Anybody worried?

One of my first year students was a former surgical nurse, in her 30s, who had had to defer her dream of going to medical school because she had gotten pregnant as a teenager and was raising her child. Though she graduated, did a challenging residency and now has more children, I wonder how many other young women with the dreams we all started with are stopped at the gate by unplanned pregnancy. The recent political discussions about removing all federal support for Planned Parenthood has left me and my pediatrician sister both feeling like our hair is on fire. My student was exceptional in many ways. She did not have the luxury that we have had to worry about when it might be best for us to have our families, or the tools to make our choices feasible.

Choice about childbearing comes in many forms. In my own case, it was because I came through training at a time when professional women had trouble finding men who valued us--or maybe it was my evil temper. In any case, I married quite late and had my last child at age 39. This is not necessarily the path I recommend, but I do think that if we support women's professional aspirations, we should be committed to the proposition that all women should have access to reproductive health services. If Congress prevails, many women who might otherwise make up the next generations of mothers in medicine are going to be instead mothers who lack education, income and the privilege of being able to care for others as well as their own children, in the ways we all do.

I have been writing letters opposing the Congressional initiative to defund Planned Parenthood to my congressional representatives. I hope those who read this will be moved to do the same.

A day in the life of a medical student on her obstetrics rotation

5:20 am Alarm goes off. Hit snooze. Was up way too late trying to figure out what is wrong with my knot tying.

5:30 am Alarm goes off again. Hit snooze again.

5:40 am Alarm goes off. Groan and drag myself out of bed.

5:40 - 6:20 am Shower and dress in scrubs.

6:20 - 6:35 am Make coffee and breakfast (cut apples and peanut butter), walk and feed dog, go through younger son Z's backpack and fill out homework sheet

6:40 am Get in car, upset because I meant to leave by 6:30.

6:30 am - 7:40 am Commute in ridiculous traffic. Make a phone call to the kids' grandmother to tell her I found Z's homework sheet on my coffee table instead of in his folder. Get informed that he didn't have his homework sheet yesterday so they didn't do his homework after school. Wonder why I wasn't told about this, but keep it to myself. She promises they will do yesterday and today's homework today after school. Realize older son, S, never emailed me his science homework to print out the night before, which was already 2 days late and he had lied about not being due. Call roommate / nanny, talk her through printing out his homework from my laptop.

7:40 am - Show up at hospital for a 7:30 am cesarean section.

7:45 am - Finally get to labor and delivery OR. Manage to scrub in before attending, who was already in the room. Curse that he is much more punctual than my general surgery attending was.

8:30 am - Get to tie a few knots in the abdomen. Attending tells me my knot technique is still "invented". Sigh.

8:40 am - 1:00 pm Clinic. Running around taking fetal heart tones, measuring fundal heights, assisting with pap smears and a LEEP. Get to do an ultrasound all by myself! See the embryo moving, and cardiac activity! Manage to print a picture for the happy couple!

1:30 pm Report to OR for adenexal mass procedure. Doctor asks me if I want to grab a sandwich. I say no. He leaves and walks out. I decide I do want to eat, but I need to get cash and my student ID in my car. By the time I get it, eat, and return to the OR pre-op area, I am locked out. My badge doesn't work at this hospital. I finally get in, and they have already wheeled the patient back. Crap. I show up in the OR, and they have already started the surgery. I scrub in, and the scrub nurse in training hands me the towel over the sterile field. I take it, even though I know it's wrong. We both get royally reprimanded by the scrub nurse for contaminating the sterile field. She throws out my gloves. I stand there with no gloves and feel like crying. I finally get gowned and gloved. The attending physician pulls off some really fancy laparoscopic maneuvering, tying off the ovarian ligament with suture and graspers as the external iliac throbs right there in the background. Cool. I GET TO CLOSE!! OK, it was just a tiny port opening, but I do it, and I do a good job. I actually feel comfortable managing the instruments and do some pretty good instrument ties. The PA tells me I did a good job. SQUEEEEEE!

2:45 pm. Back to clinic. More cafe cubano and another pastelito. I am going to gain so much weight on this rotation. More clinic. I love clinic. I manage to do some gringa histories in broken Spanish. La ultima regla? Cuantos hijos tienes?

6:00 pm. The midwife tells me we are heading to the other hospital for a birth. I call my nanny on the way and tell her to get S (Z is going to his dad's tonight). I tell her that there is a frozen steak she can try to defrost if it's not too late, and that I will be coming home if the birth isn't imminent.

6:30 pm Get to hospital. Mom is at 9 and pushy. Wait outside for baby's head to descend a bit more. Round on some postpartum patients. A nurse gives me some suture to practice with. I keep tying knots wrong, and we go in to the room for the birth.

7:29 pm Time of birth. Baby is delivered onto the mom's chest. There is a nuchal cord (cord around the neck) and a true knot in the cord. Baby has 9/9 Apgar scores.

8:00 pm Ask midwife to watch me tie a few knots. She shows me what I am doing wrong. Lightbulb! I remember how to do it right now! Muscle memory is a cool thing. Get in car to drive home. Call roommate / nanny, get an earful about S's attitude about not doing his homework. Also find out they were unable to print his assignment this morning, and he got an F on it. Call his dad, and we discuss ways to handle this. Taking away his birthday party at the end of the month is on the table.

8:40 pm. Get home. Read S the riot act about his homework and attitude. Eat delicious dinner roommate / nanny left for me in microwave. Tell her she is the best wife ever.

9:00 pm. Walk dog. Change kitty litter. Sweep floor. Realize it's too late to call Z and say goodnight. Write blog post. Avoid other obligations.

Sexual Harassment?

When I was seven months pregnant with my daughter, I was a resident on an inpatient rehab ward. We were having a bit of a pre-holiday slump, meaning I had all of four patients on my entire service. Of course, as a resident, I had no complaints about this.

I was working with my attending, who we will call Dr. Massage, because of the way she sometimes reached out and started massaging residents shoulders for no particular reason. Dr. Massage was middle aged and did not look at all dissimilar to Coach Beiste on Glee. (Yes, I watch Glee. It's awesome.)

One day, someone (I can't remember who) was bemoaning the lack of patients on the inpatient ward and said to Dr. Massage, "Is there anything we can do to increase admissions?"

Dr. Massage replied, "Well, Dr. Fizzy and I could go out on the street wearing bikinis. That might cause a few accidents."

Considering, as you recall, Dr. Massage looked like Coach Beiste on Glee, I took this as an insult.

Granted, it was kind of self-deprecating as well. But I'm not sure why I had to be included in this. I was sitting several feet away from this conversation, quietly doing my work, and I was kind of shocked when I heard her say that.

What's the big deal, you ask? I guess it isn't really such a big deal. Except that I was only 27 and pregnant for the first time after being quite petite before, and I was not feeling fantastic about the way I looked at that moment. Every pregnant woman worries about weight gain and swelling and all that. OK, I'm sure some pregnant woman walk around feeling like they look fabulous all the time and never once feel fat, and that's awesome for you, really. But not me. And I certainly wasn't in the mood to hear someone making comments about how my appearance in a bikini might result in a serious accident. Of course, Dr. Massage never had kids, so maybe she didn't get it. Although I get the feeling if I had made a similar comment, including her name with mine, she wouldn't have appreciated it.

Would a man make a comment like that? Possibly, but I actually feel like men watch their mouths more than women these days. I feel like when women make insulting comments about another woman's appearance, you really can't do much (not that I ever would anyway). Another blogger recently said that a female she worked with accused her of having fake breasts (she didn't) and she just let it slide. Or maybe men are just as bad or worse, and I'm suffering from selective memory right now.

Anyway, I'm not sure if there's a moral to this story, but it's something that still sort of stings so many years later.

Guest post: One month down

I never thought this moment would arrive, but as of tomorrow, I will have been back at work for one full month after the birth of my daughter.  When I dropped her off at daycare the first day, I didn’t think I could survive it.  Now, I’m a savvy daycare mom, chatting it up with her teachers and settling into a routine.  One great thing is that she seems to love it, she smiles at her teachers and is universally known as the “happy baby with the curly hair.”  I survived and managed not to quit my job.

I’m taking a hiatus from surgical residency right now and in a basic science lab.  I hate basic science.  I’ve always known this.  However, when I found myself pregnant and bleeding and nearly passing out in ORs last year, I decided I desperately needed to make a change and I weaseled my way into a lab, telling myself I might love it and find my life’s work.  That was a lie.  I hate the lab.  Even more, I know that I would rather do a completely different type of research in my career and wish I was putting things in place to make that happen now, especially since my surgical career seems to be at odds with my new mommy desires.

My thoughts about this first month as a working mom:

#1 - People say stupid things

As a resident most moms get six weeks, and six weeks ONLY of maternity leave, which includes all of your vacation for the year.  I fought for eight weeks and I was extremely proud of being able to take this extra time for my daughter.  However, my return to work was met with some stupid, hurtful comments such as being asked how I could leave my daughter when she was so little and how they could never do the same.  But, I stand by my pride.  I fought for 2 (actually 2.5) more weeks with my precious daughter.  This is my life and our story and in this story that was a success.


#2 - Women in Medicine really do have to be super moms.

Shared parenting, at least for now, is a myth.  I feed her (I’m breastfeeding).  I change her 97% o the time.  I wash her bottles and her clothes and get her ready for daycare in the morning.  If I want to eat nutritious meals, I also cook.   If I want to eat my nutritious meals on clean plates - I do the dishes.  My husband tries, but I think only moms actually know how much moms do.  I have NO idea how this will translate one I leave the lab, I’m guessing a nanny and a maid (something else we can’t afford). 


#3 - From now on, I will always have a twinge of guilt and confusion about my career choice.

The first few weeks after my daughter was born, I was almost 100% sure that I was not going to complete my residency.  As time passes, I feel more capable of finishing.  I crave mentors and therefore read this site like a maniac.  I could write a blog entry every day about how I grapple with this issue.  While I was pregnant I wrote letters to my daughter that I plan to give to her someday.  Over half of them are in some way about my trepidation over pursuing a career in surgery and being a good mom.  My own mother was a stay at home mom and she poured her energy and love into all of her children so that we could be something great.  Now, I feel as if being something great is at odds with being a great mom. 

I had to fly out to a conference 6 weeks after my daughter was born.  It was my first talk at a national conference.  My parents, brother and sister drove down to see me.  It went really well - a big step in my career.  However, even though it felt good, my major concern was if I had pumped enough milk and all I wanted to do was get back home.

I don’t have any of the answers now.  I’ve decided to find peace in taking it one day at a time.


"cutter" is a third year general surgery resident currently taking a 2 year hiatus in the lab and the mother of a beautiful 3 month old.  She started reading this blog during intern year just as a source of encouragement from women in medicine, not realizing that she would soon be a mother in medicine too.

I Got Your Lobotomy Right Here...

Thank goodness, we have made it to the end of this youth hockey season!

My 12 year old son loves sports, especially hockey. I'm still trying to adjust to being the mom of a jock (sorry, *young athlete*). It often seems that life is made up of only two things: neurosurgery and watching youth sports.

He plays football in addition to hockey; he's also now the goalie for his school's JV soccer team. I suppose spring will vacillate between operating and cheering for excellent saves.

Hopefully it won't involve any hooliganism...

Hockey parenting has worn me out recently. I get that hockey is a physical and sometimes violent sport. What I don't get is the vitriol spouted by players - and their parents. We're talking about 11 and 12 year olds here. For instance:

Last year, our team was in the semifinals of the league tournament. Admittedly, one of our kids was very big for his age. He therefore drew a lot of attention from everyone, including referees. You might imagine that a kid so big could execute a pretty effective check. Thankfully, he never seriously hurt anyone.

Well, the game is ticking along, and several kids (including him) go down in a pile in the corner of the ice while chasing the puck. As they disentangle themselves, an opposing player grabs our big kid's leg while he's trying to get up. Probably their kid was trying to clamber up himself. Regardless, it evidently appeared to the opposing team's parents that our kid was deliberately stepping on their kid with his skate.

At this point, a mom from the other team standing close by started hopping up and down, screaming abuse at our kid at the top of her lungs. "Did you see that?! He stepped on our kid! Throw him out! ##@*^^&! I can't believe this! $$@#**..." She went on and on in the same vein.

After about 5 minutes of this ranting, I had enough. I turned to her and politely said, "Do you think it's possible that our kid might just have been trying to stand up, and that he might not have been trying to step on anybody deliberately?"

Fuel to the fire! Instantly, her vehemence redirected itself at me. "OOOOhhhhh, no! Look here, I got it all on video! Do you want to see it?! He did.... etc. etc..." waving her video camera ecstatically around her head. I stared, fascinated, as her face turned redder and redder. Finally, she shrieked, "Stop looking at me! You're STILL looking at me!!" Of course I was, sort of like rubbernecking at a car accident... I'm sure my eyes were as big as saucers at that point. What, really, did she expect?

I must admit, I have no experience with this sort of thing. Being a classic nerd, I was never involved in any fisticuffs or hair-pulling in the halls of my high school (although I have witnessed such events). But, surgeon-like, I do have a temper, as I have admitted elsewhere. By now, I was angry at her hooliganesque attitude and the things she screamed at our 11 and 12 year olds. Hence, a few low-level comments did fly back and forth as the game progressed. (I know, I shouldn't have needled her.)

Unfortunately, the offending mom became further inflamed by our team's obvious impending victory. Finally, she appeared beside me, literally dancing with rage. "I'm a dentist, and I can fix your teeth; how about THAT?!" she seethed.

As I mentioned, I am a novice to this sort of thing. Now I was thinking, "OK, if she wants to wage the war of the degrees, she's not going to win..." So I replied, quite seriously, "Well, I can fix your brain..."

This was not received in the spirit in which it was intended!

After I declined her subsequent invitation to come outside to the parking lot, rolled my eyes, and redirected my attention, my less naive husband started snickering. He had been standing behind me, knowing what I was thinking. He told me later that he was muttering under his breath, "Don't say it... don't say it.."

Well, so my knuckles (and my teeth) remain intact to this day. But I continue to be horrified by some of things hockey parents yell at kids on a regular basis. Some rinks, unfortunately, actually sell beer for adults to drink at youth hockey events. You might imagine this doesn't make things any more civil. It's not limited to just hockey, either, from the stories I hear about other youth sports. My son tells me about the profane trash talking he's heard from kids (and their coaches!) on the ice; wonder where they get that? I just can't wait to see what things are like when he's in high school.

I Wrote a Book. Really.

Two years ago my friend Jessica, who is also my patient, invited me lunch. Jessica and I met in a small group at our church. We were merely acquaintances when she first became my patient, but our friendship had deepened over the years.

After the lunch date pleasantries had past, there was a long pause in conversation. “I have an idea,” she said, “Remember when I was pregnant and I would pull out all my pregnancy books every time I felt any twinge of pain? The books would scare me to death, so I would call you freaking out that my baby was going to die from eating deli meat. Then you would explain it to me and calm me down?”

Me, “Yeah”

Jessica replied, “Well not everyone is friends with their OB and can do that. Let’s write a book together! You write the medical information and I’ll write from a patient perspective. We can write from a Christian slant as well, to help women lean into their faith to give them a greater amount of peace as they walk through their pregnancy.”

Me, “Sure, sounds like a great idea, though I have never done anything like this before.” I will now admit, I didn’t really think anything would come of it at the time.

We wrote a proposal and the first chapter. A few months later we got an agent. Then we waited.

On November 11, 2009 my husband and I brought home our son from the hospital. On November 14, 2009, Jessica and I got a book deal. The manuscript was due in four months. So when I wrote this post about my maternity leave, I left out a few stressful details: like getting up every morning at 5 am to frantically write for 2 hours before work each day.

We finished the book mostly on time. Then there were a zillion rounds of edits. I learned to enjoy the process, but it was stressful because there were so many unknowns for me.

Jessica was attempting to have another baby as we were writing the book, so we decided to start a blog to journal her process and promote the book. Sadly her journey was a little more exciting than we had planned, but after a ruptured ectopic and 4 rounds of clomid, she is now expecting a baby boy.

I was very torn as to whether to ‘out’ myself and mention my book on this blog. My publisher does not know I that I write for this site. Yes, I recognize the irony that most bloggers are eager to get a book deal, while I have failed to mention to my editor that I am a ‘blogger.’ After much thought, I decided to mention my book on this site for a three reasons:

I am so amazingly proud of the book and all the hard work that went into it. I think it’s an awesome resource for women and I want as many people as possible to know about it.

I can cross post at both my book blog and this blog and save TIME! Sadly this is probably the key reason.

I wanted to say thank you to our readers and my fellow MIM writers for their support and encouragement over the last few years. I know that my experience here helped give me the confidence I needed to attack this project.

Yesterday was our first book signing (That's me on the right). It was surreal. So, many people came out to support us and our book, that we sold out the store. It was amazingly gratifying to see all our hard work pay off.

So here's my book: buy it, link to it, contact our website if you are interested in reviewing it or simply ignore it.

When we were done with the writing, and we entered the marketing stage, I was asked to come up with "just a few lines to describe the book." Really? Describing a years worth of work in a few lines is more challenging than you would think, but here's my blurb:

"My prayer is that this book will enable women to enjoy as much of their pregnancy as possible, relishing the hope that is growing inside them, and not be deprived of their peace by unnecessary fears.”

OMG, I've got to get out of here!

In the division of labor between myself and my husband, I have been given the task of daycare drop off and pick up. It makes sense for a variety of reasons, one of which is that my husband often gets home after the daycare closes.

As a result, at the end of the day, I am sometimes FREAKING OUT that I've got to get out of the hospital before the daycare closes.

Our daycare has pretty long hours, so 90% of the time I arrive very comfortably before the deadline. 5% of the time, my daughter is one of the last kids there, but it's still no problem. Then another 5% of the time, I'm racing furiously through traffic to get to the daycare before closing time.

I've always made it there in time, sometimes with a safety margin of only a minute or two. I guess it wouldn't be the end of the world if I were late. Basically, I would be charged like $20 per minute after the deadline and I'd have to find my child sitting there all alone with a forlorn, abandoned expression on her face. That's still better than the hospital-based daycare a friend of mine was using, where they would call child protective services if you were more than five minutes late.

Most of the physicians I work with don't seem to have this issue. All their kids are older or they have a spouse or relative to help out. They say they were at the hospital till 8 o'clock the night before and just shrug like this is no big deal. In medicine, things come up. If you've got one foot out the door and a patient says he has 10 out of 10 chest pain, what are you supposed to do? There's no excuse not to stay. You can always put off dictations a little bit longer, but there's no excuse for not caring for a seriously ill patient.

It's yet another thing to consider when entering medicine. You do lose a degree of flexibility and control in your life, which can be rough when you have small kids.

Thinking Outside of the Box

I know the electronic medical records get a lot of flack. Some of it is well-deserved. But as a pathologist who started training in a void, the EMR has been an invaluable addition to my practice. Traditionally, we pathologists work inside a black box. We rarely venture out of our lab closet caves - god forbid going to the floor to wade around in the muck of the paper chart. We all have computers next to our scopes, and gaining access to our patients in this manner - radiology, clinic notes, etc., makes the glass slide with a two dimensional slice of Easter egg dyed tissue spring to life.

Some clinicians are better than others. Surgeons and radiologists are notoriously brief, with rare exceptions. There is a certain infectious disease specialist at my hospital that writes so voluminously and well that I feel like I am sitting at the bedside of the patient I am puzzling over. There is a big difference in the large hospital I am primarily based at versus the small town hospital I rotate at once a month. In the smaller town, clinic notes are piped into the hospital medical records (must be easier there to do this I guess - less clinics, less complication) so I can access outpatient records - the clinician's thoughts can illuminate a tough GI biopsy and make it so much easier. It saves me lots of headaches and phone calls.

Performing wet reads on CT-guided needle biopsies in radiology is a particular sore spot. I know the radiologists are busy - drain an abscess here, do a paracentesis there, squeeze in another needle between a couple of radiofrequency ablations. But I still get irked when called to a lung biopsy and the radiologist doesn't know the history. I know, I know, I don't have to worry about causing a pneumothorax and putting in an emergent chest tube or dealing with a pulmonary hemorrhage - and they do. We all have our places in the cog of the medicine wheel. Thankfully, with EMR, I don't have to worry about what the clinician did or did not communicate to the radiologist - I can just open up the computer and get all the information I need to know. Information aids diagnostic accuracy, and ability to triage the specimen appropriately.

Take for instance the other day. I was sitting in my new (beautiful - yes still a closet in a lab, but with brand new coppery Formica and linoleum hardwoods that render me the envy of all the other pathologists) office and grabbed a CSF (cerebrospinal fluid) case. The cytotech screened it and called it negative. 90-95% of the time they are right. I picked up the cytospin, threw it on the stage, and looked in the scope. Low cellularity -appropriate for a CSF - a few lymphocytes and monocytes. But wait, what was that? A plasma cell? Plasma cells are never normal in the CSF. Often they herald chronic inflammatory issues or viral illnesses. I opened the EMR on the patient.

This patient had a diagnosis of plasma cell myeloma with recent acute mental status changes. So the lone plasma cell or two I was seeing, among the lymphs and monos, could indicate leptomeningeal spread of the patient's disease process. I reversed the tech diagnosis to atypical and added a lengthy comment - unfortunately there weren't enough cells to attempt flow cytometry to assess for clonality of the plasma cells to cinch the diagnosis. But with the information in the EMR I was able to get a more holistic picture on a couple of cells and provide better care for the patient. I cringe to wonder if I might have blown them off as lymphs without my crutch.

I open the EMR every day, all day, on almost every patient. In the rare instance that I see cancer in a specimen where there is no clinical or radiographic suspicion, I can take extra measures to ensure that I have the correct specimen and gain additional consults to firm up my suspicions. I am a pathologist, but with EMR, I no longer live in a black box. And for that, I am thankful. I really don't know how my predecessors got along without it.

MiM Mailbag: Become a surgeon and have a family?

Hello All,

 

I just found this blog and was excited to see women discussing topics that I am interested in.

 

I have recently decided that I want to go to med school and become a doctor (as I near the end of my graduate education). My husband is supportive and willing to sacrifice as I start the process of preparing to apply to medical schools. I am currently 28, working full time (in the energy industry) and attending graduate school part time.

 

After that I will need to take pre reqs and then mcat before I will be able to apply to med school. This means that I will be going to school during my 30's. I want to become a neurosurgeon, but I also want to have a family. I am not sure how to do this. Since I don't know anyone else who is trying to do something like this I have no examples and would like some advice.

 

I have thought long and hard about what it would mean for me to become a surgeon and have decided that it is worth the effort and sacrifice. But I don't want to forgo family and motherhood. Is there any one of you who have experienced this same dilemma. If so, please give some practicle advice. I would like to be as prepared as I can be.

 

Thanks so much!

 

A

This one's for the girls

At the risk of exposing my musical tastes (and innate sappiness), I have a confession to make. Whenever I hear Martina McBride's This One's For the Girls, I tear up. I'm so not kidding. I'm not even a country girl--I prefer The Killers to Carrie Underwood --and I couldn't tell you another song that Martina McBride sings. But, this song has always made me want to link arms with women everywhere, celebrating how much we share in common: the broken hearts, the high dreams: reality ratio period, our struggles to find ourselves. You're beautiful the way you are. See. There I go again. (NB: for all of you who have never heard this song, I suggest playing the YouTube video linked above but just listening; the video kind of weirds me out. Who directed that thing?)

It's with this background that I write this post, a post I've had in mind for awhile now and directed to all of you in your 20's.

What I wish I knew in my 20's: it gets so. much. better.

When I was in my 20's, I remember thinking that this must be my peak age. Bone mass and fertility peak...it must all go downhill from here. I had no reason to believe it shouldn't. I steadied myself for a future of decline in all respects.

Now, comfortably past the mid-way mark of my 30s, I would never trade being in my 20s again for now. Now is awesome. With time, the insecurities, the not knowing myself, have gradually slipped away. I feel more powerful, confident, and, yes, comfortable in my skin than ever before. With time, I know me, accept me, in ways that the younger, more stronger-boned and fertile me could never have imagined. Plus, now there is a growing family - and the joy and richness that brings, a more mature (and ever stronger) relationship with my husband, and a satisfying career on a path that I'm setting, not anyone else. The 30s rock.

And, I have a suspicion, and a hope, that it just keeps getting better. Perhaps "all you girls about forty-two" could chime in...

There's no need to fear growing older, MiMs. Look forward to it. The best is yet to come.

Battles: health vs not health

The battles begin, continue, and at times seem to never end. And while I'm defining "battles" quite loosely, such is parenting. For at least one of my two children, (glass half full, that's 50% of my kids where parenting goes smoothly!) we battle over things we humans needs to do. In a pseudo-valiant attempt on my part to limit battles to those things that would impact one's health, I've let lots of things go, but not when it comes to her health... so what really constitutes health for this MiM? Might depend on the day and my patience.

• Brushing teeth? Health. Must happen twice daily. Worth the battle
• Brushing hair? Jury's out on that one. Might be health. Battle not worth it, but still occurs
• Washing hair? See above
  
• Wearing coat? Survey says: Not health. No battle.
• Eating vegetables, or even one vegetable, even one time? Health. Worth the battle, but losing it.
• Eating fruit? Health. Mission accomplished.
• Refrain from antagonizing brother? His health. Battle would ensue, but tenets of role modeling would say to avoid battle and let them work it out.
• Going to bed at a reasonable hour? Health-related. Battle prolongs time awake. Fail.
• Letting this MiM sleep a few more minutes in the morning? My health-related. Battle sets bad tone for the day and promotes wakefulness anyway. Resolve not to battle.
• Hugging and making up? Ahhh, that's what it all comes down to, what are we battling for???
  

One clinic day, three responses to my pregnancy

I dislike that pregnancy forces me to bring my personal life into the office. I don't have pictures of my kids on my desk, I am vague when curious patients ask where I live and on Monday mornings I never volunteer my weekend activities to the staff.

But this pregnant belly, no matter how discreetly swathed in muted professional clothes, begs comment from everybody.

* * *

A patient comes to see me for follow-up after a miscarriage. I am acutely aware of how difficult it might be for her to see her doctor pregnant.

As I call her from the waiting room I feel that I am flaunting my fertility. I will my belly to shrink down a little, to look less jaunty, but her gaze is fixed on it as she approaches. She grabs my arm, looks at me earnestly, and says, "I'm happy for you. I really am." And I can tell - she really is - and I am moved by her graciousness.

* * *

I'm signing off results, standing in the reception area with my Sharpie fineliner in hand and a stack of cream-coloured files in front of me. One of the secretaries swivels around in her chair. "Hi, Mama!" she exclaims. I look up briefly, say hello, and slide the next chart towards me.

She looks me up and down and beams. "When I was pregnant with my first . . . " she begins, and I only half-listen as I methodically sign off hemoglobin levels and ultrasound reports.

I snap to attention, though, when I hear, "You've even got a bit of a booty now, eh?" I turn to look at her, and my expression must have some level of fierceness to it because she quickly amends, "Only a very small one, though," and turns hastily back to her keyboard.

* * *

I have lunch with a colleague in town for a conference, a forty-something man with no children, and he asks what benefits I receive as a member of our provincial medical association. I list them: CME funds, malpractice insurance, an RRSP program, maternity leave benefits --

He interrupts me. "Why should others pay for your lifestyle choice?" he asks bitterly. He gives a short diatribe on the injustices borne by childless men. I try to interject but give up when he complains about having to pay taxes for neighbourhood schools which don't benefit him directly.

"If you get a leave to have a baby, I should get paid leave to take a water-colour painting course," he concludes.

A few days later he swings by my office. He sets a steaming coffee on my desk and offers, "You can have as many children as you want, Martina."

My Favorite Patient of the Week

My last patient of the day was in quite a foul mood.

She had just come from the orthopedist office. He had told her that due to her recent roller blading injury she could no longer snow ski.

"He's a bastard," she said "I'll show him, I'll do my physical therapy and be back on the slopes next year!"

She is 76.

She is awesome.


*details changed to protect patient privacy

When a patient is not a board question

I am really enjoying my Geriatrics rotation. Although my attending preceptor is primarily a geriatrician, he also sees some patients who are younger. I took a history on a patient who was younger than me today, in her early thirties.

She started off complaining about insomnia and headaches, and then said she had some sort of an "attack" earlier this week. She quickly added that her husband died suddenly three weeks ago, and her therapist recommended that she come to see her doctor. I immediately offered her my condolences.

My mind quickly flipped to a frequent practice board question as I gently asked her about other symptoms. A 40 year old man presents to an outpatient clinic complaining of insomnia, poor appetite, and feeling helpless and lonely. He frequently thinks of dying to join his wife. He lost his wife of 18 years five weeks before. Was she suffering from loss of appetite? Was she able to return to work? Had she thought about hurting herself? What did she mean by an "attack"?

Telling the difference between Bereavement-Related Depression (BRD) and Major Depressive Disorder (MDD) is a frequent sample board question that I have come across in various forms as I have been doing patchwork board review. Bereavement is an exemption from a MDD diagnosis for two months after the death of a loved one, while the duration of depressive symptoms only needs to be for two weeks otherwise. Board review questions often dance around this time period. This BRD exemption (and the duration of symptoms for MDD diagnosis in general) is also the subject of some controversy as experts are constructing the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-V), which is the guide to diagnosing mental illness.

I snapped out of my board review musings and continued to question and console the new widow. When I got up to leave the room, I strongly considered asking the patient if I could hug her. Since it was only my third day on the rotation and I was in the room with the physician's assistant, I decided against it. I think if this would be my own patient in my own practice in the future, I would not hesitate to ask. When I left the room and told the other student about it, I teared up.

I guess my empathy toggle switch is still operating just fine.

Cross posted at Mom's Tinfoil Hat

Anger Issues

When I was in my intern year, one of my attendings named Dr. Pasture informed me that I had anger issues.

Dr. Pasture was leading a small group exercise where another intern was playing the doctor and I was playing a difficult patient. I had fun with it and tried to be a difficult patient to the best of my acting ability, laying it on as thick as I could. I was later presented with an Academy Award for Best Supporting Actress. (Just kidding, I only got a Golden Globe.)

I noticed that during the role-playing, the other intern started getting flustered to the point where I felt a little guilty. So after we were done, I laughingly apologized.

Later that day, I had a clinic with Dr. Pasture. While I was in his office, he said to me, "I want to talk to you about something, Fizzy."

That didn't sound good. I immediately started to panic. "What is it?"

"You know," he said, "it's okay to get angry. If you felt a need to apologize for yelling during that role playing, I suspect you never show any anger. I just wanted you to know that it's okay to get angry at people."

That was the last thing I had expected him to say. At first, I was just baffled. But the more I thought about it, the more I realized he was kind of right.

I do get angry, of course, but I never, ever yell. Or even snap at people. I don't even do it in my own home, because both my husband and daughter are exceedingly sensitive. As an example, a few nights ago, my daughter spilled a big cup of water everywhere after I warned her to be careful... all I did was say her name sharply, and she ran crying to the closet and hid in a suitcase. So I've kind of trained myself never to yell.

But what's so bad about that?

My husband showed me some study (I'm too lazy to find the reference) where women who didn't vent their anger at their husbands had a shorter life expectancy. I'm not entirely sure why he'd show me a study that would encourage me to yell at him more, but I guess he felt concerned that I was angry at him sometimes and just not expressing it. I'd argue that while I may not yell, I do other great wifely things, like whine, complain, and nag. I certainly don't walk around constantly feeling angry at my husband. And I vent a lot of my frustrations through writing.

Then again, I do sometimes find it hard to let go of things. Every now and then, I compose rants in my head directed at people who I feel wronged me years ago, thinking about what I wish I'd said to them. ("The jerk store called and they're running out of YOU!") Am I the only one who does that? It doesn't feel particularly healthy.

I'm not sure what to think. I don't particularly like people who yell a lot. I tend to think they have poor control over their emotions. But who's more likely to have the early coronary, me or them?