"Why didn't you just go to medical school?"

I'm guessing this is a common question posed to ARNPs/PAs, and one I figured I'd take a moment to answer personally, because I find it irksome. Well, I didn't go (or even apply) because....I didn't want to be a doctor!  I don't think it's a compliment to ask an RN/NP/PA that question, but I'm thinking it's meant to be one (i.e. you're really smart, you could've learned more/done more). But the question presumes that becoming a doctor is The Best Option for those interested in a professional graduate level healthcare career (and that the smartest people in medicine are always the doctors).  But becoming a doctor is one of several medical career options out there, and it's not always The Best One for everyone. So for this post I'm going to recount how I got to ARNPLand, given other possible paths-and how a key factor in going to ARNPLand was motherhood. Doctors are awesome (duh), but not all of us are destined for DoctorLand--for a variety of reasons.

My undergrad education was in liberal arts, which was interesting but frankly not very useful at all (a classic tale). I worked in social work right after I got my degree, and worked in social work/corrections for a while...but I wanted a job where I could DO things, and PROBLEM solve and really FIX things. And not be stuck at a desk all day long shoving paper around.

I knew that I wanted a job where I could do the following:

• Be a big nerd, and be in an environment where nerdiness was celebrated 

  

  What a cute ARNP!

• Fix things or people (or both)
• Make a good living, i.e. to support a family of at least two kids. Oh crap, we have three now; we've debated selling one but the kid market is in a slump. And yes, the third pregnancy was planned. And yes, we had an OB ask us this. We changed doctors. Think about that question for a moment...Anyway, my goal wasn't to be rich but to have enough. Comfortable enough to be like the Cleavers (well, the interracial lesbian family suburban version). Ah, but "enough" is so subjective, isn't it?

The Cleavers, "then"..

The Cleavers, "now"

• Be a mom who could go to choir performances, be home for dinner most nights, have dinner with my mom, go out to dinner with my wife, walk my kids to school sometimes,  have time to email my twins' teacher about schoolwork (and kvetch about common core math, that is a whole different post...), cook dinner on my off days, and so on. 
• Be able to have kids closer to 30, not 35 or 40 (I had twins at 29--overachiever!!). 
• Completely gross out my kids and wife with graphic descriptions of medical procedures, bodily fluids, and so on. 
• I wanted to be able to say nonchalantly, "It's just a flesh wound!" (please click HERE if you understand that allusion...you're welcome!)
• Pay $800 in student loans per month. Actually, this is a heck of a deal-ask a physician (or a lawyer). Gotta pay to play, right?
• Crap my pants as I mumble  confidently say the the words "Call a FREAKING code !!!" as I run to the room, after the RN calls me and I hear the words "EKG changes" and I see the heart rate go from 120--100--90--70--50 in 5 seconds on the tele monitor, while my amygdala fires repeatedly and my brain says "ARGHHHHH!! You totally know what to do, breathe...". Begin CPR....
• Have an unlimited supply of graham crackers to sneak from the nutrition room when the charge nurses aren't around to notice (and peanut butter, oh MAN, that stuff is good).

I also took into consideration how much I'd be able to see my kids, day to day--it was important to me to be around as much as possible...consistency. In some subspecialties (that involve years upon years of fellowship), fellows put in so many hours that it's a real challenge to balance the demands of motherhood and work--and year after year they face these dueling demands--and hats off to these women for taking it on! I see fellows in particular who FaceTime their kids nightly, because they're rarely home in time to say goodnight--especially those with young preschoolers. And sure, it's temporary--because kids grow up, stay up later, and so on--and fellows finish their programs. And fellows do have days off, of course, during which they can love their kids (in person) to pieces. But for me, I wanted more of the day to day mom stuff. The stuff that makes me crazy and the stuff I love.

My point is---to each her own. I have as much respect for the mother who is a general surgeon as I do for the mother who stays home full time. And really, it's great that those of us in medicine can FaceTime now to say goodnight to our kids so that we can maintain the daily connection despite our wacky schedules; I used to do it frequently when my twins were toddlers--I'd leave for work before they were up and get home after they were asleep. It was hard, we missed each other a lot. And it was a lot of extra work for my wife when I was gone, as she'd get through multiple 13-14 hr days on her own. So for any woman who is embarking on a medical career it's incredibly important to consider how one's choice of career will affect one's ability to parent in a way that works best for you, for years.  It's a huge, huge consideration. It's a years long balancing act--how on earth are you going to mix these two awesome things (motherhood and medicine) together successfully and keep your kids alive (and your patients)?! 

I needed the work:life balance that I thought an ARNP career could best provide, and I was concerned that I wouldn't have been able to find had I chosen medical school. Or, I suppose that I could have found it eventually, but I would have had to put off having kids for several years--and I didn't want to do that, for many reasons. I couldn't be the kind of mom that I want/wanted to be had I chosen a different career path. And what about the difference in salary, you might ask? The money is great, I think. The starting ARNP salary in outpatient oncology around here is about 100k. Inpatient oncology at private hospitals around here? Around 130k. That's enough for me, enough for my family to live well. So I'll never be The Boss, I'll never be famous, but it's enough--I'm home over half the month (I work 10-12 12hr days a month), I often pick up the kids from school, I have the time to make dinner frequently (and lunches for school, ugh), I have a challenging/brain stretching/ emotionally taxing job and it's all enough. Score.

So this is my corner in the medical world, and I'm happy in it. And frankly, ALL of us are awesome for making our lives work-however we get it done. So here's a toast to getting by with FaceTime, nannies, dads, moms, friends, support groups, childcare centers, vodka martinis, grandparents, Munchery/Pizza Hut/Whole Foods/Amazon Fresh--we're getting it done--mothering AND medicine.


Later,

ZebraARNP

Trading fake patients for real people

MS2 Terrible Twos here. New to MiM, so here is a quick introduction. I am mom to a sweet nineteen month old boy who is into everything and lacks even the faintest inkling of self-preservation. In a former life I received a Bachelor's of Fine Arts from an art school here in the Bay Area, and worked for over a decade in advertising, marketing, corporate event design, apparel, and retail packaging design until I decided that pursuing a career in medicine was truly my dream. Thanks to a lot of hard work, a loving and patient husband, and tons of emotional support from friends and family, that dream has materialized and I am (as of last week) a second year medical student in the Bay Area in California.

Having just completed MS1, one of the most challenging aspects of the medical curriculum this year has been seeing through the text books, algorithms, power points, Quizlets, acronyms, mind maps, case studies, and patient vignettes and remembering that the purpose of all this learning is to support real, actual people with rich histories and complex emotions. The majority of my patient interactions feel so forced and so awkward – so robotic, scattered, and disjointed. I hear standardized patients describe their symptoms and feel myself responding stoically, without empathy to concerns like, “is this serious?”, or "am I going to die?" as I systematically wade my way through OLD CARTS and FED TACOS and remember what a relevant ROS might include for the few differentials I know to consider.

Throughout every standardized patient interaction, every practical exam, and even every time I have performed an H&P on a "real" patient in my school's student run free clinic, I feel as though what limits me from truly developing any sort of rapport with the patient in front of me, actual or standardized, is the tunnel vision that comes from trying to dot every i, cross every t, and check off each and every box on the syllabus.

I understand that there is a learning curve with all of this. As with many professional practices, the only way to get better at them is by doing them over and over again and I recognize that I'll be working toward that for the rest of my medical career. I suppose that what worries me is the fear that throughout my medical practice there will always be a syllabus to consider, be it a QI evaluation report, an insurance audit, filling in every blank on the EMR, or tending to some other system to which I am held accountable.

I would like to believe that all the the awkwardness of MS1 will start to subside as early as this summer when I volunteer at the free clinic -- that the relief of having completed one full year will allow me to relax a little and try to integrate the systematic thinking of MS1 into just another part of my experience and knowledge. My hope is that the breadth of my other experiences prior to coming to medical school, including being a mother, will begin to materialize within those interactions, allowing me to truly connect.

When did it happen for you? When do patients, even standardized ones, cease to present solely as a collection of their signs and symptoms and emerge as actual people, and what tools have you used to transcend the awkwardness of your early medical training?

Mother duties = father duties

I recently realized something.  Something I don't like, that I've been doing without even knowing it.  I have been thanking my husband for doing fatherly duties.  Example:  He says he is going to pick up our daughter from daycare, and I say thank you to him.

Does anyone else see something wrong with that picture?  He never thanks me for picking her up the majority of the time.  He doesn't thank me for loading/unloading the dishes, or for doing the laundry.  But I thank him when he does anything more than go to work and come home.  

I have friends who have clear division of labor in different ways, where their husbands are actually expected to do laundry, dishes, wake up with the baby, etc.  Mine has never had such expectations.  The tasks are all mine, with him helping out when he sees fit and convenient.  The dishes will not pile up if he doesn't touch them for days, I will put them away.  The food will not run out, I will make sure we are stocked up.  The kids will not go hungry, I will make sure they're fed.  I don't blame him at all for any of this, because it is the precedent I have set in our marriage and home.  But I wanted to ask fellow MiM's:  What kind of precedent do you have in your homes?

think zebras, not horses

Hi MiM aficionados,

I'm ZebraARNP, and I'm so pleased to be the first non-physician contributor here! I'm a nurse practitioner in a big hospital in a big city. I've been an ARNP for about 8 years now, and I've spent all of those years in oncology. I can't imagine doing anything else, to be honest. I live in the 'burbs with my wife, to be known here as The Wife, and our three kids, to be known here as Jaybird, Hedgehog, and Egret. More about the family in my next post.

The other day on rounds, as my team was heading out to see our first patient, we encountered a large group of petite Filipina women, dressed in the green environmental services uniform provided by the hospital. Our team greeted the group then as we passed them my (tall, white) attending said to me "They're so cute, they're all so short!" At the same time in my mind I was thinking "Dammit, they're all people of color..." and I felt a wave of...disappointment? Sadness? Irritation? Hard to find a word to describe the exact feeling. I'm not even sure that the two (white) MDs with me even noticed that the ENTIRE group of custodial staff we encountered was Filipina. All that my attending appeared to notice was that they were "cute." Sigh.

The flip side of the above experience is when I see another African-American/multiracial ARNP/PA/MD in the hospital. In those moments, time slows down, music starts to play...(Chariots of Fire, in case you're wondering. It's ok to click on it..) I want to run up to them to see if they're actually real!! Should we hi-five? Cheer? OK, no. Maybe next time...

For such a big city (although <10% African-American), and such a big hospital (>300 beds), there is a dearth of African-American professional staff. Over the years I have been mistaken for kitchen staff, janitorial staff, nursing staff, but more than that people have often looked genuinely surprised when I explain my role on their healthcare team and what I actually do on our team (admissions, write orders, take first calls from the RNs re patient issues, etc). And my point is not that any of the above mentioned jobs lack importance at all; my point is that no one assumes that I have the job that I have and mostly that they express surprise at my actual position. Food for thought. That surprise? It doesn't feel very good on my end.

Always check your assumptions....because we all have 'em. Women as surgeons. Men as nurses. Someday I hope that female surgeons, African-American physicians, male nurses, etc--I hope none of that even raises an eyebrow.

More about me, since I'm a newbie-->
**********************************
ZebraARNP is an oncology ICU ARNP with three children- school aged twins (girl, boy) and a preschooler (girl). That brief sentence vastly oversimplifies the amount of joy/pain/money /insanity/Band-Aids/love/maniacal laughter it requires to raise three human beings; it’s a doozy sometimes. Anyway, this is ZebraARNP's first public/non-academic/not Facebook writing experience, or writing that isn’t a daily progress note of a critically ill oncology patient. ZebraARNP is married to a pediatric SLP who isn’t in fact really that interested in oncology but who has acquiesced to the fact that she will indeed continue to learn about it (or at least listen to random factoids) year after year simply out of love for Zebra. Dinner time conversation in our demographically complicated yet still shockingly quotidian suburban home (interracial lesbian marriage, anyone? Can someone say “intersectionality” ten times fast?!) may or may not include how much CPR was done that day, palliative care conferences, cdiff vs VRE, who did well on his/her math test (or who did not), who will go grocery shopping next, what MRSA is, what exactly IS pus made of, what actually happens when you die, arguing over who gets the last muffin/cookie/etc, reviewing hematopoiesis, and questioning whether kid # 1, 2, or 3 really did wash their hands after using the bathroom. When ZebraARNP isn’t at work or with kids, she enjoys gardening, chicken keeping, reading books (or the NY Times), and wasting time on her iPhone (oh the Amazon app…)…and not being at work or with the kids.

The Bottom Step

My six year old was crying. She has a flare for the dramatic, but this was real. She had just come home from dinner with her dad at his house. We are newly separated, though I feel as though it’s been an eternity that I have been emotionally and psychologically separated from him, and the person that he used to be.  The physical separation is only a few months old for my three year old son and six year old daughter, but they have settled into a new “normal” and have managed better than I thought they would. But tonight was a difficult night. Instead of kisses and hugs and a quick goodbye at the front door, my daughter wanted to be with her dad. She followed him back out of the house to the car, and the hugs and kisses continued as she tried all her tricks to prolong the goodbye. After some prodding, she eventually came inside, shut the door and fell to the kitchen floor, first with a “Hmmmph!” and a face of real anger, followed quickly by tears.

My three year old son, fairly oblivious at first to all of the evening’s drama, was playing with his trucks in another room and was calling for me to play with him.  My daughter was still crying in the kitchen. After a long day of work, multitasking every minute, I find myself pulled between the two most important people in my life -- wanting so badly to just play with my son and keep everything “normal”, and being drawn into the sadness and fear that was so openly being displayed by my daughter. I quickly settled the little one, and picked up my daughter and brought her to sit on my lap at the base of the stairs.

As we sat on the bottom step, I held her and she cried. Slowly, she calmed herself and the tears were less frequent and the sobbing slowed. I continued to hold her and quietly tell her I love her.  And daddy loves her too. And this is a hard time for all of us.  I don’t have anything more to say to make it better, though I desperately want to. I started to cry and I told her “I’m so sorry you are hurting. I wish Mommy could take all the hurt away. But we are going to be ok.”  Sometimes I believe we will be ok, and sometimes I don’t, but I always tell her we will -- and then I go back and think about it late at night, and wonder how I could have landed here. Me? But, then I remember that the how doesn’t matter anymore now. I’m a mom, and I have to guide these two little delicious, precious people through this storm. They don’t deserve this, and I didn’t plan this, and I never ever would have willingly put them through this, but we are here and we will be ok. We have to be.

M wanted to know why we all can’t be together. “Why can’t Daddy live with us anymore?” And then she asked me, “Remember all those special things we used to do all together?” From there, like a window opening on a cold day, her memories of special times blew in and they startled me. How did she have such vivid memories of these times at just six years old? “Remember the time, Mommy, when we were at the beach and we found all those sand dollars, and we went on that long walk together? And Daddy was with E, and we just did that together.”  And I told her that the beach was a special place, this hideaway in Maine we’ve traveled to as a family every summer since she was a baby, and that Daddy was still going to take her and E this year.  They could look for shells and sand dollars and hermit crabs and do all that fun stuff this year. During most of this conversation, she sat in my lap, with a downward gaze. Then, she looked up with her big, blue eyes and said “Won’t you be coming with us this year?”  I lost my breath.

 
This is just one of many, many, many difficult conversations I’ve had with M over the last 5 months.  They break my heart a little bit more each time. It’s that pain that only a mother knows -- when your child is sad and you can’t make it better. The kind of pain that makes you start to well up, breath deep, pause, and swallow hard while instincts tell you to suddenly “keep it together” and you figure out the right thing to say or you give a hug of just the right warmth and length and you get through the moment.  What’s worse about all this, and perhaps the hardest to bear, is that I feel responsible for her pain.  A fall on the playground, an illness, an argument with her friend -- all of those hurt, but they are the acceptable challenges of childhood, the kinds of things you expect to shoulder as a mom.  I never thought I’d be here. I never thought I’d get divorced.  How it all happened is a story for another day, though I’m certain with the deepest of conviction that I could not stay in my marriage.  But, she doesn’t understand that now. My friends and my family tell me “someday, when she’s older, she’ll get it. She’ll understand why you had to do it.” I think that’s true, but someday is a long way away. Right now, I have a six year old, with a six year old heart and brain, sitting in my arms crying over her “broken family” -- her words.  I tell her it’s not broken, it’s just different. I’m not even sure what I believe, but that’s what I tell her.

The moment passes. She feels better talking it through and looking at some pictures of a family trip from a few years back.  I take a moment and think. Silently, E crawls in on the other side of my lap, instinctively cuddles in to my chest, and asks “why are you cryin’, mama?” In this moment, we are all here sitting on the bottom step of the stairs of the house we are about to sell and move from.  And, it feels really real that we are on the bottom step of our new life.  There are 12 steps to the second floor of our current house.  We all walk up together to get ready for bath and bedtime, little E on my right hip, M holding my left hand. I can’t help but think that 11 more steps will be hard to climb, and I don’t know how we will do it, but we will get there.    

Don't forget they are someone's baby

Living in DC and taking the metro regularly provides me with ample fodder for social analysis and ample opportunities to be upset and amazed by humanity. For example, I get upset when able-bodied people see disabled, elderly, or pregnant people standing and sit in their seats anyway. Especially while pregnant, I spoke up very loudly (ex. As able-bodied men crowded on an elevator as I waddled to catch the door for a man in a wheelchair. I stared everyone down and said someone needs to get off so he can get on; we were obliged begrudgingly.). I am amazed when folks step in and help someone in need during an emergency.

An issue of growing contention in my neck of the woods is middle and high school students getting onto crowded trains. They are loud and there is often cursing involved. However, I have noticed that most of the adults regard them in a very unfriendly way or simply ignore them. The local listservs I am a member of are far worse; the disdain for these children is palpable and I have had to step in several times when the racism and classism became unbearable as well-to-do grown folks called children thugs, crooks, and goons. It literally hurts my heart!

I personally make it a point to acknowledge these teenagers every chance I get with a smile or a hello; sometimes I’m ignored or begrudgingly acknowledged, but oftentimes you can tell these young people relish the positive attention and are surprised to have been seen. I remind myself regularly that they are someone’s baby no matter how “hard” they are appearing to be. No matter how many tattoos they may have on their young skin. No matter how many curse words they and their friends yell. And I try to remember that someday my little Zo will be one of these students taking the train and I hope that others will treat him well knowing that he too is someone’s baby. My husband and I are well-read in the studies that show that Black boys like my Zo are seen as being older than they are by the majority and less innocent than they are by police (see FURTHER READING below). We know the sickening statistics of disproportionate violence against boys that look like him. We pray that folks will remember these children are someone’s baby and that he is ours.

To bring it back home to the DC metro, the other day on the train a handsome young man with beautifully styled locs and sagging skinny-jeans and a uniform high school shirt  entered the train with a young woman I assume was his girlfriend. His new-aged rap music (the kind old hip-hop heads like me can’t understand and abhor due to the crazy amounts of auto-tune) was blasting. Adults bristled. Some sucked their teeth. He walked on the train and I smiled at him, he was visibly surprised, smiled back sweetly and sat directly behind me. Every other word of his song was f--- this and blast that. I turned and said as gently and respectfully as I could “Sweetheart, don’t you have headphones or something? My old ears just cannot take all of that cursing.” He said quickly “Ohhhhh my bad! My headphones broke and I don’t have another pair, My bad!!!” I pulled out a set of headphones from my bag and said “here, you can have these!” He smiled and said “For real?!? You serious?!? Thank you so much!” And just like that - connection. Respect. Compassion. His mama would be happy.

It could have ended differently. Someone else could have started cursing at him. He could have rebuffed my offer and cussed me out. But it ended wonderfully. And I modeled appropriate, compassionate behavior for children and adults alike.

I exited the train at my stop and wished him and his lady a good day and he did so too.

___________________

FURTHER READING:

http://www.npr.org/2014/03/19/291405871/consequences-when-african-american-boys-are-seen-as-older

http://www.apa.org/news/press/releases/2014/03/black-boys-older.aspx

http://www.theatlantic.com/national/archive/2014/03/cops-tend-to-see-black-kids-as-less-innocent-than-white-kids/383247/

Are You Suffering from Overcare?

Dear MiM,

This is my first post, so I will introduce myself. Thank you so much to KC and all of you veteran MiMs for this opportunity. I've been a reader for years, since residency, and found MiM so helpful when thinking about my future career. I'm a family physician in a mid-sized Canadian city. I've been in practice for seven years, which still feels very "early career" to me. I work full time - 35-40 hours/week counting clinical plus admin time. I call it full time but always somewhat sheepishly around other physicians! I have a three year old son and one year old daughter, and a work-from-home husband. I'm involved in refugee health work and am community faculty for our medical school. For me, some amount of "big picture" work has always helped me maintain enthusiasm and appreciation for the clinical work. I look forward to reading your stories, and sharing mine!

N.

---

A few months ago, I was getting bogged down by excessive self doubt and perfectionism at work. The main way it manifested was in ruminating and worrying over decisions once I'd made them, but there was also over-thinking clinical choices, triple- (quadruple?) checking, and asking for advice when I really didn't need to. I try to take a pretty balanced approach to life, accepting the "good enough" principle and refraining from placing unrealistic expectations on myself. But "good enough" never seems to fit with medicine. I can accept vulnerability and imperfection in other areas in my life, but medicine? There's no room for it. I think our patients and society echo this as well; after all, it's comforting to think that physicians are the ultimate authorities in health and it's disconcerting that we are inherently flawed humans. We are socialized and trained in this mindset as well. Of course, we must be conscientious physicians. I'm not talking about being sloppy or less than thorough. But, recognizing that we are human, even when we are conscientious, careful and keep our knowledge and skills up-to-date, we'll falter.

During this time, I came across an excellent article on the topic of Overcare, written by the late Dr. Lee Lipsenthal and adapted from his book "Finding Balance in a Medical Life". Overcare was a new concept for me, and a useful one. Dr. Lipsenthal talks about overcare as a chronic emotional state that physicians can get into, and it involves agonizing over decisions we have made, and at the core of it, wondering "Am I a good enough doctor?" There are several factors at play. Our personalities tend to be perfectionistic, and we do carry a lot of responsibility. He talks about our addiction to being needed and how the intermittent positive reinforcement we get from patients can lead to us doing more and more, hoping and waiting for the "reward" of a satisfied patient. The perfectionism expectation in medicine is often instilled into us during training, and also informs how we judge others; we in turn also fear being judged harshly by our colleagues. This is especially true for me as a family physician. Any time one of my patients is seen in the Emergency Room or by a specialist I've referred them to, my care will be under scrutiny. I find that Impostor Syndrome often tags along with this overcare and perfectionism. If your expectation is that a "perfect physician" is the default, yet you witness your inherently imperfect self, impostor syndrome can creep in.

How can we counter overcare? Personally, it helps to remind myself that I am competent and doing the best that I can. And that I am human. I try to consciously make a decision, and make peace with the inherent uncertainty. I ask myself a useful question from cognitive-behavioural therapy for anxiety: am I problem-solving, or worrying? If the latter, move on. Do I think about patients after hours or change my mind about decisions? Of course, but I have a better sense now of what qualifies as being conscientious, and what is actually overcare.

Do you struggle with overcare? Are there any strategies you've found helpful?

Learning to Talk Back to the Voice in My Head

I am, by all accounts, a person who should be doing ok in the self-esteem department. My parents were bleeding-heart, 60s-style, brown-rice-eating leftists, which is to say I was never, as far as I can remember, punished. Not once. I am part of that much-beloved generation, the Millennials (just kidding, we are widely reviled and lamented), so everyone got a trophy for effort at my sporting events growing up. We as a generation are not shy about seeking out and giving positive feedback. I have drunk deep the milk of feminism so I'm ok with my body just the way it is, at least conceptually. I have successfully graduated college and medical school, completed residency, and am employed as a physician. I have a sweet little family that brings me much delight. Basically, there should be a lot of positive self-talk going on in this little head of mine.

Instead, here is a selected list of thoughts I had during just one hour last week, when I was doing some last minute preparation for an important work meeting:

1. I am a failure.
2. All the things I am doing are never going to amount to anything.
3. Other people would be more prepared than I am.
4. If only I had _________ (fill in the blank with more than 25 different alternate universe scenarios ranging from having gotten up earlier to having chosen a different profession)
5. I'm so disorganized.
6. I will never make enough money.
7. Some people have five children and are full-time physicians. I only have one child. Why can't I get my shit together?
8. I am a terrible mother.

Now let me be clear: on a meta-level, I don't believe these things. Rationally, I know they are distortions. If I step out of the den of snakes that is my mind, I can objectively see that I am doing ok, certainly not without my flaws (or as my rabbi says: "growing edges" -- see #5 above), but also certainly a person of value. I know that I contribute important things at work, at home, and in my community. But then there is THIS VOICE UP THERE -- let's call her Harriet -- that just keeps going at me. Harriet has been going at me for (at least) 25 of the last 35 years and I wasn't even aware of it until last week! How could I have not noticed it, all this time? I think I just heard it as the truth.

It's tempting to lay blame for the existence of Harriet on a long list of factors: the endless disempowering and judgmental messages that girls absorb from an early age about their bodies, their successes, their worth; the harsh social conditioning of medical training; the unreasonable demands modern society makes on parents and/or doctors and/or the middle class; the wildly increased expectations for connectedness and task completion potentiated by technology; and on and on and on. On the other hand, maybe Harriet is just a function of my own tendency toward anxiety and perfectionism. Certainly, Harriet is at her worst when I am exhausted, stressed, or overworked. But something tells me I'm not the only one with a Harriet in their head, which is why I'm writing this. Because it is time for Harriet to go. I deserve better. We deserve better. We deserve the kind of whole-hearted love we give our children and our patients and our friends.

Since last week, I've been noticing these thoughts and have been consciously challenging them as much as possible. You are a bad mother, Harriet says, as I leave my daughter at daycare after a rushed morning. Bad mother, eh? I counter. I show a lot of tenderness and care for my child and prioritize her well-being and our time together as much as I can. You never accomplish anything, Harriet says. Really? I say. What about Thing X or Thing Y or Thing Z? Those things went pretty well. It doesn't feel natural to say nice things about myself to myself -- in fact, I don't even believe these things as I am saying them. But I think you can grow into the truth of your own ok-ness.

So for all of you out there who may be wrestling with your own negative voices, I'll leave you with a beautiful poem by Derek Wolcott that is resonating with me as I try to exorcise my own. May the voice in your head be that of a great lover and friend!

Love After Love

The time will come
when, with elation,
you will greet yourself arriving
at your own door, in your own mirror,
and each will smile at the other’s welcome,
and say, sit here. Eat.
You will love again the stranger who was your self.
Give wine. Give bread. Give back your heart
to itself, to the stranger who has loved you

all your life, whom you ignored
for another, who knows you by heart.
Take down the love letters from the bookshelf,

the photographs, the desperate notes,
peel your own image from the mirror.
Sit. Feast on your life.

Gratitude

Not my gratitude. My kid's gratitude.

I will preface this by saying that Eve is almost always a delight. She's smart and funny and passionate about her friends and deeply upset about injustice; she usually does what she's asked without (too much) complaint and she is almost completely self-sufficient (laundry, room, homework, etc.)

And she's 16, and so she sometimes asks for things that she's not going to get, and when it becomes clear she's not going to get them, she has the typical adolescent reaction. This includes sighing, eye-rolling and detailing the ways in which her life is soooo harrrd. Our five-bedroom house is too small., Our backyard lacks a pool. We've only renovated one bathroom, and it's not hers. The hundreds of dollars she is given for a clothing budget is inadequate. You get the idea. She's not grateful.

I am not alone. A lot of my friends have the same experience. Our kids are incredibly privileged; they have rooms of their own, clothes with the right labels, and money to spend. At a more basic level, they have loving parents and safe homes and electricity and food and drinkable water. And we are shocked and somewhat hurt that they aren't grateful.

This reaction troubles me. I have the same impulse - tell me you appreciate all this. Tell me you recognize how lucky you are, how many children around the world have nothing, how many children in this country go to bed hungry while you're complaining that we don't have a backyard pool. I hear Eve rail against injustice and wonder why she can't make the connection to her own complaints. And then I answer myself: because she's 16. Because she still thinks she's the center of the universe. Because the terrible reality of poverty and war and famine and racism is too much to bear and she wants to look forward to being a grownup.

I wonder why it's so important that they be grateful. For some reason, this makes me think of Oliver Twist. "Please, sir, may I have some more?" Eve is not a waif on the streets, thank God. I trust she will never have to cower and beg for favors, and be grateful that someone granted them.  Eve was adopted; there's an extra layer of all the people who tell me she's so lucky to be our child, and she should be so grateful that we took her, and how we rescued her. Since I think we're the lucky ones, and I know we didn't rescue her - she has two biological parents who love her as much as we do - I shrink from that idea.

I realize that what I really want is a kid who appreciates - who appreciates her parents' efforts to make a comfortable home, and the work we do that makes the money to buy the clothes, and the thoughtful choices that mean we went to Paris and don't have a pool. I also want her to appreciate her privileged place in the world. I also want her to claim what is hers without apology; I want her to feel that she belongs so that she can use her secure base to advocate for the justice of which she speaks so passionately. She's sixteen. Sometimes her pendulum swings over into the petulant. I will try to take the long view and trust that it will land in the balanced center.

Why I Fired My OB/GYN

I apologize in advance that this story is a little bit TMI. Then again, I live in a world where about a third of the time, a cat or a child comes into the room to watch me pee, so nothing is really TMI anymore.

When I moved to a new town and found myself newly pregnant, I knew I had to find an OB/GYN practice. So I basically googled “OB/GYN” and picked a large nearby practice that popped up and selected a doctor with decent reviews. My first visit was pretty good, and I decided to stick with the practice.

Unfortunately, things went downhill. The worst thing was the wait. I’d come in for increasingly frequent pregnancy checks and end up waiting an hour for my five-minute visit. The most aggravating visit occurred when they called me to come in early because they were running ahead. I dropped everything at work to show up early, and STILL waited thirty minutes, until the time of my original appointment.

Also, they did the worst blood draws ever there. Any time they needed blood, I would end up with bruises all over my arm and severe pain for days. When I objected to doing the glucose tolerance test there for that reason, I felt like I was treated like a criminal by the staff and the very un-understanding OB/GYN.

But the straw that broke the camel’s back happened about a year after I delivered. I was having my annual exam done by a male OB/GYN that I’d seen a few times before and liked well enough. After he finished the speculum exam and the bimanual exam, he said to me, “Now I’m going to do a rectovaginal exam.” And then two seconds later, he just DID it.

I’m sure somebody could present me with a body of literature on the importance of the rectovaginal exam. But I don’t care. He didn’t give me fair warning. He didn’t ask if it was okay. And it was certainly not something I ever expected, considering in my 15-odd years of annual exams, not one doctor ever deemed it necessary to perform. Plus he was a man.

I’m not saying I’m traumatized or anything. I’m not having recurrent nightmares over it. I wouldn’t report him. I mean, let’s be real here—rectal exams happen. But I didn’t like the way it happened, and I would never go see that doctor again. And since I hated the practice so much, it gave me the impetus to finally leave.

(And my current practice has never made me wait more than five minutes.)

I do have to say, if you’re a male doctor, I think you do need to be careful about that sort of thing. You can’t just go around sticking your fingers wherever you like without warning your patients. Not that I can do that as a female doctor, but I think there is a little more wiggle room. (Literally and figuratively.)

A Proposal

I walked into the Dr.'s Lounge this morning and bumped into a hospitalist. I had heard over the weekend that he had been through a rough divorce three years ago. I see him daily and we talk about kids once a month but somehow I missed this.

"I'm sorry! I must have been living under a rock. Divorce is so awful I wish I had known."

"Oh who told you? Your new neighbor? I met her at a crawfish broil last weekend."

"No, not her but she is sweet we had a big neighbor cookout two weeks ago love her. It was dance moms - Cecelia's (13) big recital was last weekend. And don't tell your son you heard it from me but C told me he's the hottest ticket in town."

"His head is getting so big we are having trouble keeping his ego in check."

"The dance moms were showing me a picture of your girlfriend on social media she is super cute."

"What?" He looked confused.

"Short blonde hair?"

"Oh where the heck did they find that? That was over a while ago. It's so hard, dating and divorce. There's so much baggage."

"Yeah, I had a year of hell on match.com but finally got lucky. I met a great guy almost four years ago. He has never been married and doesn't have any kids - not that I would have minded if he did, but it is easy. The kids have their chance for a sibling with my ex and stepmom's toddler." I smiled, "he just moved in a month ago I'm so excited."

Last Saturday I caught up with an old friend I hadn't chatted with in 15 years. We talked on the phone - she's in DC - until 12:30 am. I sat out on the back deck.

"So tell me all about him!"

"Well, he's lived all over. Born in Arizona, elementary and middle school in Plano,Texas, high school in New Jersey where he started biking - rode with George Hincapie up there, biking and art school in Kansas City, then the Twin Cities and Seattle to pursue his photography. Once he delivered a pizza to Eddie Vedder in Seattle!! He decided to go back to Kansas to pursue architecture and finished his degree when Wall Street crashed in 2008. He worked in L.A. for a year then came to Hot Springs. Now he's in a nice office in downtown Little Rock with a large national firm based in Memphis - they did a lot of work in downtown Memphis. They had their Christmas party at Graceland it was so fun! We did a night tour. I had been lots of times growing up but it was his first."

"So are you going to get married?"

"Well, yeah, we talk about it but. . ."

"But what?"

"He hasn't asked me yet. I mentioned never getting married again so many times early in our relationship I think he is afraid to ask. I would be."

"You ask him."

I was flabbergasted. "I can't do that!!! You're crazy!"

"Yes you can. Do it. Ask him."

I've been thinking about it non-stop for the past two days. It would model great bashing gender stereotypes to my children. We have talked about it a lot recently, especially since things have been working out so well since he moved in.

Thinking about it has made me reflect on our time together, and on him. How we both disagree on our first date to the tour the U.S.S. Razorback submarine - July 22 or 23? Luckily he saved the tickets so he can usually find them and prove me wrong. How we disagree on our first kiss anniversary two months later - we spent a lot of time hiking and going to movies and getting to know each other before that. September 22 or 23? Depends on when midnight struck neither of us were paying any attention.

He met the kids late that fall at a picnic at Pinnacle Park - one of our favorite hiking spots. I still remember Jack grabbing his hand while stepping down a bank to the creek and his surprise then ease with the contact. The kids and I later took him to one of our favorite hiking spots that has the Cat in the Hat painted on a tree stump. He did art projects with Cecelia - a Valentine's box in the shape of a nose (her wacky idea). They painted the girl and boy mascot clay statues of the Nashville Sounds in a tux and fancy dress and won box tickets to a game - his dad and stepmom were in Nashville at the time. He easily blended into our weekend lives and a year later got a job closer to Little Rock and an apartment two blocks away, so he has been a fixture for the past two years.

There are so many things I love about him and I am really bad about expressing them to him. It's a lot easier to think about them in my head and type them hiding behind this computer. I love how he points things out to me with his photographer and architect eye that I would miss buried in my books or music or thoughts. A coal barge on the river. A detail on a building. A rock to watch out for on a bike ride. A cardinal in the backyard. I love how he collects watches and gave me one on our first trip out of town to New Orleans. I still remember him telling me he wanted me to wear it. It's a Tissot - very clean and classy - he told me then that Grace Kelly wore this watch and I was amazed he knew that.

I love how he is with kids, so easy and quiet and agreeable. How he jumps on the trampoline with Jack (10) when I worry he is stuck in his iPad too much. How he goes over Cecelia's study guides with her the night before tests - he is her favorite study buddy and calms her down much better than I can. How he rides all the roller coasters and goes on all the waterslides that I am too scared to do with them. How we take turns wishing them goodnight when they are here. Some nights Cecelia keeps him down there talking way too long and I love hearing what they were talking about when he comes back up.

Most of all I love how he is with me. He's dragged me out of my books into TV series and we are having so much fun with Ray Donovan right now I can't wait to settle kids at night. He hikes with me and bikes with me. Lately we have been getting into cooking with Blue Apron. It's so fun to put on the classical music he grew up hearing at symphonies with his father and wind down the day preparing a meal together - both of us learning how to cook. He fixes all of our computer issues there are lots! Last Friday night he volunteered to be one of the drivers with me in a Scavenger Hunt birthday party with fifty kids we had so much fun. We got kicked out of the mall by a power tripping cop; I loved that he enjoyed it as much as I did. He puts up with my singing when I've had an extra glass of wine. He's my knight in shining armor when I've had a terrible day. And he's helped me focus more on the right in me than the wrong, which I have a tendency to do.

I love that when he catches me looking at him he gets defensive like there is something wrong but really I just love to look at him. He is so handsome. I want to live in the corners of his eyes when he smiles. I want to breathe in every time he breathes out so I can catch his breath. I want to be buried in the smell of the crook of his neck. I want to spend the rest of my life with him.

So, SPS, here's the question that has been making my palms sweaty and my heart anxious, ever since my friend put it in my head to ask. It can be a small wedding, no frills - I know you don't like being the center of attention - me neither. Just you, me and the kids. I'll console Cecelia by throwing a huge party inviting all our friends and family with a band and good food and wine. I've got no ring but I've got these words and I know you value art over things so I think it'll be ok. And I'm not down on one knee but I'm hiding behind this computer on mothers in medicine which was my safe spot and my outlet in one of the hardest times of my life. So here goes. What do you say? Will you marry me?

 At P.F. Chang's - a top spot with my kids, awesome friend histotech and bestie P.A.

 Hiking a black sand beach in Hawaii at a path conference on the Big Island

Click the link below, babe (Elle King)

Make You Smile

MiM Mail: RN considering medical school

Hi MiMs,

I would first like to say thank you for sharing your stories and your day-to-day experiences and challenges of being mothers and physicians. Your stories have been helpful to me as I consider making a change in career paths. I am 25 years old, unmarried, no children at this time. I work as an RN in an ICU in the south. Prior to becoming a nurse, I studied biology and psychology and then obtained my MSN to become a nurse. I'm considering returning to medical school and becoming a physician. One of the reasons for this is that I question whether I will live up to my potential academically by remaining a nurse, and I have a thirst for greater knowledge than what I currently have. On the flip side, I enjoy my work as a nurse, taking care of patients, leaving work at work when I come home, and having a flexible schedule that allows me free time to travel and have a life outside of work. My sister is married and is in her intern year of IM and most of the time seems miserable and can attest to the strain placed on a marriage by residency. Although I'm not to the point of motherhood currently, being a mother with multiple children is something to which I have always aspired. My concern is that if I become a physician I wouldn't have the time to spend raising children and taking care of them like I hope to. I would love to hear your thoughts on this. Thank you!

Sincerely,
Laura

What does it really mean to be a mother in medicine?

As in, in real life, day-to-day, down and dirty?

Genmedmom here.

I'm working on a writing project about being a mother in medicine in practice. This is going to be the everyday stuff: the logistics, the scheduling, the practical aspects, the balancing, the conflict. Funny stories, lessons learned, suggestions, and mistakes.

As I was thinking about this project, I realized that my experience in clinical practice is drastically different from women in other specialties. There's no way I can write this without input from moms in every area of medicine!

Things I was wondering about:

When I was pregnant, it never occurred to me not to tell people. I can't keep a secret to save my life. But I have colleagues who kept their bumps hidden for as long as humanly possible, for many different reasons: worries about discrimination; fears of being passed over for promotion; superstition. What did folks out there do? If you felt like you had to hide your pregnancy, how did you, and for how long? Looking back, what do you think, was it necessary?

What about those specialities where there is risky occupational exposure, I'm thinking radiology, surgical subspecialties… How did you manage that in pregnancy? If you needed to step out of the room, how did your colleagues react?

A lot of doctor-moms don't take a full three months of maternity leave. Some take more. Does this vary a lot by specialty? Did folks feel pressured to take less than three months? Did anyone have to fight for three months?

I never pumped at work. (Long story.) For the moms that did, can you share some of the good and the bad? Were offices and hospitals supportive or not? Were facilities acceptable or not? What were your worst pumping experiences? Would you do it again?

As a general internist with no inpatient duties, my call weekends involve, well, phone calls. What is it like for doctor-moms who have to go in? For the surgeons and anesthesiologists out there, is it better to be on call from the hospital or from home?

My office clinic is low-key enough that if I need to, I can step out and answer a phone call from my kids' teachers or the school nurse. But what about for moms working in the operating room or the ICU or on a busy inpatient floor? If you need to step away to take care of your family, are you supported?

My husband travels, and occasionally, I've had to cancel a clinic day to stay home with the kids: blizzard closed the schools, kids throwing up… Have others needed to cancel their workdays for childcare? Did colleagues make you feel bad, or did they step up? For those who haven't or can't, how do you manage those unforeseen events, the school cancellations and nasty illnesses?

I am eternally grateful that I can work part-time. I know that not all physicians approve of that. For those working full-time, how do you make that work? What supports and systems need to be in place for you?

And of course there are more questions, more scenarios… We can all learn from each other!
All specialties should have representation. I would love to hear what you have to say.

Don't feel comfortable commenting here? Email me: mauroratello2@gmail.com

Story of My Life

Do you ever feel like your life is like a TV show, but not in a good way? More like a Seinfeld kind of way, when all you can do to keep from crying is shake your head and laugh?

Episode one. I present for a labor check at 38 weeks (determined to be false labor), and find out baby boy is BREECH when at my appointment the week prior, he was firmly declared vertex! The plan is to do an external cephalic version immediately, as I am an ideal candidate. I wait nearly 11 hours, NPO, cranky, uncomfortable, and tethered to an IV pole, and at last the Ob team assembles to do the version. AS they are putting on gloves, all their pagers go off. Oh no. No. No! It’s a gyn surgical emergency, a stabbing!! A resident returns to give me the choice to wait several more hours with no guarantee of doing the version, or to schedule it for first thing the next morning. My hangry state tells me to postpone… which in retrospect is likely the wrong choice. My “false” contractions progressively and subtly transition into excruciating ones over the next 8 hours at home (I’ve lost confidence in knowing what’s real after the false alarm earlier), and at 2:30am I find myself driving alone to the hospital, jaw clenched, sobbing, and pulling over for contractions (my husband is at home with our daughter). I am 9 cm dilated - time for emergency C section - and our perfect son makes his debut with a bang thirty minutes later.

Episode two. I find out a week after our son was born that, by some miracle, I’ve received a research grant I applied for last winter. The catch? I’m required to attend the organization’s national meeting in 4 weeks to accept the award at a formal dinner. After weighing all the options, we decide to go as a family. It’s a fun city, only a 3-hour flight, expenses are partially covered, and I‘d have the opportunity to attend an awesome conference. A two year old and a 5 week old in a small hotel room together? No problem! The reality? Every day we desperately invest hours in the possibility of achieving overlapping naptime so we, too, could sleep.

Needless to say, I don’t get to attend much of the conference. I try going to talks, I really do. It’s a lot to ask my husband to watch both of them, so I go to a few presentations with the baby strapped on, hanging out by the exit door. The night of the awards ceremony finally comes. Milk pumped, baby topped off, toddler excited, husband feeling strong. But alas, this is how the evening ultimately ends.

Episode three. The number one question I’m asked during prenatal care? By multiple people at every single appointment, from 6 weeks through the bitter end? “What method of contraception do you plan to use afterwards?” This is to the point where I can only assume they think I got pregnant on accident and are doing anything possible to prevent me from letting it happen again. Every time, without fail, I say, “IUD.” Even while being prepped for my emergency CS, crying in pain, someone manages to come around and ask me if I’d like the IUD inserted... “NOT. NOW!!!” I scream. Finally, the big day comes to do my IUD insertion, at my 6-week postpartum visit (which of course requires me to bring my newborn along). When I make the appointment, they ask again if I want an IUD inserted so they can allot enough time. Mid-way through the appointment, my Ob tells me, “I’m sorry, but the administrator who gets insurance approval for IUDs is out for the morning unexpectedly, so we actually can’t do the IUD today. But don’t worry, we’ll schedule you for next week, no problem!” CUE FOREHEAD SLAP.

The stories go on and on. I will share a few more.

Feeling the sweet warmth of a blow-out spread across my sleeve as my son, who won’t nap in the crib, sleeps in the crook of my arm as I frantically try to get through the RISE exam before he wakes up (I don't stop taking the test, by the way).

Watching cake batter overflow and drip down the oven rack gratings in a million little chocolate stalactites at 4:30am while baking a birthday cake for my mother in law.

Dropping said mother-in-law off at airport. So out of it and exhausted, I accidentally drive in the buses-only lane at departures. I have never ever done this in my life. An airport official runs over and tells me to leave immediately before I get fined ($500!!) and I get out of there… but alas, a cop is waiting for me at the very end. Sigh. (But with a wailing newborn in the backseat, I fortunately get off with only a formal warning.)

We have a few warm days last week. I smell something weird. I am fearful it is something with the sump pump or crawl space (we live in a renovated brick rowhome). Long long story short, there is a dead rat in the crawl space. Yes. A. Dead. Rat. Next door had an infestation, exterminators came, rats ate poison, and one managed to get through a crumbling brick and into our crawl space. And died. No words. This is an ongoing saga. Involving the services of a mason- I never imagined I'd need a real mason, but apparently I do. But it will be ok.

 

And the clincher. What inspires me to sit down and write this. What drives me to actually throw my head back and laugh with tears in my eyes. Baby has his 2 month immunizations this morning, and poor thing is angry and uncomfortable… he just needs to take a nice long nap. And THIS is what I come home to- view from his window.

This is when all you can do is laugh. And be grateful for health and for even the capacity to laugh. And embrace all of this self-inflicted chaos, the q2-3 hour wake up calls that still aren't stretching out after 8 weeks, the blow-outs, projectile vomit, and laundry. So much laundry. Laugh at the fact that your parents, who had lived just an hour away, decide to move to Asia a month before baby is born, leaving you again without family support postpartum (we tell each other it's building character). Accept the frustrating feeling of hard-earned knowledge seeping out of your brain even after a few short weeks, trying to have the will-power to study and attend resident didactics and research seminars (sometimes with a sleeping newborn hidden under your jacket), but often failing. 

But there are some TV/movie moments. When I sink my lips into the soft pillows of my son's cheeks, also becoming aware of my daughter's pudge melting away silently. The indescribable joy of seeing our daughter transform into a sibling. When my heart explodes witnessing first smiles and giggles. The sacredness of feeling the body of such a vulnerable little human relax in your arms. Awe that I can muster up secret stores of energy and patience that are fueled only by love when I have nothing left. And awe at the magnitude of this love. So it's time to celebrate- although it hasn't been pretty, we've made it through the newborn trenches once again.

Claim your space!

Equal pay, sit at the table, ask for what you're worth!

All of the above are often part of the dialog concerning women in the workplace.  Women ask for less, do not request promotions/raises, do not sit at the table.  As a big Sheryl Sandberg fan these mantras have been my mentoring rhetoric for years, starting from my own brief time in investment banking when these concepts were instilled into me through a womens group at our firm.  So, when negotiating my first contract - I asked for more and I got it, I asked for time and I got it.  I made sure to ASK ... I felt well trained.

However, just moments ago, I was chatting with one of our attendings and he was congratulating me on my job (I'm very happily staying at the place where I am doing my fellowship) and he asked why I hadn't moved into the vacant office yet. There is one vacant office in the department.  It is clearly going to be my office.  Its the small one near the bathroom that all the junior faculty get until they move up the ranks.  I walk by it longingly every day and go sit in my loud cubicle and try to work while sitting next to all the administrators constantly answering phones.  I fantasize about this office...mine in only a few short months.  Just this morning as I walked in from the garage, I was making mental plans of which pieces of my daughters art work I need to get framed to put up in my new office. I envision my name on the door.  But, NEVER had it occurred to me to "just move in."  This thought was just second nature to my male attending, meanwhile I'm sitting in the background and waiting for my turn. Maybe I'm making a mountain out of a mole hill, but I do think that we have to never stop striving to be seen and recognized and heard.  I see it in myself all the time.  I feel it. I often have to remind myself that I worked hard for this job and every job.  I walk around suppressing my impostor syndrome on an daily basis.  But, today I realized I can't be complacent.  I have to keep claiming my space.