All of the ways I forget

I had my 90-day evaluation in my new position today. I left the clinic I was working in, one overrun by burnout and toxic management, in order to remember why I went into medicine at all. I love my patients and this work, but I love my family more. I now work 3 days a week in health care administration and quality improvement. I sleep well at night now that the main cause of my insomnia has ended. My family is happier. My evaluation went very well.

Immediately after my meeting, my husband reached out and said he needed to talk. I needed to talk too. He is finishing his dissertation this week, we just bought a new house, and my parents came in town for the weekend. We have been passing like ships in the night. Both busy and not really checking in enough. With moments of hugs and kisses and simple appreciation. But overall, we haven’t been checking in frequently enough and we definitely haven’t been having the weekly meetings that are my bookends at work.

I feel lonely. He feels unappreciated. Why didn’t I offer to help with his appendices? Why didn’t I read the chapter he asked me to read so many months ago (honestly, he gave it to me and I forget and he never mentioned it again until today and now I feel like dirt). He feels that my work has taken priority in our family for years (medical school, residency, the toxic job took so much of our family’s energy just to stay afloat). And now I’m studying for my Boards again after I failed them last year (more about that later, I have a lot to say about it but it's so raw and traumatizing). And he’s finishing his dissertation and starting his first job as a professor at the state university.

When we get busy I forget that my marriage needs check-ins, scheduled ones, on purpose because they are priorities. And when we are busy, we both have to go the extra mile to make sure that my needs, his needs, and our family’s needs are met.

And I’m sitting here at work, dragging my feet because at home I am reminded of all the ways I forget. I need to go home and start remembering again. And I need to be gentle with myself because we are juggling plates and though many of them are scuffed up I pray that none of them are smashed and destroyed. I’m going to head home now in order to remember that I love him immensely. And loves me. And we can't forget.

Linky Linky

I had a piece published in the Pulse section called "More Voices." (if you read MiM and haven't yet read Pulse, stop now and go over there. I'll wait. Really. Please subscribe, and donate if you can. It's an amazing resource.)

Good! Now you're back. "More Voices" publishes short pieces on a theme topic once a month. This month's theme is Mistakes, and the first story on the page is mine. Take a look (and subscribe! and donate!)

Guest post: Jury Duty

I have a confession to make: I'm currently on day 2 of 5 weeks of grand jury duty. Yes, 5 whole weeks.

I write it in those terms because I feel embarrassed and ashamed every time I tell people this. When my family, friends, or coworkers hear that I am serving 5 weeks of jury duty, or when I mention to my fellow jurors that I am a Veterans Affairs physician, they respond with shock, "I can't believe they picked you!" or they make some sort of twisted, disgusted looking face. The impression that I get from them is outrage that I'm abandoning my patients and -- though this may simply be projection of my own feelings -- that I should have tried harder to get out of this responsibility.

I received my court summons 2 months ago and right away, I notified my supervisor to ask for guidance. He replied that I should just close out my clinic so no patients could be scheduled. My colleagues assured me that they would cover. I thanked them, but reassured them that I likely wouldn't be selected. I admit that part of me was ambivalent; wouldn't 5 weeks of jury duty be a welcome "break" from the grind of clinical medicine?

Fast forward to earlier this week. I sat in a crowded court room and soon realized that I had been called for grand jury, not petit jury, and that the two are very different. Petit jury, I have now learned, is a trial jury that determines a person's guilt or innocence. I had been summoned for petit jury some years ago and after sitting in a large room for several hours, I was dismissed without ever being called for "voir dire," which is when the trial lawyers question prospective jurors about their backgrounds and potential biases in order to select or reject that potential juror. Unlike petit jury, the purpose of the grand jury is to determine whether there is enough evidence to indict a person of a crime. Also unlike petit jury, there is no voir dire for grand jury (although I did not know that going in!).

Anyway, during the initial process of grand jury, the clerk asked for anyone who believed they couldn't serve to step forward. She explicitly stated, "Occupation is not a reason why you cannot serve. You can be a lawyer, police officer, law clerk, married to a lawyer, etc and still have to serve." So when I heard that, I stayed in my seat. She went on to list several valid examples of why a person might not be able to serve: medical or mental health issues, financial hardship (if a job wouldn't pay during jury duty), illiteracy. I thought, "No, no, no" and stayed in my seat with my nose in my laptop. But soon I noticed that the crowd had dwindled, and I became nervous. There was a break, and when we returned, the clerk asked if anyone would have an issue hearing cases related to sexual or domestic violence. I am a psychiatrist at the VA and care for a large number of female veterans who have experienced "MST" or military sexual trauma, but I thought, "Hey, I can be unbiased." I honestly felt that the question was directed more towards people who had been victims themselves.

So the next thing I know, I'm being sworn into grand jury duty with 22 other people! I couldn't believe it. I kept waiting for the voir dire, but at that point learned that grand jury doesn't have a voir dire process, and by then it was too late. I spoke to the clerk later that day, and she basically said as much: "Too late, you're sworn in now and you can't get out. Why didn't you speak up before?"

So that's the question I've been asking myself the last 2 days. Why didn't I speak up? As a psychiatrist, I've been trained to wonder about unspoken desires and ambivalence. I think part of me did see jury duty as a break. Yes, it's an inconvenience to my routine, but the day starts an hour later than my clinical day and often gets out early. It's nowhere near as mentally or emotionally exhausting as patient care. There is also a lot of downtime between cases when I can study for my upcoming board exams. And the courthouse is in a part of downtown that I don't normally frequent with lots of shops and restaurants.

So for all those reasons, I'm feeling guilty -- guilty that I put my own interests before my patients' needs. Yes, I had notified most of my patients that I may be out for the month of July. I don't do therapy, and I see most patients every 1-3 months, so I didn't have to disrupt weekly sessions. Yes, no patient appointments were actually cancelled. Yes, I have amazing colleagues who told me not to worry, that they would cover any emergencies that came up and see new patients during my absence. But I still feel like I am shirking my professional responsibilities.

I know jury duty is a civic duty. And just by being on jury duty the past few days, I can certainly say that I am contributing to the group diversity in terms of race, age, socioeconomic class, and education level. It is actually quite eye-opening and frightening to think that probably most highly educated and professional citizens get out of jury duty, which leaves important legal decisions to be made by people you might not want to be making important legal decisions. Thinking in economic terms, what's the opportunity cost of a good juror vs. of a physician, lawyer, or other educated professional? What's lost when a doctor is out of clinic vs. when an uneducated person is chosen for jury duty? I guess you could say, "Well, a doctor went through 7-9 years of post-college education to get here and is helping sick people, so their time is worth more than any Joe-Shmoe who could serve as a juror," but then is that fair to the defendant? Would you want a Joe-Shmoe to serve on a jury if it were your case? Can you really say that someone's health is more important than whether an innocent person goes to jail or a guilty person goes free?

I'm seeing that there is no clear answer, but all I can say is that I am still feeling pretty lousy about being on jury duty. The cases have been interesting, but I feel guilty being here and inconveniencing my patients and my colleagues and for getting this "break."

What would you do? How do you handle jury duty summons? Have you ever served? Do you think physicians should be exempt or always try to "get out of it?"


~~~~~
Bio: I am a new attending psychiatrist at the VA in a Mid-Atlantic city, studying for my board exams in September and mothering 2 young sons.

Math is relative.

It's 3 am. Perfect time to blog, right? With the baby sleeping through the night, I can't sleep anyway.

I want to write about work, probably not for the last time. I'm currently a burn and trauma visiting research fellow in Lilongwe, Malawi, for the upcoming academic year. Kamuzu Central Hospital, one of the country's 4 central hospitals conceived of as tertiary care referral centers, is a half hour's walk or 5-30 minute drive from our house, depending on traffic. This, taken from the hospital website, is what you see entering the visitor parking lot:

According to dictionary.com, a "hospital" is "an institution in which sick or injured persons are given medical or surgical treatment." But that's the factual definition; the cultural load of a word is where stories lie, and where misunderstandings arise. For example, if I free-associate on the word "hospital" for 2 seconds, I come up with: "white, clean, nurse, love, drugs, pain, death, friends, disinfectant, recovery, fear, babies, surgery, pager, large building, cockroach, elevator, work, hope, despair, emergency room" etc. Your list will be different. The list of a patient will be different from that of a doctor; the list of a woman who delivered a healthy baby different from a son who's just put his mother in palliative care, the list of a Malawian patient different from that of a Malawian doctor, of a Polish patient from an American one, etc, etc, etc. Language operates on an agreement about the factual underpinnings of itself (that is, word definitions), or else all speech would be a subjective hodgepodge of un-translateable experience and we couldn't communicate at all. One of the things I love about traveling is that it forces you to reinterpret and question those factual underpinnings of words and concepts which we take for granted in our own culture.

Hospitals are frequently described in terms of the number of beds and operating rooms they contain. Those numbers help to illustrate a hospital's volume of patients, its importance and function. And they should be easy enough to get, right? Count the beds per unit, add up the units, and voila. Ditto for ORs. But KCH is variously described as having anywhere from 700-1200 beds, depending on the source. How can that be? Math, after all, is supposedly universal. Does 1 bed magically become 2 beds, or half a bed, depending on who's doing the counting? Can Malawians not count? Are they so bad at keeping records that they don't even know how many beds one of their flagship hospitals contains?

The answer, of course, isn't that simple. For starters, the definition of a "functional" bed may include the one placed in the outdoor hallway that connects the rooms, which aren't technically part of the hospital census but which are routinely used to increase the treatment space of a hospital that was built for a much smaller population. Like this, taken from the Malawi Project website:

Next, "functional" beds aren't, when they're in a unit that's under construction. For example, all the main operating rooms at KCH are currently closed for renovation. If you need your leg pinned with orthopedics, it will happen in the dental operating room; if your baby needs a stoma because of her imperforate anus, she will receive it in the burn OR because the main ORs are just, simply, closed until further notice. So I can't really tell you how many ORs there are at KCH at this time, nor when the main ones will be available again.

Finally, I bet that in your free association on the word "hospital" you did not picture a bed containing more than the patient, and neither did I. At KCH, they do. In the privileged wards, like the burn unit, it's because the whole family might sleep in the same bed with the patient. In the most overcrowded wards--the pediatric ones, for example--it's because there are multiple patients per bed. So depending on how you count, one bed does become two, or three, or maybe even 4.

The thing is, you don't need your own bed to heal. We expect it, because that's our cultural and socioeconomic norm, but your healing isn't contingent on private sleeping quarters. OK, maybe if the patient next to you has tuberculosis or leprosy, that may not be too conducive to health, but in general, a single bed occupancy could be thought of as a luxury; especially when you consider all the other things we take for granted. Like a trained surgeon, or morphine for dressing changes, hot water, air conditioning, blankets, food. But more on those in another post. I do have to get up in 3 hours.

This entry was also cross-published with minor changes on my travel blog, malawijo.blogspot.com

"Psss... You have skin cancer"

Recently I was at a pool party that my daughter was invited to. Several of the adults also dared to wear swimsuits, so needless to say, there was a lot of skin showing.

And I happened to notice that one of the mothers had a lesion on her back that looked a lot like skin cancer (not melanoma).

Of course, I wasn't sure. I'm not exactly a dermatologist or even a PCP. It could very well have been a benign lesion. But it did look like some of the cases I saw during med school.

I ended up not saying anything. I assumed she probably knew about the lesion and whether or not it was cancer. And even so, it would have been incredibly uncomfortable for me to go up to a woman I didn't know very well and start questioning her about a skin growth. That is a surefire way to ensure your child will never be invited to another party again.

Sometimes it's hard being a doctor in the real world.

My Target Guardian Angel

     I like to think of myself as someone who generally has her sh*t together. Someone who is skilled at multitasking, who keeps her cool when things get stressful. Which is how I found myself at Target last week staring at one cart full of children squirting poop and tears and another piled high with cartons of diapers and wipes. Oh, and three huge containers of animal crackers mixed in there for good measure.

     My plan had seemed foolproof. (Okay, at the very least, doable.) Feeling too guilty to have a huge order of mega-packs of diapers shipped when there was a store nearby and I had a day off from work, I had placed my order online and selected in-store pickup. The next day, I loaded up my sons, two-year-old Bean and three-month-old Teeny, both freshly fed and changed, and headed out. Bean’s naptime still loomed a good two hours away and Teeny usually snoozes happily on and off throughout the day, so conditions seemed ripe for success.

     All went smoothly as we circled the store to grab a few small items and made our way through the checkout line. We headed over to customer service and the guy behind the counter pulled up our record then wheeled out a shopping cart filled with large boxes. He eyed the cart I was pushing, the main section of which held Teeny in his infant carrier and the front section of which held Bean. “Do you need help?” he asked halfheartedly, as I started loading the boxes underneath. I waved him back toward the counter where other customers had begun to line up because, I figured, I’ve got this.

     The tipping point was when I tried to snug two of the containers of animal crackers in the front with Bean. He didn’t want to share his space – in fact, he suddenly wanted out of the cart right now - and began to whine, which escalated quickly to a wail. Teeny, who had woken up a few aisles back but until now had remained quiet, decided that he, too, was done with this expedition and would prefer to be held and fed. It was around this time that he also let out a poop explosion that not only blasted out of his onesie but, as I would later discover, puddled into the carrier, soaking the seat cushion and dripping through the cracks to the coat the plastic base.

     I tried firmness and then bribery with Bean, trying to coax him into letting me stuff several items in the seat beside him as I simultaneously tried to shove another carton of diapers onto the shelf below. I’ll just squish everything together, I thought, as the boys’ cries continued to escalate. It will be fine, I reasoned, with less and less conviction.

     “Can I help you?” a new voice asked. I looked up to see a petite woman eyeing our situation with concern.

     “Oh no, it’s all right,” I said, waving a hand at the general chaos before me. “We’ll be fine.”

     She frowned. “There’s no way you’re going to fit all of that. Here, I’ll wheel the other cart out to your car.”

     “Are you sure?” I asked. “I mean, only if there’s nothing else that you need to do.”

     “Only return a pair of shoes,” she said, “and I can do that after I help you.”

     I sighed. The boys’ chorus continued. I acquiesced.

     “I remember having young kids,” she said as we headed out to the parking lot.

   I wanted to explain that it’s not usually like this. That during residency I resuscitated babies while swollen from belly to ankles as I carried my own; that I managed the ICU with no in-house fellow or attending. That I pride myself in working full time, raising my kids, and keeping our house and lives in order. That complications and multitasking are kind of my thing. And yet as we wheeled our way down one row of cars, stopping so that I could survey the lot in search of my vehicle, realizing only after I spotted it that I driven my husband’s car and not my own (and moments after that that while I was now searching for the correct model of car, the one I was currently steering us towards wasn’t actually ours), I felt like my sh*t couldn’t be less together. I hurried along, willing this interaction to end so I could return to at least pretending to be a competent parent and adult.

     We parked the carts once we reached the right car, and I hustled the boys into their seats, promising Bean that he could have some animal crackers if he would just wait a moment longer. I began loading boxes into the trunk, praying that the woman wouldn’t notice that we were also barely going to be able to fit everything in the car around the clutter already there and wondering from which of my sons the scent of stool was now wafting.

     As I thanked her, perhaps too hurriedly, the woman paused and held my gaze. “This was my random act of kindness.”

     I must have given her my best What, now? look because she quickly pressed on. “One of my friends just lost a baby. Her other friends and I are doing random acts of kindness this week as a tribute.”

     I don’t know what I said next. I’m not even sure what I felt. I know that the woman wished us well and that, sitting in the parking lot with the air conditioning blasting, no longer in a hurry, I ate animal crackers with Bean. I stripped Teeny down, sopping up the poop as well as I could but also knowing that whatever I missed could be washed out later. I nursed him until he calmed and then buckled him back into his seat. I drove my boys home. And I hugged them hard.

             

*Cross-posting with The Growth Curve

A quick intro since this is my first post:
Hi there! I'm Beckster, mom of two little boys, wife of my high school sweetie, and pediatrician in Providence, RI. I love to write and luckily I realized early on that it just might be the thing that keeps me sane through my medical training and practice. I'm currently a fellow is Hospice and Palliative Medicine (and one-year position) and after that will begin a fellowship in Pediatric Hematology/Oncology.

Louis Gene Singleton: A Tribute

Gene is from Cherry Valley, Arkansas; somewhere between Wynne and Jonesboro on Hwy 1. As a boy he fished in a creek on Crowley's Ridge. He remembers his mother frying the small fish, bones and all, to feed their family. His rural farm childhood shaped him, and although I don't know much about his service as an officer in the Marine Corps, I imagine that shaped him as well.

I met Gene when I interviewed for my current job. He jestingly boasted to my father, a neonatologist, that I was to be his replacement ten years ago. I felt proud to be set up for that position. I learned that he had three children and 16 grandchildren; a fact that left me in awe. Now he has six great-grandchildren.

When I first started my job after residency, I was naturally fear based. Gene was my rock. I showed him so many cases in the first couple of years I worried for him; but his patience, calm and good counsel kept me coming back for more wisdom. He never gets angry, I heard the gross room physician assistants say. He never gets flustered, I heard the histotechnologists say. If he raises his voice, said the collective voice of the laboratory, then something really bad has happened. He doesn't need to get mad; he just subtly draws boundaries, and you get it. He quietly leads, and people follow.

So I followed, and I learned. He taught me when to dig down deep in the books, and when to send a case out for expert consultation (rarely). He taught me how to subtly and sweetly correct a clinician when he or she was missing the point. He taught me when to let go of my dogged pursuit of righteousness for a greater good, always keeping the patient in mind. That's why we physicians are ultimately here: for the patients. Being right among our peers is less important than being of service to our community. Early in my career one of my diagnoses was attacked by an outside pathologist, and he stood by my side and defended me to show me that this is what the world can be like, and that part of our job is to protect the truth.

There is an art to medicine, one that is lost in our current climate. Gene is the embodiment of that art. I have gathered over the years that he is a religious man, but he doesn't wear it on his sleeve; it is discerned through his actions. He retires tomorrow, and I am heart broken to lose him as a consultant. He went part time a couple of years ago, and I am constantly reviewing the schedule to see if he is here when I am. When I bumped into him in the hall yesterday I realized it is time to let go. He has promised to visit, but he will no longer be a fixture here. Retirement is not just an end, as I learned from my father at the ocean last week. It is the beginning of a new journey.

I've been grieving lately, taking my own stroll through the five steps - denial, anger, bargaining, sadness, and acceptance. I'm finding comfort in the knowledge that his qualities and characteristics will live through myself, my partners, and my future partner joining us next month; our first hire in the ten years I have been here. I need to teach her some of what I learned from him; a job as much daunting as exciting.

The best servants of God leave the strongest imprint on this Earth. Their legacy is the future. A part of Gene's legacy is the countless number of patients he has helped from behind the scenes. While I will  miss Gene's daily presence, I look forward to witnessing his next step in life, and know that he will only be a text away. People have real ages and chronological ages. His visage belies his actual age by about two decades, so I am comforted that he will be around for a long time in case I ever need him.

I wish him well. I wish that he will enjoy his children and grandchildren and great grandchildren. That he will continue to honor and support and enjoy time with his wife in the same way I have witnessed throughout the years. That he will find a way to continue his chosen profession in a new configuration; once a doctor, always a doctor. That he will know that his partners revere him, and that we will continue to be there for him whenever he needs us, as he was there for us in countless ways throughout his career.

Gene Singleton is one of the best fathers, friends, and pathologists. He's the best mentor anyone could ever hope for, and if I can be half of the mentor and pathologist that he was to future members of this group then I will be proud. I'm going to miss you Gene! Hail to the Chief:). Sniff.

Much love, Elizabeth

Guest post: Have baby, will travel

I had my first baby during medical residency, where we were allowed 6 weeks off (including all the year's vacation) without extending leave. My daughter was, ahem, rather "colicky" (read that as "screams for no reason unless being walked on your shoulder for hours a day, or possibly asleep on mom"). I love her but after 6 weeks I was sick of watching Law-and-Order by myself at home (boo hiss lack of US paternity leave support), and starting back into a relaxing research rotation was a relief. Even if it was hard to find a private place to pump. With number two I vowed not to isolate myself so much. To go out and about more with baby, even if it meant breastfeeding in public a bit. (I was just too self-conscious to do it with number one, even with a sheet) So, while pregnant with number 2 during my first year of Oncology fellowship, I realized ASCO (the big annual oncology conference), which I very much wanted to go to, would occur about a month and a half after he was due. Should I go for it?

Being a mom in medicine feels like a mixture of wanting to have my cake and eat it too. I want to work, I LIKE work. I want to have babies, I LOVE my babies. I want to breastfeed exclusively. I hate pumping. I'm going stir crazy after a few weeks of being a stay at home mom. I'm incredibly anxious about the prospect of leaving my baby. It's so nice to be among adults and using other parts of my brain again. Etc.

So, should I plan to go to ASCO?
With a one month old?
While breastfeeding?

First I did a Google search. I found a few articles on graduate students going to conferences, and that people were generally supportive. But nothing specific on ASCO. OK.

Could I keep the baby on me with a sling? Run out if he starts to fuss?

Sadly the answer to that is very much NO. ASCO does not allow any children under 16 in the conference, for "safety reasons." No exception for pre-mobile and breastfeeding babies.

So, I would say it's mostly impossible to attend ASCO if you don't have some kind of secondary childcare arrangement.

However I am incredibly lucky in that my parents are in Chicago, close to where ASCO is held. I was planning to stay with them anyway. My father no longer works and is very supportive. So, I did go with my baby to ASCO, and it was a good experience. Here's how I made it work.

1) Knowing my priorities. For me, my baby and establishing breastfeeding was my number one priority, so if there was a conflict I would choose that. Anything I got out of the conference would be gravy - some conference would be better than no conference, I reasoned. Especially since given the timing of my baby's birth, I was actually still on my 6 weeks of maternity leave while at the conference.

2) Having on-site childcare. In my case, my parents. What we ended up doing was, I went to the conference center with my father and my baby with a stroller full of supplies; there were a lot of common areas we could all go to. I would go to sessions, my dad has a book (did I mention he's tremendously supportive??!). When the baby got hungry and fussy, my father would text me and I would dash out to feed him. There was a first aid station where I could go nurse in privacy. I had my nursing pillow stashed with the diaper bag in the stroller.

3) Only go in-person to the in-person stuff: At ASCO at least, the talks are streamed online! So I could watch those in the luxury of a living room with some water and nursing a baby any time after the talk happened. There's really not much interaction at the talks, in fact sometimes the sessions are so full you end up running from room to room to watch it streamed. The poster sessions, on the other hand, I could read online beforehand then go and talk to the presenter one on one. Bonus, I could run in and out without any issue! I identified which sessions would be most valuable to me and went to those, running out for a half hour here and there when I got a text.

-- I did miss out on the "fellows lounge" as I did not know about it, apparently a good spot to be. Maybe next year!

Things that wouldn't work:
-- not having on-site childcare
-- pumping. Unfortunately the first aid station did not have a breast pump, you have to bring your own. And the site is HUGE. I did try to go one day on my own with a pump, and hauling all the supplies around was just obnoxious. They don't even let you stash them at the first aid station. So I can't recommend that.

Overall, I got to visit my parents, they got to see my new baby, I still breastfed and was with my son constantly, AND I was able to make a few connections and learn about some of the latest data on immunotherapy in different cancer types. I would definitely recommend it if you can find the support.

-Proliferating Oncologist, a first year hematology-oncology fellow.

Witnessing sorrow and grief; taking trauma home.

About a week ago, I awoke to the news of the Orlando mass shooting-that 49 people had been murdered in the Pulse nightclub--for no other reason than that they were gay, and most were Latinx. The mass shooting du jour in America. You know the rest of the story, because unfortunately we've all heard these stories repeatedly. But it made me wonder about something else, tangentially related--but related to us in our work.

I came across a Facebook post by Dr. Joshua Korsa, an Orlando resident who described his experience caring for the surviving victims. Check out his story here (original post) or here (short news story)--. The "tangible reminder" he refers to below? His blood soaked Keens. He writes (about the survivors of the shooting):

"They've become a part of me. It's in me. I feel like I have to carry that reminder with me as long as [those patients] are still under my care. So this is a tangible reminder that the work's not done. That there's still a long way to go" 

Later I read the NY Times' "Orlando Medical Examiner: ‘Take a Typical Homicide Scene, Multiply It by 50" which was just amazing (for lack of a better word)--in less than 48 hours they were able to identify all 49 victims and in less than 72 hours autopsies were done on every single one of them. That's a logistical accomplishment and an emotional....quagmire. I cannot imagine being a part of that. I cannot imagine how hard that must have been. What exceptional work-- bringing confirmation to each of the 49 families and countless loved ones involved.

But wow, logistics aside--consider for a moment about the pathologists and technicians who did this work, who painstakingly photographed each victim, prepared them for transport to the morgue, the pathologist/assistants who later performed the autopsies, cleaned the bodies--these are the unrecognized people behind the scenes in such catastrophic events. How are they doing this week? How are the police officers? The crime scene technicians? Are they ok? How do people that witness such awful mass casualties cope? 

So that got me thinking (this is how my ADHD brain works, one topic to another, bouncing along)...WE deal with some really difficult stuff.  Not mass casualties (I don't think most of us do, anyway) but day to day casualties of life. Car accidents. People losing limbs. Diabetes, heart attacks, cancer, strokes. Kids dying. Homicides, suicides, accidents. Alcoholism. Lung cancer. New diagnoses of leukemia (surprise! you didn't just "have the flu"!). Homelessness. Stillbirths. Domestic violence. And so on. It's a lot to deal with.

How do you deal with the anger, death, violence, despair, stress, grief in your job? Sometimes it isn't even the death that's so hard, it's the sorrow, the daily witnessing of human distress. Death is a separate entity, and varies in it's impact on me--some deaths leave me with a sense of calm, some break my heart and I swear I never want to go back to work again (but I keep showing up.). Some don't seem to affect me emotionally much at all, and that's ok too. Every one is different.

As I walked around the oncology ICU recently, several rooms were empty-- and I realized as I walked around that I associate almost every room with a patient I have cared for in that room--and who has since died. I often think of them as I pass by (Oh, that's J's room...oh, that was D's room...etc).

As I walked down the long hallway to grab lunch, I thought:

• M's room-she was my age--she died in that room over there, overlooking the water. She and her husband were avid skiers and mountaineers and he shared incredible pictures of their adventures together. I swallowed back tears during rounds that day; that was the second time I'd cried that day. M died of relapsed leukemia and candidemia. 
• D's room-she coded suddenly, and died before her daughter could make it in. The chaplain put her daughter on speaker phone so she could say goodbye to her mom as her mom underwent CPR ("Tell her she was a good mom....tell her I love her....tell her she was a good grandma"). D died of advanced lung cancer.
• M's room-an older woman with AML, the same age as my mom. Wonderful family, with a toddler grandchild who liked to sit on the bed and who was fascinated by the sat probe on grandma's finger. That boy lit up the room. M died of a disseminated fungal infection. 

And so on. I remember many. 

We carry our patients in our hearts and in our minds--they are with us/in us, year after year. And sometimes memories of them/their deaths are comforting while at times they are heart breaking and hard to revisit--even years later. Some patients/deaths I look back on and I feel peace, and I smile at the memories that surface. Some patients/deaths I think back on and tears still come to my eyes-and the deaths were years ago. Some I look back on and my heart rate increases--because their deaths were so awful that I still have an emotional/visceral response. 

So I wonder. I wonder how the nurses, doctors, EMTs, police, pathologists-how everyone that helped victims of the Orlando massacres is doing. And I hope they're ok. And I'm grateful they were there to face such horror, to run into a scene that hopefully none of us will ever have to face. And I hope now that they've taken care of so many others, that others are taking care of them.

And last but most certainly not least, may we never forget these 49 people, almost entirely queer people of color, murdered en masse for being...themselves. 

ZebraARNP. 

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In Memory.

June 12, 2016.

Stanley Almodovar III, 23 years old

Amanda Alvear, 25 years old

Oscar A Aracena-Montero, 26 years old

Rodolfo Ayala-Ayala, 33 years old

Antonio Davon Brown, 29 years old

Darryl Roman Burt II, 29 years old

Angel L. Candelario-Padro, 28 years old

Juan Chevez-Martinez, 25 years old

Luis Daniel Conde, 39 years old

Cory James Connell, 21 years old

Tevin Eugene Crosby, 25 years old

Deonka Deidra Drayton, 32 years old

Simon Adrian Carrillo Fernandez, 31 years old

Leroy Valentin Fernandez, 25 years old

Mercedez Marisol Flores, 26 years old

Peter O. Gonzalez-Cruz, 22 years old

Juan Ramon Guerrero, 22 years old

Paul Terrell Henry, 41 years old

Frank Hernandez, 27 years old

Miguel Angel Honorato, 30 years old

Javier Jorge-Reyes, 40 years old

Jason Benjamin Josaphat, 19 years old

Eddie Jamoldroy Justice, 30 years old

Anthony Luis Laureanodisla, 25 years old

Christopher Andrew Leinonen, 32 years old

Alejandro Barrios Martinez, 21 years old

Brenda Lee Marquez McCool, 49 years old

Gilberto Ramon Silva Menendez, 25 years old

Kimberly Morris, 37 years old

Akyra Monet Murray, 18 years old

Luis Omar Ocasio-Capo, 20 years old

Geraldo A. Ortiz-Jimenez, 25 years old

Eric Ivan Ortiz-Rivera, 36 years old

Joel Rayon Paniagua, 32 years old

Jean Carlos Mendez Perez, 35 years old

Enrique L. Rios, Jr., 25 years old

Jean C. Nives Rodriguez, 27 years old

Xavier Emmanuel Serrano Rosado, 35 years old

Christopher Joseph Sanfeliz, 24 years old

Yilmary Rodriguez Solivan, 24 years old

Edward Sotomayor Jr., 34 years old

Shane Evan Tomlinson, 33 years old

Martin Benitez Torres, 33 years old

Jonathan Antonio Camuy Vega, 24 years old

Juan P. Rivera Velazquez, 37 years old

Luis S. Vielma, 22 years old

Franky Jimmy Dejesus Velazquez, 50 years old

Luis Daniel Wilson-Leon, 37 years old

Jerald Arthur Wright, 31 years old

Hello, from Paris; or an utterly disorganized hodgepodge of introductions and Father's Day musings

Now doesn't that sound fabulous? I'm sitting on the terrace of the one-room-with-a-kitchen-and-bathroom apartment we VRBO'd for this week, and writing my first blog while the children and husband sleep off their jet lag. And I'm wearing all black! My former poetry major self rejoices. My surgical ego wants to know: What's next? Is this the right thing for me? For my family?

I'm a PGY 4 in general surgery who took the optional 2 years for research, and this June we are on our transit to Malawi, Africa for the second of those years, where I'll be doing trauma and burns research. First year was an MPH and part-time clinical burns work. We are on a stop-over in Paris to visit my brother in law, who's a French citizen and hasn't met his newest nephew yet. My kids are 6, 4, and 7 months. The oldest worries that she won't make any friends in Malawi; the middle recently confided that he's worried about being eaten by a crocodile; only the youngest continues to smile at me every time he sees me with that untouched, utterly trusting smile of an infant who hasn't experienced any parental disappointments or discipline yet, and who just knows that I'm the best thing ever.

Most people who hear that I'm moving the whole family to Africa for a year divide into two reaction camps: one thinks that I'm crazy, period. The other thinks that I'm crazy, but mixed in is a healthy dose of jealousy for this opportunity. I totally agree with both. I'm so excited to have this incredible chance to travel to a country, make a difference and have it count towards some sort of a career; but it also reminds me that I'm insane and that at this point, that's unlikely to ever change.

But I think the truly insane choice was to have 3 children as a surgical resident in America. Next to that, moving them to a developing country seems small potatoes. As all working mothers do, I beat myself up daily for my inability to have it all and have a shred of energy left; I resent a society that reveres "perfect motherhood" while being unable to define what that is and unwilling to support it with policies that make sense for all mothers, working or not; I sometimes resent myself for my inability to be satisfied with "just" raising the children--why do I have to be a surgeon, of all things?--and then I have to laugh, because for this gender-role bending sworn feminist, the idea that one could be jealous of the stay at home side seems preposterous. But it's there.

Any successful insane person has someone as a rock. My parents have always stood by me, in their way, even though they don't understand how I make most of my choices and don't always support where they lead. But my husband--this is the Fathers' Day part of this post--he's my rock, or some would say, my enabler. When I go to work, he works at home, and faces the same isolation and loneliness as a stay at home dad who's not a "stay at home dad at heart," as I do as a surgical resident with kids who actually enjoys both work and kids. At some point I will unpack that statement but it won't be in this blog. Anyways, he makes me and us possible, and I am forever and utterly grateful to him for always in the end coming around to supporting this craziness that I call my--our--life. I work hard, and I get the credit--but he works just as hard, if not harder, and it's not always appreciated or acknowledged. There are "fathers of the year" who get kudos for making it to their kids' soccer practice--and that's important, and legit, and awesome--but he changes diapers, makes dinner, buys groceries, makes sure the kids are on the school bus in the morning and remembers to pick them up after school--and he never complains. He puts up with a wife who's more like a bad college roommate, who is rarely at home, never cleans up her laundry, eats all his food and sleeps most of the time when she is there. He's the steady to my mercury and the rock to my water, and together we seem to make this circus work somehow, if sometimes only with duct tape, some sticks and a prayer. Here's to all of medical moms everywhere--may you find your rock, or if you've already got one, may you always cherish him or her. Happy Fathers' (or Partners') Day!

On Five Year Plans

This is a throw-back to a MiM post back in 2013 that really resonated with me at the time, and still does, in which T writes about someone asking her, "Do you have a five year plan?"

When asked this recently, I fumbled. Actually, I tossed back the answer, asking the asker to mentor me through getting such a plan. It wasn’t even someone who knew me well and it had been asked in a fairly casual way. Regardless, I was not able to answer the question. But if I were to answer it, the answer would be, “No I do not.”

The comments that followed included other MiMs stating that they too did not have five year plans. People cited living in the present, and checking in periodically to ensure satisfaction and fulfillment, but not necessarily a structured plan. Others did have plans, which they found informed their present-day decisions. I was on maternity leave with my first when I read this post, and was feeling very unmoored. I felt that I should have a very clear path of where I wanted to go in my career.

I remember being asked the same question by a male faculty member during my first week of medical school. I fumbled too, as I entered medical school interested in family medicine but open to possibilities. My surgeon-keener classmate piped in with his plan for surgical specialty x, making me feel even more self-conscious. In retrospect, I don't blame myself one bit. I think some people do well with a well-defined, honed-in focus. Others, like myself, find the goals harder to identify; my priorities have to emerge - they can't be easily forced out.

I have broad goals - community contribution through medicine and beyond, strong faith and family, a healthy lifestyle. I have diverse interests; one is health equity, which has led me to refugee health. Various other interests have led me to different projects over the years.

I do find it helpful to have short-term career priorities; a necessary honing-in to avoid over-commitment and burnout. Dr. Mamta Gautam, the Canadian physician wellness expert, tells physicians that as people who have plenty of interest and enthusiasm about many things, there will always be more interesting things that we want to do, more than we could possibly have time for. So, it is a matter of choosing and narrowing down options.

Right now, I'm focusing on clinical work, local refugee health coordination efforts, and writing - both here, and on a blog aimed at patients. I supervise learners periodically, but have flexibility. There have been other tempting opportunities recently, but I have declined them in order to preserve family and self care time. Personally, I need regular downtime. I schedule a day off every month, sometimes more. I need some "empty space" on the horizon in my calendar, which can involve self care time, and sometimes catch-up work and projects. With two young kids, I've found the regular days off invaluable for recharging.

With the births of my two children, the last four years have been full of transitions. I think motherhood fits naturally with evolving priorities and goals. I look forward to more changing priorities over time. And I'm still OK with not having a five-year plan.

Let’s be like Sweden...or Why doesn’t anyone talk about paternity leave?

Hi everyone, I’m Anna Plasia.  This is my inaugural post for MiM!   A brief introduction: I am a pathologist with a new baby, but I've been reading MiM since long before I became a mom.  I'm married to my best friend who also happens to be a father-in-medicine.  I'm honored and excited to be part of the MiM family!

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I have to admit that I was reluctant to get pregnant.  I was happy, and I didn’t want anything to disturb that balance.    My husband and I are both physicians, and our relationship up to that point had been that of equals.  Obviously there are things at home that one or the other of us has taken over due to interest or entropy, but overall our relationship was egalitarian.  And honestly, I didn’t really see examples around me of parenting relationships that were what I hoped for.    My own parents were both professionals, but it was my mom who stopped working for several years when I was born and it was my mom who managed all doctors appointments, birthdays, shopping, cooking, cleaning, etc.  I was sure that my parents’ relationship must have been similar to ours in the beginning -- but becoming parents made them became so...traditional.  So is having kids just inherently unequal?  Obviously men can’t actually have the baby, but are women really genetically better at managing doctors appointments and birthdays and cleaning, or is there something structural going on that makes things turn out this way….every time?

It turns out that the seeds of parenting inequality may be sown as soon as the baby comes home.   According to a report produced by Boston College Center for Work & Family in 2014:

When we ask why it is the case that most men aspire to be equal partners in caregiving but often fail to meet even their own expectations, there can be many possible explanations for this shortfall. One cause that seems clear from our work and that of other researchers is that this performance gap begins in the very first days following the birth or adoption of a new child, when the disparities between the experiences of mothers and fathers emerge immediately. In our research, the majority of fathers take only about one day of leave time to bond with their new children for every month the typical mother takes….During that time at home, fathers are seldom “flying solo” in caring for their newborns (Harrington et. al, 2011).  

It makes sense - - if mom is the only one home with the baby for the first three months then of course she is the one who knows the most about baby.  She knows what baby eats, what soothes baby, what baby wears.  When dad comes home from work he’s stepping into mommy territory.  When baby needs soothing it’s just easier for mom to do it because she already knows exactly what to do.  And if mom has been off of work for a few months then she’s definitely the one getting up at night with baby.  When she goes back to work she will continue being the one getting up with baby, leading to exhaustion, burnout, bitterness, and curtailment of professional duties.

So the question then obviously becomes what happens when men take off their own version of “postpartum” time? In several Scandinavian countries (see Iceland, Sweden, and Norway) fathers are provided with paid paternity leave that they must use or the time is lost.  In Germany and Portugal mothers get bonus time if dads take their allotted time.  It turns out when men take more time off with their new babies the benefits last for a long time.  A survey of parents in Iceland which looked at how childcare duties were divided both before and after a paternity leave policy was implemented found that “there is a direct correlation between the length of leave taken by the father and his involvement in care afterwards.”

My husband and I both agreed that equality in parenting likely begins in the first weeks...so my husband decided that he would take two months of paternity leave.  We are lucky that both of our jobs were covered by FMLA, and we did not fear permanent professional repercussions from taking time off.  But this is definitely the exception, not the rule for physicians.  This decision came at a significant financial cost as both of us took unpaid leave, but we decided some things are priceless - money be damned.  Because it’s unusual for a man in the US to take off a significant amount of time for a new baby, no one could wrap their head around it.  The reaction was...confused.  “Wait, did you say two weeks - or two months???”  No one had ever heard of a father doing this...especially not a physician with an “important” job.  No one tried to dissuade him from doing it, but it was definitely seen as an unusual request.  I am so proud of him for sticking to his guns...honestly it takes courage for a man to buck the trend.

My husband’s extended leave was one of the best decisions we made about having a baby.  We spent the first month at home together.  I can’t imagine being left at home alone with a new baby a week or even a few days after giving birth.  That first month we woke up together for every nighttime diaper change and feed.  Those first nights are long, lonely, and dark, and I can’t imagine going through them without my best friend beside me.  At the end of my leave, my husband took his second month off, and it made the transition back to work so much easier.  Every morning I left our baby with my husband - who knew what to do since he spent that first month at home.  There was no mommy guilt about returning to work with a 10 week old.   And now I really don’t feel like one of us is the primary parent - we are both just parents.

Unfortunately, our experience is not the norm for physicians.  As a physician, unless you are employed by an academic center or a large hospital, your job is often not covered by FMLA.  Many physicians are employed by private practices with fewer than 50 employees or are self-employed and cannot afford to put their business on hold for an extended period of time.  I was told up-front at several (private practice) job interviews that I would only be able to take vacation time for maternity leave.  If it is this hard for physician moms to take medically necessary maternity leave, imagine how much harder it is for physician dads to take off extended paternity leave.  At the same time I am sometimes surprised when I hear of physician dads who take off less time than they would for a vacation when their partners have a baby.  Obviously there needs to be a shift in both the cultural expectations surrounding paternity leave as well as the law in the US before this becomes a more commonplace occurrence.

I also realize that we are very privileged that we could afford to both take off time from work.  The sad truth is that for many Americans this is not a choice they can afford to make.  Ours is the only developed country in the world whose government does not guarantee any paid leave to new parents (source).  Due to exclusions built into FMLA, only 60% of workers are eligible for the unpaid leave guaranteed by FMLA.   Only around 25% of US employers offer paid maternity leave, and even fewer offer any paid/partially paid gender neutral family leave (which includes paternity leave).  It is the lowest paid members of the workforce who generally have the least access to paid or unpaid leave.  And since family leave is usually unpaid, fathers are even less likely to avail themselves of it as they are often the higher earners (source).   Most families can barely scrape by on one salary for any amount of time, never mind three full months.  Having an egalitarian paid parental leave policy in the US would go a long way toward making parenting a more equitable experience.

Did anyone else’s partners take off extended paternity leave?  How was the request met?  Do you think this is viewed differently in medicine than in other fields?

Doctor Day

Recently, I had the opportunity to teach my younger daughter’s preschool class about being a doctor. Sometimes I think that part of the reason I became a doctor was just so I could get to do that.

I was nervous. I’m not sure why I was quite so nervous, considering in retrospect, I can’t honestly think of anything that could have gone wrong. It wasn’t like I was lecturing to a bunch of Harvard professors--these are individuals who pick their noses and eat it. In public. This was like the least discerning audience of all time.

I started out by introducing myself and asking the kids, “Do you know what a doctor is?”

One kid’s hand shot up and I called on him. “A doctor gives us s-----,” he announced.

I couldn’t make out the last word he said, so I took a guess. “A doctor gives you socks?”

The kids burst into hysterical laughter. He said “shots.” How did I not know that? That is literally the only thing children know about doctors.

I had this brilliant idea to bring in a pile of rubber gloves for the kids, so they could each put on a glove and feel like a doctor. Except this turned out to be the worst idea of all time. Kids are apparently unable to put on gloves on their own. Several teachers had to be recruited to help. This ate up, like, ten minutes.

After that, I had the kids listen to each other’s chests with my stethoscope. They came up in pairs of two so I could help them. Except about a quarter of the class was completely deaf.

Child: “I can’t hear anything!”

Me: [adjusts stethoscope] “How about now?”

Child: “No! Nothing!”

Me: [able to literally feel small child’s heart pounding with my hand on the diaphragm of the stethoscope] “Um… sorry?”

Then I broke out my reflex hammer. You want to hear something sad? I actually bought a new reflex hammer just to use in my daughter’s class. The fact that I was using it on patients wasn’t motivation enough, apparently.

The teachers looked a little nervous about that hammer. Understandably so. It was fine though. Nobody was beaten senselessly with the hammer or anything like that.

Soon after, we ran out of time, which was a shame because I was just getting into it. The teacher asked the children, “Do you have any questions for the doctor that aren’t stories?”

A boy raised his hand: “I went to the doctor and I got a shot.”

“Questions that aren’t stories,” the teacher clarified.

A girl raised her hand: “My mom took me to the doctor and I got a shot.”

And it just sort of went on like that.

In any case, it was a really fun experience. Highly recommended.

Diagnosis

This is a Daughters in Medicine post.

(which really does describe me - I'm a third-generation doc. And that is and isn't relevant to this post.)

When my grandmother was in the last years of her life, she fell out of bed. They took her to the ER, where she was Xrayed, pronounced intact, and sent home (where she lived with my grandfather, the retired internist, and a full-time caregiver.) The next morning my mother called me and said "Your grandfather is upset because your grandmother refuses to get out of bed." This was in the 1990s, before digital radiology and Nighthawk came along. I said "Tell him to call the hospital and ask for the radiologist's interpretation of the film. She might have a non-displaced fracture that the ED doc didn't pick up." Mom called me back several hours later and said - in a deeply suspiscious voice - "How did you know that?" I said "You sent to medical school. I learned stuff."

It's now 25 years later. My mother is the one with dementia, living at home with 24-hour care. No retired internist in sight; my father died nearly ten years ago. Last week Mom fell. The caregivers thought she was OK; a few days later, the pain was worse and she was refusing to bear weight. I said "She needs Xrays; she might have a nondiscplaced fracture." And sure enough. She sent me to medical school. I learned stuff.

Mom doesn't need surgery, thank heavens; we'll get equipment into the house and she'll stay in bed most of the time for a while. She's not having any pain.

But I know what it means when someone with moderate to advanced dementia breaks a hip. I'm a palliative care doc. I know where we're going. She sent me to medical school. I learned stuff. And some days, that stuff breaks my heart.

My cherries are damaged!

Ingenious idea, I thought! Youtube, my trusty friend, came through yet again with a genius how-to video to answer some mundane question of mine. We bought some yummy delicious cherries, and TC, my little Toddler Child, loves fruit. I didn't want him to aspirate a pit in a cherry fueled excitement. Last time he had cherries was several months ago when grandma methodically cut the goodness around the pit. But grandma has time and patience that I completely lack. I needed some quick and easy way to pit lots of cherries. Supposedly such gadgets as cherry pitters exist. But (a) I was sitting with a bag of cherries and a hungry toddler, and I needed something NOW and (b) I hate buying useless one trick pony kitchen equipment. Youtube how-to video to the rescue!

An empty wine bottle. Check. Chopsticks. Check check. So I spent the next 10 minutes pitting a lot of cherries. I may gone a little overboard, but there is something oddly satisfying about excising the pit out of a cherry with precision in one swift motion. Ten minutes later I proudly presented TC with a bowl full of "safe" cherries whose pits he wasn't going to aspirate or break his newly sprouted teeth chewing on. At first, TC let out an excited "Chays!". Yes, TC, delicious chays, dig in! TC picked up the first cherry, and his smile was quickly replaced with confusion. How strange, the first cherry was damaged with a hole. He continued to pick up cherry after cherry and putting them back, now with full-on disgust. I knew it was coming, and there it was! TC tossed the entire bowl of cherries on the floor, laid his head on the table and sobbed his lungs out for half an hour. Because his cherries were damaged.

Anyhoo, with that story as an introduction, I am excited and delighted to be writing for the MiM community! I found MiM a few years ago when I was pregnant and freaking out about how I was going to swing this whole motherhood thing while going through med school. As for all life advice, I turned to Dr. Google, who directed me to this blog. Through the years this blog provided me with some  reassurance that this whole mothering and medicining process doesn't always look pretty but there are others out there in the same boat who are making it work. And they are willing to share those messy stories. I felt that it was time to stop lurking and start giving back and putting my stories out there. You can find more about me in the about page of this blog. I also write my own blog, Mrs MD PhD, where you can find more about me. Feel free to regale me in comments below of how your toddler (or not so toddler) child(ren) laid waste the fruits of your labor and/or cunning.