PICU and the Biting Beast

I don’t know when it began, but somewhere in between finishing first year of residency and starting in the Pediatric Intensive Care Unit (uggghhh, acckkkk, poooo), my cute talking toddler became a biting, hitting, aggressive little beast. Sometimes he’s soo sweet and soo cute and I forget that at any moment, when we run out grapes or he can’t find his motorcycle, things could get very ugly, very fast.

When it’s ugly, he hits, he bites, he smacks. Who? Me, my husband, his favorite friends, his not-so-favorite classmates, his bath toys, his Froggy. Oh yes and when we recently tried to redirect him by holding his hand when he swats at us, he even tried a head butt. My husband and I sat stunned, where does he learn these things?

And did I mention I’m in the PICU?!? It makes everything worse. The guilt I feel about his aggressive behavior is exacerbated by my sheer emotional and physical exhaustion. I arrive home sometime during twilight outdoor playtime only to take him away from his beloved friends and the sandbox. I then clean him up and prepare him for bed while he wails and hits. Daddy pours the wine, puts his headphones on, and begins his nighttime graduate-student-writing routine. The only respite I get is story time, where Zo picks out his favorite books and says, “Sit down Mommy” and pats the couch beside him. Then I rock him to sleep as he cuddles and rubs my ears. After that I sit mindlessly perusing the internet for the countless hours while my husband repeatedly says, “Don’t you need to go to bed, don’t you have to get up at 4:30am?”

I have begun polling friends and have gotten: smack him, give him time outs, redirect him, it’s a developmental milestone, this too shall pass. Knowing that this phase is developmentally “normal” means nothing when I pick him up from daycare for the first time in weeks and his teacher says, “Sorry Miss, but Zo bit a friend, again” as she points to the cherubic chunky boy Zo has taken to like an apocalyptic zombie.

I can now proudly say that PICU is over and I learned a lot. I can also proudly say that Zo has made it 3 days in a row without biting anyone besides his toys, we celebrated at school today with dancing and he seemed very proud of himself. He starts everyday with a new family mantra “No biting people!” It’s the little-big victories; we have at least temporarily slewed the PICU and the Biting Beast.

Guest post: When doctors become patients

I recently gave birth to a beautiful baby girl.  My entire pregnancy was so incredible -- I loved every minute of it!  I never thought for one minute that my baby could have anything wrong with her.  But alas, she was born with a hand deformity that was not diagnosed in utero.  I cried non-stop for days.  My husband would come home from work and cry with me, hold me while I sobbed, "Why our baby?" While I know that this hand deformity will not stop her from becoming an amazing person, amazing daughter, I know she will struggle because of it.  I wish it was my hand, not hers that was deformed.  I wish I could take back whatever I did wrong during my pregnancy.  I wish so many things.

So it started, the doctor visits. Today was our first visit to the orthopedist.  He didn't have any good news for us.  He just said, "We'll have to try to give it function. When we walked out of his office, I was stunned.  "Why didn't he tell us more?  Why didn't he know what else to say? Why didn't he give us a clear answer about what the future holds?"  My husband pointed out that he probably did not know what the future held.  That he probably didn't know what else to say.  That only time would tell what the outcome would be.

I made an appointment with another orthopedist, in hopes of a better and clearer picture of what to anticipate. But I know that probably nobody will be able to ease my mind the way I'd like.

I know it could be worse.  There are children out there with cancer!  With immunodeficiencies. With cerebral palsy.  With all kinds of terrible things.  How lucky I should consider myself that my baby only has a hand deformity.  But I can't consider myself lucky. I just cry and cry, and ask myself, "Why my baby?"

did you take his name?

I think I had already decided to keep my name even before my boyfriend-at-the-time told me his (rather long) surname was old German for "caveman", "neanderthal" or "man who lives in a hole in the ground". I would be lying, however, if that bit of information didn't help solidify the decision.

I got married at age 25, while I was still in medical school. No one in either my personal or professional life gave me a hard time about keeping my maiden name. I thought at the time that most people would assume I had changed my name and we would, at least socially, be known as "The Caveman Family", when children eventually came around.

But that hasn't been the case. People are, for the most part, careful to acknowledge that I do not share the same last name as my husband and children. I should also note that my last name is nothing beautiful itself - my sister describes it as a grunt and has vowed that, should she ever get married, changing it would be the first order of business. Perhaps now it is clear why I never really considered hyphenation. One borderline unattractive name is not improved upon by the addition of a multi-syllabic and even less attractive name.

Wedding invitations and baby announcements are addressed to Me Grunt, Husband Caveman, and Children (1) and (2) Caveman. When told I wont be home for dinner, my daughter will reply "We'll have Caveman family night!", the obvious implication being that my last name would exclude me from "Caveman family night", which is too bad because it usually involves movies, ice cream, and late bedtime. 

I have mixed feelings about this. I guess I just care less about my name now as compared to when I was 25. I think my self-identity would just as intact if I were Dr. Grunt or Dr. Caveman. The work I did in undergrad or medical school would not be wasted if I then practiced under a different name. 

I am not sure that I would make a different decision if I were getting married now (at age 33) and I certainly don't care enough to change it at this point. I am, however, surprised by how wistful I feel when seeing my name separated out from those of my family or when my daughter talks about "Caveman family night". Honey, I might not have given you my name, but that chin dimple of yours? That's from me. 

MiM Mail: Bringing family on the residency interview trail

Hi,
I've been reading MIM since my M1 year, and I'm finally an M4 applying for residency!  Come interview time, I'll have an almost four year old and a six month old.  My husband has a lot of time off between Nov and Jan, plus my mom offered to go with me on any trips my husband can't come on, so we're going to make the interview trail a family thing.  I know I'll be busy with dinners and interviews, but being able to tuck in my three year old and nurse my baby at night will mean so much to me.  Did anyone bring kids along on their interview trips?  Any tips?

Sarah

Reaching (or not reaching) breastfeeding goals

Apparently, most moms who want to exclusively breastfeed their babies for three months fail.

There are all sorts of hypotheses for why women don't reach their breastfeeding goals. But I think we have a perfect sample here of educated women who can accurately assess the positives and negatives of breastfeeding.

If you didn't meet your breastfeeding goal, please share with us why not....

Guest post: In one's element

In his NYT bestseller 'The Element', Ken Robinson argues that we are in our element - doing what we should be doing - when we do the thing we love, and in doing it feel like our most authentic self.

This got my attention. I've often felt that the place I am most me is in the clinic, and I find that somewhat disturbing: how can that be, if my children and closest friends never experience me in that context? I feel I'm less the real me at home - or maybe that's wishful thinking. At any rate, I like myself best at work, and the following description by Robinson of people in their element holds true:

". . . time passes differently and they are more alive, more centered, and more vibrant than at any other times." p21

He suggests that we find ourselves in our element when four things align: aptitude, passion, attitude and opportunity. Because his description of the attitude necessary to find one's element (perseverence, ambition,  wanting something strongly and being willing to exert oneself for it) is, I think, almost universal among physicians, I've 've taken the liberty of replacing "attitude" with "need" for the purposes of applying this to medicine.

And so, the four pieces that fit together when in one's element

1. aptitude (what you're good at)
2. passion (what you love)
3. a̶t̶t̶i̶t̶u̶d̶e̶ need (in the world, that your work fills)
4. opportunity (a position where you can do the work)

I'm a good physician, I love medicine, I provide primary care to refugees, and I work in the only such clinic in the province. Perfect score.

Thinking over other positions from which I've moved on, or avoided, or wished for, I can identify which of the above was missing. I lost my passion for work in Vancouver's downtown east side when I came to view the work as palliative. In private practice in an affluent neighbourhood of Vancouver's worried well, the preponderance of women complaining that their hair had lost its lustre left me feeling my work wasn't filling a genuine need. I've avoided high acuity settings (emergency room, deliveries) because I haven't kept up those skills. And I don't work in a medical practice where I'm given paid time to write because I haven't found the opportunity.

I do think that health care workers have an advantage in finding our element in that the need is so obvious in our work. We care for sick people; what's more basic than that? It's less tangible for people like my husband, who works in business software. And I think it's more difficult still for artists to define and defend the need for their work.

The concept of opportunity trips me up a little.  My current job, and the one before that (HIV clinic) were both positions that I did not seek out. They were offered to me. Sometimes I second-guess myself: isn't accepting an opportunity a passive choice? Picking the low-hanging fruit? Shouldn't I be actively pursuing the perfect, hard-to-get position, chasing it down? (But what would that even be?)

Maybe we can increase our work satisfaction by changing what fills those four criteria. If I were to increase my skills (say, learning some basic surgical skills like appendectomies) and set up shop where there is greater need (rural Zambia) would I be even more satisfied? Perhaps that's why so many 50+ physicians do exactly that.

I like the idea of applying this framework to job considerations in the future. I've been dipping my toes into adminstrative work. There's a need for (young) medical administrators, and plenty of opportunities. But I haven't had enough experience yet to determine whether I have a passion for it, and whether I have (or can develop) the necessary skills. Whether I would find myself in my element there remains to be seen. At least I know what to look for:

"One of the strongest signs of being in the zone is a sense of freedom and of authenticity. When we are doing something that we love and are naturally good at, we are much more likely to feel centered in our true sense of self - to be who we feel we truly are." p90

And you? Are you currently in your element? If not, which is missing: skill, passion, need or opportunity?

[cross-posted at www.freshmd.com]

Guest post: Men in Surgery (A Satire)

As a woman in surgery, gender issues come up frequently.  It’s something that really weighs on my mind, and I want to take this opportunity to set the record straight.  Gender equality matters, and we all need to do our part to even the playing field in surgical specialties.

The fields of sewing and knot tying have historically been dominated by women.  For thousands of years, everything that was sewn by a human was sewn by a woman.  In the modern era, women are taught from a very young age to handle needles and thread, and go through rigorous afternoon craft sessions where our work is critiqued and judged until it reaches a level of precision suitable for a surgeon, or at least enough to hold our handmade pillow case together.   When we wanted to cement our social standing with our best friend, we were forced to undertake a tedious and tiresome knot tying ritual known as “making friendship bracelets.”   The intricacy and precision of the bracelet was believed to be reflective of the commitment to the friendship, forcing BFF’s to engage in a never ending competition to out-tie and out-braid their brightly colored mess of threads into a work of art. Our hands would ache, our eyes would water, and all we could think was  “one more knot,  just one more knot….”  Looking back at my Girl Scout experience, it really could be renamed “Surgical Technique 101.” Except there would be less cookies.

Despite our natural and obvious dominance of the skills required for surgery, women must actively work to welcome men into the field of surgery.  This revolutionary and controversial viewpoint is not embraced yet by the mainstream surgical audience, so allow me to make my case.  I truly believe that there is a role for Men in Surgery, and that, over time, we will come to find them a truly valuable part of the surgical community.

Despite their obvious deficit in sewing and knot tying based on childhood experiences, men can in fact develop these skills if given proper time and training.  A patient teacher and an abundance of motivation must be present in order for these men to make up lost time, but it is possible.  There’s a growing body of evidence that video gaming at a young age improves laparoscopic skills.  So we should remind them that their wasted youth, devoid of knot-tying, may still have some usefulness.

Another obstacle that men must overcome is their natural urges and biologic shortcomings which often distract them from surgery.  Their frequent requests for time off to attend major sporting events, improve their golf game, or simply to fart and scratch themselves at home, must be met with tolerance and understanding.  The biologic differences between women and men cannot be changed, but we must work to adjust our expectations and work schedules to account for these inconvenient and unexpected interruptions to the work flow.

The operating room can be a hostile place for men in surgery, and as women we must actively work to reform this.  Both circulating and scrub nurses are almost uniformly female, and careers in anesthesia (including CRNA’s) is rapidly trending toward a female predominance.  Many scholars have postulated that men are simply no longer a relevant part of the operating room culture.  The sisterhood that has developed often alienates men. They are kept out of the social circle by their lack of understanding of our reality TV show and Glee references.  Metaphors related to the contestants on the Bachelor often go over their head  and they find themselves lacking a common language as their female peers.  As women in surgery, we must actively reach out to these men.  Take time away from the operating room to review common metaphors which they may overhear.  Answer their questions about Grey’s Anatomy in a honest and respectful way.  It’s not their fault that they cannot participate in the female-dominated operating room culture- they were simply raised differently.

Change must come from the leadership in our field.  There is no room for gender bias in the hiring process. Science has proven repeatedly that women tend to be more detail oriented, more patient, and better at resolving complex emotional and relationship issues- all of which are highly valued in choosing which surgeon to hire for an open position.  But I urge my colleagues to consider some of the lesser known traits of men which may in fact be just as valuable.  For example, I bet you didn’t know that men can lift very heavy things.  Additionally, men tend to have larger hands.  While this makes them struggle in many of the fine and delicate aspects of surgery, it could be seen as a positive when considering stool disimpaction.  Lastly, remember that men have feelings too.  They just might surprise you with their compassion and grace.  Oh yeah! And they are tall.  Think of all those dead light bulbs they could change.

Allowing men to become surgeons enhances the diversity of our work force, which I’ve been told is a good thing.  If we hope to remain a vital and relevant field amongst medical specialties, we must embrace all gender equally- even the ones with external genitalia.


-A happily married PGY-3 general surgery resident
.

My Brain Doesn't Work Like This: chronicles of an aspiring primary care provider in the PICU

I am in the throes of my first Pediatric Intensive Care Unit rotation. I was shocked that by Day 2 I wanted to run away and hide under my covers. Shocked that soo early into the rotation, I was hitting  the snooze button soo many times that my husband who sleeps through anything (except my occasional snoring and Zo crying) ordered me out of bed.

I am NOT that Resident. I’m not the one who hates residency. On most days I am so excited to serve patients and work with amazing colleagues. But I fear I have become THAT Resident. The grumpy one. The one who doesn’t want to be here. The PICU and its acuity has brought it out. Stealing the “oomf” from my life. Encouraging family members and friends have given me pep talks as I weep into the phone about how draining dealing with such critically ill children and their families has been; children with devastating neurologic damage or those with genetic syndromes with abysmal prognosis.

And top off the emotional heaviness with the fact that my brain just doesn’t work like this! The Attendings and Fellows are amazing. Without a single written note, they can recall doses of infusions from the prior week, what the Neurologist or Infectious Disease Consultant said 8 days ago, what I and other Residents said at every moment of the day, and various other details that I cannot ever imagine myself being able to recall without very detailed notes. Ventilators and infusions and cardiac physiology after a specific surgery, my brain screams out, “give me 5 minutes, 5 more minutes with the Peds In Review or Up-to-date and I promise I’ll have a detailed explanation!” but no, I have 2.5 seconds before I get the “you are dumb, hush up now” look. And of course I am now tachycardic and sweating and feeling hypoglycemic in the third hour of rounding.

I have tried to somewhat let myself off of the hook. I will never be a great PICU Resident, but I’m getting better and might even be pretty darn good by the end, nor do I endeavor to become a great PICU Attending. As an aspiring primary care provider and maybe even a Nursery or part-time ER Attending I will know how to keep critically ill patients alive until the Intensivists arrive. And even now, I am keeping my patients alive. I am learning how to more efficiently and effectively manage their acute issues and prioritize. I have come up with some good ideas and my brain works really well sometimes. But feeling adequate most of the time, just doesn’t feel good. And then my brain screams that it just can’t work fast enough to be excellent in this setting. And I acquiesce because it’s right and this is something I’ll just have to come to terms with as I snuggle even more under my covers while pressing snooze one more time. Because now more than ever, my brain needs its rest.

Night Float - The Bad Beginning

A few years ago my family medicine residency program, realizing that duty hour changes(*1) were coming soon, decided to start a night float system (*2).  The new duty hour limits were not in place, so residents worked 14 hour shifts for 14 nights in a row (*3).  (Then we got one day and one evening off in preparation to return to work - on day shift.)

In case you were wondering, this was a horrible idea.

Just a few generalizations about night shift - when you work nights, you never, ever feel good.  You always feel tired, like you need to go to bed, or like you just got up from an ill-timed nap, or like you desperately need a nap regardless of the timing.  You feel disconnected from society – just as people are going to work, you are headed to bed, and just as the kids are getting home from school, you’re trying to wake up again and get ready for another workday.

I know that six nights in a row can be difficult and taxing but 14 were just monstrous (*4).  By the second week, I started to lose perspective.  I was crying every night on the way to work.  I left home with my child in tears as well and my husband frustrated at being thrust into single parenthood with a very angry roommate.

I was angry – initially at the program directors, but gradually at the nurses, the other residents, and ultimately the patients.  I wondered why I was getting so many stupid pages, and why none of the other residents could do their own work without dragging me into it, and mostly why all these stupid people had to choose tonight for their shortness of breath/chest pain/drug overdose.   Not a good attitude.  Add to that the directors’ insistence that no one ever, EVER nap on nights even if all the work was done (“Because you have all DAY to sleep”) and their refusal to consider putting a day off in the middle (“Because it would disrupt the sleep schedule” (*5)).  By the end of that two weeks, I honestly hated my program and was wishing heartily that I’d gone with my second choice.

Then I reverted back to days and life improved tremendously.  I still had a chip on my shoulder for a while, though.

*1) No longer allowing interns to work 30 hour shifts.
*2) “Night Float” means that a handful of residents take care of the hospitalized patients all night so that no one has to work a 30 hour-shift.
*3) Yes, this means a 98-hour work week.  As long as they averaged the first week of night float with the week before it and the second week of night float with the week after it (and each of those weeks were electives), we still satisfied the ACGME requirement of <80 hours per week average.
*4) I don’t want to sound like I think I had the most difficult job in the world –  I just want to make a few points about how badly it went for me personally.
*5) By this logic, no one should ever take weekends off, because most people sleep in on those days thus disrupting the sleep schedule.  However, the program directors did not forego their own weekends off.

MiM Mail: Regret going into medicine?

Dear MIM,

Hi there,

I am a 2nd year medical student, and I have a question for all the MIM's out there: Do you regret going into medicine?

The statistic has been steady around 50% for several years. This seems like a large percentage to me! I know that as humans, we tend to minimize challenges that we have overcome. For example, I remember there were so many times in first year when I felt like my world was collapsing, and that I would just never get through it. But when I did, I oftentimes found myself unjustly minimizing the past, saying "It wasn't all that bad."

So, I'd like to hear your authentic thoughts and reflections:  Do you regret going into medicine, why/why not?

Sincerely,

Andrea C.

Guest post: Struggle

I struggle with it every day. Every day that I get into my car, turn it on and drive up my driveway. Every day that I drive away from my baby to go take care of other’s babies.

I am fine after I arrive to my office and get into my day….after I see the faces of my patients whom I adore and after... I deliver a new life into this world.

But, still I struggle. It is constant. The feelings of guilt that I tackle on a daily basis are at times overwhelming.

I never anticipated this. I adore my career, my life, my husband.

I find myself playing “what if” scenarios as I drive to work. I glance over at a minivan and see what I imagine is a “stay at home mom” with her children in tow. I think to myself, that could be me. My husband tells me, quite frequently, that he would support whatever decision I make. That, if I wanted to leave work as an OBGYN, that we could figure things out. So, when I see that mom in the minivan, I put myself in her shoes. I imagine a day where there is no call, no missed bedtimes, no missed story time , no missed bath times and no missed kisses and hugs.

Oh, what a glorious day that would be. Nothing but memories of day after day with my sweet Joseph.
Then, my cell phone rings. Labor and delivery comes across my phone. Catapulted back to reality I answer it. A favorite patient of mine is in labor, I delivered there first and now she is getting ready to deliver her second. I smile.

I realize that no, I am where I need to be. God has put me in this place for a reason. I love my job, my patients, my staff, my partners. I love delivering life. I love being an OB.

But still I struggle. I struggle when my mind slowly lets the thought…”he knows his dadda more” creep into my mind. I struggle when I hear him call his Nanny “momma.” I struggle when I am home with him for a day and feel clueless in regards to his daily routine.

It is a balance that I have to work every minute of my life to achieve.

My heart aches when I start thinking about Christmas and Halloween and being on call. He is little now and these holidays mean little to him. But, being a momma, I sometimes dread ..the future ..of perhaps missing a costume or a present because I am at the hospital.

So yes I struggle. I think to myself will it always be this way? Unfortunately, I know it will. It will only become more difficult. But, I will make it. I will be Joseph’s momma, John’s wife and Dr. Watkins the OBGYN.

The doctor problem

As other bloggers have mentioned in the past, it's always hard to tell new moms you meet that you're a physician. I worry about the reaction, that it will make people uncomfortable, that they won't want to be friends with me anymore.

But lately I've hit on a solution:

Other mom: "What do you do?"

Me: "I'm a physiatrist. Do you know what that is?"

Mom: [likely thinking: physiotherapist, podiatrist, etc] "Oh! Yes!"

And she has absolutely no idea I'm a doctor.

I Care About You, But I Hate What You're Doing: The Internal Struggles of a Primary Care Doctor

Gizabeth, a pathologist, just wrote about needing to maintain a "poker face" when she did a patient's biopsy, because she knew the diagnosis was metastatic cancer, and she knew it wasn't the right time or place to deliver that diagnosis.

This hit on something I've been struggling with for some time, now, and what I suspect many doctors struggle with (unless they've become completely detached):

Over these past five years as an internal medicine attending, there have been patients who have broken my heart, who have made choices I strongly disagreed with. Of course, as long as the choices are legal and not harming anyone but themselves, they can do that, and the point of my writing about these cases is not to debate these choices. It is to learn how to manage my emotions as both a physician and as a thinking, feeling human being.

How do other doctors deal in the immediate moment, and then in the long-term, when a patient follows a path you believe is wrong?

 I'm thinking of several cases (all details obscured or altered to protect true identities):

Several years ago, I took care of lovely, vibrant, fifty-ish year old woman, who in addition to living extremely healthfully, also saw a holistic provider. One appointment with me, we reviewed some test results that suggested she had cancer. I arranged for immediate referral to a wonderful specialist. The specialist confirmed cancer, and outlined a reasonable treatment plan that involved surgery and chemotherapy. About a week later, the specialist sent me a note that the patient declined all of it, and instead chose her holistic provider's plan of herbal remedies.

I was horrified. I called the patient and asked her if this was true. She said yes, that she thought of cutting and chemotherapy as worse than cancer, and would take her chances with the herbal tinctures, powders, teas, cleanses and energy healing offered by her holistic provider.


What would other doctors say to that?

I said, something along the lines that I respected her decision, but felt that I, as her primary care doctor, needed to inform her that she was choosing untested and unproven treatments, treatments that were not likely to help her at all. She said she would take her chances, and we hung up. That was the last I ever heard of her.

The above case is actually a combination of a few similar cases... It's not unusual for patients to turn down the 'Western medicine' treatment plan. Again, of course, the choice is the patient's, that is not debatable. What I struggle with is my own feelings. Because I know that when this situation comes up, when I KNOW the "Western Medicine' plan, though imperfect, is the patient's best shot at extending their life and quality of life, I know my heart beats like crazy, my palms sweat, and I have to work very hard to control myself, to NOT stand up and scream: "ARE YOU CRAZY?? You're planning on taking all kinds of potentially toxic and useless herbal crap when you have access to the best treatments in the world for this, and suffering people in every developing country would give anything to be here in YOUR place with the chance YOU have at a cure, and YOU are turning it down???"

Then, there's the opposite scenario.

I once took care of a lovely and also quite seriously ill man. He was extremely elderly and debilitated, with some dementia, enough dementia that all of his finances and logistics were managed by family members, though with enough insight and judgment to contribute to his own medical decisions. He had a terminal cancer diagnosis, on top of multiple medical problems, making his care quite complex. He was feisty at times. He had been asked to consider his palliative care and hospice care options on several occasions, and always became quite angry, usually ending up by shouting things like "I'm not going to let you kill me!".

He was admitted for serious, life-threatening complications related to his cancer. It was very likely that he would end up on life support without a chance of any meaningful recovery. He was asked again if he would consider hospice/ comfort care. He refused. His family, who had power of attorney, chose to abide by his wishes. He ended up near cardiac arrest and was sedated and intubated, and stayed in the intensive care unit on a ventilator for a very long time before he passed away, without ever having regained conciousness.

I don't need to tell many people in healthcare that this scenario is so common, I've seen in many many times. It plays out every day. It's just as heartbreaking to me, to see someone choose the cold, often prolonged ICU death, when they could have had the chance to go a homey hospice - or even home!- with the comfort of a morphine drip, holding hands with family members all around them, saying goodbyes or telling stories, until a naturally peaceful end.

Again, the choice is the patient's. But how do you deal with seeing this over and over again, trying to convince yet another human being that the choice they are making really, really sucks?

There are many other situations where my heart breaks. I hesitate to write about it, such a huge can of worms is the subject of abortion. It's with a heavy sigh that I even type this, as I know it stirs strong feelings and stronger words, pro- and anti-, either way. My point in writing is, again, not to debate the choice. In this country, thank God, the choice is up to the woman.

But I struggle, sometimes, to contain my own emotions when I am counseling a patient through her options.

I am pro-choice, and do believe that someone needs to provide safe pregnancy termination services to those who choose that. But at this stage of my life, I am personally, for my own self, pro-life. I did not choose to have any early risk assessment in my pregnancies, despite my own advanced maternal age. It wouldn't have changed mine nor my husband's decision; we agreed to carry on with any chromosomally imperfect fetus. We had even agreed to carry on with a pregnancy if it happened before we were married. We agreed that we have the financial resources and family support to care for a child, any child.

So, I struggle when I am counseling women who, like me, are financially stable, partnered, educated... who, in short, I perceive as having the resources available to care for a child, any child, special needs or not... and yet, they choose to terminate a pregnancy. In the room with them, I am professional; I smile kindly; I hand them the list of termination clinics; I counsel on birth control; I often see them after a procedure for followup.

But it is not uncommon that I tear up. I often need some space after one of these sessions to recover before I can go into the next patient's room. And I take it home with me. It makes me very, very sad.


How do other doctors deal with this? Especially, doctors who are mothers?

So many situations in medicine can affect us. We are all different in our beliefs and actions... But there must be situations that affect all of you, as healthcare providers. What are they? What touches you, and what do you do about it?

MiM Mail: Pathology vs General Surgery (long-term goal: breast surgery)

I have been following this blog for the last 3 years. I am currently a fourth year medical student who is about to apply to residencies … and I am a confused fourth year student. I am also a 33 years old mother of a 3 year-old boy. 

I applied to medical school thinking about becoming a pathologist. It was my mother’s dream and had some exposure to pathology when I had worked at a clinical laboratory as a phlebotomist and a lab assistant during pre-med years. During the third year clinical clerkships, I fell in love with general surgery and scheduled all my sub-I’s having surgery in mind. Now finishing up my first sub-internship and having taken a couple of 30 hour trauma calls, I start to doubt my decision for the first time.  I am now torn between pathology and general surgery for the first time since the middle of the 3^rd year. Feeling physically tired contributes to it but what I have recently realized is that I do not know much about neither residency schedules in either specialty nor about lifestyle of neither general surgeons nor pathologists. I am worried that if I choose pathology I will work just as hard during residency but would be thinking about how would my life be if I chose surgery. I heard that it is best to choose what you love the most and the schedule will work out at the end. Would you agree with this statement? I also heard statements about applying to general surgery only if one can not imagine doing anything else but surgery, but I also find it hard to believe that the general surgeons, especially mothers,  never doubted their career choices.

Here are my questions, and I would appreciate input from Cutter and Gizabeth.

-       What are the approximate work hours in residency (pathology and general surgery)?

-       Do the hours in residency depend more on a specialty or more on a type of a program?

-       How will my schedule look like when I become a breast surgeon vs a pathologist?

-       What is an attitude towards family in pathology and a general surgery residency?

-       My husband would really like us to have another baby.  Would it be feasible to combine internship, 2^nd or a 3^rd year residency with a pregnancy / new baby?

-       If my marriage does not work out, would it be possible to continue residency and take care of my kid as a single parent?

-       I am shy about asking my current residents and attendings about their schedules since I am on an audition rotation. Do you have any ideas whom I should ask and what else I can do to try to figure it out within the next few weeks? (Ideally, I should be submitting my ERAS application between September 15 and October 15).

how did you celebrate?

My dad cried loud, heavy tears on the day I graduated from medical school. My mom cried too, although not as intensely as my dad. My parents, sister, in-laws, and two closest friends came to my graduation, one of whom had flown cross country to be with me for the event. We had dinner together at a Thai restaurant after the ceremony. My husband gave me a pair of emerald earrings. 

I don't remember crying. I remember feeling happy that I graduated and glad to be with my family, but as I had correct anticipated residency to be more difficult than medical school, I didn't feel overly celebratory about the milestone itself. 

I felt differently about the completion of residency.  When I walked out of the hospital for the last time, I looked back at the inpatient towers, thought to myself I never have to go back, and was surprised by the wave of relief that flooded over me. I'm glad no one was around to see what must have been the biggest, dopiest smile pulled across my face. 

But there wasn't time to celebrate. I graduated from residency on a Friday, moved over the weekend, and started fellowship on Monday. If I bought myself something to commemorate the occasion, I don't remember what it was. Although this achievement meant more to me than med school graduation, it's significance was eclipsed by the need to move and instability of my first few weeks of fellowship. 

Now I am graduating again, this time from fellowship, a milestone that will finally mark the end of my  medical training. 

Memory is an imperfect tool, a shortcoming I appreciate when trying to appraise the individual steps and aggregate of my medical education. To the best of my recollection I was happier in medical school than I was in residency and happier in fellowship than I was in medical school. But then again, my life outside of training was significantly different during these periods that it is difficult to assess them based on just the training itself. I had good friends in medical school. During my fourth year we all lived in apartments close by and spent weekend nights drinking so much wine that it gives me a headache just to think about it. I realized shortly after starting residency that I didn't much care for inpatient medicine. I had fewer friends in residency, a husband who traveled, and an unplanned pregnancy that affected my emotional health during what felt like an unending string of thirty hour shifts. In retrospect, I think I was suffering from postpartum depression where I told myself it was "just the blues".  Thankfully, it passed. Or maybe resolved when I completed residency.

And perhaps it is strange that consider myself happier now, in fellowship, than I was in medical school or residency even though, at the end of my first year of fellowship and just after finding out I was pregnant for the second time (yes, this one planned), I called one of my attendings (a female and the only remotely "mommish" of the faculty) crying. I told her I worried I wouldn't make it through another two years if they were as bad as the first. Even though I hated parts of medical school and residency, I never occurred to me to quit. She told me it gets better. And it very much did. (I am also fortunate that she never held this episode against me nor told anyone about it.) 

I started medical school just before my 22nd birthday. I am through five years of medical school (I did a research year between my 3 and 4 years), three years of residency, three years of fellowship and, last week, turned 33.  I am married with two kids and feel good about the job I have lined up and the career  ahead of me. 

In other words, I want to celebrate. 

And need some ideas. I have a friend whose husband through her an elaborate party (doctor themed) at his family's restaurant. Another friend put a trip to Jamaica for her family of four on a credit card and took off for a week after graduation. One of my (child-free) co-workers is spending six weeks in Europe. 

I don't think I will do any of these things. Although I am feeling indulgent, we are hoping to buy a house soon and will be moving. I don't need another big expense. 

So what did you do? Memorable dinner? Earrings? Party? Trip? Nothing at all?