Code Indigo

The season's first snow is falling. It's raw and grey outside the hospital. Inside, Ella Fitzgerald croons a languid "White Christmas" from the internet radio station. We're wrapping up at the O.R. desk after an uneventful morning case.

"Attention all personnel. Attention all personnel. Code Indigo, third floor. Code Indigo, third floor."

I look at the nurses. "Indigo? Which one's that one again?"

Every hospital has coded security alerts for unusual events - emergency room on diversion, airway crisis or cardiac arrest, infant abduction, bomb threat, unruly patient or family member, etc. I don't recall having heard a Code Indigo* recently.

"Missing patient," says one of the nurses.

"Probably just went out for a smoke," says another.

I go to do post-op rounds. The all-clear sounds overhead for the Code Indigo. But when I get to the post-partum ward, a nurse there tells me as I leaf through a patient's chart, "Don't bother. You won't find that patient."

"Breast-feeding class?"

"No. Just gone. That was the Code Indigo."

"Oh! I thought I heard an all-clear a while back."

"Yeah, because the patient's definitively gone. Baby's still here, though. Wanna see?"

She lifts a swaddled bundle of warm, sleepy perfection out of a bassinette. The baby starts drinking formula from a small bottle the nurse is holding.

I start to think of another baby, a patient I had had to discharge to a foster parent during my internship. The baby had been hospitalized with bilateral spiral femur fractures. Yet every time I approached his crib to examine him, his face would light up with a bright smile that held nothing but joy. After I turned him over to foster care, I went into the call room, called my husband, and sobbed on the phone to him, utterly disconsolate.

My mind starts churning around my current situation, trying to figure out if there's some way we could take care of this baby ourselves. But of course we're not at all prepared for a decision like that right now; all I can do is call the social worker and make sure she's on top of what needs to be done to get this child into a suitable pre-adoptive home. It seems like such a small, ineffective measure to take.

The snow has turned into something a little wetter and clumpier. It's dark by midafternoon on days like this. I've turned on a mix of Christmas music - a little Nutcracker, some Kathleen Battle, a little Boston Pops and Leroy Anderson. I go back up to the nursery to hold the baby. The nurses welcome the break.

"Here, Dr. T - have a seat right here."

The baby sleeps in my arms. His cheeks bulge out like rosy little fruits. He is totally at peace. He has no idea that either nobody loves him at all, or someone loves him so much that she felt she had to set him free. He is blissfully unaware that he is alone in the world. Abandoned.

"At least she didn't try to flush him down the toilet, like the kid we got last week."

Thank heaven for small blessings.

Advent starts today: the liturgical prelude to the Christmas season, and the new beginning of the liturgical year. There's something in the baby's given name that conjures up images of light. Light, on this grey, darkening day.

"The people who walked in darkness have seen a great light." I wish, I wish, I wish.

I start humming the baby a lullaby. My favorite song of the season, half ancient chant, half carol for a newborn.

O Come, O Come Emmanuel
and ransom captive Israel
that mourns in lonely exile here
until the Son of God appear.
Rejoice! Rejoice -
Emmanuel shall come to thee,
O Israel.

I hope this baby gets his Christmas wish, the wish all babies are born with: a wish for love, for a life that matters, and for a world of hope to be cradled in.


*(Not the actual alert used.)
Cross-posted at Notes of an Anesthesioboist.

Round 3

I am a Mom of 2 kids and now soon to be 3....yes, I know it's crazy but despite the tough balancing act, my children are the best thing that has happened to me so we have decided to add one more.

It's been very interesting sharing the news of my pregnancy with colleagues, family and friends. The response I get is different for this third pregnancy.

With my first pregnancy, people were generally very excited for me. I was embarking into the world of parenting and people congratulated the decision and celebrated the novelty with me. I got lots of advice on how to manage the pregnancy and what to savour BEFORE the kids come.

With my second pregnancy, people seemed to react as though it was the natural next step. It was more a 'matter of fact' and parents with multiple children shared parenting advice on how to cope with the extra chaos.

With the third pregnancy, I find that the reactions depend on personal situations:

Those who are not yet married, or married without children, think I'm crazy to go for a third (they just can't relate);

Those with three children of their own celebrate the news and reassure me that life will just get better;

Those with two children (young and old) all recount to me how they came to the decision NOT to have a third, as if my news has made them revisit their decision;

And those with only one child feel the need to explain why they haven't yet had a second!

Ironically, even my husband has found the same trend in responses.

Regardless, we are absolutely thrilled and praying for a healthy pregnancy and baby and eager to hear any advice on going from 2 to 3!

Happy Thanksgiving!

A Lesson for Youngest - and his mom

I'm often asked to speak at support group meetings for the various conditions I see in my practice. I try to go to as many of these as I can; it's a great way to meet with individuals on an informal basis. Many of these patients don't have much insight or knowledge about their condition (or worse, have a skewed picture of the future based on misinformation), and I hope I can change some of that in the time I spend with them. As could be expected, in my attempts to balance work and home, I occasionally run across some problems with time constraints. This happened a few months ago. I had promised a group that I would meet with them, but the week became filled with mandatory department conferences and other events which kept me away from home, so on the evening I was scheduled with the support group I was greeted with a chorus of "You're going where? Why can't you stay here for a night?" In a desperate attempt to spend some time with my boys, I asked them if they wanted to come with me. Eldest declined with a bit of a sneer, but Youngest jumped up with enthusiasm. His question, though, gave me a bit of cause for concern: "Can I bring my GameBoy?"

As we pulled into the parking lot of the church where the meeting was being held we could see a steady stream of cars pulling up to the entrance. We parked in a far corner of the parking lot and while we walked to the building we watched people in wheelchairs and using walkers approaching the doorway and struggling to get through. As we got closer, I suggested that Youngest might want to hold the door for some of the people we saw. He looked at me sideways, but then ran ahead. I could hear him talking to a couple wrestling with the door (which didn't have any modifications for people with disabilities); then with a smile, he opened the door as wide as he could so that the husband could push his wife through. After he assisted a few more individuals it was time for the meeting to start.

Before I knew it, Youngest was talking with the facilitator of the group and passing around cookies and punch to the members there. He sat quietly while I spoke to the group and answered questions without bringing out his electronic toy once. As the evening was winding down, I was approached by a woman who had been sitting quietly in the back. It was obviously difficult for her to move forward, even with the rolling walker she was using. Watching Youngest's face, it was apparent that he felt removed from this group. I could almost read his thoughts, "Poor folks; too bad they contracted this disease. Thank God it will never happen to me." The woman thanked me for the information I had provided, and the enthusiasm and encouragement she felt I had brought to the group. And then she said, "You know, I've been battling this since I was 16 years old. I never thought I'd be around this long." Youngest's mouth dropped wide open at this point - with just a few words, this woman had made him realize that none of us are immune to whatever it is that our futures hold. Before I could say anything, Youngest had moved next to the woman and said, "I'm so sorry to hear that. May I give you a hug?" While I answered questions for another person in the group, I could see Youngest speaking softly with the woman.

Afterwards, he and I helped the facilitator clean up the napkins and cups. Youngest didn't say anything while he gathered up debris and placed it in the trash can. As we began to walk through the now-quiet parking lot toward our car I said, "I'm proud of you. I think you did a very nice thing tonight."

His response was typical pre-teen. "WhatEVER, Mom. Race you to the car!"

I wasn't sure how much of that evening Youngest retained, or what an impact it had made upon him until recently. As we were talking about the upcoming Thanksgiving holiday, Youngest suddenly blurted out, "I guess we can all be thankful that we're healthy, right?"

Right, son. And I'm thankful for lessons that are learned without trying.

And to all of you - I wish you a healthy, happy Thanksgiving (and quick healing to you, Happy Mom).

A

Seriously, I wanna know...

What are your plans for Thanksgiving? Do you cook the turkey, stuffing, potatos, greenbean casserole or do you eat nontraditional fare? Have you tried a prepared dinner from a grocery store?

I could never be a pediatrician...

When I was first starting med school, I was Peds Girl. I was joined the Peds Club, I helped organize Peds Playroom in the hospital, and I loved kids. I was fiercely insistent on my future career choice.

Professor (who was also an orthopedic surgeon): "So what field do YOU want to do?"

Me: "Pediatrics."

Prof: "Christ, what a waste. You may as well become a veterinarian."

Me: "Um."

Prof: "You know you won't make any money in general peds."

Me: "I may specialize in pediatric endocrinology."

Prof: "They make even LESS."

Actually, I think if you do pediatric endocrinology, instead of getting a paycheck, they remove money from your bank account each month. So you really have to love it.

In planning my third year schedule, I took peds as my third rotation. If there's a specialty you think you really want to do, you're supposed to do it third. That way, you can decide early on if it's really for you, but it's not so early in the year that you're still a bumbling idiot.

Long story short, I'm not a pediatrician. I could say I hated the parents or that I had trouble looking in tiny ears, but really, it was that I couldn't deal with the sick kids... I mean, the REALLY sick kids. There was nothing more heartbreaking to me than an ill child. Even reading a fictional clinical vignette about a child with cancer ruined my day. It didn't matter to me that I was helping them or even saving their lives... I just couldn't bear it.

And now that I have a child, I am doubly glad that I made this decision. Every time I pass the peds floor in the hospital and hear children crying, I think of my daughter and my heart aches. Maybe I would have grown accustomed to it. I don't know. I'm grateful other doctors are able to distance themselves enough that they can do this kind of work.

Luckily, sick adults don't make me nearly as sad.

Extending the invitation

After Thanksgiving Dinner last year, my husband and I decided we would henceforth make an effort to invite people over who may not have family or friends nearby to spend the holiday with. Our house was feeling so warm and festive, dinner was so lovely, and it seemed a shame that we didn't have more people over to share it with. A new family tradition. One that I wanted my children to grow up with.

I can't believe I almost forgot about this.

So, today, I started to think of who I should ask. How does one go about inviting someone over? I didn't want to make someone feel self-conscious about it, like, Hey, since you seem like you have no friends or family...

I decided to start with a general probe. I asked a co-worker whether she had family in the area. (Yes) Great! Back to the drawing board.

Driving home, I thought of one of my residents. The more I thought of him, the more I thought he might really appreciate an invitation. I impulsively called him. "Hey, do you have plans for Thanksgiving?"

"Why do you ask?"

It turned out well. He said he really appreciated the invitation and he'd get back to me. He also asked whether this could extend to some of his colleagues. "Sure," I said. Smiling.

I hung up and felt the most amazing rush of, well, euphoria. The thought of opening our home to residents who might otherwise be alone on Thanksgiving filled me with immense joy. I'm hoping, hoping that we'll have extra guests at the table on Thursday. And even if they don't come, this feeling of just extending the invitation is pretty awesome.

Pay it Forward

There’s been some sadness at our house recently. To be perfectly honest, the holidays have been the last thing on my mind. Wallowing a little too much in self pity, has become a hobby over the last week or two…. but today was different.

I had a great day.

The morning office went surprisingly smooth. I escaped for lunch to meet my husband and son at Cracker Barrel. This is quite a treat, I rarely get a full lunch hour, rarer still to get to leave the hospital. We had a pleasant lunch. Boy Genius was thrilled to get pancakes for lunch (husband also ate “second breakfast”). As we finished eating, I noticed that a few tables over was a lady sitting alone. Shortly there after, she came over to our table and with a huge smile handed my son a crisp one dollar bill and said “Happy Thanksgiving.” She then proceeded to take a our check and say “I’m going to take care of your lunch, and Yall have a blessed day!”

I was quite flabbergasted. I tried to protest, but she gave me a motherly “don’t even think about it “look. So we simply said “ thanks” as she walked away.

Her random kindness invigorated my spirit. I’ve spent the whole rest of the afternoon thinking of ways I could pass on blessings to others.

This may seem like a cheesy e-mail spam story… but I promise it happened to me today. My sadness is still there, but the self pity is gone and replaced with the reminder that this is the season to be thankful of our blessings and look for every way we can to bless others.

Twisted for Twilight

As an avid reader, I pick and choose across the genres of fiction and nonfiction. I am an equal opportunity consumer of the printed page. When looking up my member card at Barnes and Nobles, the cashier says "Oh, I see you come here often." Basically I'm looking for a good story - the kind that is hard to put down, will make me schedule my lunch hour in a quiet location just to get through a couple of chapters. Now as I write blog posts and dabble in fiction, I find myself asking what makes a good story.

Can't tell you what made me pick up Twilight. Maybe it's the buzz about the movie that I've read on other blogs. Maybe it's that desire to have a reading feeding frenzy. Stephanie Meyer hooked me - through all four books and the trials of Bella and Edward. Couldn't put them down until I finished them all. Went back to Barnes and Nobles on a Sunday night to buy the third and fourth because I couldn't wait for USPS to bring my Amazon delivery. Emersed in this world of "vegetarian" vampires, I find myself having philosophical discussions about the books with my teen patients.

Now the movie is coming out this weekend, and I'm trying to figure out how to get my boys to go see it with me. Movies are a shared passion between my two sons and myself. Husband bows out graciously whenever we go because he says he can nap for free at home. Sometimes finding common ground between the three of us is tough. The oldest likes action, noise, and can follow the twists and turns of plots well. The younger (age seven) son still likes animated films, but doesn't do scary well. I like a clever plot with not too much violence. So I'm thinking that I can sell this movie to my kids as kind of action-adventure and still get my romantic, girly fix.

Trying to explain this preoccupation with high school vampires eludes me. Is it the classic girl meets boy story? Is it the element of danger in Bella's longing for a vampire boyfriend with pulsing teenage hormones? Is it the pace? In my second reading of the first book, I tried to look at the writing from the perspective of a writer. The words are not complicated, and the storyline is kind of predictable. Still, I'm hooked.

Voice

I used to have a lovely voice. I thought so, at least.

On Facebook, many friends I meet again from my high school and college days ask if I'm still singing.

Well, yes.

"What's gonna work? TEAMWORK!" (I loves me some Wonder Pets).

And let's not forget the Mail Song from Blue's Clues.

But here's the kicker. Son doesn't appreciate my musical stylings. He actually shushes me when I sing along. I'm crushed.

I thought myself brilliant once. But I'd take the role of mama over broadway star any day.

How to get a part-time job in medicine

I got married near the end of my last year of residency. When I started medical school, in fact when I started residency, I hadn't yet even met my husband, and I didn't have any of the 3 kids I now have. That's probably a good thing because I would surely have talked myself out of the specialty I really loved into something more "family-friendly". There's nothing wrong with family-friendly, mind you. I always read the classified ads in the New England Journal just out of curiosity, wondering whether there are more part-time jobs cropping up as women, who more often work part-time than men in general, represent a greater share of young doctors. So far, I don't think much has changed in the job advertising sphere.

When I happen to have a bad day at work, which is fortunately rare, I permit myself to back up and take a different fork in the road. In my alternate life, maybe I became a dermatologist, where "full-time" seems to be 4 days a week...but who works full-time anyway? Or infectious diseases, where every other ad seems to start "Full-time or part-time". Ah, travel clinic...seeing some healthy people and getting them ready to travel to exotic locales. Lest fear of boredom be a factor, keep in mind that the occasional traveler will come home with a fever of 40.8--is it malaria? Dengue fever? Ebola? See, that would spice things up. And clinic finishes at 3p.

But snap out of it. I became a medical oncologist, had my first baby midway through my second year of fellowship, another baby at the end of my third year, and a third baby about a year and a half into my first "real job". At some point in late second year when other fellows were beginning to do their job talks and interviews, it dawned on me that I didn't want to be away from my son and his future sibs for 60 hours a week. I didn't want to miss first steps or first words or first anythings. It didn't feel right to me that someone other than me--indeed, someone I hadn't even met yet--would be there for more of my kids' waking hours than I would, and that's exactly what working full-time meant.

I starting looking through journals, online, anywhere for part-time medical oncologist jobs. Zip. Zero. Nada. I even tried monster.com, and all I got for combining "part-time" and "oncologist" is: Busy oncologist seeks part-time front office staff. Bummer. Oh, and did I mention that I had kind of subspecialized to one particular type of cancer. And can't move out of the area because my husband is in the military, unless they tell us to move, in which case I have to pick up and leave instantly. When I told people that I wanted to work part-time, and no I didn't want to just take a hospitalist job, and no I didn't want to work in an urgent care, and no I didn't want to review charts for utilization management or do life insurance physicals for a living, and yes, I did plan to work as a doctor, and yes, I did plan to work as an oncologist, and yes, it had to be in this area, they just looked at me with some blend of pity, empathy, disbelief, disdain, and said, "Well...good luck."

Six months later, I was agonizing over my choices: one job working 3 days per week as an academic oncologist, one job in private practice oncology working 2-3 days per week, and one job in oncology public health/health policy working anywhere from 2-4 days per week. All of them were within 30 mins of my house. All of them were in the particular subspecialty of medical oncology that was my interest. None of them was advertised. None of them existed when I interviewed. So, what's the deal?

If you happen to fall in love with a specialty of medicine that doesn't bear the family-friendly label, here are your career choices at the end of your training, assuming you aren't willing to compromise on the family side:

1. Let this specialty be the one that got away and pick something that's more family-friendly.
2. Train in your specialty, but work in a more general field with your specialty as your area of expertise (e.g. take a part-time internist job with an interest in pulmonary disease--a big group private or academic practice may be glad to have one internist who likes to see all of the asthma and COPD folks, there are plenty of them, and is comfortable with critical care if patients get admitted to an ICU).
3. Move beyond the standard black or white career paths--academic or private practice--and look at jobs in the government (FDA, NIH, CDC, etc), public health, the pharmaceutical industry, hospices, and so on, many of which are more amenable to part-time employees.
4. Interview for your dream job, whether academic or private practice or whatever, and give them enough time to decide you are their dream candidate. When they start trying to recruit, play your part-time card. Most will use salary or benefits to try to sweeten the deal. What you want is flexibility or fewer hours or whatever it is that you want. Take a deep breath, picture your kids clinging to your leg as you try to leave for work in the morning, and then speak up without apology. You will surely benefit from a part-time job if that's where your heart is, but there are also benefits to the employer, and you should point them out: cost savings (part-time employees generally accomplish more on a per hour basis than full-time employees and generally cost their employers less in benefits because fewer benefits are provided), greater loyalty (from grateful doctor-moms such as yourself who are committed to making part-time work work) and therefore less employee turnover, improved staff morale, and fewer absences from work (you can schedule the kids' well-child visits and your tooth cleaning on your days off, and , if you're lucky, some of their colds and vomiting illnesses might even occur on your days off). You will likely be pleasantly surprised. I interviewed for all of the jobs I mentioned above, and they were all full-time. After I made my priorities for recruitment known, all agreed to work with me to tailor a part-time arrangement. In the end, I actually created a hybrid of 2 of the part-time jobs I had negotiated, working a total of 3 days per week, and it has been wonderful.

Bottom line: If you assume it will be impossible to find a part-time doctor job in your specialty, it will be. If you assume it will be possible, then it will be.

Not old yet

Still enjoy animal crackers, mac and cheese, grapes.
Still enjoy playing the bongos.
Still enjoy seeing Grandma.
Still enjoy painting.
Still enjoy Clifford, Berenstain Bears, Mo Willems.
Still enjoy They Might Be Giants, Dan Zanes, Laurie Berkner.
Still enjoy wearing mittens.
Still enjoy going to the zoo, zoo, zoo, how about you, you, you?

Don't like too many snaps, buttons, and zippers.
Don't like wearing shoes when riding in the car.
Don't like keeping quiet.
Don't like coats.

Can't help interrupting.
Can't help staying up late.

But the jury's still out on stinky diapers, classical music, carrots, clothes with holes, tub time, hats...

I am Old

How I know I'm getting old:

1) I remember as a kid, I used to love going down slides. LOVED it. Especially those twisty slides where you go through a long tunnel. In the last year, I've had the pleasure of going through a handful of slides with Melly on my lap, and every time when I get to the bottom, something hurts. Usually my butt. Those slides are treacherous.

2) Prior to a year or two ago, I had never experienced lower back pain. Never. When I was stooped over a patient for whatever reason, the attending would often warn me, "Be careful you don't hurt your back." I would scoff. Back pain? No, I'm way too young for that! But in the last year, I've had back pain constantly. So far, it's all just been muscle strains that got better in a couple of days, but I suspect I'm on my way to a herniated disc. I try to be careful... I tell my patients to take off their own damn socks for the EMG. I'm aware of the correct way to lift an object so as not to cause back injury, but it's hard to lift with perfect form when you're lifting a quickly moving, wriggling object, if you know what I mean.

3) I used to love roller coasters. When I attempted to ride a roller coaster a few years ago, I found that I not only did not enjoy it, but when I came home, there were actual bruises all over my poor back.

4) About a year ago, I found my first gray hair. I haven't seen any more since then, but I'm clearly still traumatized.

5) I still get the standard "gosh you look way too young to be a doctor are you sure you aren't still in grade school" response from patients, which I know most of us have experienced. The only difference is that now I'm really HAPPY when they say that to me. I don't even get fake insulted, like I used to. Then I get overzealous and injure my back while examining them.

I am impressed that people have kids after age 35. I'm not even 30 yet and as you can see, I'm already falling apart.

(Yes, I'm under 30 and complaining about feeling old... go ahead and mock me.)

You know you're a physician-mother when . . .

. . . your first inclination after diagnosing your child with fifth disease is to photograph it for your private collection of pediatric exanthems:

And your next thought is gratefulness that the diagnosis does not preclude daycare attendance. Alarming though that will be to the non-medical parents.

(For the uninitiated, I posted a summary of fifth disease here.)

Topic Day: The advice we wish we had in medical school

Welcome to our third Topic Day on Mothers in Medicine! Throughout the day today, we'll be featuring posts about the advice we wish we had in medical school. What words of wisdom do we have for entering women students? For our younger selves?

Posts will be publishing at regular intervals today so be sure to check back. Feel free to add your advice in the comments section, or if you are currently a medical student, what you think of our advice!

Scroll down to see the posts...

A straggling piece of advice

I was held up yesterday so my post is late. Straggling, as it were.

People in my medical school did not talk much about life, the universe, and everything. We were concentrating on the cerebral aspects of medicine, not necessarily the humanitarian elements, and not the life outside med school.

So if I did medical school again (and, yes, I absolutely would), I would take this advice back with me: have a human perspective on all things. During my training, we all tried so hard to be professional, but I think that, in the process, we started to ignore or even invalidate our own feelings. Our emotions and reactions may not always need to be open and visible, but it's okay to feel the burden of your patients' experience and not be closed off to it. I think too many people have the fear that allowing themselves to feel too much will cripple their medical ability. I don't think so.

In my years since medical school, I have seen many of the best and brightest doctors from various disciplines getting their hands and their hearts dirty (so to speak). They have an intimate knowledge of their patients, and I see how they are invested in their patient's care. These professionals have taken down the wall that is supposed to exist between the medical brain and the feeling person underneath. I have immense respect for them and the care that they provide. They manage to be involved, yet they don't make inappropriate recommendations or have nervous breakdowns. They just see the patients (and themselves) as the human beings that they are.

These are my role models, from my unique spot from behind the microscope. But if I were a medical student again, I think I would allow myself to feel a little more sadness, frustration, helplessness, and love.

My Two Cent’s Worth about General Pediatrics

A new doctor on the medical staff of my hospital parks his Rolls Royce in the MD parking lot. It sticks out among the Mercedes, Suburban’s,and Hondas that other doctors park there. It gives me pause to fantasize about the life this physician has and how different it must be from mine – no school loans, kids grown and out of college, retirement nearing with a nice nest egg (or at least decent after the recent downturn of last month’s market.) As a Pediatrician, I know this will not be my life, and I’m absolutely fine with it. As Nancy Snyderman, MD, told Matt Lauer recently on the Today show, “Pediatricians don’t go into medicine to get rich. They go into medicine because they love children.” Lesson #1: Think about another specialty in medicine or another career altogether if money is high on your life priority list. Don’t get me wrong. My family and I are comfortable, but there’s a reason (which is best left to a future post) pediatrics winds up on the bottom of the pay scale every year.

Lesson #1 has a couple of corollaries. The first is do what you love and the rest will follow. Sometimes what you love changes, and be willing to follow that path, too. It’s ok to reinvent yourself midlife (or sooner) if you decide another field suits you better. Six years ago, I decided to apply for dermatology residency. It was a period of time that had me reaching for the stars, but I had to do it to be happy with my choices. Derm programs are very choosey, and no program wanted to pick up a practicing pediatrician and put them back in the rigors of residency no matter how glowing my letters of references or work experience shined. Instead, I opened my own general pediatric practice, and have found success and happiness in the autonomy that followed.

Corollary number two is if you have wealth as a pediatrician, it is best not to flaunt it. Maybe your great, great uncle with no children left you a trust. Maybe you can get away with driving that Porsche in a really upscale area. In my suburban community, I often encounter parents and patients when I’m grocery shopping or making a Starbuck’s run. They check me out – what car I drive, whether it has a booster seat in the back, what shoes I have on, what’s in my shopping cart. There’s something about taking care of sick and miserable children and displaying luxury possibly gained (or not) from delivering this care that is incongruent to me. It may be the stuff of deep pockets that malpractice lawyers and litigious patients look for. Save the pictures of the fabulous vacation in the Caymans for home.

Lesson number two is that in pediatrics lifestyle and money are two choices (of many) that may determine your path to happiness. One of the beauties of my specialty is that it is family friendly and very flexible. One of my colleagues is getting back into the workforce right now after three years absence. She needed time to care for her daughter with Type 1 Diabetes. Other physicians choose to work part-time or job share. In my practice, I have learned that I deliver the best continuity of care with my patients if I am there at least three days per week (I average 4 days per week), but I also employ a physician who works two days per week and takes no call. My compensation is higher because I see more patients. Her lifestyle is different than mine because she is part time.

Primary care is a production business, and that’s something to consider as you make your choices in medicine. During a typical work day, I need to see at least 23 patients to be able to pay my overhead – office staff salaries, lights, medical supplies, insurance filing fees – before I pay myself. I’m conscientious of this because I own my own practice. Whether you work for yourself or are employed by a major healthcare system, general pediatrics is about seeing lots of patients. Employers track these numbers, too, and compensate you accordingly. So if you like to chat with your patients like I do, you’ll see fewer and be paid less than the guy down the street who sees 60 patients per day and says very little. My whole office is a beehive of activity each day to accomplish each patient encounter. When I hire new staff, I let them know up front that pediatrics is fast paced.

Why, you may ask, have you focused so much on the economics of medicine when all I need is advice about how to be a good clinician or balance my family life? The body of knowledge needed in medicine in infinite, and I am humbled daily by what I don’t know. Yesterday I encountered two new medicines I had never heard of before reading a specialist’s notes. Your focus in training needs to be on assimilating as much of this knowledge as possible. The reality, though, is that medicine doesn’t exist in a vacuum. Eventually you will need to take all you have learned and apply it to the world we live in with all of its variables (insurance, national quality guidelines, patient compliance – just to name a few) – broken healthcare system and all.

What My Medical School Acceptance Letter Didn't Say (but maybe it should have)

Congratulations! You've made it to medical school. All of your hard work, community service, pretending to be interested in anesthesiology in order to be able to shadow a physician (any physician), over-involvement in extra-curricular activities, long nights spent studying whilst your English major roommate goes out and enjoys the college experience, and never, ever getting to schedule all your classes on only Tuesdays and Thursdays (so the better to enjoy a 4 day weekend) has finally paid off. Well, sort of. We'll get to that "payment" issue in a minute.

Right now you are, no doubt, a very "big fish" in a little pond. You are probably known as the smartest, most ambitious, and most masochistic, ahem, of all your friends. In medical school, you'll be surrounded by 100 + of people just as smart, ambitious, and masochistic (if not more so) than you. You will probably be, maybe for the very first time in your life, average. And as much as that may give you angina right now, you need to know that "average" is actually ok! No, really!

You thought you studied hard in college, but you are in for a surprise. You *did* study harder, relatively, than anyone else you knew. You also routinely got paid off in As. In medical school, you will sit in the same position for 8-9 hours a day, pausing only for bathroom breaks and pasta, reading, re-writing notes, and reading again, only to score an 80% on your exam. You need to go to lecture, but if you don't go to lecture, then you need a good note service, and, unless you are a hell of a good transcriptionist, if your medical school employs a lot of professors with thick accents, then you will probably need to ante up the cash for someone else to transcribe "your share" of note service lectures. Take some time to go "off campus" for lunches with your friends, and allow yourself to skip a lecture for a mental health hour every now and then. It will be worth it.

The first two years of medical school, you will work, and study, and take tests, and drink copious amounts after tests, and wonder why in the world you ever wanted to go to medical school. Keep the faith. The MD/PhD candidate that sits next you in the third row and your gross anatomy lab group will likely form the core of your best friends throughout your four years together, even though at times you want to throttle all of them. Familiarity breeds contempt, but you are all going through the same hellacious experience. You will value these memories, even if you don't believe it now.

You will have a med school fling. It will be fun, but won't last (and you'll be totally ok with that.) You will make mistakes. You will fail (yes, I said FAIL) a test. You will cry, a lot. You will feel like everyone else smarter than you. You will wonder, more than once, if you have chosen the wrong path. You haven't. You will eat too much, drink too much, and exercise too little. Try to take better care of yourself, that extra hour of studying probably won't make a difference, but that hour of exercise could mean a healthier you four years from now. Don't forget about your family and friends. Try to stay in touch with the people that mean the most to you. Their support is important. Life is going on outside your little microcosm, and you'll be sorry that you lost touch with the friends that knew you before you became a med bot.

Once you start clerkships, you will remember why you started doing all of this in the first place. Taking care of patients! You will *like* what you are doing again, and, all of the sudden, some of the lectures that seemed like absolute nonsense will actually begin to become more clear. No matter what you think you may want to do, clerkships will change your perspective on everything.

Be a good student. Know your patients. Have the patient seen and the notes written before your (overworked) intern hits the floor. Keep a running list of scut that needs to be done on *all* patients on your service (not just *your* patients, remember, you are working as a team) and be sure it is done before you leave the hospital. Check in with your resident/intern often, they are too busy to page you, but you may get to see (and do) some cool stuff if you stay visible. Learn how to write orders and practice whenever you can. Do everything you can to make your resident's life easier. Write prescriptions, skeletonize discharge orders ahead of time, and offer to get them food if you notice they haven't eaten. Stick close to your resident on call, but *go to bed* if they tell you to go! Don't try to show off how much you know, it is obnoxious and will likely come back to bite you. One of your patients will likely die, and you will never forget it.

Once you find out what it is that you want to do when you "grow up," be sure to make yourself known to the residents and attendings in that specialty. Ask lots of questions. Find a resident that needs help with research and offer your data gathering skillz. If it is a surgical specialty, make an effort to scrub in on as many cases as you possibly can. Center your fourth year electives around the specialty early in the year, so you can make the proper connections for letters of recommendation. Make yourself invaluable to your team. It will serve you well no matter what specialty you choose.

Even if you have met the love of your life, and think that January is a wonderful time to get married, think twice about planning a wedding in January of your fourth year. That is right in the height of interview season, and you will cause yourself undue stress trying to plan interviews around your wedding! The good news is, it is quite possible to nurture a fledgling relationship through the stresses of medical school (and it will prepare your spouse to be twice as awesome as he supports you through the worse stresses of residency!)

When you finally finish medical school (it is a marathon, not a sprint!), you will not be the same person that you were. You will be in debt up to your eyeballs, literally. It will take you years (some as an indentured servant) to pay off hundreds of thousands of dollars just for the privilege of being tortured, erm, learning for these last four years. You will realize that you will never be "rich," like your classmate that quit second year because he was making more money day trading stocks than the average family medicine attending. However, you will be a physician...fallible, over-educated, and under socialized, and you are going to help patients in ways you never even considered when you first sent in your application.

All the best of luck (you could use a little of that, as well),



Future Dr. Whoo

If I were a first year med student right now, I would...

As a third year med student, I was involved in some sort of group discussion session with first year med students. All of us older, wiser third years were offering advice to the first years in the form of "If I were a first year med student right now, I would..."

I had just finished a particularly grueling internal medicine rotation and I was feeling fairly disenchanted. When it came to be my turn, I said, "If I were a first year med student right now, I WOULD QUIT."

Everyone kind of stared at me in shocked awkward silence, then quickly went on to the next person.

But you didn't come here to read that kind of advice, so I'll give you some revised sagely advice from an even older and even wiser me: I wish I had taken a year or two after college to see what else was out there, instead of going straight through to med school.

It seems like the happiest people in med school were the ones who were in their mid-20s when they started out, instead of 22 like I was. They had taken a few years to see what else was out there and realize that it wasn't for them. Oddly enough, some of the people who were significantly older seemed to be just as disgusted as us young'uns, possibly because many of them had families that med school was taking them away from.

This is my graphic representation*:



I wish I had taken a couple of years off. At least then I could stop romanticizing all the stuff I didn't end up doing. Maybe I would have realized that being an actuary (i.e. calculating insurance rates for companies) isn't such a fabulous career, despite how nerdishly excited I get over making a graph (see above). And I could have written that novel I always wanted to write... about the compelling protagonist with an obstacle to overcome, where some friends become enemies, some enemies become friends, and at the end my main character is richer from the experience... (you get the idea)

*Graph not based on actual data

Answer to lingering questions...

I know you always wondered how preceptors graded you on the rotations. And you always wondered why your grade was less than what you thought it should be for the work and energy and time that you put in. Now as an attending I understand - those that clearly like the rotation, get jazzed about it, do the work in a way that you can trust them and not have to repeat the work, or just do it themselves to get it done right - those are the med students that do well during rotations. BUT SO WHAT!! you did everything you needed to do, studied the way you needed to to pass, slugged out a horrible internship year which made you question going into medicine at all. Then you saw the anesthesia light at the end of the tunnel and you're life only continues to get better from there. You chose the ABSOLUTE right profession. Yes, if someone said I could not continue to practice unless I go through med school again - I NEVER would do it. But now being at the other end, I'd NEVER give it up! My advice? If you've started - get through it and enjoy as much as you can without killing yourself... the results are worth it. If you haven't started DON'T unless you're ABSOLUTELY SURE!! And of all the people in my med school class, those that came with kids, those that had them during med school, residency etc, and those that went straight through - we are ALL satisfied about where we ended up!!

Note to self

Dear KC,

Hey you. I don't mean to blow your mind, but I'm you, writing from the future. No, you are not on Punk'd, I assure you. You don't believe me?

Well, I know you have a crush on that cute guy in your class you went to coffee with the other day. The one you talked to for hours, losing track of time. You are going to be married in 6 years. I know, score! Your wedding day is going to be the most perfect day, ever, complete with birds chirping and a gentle breeze blowing. Don't be scared by the weather forecast. The clouds will literally part that day.

Are you with me?

I wanted to pass on some advice because I think it will save you a lot of stress and anxiety. Listen, all of those years of stress and anxiety about everything from career choice to thoughts about the future and families really can add up (really add up = multiplying white hairs = a return to getting highlights again = major upkeep commitment = $$$). So, in essence, I'm saving you time and money by sending you this note.

1) Go with you heart when choosing a specialty.

I remember how much you wrestle with this. I know it's hard sometimes to imagine what you might like to be in the future, but whatever you choose will have to sustain you intellectually over the years. Do what you love. Do what challenges you. Your career is going to take a few unexpected turns (I'm convinced that it always does), but it will lead you to where you are now, in the future, and it is so meaningful and fulfilling for you. If you love what you do, you'll find a way to have the kind of life you want in that specialty. You'll "make it work," (reference to a show in the future that you will absolutely adore.)

2) Having children does not mean giving up on your career.

You may think now that choosing to have children early on in your career will necessarily mean a hiatus from doing anything productive, career-wise, for many, many years. You may be resigned to not being able to accomplish your career goals because of this. Don't. Because I'll tell you that having time constraints because of your family can make you that much more productive during your other times. You'll have rushes of creativity, of ideas, moving ahead productively in ways you would never have imagined.

3) Having children will make your life unbelievably rich.

It's amazing. It's all that you dreamed of and more. Go for it. (But, no need to rush in - enjoy the alone time with your husband - travel, explore, really solidfy your two-ness. Children are wonderful but you'll miss that two-ness later on.)

4) Take calcium supplements now. Hello, peak bone mass?

5) When making your residency rank list, remember that it is MOST important to be around people you love who can support you, not the fine details of the program.

6) Dream big.

Don't stop setting high goals for yourself. Don't settle. As a woman in medicine, as a mother in medicine, you can do great things. Dream big.

See you in the future,

Me

Years from Now

Dear Fat Medical Student,

You worry too much. It's gotten you this far, but enough is enough.

Years from now, it won't matter if you get a 92% instead of a 100% on an exam. You won't care if a resident thinks you are lazy for wanting to leave just two hours late. You won't even remember your step one score, but you'll remember the hangover from the celebration upon passing the test. Years from now, your patients will love you because you care. They won't care if you don't know all of the answers as long as you know how to find them.

You'll be a family doctor, a combination of all of your "favorites"...internal medicine, pediatrics, obstetrics/gynecology and psychiatry. You'll know a little about a lot of problems but not a whole lot about any of them. You will be comfortable referring to specialists. People will tell you their deepest secrets and will care about your opinion. Don't let them down.

Years from now, a lot of your "hero" teachers will seem emotionally immature to you once they are your colleagues. You'll watch them be cruel to ancillary staff, students, their families and, heartbreakingly, some patients. You'll feel superior to them in all ways other than raw knowledge. Don't put them on a pedestal until you are sure they deserve it.

Don't be so desperate to find a mate now. You will marry your best friend and have happy children. You'll see.

Years from now, you'll be sorry you quit walking the dogs when you got a fenced yard. You'll regret those drug-rep bagels, too. Stop when you are 15 pounds overweight and you'll never be 140 pounds overweight.

You will hurt many patients...not with malice but with honest mistakes, misjudgments and quirky fate. Decide now how you will handle it so it doesn't kill you. You'll cry about these circumstances because you are a good person, but don't let the bad outcomes make you jumpy.

Years from now, you won't care about money because you'll have some. Save for retirement and live below your means. Your loan payments will be a small part of your overall salary because you borrowed wisely.

Years from now, you'll find yourself wanting to snap at people in "ordinary" life. Practice now how to manage fatigue so you don't become an ass. Medical students will turn to you for a kind word or emotional support and you should give it. Always.

You'll be glad you spent time with your nieces and nephews even when finding time was difficult because the children make your life whole. Invest love in them and it shall be returned when you are back in diapers.

Years from now, you'll be a generally happy person. Of course, you'll wonder what might have been in you hadn't chosen medicine. You'll consider chucking it all and going to cosmetology school. Don't let your mind go there. On the day when you decide you are in the wrong career, a patient will tell you that they credit you for helping change his or her life. It will feel good.

Enjoy the success...it's what you wanted.

XOXO,

Future Fat Doctor

Express Yourself

Most medical schools have satirical student productions. The most rewarding thing I did in medical school was to be deeply involved in ours, called the second year show. I can still remember classic skits: the first year student doing a physical on a cadaver and missing that the patient was dead, for example. The accompanying song still runs through my mind whenever I teach phyisical diagnosis. Playing music, singing and dancing with classmates is a tremendous counterweight to both the isolation and the competitiveness that seem to be a leitmotif (or maybe I mean heavy motif) of medical
education.

Oh the Places You'll Go!

8/ 01/1997

Dear RH+,

Well here you are…. All grown up and getting ready to start Medical School. The things you are going to experience are going to blow your mind. No matter how hard things get I want to let you know its all worth it. In the future you are happy and love your profession. But, there are just a few tidbits you should know:

Those student loans are really hard to pay back. Don’t take out any more than you need. Also read the book “The Millionaire Next Door” as well as “The Richest Man in Babylon” the summer before you start med school.

Don’t become a D.O. Right now you are sure that you are going to practice rural family medicine, this will change when you start rotating through different specialties. You are being told that being a D.O. will not affect your ability to get into residency. This is not true. You will seek to match in a competitive specialty, and it will be harder for you to get a spot. It will also make it harder to get a fellowship. (This is not meant to spark controversy. I feel my Osteopathic training was outstanding and I love the profession. It was however detrimental to applying for residency positions and I was mislead on this issue when I entered school)

It will all work out. Don’t freak out when you realize that you want to be an OB/GYN. Do what you love. YES, you will be able to have a family and a somewhat balanced life.

SUPPORT you fellow female students/residents when they say they are being sexually harassed. Never just think they don’t have a sense of humor. Never look the other way when people say sexist or racist comments, even if they are your superior, stand up for what is right.

When you are an intern you will be convinced that your Chiefs are evil (well one of them is, but she will get fired). They are not. They really are trying to help you and they are just trying to survive as well.

Don’t eat so poorly as a resident. If you eat a second “dinner” at 3 am, you will, in fact, gain 20 lbs in 6 months.

Nothing I can tell you now will prepare you for having a baby. Just a hint, there is nothing better in the world than seeing your child for the first time. Your heart will grow in the most dramatic way. The nausea, constipation, Mag….. all worth it.

Shave your legs with your left hand. This will help improve your dexterity and surgery skills.

Don't wish away your life (except intern year. It will be awful and life will be significantly better when its done). Enjoy each stage as much as you can.

You husband, family and friends are amazing. Don’t ever take them for granted.
Enjoy the ride!!!

Love,

RH+ 11/2008

Things I wish I knew in medical school

Things I wish I knew in medical school (and beyond):

-When starting, I wish someone would have told me that the daily grind of medical school would be the hardest thing that I’d ever done to that point.

-The smell of the anatomy lab will eventually fade. With luck, everything you learned there won’t.

-It’s OK to not know what you want to do with your life; spend your time during rotations and clerkships learning as much as you can. Likewise, it’s OK to be completely grossed out by sputum samples.

-Learn to listen to your gut regarding patients and yourself. It’s part of the art of our profession.


-Every once in a while stop to thank your support systems: parents, siblings, friends, significant others, spouses. Med school is a tough row to hoe (so to speak), and they’ve got your back while you’re cramming for yet another exam. Don’t get crazy - you haven’t got that kind of time.

-You’ll never know it all, so don’t panic when you realize you don’t. This profession is built upon learning regularly, so learn to learn quickly and efficiently. And teach what you’ve learned – it’s the best way to reinforce your knowledge and pay back those who you feel were good teachers.

-Above all, remember that you're never alone. Don't be afraid to ask for help.

A

Guest Post: You can have a child (or four) during medical school

I recently read an article in Newsweek by Dr. Nancy Andrews, Dean of Duke Medical School encouraging students and faculty to "go out and do whatever they want to do." And that reminded me that I wanted to echo that sentiment here by writing about having babies in medical school. A few months ago, I read a funny yet less than positive post on here outlining how really there is no perfect time to have a baby in medical school. There is a lot of legitimacy to that type of post: It is hard. True enough, there may not be a perfect time but that is not the same as saying there is no time. And for the nontraditional female student who feels trapped and conflicted about whether to do medicine or do to a family, there are fulcrums to that tension. You can have a child in medical school and you can do it with assurance that that baby will turn out just fine.

As I reflected on what might be helpful, I came to the conclusion that some of the best support I received along the way was hearing other women's stories. For me, it helps to have anecdotes of success to reassure me along the way. Nothing has been more uplifting than knowing that I am not alone in this journey of motherhood and medicine. It has been other women's random stories, hodgepodged together, that have given me strength, motivated me, and given me ideas on how to improve: do it differently, do it better.

The other day I was at my pediatrician's office with one of the boys. I encountered another pediatrician who was substituting that day in the clinic. "Dr. K, I'd like to introduce you to MSM, she is a med student with three boys and another baby on the way." Dr. K looked up from her chart and flashed me a huge smile. She pulled me aside and immediately introduced herself and gave me her story.

"Oh, I started medical school 8 weeks postpartum with our third child. In the summer after second year, I gave birth to our fourth. I wanted to take a year off to be at home with my kids. I suggested to the dean that if men were allowed to take a year off between second and third years to 'find themselves' that I was already 'found' and needed to cultivate it. I took the year off and returned to school; subsequently, I matched into a peds residency on a part-time basis for the first year and then finished full time."*

She then continued on as I stood there with my mouth open. Rarely do I encounter women with stories quite so similar to mine.

"If you ever feel like quitting, if you just have one of those weeks and everything feels overwhelming and not worth it, if you feel like your babies don't know who you are and you're stressed, call me. I can guarantee that I have been there. Many times, in fact. But I can tell you, for me, it has been worth it. And I would be more than happy to help if it ever comes to that for you, too."

She then handed me her number and went on to see the next patient. I have to say this made up for all the times that people have looked aghast when I tell them that, “Yes, we are having a baby. And no, it's not our first or even our second, but our fourth.” I feel like a rare irresponsible bird, which I loathe. I suspect they think I must have slept through the reproductive medicine lecture on IUDs, and what a wonderful contraceptive device they are. But ultimately, I've learned not to say anything. I often hear from fellow classmates, "I don't know how you do it. I can't even take care of myself." Despite the desire to retort, "I don't know how you go out drinking as often as you do and still make it to class, functioning no less." I decide not to. Since it's rhetorical anyway. Right?

But here's my long winded point: so far I've experienced a pregnancy in every year of medical school. I had an infant when I started first year. Halfway through that school year, we started trying for number two and ended up with a bonus (I got pregnant with twins). At that point, I took a year off to do research and to care for the babies. The following year, I returned full time and got pregnant at the end of second year. I passed step 1 and started my third year with my surgery rotation. There have been good and bad points along the way. But for me, it has been an extremely rewarding, incredibly busy, but amazing period of my life.

The chaos that accompanies four small children (or even the kids themselves) is not for everyone. I’m definitely not recommending this path to everyone- but to the women out there contemplating entering medicine but hesitating because they feel overwhelmed by the impossibility of family, school and medicine, I can finally return some of that reassurance I have received over the years. Follow your dreams: their individual paths diverge less than you fear, and you can always problem-solve ways to bridge the divide.


*I didn’t have the chance to ask Dr. K’s permission to share her story so I changed any identifiable details, though, I don’t think she would mind inspiring or reassuring anyone out there.

MSM is in her third year of medical school and has just had her fourth child. She enjoys running, cooking and being with children. It will come as no surprise that she's planning on going into pediatrics.

Too swamped to write

Well, I have been meaning to post here for months and after several good-natured nudges by our organizer I finally made it! I am amazed that you all have been able to share so much and maybe that's what I am here to share- that I've felt so swamped the last year I haven't even felt I had time to write about it. I have definitely found that as our 3 children get older I have felt that although there is a certain freedom that I appreciate in them having independence like getting bathed and dressed alone, keeping track of homework, playdates and sleepovers and reminding me about birthday parties, I also dread other aspects of their independence- like my nine year old daughter insisting on walking a mile to school without a parent when I have to race out the door to work, leaving me feeling very unsure about her safety and wanting to hold her hand all the way to school. Another whammy that came recently was when she cried so hard at bedtime saying "why do you always have to go to work and just leave us with babysitters our whole life"-- wow, that one was unimaginably painful! Like many of us I presume, I alternate between periods when I feel quite happy and satisfied w/ work and home life and then others when I feel I am drowning- this is one of those drowning times so I'll spare you all any more of this debbie-downer post and look forward to returning when I'll have something more cheerful to write about :) Go moms!

Pretty girls don't need to be doctors!

On my last rotation, I was sharing an office with a former beauty pageant winner. She was gorgeous. And you can imagine how terribly attractive this made me feel, what with my wrinkled white coat, my shirt stained with baby food that didn't come out in the wash, and shoes that are probably similar to the ones your grandma wears. But she was such a nice girl, it was hard to feel too badly about it.

Anyway, Miss Beauty Queen was interested in going to med school.

Over the course of the rotation, I did my damnedest to talk her out of it. Every single day, I told her a different true story, some titled "Med School Sucks", others titled "Being A Doctor Sucks", most under the general heading of "I'm Really Tired". Some of those stories were lifted right off this blog. Also, she would be a little older than the traditional students and I reminded her that OMG, your biological clock is ticking! Babiezzz!!!

She was very surprised by some of the things I told her. She said that most people were really encouraging when she told them she was thinking of going to med school, especially when she told them she had doubts about it. (I was surprised by that, because I thought all doctors were bitter.)

Whenever I meet a pre-med, as a rule, I always try to talk them out of going to med school. It's not so much that I think nobody should go to med school. Clearly, there are people who are born doctors and love it. And if nobody went to med school, I'm pretty sure everyone would end up getting diagnosed and treated by Dr. Wikipedia.

So I'm not against med school. But I figure if there's something that I can say that is enough to talk a person out of going to med school, they're probably better off changing career paths now than when they have negative $200,000 in their bank account. Because medical training is damn hard and most people just don't understand that, I mean really understand that, until they're in too deep. I feel like if I can keep even one person from making a mistake, it's worth it.

On the last day of the rotation, Miss Beauty Queen told me she was going to business school.

WAKE UP CALL

Okay, I'll just come right out and say it: I was T-boned by a bus on Tuesday and have a type III odontoid fracture. I am now in a neck brace for 6 months but lucky to be alive and not paralyzed. I cannot even begin to explain all the thoughts and emotions that one goes through - from the coldly rational (wow, this is what it's like on a backboard, in a collar, in MRI) to the wildly emotional (DAMN DAMN DAMN, there goes the concert I was going to give, there goes the clinical study that was going to make JAMA, there goes the dressage show I'm ready for, and there goes vacation with the kids in the Carribean). But the one thing that is the MOST heartbreaking: not being able to scoop my kids up into a big bear hug.

Trying to be the optimist I'm struggling with what to do with months of non-physicality. Go ahead I think, perfect that Spanish, read all the library books, type up my diaries, catch up on all the movies - but somehow it pales in comparison to the dreams I was already embarking upon and achieving. And although I'll be home (always), I'll see the kids less because I won't be taking them to piano and swim and school and birthday parties like I usually do. But it's early yet - perhaps as a result, the kids and I will have more bonding time with the hubbie and our nuclear and extended family as well as friends may become closer still.

The weirdest thing is (harkening back to psych) that my schema of myself is slow to change. I keep having to remind myself that IF I move my neck the wrong way, or trip and fall, it could be disastrous. But it still doesn't seem real until in moments of sobbing I realize it is. Now excuse me while I go cry.

Guest Post: You're Fired!

Today a patient returned to my office for followup of my treatment of her spinal problems. She has back pain that clearly will not do well with surgery, so I’ve been trying to treat her with other modalities. She has been through PT, medications, and (most recently) 2 epidural injections. I do most of my own patients’ injections and did both of hers, spaced several months apart. She’s not a candidate for surgery, but I’m trying to help her.

At her first visit, I spent 45 minutes with her, evaluating and discussing her problem, showing her the MRI films, explaining what the options were. We discussed her anxiety and depression and talked about how that fed into her chronic pain. She did well with one injection, and seemed fine at that 20 minute followup visit. Now she returns after the second injection:

“Why didn’t you make me numb for this shot like you did the first time?” Tears. “It hurt so bad!” Tears. “Why did you let me be so anxious in the recovery room?” Angry stare. “I have some QUESTIONS.”

Now, I do the same protocol with every injection, including IV Versed for sedation. I know I did nothing different the second time, but no matter what I say, she gets more upset. Finally, after accusing me of telling her at her first visit that she needed surgery, and now telling her something different, she announces, “You and I are done, then.” I offer to refer her to another physician, and she snaps, “My own doctor can find me plenty of doctors who will care more!”

Fine.

As a professional, I’ve been here before, and I know not every patient is going to get along with me. It’s her choice, and I’m fine with that. My brain tells me I shouldn’t let it bother me and that this patient has issues I’m not going to be able to solve anyway. *You can’t make everybody happy all the time.* I can’t even make the fixable problems better 100% of the time. The studies confirm that.

My heart tells me that I went into neurosurgery to fix people’s problems, and I should be able to help every patient I see. Because I do care so much about every patient and because I try so hard, every patient should understand that and be happy and grateful. If a patient doesn’t get better or doesn’t like me, that’s my fault. I’ve done something wrong or not done enough, been supportive enough.

No matter how much my brain tells my heart to shut up and be realistic, I can’t reason it away. This will bother me for days. It always does. The 29 patients I saw back today doing great, who’ve thanked me for my help, don’t make this better. I love the successes, but I wish the failures wouldn’t hurt so much.


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.

Next Topic Day: Things we wish we knew in medical school

Our next Topic Day will be on Wednesday, November 12. We'll be sharing the advice we wish we had while we were in medical school.

As always, we welcome guest posts from readers. What would you tell entering women medical students concerned about future work-life balance? Career choice? Residency? Being an attending? Being a mother? What would you tell the younger you, if you could time travel, about life on the other side?

Please send any submissions to mothersinmedicine(at)gmail(dot)com and include a brief bio if you'd like.

Burying the message

We recently had an ant problem at home. After getting through the hot months without any real indoor ants, which are usually a summer problem in this area, we began noticing during a couple ants on the floor in late September, a little trail marching by the patio door, a few appearing under the sink...then full-on ant explosion. They were everywhere. Major ant problem. We made a valiant effort with the Trojan horse model, the little environmentally-sound childproof baits that are supposed to result in poison being carried home to the grand matriarch, then watched as our ants consistently walked a wide circle around them to get to the food remnants my 10 month old is eternally throwing on the floor. After a week or two, we gave in and called an exterminator.

A nice fellow came out, looked around, sprayed some stuff inside and out, then rang the doorbell again to give me the receipt. I thought the transaction was over, but it was just beginning. He also had a very long verbal list of suggestions of things to do to keep the ants from returning. It included removing all of the flowers from the beds adjacent to our home and sidewalk and replacing them with stone (or nothing), taking out all of our bushes whose roots might contact the home, removing the vines and other random vegetation touching our foundation, cleaning out the dishwasher filter twice a day and promptly cleaning crumbs, drips of juice, etc up when spilled, recaulking our kitchen counters and every other little gap in the kitchen, installing quarter-round moulding in several areas of the kitchen, emptying out our sandbox on the deck and powerwashing the desk, and "ideally" redoing our relatively new deck floor so that the gaps between the boards would not be so small as to provide a place for the ants to set up shop and build their nests. I'm sure I've forgotten some of them, but those were the biggies. When he started talking and told me that just spraying wouldn't be enough, we would also need to do a little work around our house, I thought, "Sure, of course, that's reasonable. He's going to tell me to try to mop the kitchen every day--I can do that, in fact, I'd like to anyway." Then the list started and went on and on and on. At some point in the list, I was amused, then kind of annoyed, and eventually came to a complete and final stop at hopeless. There was nothing to be done. We would have ants forever. So be it.

The next day in clinic, I heard myself giving a patient the list. It was a woman with cancer and a number of other medical problems, many of which were caused or exacerbated by lifestyle choices. I sensed that we had a strong connection, she was really listening for the first time ever, she seemed motivated and invested, and I had my in. This was my chance to really change her behavior. So I went for broke. I said she had to stop smoking, period. Her chemo wouldn't work as well if she continued smoking. Her breast reconstruction was more likely to be unsuccessful, from a vascular standpoint, if she continued smoking. If she survived the cancer she had, she'd be far more likely to develop another unrelated cancer if she continued smoking. She needed to eat less fat and lose some weight because we know that obesity is associated with a worse outcome, and a low-fat diet has been shown to reduce the risk of recurrence in a large randomized trial. And she should stop taking phytoestrogens--there were lots of them among her lengthy list of supplements. If she could manage to do an hour per day of exercise, that would be helpful too, and ideally, the program would include a half hour per day of the most vigorous exercise. Oh, and the other thing is...on and on and on. I saw her eyes glaze over the way mine did with the exterminator. I had her for a minute, then she looked vaguely amused, then she got a little irritated, and then she just got the zombie eyes and nodded in completely non-genuine assent. She had no intention of doing anything I asked. The requests were too numerous, too overwhelming, too unrealistic. The message--that she had the power to change her lifestyle and really impact her health in a positive way for the first time in her life--had been buried. In my enthusiasm, I had slammed shut the window of opportunity.

I saw another patient later that day who admits to smoking 3 packs a day, which probably means 4, and has for over 40 years. She also has a long list of medical issues related to lifestyle choices. At the end of the visit, I said, "I'd like to see you try to smoke less. Do you think there's any way you could cut your smoking back by one cigarette per day each week?" She said, "One less per day? That's it? Sure, I could probably cut out 2 or 3 without even missing 'em. You really think that matters, a couple cigarettes less per day, when I smoke 3 packs a day? Yeah, I can definitely do that. You watch, doc, I'll be down to 2 packs a day when I come back to see you in a couple months."

Sounds like a plan.

A full day's work by 9 AM

I start work at nine. I get up at six.

Even though we make lunches and lay out everyone's clothes the night before, we need that much time to get all five of us packaged and delivered to our respective places of work and play in good spirits.

I shower, dress and oversee the kids pulling on play clothes or school cardigans while Pete makes breakfast. There's a flurry of smoothing hair into pigtails, stowing rain boots in backpacks, pouring coffee and hunting for library books. We drive Saskia to before-care at her school. Then we head over the bridge and into the city, where we bring Ariana to daycare and Leif to preschool. Finally, Pete swings by my clinic and drops me off on his way downtown. I use the half hour before my first patient to review lab results and catch up on work email.

At two minutes to nine my colleague flies through the door, unstrapping his bike helmet. He's forty and single. His hair is a mess, he's out of breath and he seems exhilarated. "I woke up ten minutes ago," he announces. "I just rolled out of bed and out the door!"

Watching him hang up his reflective jacket and rummage in his briefcase for a granola bar, I vaguely recall a life where my only real responsibility between waking up and presenting at work or school was to put on clothes.

Now, I can hardly remember what it's like to show up at the office without feeling like I've already done a full day's work.

Lifestyle specialties

I work in a field called Physical Medicine and Rehabilitation (PM&R), which means that I'm pretty much constantly explaining what I do...

"I'm a PGY4 in PM&R."
"You're a what in what?"

Basically, we deal with sports and other musculoskeletal injuries, as well as the subacute medical management of patients with neurological injuries, including brain and spinal cord injury. It's supposedly a "lifestyle" specialty, which is illustrated by the joke that PM&R stands for Plenty of Money and Relaxation.

Of course, it's not all money and relaxation, especially during residency. But considering I had no in-house call, even during my first year after internship, I can't complain too much.

Lifestyle specialties are usually popular among all applying med students, not just women who want to have kids. That or skin is just SUPER interesting. It's definitely a lot easier to have children if you're in a specialty where the hours are manageable. I won't lie and say that lifestyle wasn't a significant part of my decision.

PM&R is somewhat like psychiatry in that it's a lifestyle specialty that isn't terribly competitive, probably because people don't want to do what we do or don't know about it. The more competitive lifestyle specialties are dermatology and radiology. Family medicine is another favorite among women who want to have kids (it's got "family" in the name, so it MUST be family-friendly). There are some internal medicine specialties that seem to attract more women, like rheumatology and endocrinology; cardiology, not so much.

Anesthesiology was extremely popular among women in my med school class. I never quite understood that, because the hours in residency seemed pretty rough, and it's one of those residencies that tends to get harder as you progress, with more responsibility. But apparently, the jobs after residency are great.

As everyone knows, the field that is probably most dominated by women is OB/GYN, which is decidedly NOT a lifestyle specialty. But I guess you have to do what you love, even if it doesn't necessarily have hours you love.

To Infinity..... and Beyond!!!!

“Bob the builder! Can he fix it?
Bob the builder! Yes he can!
Scoop, Muck and Dizzy…….”

So today I sang the entire theme of Bob the Builder….. while doing a pap smear. My patient was a stay at home mom, with no one to watch the kids. She attempted to keep the pacifier in her baby’s mouth while I did my best to “entertain” a four year old boy. Which entailed singing, while I inspected his mother’s nether regions. Later, I had to push him away from the biohazard trash with one hand, while hold “specimen” in the other. This is pretty much the norm. I guess this could be one of my multitasking skills.

My patients often have to bring their small children to their appointments. I have great sympathy for this having hauled my own boy genius around a few times. So I often find my self trying to help them entertain their children while I ‘m doing their exam. Whether it letting the kids hold the Doppler to listen to the baby’s heart beat or in depth discussions about Thomas the Train.

Recent interaction:

“I see you like Thomas?”

“Yes, my favorite engine is James”

“No that ‘s not Thomas your holding, that’s Gordon”

“No, Thomas doesn’t have a coal car, and he’s #1 Gordon’s #4”

“Yes, I’m sure I’m right”

I hope my patient ‘s appreciate the effort … and don’t find it creepy that I’m singing the theme to Elmo's World while checking their cervix.

"The health of the mother"

Considering that most of us probably have an opinion about a certain upcoming national event taking place on Tuesday, let me applaud us for having shown surprising restraint when it comes to talking politics on this site. A usual TV non-viewer, I know that I am dashing down from bedtime books with the kids to the couch every night now, eating up CNN with a spoon. I am off in la la land as I sit in boring meetings, wondering what the latest polls show.

But as a doctor-mom of 3, I am hopelessly behind. I frequently gush over movies I have seen over the weekend only to have people say quizzically, "You mean 'Walk the Line' that came out like 3 or 4 years ago?" Yeah, that's the one. I have made my peace with the fact that I will never catch up.

Anyway, I am ashamed to admit that I did not see the last Presidential debate (which took place over 2 weeks ago for those of you who are also 3 weeks behind on dictations and looking at 6 loads of laundry next time you can bring yourself to go to your laundry room) in real time. I recorded it to watch the next day--ha, ha, right! Anyway, I finally watched it tonight, before the election at least, and holy mackerel!

There is a moment in there where Obama and McCain are discussing abortion. Obama says, "I am completely supportive of a ban on late-term abortions, partial birth or otherwise, as long as there's an exception for the mother's health and life." McCain proceeds to offer his rebuttal and says IN AIR QUOTES "health of the mother", not once but twice. Here's a link to one video on youtube that shows just this brief exchange, rather than having to sit through the whole debate for those of you who were together enough to watch it in real time: http://www.youtube.com/watch?v=SGZOyxfiNoU

Whether you are Republican or Democrat or Independent, pro-choice or pro-life with or without conditions/exceptions, can any woman, particularly a woman in medicine, watch a potential future leader of this country put the "health of the mother" in air quotes during a mainstream media event watched by tens of millions of people without falling off the couch? I managed not to hit the floor, but just barely. And I'm posting at 1:30am because I cannot sleep for wondering the implications of such an attitude for the women of our nation.