Oh my god....

Yesterday, I collected a receipt from our daycare for tax purposes. In the past, I've always gotten the receipts on a month by month basis, but this time they had a receipt for the entirety of 2012. My husband and I couldn't stop staring at the number on the receipt:

$39,000

Spent on daycare. Before we pay our rent, before we buy even a single frozen chicken nugget. Just for daycare.

Wow.

Guest post: End of residency rant

One short, miniscule, month. And I can’t get my shit together.

I started medical school almost eight years ago. I had the world at my feet. I was married five weeks before med school started. My husband was in graduate school about an hour away. I had a wonderful social life, and the resume-padding was unbelievable.

Then, unexpectedly, just before the end of my first year, I was pregnant.

Now, I am blessed with three beautiful children, the same wonderful husband, a dog, and a cat. I am about to start an exciting, rewarding career. I have a loving family and, once we dig out from under the mortgage-sized debt of my medical training, the prospect of a secure financial future. My licensing exam is completed – and passed. My application for independent practice is submitted.

Tick, tick, tick goes the checklist.

So why am I so blue?

Because I am sitting in my “office”, in the basement, for the gazillionth time, while my husband puts the children to bed. I am supposed to be finishing my resident research project, but all I can think about is the sacrifice that went into this whole deal. And I feel like I just can’t do it one more time. I can’t sit down here, while my kids do their thing, while my husband cooks and wipes little faces and hands, and dresses and changes, and talks and explains and answers little questions, while he washes hair and towels dry and finds pajamas, while he surfs the net in lieu of my company and attention. I spent months studying for my exam down here. I still spend endless hours down here administering to administration, to licensing bodies and colleges and universities and evaluations and preceptors and the endless litany of mindless work that only I can do. And I just can’t do it anymore. I am utterly spent.

Where are the other medical mothers who feel this way? Is acknowledging this darkness akin to yielding to it? Because I have noticed that no physician who does creative writing in popular medical journals seems to get published unless there is a vein of hope, silver lining, outwardly optimistic, or putridly glowing endorsement of the profession tucked into the moral of the story. We only want to hear tales of physician woe if the tales end with the message that we are the fortunate, rarefied few who get to struggle in this way. We hold our noble heads high.

Give me a break. Give me the sweaty mothers who can’t afford a nanny or a housekeeper or even a babysitter for a night out. Give me the stressed out mothers with messy homes and offices and cluttered minds and hearts. Give me the medical mothers who nurse their infants while reading their journals, then feel guilty about splitting their attention. I want to befriend the other mothers who adore their children so much that their hearts break on a daily basis – yet can’t stand the same children disturbing their few hours of consecutive sleep. Give me the doctors who love medicine, who want to see patients all day and night, who listen to medical podcasts and fantasize about intubating crashing patients while doing their completely irregular workouts (it does get the heart rate up), who obsess over the evidence basis for PSA testing and feel crushed when they miss a diagnosis. I want to be friends with dedicated mothers and dedicated doctors, and I want to acknowledge the horror of combining those two wonderful people into one. Because it isn’t as pretty as it sounds.

So, as I sit down here, I just can’t get my shit together. I can’t decide if it’s all been worth it or not. On the very cusp of being “done” with training, with one foot raised and about to touch the start line of the rest of my life, I can’t decide. Or maybe, I’m a little bit sickened. Because maybe, I want to admit, that the sacrifice has been too great, and if I could do it all over again, maybe I just wouldn’t. Silver lining be damned. I’ve always wanted to be a mother, more than I ever, ever wanted to be a doctor. And while being a mother has undoubtedly made me a much better doctor, I cannot say that the reverse is true. In fact, being a doctor has stolen gaping wounds of time and attention from my mothering soul.

But I can’t bring myself to say it just yet. Somehow, despite the sickness in my heart, I just can’t say it. Perhaps the future knows something I don’t. Perhaps I just can’t bear to close a piece of writing on a negative note.  Maybe I am copping out, playing to the audience, telling you what I think you want to hear. I don’t know. So I sit in my basement office a little longer, the children are asleep, and soon I should be, too. Because tomorrow the children will want me, it will be my 27th-last day of residency, and there is still, always, work to be done.

Being introduced

My mother, not in medicine, and this mother in medicine, went to have a biopsy.  Her biopsy.  By a surgeon.  I am not a surgeon.  Nor am I a doctor for adults.  My day to day is infants, toddlers, school-aged children, tweens, and adolescents.  And medical students.  

How does your mom introduce you to her doctors?  My mother introduced me to the surgeon whom she herself was just meeting at that moment, as her daughter.  Sounds reasonable.  Started off well.  Though this was immediately followed by, “she’s a pediatrician.”  I paused briefly at the stark declaration, and softly came up with, “…who knows nothing about what you do.” 

Why did I demur?  Why so modest?  The surgeon and I might indeed speak the same language (though she much more tersely).  But I need not hover, make her nervous, nor imply that the reason I’m there is because I’m a doctor too.  The reason I was there was to support my mother.  As a daughter.

But alas, I guess I was also there because I do speak, or at least understand, that language.

[Results not in yet.  Somehow felt okay to post here on MIM in the interim.]

Mom's Group

Back when I was on my last maternity leave, forever ago, I joined a local Mom's playgroup.

At the time, it was sort of fun. We met up on the long boring weekdays and chatted. (We never ate, for some reason. We'd have these playgroups going from 10AM to 2PM and god forbid anyone would ever suggest having lunch. Mothers don't consume food, right?)

Eventually, I went back to work. And that was it for the playgroup and my playgroup friends.

I still get emails about the playgroups. They're always on weekdays, and even if I happen to have the day off, I'm usually playing catch-up on errands. And whenever I suggest doing something on a weekend, everyone tells me that's family time.

I think this is why working moms and stay-at-home moms can't really be friends, not because we have nothing in common. SAHMs want to fill their weekdays with activities, whereas on weekdays, working moms are either working or too exhausted to contemplate going out.

Still, it makes me sad every time I see those playgroup emails.

MiM Mail: Rank List Dilemma

Dear MiM,

I am a fourth year medical student anxiously awaiting March 15 (match day). I enjoyed almost all my rotations and nothing jumped out to me as "the one." I ended up applying in Emergency Medicine and Internal Medicine (2 different specialties, I did not apply to any combined programs).  I also have a toddler who IS my joy and passion. My ultimate career/mom goal is working as a part-time ER doc or as a hospitalist with a week-on-week-off schedule, which, as far as I could see, would allow me the most time to spend with my child while still practicing medicine.

Here’s the catch: my husband, also a fourth year medical student, is applying in General Surgery. I have no illusions about how much I would see him as a surgical intern/resident anyway, but to add to that, he's applying to programs that (while less than an hour away from where I hope to be) will necessitate him living away from my daughter and I for several months out of the year (the program he's looking hardest at rotates where I'll be a good bit). I want to stay where we live now because we have an  awesome/ideal amount of family support and a nanny that we love.

Most of my anxiety stems not from actual worry about intern year, but rather about never seeing my daughter. To that end, I'm basing my rank list on whichever program will allow me to spend more time with her (because, again, I love EM & IM both, and can't find another way to choose...also, she's my priority).

I've been able to negotiate with my favorite IM program a 3 months on, 1 month off format, which will extend my residency from 3 to 4 years (however, they're reluctant to do this with intern year, which I understand, but still isn't ideal). I am not sure if it would be better for my child if I was gone all the time for a shorter period of time or home one month out of four (but extending residency by a year). Stability vs. Seeing Mommy (at least sometimes). Of course this also has decreased salary and benefits. On the other hand, EM would mean not seeing her much at all on days when I work (usually 10-12 hour shifts) but then having whole days with her when I'm off (and still getting out in 3 years). There's also the night work, which means some more day time, but having to arrange night time care (fortunately, I am in a situation where I can do this).

I know no one can make this decision for me. Nevertheless, I appreciate the chance to get some feedback on my situation from people who might understand it better than most. Any thoughts on which one is more do-able (in the short and long run?). Rank lists are due Feb. 20 and I'm going back and forth on this.

Sincerely,

At a Crossroads

Should I go to medical school?

I have gotten several emails though my blog, some from people who found me through Mothers in Medicine, asking me for advice. I am so touched that people reach out to me. I used to answer these emails individually. I have not answered the last handful, for many reasons.

Most of all, these reasons are personal. Intern year is much different than fourth year as a medical student. I have had a lot more demands on my sleep schedule, my time, my emotions, and my responsibility. I haven't been blogging much in general.

I also did not match last year, and have spent most of this year questioning my dreams. I don't want to rain on anyone's parade with some sort of bitter reply. Which, I wouldn't necessary give, but I have to be honest in my answer. Being a single mother in medical school and residency isn't a piece of cake. But, being a single parent in this world isn't a piece of cake, either, and being a medical student and / or resident isn't a piece of cake. Foregoing medical school isn't necessarily the answer to any of that.

Here is some general advice I will share with parents, single or otherwise, who are facing decisions about medical school and residency. These answers cover a mishmash of frequently asked questions that come up in comments and emails. I looked it over, and I use the qualifier "very" a lot. I usually avoid that word, thanks to my father's influence. He told me to edit by replacing every "very" with "damn", and then to edit out the profanity. I have left them in, because this topic is very damn very challenging.

For single parents or parents whose partner will not be available for child care:

You will need to have a very, very flexible, very solid support system. For clinical years and residency, you will be expected to change what time you come and go on a moment's notice. The rotation you are on most likely will change every four to six weeks, and the demands, time wise, may change day to day on certain rotations. These hours can be as early as 5 am or even earlier, and you can be expected to stay way past midnight, even all night. Some of these times you can plan for, and some you can't. Living near family is very, very important for those of us who can arrange for that. It definitely can be done without family, but please keep in mind the expense and issues with screening and turnover of caregivers.

For people who are facing custody issues, possibly moving for residency, lack of familial support in their particular area:

I feel for you. Coparenting arrangements are very, very difficult. Depending on a lot of factors, you may need to be willing to move for residency, especially for certain specialties or even for some of your rotations. This may involve moving to a place your ex doesn't want you to move to, or moving to a place away from familial and / or social support. The judge may not look to kindly upon you leaving town with a child or children to a place where you know no one and will be working 80 hours a week, including nights, no matter how much you love your kids and parent well. And, there is a reason for that. Is it doable? Yes. Is it a good idea? Depends. Keep this in mind before embarking on medical school. This is one reason I wish I had done ARNP midwifery instead of medical school, occasionally. I wouldn't have to do the match for obstetrics residency. I had reasons not to go the nursing route then, and those are still valid.

For people trying to decide between nurse practitioner, midwifery, physician, and other avenues of the medical profession:

I really stumbled into medicine without a full understanding of how involved the process was, when it came to board exams, residency match, etc. I am still not fully informed on what it takes to be most of the other options available. Please research the nitty gritty, and you will still be surprised by the reality of how the sausage is made. I found studentdoctor.net. With all of its problems (and there are MANY), it is a decent place to find out practical details of many steps of medical school, from pre-med through fellowship and beyond, if you can fish through the trolling, bragging and nonsense.

As for whether or not you can handle it...sigh. I think we can all handle a lot. I think there are times at work, even at 4 am, in which I am exhilarated, and so happy that I chose my path. There are times when I am with my kids that are quality times, and everything seems to work out. There are times in which I feel completely overwhelmed, where I cry at work, and then cry at home because these kids who I wanted to desperately to spend time with when I was stuck at the hospital are bickering with me and with each other, and all I want to do is send everyone to their rooms. No matter what happens this March when I find out if I match in obstetrics or family practice, I will be happy as a physician. I will also have regrets. I think this will apply to anyone, no matter where their choices lead them.

For people who are older:

I was not the oldest person in my medical school. I am not the oldest person in my residency program. I think it is more of an issue with your peers than with your professors and attending physicians, who may be your age. They don't think they are less skilled, and may identify with you more readily than they do younger students. Some people may say it's a waste of investment of a medical school spot or residency spot that a younger person who would give more back deserves more. People say this about women in medicine, too, and that we want to go pop out babies and work part time when we are done with training. All these people can, um, stuff it.

For people who have a history in the "natural" birth community, i.e. doula, midwife, or are just crunchy types looking into medical school:

There is definitely room for us in all aspects of the medical community. I was pleasantly surprised by the diversity in my medical school and in the medical community. One of the first events I participated in for medical school was a social event at a bar, and one of my classmates, a massage therapist, was a few sheets to the wind and offering to balance my classmates' chakras in a wobbly kind of way. I sat next to a grandmother who caught her own grandchild at a home birth all of my second year.

However, medical school is long. Residency is long. It is a grueling, intensive slog. Make sure you are doing it to become a physician. If you want to be a doula, be a doula. I will not be a doula or a lay midwife if I am an obstetrician, or even if I am a family practitioner. It is not worth the effort to go through all the extra training, and the infrastructure is very inflexible and unforgiving. You potentially will be choosing battles constantly, and need to know your place as a matter of respect and experience and survival. Does that mean always stuffing it?  No. But, it means often stuffing it.


If there's anything I missed, please add it in the comments.

Liquid Gold

Breastmilk, girls.  That's what I call it.

I believe I got that name from a book I read while I was learning to breastfeed my daughter, Ce-silly.  "So That's What They're For:  Breastfeeding Basics."  Pause while I look up the author.  Janet Tamaro.  It was full of hilarious anecdotes.  I prefer learning with humor than by rote education.

With Ce-silly, I was obsessed and terrified of nursing and pumping.  I had a wonderful breastfeeding mentor, a resident two years ahead of me, named Mellificent.  No, she is not an evil stepsister, as the nickname implies.  She is magnificent.  I wrote about breastfeeding once before, you can read it HERE.  I recently re-read it myself so I wouldn't repeat too much here.  Eek.  I highly do not recommend re-reading old things you might have blogged - way too embarrassing.  I laughed as I read it though - implying that Cecelia was easier than my son Jack.  The beginning with her was oh so rough.  The cracked nipples, the bleeding, the feeling that every time your infant needed to nurse your sensitive nipples were being attacked by razors instead of baby gums.  I found breast shields, and used them until I healed.  I felt like I had been visited upon by a miraculous wonder masquerading as a piece of soft plastic.

I was in Conway last Friday - there is something magical about going to a different location once every month or so.  Pluses and minuses.  I am a fish out of water for sure (new electronic medical records, not my office with my reference books in my order) but I can relax in a way that I cannot at my home base in Little Rock.  Without the demands of my space - bills, kid things to attend to during my spare time - I open up a little more with the lab techs and administrators.  I was having a long hour lunch - a luxury for me.  I usually heat up a veggie burger and make lunch 5-10 minutes.

I was having a conversation about nursing with a lab tech and a lab administrator.  One of them told me her story. When she was having her first child, she was living in the Mississippi Delta.  Very isolated from family and friends.  It was back in the day when women came into the hospital in labor, were snowed with drugs, and woke up with a baby usually many hours old.  When the female nurse propped her new son on her lap, after she had woken from an unnatural slumber, she expressed a desire to nurse her baby.  This was what she got in response.  "What?  Nurse?  I have already fed your baby two bottles, and he took them better than most.  Are you going to ruin my efforts by trying to nurse him?"  Ouch.

The other woman at our common table in the break room expressed different, but similar reasons for not being supported in nursing.  It was in the eighties.  The eighties were tough for nursing moms.  My mom nursed both my sister and I in the seventies, but my brothers were born in the 80's.  My dad's best friend at the time, a great guy, was a formula rep. My mom was busy with growing her brood from two to four and her career pursuits.  Both my parents have individually expressed regrets to me about not nursing, especially my middle brother, who is seven years younger than me (I'm 39.  No really.  40 this year, ugh.  I mean yippee.  But I did get carded tonight, and she told me she had to card everyone she thought was under 30, so yay for that, it made my decade).  He has a terrible case of Crohn's.  I diagnosed that today on a biopsy, and thought of him.  He is a successful graduate of the Culinary Institute of America and holds a Ph.D. in food science from Cornell.  He has a great job in industry and lectures all over the country in his field.  Who is to say that nursing would have saved him from all his health issues?  Who am I to judge my parents here?  Our wounds make us who we are today.  They make us strong and successful.  We are our own worst critics, we don't need anyone else tearing us down.  Especially our sisters.

And do I sit in judgment of my lab tech friend and administrator friend for their issues around nursing?  Hell no.  I worked hard to nurse and pump.  I wanted to go for a year for both, but I did 11 months for Cecelia and 8 for Jack.  Do I look back at myself and see my failure there?  At the time, yes.  Now, no.  I am proud as hell for what I did there.  With all the support I had.  When I was at a very unhealthy juncture in my marriage, I let a freezer full of milk in an outside carport languish for months.  I was a veritable cow - could pump 36-40 oz. a day.  One of my friend's husbands at the time told me I should sell my milk online.  At the time I freaked out at the thought, but I hear there are donation stations for premies and I wish I would have investigated back then.  I finally asked my ex to throw the milk out in a fit of OCD cleaning while I cried in the house.  I could no longer face my own failure there.  I needed it to be removed from the premises, because the presence weighed on me like an anvil.  I was not organized enough to get my Hispanic sitter to use it or to even go out and get it myself.  I forgive myself.

My neonatologist dad is a great counselor for anxious new parents who are dealing with more than they bargained for.  He tells them this.  There are babies and toddlers in other countries and our own that survive on much less.  Rice filled with bugs and stones.  Peanut butter sandwiches for years.  But they survive.  There isn't much you can do to hurt this little one as long as you are loving it.  I agree.  Those babies grow up, some of them, to be so strong.  Wearing their wounds like a badge and using them to educate others and change the world.  Isn't that the coolest thing on the planet?

I wrote this blog last night, and was trying to insert a video from YouTube.  Was having trouble, and accidentally deleted my blog around midnight (a first in many years of blogging).  I was so upset, but resolved to finish it.  The video is Mining For Gold, by the Cowboy Junkies.  I'm not going to try to embed again, ha ha.  It is a cover of an old work mining song, original author unknown, as far as Wiki goes.  Ce-silly reminded me this morning when I was telling her of my bad night that of course she knew that song, it was burned in her brain, I sang it to her over and over when she was a baby and a toddler.  Go check it out on YouTube if you are interested.  It is a lovely song, and reminds me of why songs are so ubiquitous and full of empathy.  I can be nursing my babies, and feel the pain and glory of gold miners from many years ago.  We are all mining for different types of gold.  As Mothers In Medicine, our gold may take a different shape, but it's not breast milk really.  It's love for our children, and dedication to our jobs.  We are miners.

I went to a popular restaurant tonight in LR with a girl friend.  I saw my sis-in-law and her husband, toddler, and baby.  She was nursing her son at the table.  It was one of the most beautiful sights in the world; my head did a little dizzy happy spin watching her and reliving my own memories.  She is a path resident, following in my footsteps, and I am so proud of her individuality and unique spin on the path I took before her, in mothering and in medicine.

Thanks R, a dedicated fan, for e-mailing me last week and inspiring this post.  You are awesome - get to the gold mines, girl.

When Baby Is Not Sleeping....

When Baby is not sleeping, Mommy is not sleeping.

We need a sleep consultation!

Everyone with kids can relate to this issue, and I'm sure there's good advice out there. I'm open to hearing almost all of it.

The data:

Our Babygirl is 13 months old, perfectly healthy, and very happy. She's a chatty, impish little creature, with great dark eyes, so dark brown they're like Little Orphan Annie eyes- you can't see the pupils. She's adorable; we marvel at her cuteness multiple times a day. She laughs, giggles, babbles and imitates, playing to her fans like a pro. She's starting to toddle, and is so excited about walking, that's pretty much all she wants to do. That, and whatever it is big brother Babyboy (2.5 years old) is doing. She's a great napper, consistently and easily napping 2 hours around midday.

She'll go to bed around 6:30 if we have our act together. If I'm late home from work, or Hubby is late home from traveling, then the whole bedtime routine is delayed and/or fragmented, and sometimes, she's up until 9 p.m. Regardless of when she falls asleep, she's up many times a night, and then up for the day around 6:30 a.m., cheerful, chirpy, and ready to roam.

Lately, she seems to be waking up more then she ever has: one, two, three, sometimes four times a night. She cries until she has a bottle of warm milk. Then, she falls back to sleep, pretty easily.

If we don't go get her, she cries and cries until she throws up, not only requiring a crib change, but also  waking up Babyboy, who then needs to be comforted and rocked back to sleep, and sometimes also wants a sippy cup of juice... in short, total late-night messy disaster.

That is just not Okay.

Though it means sleep disruption, we would extremely prefer the usual (getting up to her crying, taking her downstairs where she will not wake Babyboy, warming up a bottle, sitting downstairs with her while she drinks it, and then putting her back to bed), to the cry-it-out, which results in unacceptable disaster and even more sleep deprivation.

We are, however, becoming very, very tired. I'm wondering if my patients and colleagues can tell how exhausted I am... A few seem to sense it and ask how I'm doing, and Is the baby sleeping yet? I get lots of free advice there too! Meantime, for the first time in my life, I'm drinking coffee in the mornings and the afternoons.

I am grateful to my hubby that he shares the overnight duties... when he is home. He travels a fair amount, and when he is away, I'm on baby-bottle call... This is hard, of course, when I have to be up at 5:30 a.m. three days a week to commute to the Big City to see my clinic patients. When he is home, and I have to be up early, he is on baby-bottle call... though I wake up anyways, as we moms all do when baby cries.

I am also grateful to my mom, who will keep Babygirl overnight sometimes, when Hubby is away, so I can get caught up on sleep.

Despite all that help, I can count on one hand the number of nights I've slept a continuous six hours over the past 13 months. 

I don't know how we got here, as Babyboy was magically sleeping through the night at 3 months of age. Somehow, we have a 13 month old girl who just wakes up alot.

I keep hearing from friends that cry-it-out is the ONLY way to get a baby to sleep through the night. Even if we have to line the bed with newspapers to catch the puke, and even if I have to sleep somewhere else, and even if we will all need therapy, that's the only thing that is going to work...

BUT, the people I know who have done cry-it-out with their own kids recall "those awful nights" with a shiver and some horror, like they're reliving physical pain. My aunt describes doing cry-it-out with her then-toddler son: they padded the walls with mattresses so as not to let his screams wake the neighbors, and then she cried, herself... she says she's still traumatized, and that was 30 years ago....

I just don't buy cry-it-out. We're not going to let Babygirl cry, puke, wake up the whole house, and then end up in therapy ourselves, or at minimum, reliving the horror every time someone else is going through the same thing....

There has got to be a better way.

So, making it clear that cry-it-out is not a viable option for us, I still put our baby sleep issue out there, to see what experiences, and even what advice, others have.

MiM Mail: Career impasse in academic medicine

I was so pleased to come across this blog while trying to research career options. I am currently at an impasse in my career and looking for some insight.

I am currently two years into my first position as a full-time medical oncologist at a major academic center. As a bit of background... I have been at the same institution for medical school, residency, fellowship and now as an attending. I am specialized within oncology, but did complete my board certification in IM, hematology and oncology so as to keep my options open in the future. I chose my specialty with no consideration of future family planning, but because I love these patients and find the work very rewarding.

I met my (now) husband in medical school and we have since married and have a 6 month old baby at home. He (my husband, not the baby) is also currently embarking on an academic career.

I am only now realizing the extent of sacrifice that will be required of both of us to have successful careers in academic medicine. I find that my priorities may be shifting now that we have a child and plans for future children and I am struggling to decide how to juggle my career and family. I am no longer sure I am willing to sacrifice so much time with my child for work obligations.

I am trying to see what opportunities may be out there for both clinical and industry work if I were to take some time off or switch to a part-time position for a few years or permanently. I am just not sure if I can take time off at this point in my career and expect to be able to find a position down the road.

What I do know is that my child will only be little for a short time and I want to be with him as much as possible.There are also certain financial issues to consider given that we are both in academics and have a pretty sizable amount of debt from med school.I would love any feedback from those of you who have been in a similar position. Particularly to those of you who have found part-time work.... is this a common situation? I know that at my current institution, it is unlikely that I would be able to stay on faculty part-time, so I would need to find something elsewhere.

Thank you so much for providing this blog as it reassures me that I am not the only one struggling with these decisions.

Guest post: When the Pediatrician Calls the Pediatrician

I was changing my daughter’s diaper the other night when I noticed some spots. There was a cluster of six or so around her belly button and a line of them tracing her bottom rib on the right. They were reddish-brownish-purple pinpoints and when I pressed on them, they did not blanch. She did not seem bothered by them at all. I, on the other hand, began to quietly freak out.

I am currently rotating on the pediatric hematology service where reddish-brownish-purplish spots that do not blanch are the opening line in a number of slow-motion tragedies involving such things as leukemia and bleeding disorders. Then again, they also play a part in a number of totally benign and boring stories like heat rash and bruises. Infant skin is like one of those word searches that looks totally random from a distance: a lot of what goes on there means nothing, but every once in a while you need to pay closer attention.

So I saw the spots and I wanted to call the doctor right away. It was 7:15pm, a totally reasonable time to call the on-call pediatrician. But I felt sheepish. When you are a doctor, calling the doctor can be awkward. You know all the questions they will ask. You have completed the physical exam that they would have completed if your child were in the office. You have your own differential diagnosis in your head, and you have a rational sense of when or if your child needs to be seen and what if any further evaluation they might need. Why, you wonder, are you calling someone else when you know the answer already? But then there is also a loud voice in your head that is screaming, “WHAT IF SHE HAS CANCER? WHAT IF SHE HAS BACTERIAL MENINGITIS? I KNOW EVERYTHING IS OK BUT WHAT IF IT ISN’T?! ACCCCKKKKKKKK!!!”

I called my partner, C, up to see the spots and she said, “Hmmmmm. Looks like she might have fallen against a toy.” I had to agree. I could almost make out the shape of said toy, a rectangle with one corner at the belly button and the other corner up near her rib. Still, I was not reassured. My partner doesn’t even know what petechiae are. “She’s fine,” C said and went back downstairs. Once again, the rational part of me had to agree. She was not sick. She was totally 100% well-appearing. This was a problem that could wait until the morning. This was likely a problem that was not even a problem. I resolved to let that be the end of it. I put my daughter to sleep and then got ready for bed myself. (Yes, I have the same bedtime as my one-year-old. This is what it means to be an intern).

As I lay there in the dark, it became clear that I would not be able to sleep. I worried about the spots. I thought about my patients and the day ahead. Then I worried about the spots again. That very day on rounds, our attending had told us about a case from his residency, a boy who presented to the ED with petechiae, eating his McDonald’s lunch, and was dead twelve hours later from overwhelming sepsis. Sure, he had sickle cell disease, and a fever, but I couldn’t put it out of my mind. I checked on my daughter and tried to palpate her liver without waking her up. I went back to bed. I stared into the dark. Nine o’clock became ten o’clock became eleven o’clock. I snuck downstairs and called the pediatrician’s after hours line, hoping my partner would not hear. I needed to sleep in order to function the next day, so I rationalized that it was for the benefit of my patients.

A nurse called me back thirty minutes later. We talked through the situation. “I’m worried she has petechiae, but she’s totally well-appearing.” The nurse paused. “If you’re telling me she has petechiae, she has to go to the Emergency Room.” “I don’t know if they are petechiae! They don’t blanch.” She paused again. “Well, lots of things don’t blanch. Are they more red or more purple, because if you’re telling me she has purple spots, she has to go to the Emergency Room, but red spots are fine.” I could tell she had sized up the situation and was trying to reassure me, but she was sitting in front of a protocol book and protocol books do not care about over-anxious intern mothers in the middle of the night. We went around and around a couple more times. “Why don’t I call the doctor on call,” she said.

As I waited for the return call, I sat in the dark in my office chair. I thought about my little girl. I indulged in some worst case scenario rumination. I imagined her having to go through the heinous trial of chemotherapy, the endless sticks and vomits. How would we even get her to sleep in a bubble-top hospital crib? I couldn’t imagine a hospital room containing her, so active and curious and on the move.

My thoughts turned to "R", a toddler who had died of leukemia while in my care. There are patients who travel with you forever, and R is one of those patients for me. Time does not make my memories of him less vivid. I was a sub-intern in the PICU at the time, a medical student in my last year of medical school. R had been transferred to the PICU in the middle of the night, gravely ill. I was out of my depth caring for him -- his oncologists were still talking about treatment while the PICU doctors intimated that he would likely pass away soon. I did not know who to believe and I didn’t have my own experiences to guide me. His room scared me, but I was also drawn there. I could sense that the work of love was being carried out there, despite or perhaps because of the terrible inevitability of his death. R was pale, almost colorless, and swollen from the chemotherapy and the cancer. He had lost all his hair and he was sleepy most of the time, but still comforted by the presence of his parents. He was so beautiful and I felt a tenderness toward him that I could not explain to myself. Every morning as I went through the familiar steps of the physical exam, I touched him as I would my own child. I wanted my touch to if not heal him, at least bring peace and rest to his suffering body. R’s heart stopped an hour before the end of my last shift and he was coded for close to an hour before his parents asked the team to stop. I hovered beside them the entire time, not knowing what to say or do. His mother sat in a rocking chair crying and his father stood behind her with his hands on her shoulders and there was so much in that gesture about their love for each other and their helplessness and their strength. After R died, they went into his room to hold him and everything became quiet. I had a flight to catch, so I had to leave, and I never had a chance to talk to them again. I think about him and them often, though I have never spoken about him to anyone.

The phone rang. It was the nurse. “I talked with the doctor on call and she thinks it’s probably nothing. Wait until the morning and if they are still there or you are still worried, call the office and make an appointment to be seen.”

“Thank you so much,” I gushed. “Thank you so much.” I wanted to convey to this person how grateful I was to her and to the doctor, whoever she was. “You have no idea what a gift that is.” I was crying, embarrassed and euphoric. The safe over-the-phone answer would have been to send me to the ER, but one of them or both of them had understood that if my daughter had truly needed to go the ER, I would have already been there. They understood that what I needed wasn’t medical advice, it was reassurance, and they had the courage to reassure me.

By the morning when I woke up, I couldn’t believe how scared I had been. In the light of the day, the spots were clearly a bruise. Two days later, they were gone, with only me to remember them.

I wonder how the situation would have played out had I not been a doctor. Either I would have made nothing of the spots, or called about the spots and ended up with a long and fruitless ER visit. Either way, I think the quality of the terror would have been less acute. The average person does not have a repository of worst-case-scenario images to match every sign and symptom. As a pediatrician, I didn’t need reassurance less, I needed it more.

I did not realize before the spots episode how much effort I expend maintaining a separation between the reality of illness that I inhabit during the day and the reality of wellness that I inhabit at home. Sometimes the one intrudes on the other in ways my rational self cannot prevent. I hope this will not negatively impact my daughter (or my partner, who relies on my medical judgment and was understandably shaken by this false alarm). On the other hand, I never take my daughter’s health for granted. The possibility of illness sits on my shoulder and reminds me to be humble and present, both for myself and my family and for all the parents like R’s parents who are suffering the unimaginable. It makes for a state of parenthood that is more anxious but also more alert and sacred. I am grateful in advance to all the pediatricians who will care for me and my family over the course of my daughter’s life, who will allow me to be afraid, who will give me the gift of reassurance, who will hold my anxiety in confidence and allow me to be a parent instead of a physician. 

Miriam Stewart is a pediatrics intern and lives in the Philadelphia area with her partner and thirteen-month-old daughter. She blogs about the joys and challenges of juggling motherhood and medical training at whatbeginswithm.wordpress.com. Details about "R" have been altered to protect patient and family privacy.

Part-time

I work part-time.

Some people think that women who work part-time are ruining medicine and contributing to the physician shortage. So I want to present my very reasonable list of reasons why I work part-time in a flexible job:

1) I am sick constantly. Constantly. My kids are Petri dishes. And it always lasts forever. Even as I'm writing this, I'm coughing and my left ear really hurts and keeps popping. Is it easy to work under these circumstances? Not particularly. Maybe mothers of small kids who work full time have better immunity than me. Or maybe they're just better at working while very sick.

2) I don't have family members who can quickly cover for me in a pinch. Like when the daycare calls, saying my daughter has conjunctivitis and must be picked up NOW NOW NOW. (Literally, I am required to show up within an hour. OR ELSE.) Ideally, I would have a babysitter who waits by their phone, constantly on call for just this situation. Do those exist?

3) If the workday "ends" at 4PM, that's the only way to guarantee making it to the daycare by 6:30PM. I have no back-up if I can't make it.

4) I kind of like having two days off to recover from the week. It's called a weekend. It probably seems crazy luxurious to you, but believe it or not, it's actually sort of normal to most people.

5) When I feel like I'm rushing around and getting pulled in too many directions and expected to do three different jobs at once, I actually get kind of stressed out. And depressed. I don't like feeling that way.

6) There are things I enjoy doing that don't involve medicine OR my kids. And if I work part-time, I get to actually very occasionally do some of them. It's important to me. I feel guilty saying it, but it's true.

7) When I am really stressed out, I am not super pleasant to be around. I start screaming at the top of my lungs and then burst into tears because my daughter won't put her sneakers on in the morning. I'm sure I have inferior stress-compensation (likely genetic) compared to full-timers, but I just hate being like that.

8) I have trouble with night call. I never liked it, but at some point, between waking up for my baby's cries and waking up to a beeping pager, my sleep became very dysfunctional and a major source of stress. I've seen professions to address it, and it's better, but I can't deal with working at night.

9) I don't have the physical stamina you do, apparently. After working a very busy 10 hour day, I am too tired to play with my kids. I was never a high energy person. Somehow, I didn't realize how important this was when I went into medicine. I wish I had the energy, but I simply don't.

10) I am not a Type A personality. I just can't do it all at once. And if I tried, I wouldn't do it well. Does that mean I shouldn't be a doctor?

Trust me, I feel guilty that I can't work the hours some physicians work. Sometimes I wonder what's wrong with me, that I can't seem to juggle the same number of balls as some other women. But I have found a balance of career and family life that seems to work for me.

I'm sorry I'm ruining medicine.

The Little Itty Bitty Ones: a.k.a. premies in the NICU

I didn’t think it would happen but I fell in love with my Neonatal Intensive Care Unit babies. Here’s how it went down:

Sign out prior to the beginning of the rotation: From the Intern finishing up her rotation: “everyone just survives this rotation, be prepared to write lots of total parenteral nutrition orders (TPN).”  Sign out ended with me congratulating myself that I hadn’t started crying just hearing how sick some of my new patients were.

Day 1: Examining those tiny babies had to be the scariest thing I have done in my life. I’m used to 6 pound babies in newborn nursery, not 1 pound babies who are ventilated and in incubators. I made it, my patients made it. I’m used to talking about urine and stool counts and giving breast feeding advice. I’m not used to talking about glucose infusion rates, assist control ventilation, bubbles CPAP, and making split second decisions based upon arterial blood gases and urinary output.

Weeks 1 - 2: struggled with patient management, presentations, note writing (many nights I finished around 10pm), and TPN. Struggled with missing Zo’s bedtime.

Weeks 3 - 4: started getting used to the routine and began enjoying deliveries (dry, stimulate, and ventilate). I also began enjoying the daily mechanics of managing my “feeders and growers” and even got to do a really cool creamatocrit to assess the nutritional content of a patient’s maternal breast milk. Surprisingly, I also started to really like managing my complicated patients and the daily brainstorming that goes on with our consultant specialties. Establishing relationships with the parents was really the best thing about this time and the staff who work in the unit are outstanding and know their trade exceedingly well. On the homefront, I still had not gotten used to the lack of sleep and was really started feeling badly about how junky our house was becoming and how my husband had essentially become a single father.  

Week 5: started feeling the first tinges of confidence or was that my upper respiratory illness superimposed with sinusitis and a head full of medicine? I guess I’ll never know, but I was sad on my last day. Sad that I had to sign out to another Resident (who I totally trust but still they are “MY” patients and families). Sad that I was just starting to become confident and then bam, on to the next rotation. Sad that I wouldn’t see the daily progression of the little itty bitty babies who had surprisingly stolen my heart.

Snowmaggedon/Snowpocalypse/Showers

For some states it takes a hurricane to bring it to its knees.  For Arkansas, it only takes a little snow and ice.

We had a big snowstorm here on Christmas night.  It started with ice, then 8 inches of snow came tumbling down. I had my brother drive me back home from Christmas dinner with my mom and dad, so I could trudge up the 1/2 mile to my car the next morning to get to work.  Well, that's a little exaggeration.  My partner had already texted me to stay home, because there wasn't much work, but I still had to get there on Thursday and Friday.  The power went out on Christmas night around 9:00, and didn't come back on for 5 days.  Luckily the kids were with their dad and stepmom, so I only had to worry about myself.

The first night I slept in my bed, but it was so cold the subsequent nights that I spent time by the gas fire on my son's twin mattress from his bunk bed.  Had the neighbors for lunch the next day - heated up Christmas Eve Chocolate Lightning Chili (thanks again bro!) on the gas stove with a fire starter.  It was fun and adventurous.  And dirty.  I didn't shower until that Thursday when I finally went to work.

My dad suggested I go to the OR - surely they would have a shower there.  He was right and the staff were inviting once I announced my status - they were a little wary of a disheveled woman in bulky sweaters, jeans, and combat boots.  My hike up to my car that morning took me through tangled downed power lines and fallen trees - I dressed for need and not professionalism.  My guide assured me that the shower was clean, and I would enjoy it.  He warned me that no one had used it in years.  I was so excited to get one after almost three days, I didn't care.

The water was tepid at best and the shower pressure was akin to a crappy light massage.  Once I had dismantled my clothing, however, I was all in.  I rushed and shaved and cursed my darned luck.  Swore the next day I would search for a better one.

Someone in flow (cytometry) told me the Baptist Rehab showers were pretty good, so I searched them out on Friday.  The locker room was clean with a surprisingly warm and modern decor.  I bumped into a Chinese woman who was obviously finishing what I planned to start.  We shared stories and empathized about our predicaments.  She lamented, with a heavy accent, about not being able to iron her uniform for work.  I worried about the water temperature based on my experience from the day before.  She said, "I like very hot water.  This was a bit of a disappointment, but it did the job."  As she was leaving I disrobed and assessed the situation.

There were two showers.  One was equipped for handicapped and one was small.  I normally like the larger environments - I'm pretty tall - but the drain was pooled with dark hair and chunks of unnamed stuff and that grossed me out so I chose the smaller shower.  Braced myself for another cold one but it was hot and lovely.  Left me wondering about the the standards of my new friend.  Did she like showers so hot that her skin boiled?

I was so impressed with the Rehab showers I went again on Saturday - I had to finish up a couple of tough cases before calling it a weekend and I needed to get clean.  Scanned the larger shower and it still wasn't clean.  Walked to the smaller one from the day before.  There was a problem.

Something was on the floor of the shower.  Bits - about ten or twelve, I gathered.  At first I wondered if it was dead bugs, but they were all different shapes and sizes so I rejected that hypothesis.  I looked back longingly at the larger shower, but the hair mocked me.  So I decided to grab a paper towel and clean the small shower.  I mean ten paper towels - protected my hands, closed my eyes, and scooped it all up.  Right before I disposed of it in the trash, I couldn't help but look.  The brown casing exposed green underneath.  Yup.  It was puke.  I almost dry heaved, but I didn't.  Kids prepare you for a lot.  I couldn't help feeling sorry for the poor soul that had puked there, and didn't have the energy to clean it up.  I wondered, cancer being treated with chemo?  Did they get a good swim in the pool before the shower incident?  I sure hoped so, and felt a little pride in helping clean up their mess.

I hosed down the shower with lots of body wash and scalding hot water (at least according to me - my friend from the day before would disagree) and jumped in.  As I lathered up, I thought about what my hardship had taught me.  That given the choice, I would choose a shower with puke rather than one with clumps of hair with chunks of unnamed stuff.  And I loved that I was put in the position to have to make that decision.  Life is full of wonderful surprises.

Thanks to all the good folks at Entergy we all had power within about a week.  Some were luckier than others.  Yesterday we had another ice storm.  I worked late, parked up at the bank, and walked down the hill to my street.  Had to crawl up my hilly yard covered in a sheet of ice, purse and computer bag in tow, to get to my front door.  Loved entertaining my kids, again thankfully with dad and stepmom, with that story on the phone.  Mom in adventure movie.  This time we've got power and the promise of a thaw by mid-morning.  There are lots of things in life to get you all in a tizzy, but this isn't one of them.

Hope everyone out there is warm and safe and power-ful, ha ha.

Inner Voices

On Monday my best friend from med school called from her car.  She usually calls me on Monday around noon and if it works we chat and catch up.  She has a drive to go to a smaller town to do clinics on Monday afternoon after working in her ophthalmology clinic in the morning.  It had been a while since we talked because holidays kept us busy.

Lys told me about her five year old daughter, who has amazingly beautiful curly hair that draws a lot of attention, and how she notices that she looks at magazines and seems to admire women with straight hair.  It reminded me of when Cecelia, now 9, was 5, and she used to admire women with blond hair.  I am blond, with the help of highlights in my older years, and Cecelia has beautiful brunette hair.  We discussed talks with our daughters about wishing for what you haven't got, and also trying to give our daughters a taste of what they wanted because we worried that by holding out and shutting down we might create obsession.  I remember buying Cecelia a wig.  Lys, who has gorgeous auburn locks, gets her hair straightened when she goes to the hairdresser, just for the day.  She is planning to surprise her daughter this Thursday by doing this when she gets her hair cut.  I can't wait to see the pictures.

My daughter Cecelia, who has been the same size for about 6 years now, has suddenly grown and blossomed this year.  We have gone through many wardrobe changes, with lots of tears and frustration on her part.  She is not overweight, but beautiful and curvy, without the height (yet maybe) on my side of the family.  She compares herself to taller, twiggier girls in her class and comes up short in her own mind.  It pains my heart.  I focus on healthy eating and mind makes us beautiful but our society makes it a tough battle at times.  I find that it is better to get her clothes that make her look good and feel comfortable so go to great lengths to make this happen.

We are reading a book that my Mom gave us called Iron Hearted Violet, by Kelly Barnhill.  I still do chapter books with the kids at night - one chapter before bed (most nights, anyway).  It is fantastic so far - princesses, dragons, Kings, and Queens.  Lots of adventure.  The young princess Violet thinks she is ugly, and despite her magnificent storytelling capabilities was shut down by the court for telling a story about an ugly princess.  "Princesses are supposed to be beautiful."  In the chapter last night, she is looking in an ancient mirror with carved, writhing lizards on the edge and judging her lopsided face and mismatched eyes.  Both my kids looked at the illustrations and defended her beauty.  Cecelia said, "She has such long, wonderful skinny legs."  Jack said, "Her hair is long and curly and so pretty."  I decided this was an opportunity.

"Well, that's her inner voice telling her she is ugly, but our inner voices aren't always true.  Everyone has an inner voice telling them they aren't good.  What does your inner voice say?"  Jack (7) was a little over enthralled with a recent gift of a lava lamp, so he didn't engage.  But I overheard a conversation he had with his older cousin Joshua at a pizza restaurant in Atlanta last week.  "Well, Joshua, I'd like to play soccer with you, but I'm not very good at it.  I hear from my Mom that you are very good.  I would be embarrassed to play with you."  I rescued him by suggesting that Joshua show him some moves, but our week was busy with cousin fun, so that didn't happen to my knowledge.

Cecelia did engage.  "My inner voice tells me I am not very good in sports."  She is trying hard in basketball this year, and got a goal at her dad's house for Christmas.  She may not be a star, but I love that she is trying.  More than I was capable of at her age.  "It also tells me that I have big cheeks.  Look!  Even when I smile I look weird."  She hammed for me on the bed.  I laughed.  "Cecelia, those are called chipmunk cheeks, and you got them honestly.  They run in my family.  I had them too.  On my first day at private school in 8th grade, the first thing someone said to me as I was walking in was 'Are you the new girl?  Oh my, you've got chipmunk cheeks!'  Good news is, they go away as you get older.  And they are very cute when you are young.  But I understand, I didn't like them much either."

I told her the story of my friend Lys' daughter and she loved it.  I reminded her of her longing for blond hair at that age and she (!!!!) didn't remember.  Last night I watched the Sheryl Sandberg Barnard commencement speech that was recommended in a comment thread, it was excellent.  We women do tend to let our inner voices dictate our lives and bring us down.  Not that men don't have them either, but her statistics are pretty telling.  I never really make New Year's Resolutions, but if I did, I would take that inner voice and toss it out the window.  And Cecelia's.  And Jack's.  But I know I can't do that, so I will keep trying to bring up this conversation about once a year so that they can voice their inadequacies and I can squash them.  Or at least try.  It's my job as a Mom.

MiM Mail: Surgeon versus family

I am so happy to have found this website!

I've been so torn between having a family and becoming a surgeon. All my life, I've wanted to become a surgeon, and I've never imagined myself doing anything else. However, family is super important to me and nothing would make me happier than being able to pass on my knowledge to a child or two. Given my career goals, I probably would only be able to have one child. But I'm still so confused about whether or not I should even have children. I love children but am too young to really gauge whether or not I want one of my own.

I plan on taking a few gap years between undergrad and med school, however even after two years out of undergrad, I'll only be 23 -- I don't know if this will be enough time for me to even find love, let alone a supportive husband and potential father of my children! I don't know if I want to extend my gap from two years to five so I can start a family. I don't know if I should wait until I'm out of residency. I just don't know. And I've found it so hard to seek guidance. Your website helps so much.

It's crazy how much my passion will impact my ability to have a family. But I'm learning so much just going through the blogs, and I'm looking forward to hearing more from you all. I'm so glad I'm not alone.

By the way, I'm 19 and a sophomore in college.