Stop scaring the "fresh meat"

I volunteered recently at a meeting for Latino high school, college, and medical students as a member of my hospital’s Residency Diversity Initiative. I had gotten the announcement a few months prior and realized I would be on a pretty straight-forward month with weekends off. I checked with the hubby that I could take about 3 hours during his prime studying time to volunteer and he agreed.

The students were engaging. The high school students asked silly yet endearing questions. One absentmindedly asked another resident and myself our specialties three different times because he kept forgetting what we said. He was sweet, but goodness, I hope his focus and attention span increase before starting college.

Several of the medical students asked very educated questions, ones that showed they knew where they were going. One particularly prepared medical student, dressed smartly in an off white blouse, flattering pencil skirt, and pearl necklace asked a series of questions that we answered. She thanked us and left. Then she came back later to chat some more. She began her new string of questions with “I don’t mean to sound, ummmm, superficial or anything, but even though I’m interested in all types of medicine, I am worried that if I go into Family Medicine instead of Internal Medicine that I won’t be able to pay off my loans.” I shared a quick, knowing smile with the Family Medicine resident sitting next to me and we began to talk to her about following ones passion. We also reminded her several times, indirectly and directly that regardless of what type of medicine you practice, each of us will be in the top 1% of US income-makers. The top 1%.

Yes I know $120,000 instead of $200,000 (in a surgical subspecialty) seems like a huge deal, but honestly, every single Family Medicine Attending the other resident knew and every single Pediatric Attending I know is living very well. Yes, they may have a ton of debt they are working to pay back, but every single one has a family that is well taken care of. Everyone I know has a nice house (mostly owned and not rented), a decent if not really really nice car. And none appears outwardly to be struggling to afford their basic needs. I apologize if these are material things, but that’s what she was asking about and we answered because it’s a very real concern.

And that’s the Attendings, not the Residents. Every Resident I know, including myself, lives in a nice apartment. Many Residents in my program own houses, not rinkey-dink jacked up houses, but really nice grown-up houses with nice yards. We can afford to go on vacations and we buy what we want at the grocery store including at Whole Foods (which my father-in-law refers to as Whole Check). My husband and I budget our limited money well and hope to buy a house in the first several years out of residency. And we are already well on our way to having my student loans paid off within 10 years using the income based repayment straight out of medical school. Don’t get me wrong, if we didn’t have my husband’s graduate school scholarships, our family of 3 with a single working adult (me), we would be very close to being eligible for public benefits (Section 8 housing, food stamps, WIC, you name it); some of our neighbors are on assistance now.

So, seriously, I know many of us including myself are in debt. And I know we need to do things to overhaul “the system” so that serving patients and saving lives is compensated in a common sense and equitable way. One that values innovative, smart approaches such as preventative care and comprehensive services. One that doesn’t cause very capable and compassionate students who are interested in our field to go running the other way as they eye the ever-mounting price tag. But even at the lowest-paying end of the spectrum, we all will make more money than the majority of our country. And if we help each other to become more business-savvy, we should never have to struggle to live well.

The medical student left smiling. I left more inspired. Hopefully we encouraged her to pursue what will ultimately make her the happiest so that she can bring her “best self” to work every day; she owes it to herself and to her patients. Yes, it’s a daunting task and the realities of practicing medicine in our country are scaring the crap out of many of us and our future colleagues, but again, we are still positioned in one of the best fields that exists. I am committed to reminding myself, my colleagues, and the “fresh meat” that this is the reality we find ourselves in. A bit daunting, but not too scary.

Introducing myself...

Hello MiM community!

I am so pleased to  be joining you!  A little bit about me... (as stolen from my bio...)

I am a psychiatry resident.  I am very happily married to Hubby, who is also a resident, and I have a sweet and loving daughter, my little Doll, who made her grand entrance in the summer of 2013.  I like to read, write, and google useless things throughout the day.  Some of my goals include reading more psychiatry and less on google, exercising, eating more vegetables and less chocolate, starting to write a novel, and being the best mother/wife/doctor I can be.

I've been reading MiM for years.  It started when I was googling "lifestyle of an ob/gyn" and along came a list of entries written by various MiMers about a day in the life in their field.  I've been hooked ever since!

Anyways, just wanted to say hello!

MiM Mail: From a doctor in physical therapy

Please bear with me through the beginning of this post, but I feel the background is pertinent.  I'm not exactly sure where to start.  I am 33 years old, a wife to a military officer, a mother of a precious 4 month old son, a doctor of physical therapy, and an endurance athlete. 

When I was younger, I spent 4 years in the Air Force as an aerospace physiology instructor.  I completed my A.A.S. in Aerospace Physiology Instruction through the Community College of the Air Force, and my hard work and high performance was recognized numerous times and at various levels through awards, such as the junior enlisted member of the quarter and year.  My flight commander felt that as an enlisted member, I would never reach my full potential, so he encouraged me to separate from the military to complete my degree.  I followed his recommendation, separated from the military in 2005, and took the remaining classes required to complete a B.S. in Biology.  I remember studying for a biochemistry final, looking up at a poster that read "Physical Therapy- We're Hands On," and thinking that might be an interesting profession to look into.  I shadowed with a home health PT who LOVED her job after 20+ years, then worked as a physical therapy technician in an outpatient orthopedic clinic for several months.  I educated myself on the profession, read the APTA's Vision 2020 about how the physical therapy profession was moving towards direct access, autonomy, lifelong learning, and educational programs were now doctorates.  My undergraduate GPA was good, but not stellar, so to demonstrate my ability to succeed academically, I completed a rigorous M.S. in Biology while concentrating my studies in neuroscience, cell and molecular biology, graduating with a 4.0 GPA.  I scored the highest in all of my classes- in fact my pharmacology professor wrote a note on one of my exams thanking me for scoring so well because after grading my classmates, she was beginning to think she was failing at teaching.  My hard work paid off- I was accepted to the University of North Carolina at Chapel Hill Doctorate in Physical Therapy program.

Fall 2008 I started my doctorate.  About a month into the program, I noticed I wasn't as interested in the physical therapy coursework as I was in the pathology or pharmacology classes.  I missed the "science" I had loved so much during my masters...  This trend continued.  I began thinking about medical school, but had committed to physical therapy and thus felt I needed to give it a chance. 2010 I bought an MCAT book, but again talked myself out of it.  Student loans were piling up- did I really want to increase those?  2011 I graduated and began working as a physical therapist.  I spent over $4500 in continuing education that year in an attempt to find something I liked in PT: lymphedema, manual therapy, vestibular therapy, biomechanics of running, treating the multisport athlete (these last two were very interesting, especially since I am a triathlete), etc.  I am a very positive attitude person, yet have found very little in PT that I love besides being a clinician and working with patients.  My masters research involved neuroelectrophysiology on CA3b neurons in the hippocampal formation and very little human contact- although I loved the research, I missed working with people (and my PI never spoke to me).

I thought becoming a doctor of physical therapy would enable me to teach (which I love), but most universities require a "terminal degree" such as a PhD or EdD.  I thought direct access would allow patients to walk into my office with acute injuries and I could treat them before these injuries became chronic- well, not all states are direct access, a lot of insurance companies don't pay without an MD Rx, and in some states I can't even perform Grade V manipulations- something I am well skilled in doing!  Differential diagnosis was heavily emphasized throughout my schooling and clinic work- I am able to recognize flags that warrant a medical examination and referral to a medical doctor.  What is the point of the profession moving to a doctorate when, even as doctors, we are so limited?

Fast forward to today.  I think about applying to medical school everyday.  I read books on perinatal stem cells, biochemistry of obesity, metabolic pathways, pathologies affecting the nervous system and I get EXCITED!.  I want to treat patients- not by teaching them how to walk or improve muscle function- but I want to attack their diseases at the cellular level!  I want to physically excise tumors, shrink them pharmacologically, and get involved in research.  Yet, I hesitate and question if this is practical.  I have read several mothers in medicine posts about burnout, disillusionment- would this happen to me?  If I apply and am accepted, my family will be supportive, but I will be increasing my student debt (I already have $160K), taking time away from spending time with them, and I'm certainly not getting any younger- am I selfish in even wanting to become a medical doctor?  If I become an MD- or even an MD/PhD (I do love research), complete a residency, and fellowship will I have time to spend with my family, continue training and competing as a triathlete, or even just sit back and relax?  Also, my husband plans on spending 8-14 more years in the military before retiring.  I have spoken with PTs that became MDs and are now much happier- but they have all been male.  I have sought guidance from my mentors from PT school- they encouraged me to stay in PT...

I was excited to find this blog!  What thoughts do you all have?  I feel I need to make a decision- this contemplation has been going on since 2008...

Sincerely, Kelly

Evidence of things not seen

I usually don't cross-post from my personal blog, but this recent piece seems to have really resonated with fellow residents and physicians in general. People have approached me in the hospital to talk about it, and as a result, I have had a lot of honest, wonderful conversations with my colleagues -- about their love for medicine and for their patients, about the traumas of training, and about the systemic problems that make their jobs less satisfying than they had hoped they would be. These conversations have reconnected me with my own deep motivation to serve patients and have inspired me to fight for a better system. I look forward to hearing from fellow MiMs about your experiences and hopes and ideas for how to better heal our patients and protect ourselves from burnout. 

*         *         *         *         *

I am on retreat with my residency class. We are in an otherwise empty hotel on the Jersey Shore whose just-an-average-hotel-ness is intensified by the lonely quiet of the off season. I can imagine the bustle of summer filling up the space -- trails of sand from little feet tracked in from the beach, brightly colored umbrellas stacked up on the deck, all the various sounds that people can make from within hotel rooms -- but in the emptiness of winter the rooms seem tired. Why are hotels decorated in brown and beige? Are there people who are offended by color? Or is it just to mask wear and dust and dirt? Is the bored eye less likely to see?

There are few opportunities in my life to sleep in but today I could have slept until 8:30am, which as all parents of toddlers can attest, is the new noon. I went to bed early last night, in fact, because I wanted to experience the sensation of restedness this morning, the feeling of waking up out of readiness instead of necessity. But because the universe has both good wisdom and a good sense of humor, my eyes opened at 5:45am -- the very time that my alarm will ring tomorrow morning -- and I couldn't go back to sleep. At first I was filled with a familiar sense of cynical irritation, the "why me" and "well isn't that always the way" that residency has brought to my life despite the comforts and advantages that I enjoy. But then I thought to myself, how often do I get a chance to walk on the beach as the sun rises? According to weather.com the sun would be rising at 7:01AM. I put on several layers and slipped out of my shared room, through the muzak in the lobby, and out towards the ocean.

There was no one else in sight. I walked toward the ribbon of pink spreading up from the horizon. The hard, frozen sand up near the beach grasses gave way to the satisfying sink of each step into the wet shore. Several gulls circled and dipped. I looked for shells to bring home to E -- not too small, not too sharp -- and came across some of the odd hints that the ocean delivers up to us about itself. Cracked orange crab shells and dismembered legs half buried in the sand. Plant fronds of various colors and textures and widths. A foot-long brown spear that widened up to what looked like the end of a bone with some white and yellow flesh still attached -- tooth? spine? tail? Breaking the smooth contour of the shoreline, a sudden small pile of sea sponge. I walked for an unknown distance. The sky became lighter and lighter beneath and around the layers of cloud. I wondered to myself when the sun would rise and what would mark the sun's rising. I looked at my watch and it was 7:13, already past the appointed time. The part of my legs between the top of my boots and the bottom of my coat began to tingle and sting with cold and I turned to walk back to the hotel as the daylight continued to bleed into being around the edges of the sky.

*         *          *          *          *

How should I say this? I am worried about the state of health care. I am worried about the state of my own heart. I am worried about the way doctors are trained. I am worried about the way health is defined. I have been in and around hospitals for almost a decade at this point and I feel like I know less and less about how to help people achieve well-being. I feel like I'm getting better and better at keeping people alive and less and less good at helping them live well. I am maybe a little depressed or to use the somewhat more socially acceptable term, burned out.

I went into medicine with a desire to be with people in life's most terrifying and difficult and potentially ecstatic moments. I wanted to understand the body, to understand more about life and illness and death. It's a cliche but a deeply felt one: I wanted to be of service. I also wanted financial stability and the ability to provide for my children. I wanted a job that would be meaningful even on the worst days. But mainly I wanted to form deeply satisfying therapeutic relationships -- it's what I wrote my residency application essay about and it is still what I aspire to accomplish, somehow.

Now, almost ten years later, I spend more than 90% of my day in front of a computer. Sometimes the computer is actually physically located in between me and my patients and I have to crane my neck around its unsleeping eye to see them. I type through the majority of my clinical encounters. During a typical day on the wards, I see my patients for -- at most -- 5-10 minutes per day each. My day is filled with entering and reentering orders on the computer, writing endless admission notes and progress notes which recapitulate information that is already recorded elsewhere in the medical record, waiting on hold to talk to primary care doctors' answering services, calling pharmacies and insurance companies for prior authorization, calling subspecialists to address each of the body's organ systems, and coordinating the complex behemoth of a large tertiary care center to get tests and studies done for my patients. I work up to 28 (actually more like 30 but shhhh don't tell) hours in a row every fourth night which wouldn't bother me except that of those hours I spend at most 2-3 in total with patients. Patients turn over so quickly in the hospital that I might be responsible for the care of over 100 patients during a given week. During clinic hours I am perpetually beset with anxiety at how far behind I am, unable to get through a well child visit meaningfully in the 20 minute time frame allotted for this purpose and because of the fragmentary nature of residency scheduling, I often do not see these patients again. I want to form relationships with my patients, but at times it feels like talking to patients just takes time away from the tasks that need to be done for them. It's crazy, but it's true.

Some of these issues are unique to residency, which is time-limited (though formative), but surveys of post-residency physicians suggest that as a group, we are in trouble. In a much quoted and discussed survey of 24,000 physicians by Medscape in 2013, only 54% reported that they would choose medicine if they had it to do over again. Fourty-nine percent of physicians surveyed reported at least one symptom of burnout and 40% reported that they were burned out.

On the receiving end of medical care both as a patient and as a loved one advocating for sick family members, I know what it's like to receive care from a system of overwhelmed and/or burned out providers. Test results are not communicated. Small details are missed. You wait 7 hours to speak with the doctor, then that person does not know some of the basic details of your case. The care you receive addresses a symptom or a part of the problem, but rarely the whole problem, and rarer still, you as a whole person. I fear being that kind of provider yet I have been that kind of provider despite my fervent desire to avoid it. There are just too many patients, too many data points, too many notes to read and write. There is so little time for relationships to form. There is no magic there.

Doctors are a hard group to sympathize with. Once we finish training (it's long, but let's face it, life is longer) most of us land in the top 10% if not the top 5% or 1%. Training is hard and the hours are long but we choose this life with full knowledge (as much as you can have full knowledge) of what we are getting into. We hold a lot of societal and political power and on an individual level,  in hundreds of thousands of exam rooms across the world, we have the power to examine, to question, to diagnose, to prescribe, to get it right and heal or get it wrong and harm. But if we as a society want to get the kind of health care that not only cures but heals, we are going to have to look at how doctors feel, how they are trained, how their work-life is organized, what we ask of them, and how we support them in their work.

*          *          *          *          *

If you work around sick children long enough, there will be a death that crushes you, that doesn't let go, that you can't let go of. Little O came into my care last month and a few hours later passed away under the most difficult of circumstances. Oddly enough, I don't remember her name -- perhaps because the intensity of our efforts to keep her alive and the adrenaline coursing through my body erased it from my data banks, perhaps because I have been afraid to reopen her chart. I think of her as little O, the little O of her mouth, the round moon of her little face which I saw for weeks every time I closed my eyes. If I will it, I can hear her mother's screams in my mind's ear as vivid as the sounds of my household humming around me as I write: "No es justo! No es justo!"

I want to make contact with her family, to tell them that I feel for them, that I think of her, that even though our lives touched for only a few short hours, I feel the weight of their loss. I have never done such a thing before and I'm not sure if it is even appropriate. Who should I ask? Do I need to get permission from my program director? Do I need to run it by risk management? In the end, the question comes down to one of the nature of my relationship to that baby and her family. Was there one? And if so, what was it? I have been training for many years but have received no apprenticeship in this most important aspect of my profession.

So many hundreds of children pass through my life and I through theirs and we are like ghosts to each other. There are so many layers between me and my patients, layers of bureaucracy, legality, scheduling, vulnerability and power traded back and forth in a complicated dance. Was this always so? Sometimes I fantasize about becoming a small-town doctor, about being part of the community I serve, of knowing my patients and allowing them to know me.

I will likely never send a card or see little O's family again, but this is what I would want to tell them: I will hold your daughter in my heart forever.

*          *          *           *          *

Meanwhile, back at retreat, I am surrounded by the loveliest people. My co-residents are intelligent, accomplished, funny, and kind. To a person they are motivated by the desire to be of service. They are scientists and humanitarians who hold as sacred the trust placed in them by children and their families. They are also spouses and parents and children and friends who struggle to balance the commitments they have made in so many domains in their lives. I feel lucky to know them and I think children are lucky to have them as their doctors.

What I wish for them and for myself as doctors, what I wish for myself as a patient, for my patients, and for my loved ones who are someone else's patients, is a system that allows us to be healers, that helps us to heal. I want a system that allows me to express my compassion, that gives me the space and time to care for people in a meaningful way. Unrealistic? Selfish? Possible? I hope to find out.

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