I was at a meeting recently with several female physicians and young therapists. We were discussing a patient who was 45 years old and had a six year old son. One of the therapists commented:
"So that means she was.... 39 when she had a baby. That's so.... old!"
Crickets chirped. Almost every physician in that room had children at 39 or older.
On Facebook this morning, one of my friends posted an article about how families are having children at older ages and the consequences of this decision.
In case you don't to read the article, these are its main points:
1) The chances of learning disabilities as well as certain other problems such as schizophrenia and autism increase severalfold in older parents.
2) Women who have their first child at an older age are less likely to have the number of children they wanted ten years earlier.
3) Reproduction becomes more difficult and costly as you age.
4) Having children at an older age means having older grandparents for your kids.
5) Having children at an older age means dying when your kids are younger or at least being more infirm for most of their adulthood.
At the same time, the article also cites that children of older parents grow up in wealthier households, lead more stable lives, and do better in school.
Ultimately, it's a very personal decision, but I know when it comes to motherhood, we are all wracked with guilt about our decisions, and one of the earliest decisions you have as a mother is when to have babies.
Wednesday, December 12, 2012
Tuesday, December 11, 2012
MiM Mail: The what-ifs
Ever had one of those cases where you look back and just wish you'd done
things differently? What's your way of handling this feeling? Might you
be willing to share your moving forward strategy?
I'm an anesthesiology resident transitioning back to work from maternity leave. While I love what I do, there have been quite a few days when I definitely feel that the transition back to work is not as fast as I'd like. The days where I feel like I'm relearning things I used to know. Yes it's kind of like riding a bike after you haven't been riding one in a while, but when you're training, sometimes you don't feel like you ever really knew how to ride it that well even. And I have many moments where I am mentally kicking myself because I just remembered something I should have done or handled differently.
[The case below has been changed to protect patient and staff confidentiality]
For instance, recently there was a code blue at the hospital. A man who had been undergoing a line insertion was now having massive hemoptysis. A double lumen tube was inserted to isolate the bleed. Some air seemed to be entering one lung. The PAC balloon is inflated and the hemoptysis seems to have stopped for a while. The patient seems relatively stable with good sats and bp and the patient's main physician consults ICU to take the patient for close observation. At the back of my head is this niggling feeling as I am not quite sure whether this tamponade from the PAC balloon will hold - should we consider if we need a surgeon to sew up whatever's bleeding? But soon, the patient is bleeding again, CPR is started, the surgeon shows up but the patient is too unstable and despite best efforts, the resuscitation is unsuccessful. When I get back home, I read up on this, and more questions fill my thoughts. What if we'd gotten a cardiothoracic surgery consult much earlier on? Or heart-lung bypass? But now it's too late for the what-ifs and should-haves. I just wished I had known more at the time to be more useful.
Shortly after, I was in a simulator session. While I was fast on initial management managing a crashing patient and securing the airway, I got hung up on troubleshooting ventilator equipment that had failed, without moving on to switching my equipment. It was one of those how-stupid-of-course-I-should-have-thought-of-that moments - if something's not working, sometimes the best option is not to try and fix it, but to switch it entirely. I know that! But hadn't done it fast enough. In a simulator, it's not a real patient crashing and that's great. But if this was a real-life situation, that patient may not have been as good.
I find it hard not to mentally kick myself, or to look with envy at other colleagues and wonder how they seem so much more confident and competent. When I look at my flubs, I often feel like a Bridget Jones while others seem like a Grace Kelly or better yet a MacGyver - always there with the best plan in the nick of time, executed with calm and grace.
I hope I'm not the only one out there who has felt this way - trying my best but feeling incompetent or stupid at times. Yes it is a learning opportunity, and yes, I hope it gets better, and yes I feel I know more than I used to - but when does one start to feel confident and competent, and bring-it-on-because-I-can-handle-it rather than I-hope-I'm-seeing-bad-stuff-when-there-is-someone-else-on-who's-better-than-me-there-to-guide-me-through-it? When I was a med student, I looked at the residents with awe for their competence and confidence, and now that I'm the resident, I don't know that I feel that way.
Have you ever felt this way? Have you ever had cases that didn't go as well as you'd liked? How did you handle it?
RLMD
I'm an anesthesiology resident transitioning back to work from maternity leave. While I love what I do, there have been quite a few days when I definitely feel that the transition back to work is not as fast as I'd like. The days where I feel like I'm relearning things I used to know. Yes it's kind of like riding a bike after you haven't been riding one in a while, but when you're training, sometimes you don't feel like you ever really knew how to ride it that well even. And I have many moments where I am mentally kicking myself because I just remembered something I should have done or handled differently.
[The case below has been changed to protect patient and staff confidentiality]
For instance, recently there was a code blue at the hospital. A man who had been undergoing a line insertion was now having massive hemoptysis. A double lumen tube was inserted to isolate the bleed. Some air seemed to be entering one lung. The PAC balloon is inflated and the hemoptysis seems to have stopped for a while. The patient seems relatively stable with good sats and bp and the patient's main physician consults ICU to take the patient for close observation. At the back of my head is this niggling feeling as I am not quite sure whether this tamponade from the PAC balloon will hold - should we consider if we need a surgeon to sew up whatever's bleeding? But soon, the patient is bleeding again, CPR is started, the surgeon shows up but the patient is too unstable and despite best efforts, the resuscitation is unsuccessful. When I get back home, I read up on this, and more questions fill my thoughts. What if we'd gotten a cardiothoracic surgery consult much earlier on? Or heart-lung bypass? But now it's too late for the what-ifs and should-haves. I just wished I had known more at the time to be more useful.
Shortly after, I was in a simulator session. While I was fast on initial management managing a crashing patient and securing the airway, I got hung up on troubleshooting ventilator equipment that had failed, without moving on to switching my equipment. It was one of those how-stupid-of-course-I-should-have-thought-of-that moments - if something's not working, sometimes the best option is not to try and fix it, but to switch it entirely. I know that! But hadn't done it fast enough. In a simulator, it's not a real patient crashing and that's great. But if this was a real-life situation, that patient may not have been as good.
I find it hard not to mentally kick myself, or to look with envy at other colleagues and wonder how they seem so much more confident and competent. When I look at my flubs, I often feel like a Bridget Jones while others seem like a Grace Kelly or better yet a MacGyver - always there with the best plan in the nick of time, executed with calm and grace.
I hope I'm not the only one out there who has felt this way - trying my best but feeling incompetent or stupid at times. Yes it is a learning opportunity, and yes, I hope it gets better, and yes I feel I know more than I used to - but when does one start to feel confident and competent, and bring-it-on-because-I-can-handle-it rather than I-hope-I'm-seeing-bad-stuff-when-there-is-someone-else-on-who's-better-than-me-there-to-guide-me-through-it? When I was a med student, I looked at the residents with awe for their competence and confidence, and now that I'm the resident, I don't know that I feel that way.
Have you ever felt this way? Have you ever had cases that didn't go as well as you'd liked? How did you handle it?
RLMD
Thursday, December 6, 2012
11 months in, 42 pounds lost
Hey, remember me? I'm the internist who had two kids in two years, ate everything I wanted throughout both pregnancies, and then realized I had gotten REALLY fat and out of shape. Like, BMI 30, obesity fat. I started a South-Beach-Style low-processed carb diet and started exercising- which was VERY painful at first. See previous posts on that. I think I wrote that my first time back jogging I felt like a manatee on land.
Since then, I've maintained a basically low-carb diet (with the occasional celebration/ feast), and a basic exercise routine (with the occasional lazy week), and I've continued to slowly burn fat and build muscle.
Now, I've gone from 163 pounds to 121 pounds. At 5 foot 2, this puts me at BMI 23!
I am not yet at my goal, which is for 50 pounds lost, back to my pre-pregnancy weight of 113 pounds. I'm trying not to feel like a failure because I'm not there yet. (How Type-A is that?) But I am proud of what I have accomplished so far, and I offer myself as an example to others, including my patients.
Here are some take-away points and tips:
GET SUPPORT: Last January, I stated my intentions to my family, and they were enthusiastic to help me. I work part-time, 5 clinical sessions of primary care, which really is a 40 hour week at least. My husband works as a writer and broadcaster so works from home alot but also travels alot. My mom helps with childcare, and we have a babysitter. So, in short, though I work alot and intensely, and hubby works, I have alot of support to help me with logistics/ kid care. But more importantly, my family has been all-in behind my efforts. My husband shares the grocery shopping and cooking; he buys healthy groceries and cooks good food. He eats and enjoys the healthy food I cook. Our family gatherings tend not to be laden with "bad" stuff. So that helps. Everyone is happy to let me have some "me" time to exercise. This is key!
SLOW AND STEADY: I'd go many days of staying consistent on my diet and then have a slip-up day. That's OK as long as you get back on the horse as soon as you have your senses back. Like, when hubby was hospitalized with a diverticular abscess; when both kids and us got sick with some nasty fluey virus; and when we went out of the country on vacation, and several other times, I did not pay much attention to my diet. But as soon as I could get back into any semblance of a routine, I started eating healthy again. So, over time, I had many more low-carb calorie-restricted days then I did "bad" days.
PICK A DIET YOU CAN LIVE WITH: I'm doing a South-Beachy-Style diet where I eat 3 meals and 3 snacks a day, so I eat SIX times a day. I aim for 1200-1600 Kcal daily. I like my eat-six-times-a-day-low-processed-carb diet because I like eating every two or three hours, and I like fruits, veggies and lean proteins. I don't miss cake, bread, pasta, cereal, cookies etc. because I feel pretty good on berries, yogurt, apples, cheese, big salads, grilled veggies, seafood and chicken, and nuts. It also makes the occasional really good hot bread slathered with butter that much more special.
WRITE IT DOWN: I got a 79 cent spiral bound notebook and write down everything I eat over the day, aiming at 3 small meals and 3 snacks, eating 6 times/ day, and calculated out to about 1200-1600 Kcal total per day. At first this involved looking up calories a it, but after awhile, I had all the calorie counts memorized. Clementine or small apple, 50 Kcal. Yogurt, 150 Kcal. 2 small hardboiled eggs, 160 Kcal. et cetera. I didn't stick to 1200-1600 Kcal all the time, and I didn't write it down all the time, but doing this most days really helped me stick to it. It also felt SO good to flip back over the pages after a few months, with the occasional weigh-ins recorded, and see the pounds just going down, down, down.
EVERYTHING IN MODERATION: It's OK to have the occasional slice of hot buttered good bread. A diet is not "ruined" by a big treat, or even a week of treats. You're in it for the long haul.
GET IN ANY EXERCISE YOU CAN WHEN YOU CAN: You don't have to go to the gym to get exercise. In the beginning, there were many nights when all I did was some core exercises on the floor by the side of my bed. I've worked up to at least two days a week of either running, or a gym workout, like Stairmaster and light weights. I try to walk with the kids, or even take one or the other out with the baby jogger. I try to use a basket instead of a cart at the grocery store, and switch arms like I'm lifting weights. I try to get out and rake, or shovel, or just fill the birdfeeders. Whatever, whenever.
GIVE IT TIME: Quick results tend not to be lasting results. The goal is fitness and health for life!
Since then, I've maintained a basically low-carb diet (with the occasional celebration/ feast), and a basic exercise routine (with the occasional lazy week), and I've continued to slowly burn fat and build muscle.
Now, I've gone from 163 pounds to 121 pounds. At 5 foot 2, this puts me at BMI 23!
I am not yet at my goal, which is for 50 pounds lost, back to my pre-pregnancy weight of 113 pounds. I'm trying not to feel like a failure because I'm not there yet. (How Type-A is that?) But I am proud of what I have accomplished so far, and I offer myself as an example to others, including my patients.
Here are some take-away points and tips:
GET SUPPORT: Last January, I stated my intentions to my family, and they were enthusiastic to help me. I work part-time, 5 clinical sessions of primary care, which really is a 40 hour week at least. My husband works as a writer and broadcaster so works from home alot but also travels alot. My mom helps with childcare, and we have a babysitter. So, in short, though I work alot and intensely, and hubby works, I have alot of support to help me with logistics/ kid care. But more importantly, my family has been all-in behind my efforts. My husband shares the grocery shopping and cooking; he buys healthy groceries and cooks good food. He eats and enjoys the healthy food I cook. Our family gatherings tend not to be laden with "bad" stuff. So that helps. Everyone is happy to let me have some "me" time to exercise. This is key!
SLOW AND STEADY: I'd go many days of staying consistent on my diet and then have a slip-up day. That's OK as long as you get back on the horse as soon as you have your senses back. Like, when hubby was hospitalized with a diverticular abscess; when both kids and us got sick with some nasty fluey virus; and when we went out of the country on vacation, and several other times, I did not pay much attention to my diet. But as soon as I could get back into any semblance of a routine, I started eating healthy again. So, over time, I had many more low-carb calorie-restricted days then I did "bad" days.
PICK A DIET YOU CAN LIVE WITH: I'm doing a South-Beachy-Style diet where I eat 3 meals and 3 snacks a day, so I eat SIX times a day. I aim for 1200-1600 Kcal daily. I like my eat-six-times-a-day-low-processed-carb diet because I like eating every two or three hours, and I like fruits, veggies and lean proteins. I don't miss cake, bread, pasta, cereal, cookies etc. because I feel pretty good on berries, yogurt, apples, cheese, big salads, grilled veggies, seafood and chicken, and nuts. It also makes the occasional really good hot bread slathered with butter that much more special.
WRITE IT DOWN: I got a 79 cent spiral bound notebook and write down everything I eat over the day, aiming at 3 small meals and 3 snacks, eating 6 times/ day, and calculated out to about 1200-1600 Kcal total per day. At first this involved looking up calories a it, but after awhile, I had all the calorie counts memorized. Clementine or small apple, 50 Kcal. Yogurt, 150 Kcal. 2 small hardboiled eggs, 160 Kcal. et cetera. I didn't stick to 1200-1600 Kcal all the time, and I didn't write it down all the time, but doing this most days really helped me stick to it. It also felt SO good to flip back over the pages after a few months, with the occasional weigh-ins recorded, and see the pounds just going down, down, down.
EVERYTHING IN MODERATION: It's OK to have the occasional slice of hot buttered good bread. A diet is not "ruined" by a big treat, or even a week of treats. You're in it for the long haul.
GET IN ANY EXERCISE YOU CAN WHEN YOU CAN: You don't have to go to the gym to get exercise. In the beginning, there were many nights when all I did was some core exercises on the floor by the side of my bed. I've worked up to at least two days a week of either running, or a gym workout, like Stairmaster and light weights. I try to walk with the kids, or even take one or the other out with the baby jogger. I try to use a basket instead of a cart at the grocery store, and switch arms like I'm lifting weights. I try to get out and rake, or shovel, or just fill the birdfeeders. Whatever, whenever.
GIVE IT TIME: Quick results tend not to be lasting results. The goal is fitness and health for life!
Wednesday, December 5, 2012
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.
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.
Tuesday, December 4, 2012
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.
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.
Monday, December 3, 2012
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
Wednesday, November 28, 2012
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?
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?
Tuesday, November 27, 2012
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.
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.
Monday, November 26, 2012
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.
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.
Wednesday, November 21, 2012
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.
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.
Monday, November 19, 2012
MiM Mail: Ready to quit
Hello to whoever might be reading this,
Thanks everyone.
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.
Wednesday, November 14, 2012
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?
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?
Thursday, November 8, 2012
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?
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?
Monday, November 5, 2012
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.
"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.
Thursday, November 1, 2012
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.
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.
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