MiM Mail: New mom starting residency

Hello!

I am starting family medicine residency in June when my baby girl will be turning just 6 months old. My husband and I live apart due to his work, but he visits once a week. While I am excited to start residency, I am scared of  babysitting issues (besides the price) as I practically live like a single mother. I suppose I am seeking words of wisdom and encouragement from MiM, as I am afraid of the guilt and afraid of  being bitter about my career choice when facing the fact that I will spend most of my salary to pay someone else to raise my child for 3 years. Can I enjoy motherhood and residency at the same time?

Thank you!

I am getting old....

Last weekend, I took little Mel to a carnival, and BOY did that make me feel old.

I bought an armband to get unlimited rides because, hey, it's a carnival. About sixty seconds after buying the armband, I deeply regretted this decision. I think it was when I watched the passengers on one of the rides careening over my head and I almost threw up. I almost threw up just from watching the ride.

The first ride Mel and I went on was the ferris wheel. That seemed like a safe bet. It just went up and down, no spinning, no turning, nobody on the ride was screaming. But as it turns out, I'm now afraid of heights. When did that happen?

I wanted to keep my feet on the ground after that, so Mel convinced me to go with her into this funhouse. It was very much like this funhouse. However, unlike Olivia Newton-John, I almost killed myself trying to get through the rotating circle. Believe me, there was nothing sexy about my attempts to get through that stupid funhouse. Every time there was a spinning or rotating thing that I could avoid, I tried to do so. And the funhouse ended with a slide. Let's just say that I can't go down a slide anymore without spraining some muscle beginning with "gluteus."

As soon as she got out, Mel said she wanted to go again. I suggested she go herself. And the time after that too.

Next we got to a ride that was called "Optical Illusion." I figured, how bad could this be? It's just an optical illusion! When I got inside, it was just a single stationary walkway where the walls had spinning dots. But nothing was actually moving. Except the second I stepped into the walkway, it literally felt like the universe was rotating. I almost collapsed. I came running out the entrance, saying I couldn't go through with it.

After that, I mostly let Mel go on rides by herself. I noticed at that point that I was the only adult who was dumb enough to buy an armband.

When it was getting time to leave, I told Mel that I'd go on the Tilt a Whirl, because she'd been begging to go and she was scared to go alone. I was almost having a panic attack while we were waiting for the ride, but I kept telling myself it would be okay. Sure enough when we got on the ride, it was a lot of fun. But the second I got off the ride, I wanted to DIE. I was dizzy, nauseous, and I had a splitting headache.

Best of all, Mel still had tons of energy and wanted to ride like ten more things before we left.

I don't get it. When I was a kid, I used to LOVE all those rides. Tilt a Whirl was my favorite! What happened to me??? When did my brain decide that spinning and whirling isn't fun anymore?

Next topic week: On being an imperfect mother

We mothers in medicine may be very different. We've chosen different specialties, have one child or multiple, have stay-at-home husbands or husbands who travel for work more often than they are at home, are of advanced maternal age or had kids at an age earlier than average, have different ideas of a balanced life. But, I can guarantee we have at least two things in common: 1) we are trying our best for our children; 2) we are not perfect parents.

Our next topic week starting April 29 will be about celebrating our imperfections. (During topic weeks, we feature posts by our regular contributors and guest posts submitted by readers, all centered on a specific topic. During previous topic weeks, we've covered everything from a day in the life to work life balance to childcare.Well, they started as topic days but we realized we had so many posts that we needed to spread them over a week to avoid massive post fatigue.) Posts may cover anything related to being imperfect - confessions, reflections, laugh-with-me-so-I-don't-cry stories, personal philosophies on parenting, you name it. 

We hope you will join in and write something for topic week. To be included, please send your submissions as a Word document attachment to mothersinmedicine(at)gmail(dot)com by April 28. Submissions can be anonymous. For more examples of past topic days/weeks, see Labels in the sidebar.

Thanks for reading and making MiM such an amazing online community.

Most Embarrassing Doctor Moments

I'm a tall girl.  Not an amazon (wish!) but a healthy 5'9.5".  So I like the handicapped toilet better than the regular toilets.  I feel like I am sitting on a regular chair, rather than a child's seat.  Much easier to get up afterwards.

Once, about five years ago, I went to the bathroom at work.  Stopped in a public hallway one on the way to a thyroid needle in another building.  Walked straight back to the handicapped stall and got situated.  All of a sudden I heard someone speak.  "It's ok Mom, just try to hold it.  The stall is occupied.  I am sure they will be out soon.  Sorry for your wait."  I looked down through the gap under the bathroom door and saw wheels.  I was mortified.

I quickly attended to my business, all the while sweating and stressing.  Not only was I an able bodied, ambulatory individual, I also had my doctor's coat on.  I flushed, got dressed, and decided no way in heck could I walk out wearing that coat.  I took it off, rolled it up, and stuffed it underneath my armpit.  Took a deep breath, opened the door, and muttered my apologies as I escaped the bathroom to my needle.

I am still guilty of using the handicapped stall in restaurants, but not until after I have cased the area for those who might need it for reasons other than comfort.  I have not since used the handicapped stall at my hospital, despite never having seen another wheelchair in that particular bathroom in the last five years.

MiM Mail: College freshman fears

Dear MiM:

I am about to finish my freshman year of college and have started to second guess my dreams of becoming a doctor. I know, it's early, but each step I take now is one step closer to my future. It's somewhat silly, and I have so much time, but my fears are haunting me:

1) Prerequisites for med school: I have yet to take chemistry at a college level. I am terrible at math and chemistry and fear that I don't have what it takes to even make it to med school (or in med school)
2) Nausea: I have somewhat of a weak stomach and am concerned about certain rounds. I know it's part of the job, but not EVERY job, right? Fainting or throwing up is probably not received well.
3) I am 100% positive that I am currently dating the man I will marry. Which means that marriage will come right before med school (and grad school for him) and, more than likely, babies to follow. I know that you women do it everyday, but it seems so daunting. Especially since we will more than likely have to move away from our families in order to both be able to attend a school in the same town. But on the flip side, I don't want to wait forever to have children, and even waiting until my early 30's seems too long to wait for my desire for a large family.

Thank you for reading this and attempting to ease a potential MiM's fears. Likewise, if you truly think I should not be in medicine due to any part of this, please be honest.

When shared parenting means you are no longer number one

Recently, my daughter went through a period of preferring my partner, her other parent. For about a week, I would come home from work, starved for time with her,  and she would run to my partner and make a big show of hugging her and demanding to go into the kitchen with her. At dinner time, she refused to be fed by me, accepting food only from my partner, her Baba. At bathtime, I would have to pry her from her Baba and endure her bitter tears as we trudged upstairs for what is usually our most joyful time together. I was on a particularly miserable month, working the longest days I've worked all year and feeling resentful, bitter, and guilty almost every waking moment because I was spending so little time with her. When this theater of cruel preference happened for the first time, I went upstairs, turned on the bathroom faucet, sat on the tile floor, and sobbed for fifteen mintues. Then I came downstairs and tried to be as cheerful as possible as I sat next to the high chair and watched dinner progress without my participation. The situation was no fun for my partner either, as my time at home is the rare window of relief when she can check her email and recede into her own mental world for a while. Only E seemed to be having a ball, cocking her head to one side and making flirty toddler eyes at my partner while pushing my hand away from the food on her tray.

A male colleague once complained to me that his son prefers his wife, even to the extent of screaming and pushing him away when he goes to to pick him up in the morning or comfort him at night. As he told me this, I'm ashamed to admit that I thought, "Well she is his mother," as if motherhood is synonymous with being a child's primary go-to, as if a father should be resigned to being second pick. Well, here I was faced with the same situation and I was not resigned. 

I am not my child's primary caregiver. As an intern, I work until 6pm on the best days which are few, 7pm on most days, and 9pm on the worst days which happen at least 1-2 times per week. I have a week each month where I am gone from 6pm - 9am six nights in a row. The rest of the time I leave the house before my child wakes up and then I do bath and bedtime whenever I can, which is 3-4 days per week. Every day I have off, every evening hour that can be squeezed from the stone, every hour I can delay going to sleep post call, I do, but it still doesn't add up to 50%. Not even close. So I am not my child's primary caregiver, but up until the aforementioned week, I was pretty sure I was her go-to, her first draft pick. After all, I carried her and birthed her and nursed her and I am the only one in this family who takes rectal temperatures, let the record show. Prior to this episode, she had always been pretty happy with either or both of us, absorbing the love and care and attention of whichever of us was available at the time, so the assumption I had made about my being somehow more sacred and important had never been tested.

It was not a pleasant situation. In fact "My child will prefer her other parent" is probably number 2 on my list of top fears about being a working mother, right after "My child will be maimed or die while in someone else's care." I googled "My child prefers her other parent" and discovered that this happens to lots of people. Some children prefer their working-outside-the-home parent to their working-in-the-home parent and for some it is the other way around. In families where both parents work, the preference cannot be so easily explained away. Sometimes the preference is temporary and sometimes it is more deeply ingrained. In families with multiple children, one child might prefer one parent while another child prefers the other parent. None of these preferences seem to fall easily along gender lines. It was comforting to read post after post about this problem, but none really addressed my fear which was that by working so much, I was losing the right to be my child's number one. (Of note, I encountered not one post from a man complaining about this. Do men just not post on online parenting forums? Is this something that does not disturb them? It's an interesting question.)

When I was forced to examine my need to be number one, I realized that the whole construct is flawed and not relevant to our family. I was our daughter's primary caregiver for the first six months while my partner finished graduate school, now she is the primary caregiver while I am in residency. We have divided the work of parenting in a way that feels natural to us and that has nothing to do with traditional divisions of labor. My partner cooks. I deal with illnesses and sleep. We both work and make money, though my job is currently more time-intensive and less flexible. I'm good at helping our daughter achieve developmental milestones, my partner is good at structuring her days and giving her the downtime she needs. My daughter has two parents who work cooperatively to meet her needs and I'm very proud of that.

I'm not going to pretend that this transition in my thinking has been seamless or complete. There are still moments of panic and jealousy that my partner is so much more present in my daughter's life, for now. Thankfully, the phase passed and my daughter is back to taking the love from wherever it cometh, but I can't deny that I am secretly pleased and relieved when she leaps ecstatically from my partner's arms to mine when I come home. But I am teaching myself to be just as happy when she leaps from me to my partner, because the net of safety and love that protects her is so much stronger than it would be if she were relying on only one person to meet her needs. If I weren't working so much, things might have played out very differently in the dynamics of our family, so in a way I'm glad that necessity has created the opportunity for a more shared model to evolve. Ok, I'm not glad. But I do think some good has come of it.

Muffin tops, belly jiggles, and other mommy "war scars"

Zo will be 2 years old in a few months. I was very healthy prior to and during pregnancy; I regularly did prenatal yoga videos, walked daily, and even did Zumba until I was 5 months pregnant. Sometime during my 8th month, I developed an abdominal hernia. I knew it needed to be assessed, so 8 weeks post partum, I went to see one of my favorite Professors. He is a round-bellied, wonderfully abrasive Surgeon with a penchant for throwing things in the Operating Room. He’s a no-nonsense type of guy with a plethora of jokes and a desk with an ample candy jar. He is an excellent Surgeon and his patients love him, and I guess at the end of the day that’s the important part.

During my appointment, he examined my hernia and said “just wait until you pop another one out before doing anything with this.” I asked about the extra flub and stretch marks and he said “give yourself a year, things should tighten up by then”.

18 months into the game and although I dropped the baby weight quickly (another perk of nonstop breastfeeding, a healthy diet, and frequent stroller walks), these muffin-top-wiggle-jiggle and hip flub-shakes just does not want to budge. My various corsets and girdles help to camouflage it when I want to appear shapely, but nothing helps when I am naked or even worse when I am at my beloved Zumba class shaking it up in workout gear with all of the skinny-minis.

I started working out again (ie, getting in a once a week Zumba class or some core strengthening training on Youtube while Zo is asleep) a few months ago. I looked at my bulging belly and hips and cringed. O is happy that I no longer look as malnourished as I did between 4 to 6 months of nursing, but neither of us loves the extra jiggles and low self esteem that come with them. I began to understand how folks slowly become overweight and out of shape. It’s like a slow decay creeping in. One day you skip a workout and then a few weeks later you realize you haven’t worked out since God-knows-when. You see your morphing shape and think (through my Pediatrician’s lens), I am soo tired, who has time to work out when I am trying to feed my family and cuddle my baby before going back into the NICU to keep really sick babies alive?!?

But it is important. And I do have to make time. I realized during undergrad that I need to work out. My body, mind, and spirit need it. When I am in shape and feeling good about my body, it is amazing. When I don’t exercise I feel downright yucky. Add replacing my beloved six-pack abs with this stretch-marked-middle-jiggle and you get the picture. Folks (my mother) who have seen the immediate post-partum belly and what I have now say it’s not soo bad, but to me it is.

I have vowed to continue to shake my mommy-bulge at Zumba and try to step up my efforts. I am planning on tightening up what I have so that I can feel better about the new mommy-me. These are my war scars. I’m in the trenches. Mommy-pouch boot camp begins now!!!

MiM Mail: Didn't see this coming

Dear MiM,

I've been following your posts since before I began Medical school!  I'm currently an M3, my journey has been far from traditional.  I put my medical school dreams aside after college to help out at home and take care of my mother.  Fast forward many years and I began my medical school career at 33 as a daughter, wife and mother of two gorgeous little girls (5 and 2 at the time).  It has been a lonnnnnng road needless to say.  Just three years later, I face M4 year and residency as a single mother of two living back home with my mother.  The ex's insecurities (non-medical) and later infidelity became too much to bear.  Although, he is a phenomenal father - very hands on and picks up a lot of the slack.

So, to my current state! I'm two clerkships shy of completing 3rd year and have yet to find my "calling."  I absolutely loved OB and I keep saying if I were single and 10 years younger, I would totally do it.  I love EM, but do I really want to put the girls through not having their mom so much at nights, weekends and holidays? I felt as if FM didn't get the respect that they deserved, and going through one more day of rounds in IM would have been the end of me! Psych, so help me God, if I fell for one more drug addict's story, I was going to institutionalize myself.  Peds left a sour taste in my mouth due to the company....

So now what!? I apologize if I offend anyone, I'm just trying to be honest and show you a glimpse of the million things in my brain.  I need to be moving, I love variety, and I'm a hard worker! But let me be honest to myself! I'm 36 and I'll be almost 500K in debt when we graduate! What's going to pay the bills, provide my daughters with a mother, and allow me to be a great physician?

After residency is over, my oldest will be 12 and youngest 10. So much time they and I have sacrificed and for what!? For their mother to have no clue how she's going to move forward alone and completely in debt? Did I mention the divorce lawyer said I'm confined to my state for residency or risk losing the girls? As if finding a residency wasn't hard enough.

I just need advice. I have no idea what to do.  I've kept it together this long and now the pressure to make a decision on a career seems to be putting me over the edge.  I just didn't know the amount of sacrifice medical school would entail.  I know there is always light at the end of the tunnel...but at this point I would have never done this had I known. Obviously my love for the field was more than my love for my marriage because I chose medicine over it. The question now is: how do I make all the sacrifice pay off?   I need direction and I can't talk to my 26 yo single friends who make it seem so simple.  For them with no responsibilities, it is!  At this point I just feel like I've been a completely selfish person having decided to ever pursue this and I feel obligated to pick a field that will help me start repaying my time lost with the girls.  Is that even possible?

Sincerely,
Selfish Mommy

Part-time Residency

Apparently, some residency programs lately, notably in pediatrics, have been offering the opportunity to do residency part-time. According to a Newsweek story, about a quarter of pediatrics programs nationally offer this option. It sounds like the programs may offer reduced call schedule and months off, all with a prorated salary.

If anyone who has done a part-time residency wants to weigh in on this option and what it's been like for you, then that would be great. But according to the article, hardly anyone does it.

Considering a lot of pediatrics residents have children during residency and then choose to work part-time after graduation, it seems like this would be an option more people would choose. Granted, it does extend residency about about 15 months and who wants to be a resident for an extra year? Still, what's an extra year, really?

The article hypothesizes that women don't choose this option because they want to be taken seriously. We don't want to be labeled as the part-timer and have that follow us our entire career. I've noticed a general theme in medicine that women often don't want to be granted exceptions because we want to be equals. Yet.... do we wanted to be treated as equals? Yes, we want to be treated with an equal amount of respect, but I personally feel like we're not equal. So I'm not sure if I want to be treated just like a man.

If there had been a part-time option in my residency, I don't think I would have taken it. It probably depends what it would have entailed. We didn't have a heavy call schedule and the days weren't long, so the only thing they could have offered me would have been blocks of time off, and I'm not sure how much that would have helped me.

Motherhood changes you: cooking and hair braiding

This is not a story of the profound and amazing ways that motherhood changes you.  Its about two simple ways that it has changed me.

Before I had my daughter I had NO domestic capabilities.  I could read directions from a cookbook but my husband was the adventurous one in the kitchen.  Also, despite having a lot of hair, I was completely incapable of controlling it!  When my family members found out I was having a girl, after the congratulations many of them laughed at me and said they felt sorry for my future child and the ridiculous hair she was bound to have!  However, on this almost last day of my vacation I find myself cleaning the kitchen to prepare for tonights culinary adventure and tonight I will engage in a hair-braiding adventure with my beautiful girl in order to be ready for church tomorrow.

My daughter LOVES food.  She is the smallest child in her daycare class but requires two breakfasts in addition to the one dad gives her on the way to school, gets a double portion of lunch and eats two snacks and an adult portion of dinner.  She is a rail thin ball of energy.  She devours everything I make. She smiles and licks her lips and yells things like "SO GOOD MOMMIE!!!!  YUMMY IN MY TUMMY" and my favorite, "I LUB IT!!!!!!"  She loves all the different cuisines I try, Spanish food, Indian dishes, Caribbean dishes, attempts at French cuisine - and it just fuels me to cook more and more.  Thanks to the Pioneer Woman and my Le Creuset pot (a gift because there's no way I could afford one), I am a cooking machine.  My mom gave me a recipe book of family dishes at my bridal shower, I had barely touched it before my daughter was born, and now I use it once a week and I've added a few dishes of my own.  With my busy schedule its something I enjoy and can share with my daughter and provides her with meals even when I'm away from home.  Motherhood made cooking about love.

My baby girl was born with a head FULL of hair.  At two she has a beautiful head full of soft curly hair that stretches down her back.  My husbands hair wrangling abilities are measly at best so I needed a way for her to get to daycare looking un-hobo-ish in my absence.  So with the help of wikipedia and my dads response to my mom mentioning my hair braiding insufficiencies that "She can do anything she wants to do, no reason it will be any different with hair braiding" - I decided to figure it out!  Now each night after bathtime, we sit and watch Dora and I braid like crazy.  I treasure this time with my baby and when I'm done I tell her to go show daddy her "princess hair" (everything must be princess something right now).  She smiles so big and touches her hair and runs to the mirror.  All love.

What Would You Do: An Encounter At The Playground

So I had some free time on a lovely Saturday morning a few weeks ago. I wasn't on call, and I had no major errands to do. Babygirl was due for her nap, so I left her with her dad, and took Babyboy out in the jogger stroller, to the playground.

The playground is very large, with a baseball field, a grassy stretch, and several sets of gym equipment, slides, swings, and a sandbox. Babyboy always aims right for the sandbox.

There was a dad there, with two kids, a boy about 4 years old, and a toddler girl. The boy was doing his own thing, digging under the swings, and the dad was following the toddler around. We didn't interact really, except when Babyboy ran over and grabbed one of the boy's shovels and took it back to the sandbox. The boy didn't seem to notice; I apologised; and the dad nodded that that was fine.

I was sort of playing with Babyboy and sort of spacing out for awhile. It was a clear, sunny day. I heard the Dad say something like, "Son, your sister needs a diaper change, so I'm going to go do that, alright?" I figured he must have brought a diaper bag.

Some time later, I idly turned towards where they had all been, and there was only the boy, still digging under the swings. The dad was off in the distance, carrying the toddler girl,  probably a good football field's length of distance away. I watched as he kept going, down the road, up the stairs to a house, inside, and shut the door. He never even looked back.

Now, this is a big playground, with parallel fences on two sides, and parallel roads on two sides. The road entrances are not gated, they are open to traffic. One of the roads is heavily traveled. It would never occur to me in a million years to leave any age child unattended there.

Though the little boy didn't seem worried that his dad had taken off, he did suddenly seem to notice us. He saw me watching him and smiled. I felt terrible for him, being left alone like that. I felt responsible. I smiled back and called over to him: "Hey, want to play in the sandbox too?"

He got up and ran to us, happily, and both boys dug in the sand, not really interacting. Then he hopped up and ran to the slide, and went down a few times, running around it and giggling. Babyboy was taken by this. Babyboy doesn't seem to like slides much, but is fascinated when other people go down them. The kid kept running around and Babyboy watched.

I thought about this dad leaving his kid alone in the playground. He didn't even ask me if I was willing/ able to watch his kid for a few minutes. What if he had? I would have said yes, but I would have felt a bit put out. We weren't planning on staying there forever. Also, he didn't even know aything about me. He didn't know I was a responsible physician. I could be a kidnapper. Or just irresponsible, and leave the kid totally alone.

I thought all of this, and wondered if I would say anything when (and if) the dad ever got back.

Then, after a total of about ten minutes, the dad reappeared at the far edge of the playground, with the daughter. But they didn't come right back to where they had been. They dawdled way on the other side, while she toddled around on the grassy area.

Meantime I was kind of annoyed. Babyboy and the abandoned boy were sort of digging in tandem. Babyboy kept grabbing things from him though, and he was getting feisty. I kind of needed the dad to moderate.

As soon as he came close enough I planned to pack it up. He did walk over, calling to his son that it was time to go.

I didn't say anything.

What would you do?

1 step foward, 2 steps back

My husband and I went on our first vacation sans bebe. It was magical. Nestled in the hills of a Midwestern state, we drank lots of wine, watched tons of movies, got a couples’ massage, and even managed to do some work.

At 2am the day before heading home, we received a frantic phone call from Zo’s grandfather (my father) and our babysitter while we were gone. Zo had a fever, to 102! Granddad was ready to head to the ER. Vacation-mode-mama put her momma-doctor hat back on. Triage mode: he was indeed fine (eating, drinking, pooping, peeing) and most likely just had viral upper respiratory symptoms. Watch and wait I told Granddad. We okayed foregoing fitful sleeping in his pack-and-play for cosleeping and Zo happily snuggled with Granddad until breakfast.

Flash forward to our return. Zo was a febrile, coughing, sneezing, whining fussy-fuss-face with 2 molars and 4 teeth coming in. We returned to purgatory and Granddad went guiltily back to Grandma. Our week went like this: waking 5 times a night for cuddling because self settling just would not do, alternating ibuprofen and acetaminophen, a trip to the Pediatrician for an ear, throat, and lung check, and finally the dreaded call from daycare “Zo is fussy and has a fever, please come get him.”

And every day he kept having fevers so he ended up out of daycare for an entire week. The gains O and I had made in sleep and patience quickly evaporated and now we are back to a little one who wakes up multiple times throughout the night to be consoled. What is this behavior?!? Who is this tyrant? Not to mention we ended up in the Emergency Room at 3am (post to come). Our week was one of my most difficult of Intern Year in spite of being after a 5 day vacation while on an elective; 1 step forward, many many many steps back.

I start a week of nights tonight and O will be on his own. Fingers crossed and prayers uttered that Zo gets with the program and begins sleeping through the night again. We are soo very tired but Zo has made it successfully through his first day back at daycare.

**** Shout out to Fizzy for your timely post entitled “Need a Vacation”. Vacations are work and I’m not sure if they are worth it at this point either ****

MiM Mail: Delay fellowship?

Hello! Longtime reader here! I am a third year Medicine resident at a notoriously grueling program in the southwest (which I love and would choose a thousand times over if I had to do my Match again...) on the brink of finishing my residency. I am heading into a Chief Resident year which should be a nice break - at my program we are junior faculty, paid as such but only attend for two months and have 10 months of administrative and educational work. I am mom to one lovely 9 week old baby girl. My husband is not in medicine and is currently a stay-at-home dad. I'm struggling in my decision of when and whether to pursue fellowship, and here's why...

As an intern I fell in love with critical care. I loved the fast pace, the gratification of seeing a septic shock patient turn around in hours, loved working with a big team of folks to bring someone back to health. I even liked the end of life issues and family discussions. I liked the idea that even when I had nothing in the way of medical treatments to offer I could still help the patient (and more often, the intubated/sedated patient's family) come to terms with the end of life. I did a block of Pulmonary Consult at our large tertiary referral center and found the physiology and multisystem diseases that involve the lungs very interesting as well.

I'm not sure what happened this year - if I just got tired and burned out (we have 4 ICU blocks a year, still have 30h resident call q4, minimal outpatient stuff) - but I grew tired of the same old thing in the ICU. I got annoyed when families wanted their 85 year old grandfather with two primary cancers and septic shock to be a full code. I got tired of the overdoses and alcoholics in DTs we see at our county hospital coming in night after night, their self destructive behavior the reason for thousands of our taxpayer dollars being spent to dry them out, extubate them, and discharge them to homeless shelters or broken homes to continue their substance abuse. Even some of the pulmonary sub-specialty patients started to annoy me; most of them are in and out of the hospital frequently and have been sick all their lives with congenital heart and/or lung disease and have the "sick person" mentality.

After slogging through months of call while pregnant and finally having my baby girl here with me - the thought of heading into fellowship after my Chief year makes my stomach turn. I am so tired of being a resident! The toddler inside me is stomping her feet and wants to be the BOSS already and stop having to run everything by an attending all the time. I'm tired of 80 hour work weeks. I'm exhausted.

I am considering taking a year to work as a hospitalist and consider my options. On one hand - hospital medicine pays enough for us to live comfortably, in my opinion (I did not grow up with much and neither did my husband) and the moonlighting opportunities in my area would enable me to very easily make an extra $50K by working three very easy nights a month. Scraping along on $50K as a fellow for three more years makes me feel sick...and we want more kids - it would be way easier to do that as a hospitalist than a fellow in a program with 3 or 4 fellows per year.

On the other hand - in my heart of hearts I fear general hospital medicine will not be enough for me. I want to be a specialist - someone who is consulted to assist with a sick and complicated patient. I like pulmonary medicine and while I would probably not do critical care full time or even half time, I wouldn't mind keeping a toe in the water in an academic Pulm/CC position - a few consult months, a few inpatient ICU months, etc. I can't imagine doing any other fellowship really...so if I do specialize, I think Pulm/CC is it for me. And I fear if I go the hospitalist route I will never go back to do my fellowship.

Any ideas? Is it better to do fellowship now when my kid(s) are young? Should I just gut it out a few more years and get through it? If I wait to do fellowship, my kid(s) will be older - won't they miss me more? But I can't stomach the thought of doing a fellowship now. Would love to hear the perspective of you brilliant ladies :)

Things Aren't Always As They Seem

I saw a thoracic surgeon in the doctor’s lounge today.  I have read his cases and frozens for a year or so, but never introduced myself.  I still get intimidated in that man’s world of the doctor’s lounge.  It's not just me, my female partner was urged by her male recruiter to eat with him every morning in the lounge when she started seven years ago, and chit chat with the men.  She said although she realized he was trying to be nice, it was excruciating and she bowed out politely after a few weeks.  Walking in there is like walking into an all male club room.  The thoracic surgeon was sitting around the table with a cardiologist, an OB/GYN, a surgeon, and a hospital administrator.  All men I knew individually, but I’m a silent parasite in the lounge, at least during the morning rush.  I breeze in, grab my coffee, smile and wave occasionally, and breeze out.  I wanted to talk to the surgeon about a case, so I waited until he finished regaling an entertaining story about his son’s report on a holiday for school, took a deep breath after grabbing a couple of hard boiled eggs for my lunch in a few hours, and walked over to the table. 

“Hi, I’m Gizabeth Shyder.  I don’t think I’ve met you before.”

A couple of hours earlier I had read a frozen for him.  I called him on the OR bat phone.  Gave him my diagnosis.  “Abnormal lung.”

He countered me sarcastically from the OR.  “Um, abnormal lung?  Is it benign or malignant?  Do you see signs of DAD (Diffuse Alveolar Damage)?”

I took a deep breath.  We use the words Abnormal Lung as a catch all for interstitial lung diseases, which are notoriously difficult to diagnose on frozen section.  Of course I had combed the patient history and knew that cancer wasn't high on his differential.  He wanted more, however.  I gave it to him.

“Well I don’t see any hyaline membranes on frozen section, but they are much easier to see on permanents.  There isn’t much well developed fibrosis in this section.  Or inflammation.  There are a lot of macrophages, I’m wondering about DIP (Desquamative Interstitial Pneumonia).  But that’s not something I would ever diagnose on frozen.  We need to see a lot of tissue to get a good reading on interstitial lung diseases.  I’ll be able to tell you more tomorrow.  I can tell you it is not malignant.  There is no cancer here.”

I think I gained his confidence.  At least his ear.   He replied, “OK, thanks.”  I hung up the phone.

In the lounge, he shook my hand and I struggled briefly to maintain my composure now that I was the center of attention.  I was happy to find that my excitement about the case relaxed my nerves.  “Remember that case we had the other day?  Mediastinal lymph nodes?  The one that was granulomatous inflammation?  All the frozens showed just that, and I reviewed them ad nauseum because you questioned me, thinking there was more, from the OR.  When I got the permanents I found more.  Not on anything you froze, but on your fourth specimen.  D2 to be exact – there were swarms of classic Reed-Sternberg cells.  Not the Owl’s Eye type that's always on the boards, but the mononuclear version.  There were also mummified cells – ones that looked like the nuclei had been squashed by the palm of my hand.  It’s Hodgkin’s.  Hodgkin’s can have granulomas, but I’ve personally never seen them so diffuse and confluent.  They masked the disease entirely in your frozens.  I turfed the case to a lymphoma specialist, and the stains were still pending yesterday, but I’m confident that’s what it is.”

The thoracic surgeon was listening and became energized.  He stood up and walked me to the door – opened it and held it for me.  “I knew there was something more!  Thank goodness it’s lymphoma.  I always tell my patients that’s a much better diagnosis, with a much better prognosis overall, than carcinoma.  Is the report out yet?”

Suddenly I became nervous.  I hadn’t seen the stains, what if my hypothesis hadn’t borne out?  What if it was some sort of rare T-cell lymphoma, with a worse prognosis, that mimics the Hodge (as we affectionately call it)?  I covered up my doubts with confidence.  “I’ll check on it for you.”

Turns out my partner had released the report as Hodgkin’s, just as I suspected, a half hour previous.  Whew.  The surgeon had followed me to the lab and I reported this to him.  We chatted about some other difficult cases he had that week that I had signed out, marveling at the combination of clinical and pathology; patient details he revealed to me matching findings under the scope that I divulged in detail to him.

No matter how far along we get in our careers, it isn’t always easy to handle cases. I’m learning that good communication helps.  Experience and confidence can make a dicey situation more smooth and clear.  But just when you let your confidence allow you to stand up a little too straight, a challenging case will take it down a notch.  This is probably a good thing.  No matter how good we get at diagnosing and treating diseases we will always be reminded that each human is unique and patterns, while helpful, aren't always predictable.  There is a larger design, one that is not in our control, as much as we would like it to be.

The hospital I work at is large.  We no longer have town meetings, we don’t get to know our colleagues easily.  But the extra effort can make a difference.  Now I've got one more person I can speak to informally on the bat phone.  "Hey, this is Giz.  Here's what I see.  Does that fit with what you see?  With the clinical picture?  With what you are thinking?"  The more informal and comfortable we are with our colleagues, the easier and quicker we can diagnose our patients.  There is no room for fear or intimidation in patient care.  Things work best when smart, well-trained people put our heads together to solve the puzzle.  Puzzles aren't single cases necessitating week long work-up, like on TV.  They come hard and fast and in massive daily numbers.  We are all trained intensively over many years to handle it, and we step up to the plate every day.

I got the permanents on the interstitial lung, and was glad I was hedgy on frozen.  With more to look at, without all that nasty frozen artifact, there were loose balls of fibrous tissue filling the alveoli and mild chronic inflammation.  An organizing pneumonia pattern, classically patchy - somewhat nonspecific histology findings that nonetheless direct patient care.  In this case there was a clinical scenario that fit like a glove.  One of the things I love about my specialty is that there is quick satisfaction of closure - 95% of cases are turned around in 24 hours.  99 plus% in 48.  But a first glance, without the clinical and radiographic picture to fill in the gaps, can send you down the tubes if you don't keep an open mind.  Things aren't always as they seem.  A wise clinician holds that thought in the back of his or her mind.

Guest post: Come back when you are ready

Come back when you are ready.

Those are the words that my boss said to me when I called to tell him I was in labor. And he meant them.

My boss is one of the kindest, most generous and supportive people I know. So after 11 weeks I will return to work, not necessarily because I am ready but because it is time. 

Why 11 weeks if I feel I am not completely ready? I work in a small anesthesiology group and know that my coworkers are covering all of the call I normally take. It allows me to start after Easter and start fresh at the beginning of a month. I also took some of my time off unpaid so I could save some of my vacation weeks for later in the year. If only I didn’t have school loans and bills to pay I could have taken more unpaid time off! So 11 weeks it is.

It got me thinking though, when after the birth of a child would I really feel ready, if ever? Would it be when they learned to sleep through the night? Or would it be when they learned to say mama? Would it be after they weaned from breastfeeding? I thought that since this was my second child, I would not have all of the irrational fears of returning to work that I had with my first. My first child in fact did not prefer the nanny over me and is now 3.5 years old and shows no signs of being scared for life because his mom works. I was able to breastfed for 6 months during residency before my supply tanked and I am worried I won’t be able to even get that far this time. So here I sit, one week left of maternity leave having many of those same irrational fears.

I was in my third year of residency when I had my first child. I was blessed to have supportive attendings and an amazing program director. Yet I struggled for a good 5 months before I learned to let go of some of the guilt of being a working mom. I love my profession but I of course love my children and husband more.

This time, my husband is staying home with our two lovely children. He started staying at home with our first as soon as I finished residency. He is making a sacrifice by leaving a job he really enjoyed to stay home for a few years, and I sacrifice by working full-time. It is what works for our family and my sanity.  Like everyone else, I am searching for that perfect life work balance. Depending on the day or week, I think I might have found it. Yet sometimes the mommy guilt rears its ugly head just when I think I have gotten it under control.

So I pose the question to you. When were you ready to return to work after having a baby?

I would like to thank everyone who contributes to this blog. I have been following for over a year now. It has been really supportive to read these posts and see how we are all just trying to be the best moms we can be.  


- an anesthesiologist in a small private practice group with two children under 4.