10 lessons learned in 10 years of Private Practice

This summer marked two major milestones in my life: My 40th birthday and 10 years in practice. Both have prompted some serious reflection on my part. As I thought about the most significant lessons I've learned over the years, I realized some were grasped the hard way and others came from great advice (some of which I got from this blog). For those of you in residency or just getting your ears wet in practice, here's a bit of what I've learned, hopefully it might help a little.

1. Make friends

When I first started practice I would often ask senior physicians what advice they would have for a new kid starting out and I was surprised to hear from several colleagues (male and female ): make time for your friends outside medicine. Several remarked that the felt lonely and isolated as they got older having devoted most of their effort to their career with what little time they had left over to their families.

Quality friendships require the one thing I hold the most precious: time. However, thanks to this early advice, over the years I have been very purposeful about making an effort to make time for relationships. Now I have a community of close friends who truly enrich my life and offer me a reprieve from the drama of the medical community. This year I unexpectedly lost my father and I'm not sure how I would of have survived without the support of my girlfriends.

2. The sky is not falling

Since the day I started medical school in 2001 I have heard how the sky is falling. Managed care, EMR, meaningful use, ICD 10 these were all going to send us to the poor house and ruin medicine. Yes, they have caused me some headaches and I may not make as much money as doctors did in the glory days, but I still can pay my bills, take care of my patients and enjoy my job. (see #10)

3. Lean in (but don't fall in the damn lake and drown)

I hate self help books, but if you haven't yet read Lean In then stop reading this post and go to Amazon right now and buy it. In medicine many committees may feel like pointless wastes of time. I would encouraged you to attempt to find one you can be passionate about and get involved. (If not "passionate" than at least one that doesn't make you want to bang your head against the wall out of desperate boredom) By being willing to say "yes" and giving a little bit of your time to get involved in the processes of your organization, you can learn a lot about hospital administration and make valuable networking connections.

I can always find time for a least one committee, but sometimes I can get a little carried away with my ambitious projects. Recently, I found myself on 4 major committees (all volunteer) at my hospital. That was a little too much. I'm still learning to find the balance between leaning in and falling in.

4. I can't please everyone

In medicine, there is a lot of emphasis on patient satisfaction. It's not enough to provide good care, you must be nice as well so the you and the hospital get good grades on our score cards. That's not to mention internet ranking sites, blogs and facebook. If someone hasn't written something nasty about you that wasn't true, then you haven't been doing this long enough.

Of course, we all want to be liked, but in medicine, sometimes you have to be the bad guy. At the end of the day you must be kind and compassionate to all your patients. They will not always like you and that's OK.

5. Know my stuff

Some of the best advice I got as a resident was that you can't know everything, but the key is to know your bread and butter conditions, learn what's normal, know your emergencies and you can look up everything else. I remind myself of this advice when I begin to feel overwhelmed with keeping up to date in my field. I focus on knowing the basics inside and out and keeping references handy.

6. Find my own version of work life balance

To me my work life balance is a combination of having a fantastic SAHD husband, living 8 minutes from my office/hospital and the flexibility of being my own boss in private practice. When I first started practice I would frequently fret during slow office weeks that I would never make my overheard and equally fret during busy office weeks that my children would grow up never seeing their mother. I slowly learned to enjoy the slow season and embrace the fact that the busy season would help me pay my kids tuition.

{In my opinion no one has ever explained work-life balance better than FreshMD right here on this blog.}

7. Be kind

Be kind. Treat the janitor with the same respect you treat the CEO. Treat the cokehead patient with the same care you would your best friend.

Especially in surgical specialties practitioners tend to yell and pitch fits to get their way. I've seen nurses chewed out for pulling the wrong size gloves for a doctor. To be a confident, respected female physician you do not have to be a bitch. The only excuse for yelling is emergent situations where patient safety is being compromised. I'm not saying to be a pushover, but you can be assertive without being mean. When you are characterized by levelheaded kindness, your true complaints will be taken much more seriously by your supervisors.

8. My kids will not be scarred for life because I missed a few bedtimes

I've missed a lot of bedtimes over the years. I still hate the fact that I have to miss out on important events in the lives of my littles because of my job. But at age 11 and 6, they are doing fine and I can already see that the missed bedtimes are harder on me than them. And I promise all you resident mamas out there: LIFE DOES GET BETTER!

9. Have a financial plan

Again, I hate reading non fiction, but one of the best financial book I have read is The Millionaire Next Door. The title is rather misleading, seeming to be yet another "get rich quick" book, but the actual point of the book is to learn to live well below your means and focus on avoiding the traps of debt. I wish I had read it as a resident.

10. I love my calling

There will be rough days. Patients will die, you will get sued, many nights you won't sleep but through all the crap, try your hardest to focus on the times you made a difference. Don't let yourself become a bitter and filled with self pity. This isn't a job we have, but a calling. Concentrate on the moments you saved a life, provided comfort to the grieving, eased someone's pain and changed their lives. If you find the grey cloud of negativity hovering for too long, then make a way to cut back your schedule and refuel your soul.


I'm not vain enough to believe that what's worked for me, will be the answer to all. I tried to leave out all the obvious things like eating your broccoli, exercising and maintaining your marriage. Hopefully even if my advice doesn't apply that much to you, it may make you pause and think.


Anybody else have some lessons to share?

The Gauntlet

We have entered the time of year I call The Gauntlet because I feel like I am running through one. Historically, this refers to two rows of men with sticks and other weapons that who beat the person who runs in between rows. In my house, it refers to early October to late February. During that time, we celebrate Halloween, Thanksgiving, Hanukkah, Christmas, New Year’s Eve, both Blurs’ birthdays, the Super Bowl (yes, it is as important as these other holidays), Valentine’s Day, and my birthday. It seems most of the kids in Blur1’s kindergarten class were born in the fall. We have soccer for both Blurs in a fall and basketball for Blur1 in the winter. In addition, holiday schedules for me and the busy season for Hubby where he works many Saturdays. Between now and December 1st, with normal activities of school, work, and religious school, we have something every day except the seven days I took off for Thanksgiving to travel to my parents’ house; everyone knows this kind of vacation is no vacation.

By the time, we hit February, I am sick of cake, having made and eaten several because the Blurs’ birthdays are 10 days apart and want cake on their actual birthday as well as at school celebration and at their party. For Valentine’s Day, I ask for flowers only as we still likely have Christmas candy (and to be honest, Halloween candy too, if I didn’t go on a rampage one day and throw it all away) still around. For my birthday, I ask for dinner at my favorite local restaurant and I make my own cake (not sad, as I love to bake and am ready for cake again after 3 weeks of no cake) which we eat with the Blurs before going to dinner without them.

I cope mostly by overplanning. I have a Word Document that keeps me organized - presents bought, menus from prior years, locations for birthday parties, etc. I make great use of my freezer and pantry and have already started buying for special dinners and foods. My Halloween costumes (this past weekend), candy (the minute it was put out) and plans (annual party) are all set. I start looking for Hanukkah-Christmas presents in July, start buying August and currently, I’m mostly done with that shopping for the Blur1 (Blur2 being the 2nd kid is always harder to shop for). I know what I’m doing for Thanksgiving (traveling or not) in July and if I’m not traveling, my Thanksgiving dinner is bought the week they put those turkeys out in the grocery store. I have a gathering on trick-or-treat (kid friendly dinner with a couple families at my house and then the kids trick-or-treat in my awesome neighborhood) so that I can decline all other Halloween parties. I buy birthday presents at Christmas sales, usually the week after Christmas but sometimes before. The birthday parties are booked around Thanksgiving but actually take place late January. If we do something for New Year’s Eve (rare because I usually work), it has to be low-key and kid-friendly and in years past has involved the same families as the Halloween trick-or-treat party.

I am somewhat envious of those of you who can just go with the flow and buy Christmas presents on Christmas Eve and “let traditions happen”. I get anxious. I had all these wonderful traditions and my mother made it look so easy. Like my father, it never crosses Hubby’s mind what presents the Blurs should get or what to serve for Hanukkah dinner or even to buy groceries for said dinner. Hubby, for his part, does a lot of the day-to-day home stuff - laundry, dishes, bathtime, bedtime - so it’s not like he doing nothing. The Blurs do get time with us, which I know you’re thinking they want more than a fancy dinner, but they do have to eat.

So if you see me in the store this week, buying Hanukkah supplies (or lamenting my uber-Christian area has Christmas stuff out but not Hanukkah stuff), buy me a Starbucks, because you know I need one.

Hormones and shots and procedures, oh my! What is it like to undergo IVF?

People are having children later in life, whether the reason is pursuit of career aspirations, travel, or riding the asymptotic curve to financial security. This truth is never more evident than in the field of medicine, where more and more women are taking the long road of training to become physicians. Some of us (like me) even choose this training as a second career, rendering us older from the start. You've heard saying such as "40 is the new 30", etc., but the reality is that a woman is born with all of her eggs and those eggs age with her. She may follow a perfectly healthy lifestyle and appear younger than her real age in many ways, but her eggs are as old as she is.

As eggs age, their quality declines in the form of DNA damage, which negatively effects their ability to make a healthy embryo that will grow into a healthy baby. By the age of 40, the percentage of eggs that have DNA damage incompatible with healthy embryo formation is approximately 75%! On top of this immutable fact, aging brings the possibility of medical issues that can affect fertility in both a mother and a father. The chance of a naturally-occurring pregnancy during any given monthly cycle of a 40 year old woman is approximately 5-10%, and due to the DNA damage I already mentioned, the chance of a live birth resulting from that pregnancy is even lower. It is truly a miracle in my opinion that women over 40 have spontaneously-conceived, healthy pregnancies.

Enter in vitro fertilization (IVF). IVF is a long and detailed process, requiring lots of resources, money, time, and patience. The first stage of a typical cycle involves, ironically, taking oral contraceptives to reset the hormone milieu and force all eggs into a senescent, follicular stage. The second stage involves stimulating the ovarian follicles with daily doses of a hormone cocktail. It is usually some combination of FSH, LH or an LH inhibitor depending on timing, and possibly GH. There is quite a bit of monitoring at this stage, including almost daily ultrasounds and blood draws to evaluate the growth and maturation of the eggs. The third stage is egg retrieval, in which all fluid-filled cysts within a certain size distribution are aspirated for the contained egg. The eggs are then fertilized with the intended sperm (by various methods depending on the presence or absence of male-factor infertility) and are allowed to grow for 3-5 days into multi-celled embryos. The last stage is embryo transfer, in which selected embryos are injected back into the uterus for implantation. This may occur using the aforementioned, freshly grown embryos approximately 5-6 days after the transfer, or the embryos can be frozen for testing and/or later transfer. Once an embryo transfer occurs, it's up to fate (and continued hormonal supplementation)... after the dreaded "two-week wait", it's time for a pregnancy test!

As you can imagine, the process is not for the faint of heart, nor is it for the person with no flexible time and no extra money. I had to do IVF to get pregnant, and these are my experiences.

Time: If a fresh embryo transfer is planned, all of the steps mentioned above take approximately 6-7 weeks to complete (not including the two-week wait). If the embryos are intended to be tested or frozen, the first three stages themselves take 5-6 weeks. After the egg retrieval, the ovaries must rest and the enlarged follicles must resorb over time. This is achieved by having a period and going back on oral contraceptives for at least 3 weeks. Then the uterine lining is augmented with estrogen supplementation for another 3 weeks prior to the embryo transfer. During this time, other testing may take place for the patient (such as a hysterosalpingogram, hysteroscopy, or endometrial biopsy) and/or for the embryos (such as preimplantation genetic screening for aneuploidy or diagnosis of genetic diseases).

Not only does each pregnancy attempt take a significant portion of a year (during which time a woman's eggs undergo further aging), but each cycle also requires quite a few appointments for monitoring, lab draws, procedures, etc. Although I sometimes had to apologetically make my schedule requests after my practice group's time deadline, I was lucky to have enough vacation time built into my yearly clinical commitment that I could take as much time off as I needed. Not everyone would need to take the entire day off for an hour-long morning appointment, but as an anesthesiologist I found that it was the only way to make things work. A physician who sees patients in a clinic might be able to shift her clinic hours back a bit to make morning appointments - which occur every other day and at times every day during the stimulation phase of a cycle. And at my fertility clinic, the egg retrievals were conveniently performed on the weekends.

Money: With some exceptions, IVF is commonly not covered under health insurance in the United States. That said, I found that certain ultrasounds, lab tests, and medications would occasionally be covered by my insurance based on the fact that they were recognized as appropriate interventions for my preexisting infertility diagnosis. Prices for IVF vary slightly depending on the part of the country where the fertility clinic is located, the medications prescribed, etc. A typical cycle including the stimulation period, monitoring ultrasounds, and the egg retrieval procedure runs $12,000 on average, not including medications (another $3000 - $5000). A frozen transfer at a later date is approximately $3000 - $5000. Preimplantation genetic testing of embryos adds approximately $5000 - $8000 to any particular cycle. A portion of these costs can be offset using "batching" techniques or multi-cycle discounts, tax deductions (in some cases), and an FSA; however, IVF in its many forms is undoubtedly going to present some financial stress for any patient.

"Heart": Egg retrievals are performed across the country using different modes of anesthesia. At the IVF clinic I used, it was treated as a moderate IV sedation procedure with fentanyl and midazolam; however, there are some clinics that do deeper sedation or even general anesthesia. An embryo transfer, regardless of whether it is fresh or frozen, is usually done with oral diazepam, and the patient does not need to be NPO. Prior to either of these procedures, an IVF patient can expect to have many transvaginal ultrasounds, which can be uncomfortable for some women. There are other diagnostic procedures that may figure into an infertility workup or IVF journey treatment plan as well, such as hysteroscopies, biopsies, hysterosalpingograms, etc. In addition to these procedures, the patient must receive daily injections of hormones during the follicle stimulation phase and sometimes additional daily shots after implantation. Most of these shots are subQ, but some of them are IM. I must admit that I myself am somewhat squeamish when it comes to being a patient, but I found the invasive nature of IVF to be tolerable. The mental aspect of the uncertainty, the waiting, the rescheduling of life so that appointments and cycles can be completed, etc. was much more difficult. But if you are a person who does poorly with procedures, this may be an important factor in your IVF decision path.

Speaking of decisions, IVF can take a toll on personal relationships - friendships, family bonds, and romantic relationships. This usually presents in the form of differences in opinion on direction of care, number of IVF attempts, or ethical issues with genetic testing/embryo selection/possibility of multiple gestation/etc. Going through IVF can also impact your feelings about yourself; many women complain of feeling unwomanly, and I was not immune to this myself. It is difficult to accept that you need assistance achieving something that is so basic to human life as reproduction. I dealt with this through therapy, quiet time/meditation, and journaling, but everyone differs in terms of what works for them to manage such stress. I recommend to every woman undergoing IVF that she at least attempt to get therapy for herself, if not couples therapy for her and her partner.

IVF is a physically and mentally involved endeavor. Copious time, financial allocation, and mental fortitude are required. But for many patients with complex infertility issues, it is their only path to genetic parenthood (as it was mine). I'm 32 weeks pregnant now and I am very happy with the path I took to get here. As a "success story" with a little girl on the way, it was all worth it!

Mothers of mothers in medicine

Hi mommas- I've really struggled to write about an issue that has been a gray cloud hovering over us these past few months. We talk so much about our relationships with our significant others and medicine and how they change once little people enter the picture, but what about our relationships with the rest of our families? How has your relationship with your own mother changed after becoming a mother? Have you had to deal with tension and seemingly irreconcilable differences between your own family and your significant other?

A blog post can't begin to succinctly describe the history and multi-dimensionality of a mother-daughter relationship in a nutshell. To those of you familiar with the Tiger Mom stereotype, this is a good starting picture to have in mind (well... maybe highly risk-averse and conservative Korean Tiger Mom on steroids haha... although this really does do her injustice, as all stereotypes do). Rather than try to paint a picture of our relationship and events, I will ask: how did your parents respond when you told them you were starting a family?

We decided to start our family in my 3rd year of medical school. I should preface this by summarizing that I am the eldest of three and always dreamed of going to medical school, however, mostly beginning in college, my mom deeply disapproved of all my decisions, which in her eyes were obstacles to finishing medical school. First, she disapproved of my significant other (now husband), especially when I decided to move overseas with him to work in a start-up company straight out of college rather than go directly to medical school. During medical school, I did research for 2 years, which in my parents' minds, was a distraction while my husband finished his PhD. When I told my parents we were expecting, I knew they wouldn't be happy, but I did not expect that they wouldn't speak to me for 2 months. When my mom finally called, there was extensive lecturing over mainly the financial aspect- how irresponsible were we to bring a child into the world on a post-doc salary while paying medical school tuition? How could we pay for day care when we were already net negative? (Valid point). How could we deal with the exhaustion when I was entering residency? (Another valid point). Did I have any idea how much of the burden a woman carries when children come into the picture? (Umm) How could we know what we were getting ourselves into? (Who does??) And how in the world could we expect her to be happy for us? Why did we have to do this under these circumstances and why couldn't we have waited? 

She came around of course as my due date came closer. But ironically, after my daughter was born, after years of a tumultuous relationship, I felt like I could finally begin to understand from where her fierceness and seemingly extreme irrationality arose. And shockingly, for the first time in my life, I felt like she was the only person who understood me. Like her, we had no outside family help when my daughter was born and it was just so so hard (with my dad in the military, we were living out of the country when my brothers and I were born). I felt like she was the only person to whom I could really express my feelings of utter exasperation and exhaustion- I entered the newborn period after a 50+ hour labor, needing to basically to be left alone and sleep for 2 weeks straight to recover- frustrations dealing with the sudden extreme gender inequity that having boobs and a vagina lead to, and struggles being at home and navigating a new identity as a mom. Despite always adoring kids and feeling very maternal, I really did struggle with having a newborn and it took me several months to settle into becoming a mom. My mom was the only person I could really speak with about these feelings openly when I felt like all I could hear was "enjoy every precious moment!" at every turn.

Fast forward a year. Moved cross-country for residency to be an hour away from my parents and on the same coast as my husband's family. My parents are an enormous support to us and we love seeing our daughter spend so much time with them, we see them every week or every couple of weeks. My husband, for the first time in our ten year relationship, feels genuinely accepted by them. But then we decide to expand our family and I get pregnant. This time, though I still tell them with trepidation, I expect that the reaction will be different from my parents- however, no such luck. A complete repeat of the previous episode with silence for weeks followed by yelling about financial irresponsibility, exhaustion, being unable to handle two, etc etc. However, there is also, why couldn't you "find someone" who can provide for you? (my husband is a PI in academia) This devastates and infuriates my husband, understandably, who by now has been made to believe that the disapproval drama was a thing of the past.

I had a miscarriage. But serious damage had been done. It's been maybe 6-7 months since then. I made amends with my parents a few months ago so that I feel comfortable visiting them on my own, in large part for my daughter. No, they are not perfect, but missed them and love them and grateful that they are close by and healthy. And I have been through these episodes so many times with them, I don't really take it personally. But my husband is different. These are not his parents, he does not have the loyalty I feel towards them. He feels like he never wants to see them again, that enough is enough. They have made no effort to apologize to him, because they feel like they have nothing to apologize for. It is like a Cold War and I am stuck in the middle. Again, number two is on its way, and I still haven't been able to bring myself to tell my parents... I keep hoping somehow things will be resolved between my parents and my husband before then. I am now solidly into the second trimester and won't be able to hide it much longer. I want to be optimistic but I do dread sharing the news. Isn't that unfortunate? I know it's not a big deal in the grand scheme of things, but I really wonder what it would feel like to not have these life events overshadowed by negativity. Any advice/thoughts/sharing of your own experiences are welcome.

This child and his sensitive skin

It all started out as a little papule on his left buttocks. In the middle of a busy week of relatives visiting and make-up clinic days, what started out as a small papule morphed into something worse. Zo has had exceedingly sensitive skin since he was 1 years old. Hyperkeratotic plaques behind his knees that sprout up in the span of 2 days if he isn’t slathered in a thick mixture of shea butter and petroleum jelly twice a day. Diffusely itchy maculopapular rashes if we miss his nightly dose of cetirizine. That type of sensitive skin.

I thought I had things under control. But I didn’t.

Monday - I see a little papule on his left buttocks. I put on a thin layer of triamcinolone 0.025% on it. Later that night, I see a few more papules. I put him in the bathtub and then put on more triamcinolone and begin our twice a day ritual for exacerbations.

Tuesday - I see more papules. He is itchy. Is that a ring? Nahhh, I’ll just step up the emollients.

Wednesday - I return home and notice him scratching. How was swimming? His response, “it was fun” as he continues to scratch. Bathtime. Is that a 2 centimeter scaling ring-lesion?!? Oh goodness! He’s got tinea!!! I don’t have time to get clotrimazole and I forget to text my hubby what medicine to get from the pharmacy.

Thursday - satellite lesions. After clinic I run to the local CVS and wait in line for 15 minutes to purchase clotrimazole and by the time I arrive home he's asleep. That peaceful sleep where you know not to interrupt them or all hell will break loose so I let him sleep as I fret about his tinea outbreak.

Friday morning - we begin twice a day clotrimazole use.

Weekend - more lesions. Lower back, posterior and anterior thigh. Areas I won't mention for fear of him one day reading this. But seriously who knew tinea could spread so quickly and that toddlers can get jock itch! Major fail!!! Quick consult to my doctor friends with pictures of all of the lesions minus his groin. Definitely tinea. Definitely spreading; it’s all of the summer camp fun and splash park play dates. Primary care friend KJ says just go ahead and suck it up and put him on griseofulvin too, it’s already too out of hand and you'll stop it before it spreads to his scalp.

And just like that, I have written my first prescription for my son. Too ashamed and time-pressed to bring him in to my new clinic for tinea corporis. I knew the liquid wouldn’t go well as he is now 16 kilograms and our last go round with amoxicillin ended in us making daily smoothies. Based on my calculations, he could do one-half of a 500mg tablet daily - and after all of the pill swallowing for kids I observed due to an awesome program one of my co-residents did, I knew what to do.

Tuesday - I took him to the pharmacy to get him excited about his new medicine to help with his itchy parts. He shook the bottle to a nice beat and did a happy dance. We got home and I cut the pill. Hubby says “shouldn’t you crush this, it’s huge.” I say “nawww, we’ve got this.” Equipped with 1 tablespoon of honey and half of the pill, I say, “okay, you’ve got to swallow this without crunching it up.” Zo smiles, says okay and then hubby offers him some extra water and then VOILA!!! My almost four-year-old swallowed his first pill!!! Proud doctor-mommy moment in the midst of a crazy week.

Last day of September

September is National Suicide Awareness month. With this last day of the month, I want to bring awareness to this heartbreaking issue.

You might be thinking: how does this relate to Mothers in Medicine? Unfortunately, it's a topic that has impacted me.

Most of you will remember Superstorm Sandy, right? Well, not only did it destroy billions of dollars in property...it destroyed lives, too. My cousin (we'll call him Bill) was living in NYC, had 2 kids and a wife, had a couple of businesses that seemed to be going well. Then the storm hit--Bill lost several properties and his car to the flooding. His wife left him, and she took the kids. He was despondent. Little did I know at the time that Bill was also abusing alcohol. He even tried to get help from a counselor.

Bill moved in with my aunt and uncle, living in their basement, until he could get back on his feet. One day my uncle came home from work to find that his son, my cousin, had committed suicide. My dad went to be with the family and had to identify the body in the morgue. Bill's suicide was the most devastating event in our family's recent history.

Since Bill's death, his parents have struggled with all the stages of grief, as one can imagine. Now three years hence his mother is ravaged with anxiety. It's hard for me to conceive of anything more tragic than losing your child.  And losing them to suicide: a potentially preventable cause. Well, that's the kicker.

As a mother and a doctor, I think it's in my nature to be concerned about the welfare of others. I mean, that's part of those jobs, right? But since Bill's death, I really try to listen *intently* to the answer when I ask someone, "How are you doing?" I try to read the body language. But despite our best efforts as mothers, doctors, friends, etc. I am sure we miss the subtle hints of people who feel they are on the precipice, without hope to carry on. When I see people I know or patients I see with depression, I am insistent that they get treated. I impress upon our housestaff the importance of treating depression, for it affects a person's self-management of their other comorbid conditions.

So to our community of mothers in medicine: we must try to reach out to others, lend an empathetic ear, connect people with medications, counseling, other treatments for depression. Let us work to prevent losing more of our children, our loved ones, our colleagues, our neighbors to suicide.

MiM Mail: Looking for a part-time pediatrics residency partner

I am a mother of soon to be three boys in search of a part-time residency in Pediatrics. I am willing to live anywhere in the continental United States to make part-time possible. I read encouraging comments from mothers on your blog who did part-time or know someone who did. I was also encouraged by an article I read from the AAP on part-time and how open programs are to it. It listed benefits of mental health, productivity and job satisfaction. However, I seem unable to find a program amenable to it. I applied to all of the programs that advertise having part-time/shared positions. I've been offered a few interviews but when I ask about part-time, I don't get very encouraging replies.

One woman wrote that she similarly got denied until she found a partner willing to split time with her. I am looking for such a person and would love it if we could find each other. My dream is to be a doctor but I do not feel the sacrifice of three solid years of working horrific hours is fair to my family. I hope there is another person out there seeking the same and we can help each other fulfill our dreams and personal goals in this way by sharing a position. If you would like to discuss further, please send an email with your contact information to mothersinmedicine@gmail.com.

Thanks in advance,
J

Tackling My To-Do List

I have always been a maker of to-do lists.  Ever since childhood, I enjoyed making to-do lists and checking of completed tasks.  But somewhere between residency and motherhood, my to-do lists got out of control. 

As an intern, I had a clipboard with a to-do list that a) ridiculously long and b) my life (i.e. if I lost the list, my life as an intern might end). 

Motherhood (which began when I was a third year resident) brought a whole new set of to-dos.  My home to-do list started to rival my work to-do list.  In the ten years I’ve been a working mother, my to-do list has become a monster that I lives a life of its own and now controls me more than me controlling it.

Some bad things were happening.  First, I would look at my list and feel a sense of panic.  Second, I felt totally unaccomplished because I could never actually get through my list or even make a dent in it. Third, I was always late because I was always trying to eek one more task into my day.

A few months ago, I decided to reevaluate my to-do list process.  I had read lots of productivity books (in fact, I’m a bit of a productivity book junkie). I had tried making a four-quartered square to prioritize tasks. I had tried to dedicate time to finish tasks at the end of the week.  But nothing was working. 

Here’s what I did.  I made a list of the domains of my work and life and created one monthly goal in each domain.  For example, I have an ongoing list of things I have to work on in my apartment. Instead of keeping an enormous anxiety-provoking list of a million tasks, I pick a room of the month and focus on it. 

My work involves a lot of writing, teaching, and administrative tasks.  In each of these domains I created one monthly, practical goal.  In the writing domain, my goal is to prepare a final version of a research paper and to start a draft of a new manuscript.  Nothing more, nothing less. 

After I set monthly goals, I create daily to-do lists that contained about five to six tasks.  These tasks work off the monthly goals (e.g. finish my MIM post) and a few other things that are more routine (e.g. clean my office desk) or just come up (e.g. buy last minute party favors for my son’s birthday).

The shorter list is a huge change from my previous lists. It takes a lot of effort to keep it short. With the barrage of emails every day, it’s very tempting to add one more task. But the vast majority of these tasks don’t need to be done today and instead can be done in a few days when I have an emptier list with more room.  The key habit it to write down the task on another day’s list so that I don’t stress out about forgetting it.

My to-do list experiment has been really insightful.  A few expected things that came up:

1. My stress level dropped.
2.  I feel a sense of accomplishment at the end of the day.
3. I’m much more connected with my kids and husband (i.e. when I get home and I am not trying to get 80 more things done and actually focus on my family).
4.  I’m on time (ok, not always but more frequently).

These were all things that I expected and was pleasantly surprised that they came true but something unexpected came up.

I became much more productive.  I did not expect this.  I thought that with a shorter list, I would get less done. What I found was that with a shorter list, I actually got more done.  I especially got things done that I had been dreading or putting off for months. 

In the course of three months of my experiment I finished three manuscripts, started drafts on three more, wrote five blog posts, and cleaned out my kitchen cabinets (this task had been on my to-do list for two years). I also watched several movies with my family and did not pull out my laptop to-do work during them (this is unheard of for me).  

As mothers in medicine, we are expected to-do an almost superhuman number of things in our lives.  Ladies – let’s take back our sanity and tackle our to-do lists!

Boss lady

I have a confession. When I was initially asked whether I wanted to take over my division as chief, I wasn't 100% enthused. It's not how I envisioned my future.  Medical education is my passion. I hoped for a future career in education administration (more on that to come), not clinical administration. But, I was able to be convinced that this could be an okay move for me temporarily. I would still be able to do everything I enjoyed (research, teaching, patient care) and still in the running for any higher level education positions that might come up.

It has turned out to be a great move for me from a professional development standpoint. It has helped develop me as a leader. I didn't anticipate the amount of reward I would receive from leading a group of physicians, mentoring them, and supporting them in their career pursuits. I love getting to set the tone for the group and to encourage a working environment of support and, yes, balance.  I'm proud to have created the environment I would have wanted.

Eleven years ago, I sat in my then-chief of medicine's office along with my then-boss (both men) and told them I was pregnant. I only had been working there for a year. I knew I needed to let them know to plan for the next academic year's schedule. Their faces dropped. There was absolutely zero joy. I could almost hear their mental calculations of how they would account for the weeks of my absence in that awkward silence. The first words spoken were, "How long is that these days, 6 weeks?" My heart dropped. "Actually, I would like to take 12 weeks."  Please know that I like and respect both of these men and still do, but their reactions left me feeling like a burden.

I remember telling some acquaintances about what happened and how sad I felt afterwards. One woman who directed a nonprofit said, "Oh honey, if I was your boss and you told me that news, I would have hugged you and asked how I could help." That struck me. Because, that reaction would have been so wonderful. Could it have actually been like that? I've kept what she said close to me all of these years and have tried to channel that sentiment when I've been the boss hearing that same news.

Last week, I met with one of my junior faculty who just returned from her maternity leave. We talked about her transition back to work, their childcare arrangements, and where she stood in terms of identifying academic areas of interest. At the end, she told me that she felt entirely supported throughout her entire pregnancy and maternity leave and that she wanted to thank me for that.

There are plenty of headaches associated with my job, but they seem so insignificant compared to the parts that are so good - the opportunity to make things better for the women (and men) who follow me.

Overheard 10 minutes past bedtime:

SCENE:  just past bedtime;  kids in our bedroom

Husband [pediatric researcher]: "Time for bed."

Daughter: no movement, keeps on reading

Husband: "Time to go to your room, please go to bed."

Son: ignores him as well, keeps on jumping around expending all remaining energy

Husband: calm, cool, collected: "Get in bed, STAT."

Repeat, qHS

Analyzing My Kid

Genmedmom here.

Our pediatrician had noticed something was up with our son at eighteen months. We were in complete denial until he was two years old. At that point, it just got too ridiculous. He couldn't say a word, only scream and bang his head on the floor... We finally made some phone calls.

Once we got connected with Early Intervention, we started to see and understand. Kudos to the very talented staff who gently- but firmly- suggested a possible diagnosis, and recommended a developmental evaluation.

Months later, we knew for sure. (I wrote about this: So Our Son Is Autistic, And It's Going To Be OK.)

Now, he's five, and he's doing great. Yeah, there's issues, but who's kid doesn't have issues? In his case, he's difficult to understand, but we are so very thankful that he's verbal. Toilet training is an ongoing frustration, but we know he'll get there. He's in a co-taught Kindergarten classroom and he loves his special ed teacher; he's got speech and behavioral therapy and OT, he and his little sister are best friends, and he's a happy kid.

We think he's fascinating, because his mind works so differently from ours. Hubby and I, we're both avid readers and writers. Though he's a sports broadcaster and I'm a doctor, we're both required to be advanced communicators: he describes and dissects sports action for the audience, and I translate medical information for my patients.

But our son is like, a little mechanical engineer. Hubby and I, we struggle with Ikea furniture assembly instructions. Hubby couldn't figure out how to install those little plastic cupboard door locks. I've had a car for three years and I can't remember how to open the hood, I have to look it up in the guide every time. Our son is such a different creature from us, in many cool ways.

He's absorbed by maps: He loves the maps app on our phones, and he studies the weather radar maps and draws out the storm patterns. Below, he's studying a map of Boston. We had to stand there for a long time. I can't even explain how many drawings of maps he'd done... Maps and highways, cars on highways. He talks while he's drawing: "Here's a map of Boston, and here's the cars going out of Boston on the highway, this is Route 93..."

He draws alot of complicated pictures, many moving parts. Below there's a picture he drew during a time of some upheaval in his little life: he was about to start at his new school, with a new teacher. The man in the middle is saying "Help" and "What should I do?" and chaos is erupting around him. He draws what he's feeling, what he's imagining.

He draws, I'd guess, probably between twenty and fifty pictures a day. Many of these, he will assemble into "books": he staples them together and then "reads" them to us. He's able to recite the same storylines over and over, even with his books that he made over six months ago. He seems to have a photographic memory.

He loves to take photos, in that he likes to study a subject by taking a gazillion photos and then examining them. Below, our big fat lazy cat; and then, me cooking. Studies of our home life...

I know that every parent is absolutely taken with their child. Of course. We're in love with this kid, like any parent is in love with their kid.

But, we're also trying to figure him out. We're still learning how his mind works, and just now beginning to truly engage with him. It's really accurate, the autism symbol: the puzzle piece. He's our little puzzle.

MiM Mail: Maternity leave policies during medical school

Hi Mothers in Medicine,

I am a medical student, a mother, and I am working with a team at my university to further develop its policies on maternity leave and flexibility for mothers in the medical program. Currently women have to withdraw from the year and repeat it the following year, or are allowed only a few weeks off after the baby is born. Surely this can be improved! Part of my role in this initiative is to research the policies that other medical institutions have in regards to this issue. If you went to a medical school that had a great policy in regards to taking time off, being flexible etc would you mind leaving the university information and possibly a contact in a comment on this post?

Many thanks,
A.


*Anyone is also free to send mothersinmedicine@gmail.com your contact information to be forwarded if you don't feel comfortable leaving it in a comment.

The Help

One of the downsides of having kids that are a little bit further apart in age, is that it may very well require separate drop offs and pick ups. I'm lucky in that I can pick both kids up at the same place, but they need to be dropped off at two separate places.

You know what's really fun to do in the middle of the winter, when it's -2 degrees out? Having to pack two children into a car, race to one school, where I have a 10 minute window between when the school opens and when my daughter will be tardy, then race to a daycare to drop off child number two. And then finally get to go to work and embark on a long day, which practically feels like a relief at that point.

My husband was supposed to drop one kid off and I was supposed to drop the other one off. But it seemed like at least a couple of times a month, he couldn't bring either of them in, and the stress of doing the double drop off meant that I would sleep horribly the night before, which would make the whole thing that much harder. It resulted in more than one fight.

Finally, a few weeks ago I decided it was enough. I was going to hire somebody to drop one of the kids off in the morning.

So I did. We have a woman who comes in an hour before school starts, who tidies up our apartment, gets both kids ready, and then drives my older daughter to school.  (In case you're wondering, the school bus does not stop anywhere convenient.)

It feels decadent to have this woman come. After all, I am right there. Why can't I get my own kids ready for school? Why can't I drop them off?  Why can't I tidy up my own apartment?  Why am I throwing money away on things I could do myself?

Yet she's sort of a lifesaver.  So I'm just going to try to enjoy it and not let myself feel guilty.

A day in the life of X-ray vision...

Disclaimer  #1: most days aren't like the one I'll be talking about but few are as noteworthy as the past couple days that I feel compelled to share.

Disclaimer #2: most days really aren't that bad and as my little C has adjusted to pre-school and I've been somewhat juggling this whole residency, husband on the east coast doing fellowship and raising a daughter and our toy poodle (did I mention I also am crazy enough to add a dog into the mix?-- but of course, the dog did happen before the baby so I am not that crazy right?) okay. I have my good days and my bad days.

But I think I may have just experienced the worst one yet!

I'm from California so please forgive me when I complain about the weather for those who experience much worse! But we have been experiencing the hottest summer ever! I've lived in California all my life and I've lived in the city where I'm doing residency since 2003! (Yes, I am one of those people that has done undergraduate, medical school and residency all at the same institution!)

The past couple days my little C has not been sleeping well due to the heat. We don't have central AC at our place but we do have a portable one but due to the usually pretty awesome weather we are used to experiencing we do not need to use it very often. However, we've been experiencing weather in the triple digits with unusual humidity so it's been a very uncomfortable situation.

So bad actually that I moved us all out to the living room where the portable AC is located and the 3 of us, me, little C and our toy poodle have been "camping." On top of this, my little C is in the midst of potty training. She's been doing a great job with #1 but #2 not so much. She has a huge fear of pooping on the toilet but she's been holding it in until she comes home from school and I put her in a pull-up. After 4 days of not pooping, I was very worried. I spent all evening yesterday trying to get her to poop---ranging from pear juice, green smoothies and grapes and finally, she did it! I was feeling pretty great until then my dog P decided to go diarrhea everywhere. I still don't know the cause of the diarrhea but either way, pretty darn gross!

It seemed like she was done after we took her outside and let her do her business some more so we went back in. I gave little C a bath. I gave P a bath. And then as I'm giving myself a shower, of course with both of them staring at me, P decided to go diarrhea again! I run out of the shower, clean up the mess and P.

As I'm putting little C to bed, I touch my hair and notice that there is still shampoo in my hair. Great. I fall asleep too tired to notice. But of course, I wake up intermittently all night worried about P making another accident. I thought I was smart by keeping her in a secluded area so if she did make a mistake, I would be able to find it.

I wake up and I find P on our couch. She escaped. I search the house frantically but luckily, I found only 1 small mistake. As I clean that up, of course, little C wakes up and I have to get her ready for school and get myself ready for work as well.

We're also potty training so I put her on potty and she goes! yay! (minor victories...) I make her breakfast of grilled cheese. She screams and yells she wants bagels. Usually I comply but this morning, I just couldn't. Lo and behold, she eventually finished the grilled cheese.

I give P another bath to wash her up and notice that the hair around her butt area keeps getting soiled when she goes diarrhea so I said screw it, I'm just going to cut it off. I find a pair of scissors and while little C stares at me, I start trimming my dog's butt hair. I sat there and could not believe what I was doing. As I disinfected the scissors, I cut myself in the process. Great!

We're about to leave and I decided to get rid of P's dog food. Great again. I notice that the heat has made the ants find refuge in P's dog food. I find a trail of ants. I panic and then of course, I had to kill the army of ants in P's food.

Okay at this point, I am just super late. I'm done. Oh shoot, I notice that little C is still in pull-ups. I try to get her in underwear but then all hell breaks loose. She just started wearing underwear all day at school. She loses it and refuses to wear underwear. I'm about to lose it too. I let her wear pull-ups.

We finally make it out of the house but oh no, we forgot blue doggy (she has to bring to him to school!). I run upstairs and grab blue doggy and we finally make it to school. I tell her teacher about the pull-up situation and her teacher says that's fine. I yell thank you and run out the door.

I finally made it to the hospital. I park. I lose it. I cry and laugh at the same time in my car. I wished someone could have filmed us this morning. The meaning of a chicken running with his head cut off has a whole new meaning.

I calm down. I walk in. I open up my work list. I check my e-mail. My attending has sent back edits on my abstract. I submit it. I start dictating my studies.

If only anyone else knew about the morning I just had...

I felt compelled to share this day in particularly because in the light of social media, people see snippets into our lives not the full picture. I get asked constantly how I balance it all and make it look so easy. I wanted to share the truth. It is not easy. I'm a hot mess majority of the time. But that's life. That's motherhood. That's residency. It's the life I choose and I wouldn't have it any other way! (most of the time anyways! I did have my moments of doubt this morning)

How I Studied For The Boards...

Genmedmom here.

I saw Mommabee's September 1 post asking for practical advice about how to study for the boards, and I felt compelled to post the link to an article I wrote on this very topic! This was written for the New England Journal of Medicine Knowledge+ blog as a humorous, but essentially accurate personal account: I Studied For The Internal Medicine Boards On The Stairmaster