KIT (Keep In Touch)

Isn't that what everyone would write at the end of the school year in their yearbook entries, peppered with inside jokes and other, long forgotten acronyms? I used to be the queen of correspondence; usually by phone if not by post (cards, letters, etc.) I did all that I could to keep my few close friends apprised of my oh-so-very exciting life. Once email came along, it was even easier to dash off an email. I have always been sort of the "counselor" in my friendships, so I enjoyed trouble-shooting and discussing things with my friends. It was an important part of who I was. Things started to shift a bit once I entered medical school. I was so focused on my microcosm, sometimes months would go by without talking to my high school and college friends before I would even realize it. A well placed phone call, or two, and all was right in the friendship world once again.

In residency, I fell off of the proverbial friendship map. In the pre-80 hour a week era, I could work up to 120 hours a week (every other night 24 hours on call). It was in residency that I developed an odd social phobia involving the phone that I have to this very day. I just stopped answering it unless it was my mother or my husband. I stopped making simple calls like for pizza or take out entirely. I think that it stemmed from the fact that I *had* to answer the pager. I didn't have to answer the phone or call anyone if I so chose. It wasn't that I didn't *want* to talk to other people. It was that I *couldn't* talk to them. I just couldn't give any more of myself away. As a result, I slowly lost touch with friends that I loved very much, but to which I couldn't be a very good friend at the time. Next came parenthood, a new job with little time off, and another baby. There was not much time for extra socializing, though I realized that I needed adult friendships badly.

As I take the steps toward a new job, closer to friends and to family, I have also begun to reach out to old friends in an attempt to reconnect and apologize for being such a crappy friend to them. A rather recent discovery that has been great for this is facebook. I have gotten back in touch with old sorority sisters and my college roommates through this networking tool, and for that I am grateful. I've arranged a few tentative visits with important friends in my life that I haven't seen in 3 years or more. I feel like I am on my way to rebuilding these relationships, due in part to a few easy clicks of a mouse. So facebook worked for me, how do you stay in touch with your close friends that don't live near you?

Doctor, you are hot!

I read with interest this CNN article about Pakistan's president complimenting Sarah Palin on her looks:

Zardari then called her "gorgeous" and said: "Now I know why the whole of America is crazy about you."

"You are so nice," Palin said, smiling. "Thank you."

And then, when Zardari quipped that he would like to hug her, "Palin smiled politely."

I was reminded of the similarly awkward exchanges that occur between female physicians and patients or colleagues. Palin employs two responses that are favourites of mine. First, receiving the compliment as an innocent remark. Then, reacting with a cool silence to an inappropriate, but not quite lewd, suggestion. It would have been interesting to see what she would have done had it escalated.

I'm curious what others think of Palin's response. Should she have been less amiable? Used a different tactic? How do you deal with positive references to your physical appearance in the workplace?

I find this tricky. Sexual comments and overt invitations are obviously inappropriate and need to be dealt with immediately and decisively.

But what do you do if a patient tells you you're beautiful? What if it's said in a frank, admiring way, with no innuendo? A woman can be told she looks great because she's healthy, rested, happy, young, well-dressed, has a good haircut or a host of other reasons. I don't think all compliments can be assumed to be romantic or sexual; they're often made as a kind gesture.

The range of scenarios further complicates things. Does it make a difference if the comment comes from a geriatric patient, or a thirty-year-old? From a one-time consult, or a long-term patient? What if the remark is made by a colleague?

What if it's a neutral observation? Is the boss who comments on the length of your hair at every quarterly meeting, or the patient who notices your new shoes out of line?

To some degree, I consider any comment on looks inappropriate, because a physician's appearance is unrelated to the provision of medical care. Such remarks are irrelevant and unprofessional.

But don't we respond differently when women pay us compliments? If a female patient comments on my new haircut, I'm pleased. If a nurse is wearing fantastic boots, I'll tell her. We don't behave as if compliments should be banned from the office altogether.

I think the most difficult situation is the one where the exchange is with a superior. When I was a medical student, a physician moderating a small group session put his arm around my shoulders, squeezed me and exclaimed, "You are so cute!" I recall that I was wearing a plaid jumper and tights. Maybe I inspired a school-girl fantasy, but more likely I just reminded him of his own teen daughters. I was acutely uncomfortable, but I didn't know what to do. So I did nothing.

Now, my approach is to trust my gut. I'll gracefully accept a one-time compliment. I'll laugh off the jokes by the sweet old man with his wife shaking her head beside him. I swiftly derail anything that becomes persistent, or comes from a patient with psychiatric issues, or causes me any unease.

None of this is to say that I am as gorgeous as Sarah Palin.

Patient was a furry, red-haired monster in moderate distress

I was watching Sesame Street with Melly this morning. Elmo was sitting on the curb, clutching his left foot and crying out in pain.

Gordon: "Elmo, what's wrong?"

Elmo: "My feet hurt!"

Gordon uncrosses Elmo's legs as he again cries out in pain.

Me: [thinking] "Oh my god, is it an ATFL sprain? Is it plantar fasciitis?"

Gordon: "Elmo, I think I see what the problem is."

Me: [thinking] "Tibialis posterior tendonitis? Achilles rupture? Talar dome fracture??"

Gordon: "You put your shoes on the wrong feet!"

Wasn't even in my differential.

Ahh, sleep

This morning as I awoke, I rolled over and stretched a lovely long stretch. My first thoughts were “I feel gre-“ but my reverie was interrupted by the sudden realization that I HAD SLEPT ALL NIGHT LONG. I grabbed the on-call phone next to my bed and anxiously scrolled to the “missed calls” file. It was empty. And then I was left with the vaguely guilty feeling that I have far too frequently after having a good night’s sleep.

When did this start? Why do I have a problem with sleeping all night long?

My first recollection of this sensation dates back to when I was an intern almost 20 years ago. A resident I worked with was fond of heading to the on-call room as soon as possible during call nights and jumping into an open bed. His rationale was that any sleep was better than no sleep and 45 minutes of sleep at 7PM might well be the only sleep of the night. I still recall the first night of call when I decided to do the same; I headed to the on-call room and tucked into a lower bunk, optimistically setting the alarm in the room for the next morning. I woke the next morning to the sound of the alarm blaring and immediately wondered why I hadn’t gotten called. I frantically paged myself. When my pager went off, I hung up and did it again. Again, my beeper responded immediately. I found a toothbrush and freshened up as best I could, then headed down to the morning lecture. On the way, I ran across the resident who had been on call with me the night before. He grinned at me guiltily and then said, “You’ll never have another night like this. Savor it. But don’t ever talk about it.” His unspoken comments implied that sleeping during a night of call was frowned upon – even if there were no patients who needed the night intern or resident.

I recall the same sensation the first night both kids slept through the night. My initial drowsiness upon wakening abruptly vanished with the realization that I hadn’t heard the baby cry. Stumbling into the nursery expecting the worst, my fears resolved upon the sight of Eldest earnestly holding a conversation with his stuffed bear; a few years later, it was Youngest’s voice singing aloud which soothed my concern after a similar night.

But I still don’t know why I feel guilty after getting a good night’s sleep. Is it because I spend so much of my time fighting fatigue that I don’t know what to do when the feeling is gone? Have I grown so accustomed to chronic sleepiness from interrupted nights that what should be normal for my brain and body is now considered the aberrant?

Even now, after having been awake for several hours, I feel “off”. Is it extra energy, lack of fatigue, hypercapnia from sleeping with my head under the pillow for an additional ninety minutes?

So MWAS, here's a really long answer to your question of the other day: 7 hours to function, 8+ to feel good (but then I feel bad). Does anyone else have this guilt after sleeping well?

A

Regular Mom

Son is asleep on the couch next to me...couldn't make it through the presidential candidate debate. I know I should move him to bed, but I love the warmth of his feet pressed against my leg.

Last night, he woke up with growing pains. My mom is staying over to help me while Husband is frolicking in Europe attending an important business meeting. She slept next to him in his bed and tried to help him. His screaming "Mama! Mama!" woke me.

I gave him some ibuprofen, then put him in my bed and tried my best to comfort him. I rubbed his legs and sang songs. Twenty minutes later, he was asleep.

I had growing pains, and I know that's what Son was experiencing, but the doctor in me went wild thinking of more unlikely, and scary, causes of leg pain. Osteosarcoma. Rheumatoid arthritis. Leukemia.

I realized, after an hour of stewing, that I would have those fears even if I weren't a physician. It's a maternal impulse to fear the worst. I'm just a regular mom.

Tugged

"Can you write an order for that?"

"How long will the epidural take to put in?"

"Mommy! There's a bug in my shoe!"

"What's for dinner, honey?"

"Attention all personnel, Code Blue, CCU..."

I am a tugged person. That can be stressful.

Last week while I was brushing my daughter's hair I started thinking of generations of women who have been brushing their daughters' hair for hundreds of years before me. The brush almost tugs her closer to me with each stroke - a wistful rhythm. It's an act that seems to expresses this tender, almost plaintive thought: stop a moment, my lovely girl; don't grow up too fast; enjoy this time to yourself, this untroubled time without complications or worries or major responsibilities, this fledgling time to be you and be entirely lovable and free.

I talked to her of our good fortune: we are women in a society in which we are free to choose to be wives or not, mothers or not, with opportunities to educate ourselves, vote for our leaders, work at professions of our own choosing.

Yet centuries of disregard for women don't fade all that fast. Just days ago I had to draw a thoughtless nurse aside for speaking to me in front of a patient in a way I truly believe she wouldn't have with a male physician.

Then I had to let it go, fast. I had a patient who was afraid to the point of tears. With her I was gentle, I hope, and reassuring. She nodded as I described things, showed relief when I explained things, clung to my hand when I rested it on her arm.

I was pulled away again for some other unpleasant business, and I had to put the harder face on, the one that has to take charge and get things done right. Then back to the patient, and more reassuring murmurings, more of what I hoped were kind words that built trust, and soothing moments.

Then the procedure began, and again, there was a need for firmness - my more business-like side, as I tried to convey important directives and elicit competent, efficient work from the team I was working with.

Then it was time: the patient awoke, surprised it was all over, refreshed. Again a hand on the shoulder. Everything's all right. You're just waking up. Procedure's all done. You did great. Tears of relief. A smile. A squeeze of my hand.

Hard. Soft. Hard. Soft. So it goes all day, every day. Compassion in the interstices, between moments where I have to take a stand, or take charge of something, or direct someone, or all the above.

Tugged.

We're tugged in so many directions. I think of trees pulled about by storm winds or rain. How can I teach my daughter to stand firm in this whirlwind world, to bend but not to break, to be firmly rooted but pliant, and most important of all, to use her health and her gifts to bear good fruit? I want her to be happy and safe. I want her to stay energetic and free. I want her to feel satisfied with her work but not to get too physically and emotionally exhausted. All day at work as I travel from patient to patient, task to task, she is in my thoughts, like a song in the background of everything I do and try to be.

What can I teach her about how to cope with wave after wave of demands on her attention, her time, her energy?

It comes to me: I will have to teach her, by example if not by word, to reach for stillness, again and again. When I return to it, sometimes it's for just a millisecond. A pause before inserting an I.V. A putting aside of annoyance at a fellow-doctor's lack of consideration or a nurse's thoughtlessness, in order to lay a hand on a patient and hold still for a second. I hold still. My daughter and me brushing hair during a weekend retreat: another moment of stillness. It's a rhythm, a habit, but one that takes practice, one easily forgotten.

I flutter around, busy, sometimes frenetic. But I have to go back to that stillness, even draw other people into it if I can, or I absolutely cannot cope with all the tugging.

Stillness. Young people so often underestimate the value of that, the gift of that. Everything now has to be high-stim, instant gratification, always on-the-move. My kids are no different. They are sucked in along with all their friends, into the maelstrom of entertainment and activity that their generation craves. But there is something in mindful stillness that none of those delights can match.

Somehow I will have to teach my children this if I can, and hope that it's of use to them as they grow (too fast!) and discover (wonderfully!) who they are.

[Cross-posted in slightly different form here.]

Seriously, I wanna know...

Jay Leno needs five. Albert Einstein needed ten. Leonardo da Vinci took his in 15 minute intervals. Hours of sleep, that is. How many hours do you need to feel human? Do you catnap?

Role Modeling

As parents, we are the shining (and often, not-so-shining) example of who and how to be for our children. Our food preferences, our political preferences, our jobs, and our recreational preferences shape the way that our children see the world. If we are doing our job, then our children grow up with the ability to decide whether or not they share our preferences. Who we are affects who they will be...good, bad, or in between. Despite the fact that in the last 20 years the medical profession is regarded more often with fear and mistrust than with respect and value, I still find myself in the role of role model and mentor for my patients, as well.

Lately, I've been thinking a lot about how one area in my life is absolutely out of control, and how it affects both my patients and my children. That issue is lifestyle, and more specifically, my weight. When I started medical school, I took care of myself. I ate well, exercised, and got plenty of sleep. Not coincidentally, I was also a healthy weight. In the 11 intervening years between the start of medical school and now, this has all fallen by the wayside. I eat a terrible diet, often rewarding myself with food, rarely exercise, and sleep is inconsistently 6 hours a night, at best. I look at myself now, 14 months after my second child was born, and I know that I no longer have any excuses. I am obese with a BMI of 36. I didn't "just have a baby." It was over a year ago!

Day in and day out, I give weight loss, diet, and exercise advice to patients. Prior to medical school I was also a weight loss counselor. I *know* what to do. How can I expect them to listen to my advice, as a role model, when it is obvious I do not practice what I preach? Worse yet, how do I model a healthy lifestyle for my 4 year old daughter? I can't keep fixing her fruits, veggies, and healthy dinners while I eat a pound of pasta night after night. I can't encourage her to keep active and fit when I come home at night, exhausted, and plant myself on the couch. Soon enough, the questions will start.

In my quest for a better work lifestyle, I am also embarking on a personal lifestyle change. Mr. Whoo and I are taking the kids for walks before or after dinner. This week I have started a weight loss regimen that requires me to track what I put in my mouth. I've started over and over again in the last 3-4 years down this road. I need this time to be the last. I'm doing it for myself, for my family, and also for my patients. It is time to realize that *my* health is important, too. I want to be able to tell my overweight/overworked/overstressed patients "I did this, this is how I did it, and you can do it, too!"

How are you being a positive role model in your patients' and families' lives?

If I can do it, why can't you?

Every year in my residency program, we are given what is basically a "practice board exam". It is hyped up as being extremely important--something that the program uses to judge its residents and something that fellowships might ask to see. We were told that if we did well, it would make our program look good compared to others, so "make sure you do good". Eep, pressure!

During my first year of residency, I was going to be 39 weeks pregnant when this three-hour exam was scheduled. Considering the importance attributed to this exam, I asked the female program director if I could either be exempt from the exam or take it under circumstances more comfortable for a woman who was nine months pregnant, since three hours straight in a tiny desk with a hard wooden chair did not sound tempting.

Before I conclude this little anecdote, I want to say that I bet I know what some of you are thinking. You're thinking, "What's the big deal? I took my REAL board exam while nine months pregnant, also while breastfeeding a one year old, and pumping during my 15 minute breaks. Also, I had eclampsia at the time and was actively seizing. And I didn't complain."

Admit it, that's what some of you are thinking.

Which isn't so far off from the response I got from my program director, who was the mother of three small children. She told me (via email), "We'll see. I was still answering pages when I was in active labor."

I'm not as strong as all that. When the epidural went in, my pager went OFF.

Still, this incident made me aware of the fact that while other physician mothers ought to be our greatest advocates, sometimes they are our worst enemies. There's a general thought from some female physicians: "If I did it, then why can't you??" I think we've all had encounters with physicians mamas who showed a surprising lack of understanding, sometimes even worse than the men.

I'm guilty of it too. When other women with kids take off a day because their child is sick, I automatically think, "Well, I came to work when my daughter was vomiting." Or when another resident started her maternity leave a whopping month prior to her due date, I couldn't understand why she was unable to work till the very last day, like I did.

And I hate myself for thinking that way. Female physicians should support each other and work together to foster understanding and acceptance of things like maternity leave or having non-insane hours that allow us to spend time with our kids. Everyone is different and just because we were able to work until the last day of our pregnancy or pop back to work three weeks after delivery or have a nanny that never calls in sick, that doesn't mean we shouldn't stand up for other women who might not be exactly like us.

(In case you were wondering, I was granted extra time for that exam.)

Topic Day: It's About Time

Welcome to our second Topic Day at Mothers in Medicine. Throughout the day, we'll be featuring posts about Time Management. How to juggle motherhood and a demanding profession? Here we share our tips, secret weapons, philosophies, and choices.

Scroll down to find the posts...

Time is sanity

For me, time management equates to stress management. When I'm less stressed, it seems that I'm better able to manage my time. To that end, these are the tricks that work for me on a regular basis. I wish I could say that I always use them, but I don't. Perhaps that's why I've been able to recognize just how well they work - because I have so many times when I haven't used them to compare!

1. Exercise. This is the best way that I've found to bust stress and keep me going. When I exercise regularly, it seems that I'm able to be more efficient in almost everything I do.
2. Write it down, write it down. Make a list, check it twice. I write down everything, from things I want to get done to gift ideas for the kids.
3. Everything has a home. This is the best way I've found to keep track of items.
4. Make use of duplicates. How many pairs of reading glasses does one busy doctor need? um...at last count, six. I have them in the car, in my office, in my bag, and 3 pairs at home (bedroom, kitchen and family room). Yes, each pair has its own home in all of those locations; the upside is that I never spend time looking for glasses. I do the same thing for scissors and office supplies (kitchen, bedroom, office).
5. Hug my kids or husband. No matter how busy I get, a hug always regenerates me in a way nothing else seems able to.

Even though time isn't my friend on too many occasions, using these tricks makes me feel like I have at least a little control over my life - and that's always a good thing.
A

Guest Post: Recipes On The Run

I try to cook healthy, fresh meals at home whenever possible. I have found that having my recipes available wherever, whenever helps me get this done more often and more efficiently.

For those who have an iPhone or are considering one, it’s been a huge help with this. I have an application called “Folders” that allows me to keep my recipes, organized neatly, at my fingertips at all times. I typed in each recipe as a word doc and uploaded them onto the app. I created folders for main dishes, crock pot dishes, side dishes, soups, etc.

Now, with my folders of recipes on my phone, I can decide what to make before I leave the office. I can then stop by the grocery store on my way home and get the ingredients, since I have them all listed in the recipe. When I get home, I make dinner using the recipe on the phone. I know when the dish is done by using my iPhone as a kitchen timer!

I can even find out what the half-price specials are at the grocery store while I’m at the office deciding on a recipe for that night. I pull up the store website on my iPhone, and if ground beef is half price, I’ll pick a dish that uses it.

The iPhone may be a bit pricey, but for everything it’s helping me do (including acting as my pager), it’s been worth every penny.


gcs 15 is a 39 year old full-time neurosurgeon in private practice in a beautiful Southern state. She has a 10 year old son who plays travel soccer and ice hockey. Her wonderful, Type B husband is a primary care MD who quit medicine to be a college professor and loves teaching premed students. She adores her job but hates the politics involved in the practice of medicine. She's always struggling to find ways to get more hours in the day.

Under pressure

As a resident, it's important for me to put aside time for studying while I'm home, so that when I graduate I'm not just a huge malpractice suit waiting to happen. Having a baby has in some ways made that more challenging, but in other ways has actually helped me (believe it or not).

My typical evening prior to having a baby:

6PM: Arrive home

6:30PM: Leisurely dinner

7:30PM: Watch television, think about studying.

8:30PM: Surf the web, usually while watching television

9:30PM: Consider studying again.

10PM: Bedtime snack

10:30PM: Consider studying again, but figure I'm too tired to absorb anything. I'll study tomorrow.

11:30PM: Bedtime

My typical evening now:

6PM: Arrive home

6-9PM: Baby care

9PM: Get out book and furiously study, write presentations, whatever

10PM: Collapse into bed, totally exhausted

The difference? When you have a kid, you know free time is scarce, so you take your studying when you can get it. You can't afford to postpone work till tomorrow, because god knows what will come up tomorrow.

As a result of all the studying I've been doing lately, I've become one of the most knowledgeable senior residents (in my very modest opinion). Sometimes I forget how it used to be and I wonder why the residents without kids seem to never have time to read like I do. I mean, what do they DO all night?

Choices

I chose a job where I had control of my schedule.

I chose to have Mondays off.

I chose to work out of 1 hospital only (God bless you crazy OB ’s that work out of multiple hospitals and have people in labor all over town)

I chose a good man.

I chose a low maintenance haircut.

I also try to start most days with a run and some time in prayer.

I finish my charting before I leave the office, but I keep a small stack of paperwork that can be procrastinated. I keep my journals in this stack. Then, I go through them when I’m stuck at the hospital waiting for someone to deliver (My office is down the hall from L&D).

I’m a optimist. I don’t let myself wallow in self pity when I have to work late or don’t get any sleep. I try to focus on what an honor it is that people let me into their lives so intimately. To deliver a baby… even at 3 am …… is still the most amazing experience in the world.

I also drink a massive amount of coffee.

Commute time is not more fun than time with the kids

Like the dog year to people year conversion factor (what is it 7 to 1? I'm no vet...), there is something funky about the commute time to kid time equation. Even though I can listen to my favorite radio hosts who catch me up on local, regional, and world events, even though I can unwind after a rough day seeing pregnant teens who didn't know they're pregnant, and even though I can make cell phone calls (hands free) to friends I don't get to see that often anymore, I will unequivocally say that time spent commuting is not more fun than time spent with my kids. A simple fact. The commute is a time-sink. And commuting in traffic is negative time. At least if I were in the car with my kids for the bulk of those travel minutes, then it wouldn't be too bad, as we talk, listen to music (on my rockin' cassette player), discuss what we see on the side of the road, and make stops at farmer's markets (always a winner) and gas stations (fun because Mommy washes both rear passengers' windshields a few times) . But commuting without either rear passenger is painful indeed. I recently obtained a navigational GPS that I thought would help me Get Places Sooner, but I find it actually gives me more choices that I can now fret about... will it be faster or slower to turn onto this side road, and why does it say "no outlet?"



One good option which serves to add precious moments to the standard 24 hour day, when I can swing it, is to skip out of work early on administrative days or light clinical afternoons, avoid traffic altogether, and surprise my children with an early pick up. And, on a typical trafficky commute, what makes up for those negative minutes are the positively huge smiles, cheers, and hugs when we all meet up again at the end of the day. And I don't dare let thoughts of tomorrow morning's commute intrude on our fun-filled evening.

Spring (for) cleaning

I've always felt I should be neater. I mean, inherently neater. Instead, I feel almost betrayed when I am confronted by my strong tendency towards chaos. Take my desk at work, for instance. Chaos reigns. But try as I might, I can't seem to keep it neat. It's like I'm fighting destiny.

Coupled with my husband's tendency to really let things go, our house has serious devolvement potential.

We lived in this precarious balance of hovel vs house for awhile before our first child. As my due date approached, my mother in law, one day, passed a piece of paper to me with the name and number of a woman who cleaned houses. "You'll be too busy."

Yet, I never saw myself as the type that would have someone clean my house. It's not like we lived in a mansion with a miniature train that traversed the living room. It seemed indulgent.

My parents both came to this country as graduate students with very little money. For awhile, their wardrobe was supplied by the Salvation Army for cents. There's a picture of me as a toddler sitting at my make-shift desk, built from 2 x 4's and milk crates.

Later, we were finanically more comfortable but saving was always emphasized. Paying someone to clean the house was out of my comfort zone. I also thought of it like a failure- as in - you should be able to do it all!

Yet, after our daughter was born, we seemed to prefer spending precious time at home eating, sleeping, caring for the baby and doing personal hygiene than scrubbing toilets. Our daughter's nanny (another story for another time) would periodically volunteer to clean ______ (insert any of a variety of areas in desperate need for attention) out of pity.

It wasn't until we moved into our current home, after growing out of our townhome, that I finally agreed that there was no way we could keep up with cleaning this house. Not with our full-time jobs and growing family. I gave in.

It's been over a year, and it has made our lives so much less stressful. I love it when I come home to find the house actually CLEAN; it's almost like a mild euphoria. If you can afford it, it is worth every penny.

Decluttering

For me, the key to productive, contented living is decluttering.

Life seems to default to an excess of possessions, activities and pursuits. It takes intention and effort to organize a distracted state of living into one that is simple and peaceful. Decluttering involves making do with the minimum required to achieve your goals, and systematically winnowing out what isn't earning its keep.

I apply decluttering to every aspect of my life. Working at two clinics had introduced unnecessary complexity to my week, so this summer I resigned at the HIV clinic to exclusively practice refugee medicine. I focus on three hobbies: gardening in summer, knitting in winter and photography year-round. No one looks inside my closet without remarking that it's the most pared down collection of clothes they've ever seen. My kids have a modest selection of thoughtfully chosen, well-loved toys. I thin my patients' charts ruthlessly. My blog has the cleanest layout possible and I haven't added any extra applications to my Facebook page.

Learning to say no is a major part in decluttering the calendar. (I was 30 when I finally learned to do this well.) When I do make commitments, I make them for a defined period of time. I'll join a knitting group for one winter, for example, or keep a blog for one year. When I take on a new position at work, I quietly decide up front for how long I'm willing to commit. At the end of the given time, I reassess. That way every obligation has an expiry date and can be renewed or replaced.

To use my time most efficiently, every weekend I plan the week ahead, including penciling in activities for my downtime. My kids are all in bed by 7:00, and that's three full evening hours for me - if I can escape the call of the Internet, probably the most distracting, time-wasting, mind-cluttering force out there. Some useful tools to make Internet use efficient are feed readers, which eliminate the need to visit blogs to check if they've been updated, and Firefox's pageaddict, which monitors the time you spend at different sites and allows you to set restrictions on your visits to inane, yet compelling sites.

Decluttering is a way of life. This method agrees completely with my personality, and I purge, streamline and consolidate with pleasure. Cutting out the extraneous allows for the clutter I do enjoy: a house overflowing with kids and a slate full of patients.

(For more on productivity, visit blogs zenhabits, unclutterer and 43 folders.)

Big Fat Time Savers!

1. Buy pre-cooked food at the grocery store deli. More expensive, but your time is worth it.
2. Lay out clothes for self and kid before going to bed. Good theory, and when I do it I'm really happy.
3. Tape a "don't forget" note to the door before bed, i.e. "don't forget bagels for a..m. meeting."
4. Hire a housekeeper to come in once a week to do floors, dusting, etc. Even if she or he is lousy, it's probably better than you could do some weeks.
5. Take Detrol-LA. Save time on those pesky potty breaks.
6. Keep your emergency pickup kid people on call. If I know I have a late meeting on Wednesday and Husband is out of town, I call around on Tuesday for someone to be on call just in case. Put these numbers on your speed dial.
7. Take your lunch or at least get it to go...sneak into the nurse's breakroom with a stack of charts and eat while charting.
8. When people offer to help you, take them up on it.
9. Brush your teeth in the shower while conditioning your hair.
10. Marry the right mate...a co-parent, co-shopper, partner in all things domestic.
    

Secret Weapon

I have a secret weapon – not a bat mobile, not a web shot from my inner wrist, not an iron suit – think domestic secret weapon.

It’s my crock-pot and in fifteen minutes of prep time – I can create the illusion of having slaved in the kitchen for the last ten hours. Magically this appliance takes raw meat and vegetables and creates a main dish, a side and gravy. This satisfies my meat and potato men (separate sides of the plate, please) and my casserole (one dish, less clean-up) mentality.

I’ve heard the concerns about crock pot cooking: the appliance doesn’t cook hot enough to be safe. What if it malfunctions (which has happened and we ordered take-out that night)? What if it sets off a fire when I’m not home? I’m willing to take the risks as I do with all the other appliances plugged into my house. Thankfully no one has gotten ill from one of my crock-pot adventures, and I have yet to burn the house down.

I own about fifteen slow cooking cookbooks, and always looking for a new take on my stainless steel wonder. One of my family’s favorites is pork BBQ. It is stupidly simple and can spawn multiple varieties. One pork butt roast with bone intact (don’t know why the bone matters but it does). Put the roast in the slow cooker ten hours in advance of dinnertime. If I remember, I try to put a liner in the cooker to ease my clean-up. Pour one bottle of BBQ sauce over the top and cook on low for 10+ hours. I keep this one very simple with just meat – but I usually add vegetables to my other slow cooker recipes such as pot roast, chicken and dumplings, (bastardized) chicken cacciatore, or beef stew.

At the end of cooking time (and this works well overnight for lunch, too), all the meat falls off the bone into juicy, tangy ribbons of pork which are easily draped over a sandwich roll. I like it by itself with vinegar BBQ sauce. Throw together some salad, fruit or baked beans, and I have a meal. Turkey or chicken can be substituted for less time with good results.

The best part ….the whole house smells like I’ve cooked all day. Heroically I can serve dinner at 6PM sharp with clean-up by 7. Not faster than a speeding bullet but according to 19th century French chef and author Urbain Dubois, "the ambition of every good cook must be to make something very good with the fewest possible ingredients."

time management 101 (minus 98)

There are only 3 things I do for my time management:




I make sure I keep track all the things I HAVE to accomplish that day.





I come in early the next day if I have left anything behind.





I take lunch behind my desk.





That's my imperfect scheme, but those three things get me home in time to have dinner with my kids, and that's what I think is important!

Gap tears

I started my fall shopping over the last couple weeks. This year’s gap hoodie is size 5T. It dawned on me, that very soon I will be shopping at Gap kids and not baby Gap. This is blowing my mind right now. We attended a private school fair recently. Everytime I answered “Kindergarten” to the question “What grade will your child be in next year?” it got a little harder to hold back the tears.

Time is going by so fast, I just want to treasure every second. I don’t know if this is because he’s my only child that I’m feeling this so strongly, or perhaps because our journey for number #2 has been such a long one. Perhaps, everyone feels this way and I’m just more vocal about it. I’m hoping that perhaps I’m “pre-grieving”. When my grandpa died, about a month before he passed I had a day where I realized the end was near. I mourned for a week, but when the actual funeral came, I was at peace. So hopefully by the time school year rolls around next fall I will be at peace with it… otherwise prepare for multiple teary posts.

Next Topic Day: Time Management

On Wednesday, September 17, we'll be writing posts that have to do with Time Management. A frequent question that has been posed on this blog by our contributors and readers alike, is: how to juggle it all? Aside from being cloned, how to manage mothering, a demanding profession and doing everything that needs to be done in a day's time, preferably while maintaining our sanity? What has worked for us? What hasn't? What do we still struggle with?

We hope this Topic Day can provide an exchange of ideas that can help us all. Please join us and send in your tips/solutions/stories to mothersinmedicine AT gmail DOT com by Tuesday, September 16 to be included.

If you missed our last Topic Day where we shared our labor and delivery stories, you can see them here.

The high price of motherhood

My little daughter takes violin lessons, typically on Saturdays. This Saturday, we had a conflict, so I took the only other spot available, a 3:00 pm Wednesday lesson. I don't get off work that early, of course, so I figure I will quickly take her and then bring her back to work with me.

The workday was packed. I wanted to back out of this cockamamie scheme that I had somehow let myself into. But I just went ahead and did it. I had heartburn and a mild headache by the time I got back. Having my daughter at work with me proved very inefficient, but by 6:00, we were set to go home, with a little residual work left for the following morning (I came in at 6 am this morning to catch up).

I don't think I have any wisdom to share. If there was a simple answer on how to have a medical career and be a mother, we wouldn't have stress or angst. I think that I have two of the most wonderful kids in the whole world, and I absolutely cherish them and thank God for them. I also have a fantastic career that I love. My payment is stress, both physical and mental. It's also the guilt I feel when I can't devote the time to my career that I would otherwise before I had kids. It's the grating knowledge that others may either resent me and/or think less of me when I have to put my kids first. But these are all payments I am willing to make, because my life is full and beautiful. Nothing truly great comes without sacrifice.

Anyway, nothing this week will top my experience yesterday at work when, during an intense conversation with one of the general surgeons about his patient's biopsy results, Sophie gets right in my face and says "MOMMY, I have to POOP! I have to poop REALLY BAD! (I was trying my best to shush her) Really, I'm NOT trickin' ya! I have to POOP REALLY BAD! MOM-MY! I have to POOOOOP!!!"

Don't worry, we made it.

This looks like more fun than it is

I remember in the last few weeks of my pregnancy, it took every ounce of my strength to drag myself to work every morning, between being sleep deprived and having pain in every joint that was capable of feeling pain. I hung in there because my maternity leave was finite and I wanted to spend every moment of it with my baby. So that meant coming in to work until the bitter end.

But it turned out I wasn't the most miserable person around. In fact, it never even occurred to me that there might be people out there who were actually jealous of me and my thirty-pound belly.

I discovered the truth one evening, while I was sitting in the office I shared with my swingin' single male co-resident. We were complaining about our workload and suddenly he blurted out:

"I wish I were pregnant."

I had never been so shocked. Immediately, a range of angry replies ran through my head: What part of pregnancy would you like? Would you like to carry 30 extra pounds around with you everywhere you go? Would you like to have to wake up 10 times a night to pee? Or would you just like to go through a painful labor possible ending in a major abdominal surgery? What part of being pregnant appeals to you the most??

I didn't say any of that though. My reply was, "You don't really mean that."

He quickly said, "You're right, I don't."

Of course, what he really meant was that he wanted to have a six week maternity leave. Except what he really meant was that he wanted six weeks in Bermuda.

To many people who have never cared for a newborn before, maternity leave seems like just that: a vacation. And those who cover for you when you're gone get resentful that they have to work harder so that you get a six week vacation, while all they get is a measly 3-4 weeks.

Comments like the above fed into the extreme guilt I had surrounding my maternity leave. When I came back to work, I was afraid to even talk to anyone for months because I assumed all the other residents hated me for getting a "paid vacation".

And even though it's been over a year since I returned from leave, I still haven't completely left those feelings behind.

"Doctors Wanted - No Women Need Apply" - NOT!

I could browse this site for hours: the N.I.H./National Library of Medicine website called Changing the Face of Medicine, which celebrates the lives of women physicians in America.

Any time I get a little discouraged or feel a little fatigued about working my two jobs - nine or more hours in the O.R., followed by a commute home directly into the next task, food preparation for the evening meal and after-dinner homework/music/general kid-help - I look up stories of women who had it MUCH HARDER than I do and try to give myself a little wake-up call. I stop whining right away.

Here are just a few of the many amazing stories that have inspired me:

Dr. Susan La Fleche Picotte, born in 1865, was the first Native American woman in the United States to receive a medical degree. She was 24 years old. She was also the first person to receive federal aid for professional education. The M.D. program at the Women's Medical College of Pennsylvania was a three-year program; she graduated after two years at the top of her class. She had been inspired as a child to study medicine by the death of a Native American woman after the local white doctor refused to provide care for her. In 1894 she married Henry Picotte; they had two sons. She had a busy general practice serving both white and non-white patients. Two years before her death in 1913 she opened a hospital in the reservation town of Walthill, Nebraska, achieving a lifelong dream.

Dr. Elizabeth D. A. Magnus Cohen was the first woman licensed to practice medicine in Louisiana. The NLM site relates, "While she was still in medical school, a New Orleans Bee editorial on July 3, 1853, had labeled the idea of a female physician treating male patients as incongruous and improper. In 1898, an editorial in the Journal of the American Medical Association blamed women physicians for the declines in salaries and prestige of the medical profession. Eventually, medical schools began refusing to admit women." Dr. Cohen recounts that as a surgeon she was called at least once or twice every single night before dawn during her thirty-year practice from 1857-1887. Other doctors apparently referred to her as a "lucky hand" in tough cases. She was married and had five children, though only one lived to adulthood.

Dr. Sarah Read Adamson Dolley was the first woman to complete a hospital intership, in 1852. Her interest in medicine was sparked by a physiology book given to her by her teacher, Graceanna Lewis, to read at home. She practiced OB/gyn and ran a medical practice with her husband, with whom she had two children, one of whom died in childhood. "Her vivid correspondence documents her success in creating a solo practice after the death of her practice partner—her husband. They also reveal her anguish over how to support her son, pay for his education (he, too, became a physician), and how to overcome the resistance of her male colleagues. But her letters reveal that in her rise to success, nothing was easy, especially without a role model to guide her."


Dr. Halle Tanner Dillon Johnson was the first woman of any ethnicity to be a board-certified physician in the state of Alabama. She was already married and a mother when she began her medical studies and in 1891 earned her medical degree from the Women's Medical College of Pennsylvania with honors. While "southern newspapers had scoffed at the idea of a black woman even applying to take the [board] exam," in that same year the New York Times took note of her success in passing the grueling ten-day Alabama State Medical Examination. Alas, her career was brief. She died of childbirth complications on April 26, 1901.


Finally, though I don't think she was a mother as well as a physician, I want to honor Dr. Elizabeth Ann Grier, the first African-American woman licensed to practice medicine in Georgia. She was an emancipated slave who alternated every year of her medical education with a year of picking cotton in order to pay for her training. "When I saw colored women doing all the work in cases of accouchement [childbirth]," she said, "and all the fee going to some white doctor who merely looked on, I asked myself why should I not get the fee myself. For this purpose I have qualified. I went to Philadelphia, studied medicine hard, procured my degree, and have come back to Atlanta, where I have lived all my life, to practice my profession." Sadly, she died in 1902 after practicing for only a few years.

It's stories like these that let help keep me going, putting one foot in front the other and telling myself, "You can do this. You totally can." I think we have to keep passing on stories like these - to our students, our colleagues, our children, ourselves.

watching from the sidelines

First swim lessons this weekend for Just Four. As a former lifeguard, current mother and pediatrician, one would think that I could have taught her some swimming basics. But despite our best intentions and her inquisitive nature, my daughter has a hard time learning from her parents. She knows Dr Mommy is the best at putting on band-aids. And that daddy can rock out on the guitar. However, our teacher-centered little girl who is frequently found to be instructing her stuffed animals in all of life's lessons, appears to learn best from Other People. We struggled with which class to choose, one in which we parents could wade in the water too versus one in which we were banished to the sidelines (instructor to parents "Step away from the pool"). Choosing the latter proved to be a wise move, as she made us proud, nervously saying Goodbye and then completing her first lesson, bubbles, floating, gliding with an occasional wave to Dr Mommy, who, behind a glass wall was watching her daughter learn and grow on her own. Needing me but not needing me. Oh, yes, and my needing her.

24/7

Mamapop had a great discussion Thursday about feminism, and how it applies to politics, specifically Sarah Palin. Feminist is not one of the labels I apply to myself (like juliaink). Just don’t consider myself a pioneer in moving the cause of women forward. I also don’t tag myself as a political animal. However, this election has me fired up because I feel that the items the media has picked up and discussed are issues in my back yard.

As women in medicine and specifically mothers in medicine, we have a unique perspective. My occupation is 24/7. I share call with other physicians, now, although I was once a solo practitioner. The ownership part of my practice is still there seven days a week and requires maintenance whether it is employee reviews I need to write, maintenance of the facilities or just a late night security call. Being a physician is a 24/7 job whether I’m on call or not – and I suspect it may be that way for my fellow MIM writers. Have you fielded a phone call from a worried neighbor or family member because you have MD or DO (or RN, PA, NP) after you name?

Mothering, Fathering and Parenting are also 24/7 jobs. Even with my two healthy children, the balance is precarious and dynamic. I can only imagine what adding intense media coverage, decision making for 300+ million citizens, and overlapping passport stamps would do to my stress level. It’s not that the VP (or presidency, for that matter) job isn’t compatible with parenthood. It is. I’m not sure the job that will require 110% focus seven days a week (or at least this is what I expect out of elected leaders ) is balanceable with children that need their parents as much as 2 of the 5 Palin kids will need their parents in the coming months.

Childbearing in Surgical Residency

My intent was not to make such a serious posting, but I did not succeed.

After 8 years of surgical residency and fellowship, I am happy to report that our lives are returning to some sort of “relative normalcy.” Stress the word “relative” as most would not describe it anything close to “normal.” Life as a junior staff surgeon involves frequent call, occasional emergencies, and the ability to pick up slack for my senior partners. But my life now carries with it innumerably greater amounts of flexibility than life as a resident or fellow.

I now have a small teaching group of 2 female medical students in their first year of medical school. They “shadow” me in clinic or the operating room once a week. Although both are interested in what I do as a surgeon, inevitably they are most curious about my decisions and experiences with childbearing and family life. I tell them about training. I tell them that it is hard but that family life and motherhood are great and well worth it.

It was harder than what I tell them, especially as most of my training was before 80-hours and “80-hours” is often still theoretical in surgical training. All medical training is difficult, but surgical training is perhaps the hardest. Finding the balance between family life and work duties is hard for all surgeons, particularly for women surgeons in training.

The “ethos” of surgery remains principally masculine and rigid. Surgeons are supposed to be particularly strong, not to complain, and to go along with the “status quo”. While this may sound backward and negative, paradoxically in many circumstances I find the first two of these qualities admirable, and I still believe surgery to be one of the most exciting and rewarding career paths that anyone could choose.

As most parents will testify, childbearing is one of the less challenging aspects of parenting. But decisions around childbearing and the time with your newborn are important shaping experiences.

The concept or image of a pregnant surgeon, whether or not in training, is still a foreign one to quite a number of surgeons, some of whom feel free to share their opinions. The decision and process of pregnancy for women residents (I suspect in a number of medical fields) produces anxiety and (both subtle and overt) comments. I have seen female residents leave surgical residency either for another medical specialty or leave medicine entirely as a result of issues surrounding childbearing. Two of my female resident colleagues “decided” to return to work only a few weeks after giving birth because one had been placed on bedrest before giving birth and the other was told two weeks was all the residency program could bear. Female residents that take full time for maternity leave often “owe” additional months (as it might be in other training programs) but also often suffer palpable resentment from fellow residents.

This is, in part, because typically the decision for a female surgical resident to have a child directly impacts the entire training system. And surgery, worse than most other medical sub-specialties, has not found solutions to address these issues. Most surgical training programs suffer from more limited people-power. When one person is not performing optimally or is absent for any reason, the entire team feels it. The call schedule might change from every 3rd night to every 2nd (of course, illegal under current regulations). This issue is perhaps the worst in some of the sub-specialties where the entire training program is composed of a handful of individuals. Interestingly, several of my female friends who have entered small private practices after training also experience similar pressures as childbearing would impact their partners' lives significantly.

Issues of maternity leave, parental leave, and time for other parenting duties in most residency training programs have not been traditionally prioritized. Not surprisingly, fields like surgery which have been slowest to find solutions and to transform their ethos feel much-needed pressure to start making changes -- as women now make up over half of graduating medical school students nationwide.

Personally, I “timed it” well, having my daughter during my years in research during residency. My 4-year-old daughter is beautiful, well-adjusted, and a great kid. And my husband and I have found a satisfactory parenting balance that works. I am extremely lucky, but I would like for my experience to be less of the exception.

Shoes: the other Elephant in the Room

So. There‘s pair of $200 shoes sitting on the floor of my closet.

They are beautiful. The smell of their leather sends chills down my spine.

When I tried them on in the store, I actually felt giddy. I’ve put them on twice…. But if I wear them outside the house I can’t take them back, so I haven’t yet.

I tell my self I deserve them. All those long nights at the hospital and hard work should be rewarded. Really, I don’t need them. My closets are full. I’m blessed. Truth is: time is money. As we prepare to hopefully adopt baby # 2, I see each purchase as time. The less I spend, the more time I’ll be able to take off to spend with the new baby when it comes. (No announcements yet but I'll keep you posted.)

I own my own practice. I’m one of 4 partners. My overhead is killer. My malpractice premium alone could buy one fancy Lexus. I do well, as long as I’m working. Taking much time off leaves me seeing red for a few months. Last year when I had to take my boards, I didn’t get a paycheck for 2 months. I accept this because it gives me complete control of my schedule. My partners are great. We get along personally and professionally remarkably well. We are all moms and we cover for each other a lot. Financially though, we “eat what we kill”. We work as little or as much as we want, take equal call, and pay equal overhead. Overhead includes salary, FICA/taxes, and benefits for two dozen employees.

I try to remind my self that the more money I spend, the more I have to work, the more time I spend away from my family. So I think the other elephant in the room is money. At least for me, since I’m the breadwinner in my family. It‘s physically painful to write out a check every 3 months for $15,000 and mail it to uncle SAM. It’s hard not to also see this as time stolen away.

I was looking at everyone’s profile in our group and it seems that myself and perhaps MWAS are the only Physician’s in private practice. Is anyone else self employed? Are taxes less obvious when you’re an employee and it just gets deducted. Is malpractice less obscene when some else foots the bill?

I don’t plan to vote with my pocketbook. I actually don’t plan to vote. (My state is so red even Gore couldn't take it.) But as I said, time is money. Every dollar more I pay in taxes and malpractice is less time spent with my family. Since the Dems came a little too close to having a malpractice lawyer on the ticket, and because I am both a corportaion and nearly "rich" some have promised to increase my tax burden, twice (don't tell my staff, but we could have to cut back). So yeah, I’m eyeing the Dems with more than a little suspicion.

Gottogo. Need to return some shoes.

The Elephant in the Room

I, like many women, and perhaps like physicians in general, am averse to political activism. Medical problems have, or we are taught to think they have, right answers. Controversy and disagreement are uncomfortable to us, implying that our judgment or knowledge is somehow at fault. Even the formal exercise of an M and M conference does not help us recognize and accept legitimate differences; at the end of the disagreement, the pathologist is there to provide the single right answer. And as women, we want to make others feel accepted and comfortable. So I am reluctant to take a political position in this blog. Some of my best friends, etc....

I am not about to rant on either candidate, but I do want to share my dismay at some of the health care issues that are going to be affected by the outcome of the next election. A friend of mine in Hawaii wrote to me that blue cross/blue shield in her state requires women to pay higher premiums than men--and gets away with it! Yes, women have expenses related to reproductive care that men don't, and yes, we live longer. But the whole idea of health insurance is to spread risk fairly through a population. Differential pricing by gender implies that men are the true representatives of the population and women somehow deviant from the norm (despite being an absolute majority). This stands the very edifice of health insurance on its head.

Beyond reproductive health care services like abortion and contraception, adequate insurance for the elderly, including nursing and other support services, are also "women's issues." When insurance fails to cover services, it is typically women--wives and daughters--who pick up the responsibilties of caregiving. When insurance does not pay for services for children, it is mothers who step in fill the vacuum. Now that women are more productive in work outside the home, the economic costs of us having to cut back our own work to become caregivers are huge, and rarely acknowledged.

The underlying problem is one of state/federal conflict, not necessarily Democratic/Republican differences. The regulation of private health insurance is a state rather than a federal function. Many insurance companies have budgets--and therefore political clout--larger than the state governments that regulate them. Only the federal government is large enough and strong enough to rein in the rogue health insurance industry. Personalities and records aside, this mother in medicine is going to vote for the candidate who believes in using the power of government to regulate crucial service institutions directly, not through byzantine manipulations of the tax code. Three guesses as to who that will be.

Girl Bonding 101: Moving Beyond Netter

I am in a state of slow, silent, ever-evolving panic.

I just looked over at my 10-year-old daughter (soon to be 11), and for a second I saw a young woman sitting in the armchair. Or at least, a young pre-woman. Ack.

She has shot up several inches and a couple of shoe sizes this year. I feel like she goes up one Tanner stage every week or so. Her face has gradually acquired subtle, more mature angles, and let’s not even talk about the rest…

She builds sand castles at the beach and sleeps with her teddy bear. But she also notices attractive young actors or singers, and her comprehension of the nuances of flirtation is accelerating at an alarming rate. She is bubbly and all smiles and hugs one moment, irate and scowling the next, at the slightest provocation. She can still enjoy Sponge Bob, but she can also start to discuss American politics and social issues. I am amazed and thrilled and in awe and totally distressed.

I want to tell her pituitary axis: whoa! Slow down! Childhood’s short enough! But it’s useless.

It’s time to have THE TALK.

No, not that talk. We had that talk when she was eight, because the kids at school were already disseminating all sorts of sketchy information about reproduction and childbirth. I told her I was okay with her discussing reproduction and childbirth but I wanted her to have the right information – and who better than her doctor-mom to provide it, right?

Now, I am sure there are lots of people out there who can describe the “right way” and “wrong way” to handle sex education. I myself got “educated” in a bit of an unusual way. I was in a book store when I was five and saw a book entitled Where Babies Come From, or something like that, illustrated with some cartoon-like illustrations. I had been reading for about a year. I picked up the book, learned the facts of life, and, bored out of my mind, put the book back on the shelf. My mom was a little surprised, I think, when, after she expressed doubt that I actually knew about intercourse, I explained the process to her fairly accurately. It was only later that the more abstract concepts came within reach.

When my daughter asked me where babies come from, I said, “Cells, of course. Remember how I told you all our bodies are made of little, tiny things called cells? Babies start out as little clumps of cells inside their mothers and grow bigger and bigger with time. The parts of the body develop as our cells make more cells.”

That explanation satisfied her for a while, but then the inevitable came: “How do the cells get inside the mommy? And is it true that mommies push the baby out through where they pee?” That was the part the kids at school were talking about.

That was the part that made me thankful I'd hung on to my Netter Atlas of Anatomy from medical school. I sat my daughter down between my husband and me and we explained the relevant mechanics of reproduction step by step. I explained a little bit about menstrual cycles. I drew simple diagrams of female internal organs and used Netter as a supplement. Last but not least, my husband and I both expressed our personal values regarding the place of sexuality in the context of human relationships. As our daughter listened I felt proud, because she seemed to be listening so thoughtfully.

Lately, though, now that she’s a little older, she has acquired a kind of embarrassed reluctance to discuss “woman stuff.” When she was eight we could almost sense a certain pride in her at being entrusted with these more “adult” concepts. Today, however, she’d really rather not talk about them. But I feel I have to get us talking about them, not only to reinforce the idea that it’s okay for us to talk and for her to have questions, but also to make sure she doesn’t feel anxious or uncertain or ill-informed. Sometimes it seems like it's almost easier to get patients to open up about personal things.

I wanted to have the talk about menarche. I think it’s imminent at this point. But how to create a level of comfort about the subject? And to make sure we’re prepared, together, before the moment arrives? I want her to feel good about growing up, to celebrate each milestone instead of dreading or being unpleasantly surprised by it.

The other night an opportunity arose. I don’t quite remember how. But the subject came up, and I asked her if she had any questions about periods.

“No,” she answered emphatically, casting her eyes down. I could almost hear her mortified mental voice asking me, Please don’t give me an awkward, long-winded lecture; please don’t start looking for “ins;” and please, whatever you do, don’t ask me if I’m sure about not having any questions.
“Are you sure?” I asked, stupidly. So predictable.

Then I started to babble. I told her she could always come to me if she felt unsure or worried about something. I told her it wasn’t at all scary to get a period if you knew what to expect. I told her I would go with her to the drug store when the time came to look at the options in terms of supplies.

Then it happened. I got my “in.”

“Actually, that’s the part I wasn’t sure about,” she said, looking up again.

“What’s that, honey?”

“The supplies part. I don’t exactly understand how they work.”

Relief! She had given me a concrete way to nurture and support her! Hallelujah! I launched into an enthused discussion - not, I hoped, an awkward, long-winded lecture - about the pros and cons of various types of supplies, demystifying the “anatomy” and mechanics of each with appropriate exhibits. I explained what I liked and didn’t like about each option.

Sometimes, whether it’s a patient or a beloved child, it can be so tough to talk about so-called “sensitive” issues. And somehow it can be much easier to be direct with total strangers. “Are you sexually active?” we ask during a comprehensive medical history. “With one partner or more than one? Male or female?” I can do all that "doctor stuff" without batting an eyelash, but somehow when it comes to the mother-stuff of making sure my daughter’s emotionally okay, or figuring out if I’m asking too much or too little, saying too much or too little, I feel much less certain that I’m doing an adequate job. There’s no Netter Atlas of Parenting, after all.

I guess I just have to take my cues from her.

Photo: reusable menstrual pad with Kokopelli motif from Wikipedia article on the history of sanitary napkins

Link of interest, for the historically inclined: Museum of Menstruation

Guest Post: Vigilance 101

Several decades ago I began medical school as one of five women in my class. Medical school was followed by internship/residency at a tough city hospital in the days before 80 hour work week restrictions. So I considered myself a non-pampered full-fledged member of the medical profession. But after fellowship finished I was elated with the offer of a half-time job at a university clinic. The hours would prove perfect for raising young children. Of course, half time in medicine means 50% pay for at least 75% time. I worked 5 days per week, 6 hours each day, straight through lunch, so I could finish the workload and get home at a reasonable time. Outside of the regular clinic hours I was also responsible for any of my patients that were hospitalized and for every other week 24/7 on-call. But it was all tolerable because of the flexibility. I essentially job-shared with a near retirement age physician who had raised a large family and he was welcoming of my bringing children to work on the occasional school holiday or child care emergency day.

My rude awakening was the chance spotting of a young male physician at the shopping mall one mid-week afternoon.

“Hi – are you on vacation this week?”

“No – Wednesdays are my discretionary time”

“Discretionary time???????”

“Yes – the day I don’t see patients. It’s the time I write my book, review residency training curriculum, do phone conferences…”

OK, I calculate. He’s my age, same amount of training, hired by the same university division. I work 5 days x 6 hours = 30 hours in clinic for 50% pay. He works 4 days x 8 hours = 32 hours in clinic for 100% pay. I did register a complaint which did nothing but label me troublemaker, but I was attached enough to my work hours that I didn’t pursue legal action. (That’s another story for when children were older).

Fast forward to August 3, 2008, The Outlook Section of The Washington Post. There’s an op-ed article by a physician bemoaning the current state of patient care in primary care medicine. No argument, primary care medicine is dying for a variety of economic reasons. But wait – our author has an answer. He claims there’s a “silver lining” in that many more women are entering medicine. Women tend to migrate to primary care fields, and they are documented to spend more time with patients even if they don’t get paid more. So there we go – cheap, undervalued labor is still with us!


Dr. Nana is a private practice internist in a suburb of a large east coast city. She has a physician son, a medical student son, and a physician daughter-in-law. Besides her clinical work, she is active in political action/legislative lobbying/educational efforts to preserve the practice of medicine, which is currently under assault on multiple fronts.

Mothering a med student

Pathmom has been off the air for many weeks, primarily due to the addition of a full time med student last month. I have a healthy amount of respect for med students (we were all students once), and this one was particularly bright and appeared to have the requisite "good eye" that any successful pathologist must have. So in the title of this blog, I don't want to sound pandering or condescending in any way, but there was an incident that I found particularly memorable, and worthy of sharing.

This young woman had a 4 month old baby girl at home. She came back from maternity leave and went straight into her general surgery rotations. Her medical school was in the habit of "farming out" students to community groups across the metro area (and even the country) for their clinical rotations. The two surgeons she rotated with were geographically close, but had a reputation for inappropriate behavior.

"K", as I will refer to her, had an initial interest in surgery, but she was fully cured of that in the process of her rotation. Apart from being bad-tempered and complaining vocally about having to have med students at all, these surgeons were apparently openly misogynistic. They reduced one female med student to tears by verbal abuse, got cited for making "inappropriate remarks" to another, and told "K" directly that the only way they would ever hire a woman was if she had a hysterectomy.

The last incident really burned me, but I was more appalled by the way "K" told me about it, almost like she was waiting for me to chuckle or at least smile.

"Are you serious? They said that to you?"

"Well, these guys are pretty old school."

"Old school, nothing! That's an extremely offensive remark!"

I had that bewildered sense of reacting very strongly to something that appeared to have no effect on someone that I would consider more or less a peer, based on age and being the mother of a small child. I explained that you can't change individuals, but that she should not take that comment as something either acceptable or amusing. I also thoroughly derided her medical school for allowing students to be with these physicians (apparently, options are rather on the slim side). Despite having quite strong opinions about many and varied things, I actually do not "soap box" very often. This, however, did ignite a spark. The term "flipped out" sums it up nicely.

I couldn't help but wonder if it was her upbringing or just a lack of social aptitude that made her fail to realize the abhorrent nature of that comment (and, yes, I am intentionally leaving out the option that I was just plain over-reacting).

I also couldn't help waxing philosophical about the whole incident. Obviously, this blog is built around the notion that mothers in medicine are worthy and capable members of the medical field. We are also, frankly, necessary to the system. If every "mother in medicine" were to disappear from the profession, and if only those women who were indeed sans uterus were allowed to practice, what then? Not so great for aging baby boomers, that's for darn sure.

This student was convinced that surgery was not an option for her - and maybe it wasn't her path for other reasons - but these horrid surgeons certainly made it clear that she wasn't a candidate based on who she was. "Of course you can be a surgeon!" I explained to her that my sister-in-law is a practicing general surgeon, and has had two girls and plans to have more. I also pointed out that 3 of the 6 general surgeons at my hospital were women, all of whom had small kids. That being the case, I had already melded her mind towards the utterly cool and completely irresistible field of pathology, so I believe it's unlikely she will do anything else (path props).

Frankly, mothers in medicine typifies a scenario that all professional women of this era face: creating the reality of how working moms fit into the American workforce in the 21st century. We're living at a time when there is no "norm" for working mothers, and the expectations and experiences are supremely varied. Some moms get months of maternity leave with full pay; others get paltry weeks (or even days) and pro-rated salaries. Some moms have to take leaves of absence; others invoke FMLA. But we are an increasingly powerful and valuable voice in the professional community, and I believe the situation for working moms reflects that more with every passing year (a generation ago, my mother in law and her female residency colleagues had to sign contracts with their programs explicitly stating they would not get pregnant - they did anyway). We are more involved in making our own reality today than ever before, and I believe that what we want to be and how we want to practice are out there waiting for us, be we single, married, pregnant, or toting around that mysterious black bag with the plastic suction devices on it. And if there are still the remnant neanderthals who feel that the possession of fully function female parts excludes someone from consideration, they are, of course, free to limit themselves thusly while the rest of the world spins ahead with diverse, talented, and dedicated mothers in tow.