Dear MiM,
I am writing you to get some advice on toddler behavior.
I am a 3rd year medical student, mom to an almost 3 year old little boy and currently pregnant with baby number 2. I have been struggling lately with my son's behavior. I used to have a sweet, smart and energetic little boy. Since he has been out of his crib and potty trained, my husband and I have had a tantrum monster on our hands. We have what we call a "spirited child," with a very strong personality and stubbornness beyond anything I have seen in other toddlers.
We put him down to bed around 8pm every night after the usual bed time routine and he usually takes anywhere from 1 to 2 hours to actually fall asleep. It's a combination of "I want different pjs/I need more water/I want daddy/I want a new blanket/ I want the light to be blue/ It's not dark out yet/ I don't want to sleep / I need to pee" but the list is endless. My husband and I try to be firm, we have tried to let him cry it out but he cries even louder so we inevitably comply with his requests so he can sleep. Even worse, he wakes up 2-4 times per night with similar complaints, throws tantrums where he arches his back, cries hysterically but won't tell us what is wrong. As a result I am getting increasingly frustrated and exhausted.
Today must have been the worst of all days yet when after 4 overnight wake ups and very little sleep overall, my son woke up at 5:30 whining, rubbing his eyes, yawing and saying that he does not want to sleep anymore. I found myself yelling and screaming, which is unusual for me and ended up breaking down in tears since I had only gotten about 5 hours of sleep myself.
Being very pregnant at this point, I am anticipating some sleep deprivation once our new baby arrives but I feel like I cannot deal with my son anymore. I cannot imagine how this situation is going to work out when I have two kids in the house who wake up multiple times per night.
Worst of all, I feel like I am failing as a mother. I am having a hard time enjoying time with my son during the day when nights are so painful and feel guilty about it. I can deal with daytime tantrums but the nights are draining my energy.
Do other moms or pediatricians have experienced similar situations and have tips on how to deal with toddlers? Your help would be greatly appreciated. Thank you.
Medmommil
Friday, May 9, 2014
Thursday, May 8, 2014
Question: Maternity leave
Lately every night I'm on call I seem to be the magnet for pregnant patients - trauma, acute abdomens, appys, choleys - you name it. During my last call as we talked about my pregnancy magnet, it lead to a discussion about having babies during residency. We happened to be a diverse group of providers with a diverse and international training background. The take away from the discussion was basically that in the US we don't value new moms, dads or babies. Those who had trained elsewhere (in surgery) seemed to feel that it was just natural to expect residents to take 4 months, 6 months, or 1 year off (mom or dad). Meanwhile we all told stories of post c-section residents NSAIDing their way through full operative days 4 weeks after giving birth. We talked about how broken your body can feel so soon after giving birth, both mentally and physically. We talked about those itty bitty 6-week old babies in daycare.
So, for those of you who have trained elsewhere in the world:
So, for those of you who have trained elsewhere in the world:
What is the attitude towards new moms and dads in other countries with more flexible and lengthy maternity leave policies?
Are residents looked down upon for taking leave (like they often are in the US)?
Does a culture of more family centric leave create a more equitable distribution of gender roles in the home and the workplace?
I'm just wondering...
Wednesday, May 7, 2014
Mommy Call
After my six-week maternity leave was over, I showed up to work after having been up all night because my Doll must have felt the change coming--she didn't sleep a wink! And I was up with her, trying to soothe her back to sleep.
I was quite embittered (is that word?) that I was scheduled for a 24 hour overnight in-house call just 4 days later, as I thought there was an agreement that I would not be on call for at least a month after returning. That night on call was a particularly slow night, and I was called by the nurses only about twice. One of the calls required me to handle a situation on the floors, and as I was writing my evaluation note, one of the nurses said to me, "it's nice to get some sleep while you're here, huh?"
No, it's not. I would have rather been up every night all night with my Doll than sleep all at work. That's how I felt then, and that's how I feel now, 9 months later.
It is finally May. I see the light at the end of this very long tunnel! Two more months until what seems now to be the golden year of residency.
I was quite embittered (is that word?) that I was scheduled for a 24 hour overnight in-house call just 4 days later, as I thought there was an agreement that I would not be on call for at least a month after returning. That night on call was a particularly slow night, and I was called by the nurses only about twice. One of the calls required me to handle a situation on the floors, and as I was writing my evaluation note, one of the nurses said to me, "it's nice to get some sleep while you're here, huh?"
No, it's not. I would have rather been up every night all night with my Doll than sleep all at work. That's how I felt then, and that's how I feel now, 9 months later.
It is finally May. I see the light at the end of this very long tunnel! Two more months until what seems now to be the golden year of residency.
Monday, May 5, 2014
Guest post: Gaining More Than Just Weight
Twenty pounds into my pregnancy with no end in sight, I began to dread stepping onto the scale at my Ob/Gyn appointments. Even more, I began to dread that moment in the exam room when my doctor would review my numbers for that day. My blood pressure was invariably okay and my urine dip was normal, but my weight continued to bound upwards in increments larger than what was apparently advisable. I would nod with shared concern as she read out the new tally – seven pounds since my last visit? Oh, my – and with determination as she listed suggestions to watch what I ate and try to get some exercise. Even just take a walk a few times a week, she said. The implication being, how hard could it be?
I would leave the office with new resolve to pack healthier snacks for work and to make time to go back to the gym, or at least to start taking the occasional evening stroll. The snack resolution I met with reasonable success, but the exercise portion proved difficult. Now in my second year of residency, I had stacked my schedule so as to complete my months on certain services – those with the greatest intensity and the longest hours – in the fall and winter prior to my delivery in exchange for a reasonable stretch of call-free maternity leave in the spring. As a result, I left the hospital each night in darkness, exhausted. I stopped even pretending that I might stop by the gym or venture out along the icy sidewalks near my home. Besides, I spent at least half of every shift on my feet, rounding on the wards or hurrying between emergencies. Surely all that activity must count for something.
Hoping that my mediocre efforts had paid off to at least slow the accumulation of pounds, at the next visit I would slip off my heavy Dansko clogs, get back on the scale, and watch as the medical assistant slid the little weights ever further to the right in order to balance my growing mass. Then the entire scene would repeat.
Eventually I gave up.
My new attitude was a mixture of It’s no use, I can’t, and Why bother. I was doing what I could, I reasoned, and if I gained some extra weight, so be it – I would work extra hard to lose it after the baby arrived. I continued to attend every check-up, only now when I nodded at the numbers, my concern was only mild and my determination feigned. I left the office feeling a combination of relief and resignation, already dreading my next appointment.
And suddenly I was not so different from my own clinic patients and their families: from the children and teenagers whose growth curves make me cringe as they surge skyward, brazenly crossing percentile lines, and from the parents (often overweight themselves) who grimace when I show them this evidence of too much intake and too little output – it’s that simple, I explain. They nod earnestly as I outline a plan of attack: cut out soda and juice, add vegetables, find time for exercise. And they look abashed when they return months later to find the curve inching ever onward in the wrong direction.
I’ve been lucky in terms of weight for most of my life. Sure, I’m a fairly typical female; I have certain body parts that I find too loose or jiggly or poorly shaped and I’ve spent too much time staring from different angles in the mirror, obsessing over these flaws. I have gained and shed pounds according to my level of stress and just how hard – probably at times too hard – I have worked to lose them. But I have never been truly overweight, never begun to dance with the complications of hypertension, diabetes, sleep apnea. Never before had a doctor grow concerned about the number on the scale.
And because I had never been in their position, I had never understood how difficult it is to try to get out of it. My belief and the implication of my advice had always been: how hard could it be?
Now I knew. The specifics of our challenges aren’t exactly the same –many of my patients can’t afford to join a gym whereas I pay for a membership and don’t go – but if neither if us is working out, what’s the difference? We’re both gaining too much weight too fast and have been unsuccessful at making the changes our doctors push for. And we’ve both felt bad about it.
I didn’t suddenly develop a grasp of how to move past the roadblocks in my life or theirs. If anything, this new knowledge makes my job even more frustrating and my motivational interviewing less motivational; how can I enthusiastically pitch ideas that, given the backdrop they are set against, are so unlikely to work? What I did gain was new understanding and empathy. And while I don’t have any brilliant solutions to offer to busy, tired people with potentially limited resources who are struggling with the trials of diet and exercise for themselves or their children, I hope that I am better able to partner with them to search for solutions or simply provide support now that I have stood in their shoes . . . on the scale.
I am a second-year pediatrics resident and mom to a 2-month old boy. I blog about my experiences at The Growth Curve (www.thegrowthc.wordpress.com).
I would leave the office with new resolve to pack healthier snacks for work and to make time to go back to the gym, or at least to start taking the occasional evening stroll. The snack resolution I met with reasonable success, but the exercise portion proved difficult. Now in my second year of residency, I had stacked my schedule so as to complete my months on certain services – those with the greatest intensity and the longest hours – in the fall and winter prior to my delivery in exchange for a reasonable stretch of call-free maternity leave in the spring. As a result, I left the hospital each night in darkness, exhausted. I stopped even pretending that I might stop by the gym or venture out along the icy sidewalks near my home. Besides, I spent at least half of every shift on my feet, rounding on the wards or hurrying between emergencies. Surely all that activity must count for something.
Hoping that my mediocre efforts had paid off to at least slow the accumulation of pounds, at the next visit I would slip off my heavy Dansko clogs, get back on the scale, and watch as the medical assistant slid the little weights ever further to the right in order to balance my growing mass. Then the entire scene would repeat.
Eventually I gave up.
My new attitude was a mixture of It’s no use, I can’t, and Why bother. I was doing what I could, I reasoned, and if I gained some extra weight, so be it – I would work extra hard to lose it after the baby arrived. I continued to attend every check-up, only now when I nodded at the numbers, my concern was only mild and my determination feigned. I left the office feeling a combination of relief and resignation, already dreading my next appointment.
And suddenly I was not so different from my own clinic patients and their families: from the children and teenagers whose growth curves make me cringe as they surge skyward, brazenly crossing percentile lines, and from the parents (often overweight themselves) who grimace when I show them this evidence of too much intake and too little output – it’s that simple, I explain. They nod earnestly as I outline a plan of attack: cut out soda and juice, add vegetables, find time for exercise. And they look abashed when they return months later to find the curve inching ever onward in the wrong direction.
I’ve been lucky in terms of weight for most of my life. Sure, I’m a fairly typical female; I have certain body parts that I find too loose or jiggly or poorly shaped and I’ve spent too much time staring from different angles in the mirror, obsessing over these flaws. I have gained and shed pounds according to my level of stress and just how hard – probably at times too hard – I have worked to lose them. But I have never been truly overweight, never begun to dance with the complications of hypertension, diabetes, sleep apnea. Never before had a doctor grow concerned about the number on the scale.
And because I had never been in their position, I had never understood how difficult it is to try to get out of it. My belief and the implication of my advice had always been: how hard could it be?
Now I knew. The specifics of our challenges aren’t exactly the same –many of my patients can’t afford to join a gym whereas I pay for a membership and don’t go – but if neither if us is working out, what’s the difference? We’re both gaining too much weight too fast and have been unsuccessful at making the changes our doctors push for. And we’ve both felt bad about it.
I didn’t suddenly develop a grasp of how to move past the roadblocks in my life or theirs. If anything, this new knowledge makes my job even more frustrating and my motivational interviewing less motivational; how can I enthusiastically pitch ideas that, given the backdrop they are set against, are so unlikely to work? What I did gain was new understanding and empathy. And while I don’t have any brilliant solutions to offer to busy, tired people with potentially limited resources who are struggling with the trials of diet and exercise for themselves or their children, I hope that I am better able to partner with them to search for solutions or simply provide support now that I have stood in their shoes . . . on the scale.
I am a second-year pediatrics resident and mom to a 2-month old boy. I blog about my experiences at The Growth Curve (www.thegrowthc.wordpress.com).
Thursday, May 1, 2014
Guest post: Post Partum Pearls
An IM Hospitalist's perspective
I’ve heard that the rigors of medicine prepare women for the arrival of a newborn, and to a certain extent that is true, but there is definitely more to it than that. Our great work ethic, patience, and calmness in the midst of a storm do give us a great base. Also, we tend to “freak out” less over any minor baby medical issues. Despite those similarities, taking care of an infant is quite an unique experience.
It’s been four months since the birth of my adorable baby girl (in my completely unbiased opinion), and I’ve stumbled upon some of my own truths that I felt like sharing.
# First few months are all consuming…kind of like Intern Year
Preparing for childbirth and care takes you only so far, just like prepping for intern year cannot get you ready for the real time situations of the wards.
I was exhausted both mentally and physically in ways I didn’t know I could be. I learned the hard way that keeping my goals simple was key. Feeding, consoling, bathing and carrying an infant is enough for the day. Squeeze in some personal hygiene and eating time and feel good about yourself.
# Infant care is the ultimate roller coaster ride
I recall at the end of my 12 hour day or night of work, my husband would ask how the it went, and in my head multiple thoughts would race, but it was too mentally taxing to convey everything to him, so I’d end up saying “ it was good…” This type of response is quite similar to my days during maternity leave.
There was a mixture of highs and lows and in between. Capturing the entire experience in one sentence seemed unnatural.
# Self-sufficiency is overrated
Though in our profession we are encouraged to ask for help every step of the way, what I’ve found more true with my few years post training, is that most of us strive to work out issues on our own. Asking for a consult every time a question pops up is not an enticing option unless absolutely necessary.
Well when it comes to infant care, support and help are key. The truth is you need your “own time” off from your infant to maintain a healthy relationship. Sure there is satisfaction in bathing, feeding, and nurturing your child all by yourself at times, but not all the time!
Take up your family and friends’ offers to help out. Learn to separate your attending/resident hat from your mother hat! Oh and single mothers, you completely deserve a lifelong standing ovation.
# Don’t feel guilty about not doctoring
As my baby has grown up over past month or so, I have found more free time during the day. At first I immediately thought (after catching up on sleep), that I should do some medicine related things, so my brain doesn’t decrepitate with time. So I filled the hours with intermittent medical reading and reviewing some stuff here and there. I even created my own blog regarding hospital medicine, but as time wore on during my maternity leave, I still found it hard to keep up with everything, and then the guilt trip started. So what I have concluded is to give up pseudo doctoring unless it truly invigorates me, like writing this article. Don’t worry, the skills will not disappear. I realized that after doing a few shifts here and there. You have the rest of your life to doctor away, no need to do fret over it now.
# Embrace your free time, it’s okay to be domestic!
If you’re blessed with more just six weeks off, you will find that your free time will actually increase (not dramatically but noticeably so). I found myself cleaning up the clutter in our apartment and going on an organizational binge. There were moments when I’d stop in the midst of my activities, and think “ oh god, what am I doing?? Did I study, train, work all those hours, and accrue all that debt to only be doing this right now…? “ And then, after bouncing these thoughts off my husband, I slowly snapped back to reality. And reality was pretty great if you are willing to accept it within the context.
For once in my life, I was not working or studying. My hours were completely dedicated to my child and to myself/family. I’d never had this type of time before, except maybe the two months between medical school and residency, except now I was more settled in my life, and that was comforting.
What did I use this time for? Well, to be honest, at first, I binged on TV. Then I started getting into social media especially all the medical related stuff. I’ve also been exploring my creative side again – doing DIY projects for décor, learning lullabies on my acoustic guitar to sing to my little girl, and learning to cook different dishes. It’s been quite refreshing.
Take Away
Overall, it really has been an internship of sorts, and this “learning how to be a parent” is going to continue for the rest of my life just like perfecting the art of medicine never stops. I do hope that my experience will make me a more caring physician when I jump back into the field. I have much to learn, and I’m looking forward to it. To all the other mothers in medicine, I applaud you. I’d love your advice and comments!
I’ve heard that the rigors of medicine prepare women for the arrival of a newborn, and to a certain extent that is true, but there is definitely more to it than that. Our great work ethic, patience, and calmness in the midst of a storm do give us a great base. Also, we tend to “freak out” less over any minor baby medical issues. Despite those similarities, taking care of an infant is quite an unique experience.
It’s been four months since the birth of my adorable baby girl (in my completely unbiased opinion), and I’ve stumbled upon some of my own truths that I felt like sharing.
# First few months are all consuming…kind of like Intern Year
Preparing for childbirth and care takes you only so far, just like prepping for intern year cannot get you ready for the real time situations of the wards.
I was exhausted both mentally and physically in ways I didn’t know I could be. I learned the hard way that keeping my goals simple was key. Feeding, consoling, bathing and carrying an infant is enough for the day. Squeeze in some personal hygiene and eating time and feel good about yourself.
# Infant care is the ultimate roller coaster ride
I recall at the end of my 12 hour day or night of work, my husband would ask how the it went, and in my head multiple thoughts would race, but it was too mentally taxing to convey everything to him, so I’d end up saying “ it was good…” This type of response is quite similar to my days during maternity leave.
There was a mixture of highs and lows and in between. Capturing the entire experience in one sentence seemed unnatural.
# Self-sufficiency is overrated
Though in our profession we are encouraged to ask for help every step of the way, what I’ve found more true with my few years post training, is that most of us strive to work out issues on our own. Asking for a consult every time a question pops up is not an enticing option unless absolutely necessary.
Well when it comes to infant care, support and help are key. The truth is you need your “own time” off from your infant to maintain a healthy relationship. Sure there is satisfaction in bathing, feeding, and nurturing your child all by yourself at times, but not all the time!
Take up your family and friends’ offers to help out. Learn to separate your attending/resident hat from your mother hat! Oh and single mothers, you completely deserve a lifelong standing ovation.
# Don’t feel guilty about not doctoring
As my baby has grown up over past month or so, I have found more free time during the day. At first I immediately thought (after catching up on sleep), that I should do some medicine related things, so my brain doesn’t decrepitate with time. So I filled the hours with intermittent medical reading and reviewing some stuff here and there. I even created my own blog regarding hospital medicine, but as time wore on during my maternity leave, I still found it hard to keep up with everything, and then the guilt trip started. So what I have concluded is to give up pseudo doctoring unless it truly invigorates me, like writing this article. Don’t worry, the skills will not disappear. I realized that after doing a few shifts here and there. You have the rest of your life to doctor away, no need to do fret over it now.
# Embrace your free time, it’s okay to be domestic!
If you’re blessed with more just six weeks off, you will find that your free time will actually increase (not dramatically but noticeably so). I found myself cleaning up the clutter in our apartment and going on an organizational binge. There were moments when I’d stop in the midst of my activities, and think “ oh god, what am I doing?? Did I study, train, work all those hours, and accrue all that debt to only be doing this right now…? “ And then, after bouncing these thoughts off my husband, I slowly snapped back to reality. And reality was pretty great if you are willing to accept it within the context.
For once in my life, I was not working or studying. My hours were completely dedicated to my child and to myself/family. I’d never had this type of time before, except maybe the two months between medical school and residency, except now I was more settled in my life, and that was comforting.
What did I use this time for? Well, to be honest, at first, I binged on TV. Then I started getting into social media especially all the medical related stuff. I’ve also been exploring my creative side again – doing DIY projects for décor, learning lullabies on my acoustic guitar to sing to my little girl, and learning to cook different dishes. It’s been quite refreshing.
Take Away
Overall, it really has been an internship of sorts, and this “learning how to be a parent” is going to continue for the rest of my life just like perfecting the art of medicine never stops. I do hope that my experience will make me a more caring physician when I jump back into the field. I have much to learn, and I’m looking forward to it. To all the other mothers in medicine, I applaud you. I’d love your advice and comments!
@psanyaldey is a 34 year old internal medicine trained hospitalist. She is married and has a mini siberian husky along with her newborn girl.
Tuesday, April 29, 2014
Rocket Scientist
My daughter Cecelia (11) has never wanted to be a pathologist. She is completely disgusted by what I do. She likes looking under the microscope, but when I showed her the Blood Bank a couple of years ago with refrigerated stocks of blood and she saw an amputated leg (shrouded by a red biohazard plastic bag) one day when we visited the gross room - "What's that Mom?" - she was mortified. She wants to be a rock star. Fine by me. I'm all up for supporting dreams coupled with education.
Jack (8), has always wanted to design video games. But he's also great at math, graduated from struggling to read Skylander captions at the beginning of this school year to hungrily devouring novel series in weeks (Percy Jackson, Hunger Games - I know, but he begged for months and had seen the movies with his dad and sis so I finally gave in), builds lego sets, and loves winding down at night making me and his class Rainbow Loom bracelets. They adorn my wrists and serve as office decorations.
But no pathologist admiration yet. Over the weekend I bought Jack an air blaster gun and he has enjoyed building the flat paper characters into 3D figures to "blast" with the air gun. One he was working on this morning while I fixed lunches had a lab coat. "Mom, you have to take this one to work with you! It's The Evil Pathologist." He wrote it painstakingly and lovingly on the back of the head.
Cecelia chimed in. "Mom, you have to put it with your rocket ship microscope cleaner." So today when I went to work I created a moon scene to show them tonight. The Evil Pathologist, my rocket scope cleaner, some "moon" sand Cecelia made for me years back, and a nice bright Emergen-C background that looks I think a little otherworldly; planet like. C said it just looked like Emergen-C packaging. Oh well.
Jack (8), has always wanted to design video games. But he's also great at math, graduated from struggling to read Skylander captions at the beginning of this school year to hungrily devouring novel series in weeks (Percy Jackson, Hunger Games - I know, but he begged for months and had seen the movies with his dad and sis so I finally gave in), builds lego sets, and loves winding down at night making me and his class Rainbow Loom bracelets. They adorn my wrists and serve as office decorations.
But no pathologist admiration yet. Over the weekend I bought Jack an air blaster gun and he has enjoyed building the flat paper characters into 3D figures to "blast" with the air gun. One he was working on this morning while I fixed lunches had a lab coat. "Mom, you have to take this one to work with you! It's The Evil Pathologist." He wrote it painstakingly and lovingly on the back of the head.
Cecelia chimed in. "Mom, you have to put it with your rocket ship microscope cleaner." So today when I went to work I created a moon scene to show them tonight. The Evil Pathologist, my rocket scope cleaner, some "moon" sand Cecelia made for me years back, and a nice bright Emergen-C background that looks I think a little otherworldly; planet like. C said it just looked like Emergen-C packaging. Oh well.
I don't need my kids to want to do what I do. But I'm happy they finally think it's kinda cool. Confession: I wiped the dust off of the shelf before I took the pic.
Monday, April 28, 2014
Guest post: I'm more like the night-time babysitter
Sometimes I feel like the night time babysitter. I am an Ob/Gyn resident and leave every morning before my 16 month old wakes up (she's a great sleeper, I should be happy). I come home and feed my daughter dinner and supervise the bath, zip up the PJs, watch a cartoon and cuddle while she drinks her bottle, and then its "night night time" and I'm done being a mommy for the day. I could keep her up later but she's tired, and I don't want her being on a special schedule just because her mommy is a doctor.
I hate being a doctor these days. I don't feel important or empowered like people say I should. I know my daughter will one day look up to me as a role model and feel proud of my career, but right now I think she just needs a mommy at home. I don't envy anyone except my stay-at-home mom friends. I wish I knew what it was like to be totally frustrated after a long day of cleaning up plastic toys and missed naps. I wish I knew what it was like to be lonely from lack of adult interaction. Instead I'm stuck taking care of people I don't know all day and getting yelled at by attendings.
I know I'm a "grass is always greener" type of girl, but many days I think I could walk away from this job and never look back. But what would everyone else think? What would my father, who paid for medical school, say? I'm "almost done" with residency-1 year and 2 months left to go, but it feels like forever. I'm already counting down until the day I graduate, so I can take a few months off, and then start whatever Hospitalist job will let me work the least amount of hours. Exactly the kind of career I used to think was an unambitious waste of a medical degree.
I don't give myself a break or a pat on the back for managing everything. I make sure my house is fully stocked at all times, I sign my daughter up for all of the best classes and lessons (to go to with her nanny). She has an impeccable wardrobe and fresh cooked vegetables in the fridge at the start of most weeks. But I torture myself that I'm not home enough. I cried when my daughter had food poisoning for the first time and I was stuck at work overnight. I refuse to sleep during the day post-call -- what a waste of bonding time. Being a working mom is hard. Being a resident and mom is even harder, but I don't regret having my daughter, she's the best thing that's ever happened to me. I guess I'm crazy, because despite what I've been through these past 16 months, we're trying for baby #2 right now!
Sara, Ob/Gyn Resident (PGY-3)
I hate being a doctor these days. I don't feel important or empowered like people say I should. I know my daughter will one day look up to me as a role model and feel proud of my career, but right now I think she just needs a mommy at home. I don't envy anyone except my stay-at-home mom friends. I wish I knew what it was like to be totally frustrated after a long day of cleaning up plastic toys and missed naps. I wish I knew what it was like to be lonely from lack of adult interaction. Instead I'm stuck taking care of people I don't know all day and getting yelled at by attendings.
I know I'm a "grass is always greener" type of girl, but many days I think I could walk away from this job and never look back. But what would everyone else think? What would my father, who paid for medical school, say? I'm "almost done" with residency-1 year and 2 months left to go, but it feels like forever. I'm already counting down until the day I graduate, so I can take a few months off, and then start whatever Hospitalist job will let me work the least amount of hours. Exactly the kind of career I used to think was an unambitious waste of a medical degree.
I don't give myself a break or a pat on the back for managing everything. I make sure my house is fully stocked at all times, I sign my daughter up for all of the best classes and lessons (to go to with her nanny). She has an impeccable wardrobe and fresh cooked vegetables in the fridge at the start of most weeks. But I torture myself that I'm not home enough. I cried when my daughter had food poisoning for the first time and I was stuck at work overnight. I refuse to sleep during the day post-call -- what a waste of bonding time. Being a working mom is hard. Being a resident and mom is even harder, but I don't regret having my daughter, she's the best thing that's ever happened to me. I guess I'm crazy, because despite what I've been through these past 16 months, we're trying for baby #2 right now!
Sara, Ob/Gyn Resident (PGY-3)
Saturday, April 26, 2014
MiM Mail: Timing is everything
Dear Mothers in Medicine,
I am not yet a mother or in medicine, but I’m currently trying for both. I guess I was never able to do just one thing at a time. I am 32 years old and I’m applying to medical school this year. My husband I were thrilled when we recently found out I was pregnant. Unfortunately the pregnancy ended at seven weeks. We are recovering and will hopefully be given the green light to start trying again soon. But now timing is an issue. I was hoping to have a baby that would be at least a few months old before starting school. Our chances of achieving that are getting slimmer each month. I could try to time things to have a baby at the end of MS1, but it took us a while to get pregnant the first time and I doubt our ability to conceive on demand. Surprise, surprise, these things are pretty difficult to plan.
My plan for now is to continue trying for both. If I’m lucky enough to have a healthy pregnancy that ends up having a delivery date close to my matriculation date, I suppose I will defer for a year. I wonder what all of you, having experience with both motherhood and medicine, would do in this situation? Would you stop trying for those months that would lead to a delivery around the time medical school would begin? Would you defer? Would you just not worry about it and wait for the perfect storm to occur? Thank you in advance, and thank you for all of your words of wisdom – I’ve been reading for quite a while!
-Anonymous
I am not yet a mother or in medicine, but I’m currently trying for both. I guess I was never able to do just one thing at a time. I am 32 years old and I’m applying to medical school this year. My husband I were thrilled when we recently found out I was pregnant. Unfortunately the pregnancy ended at seven weeks. We are recovering and will hopefully be given the green light to start trying again soon. But now timing is an issue. I was hoping to have a baby that would be at least a few months old before starting school. Our chances of achieving that are getting slimmer each month. I could try to time things to have a baby at the end of MS1, but it took us a while to get pregnant the first time and I doubt our ability to conceive on demand. Surprise, surprise, these things are pretty difficult to plan.
My plan for now is to continue trying for both. If I’m lucky enough to have a healthy pregnancy that ends up having a delivery date close to my matriculation date, I suppose I will defer for a year. I wonder what all of you, having experience with both motherhood and medicine, would do in this situation? Would you stop trying for those months that would lead to a delivery around the time medical school would begin? Would you defer? Would you just not worry about it and wait for the perfect storm to occur? Thank you in advance, and thank you for all of your words of wisdom – I’ve been reading for quite a while!
-Anonymous
Thursday, April 24, 2014
Guests of the month
My husband and I made one New Year's Resolution for 2014 together: to have friends over for dinner more regularly. Whenever we do, we love it, and the kids have a blast. However, it has always seemed like a lot of effort to coordinate, to clean ("clean" underestimates the amount of prep our house needs to be able to be opened to the public), and it's just so much easier not to do it. Plus, we're introverts. Now, it's not like we are hermits or anything (although I don't really know what a normal social life with a family is), but we both agreed that having people over more would be good for our whole family. I'd estimate that last year we probably had people maybe 4 or 5 times, but we are aiming to host dinner once a month.
As of April, we've had four families over - including neighbors, good friends we don't get to see enough of, friends we haven't seen since grad school, and new friends from church. We are loving it. We've relaxed some of that need-to-have-a-perfect-house compulsion when entertaining - and no one has run out screaming yet. (Still have some degree of compulsion, I won't lie, but it's definitely less severe that it was. Think: overall order with occasional pockets of entropy. We have a butcher cart in the kitchen that is so hopelessly disordered from top to bottom, we joke about pushing that whole thing out the front door one day in joyful riddance, imagining it dropping off the porch stairs and going straight into the garbage truck. Well, half-joke. At least I'm only half-joking. We also still have zebra streamers up from a wild-animal-themed birthday party many moons ago that will stay up until they degrade on their own. I personally enjoy the added festivity, and will enjoy it until I can't stand it anymore.)
And the kids. They run around screaming like lunatics, chasing each other in pure joy, even with children they are meeting for the first time. (Don't you miss that?)
It has been surprisingly effortless to invite people, and we're always talking about who we're going to have over next. So far so good. Reward to effort ratio remains favorable, and no sight of inertia setting in...yet. Having the house look presentable for longer than the 1 hour after it is cleaned every two weeks (sometimes the house destabilizes in 20 minutes thanks to 3 very talented children) has the added benefit of keeping me in a better mood. And, if we skip a month or two or three...no pressure. We'll take it as long as the motivation lasts.
As of April, we've had four families over - including neighbors, good friends we don't get to see enough of, friends we haven't seen since grad school, and new friends from church. We are loving it. We've relaxed some of that need-to-have-a-perfect-house compulsion when entertaining - and no one has run out screaming yet. (Still have some degree of compulsion, I won't lie, but it's definitely less severe that it was. Think: overall order with occasional pockets of entropy. We have a butcher cart in the kitchen that is so hopelessly disordered from top to bottom, we joke about pushing that whole thing out the front door one day in joyful riddance, imagining it dropping off the porch stairs and going straight into the garbage truck. Well, half-joke. At least I'm only half-joking. We also still have zebra streamers up from a wild-animal-themed birthday party many moons ago that will stay up until they degrade on their own. I personally enjoy the added festivity, and will enjoy it until I can't stand it anymore.)
And the kids. They run around screaming like lunatics, chasing each other in pure joy, even with children they are meeting for the first time. (Don't you miss that?)
It has been surprisingly effortless to invite people, and we're always talking about who we're going to have over next. So far so good. Reward to effort ratio remains favorable, and no sight of inertia setting in...yet. Having the house look presentable for longer than the 1 hour after it is cleaned every two weeks (sometimes the house destabilizes in 20 minutes thanks to 3 very talented children) has the added benefit of keeping me in a better mood. And, if we skip a month or two or three...no pressure. We'll take it as long as the motivation lasts.
Monday, April 21, 2014
Guest post: Coming home
I come downstairs after grabbing a few hours sleep in between busy night shifts. I can hear Rose crying in frustration at once again trying to grab the key from the back door. I walk into the chaos in the kitchen. My husband is absorbed in the newspaper surrounded by the toddler carnage. Why is there breakfast still on the table? Why have the pots and pans been pulled out of the cupboards? Has she really got porridge still stuck on her forehead and what on earth is she wearing? Oh and why is she chewing hay from the barn?
I open my mouth to say something but hesitate and hold my tongue. I remember that it's his turn to look after Rose while I am in work mode. We do things differently- I'm the surgeon with the perfectionist streak wanting everything to be tidy and clean; he is the artist and is happy to let Rose run free and wild. I smile to myself.
"Family hug?" I pick up Rose and we all collapse on the sofa together in a warm embrace. A memory to take with me to work that night. Invaluable.
Lotte is a 33 year old general surgery registrar in the UK with an 18 month old daughter Rose and a non medical husband. She works full time.
Wednesday, April 16, 2014
Consumer Driven Healthcare - Where is it Going?
After I read Red Humors blog on Open Notes, I struck up a discussion with a radiologist friend. We commiserate over laws and loopholes in laws that cause system abuse. I am so happy that Obama recommended to close the loophole in the Stark Law in his 2015 budget. That loophole has created some rampant abuse.
I worry about and applaud the possible effects of patients being able to read their notes online. We doctors need our own forum to make notes without worrying about hurting our patient's feelings. But patients also need to be able to review the discussion in the doctor's office in their own space, with all of their mental focus. Open Notes seems like a step in the right direction, but not entirely. We need two spaces. One for the patient, and one for the doctor.
When I was in CT, waiting on a specimen from the lung to review, I was telling the radiologist about Red Humor's blog topic. He told me that there is a push to the radiologists for the patient to be able to see their diagnosis online, as soon as it is available, before they have even discussed it with the clinician.
RED FLAG.
I wrote a post here before, called Poker Face. In a nutshell, it was about me accidentally conveying during fellowship a patient's negative diagnosis by delaying my answer too long when being probed directly by the patient. It was an excruciating experience that taught me to use expert words to delay the fact that I knew someone's cancer had returned or was diagnosed or had metastasized. After all, I am just a pathologist. I have no treatment options or good perspective on prognosis and treatment. That is Red Humor's job, not mine.
The radiologist worried, as I do, that all the great tools and information that our oncologists and clinicians have to offer a patient will not be there, in the privacy of their own home, while they are reading the ominous information. He worried aloud that the information might overwhelm them. As he was saying that he mimed a gun to his head. I completely agree.
There is way too much misinformation out there on the internet and you need an educated professional to reassure and guide you through it. I depend on my mechanic to fix my car. I depend on my accountant to do my taxes. As doctors, our patients need to depend on us to pick them up when all seems lost.
Last week the New York Times released a big article allowing patients to look up how much their doctors received from Medicare over the last year. It's telling information, but muddy. We doctors enjoyed googling each other to find out who is getting what. Pathologists are at the bottom of the list. If you consider Medicare reimbursement is about 30% of overall practice (in conjunction with private insurance), the information is not enough. It's a step in the right direction, but like many steps mentioned above, it falls short.
I see the need for change in healthcare. But the problems are multifactorial, and it will take lots of time and energy to fix them. In the meantime, let's try to keep a proper perspective to protect our patients. Let's delve back into the reasons we went into medicine in the first place. To help people, to protect and serve. Don't give them information in the privacy of their own homes that they aren't equipped to deal with, or anything that might hurt their feelings. That's a nasty can of worms that doesn't need to be opened.
I worry about and applaud the possible effects of patients being able to read their notes online. We doctors need our own forum to make notes without worrying about hurting our patient's feelings. But patients also need to be able to review the discussion in the doctor's office in their own space, with all of their mental focus. Open Notes seems like a step in the right direction, but not entirely. We need two spaces. One for the patient, and one for the doctor.
When I was in CT, waiting on a specimen from the lung to review, I was telling the radiologist about Red Humor's blog topic. He told me that there is a push to the radiologists for the patient to be able to see their diagnosis online, as soon as it is available, before they have even discussed it with the clinician.
RED FLAG.
I wrote a post here before, called Poker Face. In a nutshell, it was about me accidentally conveying during fellowship a patient's negative diagnosis by delaying my answer too long when being probed directly by the patient. It was an excruciating experience that taught me to use expert words to delay the fact that I knew someone's cancer had returned or was diagnosed or had metastasized. After all, I am just a pathologist. I have no treatment options or good perspective on prognosis and treatment. That is Red Humor's job, not mine.
The radiologist worried, as I do, that all the great tools and information that our oncologists and clinicians have to offer a patient will not be there, in the privacy of their own home, while they are reading the ominous information. He worried aloud that the information might overwhelm them. As he was saying that he mimed a gun to his head. I completely agree.
There is way too much misinformation out there on the internet and you need an educated professional to reassure and guide you through it. I depend on my mechanic to fix my car. I depend on my accountant to do my taxes. As doctors, our patients need to depend on us to pick them up when all seems lost.
Last week the New York Times released a big article allowing patients to look up how much their doctors received from Medicare over the last year. It's telling information, but muddy. We doctors enjoyed googling each other to find out who is getting what. Pathologists are at the bottom of the list. If you consider Medicare reimbursement is about 30% of overall practice (in conjunction with private insurance), the information is not enough. It's a step in the right direction, but like many steps mentioned above, it falls short.
I see the need for change in healthcare. But the problems are multifactorial, and it will take lots of time and energy to fix them. In the meantime, let's try to keep a proper perspective to protect our patients. Let's delve back into the reasons we went into medicine in the first place. To help people, to protect and serve. Don't give them information in the privacy of their own homes that they aren't equipped to deal with, or anything that might hurt their feelings. That's a nasty can of worms that doesn't need to be opened.
Tuesday, April 15, 2014
R-E-L-A-X
I'm having a lot of trouble trying to relax.
Lately I've been just completely overwhelmed with the stress of working and managing two kids. My mind is always whirling with all the things I need to do. Feels a bit like the entire universe rests on my shoulders. It doesn't help that when I'm going to the bathroom there's usually somebody knocking on the door within 30 seconds asking when I'm coming out.
It's stressful.
For that reason I've really been trying hard to think of ways to relax. I know meditation would help me but it's just very hard to do. I can't seem to turn my brain off. Plus there isn't that much time to do it.
What are ways in which you relax?
Lately I've been just completely overwhelmed with the stress of working and managing two kids. My mind is always whirling with all the things I need to do. Feels a bit like the entire universe rests on my shoulders. It doesn't help that when I'm going to the bathroom there's usually somebody knocking on the door within 30 seconds asking when I'm coming out.
It's stressful.
For that reason I've really been trying hard to think of ways to relax. I know meditation would help me but it's just very hard to do. I can't seem to turn my brain off. Plus there isn't that much time to do it.
What are ways in which you relax?
Monday, April 14, 2014
Guest post: Tales of a hybrid doctor/stay at home Mum-- Part II
April, 2014.
That day five years ago, was the lowest point. (see Part I) Today I work “full time” (whatever that means!) in what is probably my dream job: a perfect mix of innovative clinical care, cutting edge research, medical education and being a leader in my chosen specialty. I am on faculty at one of the most prestigious medical schools in the world and get to work with the brightest and the best, in an environment that is intellectually rewarding and super collegial. …and I feel this is just the beginning!
My husband (who got a raw deal in part I—sorry babe) and I have never been closer and more happier in our marriage—we are both fulfilled in our careers, but most importantly, feel like we are reaping the rewards of our hybrid parenting model now: family life is fun, filled with endless bliss and joy.
Our kids (now 10 and 6) are doing fantastic: healthy, happy and thriving at school and play.
Don’t get me wrong-- it’s a juggling act, for sure, but we are juggling joy and I have never felt more balanced in my life.
Still, the reason I wrote part I is that I never wanted to minimize (or forget) the complicated journey (and decisions) I endured to get me to where I am today.
I only wish my 2014 self could have whispered in the ear of my 2009 self and told her the following:
#1. It will get easier as the kids get older; there will be new parenting challenges and hurdles but the physical dependency will be less and that will give you more freedom. Be patient.
#2.You (as Mum and Dad) have to do what feels right to you (as parents). This is unique for every single family in the world.You have to decide how best to work to your strengths as a team.Never compromise on your childcare beliefs and preferences. Do what you think is the right thing to do and everything else will fall into place with time. Your husband is your biggest supporter of your talent and career. This is, in part, because he is equally passionate, ambitious and talented in his own career. It’s hard to have two parents be ambitious at the same time when there are two young kids at home. Right now, you have both agreed it makes sense that it should be his turn, one day it will be yours. Be patient.
#3. Whatever you do, don’t “opt out”. You will get deskilled and limit your future career options. Keep up the hybrid model—it will work to your favor in the end.
#4. Think of work as a career not as a job. Keep investing in yourself. When the kids nap/sleep engage in scholarly activities that will keep your CV looking attractive. You feel like a tortoise right now (and I know you hate that, because you are not a tortoise type of gal) but slow and steady will win the race (one day).
#5. Stay connected to the reasons you became a physician in the first place. Don’t’ let anyone distract you from that—these are crucial reasons that are core to your identity as a human being.
#6. Your ARE privileged. Your job entails you coming up with creative solutions to some of the world’s most difficult problems—you impact humanity every time you work. You also get paid better than most, have societal respect and a “voice” AND have the option to work “part time”. Many working mothers do not have that type of job. Be GRATEFUL
#7. Don’t become a hovering parent—you have seen them, overeducated parents with time on their hands creating projects in the school so that they can get called to implement them! Be a good citizen in the school but better you put your skills to use in a zip code that needs your specialized skill set, not the zip code where your kids are lucky enough to live and go to school.
#8. Always DELEGATE non- essential tasks (it will be money well spent) and use that time for love, laughter and being in the moment. Take care of those who take care of you.
#9. Learn to let go (a little)—it will all be okay.
#10. Don’t pay too much attention to labels, “working mum”; “stay at home mom”; “part time physician”. Don’t be defined by these terms, they undermine the complexity and power of who you are as an individual. You are unique, you will find a way to make it all work.
Above all remember:
Becoming a mother has made you a better physician and remaining a practicing physician has made you a better mother.
Dr. S is a married physician and mother of two.
That day five years ago, was the lowest point. (see Part I) Today I work “full time” (whatever that means!) in what is probably my dream job: a perfect mix of innovative clinical care, cutting edge research, medical education and being a leader in my chosen specialty. I am on faculty at one of the most prestigious medical schools in the world and get to work with the brightest and the best, in an environment that is intellectually rewarding and super collegial. …and I feel this is just the beginning!
My husband (who got a raw deal in part I—sorry babe) and I have never been closer and more happier in our marriage—we are both fulfilled in our careers, but most importantly, feel like we are reaping the rewards of our hybrid parenting model now: family life is fun, filled with endless bliss and joy.
Our kids (now 10 and 6) are doing fantastic: healthy, happy and thriving at school and play.
Don’t get me wrong-- it’s a juggling act, for sure, but we are juggling joy and I have never felt more balanced in my life.
Still, the reason I wrote part I is that I never wanted to minimize (or forget) the complicated journey (and decisions) I endured to get me to where I am today.
I only wish my 2014 self could have whispered in the ear of my 2009 self and told her the following:
#1. It will get easier as the kids get older; there will be new parenting challenges and hurdles but the physical dependency will be less and that will give you more freedom. Be patient.
#2.You (as Mum and Dad) have to do what feels right to you (as parents). This is unique for every single family in the world.You have to decide how best to work to your strengths as a team.Never compromise on your childcare beliefs and preferences. Do what you think is the right thing to do and everything else will fall into place with time. Your husband is your biggest supporter of your talent and career. This is, in part, because he is equally passionate, ambitious and talented in his own career. It’s hard to have two parents be ambitious at the same time when there are two young kids at home. Right now, you have both agreed it makes sense that it should be his turn, one day it will be yours. Be patient.
#3. Whatever you do, don’t “opt out”. You will get deskilled and limit your future career options. Keep up the hybrid model—it will work to your favor in the end.
#4. Think of work as a career not as a job. Keep investing in yourself. When the kids nap/sleep engage in scholarly activities that will keep your CV looking attractive. You feel like a tortoise right now (and I know you hate that, because you are not a tortoise type of gal) but slow and steady will win the race (one day).
#5. Stay connected to the reasons you became a physician in the first place. Don’t’ let anyone distract you from that—these are crucial reasons that are core to your identity as a human being.
#6. Your ARE privileged. Your job entails you coming up with creative solutions to some of the world’s most difficult problems—you impact humanity every time you work. You also get paid better than most, have societal respect and a “voice” AND have the option to work “part time”. Many working mothers do not have that type of job. Be GRATEFUL
#7. Don’t become a hovering parent—you have seen them, overeducated parents with time on their hands creating projects in the school so that they can get called to implement them! Be a good citizen in the school but better you put your skills to use in a zip code that needs your specialized skill set, not the zip code where your kids are lucky enough to live and go to school.
#8. Always DELEGATE non- essential tasks (it will be money well spent) and use that time for love, laughter and being in the moment. Take care of those who take care of you.
#9. Learn to let go (a little)—it will all be okay.
#10. Don’t pay too much attention to labels, “working mum”; “stay at home mom”; “part time physician”. Don’t be defined by these terms, they undermine the complexity and power of who you are as an individual. You are unique, you will find a way to make it all work.
Above all remember:
Becoming a mother has made you a better physician and remaining a practicing physician has made you a better mother.
Dr. S is a married physician and mother of two.
Thursday, April 10, 2014
MiM Mail: Banking for the future?
Hi Mothers in Medicine,
I am writing to ask for advice. I am a 28-year-old 2nd year medical student about to take Step 1. I got married last year. I don't want to have children until I am done with residency but I'm not sure how long residency will last because I'm not sure what I want to go into. I recently became aware of an opportunity to participate in a research study of natural IVF that would offer me a free cycle. I love the idea of having my eggs (or maybe an embryo) stored away for future use and not having to worry about my fertility anymore. I hate procedures though and I have a lot of anxiety about pain-inducing procedures (like egg retrieval). Can anybody give me some perspective on this?
Thanks!
I am writing to ask for advice. I am a 28-year-old 2nd year medical student about to take Step 1. I got married last year. I don't want to have children until I am done with residency but I'm not sure how long residency will last because I'm not sure what I want to go into. I recently became aware of an opportunity to participate in a research study of natural IVF that would offer me a free cycle. I love the idea of having my eggs (or maybe an embryo) stored away for future use and not having to worry about my fertility anymore. I hate procedures though and I have a lot of anxiety about pain-inducing procedures (like egg retrieval). Can anybody give me some perspective on this?
Thanks!
Wednesday, April 9, 2014
open notes
Today our electronic charting system was moved to Open Notes, which will allow patients to access their clinic notes online.
This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.
I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.
But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care. That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.
The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan. Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.
So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise. Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.
But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.
The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now. Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.
And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.
I don’t know. TBD.
This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.
I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.
But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care. That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.
The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan. Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.
So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise. Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.
But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.
The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now. Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.
And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.
I don’t know. TBD.
Subscribe to:
Posts (Atom)