Guest post: My secret

I have a secret to tell you. I love dropping my daughter off at daycare. Shhh...let's not tell anyone. There are people out there who will frown at the relief I feel when I drive away from the daycare. People who will shake their hands and cross their arms. People who will accuse me of being a bad mother.

Don't get me wrong. I love my daughter like I've never loved anyone or anything before. Her smiles in the morning. The way she puts her arms around my neck to kiss me good-bye. The way she tries to wink at me but closes both eyes instead. She just melts my heart.

But her headstrong personality. The incessant cries of mommy. The tantrums. The potty training messes. Those things wear me ragged.

Work is so much easier. My schedule. Examining joints. Diagnosing patients. Prescribing medications. Sitting in front of my computer in my quiet office. No baby talk. No chasing after a screaming toddler. I am the one in control, not subject to the whims of an adorable, stubborn two-year-old.

Weekends are difficult. From the minute she wakes up at 5:30 am on Saturday morning to 7:30 pm on Sunday night, I am running around frantic. Everything revolves around her schedule. When she eats, when she takes a nap. Keeping her short-attention span toddler self entertained. I cannot remember the last time I slept in. I am exhausted after I put her to bed Sunday night after reading her favorite book two times. When Monday rolls around, I happily rush to bring her back to daycare.

I applaud those moms who are stay-at-home moms. Spending all day every day at home with their children. Being a mom is the hardest job anyone can do and they do it all the time. They are super human beings. Stay-at-home moms are not recognized enough.

I could never be that stay-at-home mom. It would drive me crazy. I need to sip my coffee in front of my computer in my office. I need to read scientific journals and not just nursery rhymes. I need adult stimulation. I need to be away from my daughter to be a better mother.

So, shhh... that's my secret. Let's just keep this between you and me for now.


Karen Yeter MD

Annual call for contributors

Dear MiM community,

As we celebrate MiM's 9th birthday (!), it's time for an annual call for contributors. We would love to add a few new voices to our blog. This would be for a renewable 1-year writing term. If you are interested, send a message to mothersinmedicine@gmail.com with why you would like to write with us, and a little bit about yourself.  Call closes one week from today - Sunday, June 4.

Thanks as always for reading and being part of our community. We have some surprises in store that we are really excited about. More to come on that!

Best,
KC

Mother's Day?

I'm not even posting this close to Mother's Day, and that's just fitting. My second Mother's Day as an actual mother came and went, and a pattern has begun to emerge... I am realizing that this Hallmark holiday is a bit of a joke among many mothers. I read a funny post in an online moms' group where a woman described her Mother's Day with biting snark. She was "allowed to wake up early" while her husband slept in, enjoyed "a peaceful few hours of cooking brunch items for my family with a toddler attached to my leg" after rounding in the hospital, and then ended her day with a hot shower that was interrupted by her husband asking her to scrub the shower walls with his "fun new electric cleaning brush. So. Blessed." It got me thinking about my own two Mother's Days so far.

Last year, we had a plan to go visit my parents for the weekend. My mother makes a big deal of the holiday and holds an annual pool party, the yearly unveiling of their pool for summer use coinciding with agreeable Arizona weather right around the May date. She had a big event planned, as it was my first Mother's Day, and yet things were strained between us. At 43 and with disposable income plus a new baby, my husband and I had decided we were no longer going to stay in my parents' cramped extra bedroom on their uncomfortably small bed (replete with foot board) in their poorly ventilated home. The nearest bathroom is down the hall next to their master bedroom, and last Christmas my mom caught my husband running to the toilet in his underwear in the middle of the night. "Never again," he had exclaimed with stern eyes. Anyway, this decision to stay on our own had unexpectedly hurt my mother's feelings, given her memories of her own young married years visiting their own parents. Painful conversations had occurred, I had put my foot down, and a plan for alternative accommodation was in place. On the morning of our flight, my husband woke up feeling under the weather. I thought nothing of it and continued packing the car with myriad baby equipment, as this trip was also going to be our 6 month old's first flight. He is the picture of health, lean and muscular with no medical problems except for some recurring hemorrhoids. A week prior, I had talked him into having a band procedure, which I thought might solve the problem. In between schlepping loads, he stumbled, perspiration poured from his face, and all 6'6" of him slumped onto the couch. It took a scary minute to revive him, so we rushed to the ER, and in the harsh fluorescent lights I finally appreciated how pale he was. Hematocrit was 20%, and he was admitted overnight for a blood transfusion. I spent my first Mother's Day bringing him barbecue and magazines in the hospital (as if I don't spend enough time there already) and of course apologizing for suggesting the banding in the first place, in addition to playing single parent to my child. Trip aborted and difficult conversations sure to arise again at the next Arizona visit.

This year, Mother's Day happened when I was in Spain on a long trip... which might sound to some like an idyllic scenario. I understand that many people crave an escape from their work and hectic lives at home, but being long time rock climbers and slow travelers, my husband and I normally plan longer trips abroad where we fully immerse in a micro culture for periods of time. We had chosen the Chulilla area for its long climbing routes on tall limestone walls and its balmy spring temperatures. Only we hadn't gotten much climbing done because traveling with an active, headstrong toddler was turning out to be more difficult than we expected. The first week of our trip involved the rental car keys being thrown into the toilet by someone and then - recurring poop theme - me using said toilet before realizing where the keys were. I will spare you the details of the retrieval procedure. A couple of days later, I made the catastrophic mistake of filling our (unleaded) rental car's gas tank with diesel. WHY is the handle for diesel black and the handle for unleaded green in Europe?? Even though our pickiness and frugality usually keep us from eating out much even on trips, we decided to go out to a Mediterranean buffet in Valencia for Mother's Day. The hours for lunch in Spain are 1-5, while the hours for dinner are 8-midnight. Our normal eating time? 5-6 of course, like every other American family with a child. So lunch it was, and it was busy. We waited forever for a table in a sizeable crowd of Spaniards (we are very tall, so envision this as two giants with a giant baby swimming in a sea of tiny Europeans) on the sidewalk outside the glass doors to the buffet. The hostesses didn't even take our name; they just asked how many were in our party and we stepped back, hoping for the best. Over the course of waiting, baby grew tired and hungry. I read her stern face: What's with this late lunch business, during my naptime? We tried to calm her, but the whining grew louder, and then suddenly they took pity on us. We were seated at a cramped two-seat table near the buffet, knees touching under the table and backs of chairs touching the people behind us, and when I asked for a high chair they gave me some sort of booster seat contraption. I fussed with it for a while and then laughingly realized I had situated her in it just perfectly looking like the picture on the side - the red one with the big "X" over it. She ended up on my lap, and I barely ate anything. Hubs came and went happily many times while I entertained our crazy girl, who proceeded to fling paella and jamon in a several foot radius around our table (luckily no other diners but me became covered in food). Lunch came to a hault when she threw a plate that shattered into many pieces and then leaked through her diaper all over my lap.

A glorious day spent at the gas station after my "oh shit" moment

Like lots of mothers this recent holiday, I just might have posted some cute pictures on social media of my family frolicking on the beach (not on the day shown above), followed by comments about how lucky I am. Given the fact that for years I wasn't sure I was going to ever be one, I really do feel grateful to hear that faint little voice say, "Mama". But the sunny travel photos don't necessarily reflect the un-glamorous reality of motherhood that happens every day, with or without a dedicated holiday. Next year on Mother's Day, I don't know exactly what I'll be doing but I'm sure I'll be mothering again. And I'm sure that poop will somehow fit into the picture.

Why haven't you had your second child yet?

This is a topic that I'm sure other moms with only one kid can relate to--it's the never ending questions of why haven't you had your second child yet? It seems as if you have two children, every one assumes you're done and then if you have four, people start to question why you aren't on birth control. First of all, it's nobody business the number of children your family should have. But I feel compelled to share my thoughts so here goes.

I was beyond clueless when I got pregnant at the age of 27. I was 9 months into my internship, general surgery no less! and soon after about to start my 4 years in radiology training. At the time, my husband was in his third year of his 6 year orthopedic residency program. We were about the enter the monster of hot messes but we just had no idea. So come January 2013, 6 months into my first year of radiology residency came C. She was perfect. I was not. That is the short version of the story.

I was the epitome of hot mess. I cried a lot. My husband had to go back to work in less than week after her delivery. I was with my parents. I had help but I still couldn't get my act together. C was a good baby. She slept 3-4 hour stretches from birth. I could not sleep at all. I was overwhelmed with anxiety, guilt and basically a state of "WTF did I get myself in?" I was an emotional zombie. I was in a cycle of nursing, crying and attempting to sleep but never really getting any. It took about 4 weeks to realize that maybe I have post-partum depression.

I had all the symptoms. Feeling overwhelmed. Check. Feeling guilty. Check. Feeling empty and not bonding with baby. Check. Feeling even more guilty about that. Check. Not knowing why this is happening. Check. Check. Check

Even though, I was aware. I couldn't get myself to do anything about it. I just powered through the end of my seven week maternity leave. I went back to work. I pretended like nothing happened. But these feelings did not go away. Given the schedule of residency and the shame of postpartum depression, I did not tell anyone nor did I get the proper treatment. I went to a maternal health psychiatrist once, who talked to me after hours, off the record. She wanted to start me a low dose antidepressant but I never took it. I think these feelings never really went away. They did fade over time as I adjusted to my schedule of constantly driving back and forth between San Diego and Orange County (1 hour commute) and doing residency in between that time. I was so busy that I didn't really give myself to process my emotions. I just kept chugging along and watching C grow up was the silver lining. She transformed from this tiny infant to a toddler who was a force to be reckoned with.

When she finally moved to live with me, we encountered several other hot messes but I do believe that is what it took for me to rid of these postpartum blues. I still have the occasional feelings of working mom guilt and anxiety especially when it comes to big changes in my life (such as moving and starting my first attending job!). But I do feel "cured" but for the most part. It took time but I was finally her person. I was the one that she wanted in her time of need. I was the one that could figure out what was in that little head of hers without her saying anything. I knew then that I was definitely put on this earth to be her mom.

So yes. That is why I don't have my second child yet. I knew what triggered my postpartum depression with C. I was overwhelmed with a husband in training, my own training and my feelings of inadequacy as a mom. I told myself if and when we have another child, I will do it when I'm ready so my mental health isn't at stake.

My husband had to leave for the east coast for his fellowship training right after C moved and now he works in LA. We've done long distance for two years now. We are finally at the end of this long distance journey. I will be moving up to LA in less than 6 weeks after I complete my fellowship in breast imaging. I knew I could not handle a pregnancy, C and another baby while he was away. I learned from my first postpartum experience that  a lot of my anxiety was not having my husband around. I understood why he wasn't there but it didn't change how I felt. So I knew that time was not an option for child #2.

And right now is still not a good time. My poor C has not lived with her father yet. She spent the first 7 weeks of her life with me and grandparents. She then lived until 2 and a half with her grandparents in Orange County with seeing me almost every weekend but her dad maybe twice a month. She then experienced life with me in San Diego. She suddenly had to do full time pre school, new home and a new primary care giver. She went from being the center of the universe to being a toddler of a "single" working mom in residency. She saw her dad maybe once a month while he was on the east coast. Now that I'm in fellowship and her dad is an attending in LA, she spends most weekends with both of us. She's gotten used to that now and every Sunday, she hugs her daddy and says "see you next weekend!" It breaks my heart at times that she thinks this is "normal." I want her to experience life with both parents. every single day. before we add any more changes.

So there you have it. I know I'm getting older. My ovaries may be shriveling. My uterus is crying every time I see another baby. But I am grateful for these experiences. It made me stronger in the end. It made me a better mom, wife and physician. It taught me what I needed to know to grow as a mother and maybe one day that will be a mom of two. But for now, I am perfectly content as a family of 3.

Not everything that ends is a failure.

I’ve been gone for a while. A lot has changed in my life and some of the more peripheral activities within it (like writing for this blog) have necessarily been on pause. But I’m returning to this space now that I have the time and energy for it. In the past many months, our one family has morphed into two families --my marriage of 12 years ended. This was after a couple years of marital therapy, a trial separation (in which we lived in separate homes) a few years ago, and a lot of tears, gut wrenching atrocious fights, heart ache, issues within ourselves, issues between us, commitment, recommitment, more therapy and then…our marriage needed to be over. I truly feel that we turned over every rock looking for a solution to it all, and one could not be found.

We are recasting ourselves in our roles as co-parents only, and perhaps someday we will recast ourselves as friends. I firmly believe that a marriage that ends is not a failure, that the standard of “forever or failure” is just…ridiculous.  Does a marriage have to be life-long to be considered a success? No, it doesn’t.  We did not fail. We had a successful 12 year relationship in which we raised 3 awesome kids, bought a house, overall had a damn good time-- and I’m proud of all of that. And I'm grateful for the years we had together and I wouldn't change anything--life unfolded as it did.

But after much soul searching and countless tears, I realized that despite every good intention (on my part and on hers), and despite every effort (from us as individuals, as a couple, and by those in our families/community supporting us), I could no longer be the person that I wanted to be in my marriage any more—and even worse than that, I was becoming someone I did not want to be because I was so unhappy. This affected me more and more, and it was time for a change. I cannot speak to her unhappiness other than to say I think it was profound. And all of our combined unhappiness affected our children, without a doubt. And that was not tenable. 

In the meantime, she has moved out (and lives nearby), and the kids have started living in two homes. There have been bumps in the road, of various sizes—of course there have been. But I have every confidence that we will survive and we will all thrive, as we find a more peaceful existence. Families have survived far greater challenges than this, and our three children have two parents who love them immensely (and grandparents, and friends) and who will support them in whatever ways necessary. I am hopeful. 

ZebraARNP

Looking back, looking ahead

As I hang up my short white coat after my last clinical rotation of medical school, after the celebrations of commencement week subside (I have had more than my fair share of these), and before the reality and terror of starting as an intern starts to set in, I find myself looking back and looking ahead. What a wild ride these past years in medical school have been! Spending all these years preparing for the first day of internship. Along the way, also learning on the job of raising a child. As I enjoy the lull of these last few carefree days between completing medical school and starting internship, every now and then I feel like I should brush up on my clinical knowledge to allay intern year anxieties. Then I remind myself that no amount of preparation could have really "prepared" me for being a parent or a medical student, and nothing will really make me feel "ready" for intern year. Best to savor this time with family and friends.

Recently I came across this article in the New York Times titled "The Gender Pay Gap Is Largely Because of Motherhood". It goes on to discuss not only the impact of motherhood on income, but also career decisions made by mothers to give up job opportunities, inequitable distribution of household and parenting responsibilities. Looking back at that experience of mixing parenting and medical school, I have reflected on how things would have been different if I didn't have my baby during medical school? How would things have been if I had gone through this experience without being a parent? I may have done better in some rotations, or gotten better grades on some tests. In the end, those things didn't matter as much as I thought they did. I ended up matching to what and where I wanted to end up for residency. Even if I had a perfect application for residency, my desired outcome wouldn't have changed.

I am pretty early in my career to measure the impact of motherhood on my career and quantify it in terms of lost opportunity or income. In some ways, I can't imagine the alternate reality of going through the medical school experience without my son, my experience as a medical student is so completely intertwined with being a new parent. Sleepless nights dealing with baby eating into precious few hours to sleep during clinical rotations. Being in a perpetual rush to pickup or drop off my toddler from or to daycare. Dealing with meltdowns in the morning struggling not to be late. Preparing for tests while distracting my toddler without distracting myself from studying. However dealing with the responsibility of raising a little human taught me patience, empathy and humility, which I like to believe, made me a better human being and will make me a better doctor.

Boards, wards and...umbilical cord?

This is going to be one long rambling post. I know I've been mia (sorry KC). After finishing first year I just didn't have anything to write about. All I wanted was time to myself and with my family. Then second year came and went. I was able to stop pumping at lunch and ate lunch like a normal person (read: in the library, eating over my laptop, looking at slides). During winter break this year, we went on our usual family vacation to visit my in-laws and I spent two weeks loving life. I felt rejuvenated and was ready to attack the second half of 2nd year plus everyone's favorite, Step 1. Yes, I can do this, I am awesome and wonderful and multitasker extraordinaire. Want to see my color-coded Excel spreadsheet with my study schedule?

A few days into January, I felt funny. Funny, not like haha funny but rather oh shit I might be pregnant funny. I only had an expired cheapo Amazon pregnancy test. I don't think the second line could have appeared any sooner. It's just faulty, it's expired anyway (note: clearly scientific brain was not working at this moment.) My poor husband ran to CVS at 10pm at night and got me two real pregnancy tests and the first one I took turned positive just as quickly as the expired one. And then, I cried. We both didn't know what to say the rest of the night. We have two kids, we're living in student housing in a 3 bedroom apartment. I'm a medical student, staring down Step 1 and going onto the wards. He works full time and is doing a part time MBA. How would this even work? And for the next few days we honestly didn't know if we were going to go through with it and I found myself dumbfounded that I would be in this position, thinking about termination. Me, pro-choice advocate, having to decide for myself what my choice would be. I'll save you the drama and the back and forth, but long story short, we decided not to go down that route and we warmed up to the idea of having 3 (and by warming up, I mean we've accepted it and we're now excited but have no idea how we are going to deal with it come September). But can I just say how amazingly privileged am I to have been able to make a choice for myself, about my body? And equally important, privileged enough to have the resources to actually support another child. End political rant.

My first trimester was a blur of keeping up with school and keeping down my food. I had a meeting with my Dean and asked about what would happen to my third year "if one was to get pregnant." Luckily I was able to get a relatively decent rotation schedule and I start medicine during my late second trimester and finish with family and ambulatory before I go on leave. I just have to take my family shelf 2 days before my due date; I've already told my ob not to touch me during the month of September. I finished my last block of second year, which signified the end of my preclinical years. Somewhere along in there I had an NT ultrasound and my lovely doctor indulged me in a potty shot that revealed a penis, which after two girls, was amazing and surprising. I started studying for Step just as my second trimester began and the fog of nausea and fatigue magically lifted as if it was meant to be (but really, thank you placenta).

Alas, after weeks of studying, not seeing my family ever and having to rely heavily on the support of my husband, my mom and my nanny, I sat for the exam with baby belly, braxton hicks and stretchy pants with no pockets (so they don't make you turn them out during security checks!). I definitely felt a few kicks during the exam, cramped up a few times, but surprisingly 7 hours of testing with a fetus sitting on my bladder went by pretty quickly. And now, I have a few days off before 2 weeks of bullshit pre-wards orientation that are mandatory and then we're off to the wards.

I received an email today from the school letting me know I can't go to one of my doctor's appointments during said bullshit pre-wards orientation, that it's against policy. Because, you know, from 7:30am-5:30pm they're going to keep us prisoners with no breaks, no time for lunch or for me to slip out and see my doctor across the street. That I can do my glucose screen and prenatal check at another time (read: while I'm on call. On internal medicine. At the county hospital. An hour away from campus.) because that makes so much more sense. What bothers me most is this. I don't expect any sort of special treatment. Never in my 2 years at this school have I lamented about being a parent in medicine. I've never asked about more time for studying, I've never been absent. I haven't even taken a sick day. I've passed every single one of my exams and I've always made adjustments on my end to make things work on their terms. My school has ironically created a program called Parents in Medicine. Whoever goes to these events I'm not sure. I don't really know what the program actually is because if you're truly a parent in medicine, you don't have time to go to these things. While I appreciate that they're thinking of us, they're really not thinking of us the right way. We don't need to have events to talk to other parents in medicine and commiserate together about the system. Sure, having a fun family day is nice, but I can do that on my own. What we need is academic support and administrative support. I need to be able to go to a damn doctor's appointment, not have a 2 hour get-together in a park that I can't even attend because I'm studying. I need someone to answer my email that I sent out months before the start of said orientation about scheduling a doctor's appointment. End pregnant-lady hormone-driven rant.

Drama aside, I am excited to get on the wards and finally be closer to "practicing" medicine, but I'm also slightly terrified. I'm afraid of looking dumb, looking too pregnant, looking dumb and pregnant. Being away from my family and missing important events. Oooh and giving birth on the wards or during my shelf exam because I insist on finishing. Ironically the first rotation I'm on when I'm back from maternity leave is ob-gyn, so essentially I'll deliver baby boy huffing, puffing and screaming and then join the team a few weeks later - hey guys, remember me and my vagina? I'm already done with my birth plan. It reads like this: "No medical students please." Sorry guys, but let's be honest, it will be hard to pretend I don't know you.

Hopefully I'll have some time to write about being pregnant on rotation. I'm sure I will have some lovely stories to share.

Over exposed

The space that once gave me comfort has become a source of constant pain.  I am a breast surgeon and just  months ago my mother died of breast cancer. At my hospital. 

Before she died, I felt blessed to be here, and to be available for her.  My clinic adjacent to the medical oncology clinic, I checked our shared board and could track her through her day.  I would pop in between patients to go to her appointments.  If I missed one I walked 3 feet from my own workroom to the medical oncology workroom to chat with her doctor, my colleague.  When clinic was over or I had a cancelation, I could walk down the hall to infusion and sit with her. I would stop at the coffee shop on my walk over to grab a cookie or snack for us to share.  We would watch the Today show or some Lifetime movie while gossiping about any and everything.  These were my sacred spaces.  The places where I could be a part of healing, not just for my own patients but for my mom.  A chance to be there for her. She has always been there for me, more than I could ever express.  Even during that final admission, I could run to the cafeteria going the back way, I could tell all my family where to park, I helped navigate this monstrosity of a hospital, escorting everyone where they needed to be.  Her team was my team and it gave me a feeling of purpose, and brought her a sense of comfort.  For that I will always be grateful.  But now I sit on the other side of this comfort.  I walk on coals on the stone path from the parking lot to my office.  Each of her last 4 days began with this walk.  Every place is a trigger, every person I work with is both mine and hers.  

The list is endless. Faculty meeting takes me up the elevator to her hospice room.  I've now just stopped going, clinic always runs a "little late" and regrettably I'm unable to attend.  The long walk down the main corridor to the OR or the wards or the ER, represent a piece of her final journey.  I peek through the open door of the ER as I walk by, as if one time Ill see her there, in her pink pajamas on the night she arrived for that final admission.  Each walk through the ICU I feel my walk to her room, sometimes I feel the weight of my daughters hand as we head to visit Grandma.  I follow my chief on rounds and pray that today, I won't have to see a patient in the very same space - one day I do, and I am undone.  Each day I operate I lay before her, in the same operative room where she once lay, in a moment of hope.  The hope I have for my own patients.  Praying that their post operative story will be different than hers, longer and less filled with pain and fear.  

Soon I will walk down the same corridor for a biopsy of my own, in the same room, the same hall, the same side, the same spot.

MiM Mail: Evidence-based skincare? Maybe?

I had to renew my passport the other day and send in my previous one with my new passport photo. Man, what a difference 10 years makes! It was there, as plain as day, the effects of 2 children, 4 years of medical school, 5 years of residency and fellowship, and way, way too many nights on call. I've never been one to spend a lot of money on skincare, but I now feel like my regimen may need an upgrade.

This coincided with no fewer than 4 of my friends on facebook now selling Rodan and Fields or Beauty Counter products, both with glowing "before and after" pictures. None of these are cheap! And I found myself asking- where is the evidence? Do any of these products really work? I can't escape my medical brain skepticism!

I thought this might be an area where some of our derm MIM might be able to shed some light. Or other MiM who have just done more research on this than I have. Your recommendations are much appreciated!

Yours truly,
Tired eyes and dull complexion

On Quacks, and Cold Clinical Facts

Genmedmom here. 

We all have patients, friends, and family members who fervently believe that they have a diagnosis that we know doesn't exist. Or rather, for which there is no current reasonable believable scientific evidence.

I refuse to cite specific examples, because it's useless to refute someone's pet diagnosis. You may have examined a large body of research, read reams of textbook pathophysiology, spoken to respected specialists, but no matter what, if you attempt to disprove the entity they blame for all of their symptoms, and the treatment upon which they have pinned their hopes, they will hate you.

It's unfathomable to me that there are providers out there, some of them medical doctors, who blithely and blatantly practice non-evidence-based medicine on unsuspecting and vulnerable humans.

Infuriating.

And it sucks to sit there and listen to someone you care about describing quacky tests and (at best) useless and (at worst) potentially harmful charlatan treatments. Especially when they are paying dearly, and out-of-pocket.

Of course, I've tried to take down these totally false medical problems many times. It's what you do when you care about someone, right? And I've watched their faces shut down, as they mentally walk out the door. Or, saw them get red-faced and argumentative, unable to hear another word I said.

Sigh. So now, for the most part, I nod and smile and murmur something about how modern science can't answer all the questions and I hope that's working out for them.

After all, I can see why this is happening. Modern day M.D.'s are obviously missing something. Patients aren't getting what they need from us.

It used to be that folks had a local doctor who knew them well (and possibly also their families, neighbors, and friends). Office visits were longer, and paperwork was practically nonexistent. There was more listening, and less prescribing. The pace of the research world and life generally was slower, and slower to change. Hypotheses, explanations, and medications were more stable, things you could get your head around and use for a long stretch of time. The doctor-patient relationship was a real thing.

All that's a fever dream. Now, we docs are SO on the clock. Productivity numbers are in- you need to see more patients! And more! Twenty minutes to address all of your patient's medical problems and questions, examine, order, NEXT! Then, the deskwork. Administrative burden outmatches face-to-face clinical time two to one. It's a team of nurses doing callbacks, if the patient gets a call at all. Nowadays, it's mostly messaging through the "patient portal". The, the general public is fed research study after study after study. Papers and pundits contradict each other, data is manipulated, organizations release conflicting guidelines, medications get pulled. Textbooks aren't even printed anymore because they're outdated so fast. What a mess.

These are the cold clinical truths: There's no time to build trust. Our system prevents real connection. The scientific information world is fast-paced, chaotic, and confusing.

And so people are looking elsewhere.

Our medical system may or may not be headed in a better direction, what with the Patient Centered Medical Home movement and all. We'll see.

But meantime, behind the scenes, I am on a bit of a campaign. I recently wrote a patient-friendly article in support of evidence-based medicine for Harvard Health Blog that was well-received. At least, I didn't get any death threats.

Death threats, you say? Yes! Plenty of qualified critics of particularly trendy fake diagnoses suffer angry trolls throwing cyber-insults or writing letters with intent to harm, or kill.

So I'm trying to educate generally, not specifically. Trying to teach people how to tease apart the "fake news" from the safe news, how to be thoughtful, and consider several sides of a story. Their doctor sees it one way, but the internet says it another way. Okay, let's figure this out.

Doctors, we won't win the battle against the snake oil salesmen using facts and figures. We need to be gentle. Tread lightly. Nod and smile and murmur something about how modern science can't answer all the questions and you hope that's working out for them.

And then, if we can, listen. Try to cut through the requisite logistical bullshit and reach out to our patients. If they are feeling heard, they may trust. And if they trust, they may listen. It will take time, and open minds on both sides. But the patient may get the expert help they need, that the doctor is able to give.

The Goddamn Mayonnaise Jar

You know that little gimmicky demonstration where a person takes a mayonnaise jar and puts in some golf ball or rocks that are supposed to represent the big things in life, like your family and friends and health? And then they add pebbles to represent your job and house and car, and then sand, which is all the "little things," and finally they pour in some coffee to point out that you need to fill your time with the big things first, but that you'll always have time for a cup of coffee with a friend? You know the one, right?

I hate that thing.

I like to think that I have my priorities straight. First, above anything else, is my family: my sons Bean and Teeny and my husband. Next is my career; not so much the fact of being a physician but the dedication I feel to my patients given the privilege that it is to care for them. And I know that it's also important to take care of myself, both because I deserve it and because it allows me to do my very best at caring for others. And below that, though still important, are the things I need to take care of to keep our lives running: paying the bills, working on my research for my fellowship, doing the laundry. 

But I also like to think that I'm an excellent time manager and multitasker. I have lists. I have reminders. I can take home call while folding laundry and feeding my little men, provided they cooperate by using their inside voices. In our house, my husband and I have a saying for being super-duper-productive: Getting Shit Done, or GSD. And I, hands down, am the master of it. 

Except that lately I've been having that feeling in the pit of my stomach, the one that tells me there's not exactly a crisis looming, but there is something - or multiple things - that need some adjustments. And it's going to keep nagging at me until I stop and pay attention.

I'm doing a good job at work. I feel connected to my husband and we're honest with each other when things need work. My boys are thriving. Sure, there are moments of frustration, like when I see firsthand why threenagers get such a bad rap, or when Teeny decides that, despite being nearly a year old, he really would prefer to nurse multiple times overnight. And it's not like everything else is going off the rails - the bills get paid, the house gets cleaned (sort of... and with help), and we get together with friends and even have the occasional, not-frequent-enough-but-still-happening date night.

But maintaining things at this current, pretty-good level requires that nothing comes up. No hiccups in our home renovation (because, oh yeah, we're doing that, too). No accidentally backing into a recycling bin because I'm extra exhausted from all of the overnight nursing and then needing to get the car repaired. No last-minute plans with friends who suddenly are in town or have the evening free or some combination thereof. Because, yay!, but also, ugh.

For much of my life, certainly as long as I have been managing my own time, I have tried to cram and wedge as many things into my life as possible. In high school, I convinced my music teacher to let me leave rehearsals a bit early and my track coach to let me show up at practice a bit late so that I could play in the pit orchestra for the school musical and continue to compete with the track team despite their conflicting schedules. I did it for three years in a row, right through my graduation. And I could never really figure out why I always felt pulled in multiple directions without ever feeling fulfilled or like I was achieving my potential in any of the things I did.

Because here's the thing: the common denominator among every single particle in that jar, or the thing that each particle stands for, is that it has the potential to expand. And no matter what, the expansion of even one of these things means that the rest get pushed and squeezed into ever smaller bits of space until it seems they might never recover or the entire jar just might explode. You finish a long day in the ICU and look down to realize that your right lower leg is swollen and sore, and you know in your heart of hearts that even though it means asking the nanny to stay late and missing your baby's bedtime, you - especially in your postpartum state - need to go rule out a DVT. You buy your first house and as you begin to make the small tweaks you had planned, you discover what a fixer-upper it truly is and how many months of work lie ahead before it is truly inhabitable. You get called into work to cover for a colleague who has lost a loved one or is experiencing a crisis of their own.

And in the same way, the beautiful parts can expand, too. Your normally wiggly little boys decide that on this Sunday morning they are content to lounge in bed with Mom and Dad, tickling, giggling, and nuzzling. Your dad joins you in the other room, ostensibly to help you wrap gifts for your son's birthday, and the two of you have the most honest, heartfelt talk that you've ever shared about your mom's mounting health problems. Your nearly-one-year-old son falls fast asleep in your arms and you just sit in his dark room rocking him, gazing at the curve of his cheeks and the wispy tendrils that curl at the nape of his neck.

A meeting is postponed and you happen to have your laptop and no impending deadlines, so you sit and you think and you write.

This is where the mayonnaise jar falls short. The golf balls and pebbles and grains of sand don't change size, so you can keep adding and adding as long as there is space in the jar. But real life is far more dynamic.

Probably because I work in hospice care and do my best to ease people through the end of life, I spend a lot of time considering what I'd want to do at the end. Recently during my drive home, my mind wandered to the question of what, if I died today, I would regret not having done more of. And immediately answers sprang to mind: Yoga. Reading. Cuddling my boys. Late-night talks with my husband. But these are the things I do so little of lately. The things that always get pushed to the bottom, into the crevices, when everything else expands. And no amount of savvy scheduling or multi-tasking is going to stop that from happening.

I need to make room for these things. Make room for them to expand on the wonderful occasions when they do, and make room to buffer and protect them when the other parts start growing. I've tried for years - decades, if I'm honest - to stuff my jar with as many things as I could jam and pour in, then white-knuckled it to keep it all from exploding out each time any one of them began to expand. And something will always expand.

What all of this boils down to is a bunch of cliches. To be more present. To learn to say no to some things to allow room for others. To prioritize the things that are most important. None of which is earth-shattering. But thinking of my life as the mayonnaise jar into which I have tried to stuff every last particle and drop of hey it would be nice to and well maybe I can make that work has given me a framework that makes it easier for me to begin to change. So I have shaken a few of those less important pebbles out. And, for now at least, I'm keeping the cap on my jar.

We lost our s--t with the stranger who criticized our kid

Genmedmom here.

Hubby and I are not proud of our behavior. As a matter of fact, if anyone at the suburban quick- service restaurant managed to videotape us losing our sh-t, we'll be mortified.

Saturday was Earth Day as well as the March for Science, so we took our kids downtown to meet up with friends for breakfast and then show our support for our planet. Of course it was lovely and inspiring and all, so when we had to cut out early for a birthday party, we were a little bummed. On the other hand, the day was raw and rainy, so we were also a little relieved.

At the train station, a balloon man made a blue balloon sword for Babyboy and a pink poodle for Babygirl. Halfway home, rather predictably, Babyboy's sword popped. He wailed, then pouted, as Babygirl "helpfully" reminded him that HER balloon toy was still like new.

We didn't quite realize how upset he was about the balloon. And also, perhaps, how exhausted from our packed day thus far, dealing with new people at breakfast, trekking all over the downtown area, managing myriad sights and sounds and general chaos, then keeping it together on the train. Though he has autism, he handled it all incredibly well.

So we were probably pushing it when we decided to swing by a takeout salad place for a healthy late lunch just before the birthday party.

The restaurant was pretty crowded, and there were only a few tables open. Babyboy found a small table in one quiet corner, while Babygirl found a bigger table in the middle of the larger sitting room. Both refused to relocate.

Hubby ran to the men's room while I tried to resolve the table situation. Babyboy's table only fit two, while Babygirl's was for four, so, pretty straightforward: "Let's go over there where your sister is, honey, so we can all have a seat."

But Babyboy was done. Just DONE. He had draped himself over the tinier table, hugging it, not budging.

I gently touched his shoulder and leaned down, whispered in his ear: "Honey, we need four seats, or we won't all fit, okay? Let's go to that bigger table, okay?"

He whined: "I want to sit HERE! Why does SHE get to pick where we sit when MY balloon popped and I'm sad? I should pick because I'm SAD. I want to sit HERE."

I tried reasoning, then gentle tugging. While he did release the tabletop and shuffle grudgingly towards the larger space, he did so while whining VERY loudly:

"It's not FAIR! It's not FAIR! Why does SHE get to pick where we sit? Why does SHE get to pick? I'm the one who is sad! MY balloon popped, not HERS!"

Meantime I whispered reassuringly, soothingly: "Okay, okay, I understand, here, you can watch a show on my phone. Want to watch a show? Here, let's pick a show.." I was practically begging, but, to no avail.

The more I whispered/ begged, the more he whined, and loudly. People were watching us, with curiosity and annoyance, and I was acutely aware.

When offering SpongeBob on my iPhone didn't work, I knew we would have to leave, so I announced:

"Okay, this isn't going to work. Let's go home, guys, let's go outside, c'mon. We're leaving, right now." I said this out loud, as much for the other diners' benefit, as I herded our kids out the doors.

The kids were just ahead of me, already in the glass foyer, when I noticed a loud banging and clattering sound.

It was like a fist hammering on a table so hard, that it was making the silverware clatter.

Which is what it was.

An elderly man seated near the open door was bringing his closed fist down heavily on his table, again and again, HARD, so that his food and utensils jumped and rang out with every beat.

Only when I finally looked, did he stop. He then gestured angrily towards Babyboy, raised his finger to his lips, and made an exaggerated, furious, spitting SHHHHHH sound at me.

I froze, eyes locked with this angry old man who didn't seem to speak English.

The kids were already pushing at the outer set of doors.

Only a second passed, but this is what went through my head:

Are you kidding me, asshole?  My kid's autistic and exhausted and fixated on his silly balloon and I cannot do anything about that besides leave. Can't you see that we're leaving? We've only been here about three minutes total and we're LEAVING and you have to pull this shit? 

And then I did was something I don't think I have ever done in my entire life.

I leaned towards him from the doorway, leveled my middle finger right in his face, and said, as clearly and calmly as I could:

"FUCK YOU."

Then I followed my kids into the foyer and out the doors to the parking lot. Babygirl tripped and fell and I lifted her up, pulling Babyboy along with me as I made a beeline for the car.

Meantime, Hubby had just exited the men's room. He had heard Babyboy's whining and then the banging/ clattering ruckus. He had seen the old man pointing at Babyboy and shushing us. Somehow, he didn't catch my reaction, and thought that I had just fled.

So when he passed by that guy's table, he threw out:

"Have a nice day, sir, God bless you, and by the way, FUCK YOU!" and he ran to catch up with us in the parking lot.

In the car, I was shaking, almost crying. Hubby turned to me and shared that he'd given that guy a piece of him mind. I admitted that I had, as well.

We both smirked.

Now, Hubby and I are both well-educated working folks with professional reputations to protect. As such, neither of us uses the F-bomb, or any profanities, very often. And neither of us is in the habit of losing it with compete strangers. But we did both, and if given the chance for a do-over, I'm not sure that we would have done it any differently.

Of course, we didn't do much to advance the cause. Our classless behavior didn't help anyone to understand autism, empathize with struggling parents, or tolerate tantruming children.

I'm not sure if any of that would have even been possible, but we could have acted with more grace. So, we both feel ashamed.

We did end up going to the birthday party, where we shared our story with many very sympathetic parents. People shared their own experiences of child-behavior-shaming in public spaces, and how they reacted. It was therapeutic.

Still, I know for a fact that neither Hubby nor I will ever venture into that takeout restaurant again!

Old Photos

I am typing this on the fourth computer I've used in the past year. When I started a work-from-home job in August, they gave me a nice new laptop just as my old warhorse was dying. When I left that job in November, I sent the nice new laptop back and starting using our old desktop. A few weeks ago I bought myself a refurbished laptop for my new business. I wanted to make sure all the important old stuff migrated from the desktop computer, which we had been using for long-term photo storage, so I upgraded our cloud storage and got everything synced. And the past started flowing onto my new hard drive.

Eve and Grandpa Jim, 2004

Eve and Ga, 2004

The child in those photos is now 17; as I write this she is sprawled on the living room floor watching videos and doing homework and stretching, all at the same time. My father died two years after that photo was taken. My mother, in the late stages of dementia, no longer knows who I am. 

Over the last few days, I have paused from my business and my busy-ness; instead of looking ahead, I've been looking back. Mommabee is not the only one doing a review. I have enjoyed the last six months of doing very little work. I have not cleaned and reorganized the entire house. I have not made scrapbooks of Eve's preschool artwork. I have not trained for a marathon. I have slept well, spent time with friends, done the things I could never do because I was on call, and been the primary parent for the first time since Eve was a toddler. I have written more and sung more and read more than I have in years. Looking back at old photos reminded me that since Eve was born in 2000, we have weathered a great deal of loss, and I worked through all of it. I don't mean I worked through it therapeutically; I mean I kept working. Got up, went to work, did my job, wrote my notes, took call. The last six months have been catch-up time.

I am ready to file away the old photos (happy to know they are safe) and move toward the new ones. There will be Eve's prom photos and dance portraits and candids of her as a lifeguard; there will be snapshots of our garden and our summer vacation (wherever that ends up being) and the college campuses we visit. 

Old photos. New times. Life, as they say, goes on.

Photo credit Amanda Lynch Morris

Me, Sam and Eve at the beach, 2016

Guest post: Two lines

I have become a pee-on-a-stick expert. Ovulation sticks? Done. I have that LH surge targeted with laser precision. Pregnancy tests? I've spent a fortune on negative tests month after month.

Until this morning.

I woke up early to go over my grand rounds talk one more time. I started my normal morning routine, which starts with peeing on a stick, and then moving on to washing my face, brushing teeth, and then glancing at the usually negative test before tossing it in the garbage.

But there were two lines. Two lines! TWO LINES!!!!! I shouted at the fireman to get out of bed and come look. Did he also see 2 lines? "Any line means a positive on a pregnancy test!?" I shouted. "I don't know, it looks faint. You always say I don't know anything about this baby stuff," he replied, sleepily. His thoughts were on the extra 40 minutes of sleep he had left before another 24 hour shift.

I finished getting ready, smoked my presentation, and then took advantage of the freedom of my research rotation to escape the hospital and come back home to reflect. Two lines? I'm pregnant? I'm pregnant.

I'm a pregnant, 4th year orthopedic surgery resident with a husband who works 24-48 hours at a time. Our closest family is 3 hours away and I have no idea how we are going to do this. But there are more pressing, immediate issues to think about. I start a joints rotation in 2 weeks.

This presents a unique issue for mothers(to-be) in medicine. Do I give up my privacy, tell my program that I'm 4 weeks pregnant and I wish to be excused for cementing in all the total knee cases? If I do step out, who will do that part of the case? What if I miscarry? Do I want to have that conversation with a bunch of gray haired old orthopedists? Do I read the literature (again) and tell myself that it will likely be fine, scrub the cases and keep this wonderful miracle to myself until I am confident in my pregnancy? When I put on double lead aprons, will my secret give itself away before I even have a chance to make a decision about how to tell everyone the news?

I will only be the 2nd female resident in my program to have a baby (in addition to 2 former hand fellows), and that was at least 5-6 years ago. Until 2 years ago, the words "maternity leave" did not appear in our vacation policy. My program is considered "female and family friendly", but just because we have a larger number of female residents, and the male residents all have 3-4 kids each, doesn't mean they are ready for this.

What would you do? How did you announce your pregnancy at work?

-Ortho-Mom-to-Be

I am a 29 year old, 4th year orthopedic surgery resident married to a fireman/paramedic. We live in the midwest and, aside from our two 4-legged children, have been trying to conceive for the last 6 months.

a review through the year(s)

I cannot believe it has been almost 4 months since I wrote the post about my miscarriage, 1 year since I left a toxic work environment and dove into health care leadership, 2 years since residency ended, 5 years since becoming a mommy, 12 years since graduating from college, and almost 30 years since I proclaimed that I wanted to become a doctor.

Through it all I have learned so much and I am truly indebted to the colleagues and mentors who have helped me craft this career. I am even more so indebted to my loving husband and family who constantly teach me that my happiness is worth it and at the end of the day, a job is a job, is a job and when you aren’t in your job, the job goes on, the world does not end.

Motherhood changes you. Partnership changes you. Medical training changes you. Motherhood in particular, puts a new perspective on things. And in my opinion, it makes you question things that you had never questioned before. It makes you prioritize in ways that you hadn’t before.

For example, for my whole life I’ve known that I wanted to become a doctor. I never waxed nor waned in that belief. Though it was hard at times, I knew I would achieve that goal and I did. But I also realize that it might not have happened. My heart cries for the countless young medical students who don’t match into residencies. For the countless applicants who go into super extreme debt to attend post-bacc programs or use private loans to finance medical educations in international schools (I know far too many!) and then to not match?!? I can’t fathom that. But that could have been me, could have been any of us. It has happened to some of my friends. But now as a mother as I reflect with other women physicians, so many of us question our decision. In particularly frazzled moments, we say emphatically that it was not worth and we would not do it again and we would discourage our children from pursuing medicine. What was it that shifted our beliefs? Was it aging? Was it pregnancy hormones? We may never know.  

I started residency with a newly crawling baby. I began questioning things that I had learned, that seemed so dichotomized, so absolute because caring for my snuggly little Zo taught me that everything and I mean everything is shades of grey, covered in drops of breastmilk and smeared in shea butter and kisses. There was no more black and white,no more textbook answers to lull me into a false sense of security.

And the changes continued, each moment and each role took on new meaning. Weekends off from work took new meaning. I had a baby to raise and learn and love. I had an amazingly supportive and successful husband to dote on and love. Each moment became more precious because when I was at work, I had to completely be present caring for and keeping alive someone else’s baby. Time at work took on new meaning. Every time things got rough, I would say to myself “this is someone’s baby! This is someone’s baby! Do your freaking best! Love up on this family and this baby! Do the right thing by this baby!” and it worked. I was able to care for countless patients and their families.

I started my first attending job. The one I knew was going to be my dream job. And it wasn’t. From the very beginning. The burn out was palpable among my partners, the check in staff, the medical support staff, the nurses. In my first few weeks, I was warned by various members of the staff to literally “get out” before the patients lured me into staying forever. I didn’t know how to process it. This was my “dream job” at my dream institution, a top 10 children’s health system in a highly desirable area. The one that I was supposed to stay in, rising through the ranks, being a tireless advocate for my patients and their families. But I looked around at the colleagues who had trained me as a medical student and no one was happy.

Everyone was raging against the machine of big-institution medicine without the tools they needed and without the support of the administrators. There were partners who were months behind in charting on the outdated electronic medical record. There were partners who worked hours from home each night and who spent more time charting than seeing patients. There were incompetent team members, difficult to work with management, and mountains of red-tape and bureaucracy at every level and it frustrated us to no end! We were understaffed at every level but the message from the higher ups was “do more, see more patients! You’re not meeting your numbers!” while we providers questioned the safety and quality of fitting in another patient, of overbooking overbooked slots, of opening earlier and closing later. This scenario isn’t unique. I hear countless stories from other physicians in private and academic medicine, from friends working for nonprofits, I could go on. And when you hear it from so many people in so many industries, you realize that we are all workers. We all struggle with the same things, but it is up to us to find our niche, our space where we can deal with the “particular brand of crazy” of an organization.

My mama heart made me extra courageous, extra fierce. I began to network and met a group of other outstanding physicians many of whom were mamas who had experiences just like. They found the strength and courage to craft professional lives that were more in line with their beliefs and their experiences gave me strength and I began to let go of the made up dream as I began to develop a new dream.

If it weren’t for my husband and my family, I never would have had the courage to leave. But I did. I spent countless time and even significant money on legal fees fighting and it’s not even over yet (always, I repeat, always consult with an employment lawyer early when you first begin to worry about retaliation or have safety concerns, just do it! Human Resources works for your employer and unfortunately not really for you). But you know what - MY HAPPINESS IS WORTH IT! I trained too long and too hard to not be valued, to be underappreciated and you did too! We are worth it. We must advocate for ourselves and our happiness as a matter of survival. Physician burnout is on the rise and unfortunately so is physician suicide. Your life is worth it! You should not be miserable in your job! Being a mama made me more courageous. What would I tell Zo if he was going through this? I would tell him find a new job, it’ll be okay! You’re worth it! I know they tell us it’s our calling and although that may be true - a job, is a job, is a job!

This last year in part-time health care leadership coupled with part-time direct pediatric primary care has been a whirlwind. Scary and beautiful, overwhelming and exhilarating. Exhausting and empowering. I have been getting my lean-in on! And the view from my first big girl office is the bomb!

And because I have been courageous enough to sit myself down at the big-kids’ table I realize that we really do have expertise when allow ourselves to do what we are good at. Working with a major managed care organization, I understand why providers are asked to check off certain boxes in our patient assessments and I realize that this information must get back to the providers.  I realize how essential physicians such as myself are in re-envisioning health care.

Everyone has a boss, every organization has a parent organization and auditors to respond to. The system is such that major revision is needed to truly improve outcomes. Though my overall happiness has increased tremendously, the job is still a job. And I don’t think enough physicians, especially those in training, fully grapple with that. You still have people who are burned out; though honestly, much less here in my new office. You still have issues with incompetent people and I had to terminate my first staff member a few months ago. But “this particular brand of crazy” is one that I can deal with and is one I am thriving in. It’s one that my family can deal with.

Thank you for sharing in my self reflection.

Have you done your own personal review lately? If so, please share. What have you learned? How have you changed?