MiM Mailbag: Working abroad

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

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

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

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

Many thanks in advance,

s

www.theredhumor.com

My Morning

My morning before I even get to work:

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

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

What's your pre-work ritual like?

Your worst sick story

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

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

Sick Days, Part the Millionth

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

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

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

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

"I'm just warning you."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rescue

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

“White or red?” Red.

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

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

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

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

Treat Yo Self

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

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

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

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

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

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

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