronic conditions, or diseases with little evidence base, the online community is a godsend.  For me, it was my only “good” source of information (although it was also a source of fear, if I didn’t triage sources well).  Heck, think of how important mothersinmedicine.com is for all of us!

 Before my abruption, I was already interested in the use of technology to support patient engagement and behavior change.  After two months of bedrest, I became an evangelist for “mhealth”…

Of course, I don’t think that I was non-empathetic at baseline.  I am, honestly, one of those people who always wants to be liked.  But now I try to listen more.  I try to ask what patients are scared of.  I try to reassure more, and to include patients’ families and social supports.  I try to give clearer indications of “if/then” and “what if” scenarios:  e.g. “I don’t think you’re having a stroke, but here are the things to come back for, and here is what I think is going on”.  I now try to explicitly acknowledge patients’ and families’ fear, and encourage my patients to turn that fear to good service:  to use it to increase their engagement with their families, the online patient community, and their own bodies. 

Most of all, I am now actively researching ways to use technology to facilitate patient engagement with their own health.  I don’t want this message to stop with me.

I welcome thoughts, comments, or partnership in so doing!


Emergencymom is an academic emergency physician and public health researcher on the East Coast.  She is proud mother of 2 (aged 4 & 1), and wife of a small-business-owner.  Her work-home balance is precarious, but generally enjoyable.  She still can't believe that she gets to do research for half her work-week!  She welcomes suggestions on how to get 4-year-olds to stop whining, how to have dinner cook itself, and how to not be perenially 1 hour shy of a good night's sleep.

MiM Mail: Did you co-sleep?

Hi MiM,

When I had my first son I read a lot and had all sorts of plans for
how it would go and what type of mother I would be.  Co-sleeping did
not fit into that plan.  I knew that the American Academy of
Pediatrics did not recommend co-sleeping and that it may increase the
risk of SIDS.  So into the crib he went.  I didn't intend to co-sleep
with my second son either, but once my sleepless baby boy arrived I
ended up doing whatever worked to get the most sleep.  He naps in his
crib or bassinet but spends a good portion of the night in bed with
me.  I still worry about safety risks and I definitely worry about the
process of breaking this habit at some point.  My question is, as
educated physicians and mothers, how many of you have opted to
co-sleep with your children and for how long?  How do those of you in
pediatrics or family medicine address this with your patients?  I'm
not really looking for advice necessarily, but I think this is an
interesting discussion point.  I found out after talking to other moms
that this is a lot more common than I realized!  This may be somewhat
regional also.  I live near a very liberal, somewhat "hippy" town
where baby-wearing, cloth diapering, and making your own baby food are
often the norm.

I am a PA in dermatology and the mother of 2 boys - 22 months and 5
weeks old.  I love following MiM!

E

Why men earn more than women

Recently I came across an interesting map showing how much women earn for every dollar a man earns. The highlights:

In Utah, the average woman earns 55 cents for every dollar the average man earns.

At best, women earn 3/4 of what men earn.

There are lots of theories as to why women earn so much less than men. Some people say it's because women gravitate toward fields that tend to pay less. But even if you take this into account, women still earn less than men in the exact same job.

The difference does seem to be related to having kids. Apparently, men with children earn about 2% more on average than men without children, whereas women with children earn about 2.5% less than women without children. Women are also more likely to leave the work force for longer periods of time, which further suppresses their earnings.

As a working mom, I really get this. How could I ask for more money when I just took a 12 week maternity leave? How could I ask for more money when I just had to take sick days for a GI bug I caught from my kids? How could I ask for more money when that might make me feel obligated to take on more responsibilities, which I just can't handle right now?

I don't know what the solution is, but I'm sure I'm not the only woman who feels this way. There are probably enough of us to fill at least several binders.

Time for children

Last weekend I was at my friend's baby shower and making small talk with the mother of a baby boy a few months younger than my own son. His mother was a co-worker of my friend, both physical therapists at the local medical center, and the conversation turned to the topic of child care.

I mentioned that I had just worked with an intern who was 38 week pregnant, had planned to take a 4 week maternity leave (she was a prelim and had to start her second program on time), and had a complicated childcare plan in place that involved a sitter coming over to the house around 5 am - when she and her husband (a surgical resident himself) had to leave for the hospital, the sitter would then drop the baby off at daycare when it opened at 8am, pick the child up when daycare closed, and stay with the child until she came home from the hospital around 7 or 8 in the evening.

"Geez", she said, "Maybe she shouldn't be having children. It doesn't sound like she has time for them."

Whoa. Maybe she shouldn't be having children? I should mention that, although I hardly know this intern at all, I like her and I am worried about this plan for what I think are obvious reasons. Children get sick. Patients crash, usually right as you are about to leave. Daycare closes early on Friday for "Teacher In-service" (like every month it seems). Sitters have "things come up". And what about weekends?

My reaction to her situation wasn't that she shouldn't be having children, but that she needed a nanny to get her though a tough few years. I made what I hoped was a polite excuse and left the conversation. 

I was more fortunate than this intern in both the length of my maternity leave and that I had family that could move in with when my daughter was born, but without those two variables my situation wouldn't have appeared that different. I wondered if the same sort of judgement would be passed on me if my early months and years of motherhood were observed by similarly minded outsiders - even now as my mother lived with us for the last two weeks while I was on the inpatient ward rotation. 

I don't feel bad about how I raised my daughter when I was a resident, I feel grateful to my mother and mother-in-law. But I guess we all have different comfort levels for having other people participate in the care and raising of our children. I've had a lot of help with mine and, for the record, I've been pretty happy with the outcome so far.