The Zuckerberg: Space Does Matter

Hello everybody!  I am one new to the group and just wanted to introduce myself.  I'm originally from Massachusetts, currently a Bay Area Internal Medicine Hospitalist with a 2 year old daughter, siberian husky (mini) and techie hubbie.  Hope to contribute some entertaining stories.  The following is something I wrote last month after we moved into our new hospital. 

            The ‘space’ can make a difference.   I had already spent two years working as a physician/hospitalist at San Francisco General Hospital, and I had become accustomed to the old building and all its challenges.  Fast forward to the end of May 2016 to one my first shift working in the new building … Zuckerberg San Francisco General (ZSFG/The Zuck); change had never felt so good.

            I walked across the bridge connecting our old building to the new ZSFG which consisted of expansive windows and white beams that outlined the hall. It was a sunny day in San Francisco, and I was able to witness it for once.  At the entrance there was a quote etched into the wall  “Be the person who touches the lives and hearts of people. Be a positive light to others as you put a smile on their faces”.  I found myself taking a brief pause and a smile was taking form and there was no stopping it. 

            Onwards I trudged, only to be greeted by a security officer who looked at my badge, and then said ‘Good Morning Doctor’.  As I stepped off the large steel elevator onto the 6^th floor, different routes presented themselves; I was warned about this and the likely confusion that would ensue. Nonetheless, the room numbers were highlighted with San Franscisco themed unit names like “Mission Dolores” and I walked to the zone I needed to get to.  The heavy blue doors which were often manually opened were now beige and badge activated, opened by a mere hand wave.   This might sound trivial given that its 2016, but let me emphasize that it is not.  The design of the building was doing work for me instead of me pushing my way through everything.  

            Now came the real test…how were the actual work floors and units.  What struck me immediately was the lack of noise; it was completely quiet! A brief instance of panic set in and I thought, ‘ Oh my god, I’m on the wrong floor…. Is this the morgue’ but no, I was exactly where I needed to be.  As I walked further around, there was a spacious work station with an lcd screen showing patient room information and nursing assignments with call numbers. 

            The time had come to finally enter my patients’ rooms.  I knocked and then with ease opened the door only to find my patient sitting in bed comfortably with the most spectacular backdrop of the city I had ever seen. The room had ceiling to floor windows that beautifully displayed San Francisco at its finest, and the sunlight poured in.  I sat down at his bedside, and began to go through my assessment and learn about his concerns.  Usually at this point I would be raising my voice to overcome my patient’s neighbor who was either watching television, or talking to others in the old building.  The rooms had no natural light, so lights always had to be turned on, which was of course bothersome for many as some patients were sleeping, and others were not.  The rooms were also filled with walkers, trays, and other medical equipment that were strewn about as there was minimal space, and it became an obstacle course for staff, patients, and family whenever anyone moved about in the room.    Now with this all gone, feng shui was in full effect.  I reviewed the plan with the patient, and calmly exited the room.  As I entered the next patient’s room, similar exchanges and observations happened.  With my mind unburdened by the environment, I just focused on the subject at hand.  My patients too were not being set off by surrounding stimuli; they now had peace and quiet.

            I finally ended that morning with some downtime in one of the new provider rooms to start the lovely exercise of completing my documentation, and again I was struck by the silence.  It was like a library where I actually had the space and time to think about what I was doing.

            Noise and chaos was often the defining feature of our intense environment, and as faculty and staff, we perfected our ability to deliver high quality care to our troubled and sick patients despite our surroundings.  Now with ZSFG, San Franciscans along with our many generous donors have contributed to a building that has shifted the mileu of our work environment.   My patients now have a space that truly honors them in tough times and gives them the space within which to heal.  As a provider, I now have the space to work more seamlessly and to think and reflect on my work.  Of course our space is not perfect, but you have to start somewhere right? So let the healing begin…

Scrubs for a lucky reader

Editor's note: Mothers in Medicine was invited to review a new scrubs line by Maevn Uniforms, with the kicker that we could give away one set of these scrubs to a reader.  X-Ray Vision volunteered to receive 5 scrubs separates and write her honest review of them. See her review below, and at the bottom is information about the giveaway.

Check out the entire EON line from Maevn Uniforms here. 

I graduated my radiology residency in June. I had 2 weeks of vacation and on July 1, since I was the only fellow who also did residency at the same institution, I was given the wonderful gift of starting my fellowship as an attending, covering the evening shift (reading all ER and inpatient radiology studies) from 5-11PM for 10 days straight. We are given attending privileges during fellowship to specifically cover this shift. On a side note, it was completely terrifying to suddenly be on my own without anyone double-checking my work. Long story short, I survived!

As a (soon to be) breast imager, I don’t wear scrubs often. Contrary to the popular belief that radiologists don’t actually see patients, I see patients every day during my fellowship—whether it is diagnostic work-up that includes ultrasound, image-guided procedures or even to just relay results on a recent biopsy. For this reason, my fellowship director likes us to wear white coats and dress professionally. 

The silver lining to starting my fellowship as an attending was that I was able to try out these scrubs! I’ve never thought twice about the type of scrubs I wore but let me say, this was a total game changer.

As a trainee, I have never actually purchased scrubs and have always used whatever was provided for me by the hospital. Therefore, my comparison will have to be between regular hospital scrubs versus the Maevn scrubs.  

The 5 items I was given to review included the active top, active sporty mesh panel pant, V-neck pocket top, full elastic cargo pant, and active sporty mesh panel jacket.

Material: The first thing I noticed with the Maevn scrubs is the quality of the material. It just felt more durable. However, when I actually wore the scrubs, it was when I could really notice the difference. I especially loved the side panels from their active sporty mesh scrubs as it made the clothing much more “breathable” and light.

Color:  Our institution only provides scrubs in one color—royal blue. It’s not horrible but I do love that these scrubs come in a variety of color—including black, navy, royal blue, lavender, gray and wine.

Tops: I loved both tops. I’m a petite Asian girl. Even the smallest hospital scrubs make it look like I’m wearing an oversized garbage bag as a shirt! I loved that both tops fit well but my favorite part was the pockets. The active top had side packets that appear more discrete and the V-neck top had 2 pockets in the front—both served the same purpose. It carried my keys, my wallet and a place to hang my hospital badge. The hospital scrub top just has a single pocket overlying the right upper chest, which I never liked! If I used it to carry my stuff, it would inevitably fall out.

Pants: I loved both pants as well. However, I preferred the sporty mesh panel pants because of the mesh itself as mentioned above. Both pants also had elastic waistband, which makes it fit better than the typical scrub pants. In addition, both have side pockets, which is so convenient as also mentioned above!

Jacket: I have never had a matching jacket for my scrubs. Most of the time, I never have a jacket. I live in California so the weather usually does not require a jacket. And of course, I always forget just how cold the hospitals actually are! (especially when you’re alone in a reading room at 11PM) I loved how light the jacket is that it doesn’t feel excessive but at the same time, it serves its purpose and keeps you warm. The jacket might feel like a superfluous purchase but the material is great and if I figure you are more likely to remember to use it if it’s part of your scrubs, you can get a lot out of it.

Overall: I was surprised at how much I loved this line from Maevn. It’s the little things that matter on a busy call night. For me, it’s usually the late night plate of cafeteria sweet potato fries without the guilt that can be the silver lining but for my first 10 days of fellowship covering all radiology studies from the ED, traumas and inpatients, I was quite pleased that at least I could say I was comfortable in what I was wearing! It’s hard to put a price on that and I would definitely recommend purchasing these scrubs as an investment!


As mentioned, we are giving away one set (top and bottom in style, color, size of choice) of these EON scrubs. To enter, send a quick email to mothersinmedicine@gmail.com with Scrubs in the subject line by 10pm EST today, and we'll randomly select a winner.  Good luck!

7/22/16 update: A winner was selected. Congratulations, Sarah!

Surprise! Female physicians are paid less.

I am sure many of you have seen this recently published article about physician wage gender disparity in the New York Times. The original research article was published in JAMA Internal Medicine, and received a lot of popular press with mentions in the New York Times, Time magazine, Boston globe, Marie Claire and many others. I am always a little wary of science/research reporting. I sometimes try to read the primary research paper behind the news item, especially if the topic interests me. Pay equity for physicians is certainly a topic of interest for me.

This article put a specific number on the gender pay disparity: female physicians make roughly $20,000 per year less than male physicians. This is after adjusting for age, experience, faculty rank, specialty, scientific authorship, NIH funding, clinical trial participation, and Medicare reimbursements. This news came up in a non-work context with a male resident physician. He told me that the problem with these types of studies was that they don't account for the amount of work put in. According to him, "female physicians work less than male physicians". Well how do you mean sir? Do you mean more female physicians work part time? He said, "In my experience, women complain more and work less, period. They always have to go pick up their kids or some other excuse and they dump their work on me". Ugh! Alright then Dr. Curmudgeon.

The paper is well written and the research is pretty well done, I highly recommend reading. Sad statement, but female physicians being paid less won't come as a big surprise to anyone. Safe to say, I was being ironic in the blog post title. Gender based pay disparity occurs in the rest of the US workforce. The dicey question, which Dr. Curmudgeon raised, is the pay disparity unfair? It maybe unfair from a social standpoint. Women ending up with more childcare or household responsibility and not being able to match male productivity. But is it unfair from an economic standpoint? Are they truly being paid unequal amount for equal work? Is there is an inherent bias towards them? This paper suggests that there maybe a component of both social and economic unfairness.

Comparing unadjusted salaries, i.e. without taking into account specialty, faculty rank etc., the difference is even larger, $51,000 per year. It may be true that more women than men make choices that lead to being paid less, such as working in certain specialties or working part time. But women don't choose to be overtly discriminated against. The authors adjusted for a lot of factors that could explain the pay disparity and still found a gap of roughly $20,000. The authors lacked some information, most importantly, full time vs part time status. They did two things to counteract that. One, they used Medicare reimbursement in their multivariate analysis to adjust for clinical volume. Two, they eliminated bottom 25th percentile of income data, with the assumption that it would eliminate part-time workers from analysis. They are imperfect measures, but the best that could be done with the lack of available information.

I am pretty early in my training, and from my own limited experience, I do believe that there is at least some inherent bias. Dr. Curmudgeon is not an exception, there are more people like him inhabiting the medicine world. They may be outspoken about their biases, or maybe not, or maybe only in certain contexts. They may be aware of their biases, or maybe not. I suspect, a lot of Dr. Curmudgeons are even in positions where they can influence factors, like promotions and pays. If you have encountered one of these Dr. Curmudgeons, I'd be interested in hearing your stories in comments.

Guest post: Tampon Travesty

Another cycle. It's here. The anxious two week wait is over, and it's time for tampons. I got my period.

There are many blog posts and stories about struggling with conception. But these people aren't in medicine, they aren't in sync with the uterus, right?? They didn't have to memorize hormones and fun facts?? Right? Apparently not.

Well, we started struggling, and the foreign stories became relatable. Our trials have been so much more confusing in light of our son who grows older with every month we are unable to provide him the brother or sister I have longed for since the moment he was born. I guess they call this secondary infertility - I call it a giant, expensive, heart-breaking pain in the ass, which makes me cry on a regular basis, well by regular basis I guess I mean... approximately every 28 days.

We have been trying since our son was first born. We both want a big family, and that requires trying to have children, even during our simultaneous medical training, and what some would say are not ideal times. So, I gave up breastfeeding my son cold turkey (with ample frozen milk) to expedite my cycles returning. Well, they returned... and have been returning for close to a year now. I could have had my baby by now. I could be back to breastfeeding and snuggling, but instead I'm changing my own maxi-pads. I'm a strong woman, but this was not my plan, and I cannot will it away, or rely on our shared medical knowledge to fix the problem.

I know you're supposed to wait to see a reproductive specialist until a year, but waiting is not my strong point. We went a few months early, and are actively seeking care. It is hard to seek care as medicine folk. We are knowledgeable, but vulnerable. We want that second child so badly. So, we shall let the medicated IUIs begin.

I'm not sure why I'm writing this, but it sure feels wonderful. Partially, for my own sake and partially to break the silence of infertility. Here's a shout out to all my medical mommas trying to grow their family. A wish of wellness and fertility to all those trying and especially those struggling.

May the second pink line be with you.


MD/PhD Student Mom + Anesthesiologist Husband + One Son

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. 

*****************************************************************************

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.