Guest Post: Ruminations on Shift Work from a Mother in Pediatric Emergency Medicine

An emergency medicine physician’s schedule is inherently flexible. I can quickly switch a shift with a colleague to accommodate emergencies since there are no patients to reschedule, trade random hours of coverage in order to make it to a school function, pick up my oldest son from school earlier than the other “late day” kids when I have an early shift.

Almost thirty minutes into the resuscitation, the room has gone quiet except for the ding of the monitor alarm. This five year old victim of smoke inhalation from a house fire has a good airway, two good lines, has received several rounds of epi, fluids, even the useless calcium and bicarb and there is no change. His pupils are fixed and dilated. “Time of death 13:52.” my voice breaks the silence. I walk out of the room and wait for someone to find his mother. She was out when the fire broke out.

I finish notes, try to wrap up my shift. His mom arrives and I sit with her and tell her the news as she cries silently. I hold her hand and then the social worker and chaplain take over. I silently leave the room, sign out to my colleague, and leave to pick up my son, also five, from school down the street.

When I arrive, he runs to greet me and the sudden force of his hug knocks my hair into my face. I smell smoke. I have to hold him longer to get control of the tears that are welling up in my eyes.

Overnight shifts are great for the working mom (who is used to sleep deprivation anyway, right?) Now that the baby sleeps better, they hardly know I’m gone. Their dad can get breakfast ready and I can do last minute lunch prep and kid dressing when I come home after my shift. Then I catch some sleep in a quiet house while the oldest is in school and the baby is with our nanny.

Thirty minutes before the end of my shift the radio alert sounds. I hold my breath as the nurse answers - a 6:30 AM radio call is either a radio check or a dead baby. Unfortunately, today it’s the latter. CPR is in progress. We ready the room, draw up meds, check the laryngoscope, and wait. I review drug doses and intubation technique with the resident and all the while I am just grateful that there’s another hospital closer to my house than the one I work in, because it means that this baby is not my daughter.

She arrives and is stiff and cold. Livedo has set in. We make an effort but mostly to dot our i’s and cross our t’s and give the family time to arrive and bear witness to our efforts. We care, we tried, she is important, we are sorry...... but she is the same age as my daughter and later that morning during my protected sleep time I just lay in the bed and cry, holding one of her blankets to my face.

Shift work is one of the features that is supposed to make emergency medicine ideal for the working mom. But shift work in the pediatric emergency department isn’t really shift work after all. I hope that as I accumulate years of experience that I can compartmentalize better and not “take it home with me,” but that’s not looking so promising since I can’t seem to concentrate when I know that my kids are in someone else’s car until I hear they’ve reached their destination safely. I hope that it’s just because my kids are so young and that as they get older I will worry less - but I know that’s not true as I call the pediatric oncology fellow for her opinion on a teenager with pancytopenia and a mediastinal mass. Perhaps all I can do is somehow convince the universe that bearing witness to the suffering of other children and their families is suffering enough, and then maybe the universe will protect my own children.


*patient details changed to protect patient privacy

MiM Mailbag: Baby and OB/GYN internship - HELP!

Hi MiM! First, thank you so much for all of your posts, advice, and stories. I can't tell you how much they have helped me, and I'm sure others.

I'm writing because I have a big decision on my hands and I feel as if the women in MiM might be the only ones who can help me make the decision that is right for me. I am a 4th year med student, in the midst of interviewing for residency. I have long been in love with OB/GYN as a field, but not the atmosphere. So, I decided to dual apply in OB/GYN and family medicine, where the people were more like me, and I could possibly still do OB. My decision to apply in FM was also partially influenced by an intense desire to start a family with my husband, who is a PhD student nearing the end of his degree. We tried to conceive for about 7-8 months as I was in the midst of my surgery clerkship and then my OB sub-Is, and as might be expected my best laid plans to have a baby at the middle/end of 4th year crashed and burned. Even though I was devastated and worried about my own fertility, my husband and I decided to stop worrying about trying to get pregnant until after a few years of residency. Of course, the fertility gods decided to play a little joke on us. As soon as we stopped really "trying" - I wound up pregnant. The baby is due in August of my intern year. I really think I want to do OB/GYN, and I really don't want to lose a year of training, but I'm not sure how I will manage having a baby in intern year. I also don't want to start off on such a bad foot not only with my training but with my fellow residents, who might hate me for 4 years!!

I realize there are a lot of pros and cons to either taking a year off, or starting internship 8 months pregnant and giving birth at the beginning of internship. And, there's also the option of choosing FM over OB, since it is more of a baby-friendly residency, but I'd hate to feel like I didn't choose my preferred specialty because I got pregnant. I guess I'm just hoping to get advice from some of you who are much wiser and more experienced than me in all this. I'm not sure how many people have gone through something like this, but if there are any out there who can give me their words of wisdom, I would be incredibly grateful.


I'm a 4th year med student (I'm 27 and married), born and raised in the northeast, and currently double applying in OB/GYN and family medicine. And I'm 5 weeks pregnant.

On My Reality as a Primary Care Doc and a Mom

As a premedical and then medical student, and even as a resident, I was hell-bent to practice International Health in a third world country. I spent every clinical second I could in far-flung forgotten corners of the world, doing crazy medical stuff. I never imagined myself practicing Internal medicine at a well-to-do practice at a major academic medical center in a big city in the U.S. As a matter of fact, I scoffed at that idea.

And yet, a decade later, I made the very deliberate choices that led me to exactly this reality. Here I am; and as shocking as it would be to my 20-something self, I am pretty darned happy.

It’s a long story how I came to be where I am, a story involving first my own naivete/ a hefty dose of reality, and then my own evolving understanding of myself/ the world. And a lot of therapy. That’s a whole other essay. Now, I can comfortably talk about balancing my growing family with a rewarding career in Internal medicine.

Here is my reality:

I’ve been in practice for 3 years. I was lucky enough to be hired into this small, unique practice that sits within a very large medical complex. Every provider here is part-time. No one sees patients more than 5 sessions a week. Almost everyone is heavily involved with some other aspect of medicine- academics, administration, research. We are on call for our practice for 7 solid days every 2 or 3 months. The reimbursement and perks are pretty good, for academics. We enjoy wonderful administrative and nursing support. The environment is positive, supportive, and progressive. (And, it is subsidized by the major medical center we live in, because they need us.)

I started off heavy in academics and research as well as my clinical responsibilities, but have dialed it back to only clinical responsibilities, 5 sessions a week, FOR NOW. I’m no longer working with medical students, and no longer participating in research. The reason is that I’m focusing on my family- getting pregnant, being pregnant, being with my very young kids as much as I can. And this practice “gets” me. They’re all OK with me stepping off that career treadmill, because most of my colleagues did much the same thing. I know I’ll be back, and I am not worried.

And, Primary care is fun! After 3 years here, I can walk into the exam room where my patient Jackie is and say, ‘Jackie, What the hell! Three ER visits for weirdo bizarre accidents- A staple gun to the hand? A tool box on your toes? I don’t even want to know about that buttocks injury. What on earth is going on?’and she laughs and says ‘I know, I’m a clutz, we’re doing the DIY thing and I think me and power tools shouldn’t play together. Even when I’m not using one, I trip over it’.

Or ‘Mary, we’ve been playing this diet-exercise-and-weight-loss approach to your blood pressure for two years now, and it’s not working. Don’t you think it’s time to throw in the towel and take some blood pressure medicine already?’And she says ‘I know, I know- I was wondering when you would call me on it. I wanted to try, though, and I appreciate your letting me.’

It makes such a huge difference in my day that I am beginning to KNOW most of my patients. And, they know me. I’ve got photos of my family up, as well as this great pregnant belly, and people ask me about them, and share their own stories… I insist on 20 minute urgent visits and 40 minute physicals for my patients, and all that extra time gets used, with talking. Really talking. I think it works- not only for me, but for my patients as well.

So, for now, I work my 5 sessions over 4 days a week, and in my spare time I do some blogging. The rest of my time and energy is spent with my Babyboy (17 months old) and currently, being 9 months pregnant with soon-to-be Babygirl; as well as quality time with my husband and parents. We moved back to this city to be close to my parents, and my mom takes care of Babyboy when I’m at work. Hubby is one of those dream husbands who shares the cooking, cleaning, laundry and just about everything else, while managing his career in the media. FYI, I am the main breadwinner. Our life is not extravagant; our life IS very comfortable. We know we will never be able to send our kids to private schools, nor afford fancy vacations etc. and that’s OK. What we have- THIS WORKS.

I think that what makes this setup work so well is 1. my working part-time, 2. working in such a great environment, as well as 3. the family support we have. And all this was no accident. When I actually set about looking for a job, these key things were exactly what we (me and my husband) were looking for. We did have to move to get here. But we are glad.

I freely admit that in the world of medicine, primary care reimbursement is abysmal. I make a decent living- compared to our neighbors. Compared to my med school and residency friends who are now gastroenterologists, endocrinologists, hospitalists, anesthesiologists, and many other specialists, I make a pittance, even taking my hours into account.

I get frustrated that my med school loans are so huge. The interest grew and grew all those years while I was in training. What I earn is barely enough to pay the loans/ interest as well as the mortgage etc. I never thought about that for two seconds when I was pre-med or in med school- I always blithely assumed that it would all get taken care of somehow. We manage- and again, overall, we are very satisfied with life. But there are times when I get mad about it, too.

I get frustrated that so much of primary care work is not recognized, or reimbursed. For example, it’s my day off at home, and I just spent three hours logged into the electronic medical record to check lab and radiology results for patients, and send them their results as well as a plan; also called one young patient to inform her she has Chlamydia and needs treatment, spent 30 minutes with her on the phone; refilled numerous meds (ones the nurses could not refill without collaboration); responded to several emails from specialists regarding mutual patients; answered several emails from patients (we have a system where patients can email us with questions, which is great but TAKES TIME); and reviewed my schedule for tomorrow as prep. This is normal. The workday often spills over into the evening and the weekend. It ends up being a lot more than what is registered on the paycheck.

Having voiced all those frustrations, I know that no matter what speciality you end up in, there are always frustrations. No matter what walk of life, really, there will be frustrations- when you’re in the nitty-gritty, the negatives present themselves. But, in the grand scheme of things, I’ll take my career over anything else.

I think that as a doctor-mom, I have it pretty good. Overall, I am, and my family is, very happy.

Medicine: Not for mothers?

I have to be honest: I'm a little burned out on writing about what PM&R is and why it's so awesome. I've covered it before both on Mothers in Medicine and on my own blog. People email me questions about it frequently, which I'm happy to answer, but... it's just hard to motivate myself to write yet another post about it.

So with the permission of our lovely moderator KC, I'd like to address the topic week a little more generally, and say some things that have been weighing on me lately. Namely:

Medicine is not a great career for a mother.

There, I said it.

Since we were asked to address which aspects are not family friendly, allow me to do so:

1) Unpredictable

When you're dealing with sick people, you can't predict your schedule, whether you're doing inpatient or outpatient. You might think you're going to be done at 5PM, and then your last patient will say, "Oh by the way, I'm having 10 out of 10 chest pain." Imagine it's 6PM, your patient says that, and you know your daycare will close in 15 minutes. It can (and will) happen.

2) Unforgiving of illness

Have I written about this one enough? I think I have. When you've got two children who pass colds back and forth (and then to you), you realize how difficult it is to be in a job where you basically can't call in sick.

3) Must work part time to work "only" full time.

An attending I talked to at a VA (not exactly a rigorous working environment) said that she had to cut back to working 75% time in order to only work 40 hours per week. Between on call time, documentation, phone calls, etc, the hours on your contract don't in any way resemble the hours you work.

4) Will mess with your sleep/wake cycle

It's bad enough worrying that a baby will wake you up. Worrying that a baby OR a pager will wake you up is enough to drive you crazy. I like my sleep, so this is a big one for me. How many times have I wished to be in a job where I could sleep through the night every night... ah, heaven.

5) Residency is killer

Dare I say that no residency is actually friendly to mothers? Yes, I'll say it. I'm sure some of you will come up with exceptions, but I think it's pretty overwhelmingly true.

6) You can't take a break

In a lot of careers, you could probably take a year or two off after your child is born. In medicine, it's much harder. You forget stuff and are rusty when you get back... not a great thing when you're dealing with people's lives. Taking long breaks is also a bit of a dink on your "permanent record." I once tried to apply for hospital privileges through a computer system and the program would not let me submit because I couldn't "account for" the 1.5 months between med school graduation and the start of internship. If I had taken a year off, the computer probably would have exploded.

7) The consequences of a mistake are so horrible

When you're a doctor, you can't mess up. People's lives and livelihood are at stake. You can't be careless for the sake of getting out a little earlier.

Truthfully, I sometimes feel like the entire school system is lagging behind the idea that two parents might be working. I mean, the school day ends at 3PM, which is extremely inconvenient for working parents. Kids get random weeks off from school during the year and the whole summer. And if they get sick, they're supposed to stay home. What on earth are we supposed to do with them if both parents work?

OK, but here's the good news:

I work as a consultant, which allows me to have a lot more flexibility. While I can't just not show up, it's not as big a deal to shift my hours. And the base salary for most physicians is enough that we can work part time (i.e. normal people's full time) and still bring home a good paycheck. (If you want to read more about what makes PM&R a good specialty for mothers, you can click on the link I mentioned above.) And if you enjoy the work you're doing, presumably you're happier in general and therefore a better parent (maybe).

But it's hard not to get a nagging feeling that when you're trying to juggle both motherhood and medicine, you're failing a little at both.

Topic Week: brief thoughts...

I struggled about what to post for topic week. I feel like I should post as a voice of one of the “not family friendly” specialties and a resident, but also I feel like I’m still so much in the middle of training that I don’t have perspective yet. So, all I have to say is this - It can be done. Its hard for all of us - pediatricians, anesthesiologist, OB/GYN’s, surgeons, residents, medical students (I’m just naming some specialties that I know mom-docs). In all honesty, I think its hard just to be a working mom of any type. But, people do it. Children survive and succeed. I love medicine and patients and surgery and I LOVE being a mom. I’m just going to keep doing my best, using my support systems, asking for help and praying that I do this right.

Also, I welcome any specific questions!

Guest post: Med Peds

In medical school, I started off wanting to do Family Practice.  I always knew that I wanted to do primary care.  With Family Practice, I would be able to see the whole spectrum of ages, and care for the whole family across generations.  While I was in the midst of planning my 4th year rotations, a friend suggested that I consider Med Peds.  It was about the same time that I realized how little Peds rotations are required in Family Practice, and how much OB was required.  I knew that I wasn’t going to do OB, so it seemed like a complete waste of time. 

I ended up matching in Med Peds, and realized after the first 3 months of internship when we switched specialties that I was in deep trouble.  (My program, typical of many Med Peds programs, has residents switch from Medicine to Peds every 3 months and so on.)  Throughout my residency, I felt like I was constantly behind all my categorical colleagues.  I was also tired of having to do so many inpatient and ICU rotations.  That’s what happens when you try and cram two 3 year residencies into 4 years. 

When I got pregnant in my 4th year, I was forced to give up my international rotation.  I was very upset, and felt that I was being punished for being a woman and pregnant.  (This harkens to all the blog entries and posts about residency requirements for maternity leave, time off, etc etc.)  There were too many core rotations to do, and so I couldn’t do a “fluff” rotation when I was already going to take time off for maternity leave.  (I took 8 weeks off after having a C-section for a premie, and then in the midst of trying to establish breastfeeding, went back to outpatient clinic 2 half days a week 2 weeks afterwards, and also had to do a rotation that involved reading books and writing papers.  After all that, I had to make up 2 weeks at the end of residency.) 

In retrospect, I would have just forced myself to pick either Medicine or Peds.  It was too stressful trying to do both.  At heart though, I do enjoy being a Med Peds doctor.  I still enjoy taking care of the whole spectrum of ages, and feel that I received excellent training despite feeling behind my categorical colleagues during residency. 

The best part of it is that after practicing for a few years in a more traditional setting with lots of inpatient call, I now have a job that is 100% outpatient.  I see patients Mon to Fri, and have no weekend and no overnight inpatient calls.  Yes, I do have to be available 24-7 to answer telephone calls, but it’s a world of difference from having to go in to the hospital in the middle of the night.  With primary care, it’s entirely possible to find a group that does purely outpatient.  Additionally, you have the option of doing urgent care or being a hospitalist, and these types of options are far better in my mind than traditional outpatient plus inpatient duties.  With the increasing popularity of hospitalists, both adult and peds (though peds is now just starting to catch on), there are now more and more options for practices that allow you to work more regular hours where you can actually see your kids.  It will be not prestigious or lead to awards and recognition if you are looking for a purely outpatient job, but as long as you don’t aspire toward a distinguished academic reputation, then you have options. 

Career Topic Week

Our next Mothers in Medicine topic week (weeks where we feature posts from our regular contributors and readers on one topic; morphed from the original topic days when we had way too many posts for 24 hours...) will be next week, December 12-16, with the topic being our chosen medical specialties, as they relate to being a fit for our lives as mothers in medicine. Posts may address aspects of our specialties that are family-friendly, which aspects are not family-friendly, things we wish we would have known before choosing our specialties, opportunities for part-time work, and really any musings on the topic.

You can link to prior topic week posts from the sidebar to see examples.

If you'd like to contribute a guest post for topic week, please send it as a word document to mothersinmedicine@gmail.com. Would love to have them!

Thanks, as always, for reading and being part of this community.

Thinking big

There's a young physician named Dr. Thompson who works at my hospital. A few days ago, I heard some staff members talking about Dr. Thompson:

"Someday, I'm going to turn on the TV and Dr. Thompson will be talking about something important, and I'll be like I KNOW THAT GUY!"

On one hand, I was a little insulted that nobody would say that about me. On the other hand, I agree. Dr. Thompson is smart and has ambition. While I am thinking, "How can I help my patient?" Dr. Thompson is always thinking, "How can I help this hospital? How can I help my field? How can I help the planet?" I could never think as big as he does. Mostly, I'm just trying to get through the day.

I wonder, is it because I'm a woman with kids? Does that take the fight out of me? Is it possible to be a mother of young children and also think big?

Recently, I saw a list of all the female world leaders. There are currently 20 female presidents and prime ministers, which is a record number, and half of the 10 most populous countries in the world have female leaders. These are all women (many of them mothers) who clearly think big.

It was sort of inspiring to see that list. I guess it means I have no excuse.

MiM Mailbag: Working abroad

My non-physician husband and I have a wanderlust that is not well satisfied due to the constraints of my job. We would love to live abroad when our children are at an age where they can appreciate the experience, but not too old that they wouldn't want to hang out with mom and dad or have their education interrupted in any significant way. Ideally when our daughter is 11 or 12 and our yet-to-be-born son is about 8 or 9. We are actually pretty open to where we would live as long it is safe for a young expat family. 

There are two big issues  - the first is that (aside from broken Spanish) I don't speak any other languages and the second is that my huge educational debt would prevent me from going without a salary for very long. I don't need to make as much as I would as a US employed physician, but I can't be a volunteer. I also know that medical licenses limited to one country, and most countries will not allow you to practice without licensure through their own boards (perhaps Australia and New Zealand are exceptions? I heard they are cracking down on foreign MDs due to some recent issues with substandard care).

I have a very half baked dream of working for a US embassy (perhaps doing IM) but not sure if that is really feasible or if that circumvents the issues of needing additional licensure. Locums is also an option, but have heard mixed reviews of some of the agencies. I also emailed a few agencies and never heard anything back.

I have noticed that there is quiet a bit of international readership of this blog. I would be interested to know if anyone has information regarding American physicians who would like to work abroad.

Many thanks in advance,

s

www.theredhumor.com

My Morning

My morning before I even get to work:

--Wake up (duh)
--Shower
--Get dressed (OK, nothing remarkable yet)
--Breast pump ~20 minutes
--Pack up breast pump to take to work
--Nurse on other breast
--Change baby diaper
--Change baby clothes
--Wake up Mel
--Cajole Mel into getting dressed, sometimes doing it for her
--Make Mel breakfast
--Pour defrosted milk into pre-made bottles
--Pack up bottles with icepack + extra diapers or whatever else daycare ran out of
--More cajoling for Mel's jacket and shoes
--Get both kids into car
--Drop off Mel at kindergarten: kisses, clinging, tears
--Drop off baby at daycare: put bottles in fridge, peel off baby jacket, fill out "day sheet"
--Drive to work

Honestly, by the time I get to work, I've already been up for hours and it feels like the day must be almost over.

What's your pre-work ritual like?

Your worst sick story

After my last post, my husband still refuses to believe doctors/residents get chastised for calling in sick.

Help me out. Tell me your WORST story about you or a coworker calling in sick. Like how you called in sick and then your chief resident drove to your house and beat you to a bloody pulp.

Sick Days, Part the Millionth

I'm a PGY3 resident and my one year old baby has her first cold. I'm sick too. She's congested and can't sleep for more than about 30 minutes at a time. At 4AM, I realize that between being very sick and getting zero sleep, I don't know how I'm going to get through a busy clinic that day. I decide to text message the chief resident that I'm sick and won't be in that day, as well as sending an email.

The next morning, I wake up to a furious email from the chief, saying that my text woke her up and now she (also sick) has to cover my clinic after being woken up. I was inconsiderate on not one but two counts. (Had I not woken her up, I'm sure I would have somehow been yelled at for not letting them know soon enough.)

Later that year, I get tracheitis (whatever that is). I can't talk more than a few words. I come to work, but get sent home midday by my attending. I call the new chief to tell him I'm going to stay home the next day. I don't have anything even scheduled and was just supposed to "help out" with extra consults. "Well," he says, "I can dock you for the half day you took off today and a full day tomorrow. But the problem is, you can't take off more than six weeks in a year or else you have to make it up."

"Are you serious?" I'm baffled. "This is my second sick day. Do you have me recorded as taking off more days than that?"

"I'm just warning you."

Eventually, you get the message. Never call in sick. You get trained, like a dog or a seal.

I feel like now I need somebody to tell me when it's appropriate to take a sick day. In the past, before I got "trained," I took sick days when I needed to, sometimes more readily than I should have. Now I've gone too far in the other direction. There's a balance between being responsible about your job and ignoring family/health issues. When I tell someone that my child has a fever of 102 and is throwing up, yet I'm at work, it's almost a little embarrassing. Where are my priorities?

Recently, I had a pretty serious family emergency, and although I came to work, I left early. Unfortunately, I had a meeting in the afternoon where my presence was crucial. When I talked to the attending coordinating the meeting, I explained the situation and he said he'd have to cancel the meeting.

"Oh god, I feel awful about that!" I said. "Maybe I should just go to the meeting."

The attending looked at me like I was out of my mind. "Fizzy, stop it! You're being ridiculous. We'll just reschedule."

I felt grateful but also really ashamed over the decision I almost made.

34 Weeks and Grateful, but Man, am I Dragging!

I am so, so thankful to be pregnant, and that it’s been another uneventful pregnancy (knock on wood). I am grateful for all the family help I have at home- it’s really a little village raising our son. And I am acutely aware that the warm, flexible, pro-mom, super-supportive work environment I enjoy is a rarity for doctor-moms, especially for those of us practicing primary care.

But really, I am dragging. I’m trying, but every day is a slog. This Friday was tough. Friday is my long day: 2 clinical sessions, morning and afternoon. I need to get to work early, like 7 am-ish, to get ahead on paperwork and read through the charts of the patients I will be seeing that day. Then I typically see about 16 or 17 patients, a mix of physicals, new patients and problem visits. This mixed in with the patient phone calls and emails, lab and imaging results checking, pharmacy requests, specialist and therapist phone calls…. Then I need to fight traffic. By 7 pm, when I get home to my mini “second shift”, I am asleep as soon as Babyboy is in his crib.

But I also need to make a distinction here: while I am fatigued up the wazoo, I am not burned-out.

Other practices make doctors see more patients than I see in a day. I also enjoy an unusual amount of time per patient visit- 20 minutes for problems and 40 minutes for a physical for a person over age 40. I insisted on that extra time. We also enjoy amazing nurse triage and front desk support. Many of my colleagues in primary care, especially at other hospitals, have 10 minutes for a problem visit and 20 minutes for a physical, with absolute numbers of patients seen per session much higher than what I am doing, and far less support. I don’t know how they can function.

Also, in primary care, there is the complexity of the unpredictable: you never know who is going to walk in the door, or with what. The issues can vary wildly and widely over the course of one day. Friday, I saw a distressed young lady with pelvic pain; an asthmatic who was pretty close to needing an emergency room; an unfortunate woman with a skin-picking psychosis who was infected yet again; several folks for physicals with multiple complicated medical issues such as obesity, hypertension, diabetes, all essential to address at their physical; a man with groin pain and a possible hernia; a young man with hepatitis c and depression; a lady with diabetes and pneumonia; several folks with sinus issues, but all with varying degrees of severity and comorbidities, etc , etc…

In addition to the variety, many patients and issues are not straightforward, and require reading in UpToDate (an online medical textbook) or going to the research literature, or paging a subspecialist to get a handle on what to do. Sometimes I have to send patients for x-rays or labs, and then revisit their case later in the day. Occasionally, a patient needs to be seen urgently by orthopedics for a fracture that I diagnosed, or sent to the emergency room after my evaluation, and I have to arrange those transfers. How could anyone handle a patient every ten or twenty minutes, with all of that going on? I imagine many things do not get addressed, and it must feel like a factory.

Then, always in primary care, there is the “after-work” work. The urgent labs and imaging that you and only you can really deal with. Phone calls- we are on call for ourselves 24 hours a day Monday through Friday. Fretting- wondering, Am I missing something? Am I serving this or that patient well enough? In this business, the work day doesn’t really end at the end of the work day.

This is why, at a recent lunch with a group of five female friends who trained in primary care, every single one has left or is leaving primary care for hospitalist (shift) work, research, or administration. “Burnout” was the biggest reason, as well as “better hours for family”.

So, in short, while there are plenty of reasons for me to be headed towards burnout, I am NOT. I actually enjoy seeing my patients- even with all these issues, and when I’m “massively hugely pregnant” (as one of our nurses pronounced me recently). Between my luxuriously long patient care encounters, a good support staff, a positive environment (with a great maternity leave policy, I might add), and being part-time (I work 5 clinical sessions a week), I am still liking my job! Even the long Fridays.

Still, I recognize that my emotional energy and physical stamina are not at their peak… I waddle to and fro; just getting up and performing a physical makes me short of breath; my back hurts when I sit and my feet hurt when I stand; I have near-constant reflux; I have to go pee every 20 minutes; I’m always sweaty and can’t wear a white coat for the life of me… All of these things are totally natural at this stage of pregnancy, and they also make a clinical session that much harder.

Thankfully, the vast majority of patients have been wonderfully, surprisingly supportive. I love the friendly pregnancy-themed banter at the beginning of just about every visit for everything. Even the diabetic lady with pneumonia had to (rather breathlessly) ask me all the requisite baby-queries: When am I due, what is it, do we have names picked out yet, do I have other kids, how does Babyboy feel about this impending disruption? I can answer all of these in my sleep at this point, but it’s still enjoyable when these relative strangers take such an interest in my own life.

And then, the beautiful thing-- most everyone shares a bit about their pregnancies, or kids, or nieces and nephews, or grandkids. This big belly of mine is the perfect icebreaker.

So, as tired as I am- and it’s a bone-weary, molasses-moving, heavy-duty tired- I am so glad that I am where I am, doing what I am doing, and expecting a little girl, in 6 weeks.

Rescue

I knew something was wrong. I knew I was a little more wound up than I should be, but I figured it was normal and that I should just keep powering through - no complaining, no asking for help, just keep moving forward. Meanwhile my thoughts were CONSUMED with thinking about how we were going to manage as a family in 7 months when I leave the lab. We still only have one car, we have no family here to help, my husband’s work has gotten more demanding and I am doing so much stuff now for my daughter - how could we manage if I did less. I thought and worried about this constantly. I even had dreams about it (when I got to actually got enough sleep to have dreams!). This in addition to my constant running thoughts of what to cook for dinner, laundry, when the next feeding is if we’re out, if I packed enough snacks, if the yogurt caused the diaper rash, etc. Then, this weekend, at a medical student mentoring function the wife of one of my attendings pulled me aside as we were headed out, and after about 5 minutes of talking to me she took my diaper bag from my hands, handed it to my husband, and asked him to take my daughter home.

“White or red?” Red.

Sit down, drink, breathe. These were her commandments to me. She saw something in me - a crazy, hormonal, new mom look. Apparently I literally was no longer fully inhaling and exhaling. She saw in me what she remembered in herself just a few years ago. “Don’t quit your program” she told me. I had been seriously considering this over the past week. Even looking at jobs online.

Then came the questions. When had I slept more than 4 hours in a row? - no idea. When had I taken an hour to do something for myself? - couldn’t remember. Do I let my husband help me enough? - nope. Things have to change. Together we sat down and made a plan. Figuring out exactly what help I will need and finding ways to get it. She gave me resources, insight and direction.

I spent a few hours at her house and watched a light and silly movie while eating oreos and ice cream. No one was allowed to bother me.

She is a surgical subspecialist and her husband is a surgeon. She knows what I am facing. She put into words so many of my frustrations and fears. The next morning on my Sunday walk with my daughter I felt like I could finally breathe.

Treat Yo Self

On a TV show I was recently watching, two of the characters engage in a yearly event called Treat Yourself (or Treat Yo Self). Basically, they spend an entire day pampering themselves. They buy themselves whatever clothes they want, go to a spa, buy a batman costume, etc.

I loved that idea and it made me realize how rarely I do treat myself, even in small ways. While I hardly live in poverty, I am rarely willing to buy myself something in any way extravagant or even a little pricey. Maybe it's my upbringing by two very money-conscious parents.

For example, I was recently at Payless (the height of shoe fashion) buying my daughter some new shoes because I could literally see her little toes sticking out of the soles of her old ones. After we tried on every size 13 children's shoes in the store, Mel picked out a pair that was acceptable. Then I remembered that I needed some boots for the upcoming winter, so I decided to check out the selection.

I found a nice pair of boots that was exactly what I wanted. They were comfortable, stylish, and boots that I could wear at work without looking unprofessional, saving me the trouble of having to change shoes at work. But the thing is, I already have two pairs of boots. One is some ultra warm gigantic snow boots that I wore in the days that I lived within walking distance of work, and the other is a pair of waterproof black boots that smell really bad inside. (Yes, I tried baking soda. They still smell.)

So the new boots were a reasonable purchase. But I had to sit there for several minutes (while my daughter pranced around in a pair of size 6 leopard pumps), trying to justify to myself buying $45 boots when I already have two pairs of boots. I reminded myself that sometimes we spend $45 on a meal. I reminded myself that Carrie Bradshaw spent $40,000 on shoes and $45 is actually pretty cheap for shoes. So I bought the boots.

Clearly, I have trouble with treating myself. I wish I could just let go sometimes and get myself something nice without feeling guilty about it.

How about you? What do you do to treat yourself?