Who did what?

As a physician, I remember countless patient's details and stories, and as a medical educator I remember student's sagas, issues, and triumphs.  But I have an EMR, chart-stimulated recall, notes.  

At home I have an imperfect record.  I remember the beautiful moments and the laughter and the tears and the growing older as a family, but I sometimes forget which child's nursemaid’s elbow I reduced (3 times).  Which of my 2 children used to grind teeth at night?  Which one wouldn’t let us take the band-aid off for a month after an influenza vaccine as a toddler?  I know who had the UTI (she did) and I know who had the early --now outgrown-- milk protein allergy (he did).  And I know that she now swims, plays guitar, and reads about as avidly as she eats macaroni and cheese. And that he is now a drummer and a young scientist wise beyond his years.  My two are so distinct from one another in many ways, and yet I've forgotten whether it was my son or was it my daughter who erroneously pressed 9-1-1-send on my cell phone.  Come to think of it, they both did that.  Then again, even at 7 and 9 years of age they sometimes call me "dad." And I’m okay with it.  The memories meld together, and the love is shared.  

Does it always matter who did what?

Involved, but not quite a “Lunch Lady”

Today was my first day volunteering at Zo’s daycare. He attends a quaint Spanish-immersion daycare and we love it! My husband and I can’t say enough about the amazing ladies who run the daycare. The children are loved and now Zo knows more Spanish than both of his parents.

I grew up with a stay-at-home mother who volunteered at my school all of the time. Much to my chagrin, for a short while in elementary school she was a “Lunch Lady”. I never really realized just how much it shaped me to have my mother around so much. I may have complained in the moment, but knowing that she was around gave me a sense of stability that has truly shaped who I am.

Flash forward to today, as I sit during a “stay-cation” (not nearly as much fun as Cutter’s "Best Week Ever"), I am working on IRB revisions, completing training modules, a case report, and ordering interview dinner food, all while getting over a fierce upper respiratory infection. In the midst of the many moving parts in my life, I volunteered at Zo’s school today and it was SOO MUCH FUN, here’s how it went:

When I arrived at the agreed-upon 10am, Zo’s eyes lit up and he proudly told every toddler who tried to hug me “this MY mommy”. His teachers began singing a song in Spanish about cleaning up and getting into a circle and 85% of the children obliged. I then pulled out Zo’s favorite dinosaur pop up book “Dino Roar”. The kids, and especially Zo, loved it and we all growled and pointed at interesting pictures. At around 10:35am their amazing music teacher Miss K came in for their weekly music class! She led the toddlers in activities involving drums and little shakers. We danced and clapped our hands and she even reviewed some music composition with them. When she left, I read another of Zo’s favorite books about loving others called “One Love”. When it was time to leave as they prepared for lunch and nap time, Zo cried and I almost shed a tear.

I truly felt like the involved mother I some day hope to be. In a busy day, I incorporated Zo-time, me-time, professional time, and later in the day family dinner time. Far from my mother’s lunch lady days, I hope to maximize my available time and be present in my children’s away-from-home lives as much as possible. It truly was food for my soul.

Exercise!

Lately, I've been trying to get more exercise, which is hard for me because I've never been what you'd call an active person. Unfortunately, there have been several barriers:

1) My lack of stamina, which is just plain embarrassing. When the person next to me on the treadmill runs 5 miles while I can't even run 2, and most of that is spent walking, it just makes me feel bad. I'm sure I'd be humiliated in any class I tried to take.

2) No time. Finding even half an hour to go to the fitness room a couple of times a week is a challenge.

3) After I work out, I'm tired. That was fine when I was 25 and all I had to do after my step class was veg on the couch. But now I have two kids to take care of post-exercise.

But I REALLY want to get in shape.

Well, maybe next year.

Guest post: The Tree

When we moved to our medium-sized Canadian town for my residency in 2010, there was one tree on our rented property. It stood directly in the middle of our shared front lawn. Our south-facing back yard, though private, was utterly shade-less. Being a social and East Coast family (and also prone to sunburns), we gravitated toward the front lawn as our preferred place to play and hang out. Our dog was well behaved and stuck around, and the children loved to wave at the city bus that drove down the street every half hour. We met many neighbours as we spent time under the tree. As the children were 2 and 3 years old when we moved here, they could not be out front unsupervised. Therefore, outside time was by necessity family time, or at least one-parent supervised time with the children. When our third child arrived in the spring of 2011, his front-facing window would be left open at naptime as we played under the tree. When he woke up, the older children (now 3 and 4) would practice being "frozen" until I could scoot upstairs and return with baby boy, blinking in the sunlight.

Over the past four years, the tree has been the center of our family time. However, like a faithful friend or partner, I did not realize how much the tree meant to our family, until its existence was threatened. A large crack was discovered in the main tree trunk in 2013. Much to our relief, arborists from the city decided to bolt the tree trunk for safety, a fascinating process that we watched from our front window. This winter, when the city came to assess the tree after two large branches fell off during an ice storm, the children actually cried in the front window (all three of them, very loudly) until I could run outside in boots and no coat to receive hasty assurances that the tree was not about to be cut down. However, one week later, as I was home alone on a rare weekday off, an arborist from the city showed up at the front door. He wanted to give me some notice that the tree was indeed to be cut down. He remembered the crying children. He was sorry, but there were more cracks, and the tree could hurt somebody.

I cannot recall why I was home alone that day. I am rarely home on weekdays and if I am, one or more children are always attached to me, delighted to have Mommy present. Nonetheless, I stood in the front window alone that day, staring at the tree, and my eyes filled with tears. I watched the blue swing idly sway back and forth in the wind and snow, imagining the ground worn away beneath it, scraped by thousands of little footfalls over the past four years. I remembered nursing my baby, now almost three years old, under that tree, countless times. I remembered the kiddie pool full of water and splashing and fun in the shade on hot summer's days. I remember how many times – how many times! – we laid on our backs under the tree, watching our "tree movie", catching glimpses of blue through leafy green, one or more little hands tucked into mine, with baby gurgling and kicking in his bouncy chair, or chasing our dog across the lawn in later years. I remember hanging thirty balloons from the tree on my husband's 30th birthday, with a big "Happy Birthday" poster taped to the trunk. In the morning, we told our children that the tree was a magical balloon tree. They called it the balloon tree for months. I remember coming home from my first military assignment, an exercise in Alberta, and having my husband rush out of the house at midnight to greet me. We hugged in the driveway under that tree, and I remember being surprised to hear the rustle of leaves above us. It was mid-June when I returned; it had been April and the tree, leafless, when I left. The cab driver smiled and said how much he liked it when "they come out to meet you". How many branches has that tree given our dog to carry and prance around with and chew proudly on our front lawn? Oh, how many leaf piles have we made, jumping and squealing with delight, each fall? Our neighbours have not had to rake a single leaf since we moved here.

We had to plan when and how to break the news of the tree to the children. They all cried. And here we have another lesson from the tree, in a gentle way for young children – a lesson of life and death. We talked about seeds and new trees and how life goes on.

The tree still stands. The city has not yet arrived to take it down. In rare quiet moments, I look at the tree, and I marvel at how this one tree, amongst billions, will always be known as "ours".


MH is a wife, mother to three children under age eight, and a military physician, currently living in central Canada.

In memory

On January 28, 2014, Dr. Dwight Gustafson passed away in Greenville, SC.

He was the subject of a MiM post several years ago by neurosurgeon gcs15 that brought many of us to tears.

Our thoughts are with his family, his friends, and everyone he touched along the way. If anyone needs any encouragement or inspiration along our path as mothers in medicine, please read that post again.

Docs, do you prescribe for your kids?

Genmedmom here. I did a bad, bad thing this weekend.

Both of my kids, Babyboy age 3.5 and Babygirl age 2, have had upper respiratory boogery junkiness for weeks. Both are in some sort of school, hence, they're both sick all the time. We deal with that; it's to be expected. They were either sent home or kept out of school all last week with boogery junky coughs. Saturday: they were pretty good, on the mend, even! Sunday: horrible.

Babyboy woke up very early Sunday morning complaining of a tummyache. Then, ear pain. Then, he started vomiting. He'd hold his right ear, howling and whining, then vomit. He's had ear infections before, and this is his presentation. Prolonged congestion, followed by malaise and tummyache, followed by ear pain and vomiting.

It was kind of scary as he did something I haven't seen him do before- he was grimacing, crying, holding his right ear with one hand, and then hitting the couch with the other hand. Like, hitting the couch with the pain.

Usually, I am a stickler about bringing my own kids to their own doctor to be evaluated for anything. Yes, I am Med/Peds trained, and I passed the Pedi boards, um, ugh, nine years ago.... but no, I do not practice Peds. I hate examining my own kids; I don't have the heart to hold down anyone's head to try to look in their ears.

But.

It was Sunday. It was really, really cold out. Babyboy was absolutely miserable. And it was so, so obvious that he had an ear infection. I knew that if I called his Pedi's office, they would (probably correctly) recommend some sort of eval. On a weekday or Saturday, they are awesome about making same-day appointments happen. But on a Sunday, it's going to mean a ride into the city and a looong wait in a crowded waiting room full of kids sicker than mine.

So, I made a diagnosis. I did examine him, sort of. I listened to his heart, normal. Lungs, clear. I felt his tummy, soft. I tried to look in his ears. He screamed and pulled away. I waited until he dozed off and tried to look in his ears: He screamed and pulled away. He's not that protective of his ears generally, so I figured that was further sign of ear discomfort.

I did talk it over with another doctor, an experienced GP turned oncologist turned internist, who was our own default emergency pediatrician growing up. That would be my dad, still in solo practice after all these years. And, I got a second opinion from a very well-trained internist who happens to work at my same hospital...That would be my brother. And the diagnosis was further confirmed by our informally-trained healthcare provider, my mother, who said something like, "They're been sick for weeks. Get them on some antibiotics already." It was my dad who called in the Amoxicillin, though I figured out the dosing.

Babyboy got some Ibuprofen and Amoxicillin and slept on the couch most of the day... When he woke up around 3 pm, he sat up, rubbed his eyes, hopped down onto the floor and started playing Legos. "Can I have juice?" he asked. Ha.

I felt guilty, though. Was I wrong to diagnose and treat my own kid?

Then, more horrible. Babygirl was a bit off all day. She didn't eat well. She fell asleep pretty early at 6 pm.

Then, around 8 pm, she awoke, screaming. We tried rocking her, tried to soothe her, but she kept screaming this shrill, high scream, kicking her legs in convulsive spurts.

And holding her left ear. Actually she was sticking her finger in her left ear, digging at it, like she was trying to get something out of it. We got Ibuprofen into her and waited for it to kick in. Minutes ticked by and still she was sreaming, convulsively kicking, digging at her ear, screaming, kicking, then "Mama mama mama aaaaaah!" It was pretty awful. I was trying to think what to do. We didn't have any Auralgan... The last time I asked our pediatrician about it, he said he discouraged its use, and told us to use Ibuprofen or Tylenol instead. I thought about... Ciprodex.

Back in the old days, like, when I was a resident, the standard prescription for an ear infection was oral antibiotics plus something like Ciprodex, an antibiotic/ steroid ear drop. Research then showed that the drops didn't do much for otitis media, so the dual prescription fell out of favor. Except with my dad, who had called it in along with the Amoxicillin. So, Hubby ran to get the bottle, and out of sheer desperation, with a sweating, almost crazy with pain Babygirl writhing in my lap, I squirted a good amount of the room-temperature drops into her left ear canal.

She startled, screamed some more, still holding the ear, then, slowly, relaxed. Whimpered, cried out a few more times, then fell alseep.

Hubby and I looked at each other like, Okay? Is that it? I tried to think how the drops might have worked so well, so quickly. I didn't expect the anti-inflammatory effect to take so fast. But perhaps they did nothing more than equalize the pressure in her ear. If the tympanic membrane was bulging out, some warm fluid might have helped ease some of the distension. After all, as my mom pointed out later, an old remedy for an earache used to be warm olive oil poured into the ear canal.

Or maybe the Ibuprofen kicked in. Or maybe she had exhausted herself. At any rate, she had been insanely flailing with pain for almost 20 minutes, and now, was resting quietly. We were so glad. I was almost in tears, actually.

Then we went and pushed our luck. We had two big fresh bottles of Amoxicillin for Babyboy (with alot extra, as the pharmacist had told us to discard the leftover half bottle). We logicked it out: this is also likely an ear infection, let's get her some antibiotics as well. So, I calculated her dose, and tried to slip some into her mouth with a syringe. The first two mls went fine. She sort of gulped and took it.

The last 3 mls didn't go so well. She gagged, and then vomited all over. Ugh.

She fell back asleep and we decided to let well enough alone. She was awake several more times during the night, and we did eventually get both Ibuprofen and antibiotics into her. This morning, she is cheerful.

So both kids are now committed to a full 10-day course of Amoxicillin for ear infections, and neither has seen an actual practicing pediatrician.

So am I a bad, bad mommy? Or will the rest of you 'fess up that you've done the same in similar situations?

an unsolicited job update

The job is going well. Very well , actually. I’ve been in the clinic for over a month, gradually building my own panel of patients and seeing the patients whose oncologist had left during a recent period of high staff turnover. My scheduled was blocked at 50% for the four weeks, which allowed me to learn the different systems and clinic organization without a lot of stress. There are 2-3 people around at all times to answer work flow questions.  I haven’t rotated inpatient or taken weekend or nighttime call yet.  I’ve been seeing mostly women with breast cancer, and although this is not what I was hired to do, I’m actually enjoying it.

It’s funny to think how different this transition has been when compared to that of residency or fellowship, where “orientation” consisted of being handed a massive stack of papers on “code of conduct”, a pager, a list sick patients, and best wishes on finding the bathroom. Before I started in the clinic I had a week of training, where for the first time I actually learned the EMR program I’d been using (far less efficiently) for the last six years.

I like the people I work with. It’s not a perfect group, and still dealing with the aftermath of a difficult period of painful changes, but the other new (ish) hires seem enthusiastic and hard working. The staff that decided to weather the change are less disgruntled than I had anticipated. I’d been warned that my group’s relationship with the hospitalists (very important colleagues when many of your patients require inpatient stays) was unpleasant if not overtly hostile, and this too seems to be improving.

So, I am feeling optimistic. Optimistic that, with time, the move home and into an uncertain work situation is going to prove the right decision.

MiM Mail: Burnout (already)?

I am a hospitalist with a 3 year old child and a child on the way and I am burnt out after only four years out of residency.   The prospect of working sickens me and I want to scream when I receive yet another page from the ER about a patient who needs to be admitted with intractable pain/vomiting/weakness with no diagnosis that they could attain.   I am so tired of hearing people's complaints.   I feel like I have not made an ounce of difference in anyone's life.   I am a scut monkey for most physicians and a substitute doctor for their primary care providers.   I no longer get a rush from seeing someone critically ill and helping them become well.  To make matters worse, we are short staffed as many other hospitalist programs are with no candidates thus far.   I am in the process of looking for a job but cannot find one that will pay me not to work.   I wonder on an almost daily basis why I incurred more than $150K of debt to do something that makes me miserable.   I have contemplated switching to a clinic job but cringe at the thought of even longer hours....at least in my current position, I am free to come in and leave when I want as long as I finish my work.   The prospect of another hospitalist job is less than appealing and doing chart reviews seems like a surrender.   I have even wondered what things would be like if I had trained in a different specialty.  Would things be different?  Would I be more satisfied with my job?   My husband is a graduate student and thus the option not to work is not realistic at this point.   What can I do?  How do I overcome this overwhelming sense of disappointment and dread for my life's work?  All my life, I wanted to be a doctor and now I'm here and just want to stay home and play with my child.  

MiM Mail: Radiation risks

Dear MiM,

I am a third year radiology resident and desire to have another child.  I currently have two boys, ages 4 and 2.   My job requires performing fluoroscopy procedures (3-4/day to include HSG's) and I am concerned about trying to conceive while working with radiation.  Its hard to really discuss this topic with the health safety officer as I am only trying to conceive and am not yet pregnant.  This weighs heavily on my mind as I have recently turned the dreaded advanced maternal age.  I have read that its an all or nothing kind of thing within the first two weeks post conception and I am hoping by wearing double lead I am not increasing my risks for miscarriage.  Looking for any advice or guidance as not many women have this issue (=.

Thank you!

A Friendly Reminder to Take What Your 3 year old says with a Grain of Salt

It was a rare perfect morning.

After a rough week, I was actually getting to enjoy my day off. Sipping hot, freshly ground coffee out of my favorite chipped mug, I sat at a tiny table playing legos with the cutest 3 year old in the world. We were both cozy in our jammies relishing the lazy fun play day.

As he began arranging the legos in various piles, we chatted about his plastic construction projects. He declared he was building his house and I gave the appropriate amount of fake enthusiasm over his construction skills. He then handed me a stack instructing me to build "mommy's house."

"But I live at your house, silly head!" I said teasingly.

"No," he said, very seriously, "you live at the hospital, and I live here."

I felt the lump begin to swell in my throat and my eyes begin to sting. Then I took a deep breath.

If this interaction had happened 5 years ago with my first son, it would have driven me to immediate tears. I would have been overwhelmed with mommy guilt and self pity over my hours away.  My schedule would have been reevaluated. Long discussions would be had with me and my girlfriends about how I felt I was failing at motherhood.

Instead of falling apart, I thought a minute and asked my rather creative 3 year old a follow up question,"Where does daddy live?" (Daddy is the 'stay at home parent')

"At the Post Office." He replied quite seriously.

"And brother, where does he live?" I asked with a smile.

"At his school." He replied with a superior tone that nearly had an implied "Duh" at the end.

I smiled, explaining that these are all just places we go, not where we live. He then proceeded to argue with me. I wisely agreed with him because the other thing I've learned over the years is to PICK YOUR BATTLES with a 3 year old.

So the next time your child makes a comment that tears your mommy heart to pieces, it's OK to be sad, but remember to get the whole story. And to most definitely take what a 3 year old says with a grain of salt or perhaps the entire shaker.

MiM Mail: Overthinking medicine as a career?

Hi MIM,

 

I’m in a little bit of a predicament, hoping you can help me with. I’m a college junior, hoping to apply to medical school soon, but kind of at a difficult crossroads.

 

Let me preface this by saying that I’m 20 years old and I know that it’s maybe too soon to start thinking about children. But, if there’s one thing I know, it’s that I was born to be a mom. I’ll never admit that out loud to my college junior friends, but it’s true. I’ve always loved children, and I’ve always felt that my future kids will have to be my number one priority in my life. However, my mom gave up her dreams to stay at home with my brother and I, and the regret and resentment she feels has really affected our family. I therefore try to overcompensate and promise myself I’ll never radiate that kind of resentment towards my family in the future. But then I think, what if it’s the other way around and I start to regret not having spent enough time with them? I consistently find myself up at 4 a.m. on your blog searching keywords like “balance”, “regret”…you know, really healthy things to be thinking about at 4 a.m. …

 

I know it’s all kind of presumptuous and maybe silly that I haven’t even stepped foot into a medical school yet (to look around or even interview for that matter), and I’m already worried about these things. But the thing is, medical school is an expensive road to go down, without being 100% in it. I keep reading these terrible horror stories about people who go into medicine and drop out during their third year after having used so many student loans, ect. And for goodness sakes, it seems like every other day some media outlet is coming out with a poll about how 50% or ___% of doctors wouldn’t choose the road again if they could.

 

I keep going back and forth. Physician or physician assistant. I try to convince myself toward one or the other it seems every other week. I think to myself, “Yeah, I could work on a team. I would still be able to practice medicine.  I could still help people. I think that my time spent with my kids would make up for the feeling of not actually fulfilling my original dream. Or maybe it wasn’t my dream in the first place, maybe I’m just holding onto something I thought about when I was 12. Or maybe I made it my dream so that I would never be the resentful mother.”

 

Gosh, it’s all so confusing to me. I find myself taking screen-shots of the success stories, or “satisfied” or “happy” mom/doctor submissions on your blog, and printing it out to paste my “study” wall to help me trudge through this MCAT preparation, in attempts to keep me focused and dedicated. Can anyone out there give me insight or share some advice?

 

Sincerely,

An overthinker

Guest post: The two kinds of mothers in medicine

It seems to me, in reading these posts, that mothers in medicine seem to fall into two main groups. First, those that are fully committed to their work, feel no regret about choosing medicine as a career, see working as a positive thing in their lives, and suffer no, or very little, mother guilt. The second group suffer frequently, if not perpetually, from cognitive dissonance between medicine and family.  This group is no less committed as doctors or as mothers, but struggle to marry the two without great dollops of mother guilt. I am in the second group and find myself wondering, as I ride another wave of dissonance, how do I get into the first group?  Clearly there are factors at play which make the elusive balance harder, but even if you allow for those, is there something inherent in my nature, beliefs or values that means I will always have these ups and downs?  What do I have to develop/cultivate/realize to overcome my dissonance and mother guilt to join the ranks of the first group, to which I ache to join?  In theory, I believe that working mothers are a good role model for children, that fathers step into the home more when a woman works which adds more for the children, that mothers make excellent workers and doctors, that workplaces need to support working parents and indeed workers without children to achieve a happy balance but why can't I shake these feelings of conflict? Why can I think my way to balance but can't feel my way? I had a very inadequate home as a child, parenting that raised the interest of child protection agencies. Is this why? Which bits are me and which are over protective parenting making sure my children don't have the pain and loss that I suffered? Would I feel this way no matter what job I did? I think not, because I read so much indecision, conflict and even anguish in the posts on mothersinmedicine. I also read the comments to those posts from mothers in the first group, and I press my nose up to the glass of that group, and yearn to open the door and walk inside. So how do I join you, centered un-conflicted mothers in medicine? Or is that an unattainable dream for me?

Jess

MiM Mail: To be a stay-at-home mom or not?

Dear MiM,

I am an OB/GYN in East Texas and mother of 2 boys 9y/o and 3months.  I recently discovered your blog and am delighted to find a place where real women are having real discussions about the challenges of this balancing act. 

My question is have other MiM taken a break while their children where small 2-3 years and then jumped back in?  What challenges did they face?  Any regrets?  In my specialty I fear the "re-entry" - being given a chance by employer and gaining patient trust.  I have worked hard to be where I am and love what I do but given an option to stay home with my children for a few years and I find my heart screaming yes.  Am I over thinking this?

C

How motherhood changed my medicine

Better late than never.  Here is my post from topic week on how medicine has changed me...

I've been trying to think of what to write about for this topic week.  How has medicine changed me? I found myself at a loss.  I have been on this journey for SO LONG.  Medicine has grown with me more than changed me.  Then I thought to the one singular occurrence in my life that has changed me the most ... hands down motherhood has palpably and incomprehensibly changed me more than I could have ever imagined.  As a result, after reflecting on how medicine has changed me I really felt compelled to write about how motherhood has changed my medicine.

Here are my thoughts:

- Motherhood has given me an honest compassion that is different than the compassion I had before.  I find it hard to explain, but it is simpler and more organic.

- Motherhood has given me a more zen-like patience with which to approach the craziness and chaos of medicine and residency.

- NICU nurses like moms more than surgery residents ;)  I used this to my advantage and as a result, loved taking care of my NICU babies.

- My priorities have shifted.  My goals are similar, but now they must fit into a different version of me.

- I can't do it all and I know it.  However I will still try.

- I prioritize my time at home and at work with crazy efficiency.  I definitely think the constant balancing act has helped me in being a chief.

- I love sharing my life with my daughter, therefore while at work I am even more motivated to make it count for something, to "help people" as she tells me, to heal, to learn, to affect change.  She has inspired my medicine in ways that make every struggle of motherhood well worth the gain in every aspect of who I am.

Happy New Year.  Here's to motherhood and medicine.

MiM Mail: Deciding between residency programs

Dear Mothers in Medicine,

I've been an avid follower since the beginning of medical school, and am amazed by the amount of wisdom and advice that passes through. I'm currently a 4th year who is struggling with deciding between residency programs, and was hoping for some much needed advice.

I'm applying for PM&R programs, but applied to a limited area since my husband is a graduate student, and has a few more years of training left in the city where we live now. We met in high school, and had a long distance relationship in college, which was very difficult for both of us. We decided that we would never do that again, and made staying together a priority. We both compromised for medical and graduate school, and went to a city where we could stay together, even though the programs weren't otherwise our top choice. For residency programs, I decided to apply to the surrounding area, because I couldn't stand the idea of being separated.

I'm lucky in that there are a couple of PM&R programs in the city where we live, and a few in a city that's about 2 hours away by car, and an hour away by train. I'm currently struggling with my rank list - I love the programs that are further away, but it would require us moving in between the two cities, and each commuting an hour to 1.5 hours each way, or me taking public transportation, which can take up to 2.5 hours, taking into consideration waiting time for the train and delays. Fortunately I have a friend in the city that I can stay with on the rougher days. Since PM&R has pretty reasonable hours, and I would theoretically study on the train, I'm trying to convince myself that it wouldn't be so bad, but I'm having my doubts.

None of the programs that I've applied to are considered the very top residency programs for PM&R. However, the programs that are further away are better known, and I feel like I would get broader exposure and better teaching from the attendings. My main  question is - how much does the reputation/quality of the program matter in the long run for jobs and fellowships? Obviously there are requirements that have to be met for every residency program, and I've heard from many people that what you put into a program is what you get out. Could I get the same out of a higher quality program as I would out of a lesser known and weaker program, where I put in a lot more effort to self study and seek extra exposures?

Of course it would be easier to stay in the same city, where we have a house and are already settled. But I can't help thinking about the programs that are further away, since they seem like a better fit. I'm afraid that if I decide to commute for the programs that I like better now, the commute might take its toll on both of us, and I would end up regretting it in the end.

I've been agonizing over my rank list for a few weeks now, and still have no idea what to do. Any help would be much appreciated!

Thank you,

Stuck Between Two Cities