MiM Mail: Ever too late for medicine?

Hello, I am a 34 year old working mother of two young children (3.5 years old and 14 months). I have been working as a research scientist in the pharmaceutical industry for a number of years now. I have been thinking of becoming a doctor since 2005. I applied to one local university in 2012, received an interview but was put on the waiting list thereafter. My husband is very supportive of my decision to pursue medicine and I would like to reapply at some point in the future. There are a few things holding me back from applying any time soon though. We would like to try for a third baby before it becomes "too late" age-wise. Also, I'm realizing more and more that I like to be heavily involved in my children's lives. I enjoy the home-making side of my life very much and I find it difficult being apart from them for extensive periods of time (my current job is about 40 hours a week and I'm ok with that because I get to have dinner with the family, put kids to bed and have weekends with them). I very much want to pursue medicine but I'm so scared of losing the family side of my life and that I won't really be a part of my children's memories if I'm busy in medical school and then long hours in residency and as an attending. I have no problem studying (I love it!) and working hard, but I want to be there for my family. So my question is, would it be completely unreasonable to postpone medicine for a few years, maybe 5? 10? Or whatever it takes for me to feel that I have nurtured my children to the point where they are ok with me not being there often? (I have heard of women successfully entering medicine in their 40s and even 50s). I have no idea when I would feel "ready," and I know that age can be a factor when you want to pursue certain specialties, but I'm actually interested in family medicine with a focus on OB. I'm just having a hard time envisioning myself being both a good mummy and a good doctor at the same time. I feel like one area will suffer, and for me, my family is my top priority. I have several doctors in my extended family and have talked extensively with them but they are all males so I have not had much female perspective other than what I have been researching online and reading in books. I would really appreciate your feedback on my dilemma. Thank you so much for your time.

MiM Mail: (Un)happy match day - "It doesn't matter what YOU want"

As match approaches, it is with a heavy heart that I await the results.

This is a story which has been culminating over the years, and in fact, I have many unsent emails addressed to MiM which tell the tale. I am a 4th year medical student with two girls - a preschooler and a toddler. Both of these I gave birth to during medical school (I "took a year off" and did an MPH between 3rd and 4th year). I am married, and it is not a match made in heaven. Few relationships are perfect, but I feel like ours has some really deep underlying issues that perhaps make it stand out. We had a fun relationship in the beginning - but we got married more so because of an unplanned pregnancy. We were legally married in a courthouse. It was important to him to get married prior to the birth because he was already plotting his custody rights. I didn't tell my mother, who would have counselled me against it (and she would have been right), and none of my family or friends were in attendance. I worried about our significant age difference, but he promised me support, and we framed the relationship in that way - he has no competing career, which frees me up to pursue mine while having a secure family life. (Perhaps something like this.)

I wanted to send this story in because the title of the previous mailbag letter, "Whose dreams come first?" struck me. The reason that this resonated with me so much is that my husband told me when I was explaining my rank list, "It doesn't matter what you want."

Having children during medical school has been extremely draining, and now that I am plotting my career path, I wish I had more control over what I wanted to be and where I wanted to go. I am an excellent student and work extremely hard. Despite being a full time student, I have also taken extensive care of my children, especially as babies. I have "studied from home" while taking care of my children as infants for about 3/5 years of medical school/MPH (M1, M2, MPH) so that my husband would continue to have opportunities to work. Opportunities that I don't feel he ever took advantage of.

My husband and I have no family nearby and no family equivalents. As a result, all childcare responsibilities fall completely on us, unless we pay a babysitter. We did have a regular sitter 3 days a week for about one year, which I think was an overall great experience (with the exception that I felt from my perspective that we were hiring her so that my husband could work, with the implicit understanding that as a medical student I needed to work all the time, but from his perspective I was hiring her so that I could go to school while preserving his autonomy), but she went out of town and since the financial equation didn't add up (his overall work income = cost of sitter, and that includes time that I took care of the kids for him to work as well) by mutual agreement we didn't find someone to replace her.

There is not much of a culture of stay at home husbands of doctors. I have seen several blogs out there of the proud and self-sacrificing "doctor's wives" but nothing similar to that for the "doctor's husband." These blogs tell of the hard work of the male doctors, the pride of the doctor's wife in her husband's service to humanity, her story of self-sacrifice for her husbands career, helpful recipes, and parenting tips. My husband doesn't feel this way about my career at all. Perhaps it's because this culture doesn't exist for him. We are essentially at odds about my schedule, my need to study, the housework, the possibility of needing to move.

Because my husband decided on his own volition to be a stay at home dad, he now makes even more minimal income than before. He receives a $1000 annuity monthly from an accident.  I transfer money to him to pay the mortgage on his house/workshop and other bills. Most of it is money from my mother, and she is sending it via me to him with the understanding that he is supporting me in my career and taking care of her grandchildren. He says that he has "sacrificed" his work for my career, but in fact he adamantly did not want to get childcare and work. He has not given up financial security either - when we met, his bank account was completely overdrawn. He has recently characterized himself as been a "servant" of my "wealthy family." However, suggestions I have made that would make him more financially independent: renting his workshop space for income, getting a regular job, etc, have previously been shot down as inconceivable. We paid his leftover defaulted college loans - from almost 30 years ago! - with our tax return credits. I have also enabled him to pay off credit card debt. Meanwhile I feel like I have sacrificed much of the quality of my medical training for him, having lost out on the experience of a normal M1 and M2 year and career development opportunities along the way, but still taking on full expenses for the family either via loans or via my mother's contributions.

Rewind to the end of 3rd year: I am 9 months pregnant and concurrently preparing for the medicine clerkship exam,  starting MPH coursework, and studying for Step 2CK. I destroy the exams because I work hard. I am a machine! Woot! But things really go downhill over the next year. While in labor, I try to write a paper. It exemplifies my experience over the next year: working in pain. The intense emotional pain of trying to do well in school while your infant cries. I had done something similar in M1 year, but the memorization was much more tolerable than the reading and paper writing. And things are much more complicated now with two kids. My husband had encouraged me to do the MPH because of financial reasons - the fact that I will continue to have loans available and that my mom will continue to contribute to us if I am in school. After trying to write my paper between contractions, I give birth the following morning. It is a joyous day. Shortly after, I initiate total 24/7 care of our second child while taking 6 online courses, about 60 hours per week of work. His contribution is taking care of our oldest about 2/3 to 3/4 of the time, and taking her to school every morning. I work from 9pm-3am every night (the hours she most predictably sleeps) plus whatever else I can get my hands on. Even with this, he is pressuring me to do more school pickups for our oldest so that we are being "fair." In all this time, he theoretically could be working at least between 9am and 3pm M-F (and longer when I do pickups) but apparently does not since my mom is still paying the bills. I am feeling like sh*t, alone at home (online courses), taking care of baby, working, doing all laundry, washing diapers, most of the housework, plus the winter is complete hell and I can't even go outside for fresh air or a run because it is too cold for the baby. His first conclusion is that I am cheating on him with a classmate because I am withdrawn from him. !!!!?????! WTF ??????!!! I blow up. I tell him that I don't like him. That I could have done better. Someone younger, better looking, and more financially secure. Yes that is a very hurtful thing of me to say, which is why I guess I didn't say it until it really came to a head. And yes, I knew this about him going in, but I valued the support and partnership he promised more than any of those "shallow" things. I guess, when I felt the support slip away, I wished I had at least some of those shallow things left to hang onto.

He goes and talks to his friend who graduated from law school. Then he tells me that if I leave him, that he will keep the kids in the state. The other stuff he talked about "is between him and his lawyer."

I wish I had initiated something then (legal counsel?) but despite these misgivings, I had no plans to divorce him.  I felt like I had made the commitment, and I was going to do the best I could with it. Perhaps it was me (too picky? don't deserve better?), perhaps I would just never be satisfied with anyone, so I should try and make it work.  Living with him seemed and still seems like the only way I will ever see my children as a medical student or a resident, and they are young. They also love him and I don't want to take them away from him. I value what he provides for them as a father. So I kept it going. M4 starts and he now has finally taken over full childcare responsibilities.

He was not supportive during the application process and was more interested in my lack of sex drive than my career prospects. Then he blames me for not having worked hard enough to find a good program in our area and says I don't deserve "the best" that I should settle for "good enough." I feel like this is a recurring theme in a lot of his beliefs. He has a disdain for wealth. He calls me a "princess" for wanting to live in a nicer house and city. I am not a pro-wealth person and have a fairly nuanced view on the relationship between income and happiness, but he is full out against it, perhaps a defense mechanism for his personal lack of financial success or stability. I don't know if this attitude can be resolved. When I say that my career will bring the family financial stability, he says our kids can go to community college, take out loans, and that they would be happy living out of a van or homeless shelter. Maybe there is some element of truth to this. I think they will be happy anywhere they are with a loving family but I wonder if we can provide that.

I interviewed at 11 programs, 5 within our city and 6 around the country. In this process I have sought out advice from many people, only one of whom said I should make the "self-sacrificing" choice, most who said I should pursue my "dreams." Many have said that my husband can't keep the kids if I move out of state (they are wrong - our state favors keeping kids in the state and I confirmed this independently).

My mother called my husband and asked him if he will support me. He said he was not moving. Why? He was protecting himself from divorce because if he stays put, the state custody laws favor him, but if we move to another state and I divorce him there, then I would be more likely to maintain custody if he then moves out of state. I asked him whether in this scenario (refuse to move, keep the kids) he would continue to ask me to pay his bills? No, apparently he will get it together. Call me doubtful, but he could not pay his bills prior to having children. And wow, if he could actually work to pay the bills, then why wasn't he doing this all along? The wildly emotional thoughts running through my mind include:this man is going to take my kids from me AND live off my future income unless I do what he wants.

Long story short I submitted my rank list while sobbing. My top programs are somewhere in the middle of my list, probably never to be realized. I have given up on the possibility of living near my family - consisting of my mom and sister. In fact, I did not even rank my preferred specialty first given I was so disillusioned, and I really regret this as well. I often wish I had submitted the list I wanted and dealt with the fray rather than be here in this limbo, unable to change or withdraw my rank list. But it was my children that he threatened to keep from me. My children. It made me crazy. (He would say: no, he did not threaten that - all he said was that "I'll keep them in the state" - he is a stickler for legal language.) My mother withdrew her financial support of him and he is now calling her evil and manipulative. She will no longer help us buy a house that he would live in. Nor should she. He now says that since I'm not paying his bills that I need to share half the parenting, including school drop offs at 8:30am (long after I am supposed to have reported to the hospital), BUT that I should NOT quit medical school. I don't know if he actually expects me to do this, or if he is just holding it over my head that I CAN'T do it.

He is looking at my future resident's salary, most likely the local program I ranked first, and salivating with the income "boon" - not concerned about what it means to me. I have watched my fellow "MiM" classmates give up their dream residency for their husband's careers, and I felt bad for them. I feel less bad for those who make the practical decision because of close-by family who are supportive. Now I feel bad for myself. I do not want to pay this man's mortgage with my blood, sweat, and tears. But he has my kids, and I will not have the hours in the day to take care of them for a long, long time.

We are in counselling now and I feel worse and worse about him the more I think and talk about it. I don't think I can forgive him for the position he postured. As far as the possibility of divorce goes, I am sincerely worried that I would lose custody of my children because of my work hours. I could drop out of residency after my contractual period and then divorce him, at possible loss to my career. Then there is always the possibility of a match day miracle, whereby I get the program I actually wanted. I suppose if that happens, I will have to be nice to him if I have any hope of making the move with my family. Or, I will submit a waiver to my dream program. Or I will visit my kids on my day off. Or at this point, do I actually want that program anymore, given that I have already started to plot a career that would be better for a single mother or co-parenting situation?

I know I am not his ideal wife. I don't idolize him and will probably never be in love with him. But I have given him so much of my life. I am willing to work with him in a partnership and possibly even an affectionate relationship for mutual benefit. Perhaps I am willing to settle for "good enough" in this "romantic relationship" part of my life, but not at the expense of settling for "good enough" in the professional part of my life? He probably feels the same way. He is willing to settle for "good enough" in our relationship if we don't move and everything stays status quo, but requires my adoration to move. But I can't fake adoration. I alternate from feeling like maybe I am a "privileged princess" to think that I could actually rank the program I wanted first - big whoop, who cares, you're going to be a doctor no matter which program you go to - to feeling enraged that I worked so hard against so many odds and am placed in this situation where I have to settle.

Maybe the best solution would be to get divorced after Match but prior to graduation, drop out after the contractual 45 day period of residency or apply for a waiver, enjoy a year with my children in the interim while HE works, and apply in a more single-parent friendly specialty with the new understanding that I am restricted locally, and with a feasible plan to co-parent. Compromise like hell, but more on my terms and with more warning.

It took me some time to get oriented on my career path with some bumps along the way as a young adult. Now I feel like I am pining for my own lost potential of self-determination that I was finally on the brink of realizing. My sister recently married a nice young man she has been long distance dating for years, who will follow her unpredictable and highly specialized career anywhere, and is excited to do so, a comparison that is painfully made. I will never get to marry a nice young man who is willing to unconditionally support my career. I will never have the experience of my family celebrating my wedding day. I will never feel deeply head over heels in love with my husband. I will never have autonomy over my career. I have what I have. Such beautiful and wonderful children! So much! Everything!

But so hard.

Well, that is my long story. I don't know what kind of advice I am looking for. Past experiences? Commiseration? Strategy? A reality check?

Honoring the Pi

It's the ultimate geeky pseudo-holiday: Pi Day. A once in a century Pi Day, apparently.  When I came back home this morning after taking the boys to Tae Kwon Do, my daughter and my husband were at the computer doing some Pi education. "It's Pi Day," she notified me, "3.14.15."

It just so happened that I had been planning a huge pie bake day today--completely unaware of how fitting that was at the time.  Prior to Thanksgiving 2014, I had made only one pie in my life, maybe 10 years ago. It had turned out so poorly and so un-pie-like (mainly the crust; the crust was a disaster, harkening my former disgraceful days in organic chemistry lab) that I proceeded to avoid making pies at all costs.

Fast forward to today, I have made at least 10 pies since Thanksgiving. I am hooked. My brother and sister-in-law even gave me a pie recipe book (it rocks) for Christmas, and I'm making my way through the recipes. I even enjoy making the crust.

All butter crust- no turning back

Today, we are headed to friends' house for dinner, and I made my first banana cream pie.

Making pastry cream is no joke labor/time-wise though

Coconut cream is up next. And can't wait for fresh berries in the summer, apples in the fall.

As we get older, it sometimes feels like we did all the learning and mastery when we were younger. Residency and intense training are long over for me.  So, it feels good to master something new. Empowerment.

Plus, there's something so satisfying about making food for those I love.  But pie. That's even a little sweeter.

Happy Pi Day! May your day be filled with pie. Or math. Or just love.

Up Against The Boards

Genmedmom here.

It's been ten years since I graduated from residency. I was Med/Peds and not quite sure what I was going to do with my life. So, I took both the Pediatrics and Internal Medicine board exams, within two months of each other. I know I studied, but I don't remember feeling overwhelmed by the material or flummoxed by the practice questions. I was a resident and then a research fellow, so I'm sure I didn't have oodles of free time. Both exams were sit-down, pencil-and-paper, highly regulated, proctored, and extremely lengthy affairs. But, somehow, I passed both tests, with minimal pain. (I'm not saying I passed with the highest scores, but hey, all you need to do is pass.)

Fast forward. I've been a Medicine attending for six years, and I'm due to re-take the medicine boards. I've registered and paid and I've got a date: April 15th.

But this time around, I am struggling. Yes, I have two little kids, and may be sleeping even less than I was as a resident. Yes, I'm purely outpatient and far, far removed from acute, inpatient care. There are scads of specialists in my large, teaching hospital- based clinic, and we frequently refer patients for alot of management issues.

But I'm only studying for the Internal Medicine boards, and I've been in practice for six years. You'd think I'd be more comfortable with this material.

Now, I like to study. I'm a dork that way. In my practice, I look stuff up all the time. I earned three hundred CME credits in the course of a year just by looking things up on our favorite medical search engine (yes, you can earn CME credits that way, if you register and then print out the report). So I figured, boards, no problem.

I got the study books and the audio material in November. I read when I can (after the kids have gone to bed, or late on a weekday workday) and listen to the most BORING medicine lectures during my commute.

But, I'm just struggling. I've reviewed a fraction of the total material. I'm getting killed on the practice questions. There are huge gaps in my knowledge, that is clear.

So I'm trying to get my head around this. The re-cert is about 8 hours of testing, now done electronically in testing centers around the country. Looks like a few hundred questions, from these basic areas:

Cardiovascular Medicine
Dermatology
Endocrinology & Metabolism
Gastroenterology & Hepatology
General Internal Medicine
Hematology & Oncology
Infectious Disease
Nephrology
Neurology
Pulmonary & Critical Care Medicine
Rheumatology

There is alot of potential question material under each discipline. At this point, I won't be able to review it all, to ABSORB all the material. I don't have time.

So I'm cramming questions. I'm doing 25-question blocks, and studying the answers, trying to learn patterns, what are they likely to ask about.

The overall pass rate for the October 2014 Internal Medicine board exam was reported as 72%... Ugh. The pass rates have been steadily declining over the past decade. Why? This is, apparently, a matter of much lively debate. In one fun article from the NEJM website, several hypotheses are presented. One conspiracy-theory hypothesis purports that the people that write the exam and charge us to take it have made it harder so that they can charge us to take it more times. Like, it's a money-maker. Other hypotheses include that we're losing the ability to study effectively, because we CAN look everything up on medical search engines... Oh.

So, I hired a sitter to get me 100% protected time on Saturday afternoons; I registered for a boards review course next week; I slashed my clinic hours to two hours per session for the three weeks leading up to the exam; and I limited my time writing blog posts to about thirty minutes a week total (ha!) so I can CRAM.

How does everyone else study for their boards?

Career poll: if you weren't a doctor, what would you be?

Since beginning my clinical rotations as a medical student, I have been exposed to so many interesting, dynamic jobs within health care that I never knew existed such as Recreational Therapy, Occupational/Physical Therapy, Respiratory Therapy, Doula, Midwife, Lactation Consultant, Clinical Social Worker, the list goes on and on.

As someone who regularly follows MiM guest posts and who talks to many premedical students, I always find it interesting that exposure to other fields in medicine is so lacking. There are so many different ways to become a health care provider and though Doctors are among the highest in the hierarchy, without a diverse group of providers we not only fail to provide the best service to our patients, but we often fail to address core issues that determine health outcomes. 

With that said, for the physicians around:

• if you weren’t a doctor what medical professional would you be or would you choose a completely different field?

And for those in training:

• what other careers in medicine have you researched, considered, or shadowed in? What did you think?

My answers:

• If I hadn’t become a doctor, I would be a Recreational Therapist with a focus on alternative methods such as massage and reiki or a Doula/Health Coach/Life Coach/Interior Decorator
• Prior to my training, I didn’t really spend time shadowing Nurse Practitioners or Physician Assistants but should have. I will be entering academic community pediatrics in an urban setting and the overwhelming majority of my mentors and folks whose careers inspire me are Pediatricians. However, if I was interested in more community or rural medicine, pursuing a career as a  Nurse Practitioner or Physician Assistant would have been a possible alternate route to providing primary care with much less debt and better work-life balance.

MiM Mail: Whose dreams come first?

My name is Jenny and I am 24. I am a single mother to a beautiful 6 year old and a handsome 5 year old. Their father is not really a part of the picture. I receive no financial support from him and he sees the kids once a week for about 8 hours.

I am a research assistant at an amazing lab and absolutely love research. I have planned on going back to grad school soon. The grad school where I'm located also has a med school and there is a MD/PhD Program. I have always dreamed of going to med school. It was my dream since I was 12. And even when I became a teen parent, I still knew I wanted to go to med school. But I never thought I'd had to go as a single parent, so I've gone a different path which has led me to research. As I start to prepare to apply my heart screams with such a passion that it becomes difficult for me to hold back the tears. Med school is where my dreams are. Research driven physician is where my heart is. It's what I've always wanted. But I'm a mother now and a single mother. The program is ideal because of the stipend. I cannot take 4 years off work to go to med school when I have children. But with a stipend I could get by. And I know I have to apply. Even if I don't get accepted, I have to apply. But if by some miracle I do get accepted would it be right for me to go? I have been in school for the majority of my children's lives. If I was to do the program, my kids would be adults when I finished. My daughter would be 19, my son going on 18. I would have spent my children's entire childhood in school. How is that fair to them? I would be so busy with school there would be no dating, no man to step up and be a step father. It would just be us with me always in school and studying. My kids will be adults. I'll be 37. And eventually that will happen anyways, but how much will we sacrifice if I kept going for my dreams? Isn't the mother supposed to put the child's dreams first? I don't know what to do. I feel either choice I make will break my heart. I would appreciate any feedback.

Thank you,
Jenny

In between promise and fatigue: here's to the end of residency

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams.”

“Before a dream is realized, the Soul of the World tests everything that was learned along the way.”

“Every search begins with beginner’s luck. And every search ends with the victor’s being severely tested.”

I can see the end of residency. My schedule is set. I know that June 23 is my last official day of my pediatric residency. I am standing on the edge: the edge of my time as a “trainee” and the beginning of my time as an Attending Pediatric Physician. As one of my closest mentors says, “Medicine is about delayed gratification,” and she is so right because I can feel the end of training, it’s palpable. It stands looming in the distance. I see the promise - the chance to continue to create the career that I have envisioned for so long. One committed to the underserved, adolescents, and new families. One committed to medical student education and helping to forge a path in medicine where the marginalized student feels less alone. One committed to enhancing trainees understanding of health literacy, compassionate care, holistic care. One committed to clinical excellence and rigor.

I can feel the promise of creating a career where I can share more of the child-rearing responsibility with my husband. We have had the chance this year to experience up to 2 consecutive months of me having a “regular” or non-Ward schedule and it has been amazing (family dinners, weekend outings, dates, sleeping in). My Attending friends tell me that this is how life can be post-residency and that I have to work hard to get a schedule that allows us to feel more like a regular family. Interviews have been going very well, but none has felt quite like “the one.” I can feel “the one” coming though and am giving myself until April to keep searching and networking.

But I can also feel my fatigue. It also stands looming and sometimes sneaks in for a jab or two. The tight pull of my neck as I continue to type into our electronic medical record. The beginnings of a tension headache as I work on licensing applications during Zo’s nap time. I can feel my strain and my friends’ strain as we begin conversations about our final residency rotations with “I am soo over this!” Invariably all of our texts, phone calls, and in person conversations include our “being over” being on call, covering in the wards, and Interns doing crazy things. Then we laugh and talk about how a friend who is a new Attending has told us something wonderful about his or her life.

As my Residency Director said, “You’re not supposed to love residency” because it’s not a permanent job, it’s just a big hulking stepping stone.

As I always do when I am straddling a new transition, I have begun to re-read selections of "The Alchemist." This book has been with me since the first time I read it in 2004 as a fourth year undergraduate awaiting medical school acceptances. This road has had its share of suffering. Times where I felt failure was imminent. I fought on. In spite of a few very low points, I have experienced joy beyond what I ever could have imagined. Providing excellent patient care, figuring out diagnoses, being hugged and hugging amazing families and assisting them during their lives’ lowest points. I have experienced the joy of getting married to an amazing man that I now call my own and together we welcomed to the world an outgoing, rambunctious little boy that amazes us every day. There isn't a day that we don't pause, smile or laugh out loud and shake our heads at his silliness and love for life.

As I stand on the edge of my most recent life’s transition, I foresee some suffering, some testing, and a whole lot of joy. While I welcome luck, I also know that I have been fortified by life’s challenges and know that you can experience fatigue and promise simultaneously and it still bring so much joy.

Here’s to the end of residency!!!

Quotes above are from Paulo Coehlo's "The Alchemist," 1993.

I Just Want to Dance!

I recently had an idea that I wanted to sign my Doll up for some dance classes.  She is old enough for them, and with a quick google search I found >10 studios in the area! (And many more with a little driving.)  I called all of them.  Each one.  Not one has any classes available on the weekends for children that young.  All of the classes are offered on weekdays, right in mid-day (11AM-2PM).  There is no way I could make that work.  ::Working Mom guilt explosion::

Thought:  My child will just have to be deprived of life's pleasures such as dancing, her life is ruined!!
Feeling:  Guilt and sadness
Restructure to:  My child has many pleasures in life, but dance class will not be one of them at this point.

CBTing myself didn't quite work...I am still writing this blog, feeling deflated.  Oh well, life goes on.

Divorce

I recently recommended my mother read a book called big little lies by Liane Moriarty because I thought that was one of the best books I have read all year, and dealt with a lot of important issues. One of the issues was that the daughter of a woman who had been abandoned by her husband when the daughter was a baby comes back into their lives, and now the daughter suddenly likes the father better.

My parents got divorced when I was a toddler, and my relationship with my father always frustrated my mother. She always told me when that I was older, I would "get it" and suddenly despise my father, yet now I'm older and I apparently still don't "get it." 

This book has gotten her all riled up.  Her latest email to me says that it's better if the father dies than if the parents get divorced, because then there's no bitterness. It's better not to have a father at all than divorced parents.

Right now, I'm older than my mother was when she got divorced. I've been married for over a decade. I've see many of my friends get divorced. I've struggled with my own marital problems. So I really do think that I do "get it." These are my feelings on divorce when you have children, based on my own childhood and everything I have seen:

1) sometimes divorce really is better. If you stay with a person that you hate just for the sake of the children, the children will notice this and they won't think it's better.

2) if you do get divorced, maintain an amicable relationship with your ex. Don't make the children pick sides.

And this is the hardest one of all…

3) if it all possible, don't leave your spouse for another person. If you're having an affair, presumably you're not happy in your marriage. Don't wait for the affair to be the impetus to leave, because it sucks to be left for another person. It's a lot easier not to feel bitter if you don't feel like you were discarded for a younger or better version of yourself. 

My hero is fellow MiM blogger Gizabeth.  She's written about her divorce here, and she's had an exemplary relationship with her ex-husband.  A divorced person should use her as a role model.

Obviously, it's better to have a marriage that is all sunshine and lollipops.  But sometimes (often) that can't be the case.  Sometimes divorce really is what's best for both the children and the whole family. 

MiM Mail: Missing life before kids

I am a family doctor in southern Ontario but previously worked in remote northern Canada for 3 years. Up north, I worked in full-scope practice, including OB, ER, home visits, hospitalist, fly-in communities, medivacs and nursing station phone support. When I became pregnant, I could not have my job modified to have a healthy pregnancy. I was concerned about extremely bumpy boat rides to get to and from clinics, helicopter transfers, working in very cold environments, nearly being flooded, stray dog attacks, dust, bugs, and not having safe shower or tap water in certain fly-in communities. I had asked to not work nights but was told this was not an option due to lack of staffing.

Sadly, I left the community I had intended to stay in all my life. I moved near my extended family in southern Ontario. We bought a farm, and my husband stays at home with the baby and farms. We have the wonderful support of 4 grandparents. We now have a very happy toddler and another baby on the way in the summer.

Down here, I run my own clinic four days/week. I am doing walk-in clinics on the weekend. Although I enjoy it and have a very reasonable schedule, I am growing antsy to do more. I find that down here, even the simplest issues are referred to specialists. Compared to the north, people are not very sick when they see me. I enjoy being home with the baby, but only for a few days a week. I am happier working as a physician the rest of the time. I miss the action and adventure of northern medicine. I keep looking at job openings in the north and trying to figure out how this could work. What I always seem to conclude is what is best for me isn't best for my family.

The things that are keeping me from going back up north? Well, for one, I am 16 weeks pregnant. I plan to have two kids, so after this one, pregnancy won't be a limiting factor, but breastfeeding will. My husband doesn' t want to move north, as there are no farming options for him there. He has farm animals that require daily care, so even doing locums and bringing him with the kids isn't possible. I could go alone, but that would be very stressful on a baby and toddler.

Maybe I should just stay put and accept the current situation. I just feel like my skills are being lost for every year I don't use them. I would love to hear some advice or suggestions from others.

Early Morning Musings of a Snowbound and Homebound Primary Care Physician

Genmedmom here.

Here in Boston, we've been experiencing winter weather conditions never before seen in modern times. I'm not exaggerating. A series of intense winter storms and an unusually prolonged stretch of extremely cold temperatures have combined to create a Pompeii of snow and ice, rather than ashes. The region is near-paralyzed. Frankly, I'm getting bored of writing about it.

But the fact is, weather disasters unite us, forcing us all to realize that we are weak, small, and, well, only human, compared to Mother Nature.

As a primary care doctor, this weather has also forced me to realize some humbling truths.

One: as a 100% outpatient attending, I am not an "essential worker".

Two: I can do alot of my job over the phone, safely, and with greater patient satisfaction.

For the first two of these last four major winter storms, I was home alone with my two children under five years old. It was not physically possible for me to shovel out in time for work, and I had to cancel some clinic days. For the third, my husband was home, but the weather was so bad that between us, it was still not physically possible to shovel out in time for clinic. I cancelled again. Then, as mass transit was also shut down, and most staff had no reasonable way to travel in, our office ended up closing for a day as well. The hospital announced that basically, only employees essential to inpatient services needed to report to work. The Governor of our state announced that only "essential employees" in general needed to be out on the roads.

All of these weather events equaled alot of patients whose appointments had to be bumped. For all of these days, I reached out to most of my folks directly, and offered to handle their medical issues over the phone to the best of my ability. I felt bad, and so I made myself as available as was reasonable using our secure messaging system, email (many of my patients work at the same hospital) and my cell phone.

Everyone I contacted was thrilled that they didn't have to figure out how to get to my office; most were going to cancel anyways. What I found was that most acute issues were handled safely without a visit; physicals, pap smears were rescheduled.

Examples of issues that were managed successfully included UTIs, candida vaginitis, mild asthma, URIs and sinus infections. I've been following some more complex cases, and we were able to determine stability and plan next steps; these are folks undergoing workups for more serious symptoms.

My internal medicine colleagues described similar scenarios, diagnosing and treating everything from shingles to migraine to flu, over the phone. One of these colleagues commented that "it didn't feel good" when she realized that she was "non-essential".

It wasn't always this way. As a resident, and then a fellow with inpatient responsibilities, calling out for bad weather just wasn't done. Later, as an attending with inpatients to round on, ditto. But our practice has since turned to our hospitalist service to care for our inpatients. This was done with the encouragement of the hospital; almost all practices have done the same. Inpatient medicine is now its own animal.

Still, the idea that I'm an M.D. and also "not essential" feels odd. I feel guilty for staying at home with my kids.

A reader then introduced me to a wonderful doctor-mother blog written by surgeons called: Hot Heels, Cool Kicks, and a Scalpel: Trauma Mamas Balance Fashion, Fitness, and Family. One of their trauma surgeons has also been writing about the snow, and I was so glad to read her posts, as they alleviated my guilt, substantially. Two particularly relevant posts:

Rants of a Snow Beleaguered Trauma Surgeon

A Plea For Snow Days and Common Sense

I am learning to make peace with being non-essential. I am also considering offering telemedicine visits to my patients on a regular basis; though reimbursed at a much lower rate, the patient satisfaction would pay dividends. This may also free up visits for more acute illnesses and/ or physical exams.

My thoughts and prayers go out to the essential healthcare providers and hospital support workers who have to get in to work or stay in the hospital through weather like this, and I would be interested to read more about the experiences from "the other side"....

Guest post: Trust me, I am a mother

I never went into medicine to become a better mother. I never became a mother to become a better doctor. But, the two journeys merged in 2013 when I knew something was seriously wrong with my almost six year-old son. My son is like any other boy his age, other than occasional mild irritability that is slightly over the average and incredible creativity. He usually springs out of bed ready to tackle the day, excited about all the projects he is going to do. For about ten days, I noticed that not only was he not interested in any activities, but he was incredibly irritable at even the most minor setbacks. He has always had a high pain threshold, yet we started noticing an increase in his frequency of "got hurt" episodes. There were no focal deficits on physical exam. I sent an email to his teacher asking if she noticed any limitations at school. She said no. I didn't know if I should go to a pediatrician or a psychologist. Then, he developed a minor unprovoked pain in the shin. I jumped on it as now I had a reason to take him to the pediatrician. I reasoned with the pediatrician that given the irritability and mild low grade temps at night time for two days, his shin pain may have been an indicator of something systemic. After an exam, she ordered some blood work and X-rays which came back normal, other than a slightly elevated WBC and platelet count. She told me to trend the fevers and to come back if there was no improvement.

The same night, I noticed a slight temperature and called the on-call doctor. I explained that I was concerned about the low grade temperatures without an obvious source, and that the shin pain might point to a musculoskeletal or neurological issue. She also told us to "trend" the fevers and call her back in the morning. Completed unreassured, we took him to the emergency room. A full day waiting in the emergency room led us again to blood tests that were mildly abnormal but not convincing for any diagnosis. An MRI of the leg was done which was read as normal. I pulled the pediatric ER physician aside and told her my concerns: was there something systemic? As an adult critical care physician, I was not the kind of parent to seek attention unless I was truly concerned. I alerted her that I was concerned regarding the elevated white count and thrombocytosis without an obvious source and even more concerned that the MRI was normal. We were told to "trend" the fever, and if it became more than 101.5, to seek attention. We were also to give scheduled ibuprofen to suppress any synovial inflammation that may be happening in the hip from a viral infection two weeks before. After a dose of ibuprofen, they tested his walking, and said that it was noticeably better, so it must be Transient Synovitis, a diagnosis of exclusion. One caveat to this "give the drug, and see if this gets better, if then, it must be this" argument is that it is absolutely flawed. If the participant knows that "he or she is supposed to get better" then the free will overcomes any pain and of course, he is going to walk better. It may or may not have anything to do with the drug. We walked out of the Emergency Room still concerned.

I continued to give him ibuprofen over the next day. He continued to limp. The ibuprofen suppressed the fever, so now we had an afebrile child who couldn't walk. After no significant improvement, we took him back to the pediatrician office the next day and asked for a neurological exam and, bingo, over the course of a few hours my child developed cerebellar ataxia, clonus, and inability to stand. All of this happened within the time we saw the pediatrician, got him back to the emergency room, and a MRI was scheduled. That night as I sat at the edge of the MRI machine holding his leg, I had never been more frustrated with the fragility of the human body. I loathed hospitals. I never wanted to step foot in the hospital again. The doctor inside of me put the differential diagnosis of "epidural abscess, brain tumor, meningitis, encephalitis" on the list, while the mother inside of me put "something really bad" at the top. While the initial scout films started coming up, my husband, who is a body radiologist subspecialized in MRI, stood by the MRI technician with a solemn look in his eyes  -- one that I had never seen before. As he drew his finger in a vertical line across the computer monitor, the heart of the mother inside of me sank, while the doctor inside of me said, "Wait, that could mean it is not a focal tumor or an epidural abscess, but could it be a diffuse tumor? Maybe, it is meningitis."  With one hand on my child's leg amid the deafening noise from the machine, I kept waving to my husband to see if he could tell me something. He asked me to come outside and knowing my child was already asleep in the machine, I stepped out and could immediately notice the flair abnormality that swept across the spinal cord. As the axial cuts were pouring in, we could see the flair signal lit up like two snake eyes pointing to the diagnosis of Transverse Myelitis, which we knew only held very good prognosis one third of the time. There was no Brain MRI ordered as the ER staff wanted to "focus on one thing at a time," and it  seemed that the spine was the problem. Thankfully, the neuroradiologist who was examining the scout images, and who was about to leave in thirty minutes for the night, noticed the transverse myelitis throughout the spinal cord and asked the technician to add a brain MRI. Within minutes we found her and discussed with her and confirmed the diagnosis of Acute Disseminated Myeloencephalitis with Transverse Myelitis, a disease that occurs in my child's age group, typically after a viral infection or a vaccine.

During the hours in the emergency room, my son went from being able to walk with a limp to being unable to move both legs and becoming tachypneic. Prior to returning to the emergency room from the MRI, I told my husband that knowing the diagnosis, they will for sure want to do a lumbar puncture to rule out active bacterial/viral meningitis and this will of course delay steroid treatment if the lumbar puncture was not done in an expedited manner. We were already in the emergency room for twelve hours by the end of the MRI and given the progressive course of his symptoms, further delay could have caused him to progress into a coma and the risk of hemorrhagic encephalitis existed. Upon return, we asked the team to be present at his bedside, and we made our concerns open to them. The on-call ER physicians were skillful and quickly performed the lumbar puncture. We soon knew that there were no alterations in protein/glucose/gram stain and that we had the right diagnosis. The ER team hung the bag of 600mg of IV solumedrol before we were transferred up to the ICU and every successive day resulted in more return of neurological function. Within five days, we were at home recuperating after this nightmare of an illness. The neurologists repeatedly told us that they have never seen a child with such degree of MRI severity not have the physical signs to reflect the changes; it is likely because we sought attention right in time. The mother inside of me was strong during the five days, and the doctor inside of me was quick to decline any unnecessary blood draws and made sure that he got out that hospital as quickly as possible. For if anyone knows how deadly hospitals can be, it was the doctor inside of me. We were welcomed at home by a supportive community and his return to school and activities was a breeze because of the love and support from family and friends. When I bought my son a couple of youth basketballs to help his recuperation phase, he jumped out of the sofa, ran to me, gave me a big hug and said, "Mommy, how do you know me so well?"

I said, "Trust me, I am a mother."

"You're full of it"

I have read countless articles about how medical trainees have been berated and belittled, yelled at or pushed. I have never in my years of training felt that way or been treated that way. Yes, I’ve been questioned strongly. Yes, with lines of questioning sometimes called “pimping.” I have felt like I needed to study for 40 more hours and have gone into the bathroom afterward to cry, but I’ve never been berated. I’ve never been pushed. I never even thought of what I would say or do in those situations. I have heard my share of racist and sexist remarks and have found ways of addressing it directly and highlighting to the team why it’s unacceptable. But what would I do if someone directly belittled or disrespected me? Would I cry? Would my knees buckle? Would I yell?

Well, that all ended when a Pediatric Surgery Attending told me, “You’re full of it” in front of my staff while I was working in the Pediatric Intensive Care Unit. This particular Surgeon has a history of yelling at Resident Physicians that I learned of after the incident. That night, I was caring for a postoperative patient who had just left the operating room. During interdisciplinary sign out I asked for clarification of a medication dose as I was preparing to enter routine orders such as for PCA-administered pain medicine. The Surgeon turned and said, “No, we will enter the orders” meaning the Surgery Residents. I told him that in my experience PICU Residents enter the orders and manage the PICU patients. He said, “No, who trained you, this is my patient?”  I looked around and of course, everyone was staring at their feet. I was in my second month of PICU service and had heard countless times how our unit was a “closed unit” and that we managed our own patients, but this gruff, aggressively self-confident, tall male Attending with salt and pepper hair and a fresh tan was staring me down. I said, “You will need to speak with my Attending because this is not what I have been trained to do.” He turned, stomped away, and snuck in a low, yet completely audible, “You’re full of it.”

I stopped in my tracks and said more audibly, “Excuse me, but you just said ‘You’re full of it.’”I paused, collected myself and continued: “I feel very uncomfortable, and that was disrespectful. It is not appropriate to speak to trainees that way. I only want to provide excellent patient care.” He froze. When he turned around he had a look of utter contempt and disbelief; it was like no one had ever told him he cannot speak to people that way. His eyebrows furrowed and he spit out, “Well, I’m sorry,” and turned around. At that moment, my Attending arrived and my Fellow said, “Well, I’m glad you said it because I was about to.” I quickly excused myself as my hands began to shake and the pounding in my ears began to dull everything else out. I exited the unit, and sank onto the bathroom floor and cried. Big crocodile tears as my grandmother would say. I was anxious and nervous, but I was damned proud of sticking up for myself.

My PICU Attending found me later and asked me what had happened. I explained the facts and he shrugged and said, “I’ve heard worse,” and told me something about how that Peds Surgeon had cursed at him during his Residency. I told him that I hadn’t heard worse and had never experienced that type of behavior but that I thought it was unacceptable to speak to any member of the team that way. He shrugged and said he would address it with the Surgeon later. As I entered the Unit, the Nurses individually applauded me for speaking up the way that I had. I asked a trusted Nurse mentor if she thought I handled it well and she said I nailed it, and my Fellow echoed the sentiment. I didn’t get emotional, I said what I needed to say, and kept it focused on the patient. One of the Peds Surgery Chiefs came up to me later and had heard about it and gave me a quiet nod of support. She agreed that Surgery Residents who did not spend the night in the hospital should be consulted but they shouldn’t be the ones putting in orders since the PICU Residents are the ones who stay in house overnight. It’s a patient safety issue.

Many thanks to a different fabulous PICU Attending who a week earlier coached us on working in uncomfortable situations. She told us to use words such as “uncomfortable” and “unsafe” and keep things focused on the patient. Without her words, I probably would have shut down, my knees buckled and I wouldn’t have been able to say things in a way that would have gotten any response from that Peds Surgery Attending. I still believe, “You’re full of it” has no place when we are caring for patients.

I spoke on a panel earlier this year sponsored by the Student National Medical Association. They asked a group of underrepresented minority Attendings and Residents to discuss discrimination in medicine. I shuddered as I listened to the horror stories the Black and Latino Attending Physicians recounted. I think I would have quit if I had to endure the downright hostile environments they practiced in in their early careers. I don’t discount the real experiences highlighted by other trainees around the country and applaud them for their candor in sharing. I hope that we all are continuing to work so that abuse and disrespect are not allowed, and when they do occur can be apologized for and learned from.

That way you talk

I was in the office speaking with a parent and her kids at some point in the past year (how's that for sufficiently anonymized).  The mother was gazing at me for just a little too long.  She could have been pondering my most recent question, or may have been lost in thought, but at that moment I opted to ask her gently if she was okay.  And she simply said, "I'm sorry, I just love the way that you talk with my kids."

Oh how that made me feel that I'm right where I should be and doing what I should be doing.  She saw the way I really ask, really listen, and aim to motivate. It's working, at least in this case. 

You've probably heard similar positive comments from time to time about how you communicate with your patients.  And yet, if I could only do so at home!  I can be ever so calm and motivating, building partnerships, and serving as a measured and informed voice of reason at work.  And while I want to consistently do the same at home, I CAN'T HELP YELLING. AT MY KIDS. SOMETIMES. GOT TO WORK ON THAT.  You?

moar veggies

My older daughter has always been an amazing eater.  She eats her fruits, her vegetables, her meats, her starches, and of course everything in the baked goods food group. One of her favorite foods? Scallops.  I was a terribly picky eater as a child, so I always wondered what I did to deserve such a great eater.

Well, the second time around, I got what I deserved.

My youngest daughter is a terrible eater. The only thing she wants for dinner every night is chicken nuggets. And even then, I sometimes have to beg her to eat them.  And God forbid they have the wrong shape, like if I gave her the circular ones when she wanted the dinosaur ones, or vice versa. (I'm never going to know which one she wants until it's actually in front of her.)

Recently, she suffered a really pathetic bout of constipation, and my husband asserted that she needs to eat more fruits and vegetables. (He already slipped through some of his fiber cereal in with her Cheerios in the morning.) Well, maybe fruits are possibility, but how do you get a kid who won't even eat the yummy stuff to eat more vegetables?

And furthermore, I have to wonder if it's really worth it. If she has to be coaxed to eat french fries or chicken nuggets, I can't imagine what I'm going to have to do to get vegetables in her mouth. It would probably have to involve a slingshot. So what if she doesn't eat her vegetables? Is it really so awful?