lamentations of a community pediatrician

I am tired of hot cheetos. I am tired of juice and kool-aid for toddlers. I am tired of pizza or and wings from the local takeout. I am tired of 1 month olds being given 4 ounces of formula with cereal in it to “help them sleep” and the school aged children drinking milk or chocolate milk with every school meal even though they don’t really like the taste of it. I am beginning to see more and more 200 pound 12 year olds and 80 pound 6 year olds.

It is Well Child Check season in the land of pediatric primary care. As a private practice Pediatrician in Washington, DC I don’t actually eat those foods myself or feed them to my child (though I do love pizza and wings once a month) almost every single patient I see with elevated body mass index or abnormal increased weight gain has had or currently has some part of this in their diet.

I am beginning to worry every day I am in my office about all of the premature heart disease we are going to see in 20 year olds because I now have seen close to 10 school aged children with abnormal lipid panels due solely to their poor diet, I have seen more than my share of toddlers and school aged children with developing Blounts Disease (this is a disorder kind of like deforming kiddie-arthritis where the bones in a part of one or both knees begins breaking down due to excess weight, causing deformity of the knee), I have seen countless young women with metabolic disorder and polycystic ovarian syndrome (think bad cystic acne, hirsutism, abnormal and often heavy periods). I have seen more than my share of rotting teeth due to prolonged bottle use, inadequate teeth brushing, and poor diet high in sugar-laden beverages.

Every day I say or type in my instructions to countless children and parents “no juice, soda, sweet tea, or koolaid, it’s bad for your child’s teeth and behavior” and I cannot tell you the number of children and parents who argue that juice must be good because “WIC (Women, Infants and Childrens Program) gives it to me”. Or the kids that say “I don’t even like milk, but school gives it to me at breakfast and lunch so I just drink it”. Ohhhhh WIC and schools! If only we could divest ourselves of the sugar and milk lobby and give these kids what they need - gasp, WATER! Water, the only drink that other countries, with much lower rates of childhood obesity than the United States I might add, allow in their schools. It literally takes me a several minutes in most visits to share with parents that no juice is definitely not healthy even though it has “vitamins and minerals” and that no it’s not the same as eating a piece of fruit. And no, if your child doesn’t like milk they don’t actually have to drink it and they can just drink water and get their calcium from things like yogurt or cheese. And no, chocolate or strawberry flavored milk isn’t needed because if your kid doesn’t like milk he/ she really doesn’t have to drink it. And yes, the sugar in juice and chocolate milk is just as bad in it as the sugar in soda is and nope I don’t allow my 6 year old to drink juice, soda, sweet tea, or koolaid (except at the random birthday party or when he is with my family who simply won’t listen to me) and nope my 6 year old doesn’t drink cow’s milk. Seriously, I can recite these points in my sleep because I say them every day countless times.

My heart hurts. The ICD 10 codes: abnormal weight gain, childhood obesity, pediatric BMI greater than 95%ile dot the majority of my notes. Cutting out the “juice, soda, sweet tea, and koolaid”, cutting back on the take out, increasing the time outside or dancing and playing, and cutting out the cow’s milk would be enough in most cases to curb this trend.

We had a new neighbor in his mid-30s die of heart disease this summer. His obituary showed a child who has struggled with his weight since early childhood and multiple relatives with obesity. His story includes hypertension and pre-diabetes in his 30s. This story is going to be more frequent if there isn’t major policy and cultural change in America.

Thankfully I have had a handful of success stories and they keep me inspired to share healthy diet and exercise with all because honestly so many of my patients just don’t know. The toddlers who I have done intensive intervention with in my office and referred to our local childhood obesity program whose entire families have adjusted their diets and their weight gain has slowed and can run and play more. The adolescents who have lost weight since their last visit who walk in with their parents who are looking mighty healthy too and tell me about the weight they lost and how they no longer drink sweet tea every day and do take out much less. The mothers who breastfed for a few more months even though it was hard. The families who stopped giving their 2 month olds rice cereal in their formula (of note, the current recommendation is exclusive breastfeeding until 6 months old unless medically contraindicated. No supplemental foods - that includes rice/oatmeal cereal until the kiddo can sit up on his/her own usually between 4-6 months).

So while I lament, I press on because there is so so so much work to do. Now off to find a healthy early morning and I can’t sleep blogging snack for this 4 month old growing fetus of mine.

Panic on the Highway

Genmedmom here.

I'm like many physicians: a bit of a control freak. C'mon, admit it, it usually takes a Type A personality to push through all this bulls**t: Exams, applications, more exams, more applications, brutal working hours, exhaustion, fear, abject terror, hazing, insurmountable debt.

But sometimes, we're just not in control.

My very first panic attack, I was huddled in a sleeping bag on the cold floor of a medical outpost in El Salvador. It was 2001, the January earthquake. I was one of a small band of medical misfits on a disaster relief mission. I was a student, and my job was translator.

We were housed in the same clinic where we saw patients, on the concrete floor. That night, there were several aftershocks, but no one else on my team woke up. I imagined the ceiling and walls caving in. Some large bug landed on my face. Mosquito? Reduvid bug? Was I going to get Chagas disease? I began hyperventilating, I could not get enough air. I was panting and suffocating at the same time. Nausea overwhelmed. It was pitch black, no electricity. I would have had to crawl over my snoozing colleagues, or throw up all over them....

It was the idea of vomiting (and dealing with vomitus) that broke the spell. Even in my panicked state I had an idea that it was all in my head. Damned if I was going to puke on my attending.

Maybe it's not completely unreasonable to panic whilst in a bona fide disaster zone, although it would have been utterly humiliating, as well as inconvenient...

There have been a handful of episodes like this since, and none with such a good excuse.

This weekend, for example.

It was Labor Day weekend, and I was not on call. I was solo with the kids, and we went on a little road trip, to visit relatives a couple of hours away.

The ride home was ugly storming, the remnants of Hurricane Harvey. My kids are in this sibling rivalry phase, where rivalry means drawing blood by any means necessary. So I had the car VCR on for maximal distraction.

Still, they fought, and I fought to keep my full attention on the road as they yelled: "You wear poopy diapers on your head!" "Oh yeah, you smell like poopy and pee pee AND cat food!" "AAAUGH! MOM he kicked me!" "WAAAGH! MOM she pinched me!"

I was into a long sort of barren highway stretch when I realized that the gas tank was low. Really low. Sixteen miles of gas left low.

Hmmm. Miffed at myself that I hadn't noticed that earlier when we passed several rest stops, I paused the DVD and asked Siri "Where is the closet gas station?"

Siri paused and then ever-so-unhelpfully directed me to a gas station ten miles BEHIND us.

Okay. I kept driving South, looking for any evidence of a gas station at any of the very few exits coming up. They were all for major routes, not towns. No signs indicating restaurants, hotels, or gas stations.

The range dwindled. When the gauge read nine miles, I started to really freak out.

"Okay guys, I need to pause the show."

The kids actually quieted down. I explained that if we didn't find a gas station soon, we may need to pull over and call for help.

But I really, really did not want to do that, in the middle of a heavy late summer rainstorm and on a holiday weekend.

So I just kept driving-- like Dory, Just.. keep.. driving...

With SIX miles left, a lonely exit had a lone sign: "Gas: Mobil"

"Hallelujah!" I called, and gleefully flicked the blinkers on, aiming right, to salvation.

But: the signs then directed me to cut left, OVER the highway, towards the ramp going in the opposite direction. This required me to veer left. The car behind me honked loudly: They were going straight, and I had almost clipped them when I veered left.

Face burning (did I just almost cause an accident?) and heart pounding, I tried to sort out where the hell the goddamned gas station was. It looked like there was a small access road on the other side of the highway, but I would have to cut across two lanes of traffic getting on the highway going in the opposite direction to get there, with literally no wiggle room, just straight across.

There were so many cars! I couldn't make it! I was funneled back onto the interstate: going BACK from where we came.

I yelled, something unprintable, multiple times, banging the steering wheel, then "OH MY GOD WE ARE LITERALLY GOING TO RUN OUT OF GAS ON THE HIGHWAY IN THE RAIN! S--t S--t S---t F---k F---k..." I felt that familiar catch in my breath, that quick succession of gasps that means panic is beginning to overwhelm, except I was DRIVING on the HIGHWAY with my KIDS in the CAR.

The logical M.D. brain kicked in. Should I pull over now? But the shoulder isn't that wide, and the ground is soggy. Pulling over on the interstate could be really dangerous, and if I pull over onto the grass I might get stuck in the mud...

Hey, I can ask Siri! "Siri, where is the closest gas station?"

A Citgo twelve miles away popped up. What??? The Mobil we had tried to reach wasn't on Siri's radar. Maybe it had closed?


So there I was, speeding along the interstate, with five, then four miles left, not sure if there were any options... Crying. The kids were silent.

The next exit was coming up, for a busy route, no buildings, no towns anywhere nearby.

Deep breaths: "Okay, guys, I'm going to try to turn around and get back to the gas station that's supposed to be there that we just missed."

Blinking away tears, I managed to turn around, thinking Okay, at least if we have to pull over now, we're heading in the right direction, and I won't look like such an idiot.

Just.. keep.. driving... Three miles. Two.

I made it back to the same exit and the same veer left and over the highway and across those two lanes of traffic feeding onto the interstate... It was a miracle, there was a break in the cars, we zoomed across, and into the Mobil. With less than two miles of gas left.

As I pumped the gas, my legs shook. We took a little bathroom break. I splashed water on my face, and then felt silly for having had a truly unnecessary freakout in front of my kids.

I've since reviewed this whole incident with my husband, and we have some rules: ALWAYS gas up to the max before a long drive, and never freak out while driving. Pulling over and calling for help is way, way better than getting into an accident.

Still, another reminder that we are not always in control. (And neither is Siri, apparently.)

Photo credit Holly Mandarich: https://unsplash.com/photos/0317cop-0Ug

First Week of Medical School, and Our Uninvited Guest.

Medical school is starting up, and I have my game face on. I've moved into my new apartment with the tots (1.5 and 3yrs), and mapped out every second of every day. Wake at 6 am, take the dog out, shower, pack lunches, wake kids, dress them, and head out the door by 7 am. I soon discovered this was a little ambitious. My kids are used to getting up at 8, 9, 10am. No problem, I have to learn to be flexible, and moldable, like I said I was in my medical school essays. I tweak the schedule to start at 530am, and the kids adjust. I have interviewed multiple babysitters for evening and weekend help and found an amazing woman who is the mother of a 3rd year medical student at my school, so I know she can't be crazy. I have her come nightly the week before orientation starts so the kids can get adjusted. They love her, I love her, she loves us. Having this help reassures me that I CAN do this. Then life happens, and my first day of orientation she falls and injures her back. I'm relieved she is OK, but she will be out for 6 weeks. No problem. I am this flexible, moldable metal right? I'm flexible damn it! AND I prepared. I have multiple back up sitters with one who can step in immediately. Then my internet doesn't work, no problem, I can complete my last minute assignment using my phone, it just takes twice as long. The treadmill at my apartments don't work. That's OK, I can walk around the block. The washing machines are out. No worries, flexible, moldable, calm, cool me has enough clothes for the week. I will just wash them at my parents house on the weekend. I'm trying to be this person who has it all together, and for the most part, I am playing the part. I replay "Just keep swimming" from Finding Nemo in my head as I try not to let the little things unravel me. I like order, I like control, I like plans, but I know these things will continue to happen and if I want to be successful I have to let them go.

But no amount planning could have prepared me for what was going to happen the weekend after orientation. A category 4 Hurricane (quite uninvitedly) hit our coast and caused devastation 200 miles south. Our first 2 days of classes were cancelled, then the whole week was cancelled, then after Harvey died down to a tropical storm, classes were resumed as our administrators assumed we were out of the waters. My kids 'daycare was still closed, so I slightly panicked as I tried to find childcare for the week.  There was no need to panic, I have lots of back ups. I'm still learning to stay cool. 

But the admin spoke too soon. The city that I have called home was drowned overnight in what is being called catastrophic, historic flooding. All of a sudden my plans didn't matter. I watched on Facebook live feeds as friends of mine were rescued from their houses that had become an island surrounded by water.  I watched a local news crew drive through the streets near my house, near my kids' old daycare, in a boat. I watched the roads I take regularly become rivers. Addresses of people who needed rescue kept popping up on my Next-door and Facebook feed. Businesses were lost. Homes were lost. Lives were lost.

I also saw a tremendous outpouring as locals responded to a call for help. People brought their boats to help with the rescue efforts. Impromptu shelters have popped up all over town. Donations are being brought. Neighbors are offering their homes to those who have lost. My neighbor across the street went out in a row boat, rescuing elderly a few blocks away who were trapped in flooded homes. Those of us who were safe helped coordinate boats to pick up those who were stranded. The Cajun Navy from Louisiana even showed up immediately. Many friends of mine, including my kids' dad, are on day 3 of 4, or 5 working in the hospitals, or as first responders. My old coworkers are evacuating the hospital where I learned to be a nurse. They are strong, and resilient. They are flexible and moldable. I could use a few lessons from them. 

It's still raining here, it's not over. Evacuations and rescues are still taking place. For now, I am safe at my mom's house, an hour away from Houston. The tots are enjoying their time with grandma and grandpa. My sister is stuck in her apartment, but stocked up on chips and water for a week. Our home in Houston didn't take in water, and my apartment in Galveston is fine. I have no idea what is going to happen next. I don't know when the rain will stop, when my classes will start, who will watch my kids, if they are going to try to shove 8 weeks of Gross Anatomy and Radiology down our throats in 7 weeks, or if they are going to take away our Christmas break to make up for it. It doesn't matter. It only matters that my city and surrounding areas stay safe, and soon we will come together to rebuild and restrengthen. I'll be getting a sledge hammer to help with rebuilding, and I'm sure I'll still be singing "Just keep swimming" when I start knocking down walls. It seems like an appropriate song. 

Guest post - 7 going on 37: my baby boy gets surgery

“Mommy,” my six-year-old says to me as he stands over the toilet. “There is a big bubble on my penis.”

“Heh?” I say. “A big what on your what now?”

“A bubble. On my penis”

So I go over to take a look, and am astounded to find what looks like an adult sized left testicle – kudos to my kid for saying “penis,” and not, like, wee wee (though I thought it was awesome when he came up with “pointer” all by himself at age 2ish, and I mourn “pointer’s” passing to be replaced by anatomically correct terms), but he actually meant testicle. It’s a double mom fail: 1) I failed to teach him the difference between penis and testicles; and 2) I’ve been giving him regular baths right along and never noticed that his left one has apparently been exponentially increasing in size.

After a brief talk, we determine that it doesn’t hurt and that sometimes, it’s bigger than others. I’m thinking I know what this is, even though my experience with penises and testicles, especially six-year-old ones, is limited. I have a friend who’s a pediatrician, so I text her asking if she’d mind a penis pic being sent (that’s actually not the term I used, but I feel funny putting the term I did use out there in relation to my kid because I feel like it might be inappropriate and possibly frowned upon), and she actually says she doesn’t mind (she must be used to crazy parents), and when she looks at it, she confirms what I had been thinking: Munchkin has a hernia.

I tell hubby that we gotta take Munchkin to the doctor to check on the lump, and unfortunately, Munchkin overhears me. He’s a very conscientious child, and that is not to say anxious. No, you know what, I’m gonna say it, he’s an anxious child, and at the time this all was happening, he was going through a phase where he was very concerned with death and dismemberment, and other forms of bodily harm and injury.

Like, we had gone on vacation that year, and there was a man who didn’t have an arm staying at the same hotel. Oh. My. Goodness. My son was so affected. “Why doesn’t that man have an arm?” “What happened to his arm?” “Where did he lose his arm?” “Can kids lose their arms?” “I don’t think I want to be a policeman because I might lose an arm…” I tried to tell him that clearly, the man without the arm is doing well, because he looks happy, and he’s here with his beautiful family, but it was to no avail, we could not stop talking about it all week. And wouldn’t you believe it, on our last night we went out to a nice dinner, and guess who they sat next to us? Yup. I was basically using my body as a shield to keep Munchkin from seeing the man and saying something stupid. It was quite the ordeal.

So, when he overheard that I was concerned with his “bubble,” and that he had to go to the doctor, he was immediately all wound up about the possibility of something bad happening to his nether-region. “Why do I need a doctor? Is it because something bad is going to happen? What is going to happen?” And every day he’d ask me when his doctor’s appointment would be, and if I think the “bubble” can kill him.

The day of the doctor’s visit arrives. It’s a female pediatric surgeon, and I love her immediately, because she talks to my kid the way I talk to him: like a grownup, with big words.

“We’ve got a bubble on our testicle,” I tell her.

“I see,” she says with a straight face.

“It’s not always out,” Munchkin says. “It’s only sometimes out.”

“Well, let’s see if it’s out now,” she says.

She confirms that this is a hernia, and that he will need surgery to correct the situation. She explains the operation to me in medical terms (I told her that I’m a doctor. Why do I always feel like such as asshole saying that?).

Then, she turns to him, sitting up on that examination table, and says, “Do you have any questions?”

Munchkin very seriously says, “What bad things can happen during the surgery?”

The surgeon explains that it’s very unlikely, but there could be some bleeding or infection, or a reaction to anesthesia.

Munchkin nods, and then says, again, very seriously, “What bad things can happen if I don’t have the surgery?”

The surgeon explains that probably nothing, but the “bubble” could get stuck and hurt a lot, and it could get progressively more uncomfortable to walk around.

I’m sitting there thinking, this kid is asking more intelligent questions than some of my grown up patients! And I don’t even know whether to be proud or scared or what, since he’s clearly probably smarter than I.

Satisfied with the explanation, Munchkin says, “Ok, I’m ready, let’s book the surgery.”

Well, he probably didn’t say “book the surgery,” but he might as well have, because he did hop off the examination table, and briskly lead the team out to the scheduler’s desk. I’m still gathering my things and frantically stuffing papers in my purse, and he’s already seated in front of the secretary, and I could have sworn that he was signing consents. Even the surgeon’s trainee, who up until then had maintained perfect decorum, had to laugh.

The offer us a few dates, and he picks the closest one, next Thursday, and I say to him, “Are you sure you want that day? That weekend, you have a birthday party, and graduation from karate, and you’ll probably have to miss those things if you have the surgery. Are you sure you don’t want to postpone it?”

He says, “Oh, please, let’s not postpone it, I want to have the surgery because I don’t want anything bad to happen.”

Like, seriously? Who is this kid?

And it’s not the first time he leaves me somewhat speechless. Most recently, when he found out we were moving, and he’d have to switch schools, I was agonizing about how he’d be upset, but he said, “Okay. It’s time for a change.” Who says that?

Unbelievable.

And then, just like that, he’s a kid again. After eating a giant bag of ketttle corn, he bounces off walls for about an hour and the passes out in the middle of his Spanish lesson that afternoon, head down on the table. Whattayagonnado.

The surgery went fine, by the way; I think it was worse for me. Watching my little old man’s face as he was put out with a mask was distressing, I realized as I walked out of the OR on rubbery legs, and watching him wake up and crying “ouchie, ouchie” in the PACU was really upsetting, even though he didn’t remember it after being properly medicated.

I feel like it’s always harder on the mom… When Munchkin was a baby, and I had just gone back to work, I accidentally caught a glimpse of a baby of the same age in the OR, and almost fainted. One of our techs saw me, and said, “Funny how things change when you’re a mom, eh?” I never thought I’d turn into such a delicate flower.

Munchkin, though, he did fine. He marched in, got rolled out, and the next day was out on the playground already, showing off his battle scars and refusing to skip a beat. Mommy got a talking to by daddy though, for allowing this and not being firm enough. But I figure, kids know what they’re doing. If he were in pain, he wouldn’t have wanted to go to the playground.

How about that kid, though?? He’s 7 going on 37, I swear to God. How did I get so lucky? (poo poo poo, spit three times and knock on wood)


-Sasha Retana, MD. Originally posted at  https://andwhynotshesaid.com/

clocking

I have never been one to track my periods, but then life happened and now I am tracking them religiously.

I think back to when it all began. I was one of the last of my friends to get my period. Even though my mother had prepared me with books and talks, I still thought death was imminent when it started. So once they occurred regularly, I just went with it. No charting. No tracking.

Fast forward to my mid-twenties as a medical student. My husband and I decided to have a child before starting residency because it seemed like a good plan. Thankfully Little Zo established himself promptly after discontinuing my IUD. 3 weeks after. I had little knowledge of how truly a blessing that was.

And then life happened. The stories of loss and infertility began to trickle in. A cousin whose first child was conceived in our 20s using in vitro fertilization and who is still paying bills for it; she has been trying for years for baby #2. The friend and aunt who have both suffered multiple miscarriages. The friend who experienced a molar pregnancy and had to consider radiation therapy. The best friends who suffered a stillbirth that I wrote about here: http://www.mothersinmedicine.com/2013/07/life-loss-and-celebrations-of-love.html

Once settled into attendingdom, O and I decided to try again in order to give Zo that sibling he sometimes mentioned. I wrote in my post on December 29, 2016 entitled “(all is not) lost” about our miscarriage (http://www.mothersinmedicine.com/2016/12/all-is-not-lost.html). It was devastating.

And now, without even realizing it, I have begun tracking my cycles. 3 after the IUD was removed and then we were pregnant with number 2. And then the miscarriage.

My D&C surgery was in January 2017. And every month thereafter I prayed my cycle would return. Was that pinch the beginnings of my cycle? Was that the beginning of ovulation. 3 months later, my cycle returned. And each month that went by we still weren’t pregnant. And then. Last menstrual period May 17, 2017. We are overwhelmingly happy, frightened, joyful, petrified, and elated. Big brother Zo is happy. Thus begins a new clocking of days, weeks, and trimesters. Second trimester begins this week. So thankful.

Street Cred with a Belly

Hello everyone - I joined this blog so hopefully I would remember to take a moment to reflect on my experiences and have the chance to learn and share from you all, so I wanted to share some reflections from my last couple months.

I've always joked with people that I planned on starting a family as a family medicine resident to give me a little more street cred. I am one of those people that still gets carded walking into 18+ establishments - and hopefully someday I will be grateful for this, but at times it's hard to take advice seriously from your teenage-appearing doctor. The most common look I get when telling parents they need to wake up their baby more often because they are not gaining enough weight is the one-eyebrow-raised "mmhmm. Get back to me when you've had kids" look. So I thought on some level, baby = credibility.

I am enjoying being pregnant and seeing patients much more than I thought I would. I'm 31 weeks along now with a very obvious belly. One parent recently pointed at my belly in the office and told her 2 year old "See, she's having a baby too!". I am having so so so much fun seeing my OB patients in the office and commenting on our bellies at the same time. I feel like my advice is taken a little more seriously ("I know it's hard, but..."), but it's more so I am developing wonderful relationships with my patients. I have one patient that is due within a week of me - so we are hoping she goes first so I can still deliver her before having my own. We are delivering at the same hospital, so chances are, we'll be right down the hall from one another if that plan doesn't work out.

Something else that has been surprisingly enjoyable is the change in my interactions with patients in the hospital. Especially my lovely little old ladies. My rounds have become much less efficient as my patients are starting to ask me more about my life as I try to ask about theirs - but again, so much more enjoyable. It reminds me why I like medicine and connecting with people.

My favorite patient encounter this week was with one of my stroke patients in the hospital. She was recovering well from her stroke physically, but she continued to be unable to speak and express her thoughts. I was going in the room with one of my other senior residents to try and assess how much she was able to understand us. While the other resident was talking to the husband, my patient looked at me, looked down at my belly, looked up with a confused look at my face, looked at my belly again, and looked up at my face and smiled. I thought to myself "Ma'am, you know exactly what is going on here". She just left to a rehab facility and I hope she's doing well.

Thanks for letting me share with you all :) I am just eternally grateful for this experience right now. If you have any stories from times you were glad you were a mom or expecting while you're a doctor I would love to hear more!

Charlottesville

I've been watching the events unfold in Charlottesville, VA, over the past two days. I was already sad; now I am scared and angry as well. I wrote about it on Medium.

None of us is safe. Hate touches us all. Hate threatens us all. If you are white and your first thought is “that’s not me,” then you are not listening. You are not listening to my voice. You are not listening to the voices of people of color. They are telling you we are being murdered. We are being systematically eliminated. We can’t breathe. If it’s not you, then you must work to stop it. We all must work to stop it.

We must. Our children lives depend on it. Our lives depend on it.

(Helicopter) Doctor Moms

As my toddler becomes more and more active, I've been grappling with an internal conflict: how do I balance my desire to let her experience life and take chances within the reality of my risk-averse, medical background? The other day, my mother almost had a stroke in the park, watching my 20 month old girl teeter along on the edge of a three foot tall retaining wall while she laughed with glee at her cousins. Below was grass on one side and a stone tile on the other. "Get her down from there!" she cried. I hadn't thought anything of it: if she had fallen on the grass side of the wall, she would have been fine. She would have learned a lesson on how to place her feet to balance. If she had fallen on the tile side, things might have been fine... or they might have resulted in a broken ankle, or a broken head. Flashes of my baby intubated with a head injury in the ICU swirl through my head, and I have to slap myself to break loose.

So much potential badness and goodness in this picture

I don't want to be one of those helicopter parents. I want my child to learn problem solving, to take chances and learn consequences, and to feel the exhiliration of meeting physical challenges. And yet, as an anesthesiologist, I've seen the worst. I've seen the pediatric traumas and the burn unit cases. I've heard the PICU stories ("How did this happen?"), and I'll admit that I absorb these details differently now that I'm a mother. The information is clouded by a background wonder of what I would do if I were in the parents' situation. Sometimes I see my own child's face in that hospital bed or on the OR table.

As a teenager, I had some friends whose fathers were policemen. They always had lots of restrictions, and because their dads had similarly clouded lenses through which they saw everything, I now understand why. But overbearing parenting has been associated with what Jessica Lahey, author of The Gift of Failure, describes as "emotionally, intellectually, and socially handicapped children." How do we as parents allow our children to grow up with freedom, autonomy, and challenge while still appropriately protecting them from physical harm? If anyone has some good insights on this, I'd love to hear them!

MiM Mail: Choosing between nursing school and medical school

Hi,

I came across your blog many times while looking for answers about being in medicine. A little bit about myself: have a BA in Biology and in History, an EMT license, and I work as a nanny to small children. Long story short, my mom died when I was 16 and she wanted me to be a doctor rather than a nurse in order to support myself better. Since this was the only path in medicine we had ever talked about, I now feel like I am betraying her by thinking about nursing. I also want to be a full time stay at home mom (in the far future) which only adds to my dilemma.

In terms of being a mom: I know that it is a loooong ways off, but I am a planner. I have run a household when I was 16 and 17, and I am a nanny to several families. One of these families both the mom and dad are doctors and their kids see the nanny more than their parents. I know I don't want that for my future family. I also do not have a good support system with people who could help take care of kids.

I know for a fact that I want to be somewhere in Emergency Medicine whether it be an NP on an ambulance, a RN in the ER, an ER doctor, or a trauma surgeon. I started thinking about nursing school while becoming an EMT because of the amount of patient contact nurses have in ER. I also know that I'm great with taking care of patients as tech.

BUT, I have been struggling with the idea of nursing for over a year now. I want the higher education of being a doctor and understanding the full picture of diseases. I want to be able to practice good medicine since my family has had so many doctors malpractice. I want to be able to be there for my patients like I imagine you all are. I was accepted to a medical school and I declined because I was engaged at the time.

Things I am struggling with:
1. Patient contact in the ER (I love how nurses are more hands on)
2. Education level (I have come across all types in both fields and most nurses and doctors encourage medical school, but I want to spend more hands on time with patients which I know will not happen in the ER)
3. I want to be able to help restructure programs and protocols to help improve patient care
4. Time to complete both (It is very likely that I will not be able to have children starting around 29/ 30 and I am almost 22. This makes me concerned about residency programs and being held back a year)
5. I've always dreamed about being a doctor and a stay at home mom (reality is hitting that these do not always go hand in hand)
6. I'm struggling to complete nursing school apps (I could get through with little debt in comparison to medical school)
7. Wondering about working part time as an ER doctor vs ER nurse

So, I am looking for your opinions about medical school vs nursing school. It's been hard to find someone who can give me answers when one of their solutions to one part will not work for me. I'm hoping that maybe as doctors and as moms you might see something different, or maybe offer some clarity on the medical school/ residency process. Thank you for taking the time to read an to think, I really truly appreciate it.

Thank you,
Kelly

What is the longest you have been away from your kids?

I posted this question on my local mom's Facebook page, and answers were either never, or 3-5 days. The exception being one mom who left for 2 months to do field research. She describes the experience as horrible. So basically I didn't get the external validation I was looking for. I am about to start medical school and am thinking ahead to away rotations, as well as being heavily involved in our large Global Health program, which requires 4-6 weeks away two separate times.

So what about you mamas? How long have you been away? Was it for work, school, pleasure? How did you manage? How did you feel about it? Would you do it again?

MiM Mail: Residency applications and motherhood

Dear Mothers in Medicine,

I've been following your blog for a couple of years now, and every single post has worked for me as an inspiration to stay strong and fight for what I love, medicine. But today, I have found myself in a confusing position and I really need advice on a special subject, residency application and motherhood. I'm currently an MS4, yayy!! And as application day approaches, I have been working on my personal statement however, I'm encountering that one of my biggest assets (or so I feel) is being a mother. I have been advice by all my friends at medschool to not even mention my family, husband or 2 daughters (2yrs and 5 months). According to most people having a family will make me a less reliable resident than someone without strings attached. However, this is my story:

I married after college a few months before beginning medical school, my husband and I had been accepted to the same school, and things sounded great. During the first year we adapted to the new environment, developed our studying skills and set our expectations for matching one day.

Fast forward 1 year, and baby #1 came along. She was born during our 2nd year. We managed to fix our schedules for studying around the clock and created routines that allowed us to keep up with classes/exams while taking turns to care for our daughter. No LOA requested/no gaps, we were lucky enough that our baby#1 was born right before one break so we had 2 weeks off to adapt to our new family, and organize. Somehow, we survived and made it worked. Now, let's fast forward one more year and baby#2 came along (we wanted our daughter to have company as our families live across the country). Once again, we worked our way around it. I was able to get 1 week off during one of my rotations and resume the following monday. The attending was very understanding and seem surprised to see that I had decided it to keep going and again no LOA, no excuses given.

Today when I look back, I see that everything that I have done until this day has shaped me to who I am at this point. My desire to pursue medicine, and my determination to continue has remained strong while building the family that I always dreamt of. I always thought of medicine as a career choice not a life changer. As a mother, I feel that I learnt to be more organized and time efficient, I proved myself to be dedicated and goal oriented. So far we both remained on top of our class and have shown the same commitment since day one (I say we because this took teamwork). I took my step 1 and Step 2 CK/CS while breastfeeding/pumping because I wanted to continue to care for my daughters while working really hard to accomplish my goals. I wasn't willing to stay behind. Being a mother helped me connect with patients at more than one level, becoming very understanding of their concerns. I will applying to pediatrics because not only did I mentioned it on my personal statement when I applied to medical school as I always had a passion for peds but during these 4 yrs I realized that I'm drawn toward the field naturally. So I wonder, how can I write a "personal" statement of who I really am and why if I cannot mentioned how I became me and why I think I can be a good asset? I feel that a good physician should be able to show balance and commitment while remaining human and empathetic. Us moms, do this every day at home and on the field. Some people even believe in not even mention it during interviews but to be honest I am proud of being one and hope to become a great physician one day. Please any help or guidance. I am really confused right now.

Thanks in advance for all your help.

An MS4 hoping for the best!!

End of training!

Hello Mothers in Medicine readers,

I am Geraldine Chang. I go by Geri. I have been X-ray vision for a couple years now. Thank you for reading about my struggles of balancing motherhood, long distance marriage and residency and then fellowship. It has been hard for someone like myself who is an open book to be anonymous. However, I was always cautious during training to be so open about my thoughts and opinions.

Anyways, that ship has sailed! I officially graduated from my breast imaging fellowship on June 30th, 2017. I am currently very much enjoying unemployment, which is coming to an end. I did my residency and fellowship in San Diego and now I will be starting a private practice job in Los Angeles. After two years of being apart, my family is now all under the same roof! It has been absolutely wonderful.

But now reality is sinking in. I am about to start my FIRST attending job, which begins next Monday and I am hot mess of emotions ranging from fear to excitement. I hope to be honest and open about my endeavors as a first time attending, expanding my family in the near future and continuing this balancing act all of us workings mom do!

I had it in my head that a lot of the problems during residency and fellowship as a mom would magically disappear when I became an attending! Silly right? But I needed some of that ignorant bliss to get me through all the training but as I was ending my fellowship, I realized there is no magical solution to balancing motherhood and a career. You just have to do what's right for you.

My mom has been pretty much my only source of child care the first two years of little C's life. I am forever grateful but it has been hard on her and also our own relationship. She's no longer an option. After being with little C alone for 2 years in San Diego while big C was doing his fellowship in New Haven for 1 year and another year as an attending in Los Angeles, I grew a lot as a mother and as physician. People asked me how I did it all the time. To be honest, I don't know. When you have to do something, you just do it. And it never ends. But a lot it is just perspective (and a lot of coffee!).

Right now, I am feeling grateful for this new job. I am grateful for the flexible schedule, the obvious increase in pay and mostly, I am grateful that I get a provide my daughter with an example on how you really can do it all. Do you remember me? I wrote a guest blog on this very website.  Here it is--http://www.mothersinmedicine.com/2013/07/guest-post-hard-decision.html

I wish I could give that girl a hug. She really needed one. I still can't read that post without crying because the overwhelming guilt I felt comes back and I feel it to the very core.

But now I know, it all works out. I tell myself this as I am getting ready for a whole new set of growing pains, which includes new job, new school and nanny for little C and overall, a new routine and with that I know will come with some degree of mom guilt.

Thanks for being my support. Thanks for listening! Now that I am no longer X-ray Vision, you can also read my personal blog to little C at www.doctormomwifealloftheabove.blogspot.com or follow me on instagram at gerichangmd.

Great article on STAT on female leadership and health care reform.

Genmedmom here. I simply to call attention to a wonderful article on STAT written by a kick-ass healthcare administrator/ CEO and mother of SIX children (yes, six, and TEN grandchildren, per her profile) Annette Walker. It's titled More female leadership: a different kind of health care reform and it's spot-on.

She points out that "women hold only 26 percent of hospital CEO positions and 21 percent of executive positions at Fortune 500 health care companies even though they make up 78 percent of the health care work force". This despite the fact that "Study after study has demonstrated that organizations with gender-balanced leadership are more successful than their homogenous counterparts."

The best part of this short piece is her emphasis on solutions. What she has accomplished in her own hospital system can surely be adopted in others. She lists:

• Flexible work arrangements
• Training opportunities for women to build leadership skills
• Increased visibility of female role models
• Connecting junior employees with female senior-level mentors
• Transparent advancement opportunities and clearly charted pathways to leadership
• Shining a light on the challenges of balancing family and work needs
• Support for community programs that promote opportunities for women in our service areas
• Emphasizing STEM and academic programs for women

I love what she's saying and admire what she's accomplished. I mean, all this and SIX kids, I just can't even imagine. Two kids has almost put me over the edge. Holy cow.

This blog is certainly helping to "shine a light on the challenges of balancing family and work needs" of doctor-moms, so let's acknowledge what MiM brings to the battle! We can also take a look at this list and think of what may be applicable in our own practices, hospitals, and medical schools.

Ladies, let's take some inspiration and motivation from Annette Walker, impressive mama and hospital CEO.

The Devil You Know - A Book Review

I get really annoyed by those people who declare, "I only read non-fiction." And it's ok, if that's you, but don't say it snootily at a party when someone asks you if you've ever read this great fiction book. That's left me speechless and a bit shameful on more than one occasion - the person acts like fiction is non-fiction's red-headed bastard stepchild. And really, if I could go back in time - let's do that right now - I'd tell that person off. Fiction, I'll argue, is way more difficult to pull of than non-fiction. And I'll be damned if you can draw a straight line between the two. Fiction authors often weave autobiography into their own work, but instead of just spitting out what already happened they birth a new child. And that's pretty impressive, in my opinion.

I met Fizzy on Mothers in Medicine years ago when I first started. We became e-mail friends, she supported me through my divorce, I learned a little about her life. She is a very private person. I've met her for dinner once and I still don't know her last name. I respect that, and it comes with mystery and intrigue. We don't e-mail as regularly as we used to, but when she asked for me to read her new book a few months back and let her know what I think I felt like I had received an e-mail from Madonna (that's a nod to the book, by the way). I read it in one afternoon. Well, it bled into the evening a bit.

I read the first book, The Devil Wears Scrubs, years ago. I loved it, and talked about that here. What I loved about that book was how it captured the angst of medical school and training. What I love about this more is it captures the angst of mothering and working as an attending. It is a stand alone book - you don't have to have read the first one, but it was fun for me to reminisce about old characters as they were brought up again throughout the book.

Warning: This book will make you laugh out loud. A lot. Fizzy has always had a great sense of humor and in The Devil You Know she doles it out constantly. There was this one part about glitter - I almost put in a quote but I don't want to ruin it for you - where I was laughing so hard I had to put the book down. She perfectly combines the mayhem of being a doctor and a mother and a spouse - and doing it very imperfectly perfect. If you are taking yourself too seriously this is the book to pick up. I read it again to make this review better and it was a bunch of fun the second time around. One of the best things about it for me was I got a great big glimpse into my very private friend's - one whose blog - A Cartoon Guide to Becoming a Doctor - I've followed for years - life. No one can write a book like this without experience.

I could go on and on about the hilarious patient interactions and bumbling cast of characters at the VA (one of my favorite places on Earth where I trained) but Fizzy herself would stop me - I tend to get long-winded. JUST GO GET THIS BOOK ALREADY: HERE. You won't regret it!!

Side note to Fizzy - who ribbed me years back for never having read a book on a Kindle etc. - I have now read one book on my computer and phone exactly twice - yours.

Bridging the Wellness Gap

I have to give a shout out to my hospital (University of Utah*) and my department (Anesthesiology). We are trying. In the age when burnout is rampant and physicians are frequently leaving clinical medicine, we are working to foster camaraderie and resilience. A few examples:

The women in my department recently held an ad hoc Ladies' Lunch. We do this every once in a while, approximately once a year, but we should work on making it more frequent. It's merely a casual potluck lunch held at a faculty member's house for all the female anesthesia residents and attendings, but for me it represents more. Because I work part time in such a large group, I can go weeks to months without seeing some of the other faculty. Anesthesiologists practice their specialty alone, so in order to process work-related issues we have to consciously make an effort to seek out those connections. Our blue scrubs and hats were replaced with sundresses and sandals, and the conversation turned from patients to children, schools, and summer vacation plans. Resident MDs who have yet to venture into practice ate lunch alongside veteran tenured professors. Many of us are moms, with children ranging from 8 weeks to 19 years old. I learned some useful school information from a few of my colleagues with grade school-age girls. It was also interesting to talk to a couple of the ladies who work exclusively in the pain clinic, sharing stories about work environment and frustrations with the medical system. Two babies even made appearances: one wide-eyed, active 11 month old and one brand new infant attached to her mother's breast at the buffet table!

We started an intra-department monthly wellness newsletter (managed by my colleague Dr. Jennifer DeCou), which not only includes interesting personal tidbits about faculty members but also links and info for wellness resources. In addition, Jen has spearheaded a plan for immediate support, in the forms of work relief and counseling, when any anesthesiology practitioner experiences a sentinel event or a bad outcome in the OR.

Our hospital just opened a Resiliency Center on the medical school campus. It provides a space and some resources for relaxation, but the main advantage of this addition is a dedicated space where for on site, free and confidential counseling services. I have personally utilized the services of the third party counseling group on two occasions during my employment already: once when I experienced a health scare during my residency, and again when I underwent infertility treatment. It was invaluable to me, and now it will be even easier for employees to access the benefit since it will be in such close proximity to our workplace.

The piece de resistance... our hospital recently opened a faculty lounge that feels like an airline sky club. Attending physicians from all specialties are invited to use it for eating, changing, working, conferencing, meeting, sleeping... it has all of those features. Not to mention two fully automatic coffee drink dispensers! We have never had a physicians' only lounge before, and I'm excited to socialize there more with doctors of other specialties.

Where we could do better: childcare. As physicians, our schedules are often unpredictable and out of our own control. I live in fear of the midday call from my daycare that my child is sick on a day that my husband is unavailable to extract her, or the moment I get stuck in the OR with no one to pick her up at the end of the day. Some physician friends work at places where there is on sight, low cost childcare with extended hours, which to me would be the ultimate benefit. Within the past year, my hospital has at least added a backup care resource to their benefit package, but my experience using it so far has not been seamless.

Does your hospital, clinic, or practice group offer any unique services or facilities to enhance your work experience and promote wellness? Share them here so we may all get ideas to bring back to our own places of work!



* The opinions expressed here represent my own experiences and are not those of my hospital or department.