In praise of skin

Another work post from the burn unit, Kamuzu Central Hospital, Lilongwe, Malawi. I want to tell you about dressing change days, and interject a little ode to skin. I wrote a version of this for my private blog, but wanted to share with you all as well. As always, thanks for reading these ramblings!

Mondays, Wednesdays and Fridays bring dressing changes in the burn unit. This means that every patient—as many as 42, plus the many others who come in from home just to get their dressings changed--line up at the end of the hallway and wait their turn, while 3-4 intrepid nurses unwind and wind miles of bandages, slather ointments, and squirt morphine into their mouths. Except when there is no morphine. Then it’s diclofenac, which is, I imagine, the equivalent of getting a swig of ibuprofen right before you get scalped alive.

Walk with me. From the outside, down a dark hallway filled with people, toward the light at the back and up the stairs, three flights. The staircase is open to the outside and on each flight there's a big window with a view of the city--today it's hazy and hot, so the buildings are distant under a screen of red dirt and smog--but it's not airy or breezy. The stairs are worn from countless people walking up and down it for years, and on the second flight a woman wearing yellow wellington boots is mopping, with a broom that's seen better days and concrete-colored water. On the third floor we briefly bump along behind two policemen, big guns swinging freely, talking exuberantly and walking oh-so-slooooooowly—and finally we arrive on the third floor, and walk down the hallway to 3B, the burn unit.

Before you open the door, take a little deeper of a breath, for you're about to experience that smell. On a good day you manage to take 3 steps inside before it hits--the odor of maize meal cooked into grits-like porridge, or a paste, or a hard cake (nsima); of bodies, urine and boiled cabbage, dirty wounds, feet, doughnuts, and fear--and then you see the mother carrying her five year old daughter wrapped up like a mummy with an IV tube sticking out of her neck--and you feel ashamed for even noticing the smell.

There are six rooms, 4 beds each, lining the hallway to your right. Linking them is the open breezeway down which you’re walking, which opens onto a shared courtyard where people dry their laundry and family members cook their meals. On the other side of the rooms is another hallway, the khonde, or “outside,” which becomes another long communal room during the months when there are more patients in the unit than there are beds. During the cold season—June, July, August—the khonde is full.

Two boys, aged four and six, one with a bulky bandage around his leg and the other with a belly dressing, are playing with a glove balloon, and you toss it back and forth with them for a little while, their smiles lighting up the day.

Are you procrastinating? We have to keep walking down the hallway, to the room at the end, where all those people are queued up, since that’s where all the action takes place. Each mother dons a protective plastic gown and gloves and takes the child—the median age here is 3—on her lap. The mothers hold the children down. The first trial begins, that of forcing the morphine into the children's mouths. Most take it willingly, especially ones who have been here a while, but sometimes they purse their lips, or cry, or swat with their arms. It doesn't matter if the morphine trickles inside or outside of their mouths--there is no refill and the dressing change happens with or without it.

Next, the nurses soak the bandages in saline to help with removal. Since there are 42 patients and 3 nurses, waiting for a complete soak would take way too long. Some of the kids start screaming in the hallway; some when the mothers take them on their laps; some with the morphine; but all of them are screaming by this point. These kids are burned over 10-40% of their bodies, on average; over all possible body parts; in two main ways: they scald themselves or catch themselves on fire. It's the cold season in Malawi, no one has heat at home, and very few people have stoves; cooking happens over open fires, outdoors, and accidents happen frequently. Malawi is burnin', y'all:

 

Skin gets so much criticism. We stare at our pimples as teenagers and wish them away; at our wrinkling faces as adults, and hate their testament of the passage of time. We scrutinize moles and massage cellulite; we want elasticity and spend millions on creams and lotions that promise to keep us looking young. Even as we enjoy skin's gift of touch, in embraces, caresses, and kisses, we resent and focus on its fragility, its ability to hurt, and too often, its color. We don't appreciate scars. Skin should be blemish-less and baby-soft. Not at all like the skin I see in front of me--discolored, twisted, partially healed, in some cases with the tell-tale cheesecloth appearance of a healed skin graft. This is beautiful skin because it works in its intended way: not as pretty packaging but as a barrier to infection and pain, as the selectively permeable wrapper that allows the rest of the body’s functions to proceed uninterrupted and unthreatened, with just enough openings to allow a regulated exchange with our environment.

It's the absence of skin that exposes its absolute necessity. This six year old girl being unwrapped now has full thickness burns (what we used to call third degree) over 55% of her body: anterior and posterior thorax, both legs, both arms, a bit of face and neck, buttocks. Her big, deep brown eyes look at me with tears trickling down her cheeks as her mother’s helper raises the IV bag above her head and arranges it so the tubing is not kinked. This is a bad burn: flame generally causes deeper burns than hot water, and in this case, it looks like her clothes were on for some time, and the contact did a lot of damage. Like countless others, she was playing with her friends and tripped into a fire, where her clothes caught the flame. She cries, but not much: a bad sign. Although we teach that full thickness burns are insensate, since by definition the heat has destroyed the skin's sensory apparatus, not everything burns to the same depth, and partial thickness areas surround most full thickness burns—and those do feel pain. Her name is Chisomo, meaning Grace. She will die in 3 days.

I think about the ones we can’t save, back home, and here. I hold on to them for motivation to keep studying, keep waking up, keep leaving my family, and keep trying—and to honor their memory, although I see them usually only in a dehumanized form, although I know them usually only as bodies wrapped in dressings and not as children chasing goats, eating mangoes or diving into the lake. Knowing what makes a patient human makes me a better doctor but it also hurts more—and many times I don’t want to admit they are people because doing so makes me transiently incapable of returning to work. It’s like this in the States and it’s definitely like this here. The constant blur of activity insulates you from processing both the good and the bad, but both stay with you, and sometimes when you get a breather it all comes out, and it’s very hard to figure out what to do with all of it—so I try to just notice it and not cry, and carry on, because in the end, there are more of the ones who get to be human again than the ones who don’t, and so you keep going. As shown by the parents and patients in this burn unit, every day, with their smiles, their high fives, and their endurance, despair is a luxury. Ain’t nobody got time for that.

Three weeks in

I am three weeks into being an attending and I am writing this to all of those starting intern year (like I was when I started reading this blog), and to all of you in the middle of a long residency and questioning if you can make it through. I am writing this to put your sacrifices into perspective - all the missed recitals and mothers day lunches, the shitty clinic clothes you wear because you can't afford anything else, the many times you leave your spouse to sleep alone at night while you're on call --- I am just three weeks in, but it sure feels really worth it right now.  All I feel right now is joy (Well joy and a fair amount of fear and anxiety!! but mostly joy).  

It feels unbelievable to finally be at this point.  It has been such a long road.  I know being an attending presents lots of new challenges which I am learning about every day.  I know I may not feel so exuberant years from now.  But right now, I'm enjoying it.  I feel thankful to be in a job that I truly love, working with people I respect and feel honored to work with.  I love my patients and feel energized after clinic or a day in the OR.  I also feel very supported by the other faculty.  I feel like that bright eyed, brand new medical student 12 years ago who wanted to "help people." 

Last night, after kindergarten registration, I stared at my worn out sleeping daughter and I was proud of this model of motherhood I have provided for her.  I was proud of our new house, her new house, the house she will grow up in -  I hope one day it will be as dear to her as the house I grew up in just 10 minutes away.  My residency baby - she made me a mother in medicine.  She made me a better person, a better doctor - and every moment of this struggle feels very worth it right now. 

The special skills we have

Late last night past whatever passes for bedtime in the summer, tween daughter showed me the abrasion on her knee sustained while swimming earlier in the day.  It was the "lane rope monster" known for sheering the top layer of skin of even the best swimmer's hands, knees, etc.  She asked for me to go get her a band-aid.  Size?  Medium.  Our home is well stocked.

After checking to see that the wound was clean enough (no obvious debris), I applied the 2 inch bandage to the extensor surface of her knee, the "bendy" part.  She bent it, as if checking, testing, and then admiring my work. 

And then, with the complete absence of sarcasm (yes, even in a twelve year old) in this, the edge of the end of childhood, she asked if I went to special school to learn to apply band-aids that well.

For the degrees and formal schooling, it was 4 years college, 4 years med school, 3 years pediatric residency, plus public health and medical educator training along the way.  And most importantly, time spent as a mom. 

Summer Book Recommendations

Ah, summer. There's nothing like the joy of sitting with an iced tea and a book on the deck... or waiting in the dentist's waiting room reading tiny print from a reading app on your phone.

1. Vaccinated by Paul Offit. It was completely fascinating to learn about the early days of immunization. Even if you've learned the science before, reading about the social context is so interesting.

2. Overdiagnosed by H. Gilbert Welch. This book changed the way I look at my practice, every day. Welch is an epidemiologist and explains the principles in a very accessible way.

3. Crazy Like Us: The Globalization of the American Psyche, by Ethan Watters. A must-read, especially if you work in mental health. I see a lot of refugee and newcomer patients, and do some element of cross-cultural mental health most every day. It's challenging because our entire mental health assessment is rooted in the culture in which it was created, and the very definitions of mental illness vary so widely in different contexts.

4. When Breath Becomes Air by Paul Kalanithi. I know you are hearing about it everywhere. It is beautifully written and helped me reflect on medicine in a different way. "But if I did not know what I wanted, I had learned something, something not found in Hippocrates, Maimonides, or Osler: the physician's duty is not to stave off death or to return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence."

I was on a female memoir kick last year, and thoroughly enjoyed the following:

5. Julia Child's My Life in France. Transport yourself to France and witness the early days of her love affair with French cuisine.

6. Nora Ephron's books of essays, I Feel Bad About My Neck and I Remember Nothing were, of course, hilarious.

7. Laughing All the Way to the Mosque by Zarqa Nawaz. Zarqa Nawaz is the creator of the TV show Little Mosque on the Prairie. She diverted from her parents' expectation for her of a career in medicine and found her way to journalism and the arts instead. As a fellow Canadian Muslim woman, I loved hearing her always-funny perspective on issues she faced along the way.

8. I Was a Really Good Mom Before I Had Kids by Trisha Ashworth and Amy Nobile. A down-to-earth book about the real issues we face every day as mothers, I found it totally affirming to read.

Fiction:

9. On Beauty by Zadie Smith. "And so it happened again, the daily miracle whereby interiority opens out and brings to bloom the million-petalled flower of being here, in the world, with other people. Neither as hard as she had thought it might be nor as easy as it appeared". Filled with breathtaking passages but also dry humour and wit, On Beauty was captivating.

10. Everybody Has Everything by Katrina Onstad. Following years of infertility, a young professional couple takes guardianship of a young child when their friends suffer a terrible accident. The struggles of being thrust into parenthood of a unique sort; with the same truth that we all live with - the uncertain future.

What books would you recommend?

MiM Mail: Intern Regretting Specialty

Hello MiM!

I love your blog! It's been amazing reading everyone's stories and I hope I can get some insight or advice. I am currently a FM intern at my desirable location because I am near both my and my husband's family. We have a beautiful 5 month old daughter who is the light of my life. Since the match I've been regretting my chosen specialty. I came out of medical school loving a competitive specialty and was too discouraged to go through with it and under family pressure to come home for the baby's sake. I thought I had to do what's right for my family and return home where we can get some help and my daughter could be in a loving environment. My husband is a teacher and wasn't happy at our med school location. He was over the moon about coming home I couldn't disappoint him... But now I regret everyday I'm in this specialty.

Things I like about FM is the variety such as derm, pediatrics, and psych. Things I don't like about FM is I hate chronic health conditions. I don't like to be responsible for managing diabetes with kidney failure and liver cirrhosis plus 30 medications. My personality is much suited for a more specialized area. I don't know what to do. I want to switch into something else but I have no idea what. I would love to do dermatology but it is so highly competitive that I doubt I would get in. I also don't think my family will be willing to relocate for me to pursue options to get in such as a research fellowship. Other areas I'm interested in is pediatrics, EM, and psych. I know I know it sounds like I should do FM but I just can't take the "bread and butter" of it.

General pediatrics sounds better to me then general practice because kids don't generally have so many chronic health conditions for me to manage and I love working with kids. I didn't consider it in med school because of parents but now I am one and totally get it!! EM also sounds perfect on paper but the lifestyle scares me (nights,weekends, holidays) high burnout rate, and life/death pressure. Psych was a great rotation in med school but I know how emotionally draining patients can be. Also none of these residencies are available in my hometown and would require moving. Should I do what's best for my family? Try and stick it out? Or ultimately try and pursue something that will make me happy? I'm so conflicted because I know moving would be hard on all of us :((( and I'm scared to make things harder on my husband and me.

Any insight or advice is appreciated! Thank you!

Sincerely,
Regretful Resident

Talking Politics and Public Health With Patients- Is It OK?

Genmedmom here.

My Friday morning clinic was slow. There were two last-minute cancellations and a no-show. So when Mrs. Smith* came in for her physical, I wasn't in a rush, and we had some time to chat.

We talked about her recent hip replacement, and how thrilled she was to be finally pain-free and physically mobile, so that she could help care for her grandchildren again. Her face was bright with joy as she spoke of the beach and playground and the zoo and how much she loved experiencing the world with her two young grandchildren.

But she hesitated and frowned as she remarked: "I watch the news, and with everything going on today, I worry about them. We're moving in the wrong direction as a society. I mean, look at this presidential election, isn't it ridiculous, to think that a person so flawed could end up as a candidate? I'm frightened for their future."

Then she asked, "Your children are little, what do you think about all this craziness, do you lose sleep over it too? How can we protect them from it all?"

Up to that point, we had been slowly moving through the physical exam, and I had been wordlessly responding to her lighthearted description of her days as Nana the nanny with laughter, positive nods and smiles… When she admitted her fears, I reflected back grim countenance and shook my head, as if to mime What a shame, what a shame, but I didn't say anything. 

I had no idea at this point what her specific views were. Her comments could reflect the opinions of anyone anywhere on the political spectrum. The flawed candidate she was referring to could be either Democrat or Republican. I didn't want to say anything potentially inflammatory, or even mildly awkward.

But she sat there awaiting my opinion.

Her questions hung there, between us, as I shook my head and tried to think of something to say.

Is her idea of crazy the same as my idea of crazy?

Does she want to protect her grandkids from the same things that I want to protect my kids from?

Do I really want to talk about this? And, is it appropriate?

I thought about my morning commute. There's an app on my phone that pulls articles from all the news sources I choose, and I have chosen just about every possible news source, even those representing the far other side of my political leanings. I like to know what's going on, through all the looking glasses. I read it all on the train on the way to work.

For months now, the news has been increasingly disturbing. Mass shootings, terror attacks, senseless violence against minorities and law enforcement alike, war abroad, mass displacement… it's all horrible.

But what's worse in my eyes is that here in the land of equality, in a country founded on sound principles and thoughtful discourse, we are witnessing the ugly rise of a potential dictator. Here is a divisive fascist whose behavior already mirrors that of the worst dictators in history. Historians and scholars continue to make observations and deliver warnings. This kind of a man, this kind of rhetoric, these lies and sick ideas, are what have led to genocide and war in the past. And if that isn't a public health issue, I don't know what is.

So, what do I think about all this craziness? I think about it all the time. It makes me sick to my stomach. But specifically WHAT I think about it may not be appropriate to discuss with patients. I believe that the candidate on the right is a bona fide public health issue, on many levels. But so is gun control, and beyond asking patients if they have a gun in the house and how it is stored as a basic home safety screening question, I don't get into the issue with anyone.

Perhaps we should. Perhaps we, as educated professionals with a sworn oath to promote the health and well-being of our patients- ALL of our patients- should be open about our views on matters that effect patient safety. Maybe that could be a means of educating the public on important issues, like gun control.... and rhetoric that promotes violence.

This all went through my mind...

So, what did I say?

I murmured "I know, it's really scary…", paused and smiled and declared, cheerfully: "Your grandkids are so lucky that they have you. I'm so happy for you that the hip surgery had such a good outcome."

She smiled back, and we went on as if nothing at all was wrong with the world.



*Patient identifiers such as social history and medical issues altered.

The Buffer Zone

It's July, the time of year when new interns and residents begin their training programs. It's our busiest time at my academic hospital, where all of the anesthesiology attendings pitch in and teach the newcomers. When I'm teaching in the OR, I always ask a simple question: Why do we care about the patient's blood pressure? They usually get it right - adequate blood pressure ensures good blood flow to the brain and other vital organs. Then I sketch this diagram:

Remember the Circle of Willis from medical school? Along with redundant vasculature, our brains possess an elaborate sensor system that autoregulates cerebral blood flow in a sort of "buffer zone". (This curve may also look familiar to you as the representation of how a buffer acts to regulate the pH of an acidic or basic solution.)

Autoregulation is an evolutionary survival mechanism that is meant to ensure adequate perfusion of the brain at a wide range of blood pressures. But at the extreme ends of measurement, autoregulation breaks down. I love how analagous this is to living life. We proceed through our busy days, oftentimes like a pinball falling through a pinball machine, while stressors are flung at us like flags and obstacles in the vertical maze. Too much or too little input leaves us in dangerously unhealthy territory. The next thing we know, we're fighting a virus... or worse.

How can we stay in our own buffer zones? I try to reprioritize self-care. I take some extra vitamin C, drink warm fluids, sit in an epsom salt bath, write in my journal... Make sure I'm nourishing my body with nutrient-dense foods. Say no to extra responsibilities when I can. Sleep as much as possible!

What are the steps you take when you feel you're falling off your autoregulation curve?

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?"


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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