Kicking My Own Butt: 2 Months, 20 Pounds Lost

So here I am, an Internist and a mom, with a 3 month old baby girl and a 22 month old toddler boy, and with all that there is plenty of fodder for writing. All the priceless, precious wacky and aggravating moments that make up parenthood; all the touching, challenging, annoying moments that are doctoring. That's why we write, right? There's just SO MUCH.

But today, this is a simple update on my own journey back to my own body. Two babies in less than two years (plus a bit of an addiction to really dark chocolate) put alot of extra weight on me. I fell off my own fitness wagon. My runner's body gave way to... Obesity.

At 4 weeks postpartum with Babygirl, I realized I was at BMI 30. I kind of freaked out. I started a modified South Beach Diet. I lost alot of weight really fast, I think because I was breastfeeding. Then, when Babygirl was 6 weeks old, my husband was hospitalized with diverticulitis for a week. My plan went by the wayside. There were many days of like, Cheerios for dinner. My breast milk dried up. We went into Survival Mode.

Now, he's fine, I'm back at work, and life goes on, I picked up the free weights again. I started running: 1, 2 miles. Today, I ran 3 1/2 miles. Whoo-hoo!!!

And, even with my schedule and the kids, I have managed to lose 20 pounds in 2 months. I am now at BMI 27 (I'm pretty short.) It's hard, damn hard, but I can't give in to excuses or laziness. (Well, maybe sometimes...)

But if I expect to see change, I have to do the work. That means making myself get up at 5:30 a.m. on a Saturday to go for a run BEFORE the kids wake up. And taking the time to do abs work before going to bed. And planning meals: buying the healthy food, packing it up for myself the night before an early office day. It means resisting desserts. Most of the time.

So, while I am not perfect at all of this, I am persisting. My goal is to lose 20 more pounds, to get back to my pre-pregnancy weight. I find myself empathizing with my patients. Commiserating. Coaching.

So much of my work with patients is in trying, desperately trying, to help people help themselves to get fit. If I can use myself as an example, I will. I know how it is, I'm living it.

I can share with patients about how it's tempting to declare "Diet over!" after giving in to a little indulgence. But this is a HUGE pitfall. I'll talk with patients about how, for me recently, one chocolate-dipped strawberry led to another... and could have led to more and more, but I physically got up from the table and got it back together, and now am seeing results. I'll talk about the merits of hot herbal tea after dinner in lieu of dessert; the handiness of packaged mozzarella cheese stick snacks; the necessity of Truvia.

I can share with patients how hard it is to get in exercise when you work and have kids. How I need to make it a priority, and stay on top of it. Can't go to the gym? Me neither. I haven't re-joined my gym, because I'm not sure I would ever get there. Try running. Jumping rope is excellent exercise. I also discovered hundreds of free fitness videos On Demand. I do abs work at night before bed. I run after my toddler and lift him like weights. And there are stretches of days when I don't move much, and that's OK. It's tempting to declare, Game Over. But that's a common error. Just Keep Going, I tell people.

And I will keep going. Persisting, Resisting. Eyes on the prize.

Next week: 4 miles.

MiM Mailbag: Pumping during fellowship follow-up

Dear Mothers in Medicine,

It's been 9 months since I last wrote to you and I cannot thank you enough for your help and guidance. I was able to continue pumping for 11 months, and just stopped 1 month ago. As busy as GI fellowship is, pumping became something I incorporated into my daily schedule, and fortunately the program was very supportive.

Overall I found that pumping three times a day worked best - once before work, once mid-day, usually after noon conference or a little earlier if I had afternoon clinic, and once in the evening (this was variable, depending on consults, scopes, etc.). Talking to my program director in advance and letting him know my needs really made a difference. So it wasn't a surprise when I showed up. And it made it easier for them to find a way to accomodate me. Most of the time I used an empty exam room to pump, and was able to get work done during that time (working on notes, returning calls). Sometimes if attendings weren't using their room, they would let me sneak in for 20 minutes. Always leaving the room clean and without a trace helped too (no one wants milk stains anywhere!). Soon after I started, I found talking to the nurses about baby and nursing went a long way towards building camaraderie, and they were often supportive if I had a scope but told them I needed to pump - they would let me do what I needed to and come back in 20 minutes (of course some days were very busy and they would let me know if I needed to start scoping right away too).

Staying hydrated is key. I kept a water bottle at our work area at all times, and kept refilling it during the day. I would use rounds or conference time as a good time to drink fluids. Gatorade is amazing, and helped keep me hydrated and held me over when I didn't have time to grab a snack. Also don't underestimate the free saltines, graham crackers, and little juices and ginger ales around the hospital. Those are fantastic!

To any mothers out there who are trying to pump, it can be done but it does take coordination. There were many times when I skipped out from joining my co-fellows for lunch (or drinks after work!) because of pumping. But there were times I didn't have to either. I think setting small goals makes it doable. I initially went in thinking that I had nursed for three months at least, and if I couldn't do it anymore it would be okay. Then I got into a routine, and tried for 4 months, then 6 months, and pretty soon 11 months came around. By then he was walking, eating more solids, and transitioning to whole milk. It seemed like a good stopping point for us. I commend all the mothers out there who make this work, and thank you for your support. I'm not sure what will happen with number two (not expecting now, but thinking about it...)

Thanks again everyone!

Trayvon

Mothers in medicine is my refuge, my voice and my forum. So today, I am going to post about Trayvon. Today I will go to work with a hoodie on, I plan to do this every day until Trayvon’s murderer is arrested - AT LEAST ARRESTED. I’m sure some will wonder what this had to do with being a mother in medicine, and although it may not specifically apply, being a mother in medicine is pervasive in every part of my life. My heart aches for this innocent little boy and for his family because I now understand what it feels like to have a child. My heart aches because I have a little brother, who is my heart, who I love so much, who at age 17 wore hoodies all the time and he LOVES Skittles and Sour Patch Kids, and he is a brilliant, beautiful person, and I shudder to think that could have been him. My heart aches because the hoodie I will wear to work today is my husbands. It is the hoodie he wears home from the gym or basketball games after work. The hoodie he wears at night, in the dark and I know he is also no different from all the Trayvon’s in the world. My heart aches because I have seen first hand the violence of a bullet on human flesh. I have found the offending bullet in bodies that have, in an instant, been destroyed by a tiny yet destructive force. I have walked to the special room outside the ICU to deliver news of this destruction. My heart aches because every loss is huge and at the very least, when facing these huge horrible losses, every family deserves justice.

In case you were wondering...

…I didn’t match.

There are probably many reasons why. I was geographically limited in two ways: my custody agreement limited me to the Southeast, and I only applied in cities where I knew people. I am an osteopathic student who was competing in the MD match. Obstetrics has been a very competitive match recently. I had excellent board scores, a research fellowship, and great extracurricular and leadership activities, but my grades were very middle of the road.

So, now what? I will be doing what is known as a traditional rotating internship at a local hospital, then reapplying for obstetrics residency. It will be much harder to interview as an intern with increased responsibilities. It will be harder to transition to my new residency, if I get one, with only days or weeks off at the end of the year, as opposed to the months I will have to ponder my temporary failure this year before starting as an intern.

Sigh.

I am tired of well meaning people asking me where I will be next year. I am tired of people telling me this was meant to happen. I am jealous, painfully jealous with a pit of hurt in my insides, of my classmates who are joyfully planning their futures. Of my former classmates (I graduated a year behind my original class because of my fellowship) who already have almost a year of residency under their belts. Of people in my profession who are my age and are well into their careers.

I didn’t post about it for a while because it was too raw, too painful. And, honestly, I don’t really want to talk about it. There isn’t much to say. It’s hard enough to deal with people I work with, people in my family, and people in my life who genuinely care asking me about it in a time released fashion. I know they’re asking because they want to share in what they think will be my good news. But, it forces me to rehash my pain over and over again, like someone with a new bandage being asked what happened by every new person they see. And, then I have to nod grimly and politely when they tell me that somehow, it was meant to be.

Please allow me to be self indulgently angry and defeated. This is not how my life was supposed to be at this point. I wasn’t supposed to be staring down the barrel of forty years old, not an obstetrician, just a single mom who is wondering if I can even keep my tiny 1000 sq ft house next year on an intern’s salary. Oh, and I just got diagnosed with a chronic disease that I am managing very well, but has a small chance of crippling me. I know I am extremely lucky to be (mostly) healthy and able bodied, with good support, and smart enough to have made it into medical school in the first place. I know that this is not the end of the world – I very well may match into obstetrics next year. I can also fall back on family medicine, and then do some obstetrics, eventually, in a rural area, possibly after doing an obstetrics fellowship. Or, I can finish internal medicine and then do a women’s health of family planning fellowship.

Sigh. I am not digging for reassurance. I just needed to finally get this out.

Reposted from Mom's Tinfoil Hat

Why you absolutely need to have a baby in residency

Last week, Red Humor mentioned Dr. Sibert's blog post about how you shouldn't have a baby during residency. Is anyone else getting the feeling that Dr. Sibert is just trying to make people angry at this point?

Anyway, I was going to write a post going through several domains (pumping, maternity leave, pregnancy, etc.) and decide which was easier: doing it as an attending or doing it as a residency.

But I'll save some time for both of us. Attending wins all around. To the point where I got mad at myself for not having waited the first time around. Of course, everything is easier the second time around because you know what to expect. And I happened to have an easier second child than first child and a flexible job.

That said, I think having a baby during residency was a good experience in many ways and I obviously do not regret it. So in the interest of being positive, I present to you.....

Reasons to have a kid during residency instead of waiting:

1) Because apparently, it isn't so great to have kids after age 40. And yes, you may finish residency before you're 40, so maybe that argument doesn't hold water. Except say you're 25, which was the average age of matriculating students at my med school. You go through med school and four years of residency. Now you're 33. And because you're already in your 30s, it takes you a little longer to get pregnant, so you get pregnant at 34, first baby born age 35 (now advanced maternal age). And you want three kids. I won't do the math, but you can see how you're creeping into the 40s territory, when there's a higher risk of complications, birth defects, and infertility. (I could go on about this. I won't. But I could.)

2) It's unlikely when you get out in the real world that you will have like 20 people to share coverage for your leave. Coverage is much harder to come by in the real world.

3) If you're gonna have preggo brain or "milk brain" (it's real!), is it better to have it when you've got an attending looking over your shoulder or when it's your first year in real practice?

4) Everyone talks about "getting the career stuff out of the way" before having kids. Because you want to enjoy your kids. But how about enjoying your career? The second you get out in the real world and start building your career, do you want it broken up by maternity leaves and sleepless nights?

5) Gives you a great excuse to hightail it when attending comes up with a really stupid reason why they want you to stay.

6) Helps you to grow up and gain maturity and perspective, which, let's face it, a lot of residents really need.

7) It makes residency (which can be horrible) more tolerable.

8) Being a parent gives you a way to relate to attendings. And while some of them might give you smack for taking a maternity leave, I felt like I got a lot more respect for being a mom.

9) Because what else are you going to put a picture of at the end of your powerpoint lecture? Your cat??

10) Dr. Sibert herself had a baby prior to residency and thinks that was A-OK. So what's the hard part then? Being pregnant? Arranging maternity leave? Dr. Sibert says yes, but I say no! The hard part is having a freaking child to take care of. Is having a baby as a med student better than doing it as a PGY2 like I did? I'd again say NO. I got through my whole internship without having to worry about my kid missing me. Isn't that the hardest part??

11) In many fields, being an attending can be harder than being a resident. Especially if you do as Dr. Sibert suggests and don't work parttime.

12) Similar to one reason why women have kids close together in age: you're already sleeping badly, so why not?

13) I'm in my early thirties and I think I'm done! I never have to go through pregnancy and childbirth again! It's so liberating. (Sometimes depressing. But also liberating!)

So there you go. 13 great reasons to have a baby in residency. But ultimately, as we know, it's a very personal decision and you shouldn't let some idiot on a blog tell you what to do with your life.

when are we done with training?

At no other time in my medical training was I as confident that, with hard work and dedication, I could master the field of internal medicine as when I was a newly minted third year medical student.

Fresh from having taken the USMLE step 1, I interpreted my ability to recite the mechanism of penicillin resistance or the role of histamine in the immune response, and describe in great detail the unabridged and factual accounting of the patient’s forty year occupational history as evidence that, while I still had a ways to go, the practice of medicine could become as comfortable and familiar as reciting passages from a play or riding a bike. One day, I would just know it.

This is, of course, an exaggeration, but not one without merit as there is no other time in one’s medical training when one is so completely unaware of how little they know about medicine. Each additional year I've spent in training has only deepened my appreciation for that which is both unknown and unknowable, and despite this appreciation I still am occasionally horrified by lapses in my knowledge base. I resigned myself to the fact that my training will continue for as long as I practice, well after I am board certified in oncology and hematology. 

Many readers of this blog are likely familiar with Dr. Karen Sibert, whose name I first learned after she wrote an article titled "Don’t Quit This Day Job" that appeared in the New York Times. There were many strong responses to her criticism of female physicians who choose to not work full time, one of which appeared in this blog. She recently posted on her blog a piece titled "Give yourself a break - Don't have a baby during residency", which has also created quite a stir. This posting as been the subject of many blogger’s recent pieces and I don’t want to repeat some very well articulated responses – one of which appears here. Even the comment thread of Dr. Au's post contains interesting reflections on the competing obligations of medical training and early motherhood.

I have a different question, not related to work hours, coverage schedules, ticking clocks, or the financial or marital implications of having a baby during residency. My question is this - when are we really done with our training? It's a question I myself, still in my own training, am not in a position to answer. But I have serious doubts that the need to check current treatment recommendations, latest journal publications, available clinical trials, or consult physicians more senior than myself, isn't going to end when fellowship does. If anything it could get more difficult to maintain sufficient knowledge base once I am removed from the structure of a training program.

It is probably a good time to point out that I am not in a particularly procedure-heavy field of medicine. In the middle of the night and as a senior IM resident, most questions regarding the management of critically ill patients could be handled over the phone. As a heme/onc fellow I spend a lot of time reading and, obviously, consulting with my colleagues, usually during daylight hours. I am not sure if the same is true of more procedurally oriented programs such as surgery or anesthesiology, where perhaps there is a greater need for someone more senior to actually stand by you and aid in management. A person who might not be available once you have completed training. But I did once overhear a surgical attending loudly berate his chief and junior residents for not being able to answer a pimp question on neointimal hyperplasia, which struck me then, as it does now, as not a subject far more medicine-y than surgical. The attending went on to say (or really, more like yell) that his own residency training had become obsolete ten years after completion and that if they were not in the habit of prioritizing self directed learning now, they would soon find themselves without the knowledge base or skill set to safely operate in the community.

So, if you accept that the need to question what you do and do not know will never end, and that as a member of this field you are professionally obligated to avail upon yourself all necessary resources (including colleagues) required to provide your patients with the best care available, I wonder how relevant an end point "residency" is when trying to assess the ideal time to start a family (and again, I am not taking about call schedules).

I had my first baby as a second year medical resident. Yes, it was hard. But I learned to adjust the way I studied just as I learned to adjust every other aspect of my life. Social life, goodbye. Athleticism, goodbye. A working knowledge of current events, see ya. Mommyhood, marriage, and medicine were made my priorities then, as they would have if I'd waited until after residency, but at least by learning to restructure earlier in my career, I was doing so with the safety net of a training program rather than as a new attending.

For example, prior to becoming a mom, I had studied mostly in the evenings and weekends, usually beside my husband in whatever little apartment we shared at the time. That was simply not going to work with a baby at home. So, with IM boards looming, I requested the month of July (I was still a resident in July as I was paying back the time I had taken for maternity leave) to work on an outpatient rotation. I got up early to be at Starbucks at 5am and studied there every weekday morning until boards. No evenings, no weekends. And I was fine. More than fine. When it comes time to study for my oncology and hematology boards, will have a 4.5 year old and a 1.5 year old. Mornings in Starbucks might not be an option, but neither is not studying. I will have to adjust again.

Residency is important. Very important. But, over the course of our careers, it isn't an endpoint when it comes to the quality of care we provide our patients. Being a good doctor is no more a finite achievement than being a good mom. 

Conjunctivitis, I hate thee

Dear conjunctivitis: I don't like you. I kind of hate you. Why do you insist on repeatedly infecting the conjunctiva of my kids? Why do you create big globs of mucus in my kids' eyes? Does it give you some sort of sick, sick pleasure? And how come you're so contagious? If you like my kids' eyes so much, why not just stay there? And making me drag my screaming child to the doctor and force drops in her eyes even though your viral shell is impervious to antibiotics is just plain mean. I think you seriously need to get some help, man.

Oh, did I mention my kid got conjunctivitis recently?

Conjunctivitis is an illustration of everything that's wrong with everything. When the daycare calls you at work, in the middle of a packed morning clinic, saying, "Your baby has conjunctivitis and you must pick her up immediately," you realize that it's impossible to live like this. How do you have a career when you can get called out at any minute for eye mucus? "Sorry, Mr. Smith, I realize you took the morning off from work to come to this appointment and you've been waiting to see me, but I have an EYE MUCUS EMERGENCY at home so I have to leave immediately."

And it's not just eye mucus. Every day, there's a new note on the door of my child's classroom, saying something like, "We regret to inform you that there has been a case of [conjunctivitis, head lice, strep throat, chicken pox, plague] in your child's class. The infected child has been sequestered in a plastic bubble and rolled home, where they will stay until their mother gets fired."

Lately, more and more, the model of one parent staying home or working half days seems to be the only reasonable thing to do. What else are you supposed to do on conjunctivitis days? Or when your kid gets out of school at, like, 2PM for some reason, even though practically every adult works until at least 5PM. Or during those random weeks off. I mean, President's week? Seriously?? What is that?

Can you tell I'm a little aggravated?

Legacy

A few weeks ago my grandmother died. She is the grandmother I grew up with, who babysat me, picked me up from school, fed me, encouraged me and was there for me my entire life. She was an amazing woman. At her funeral I was asked to read a poem, and after hours and hours of searching for something perfect, I decided to write one. Writing this poem has caused me to reflect so much on her life and what she meant to me. When I think of who I am now, what I have been able to accomplish, I know that many pieces of me are pieces of her. My grandmother was a sharecropper. A sharecropper! To think that this small quiet woman once worked under the hot Tennessee sun picking cotton with her beautiful delicate hands. To think of the doors that were closed to her, a brilliant mathematician despite only reaching the eighth grade. She raised six professional children - two doctors (one the first black medical student at his school), an aerospace engineer, a math teacher, an economist, a homemaker. She seriously came from nothing and her legacy is enormous. She helped instill in me the importance of education. This generation is leaving us - the generation of sharecroppers whose grandparents actually remember slavery. So much history! In reflecting on my grandmother, I reflect on my history and the fruit of her sacrifices. I am part of her crop. I have grown up in a world where opportunities are open to me. We do not live in a country of true equality and tolerance, but it is a country where a black woman can be a surgeon, when only 60 years ago blacks and whites in the South lived utterly separate lives. I look at my daughter and I know that I must bottle up and save each bit of this legacy so that I can pass it on to her.

This past October my husband and I took 5 days and took our daughter on a “legacy tour.” She met all 3 of her great grandmothers. Two have since passed away. I am so thankful for the pictures and memories we created. So thankful that we drove over 1000 miles to make it happen. So thankful for family and legacy and my beautiful child.

Baby Names

This might be a slight exaggeration, but all women love to talk about baby names.

I feel like I missed out with my older daughter. We decided to name her after my husband's mother, whose name starts with M. Once we knew we were having a girl, I made a list of all baby girl names starting with M that were acceptable to me. I gave my husband the list, and we both picked out our top three favorites plus our #1 favorite.

We both had the same exact #1 favorite name. And our middle name discussion went something like this:

Me: "Can her middle name be _______?"

Husband: "I don't care. It's just a middle name."

It was a little harder with the second baby. We decided that we were going to name the baby after one of my grandmothers. One's name started with L, the other with E. Before we knew if we were having a boy or a girl, we immediately agreed on Lauren for a girl. But we had more trouble deciding on a boy name. And I wanted to pick one, despite my husband's insistence on waiting till we knew the gender.

I really liked Elliot for a boy. That was my top choice.

Husband: "Elliot is SO NERDY."

Me: "Oh, come on."

Husband: "That's what you like about it, isn't it?"

Me: "Maybe..."

Then I started pushing for Evan. Evan seems like such a perfectly nice, normal name.

Husband: "I don't like the name Evan."

Me: "Why?"

Husband: "Because I knew a guy named Evan and he was a jerk." (Except he didn't say "jerk.")

The L names presented more of a problem for me. I didn't like Laurence because Larry would always remind me of that guy Larry from Three's Company. I dated a guy named Leo so that would be weird, and anyway, Leonard was too old fashioned.

Although I hate to be a slave to trends, I finally got taken in by the trendiness of Luke and started pushing for that name. After all, there was a really cool boy in Mel's class named Luke. And Becky's love interest in Shopaholic is Luke. Except...

Husband: "I don't like the name Luke. It reminds me too much of Star Wars."

After much more debate, we finally tentatively agreed on Edward. I had reservations because of the whole Twilight thing, but when I checked the baby name charts, the name Edward was still surprisingly unpopular. And we weren't crazy about any of the nicknames for Edward: Ted, Ned, Ed. But I supposed Eddie wasn't too bad. I knew an Eddie who was a nice enough guy.

Then it turned out we were having a girl.

And then Lauren got scrapped for a very stupid reason. But that's a whole 'nother story.

snarky

I try not to be snarky about things in which I have no formal training. Homeopathic, complementary, alternative, and untested (excluding clinical trials, of course) therapies fall into that category. Sometimes this is difficult as I have encountered many patients who have lost the last of their time and money on such treatments.  Or as in the case of Dr. Burzynski, who, over 30 years from his discover of "antineoplastons", still has yet to publish data from a randomized, controlled study in a peer-reviewed journal (And it might be mentioned, also threatened to sue a 17 year old who blogged critically of his purported cancer therapy. Say what you will about pharmaceutical companies, but they don't generally go around suing high schoolers for defamation.)

Given what I have to offer is literally a form a poison, I do understand why patients ask for more "natural" remedies. And their inquiry is not entirely without merit if you consider that some of our most commonly used drugs, like the vinca alkaloids, were derived from plants. However, despite this "natural" origin, no one would categorize vinblastine as anything other than standard, and thus toxic, chemotherapy.  And one that has proven its efficacy in clinical trials. I try to work with patients on this issue - explain that I do not object if the patients wants to incorporate a diet high in vitamin C or the occasional coffee ground enemas into standard chemotherapy, on the condition that the patient tells me what additional therapies they are trying and that the patient understands there is a possibility the alternative (or "complementary") therapy could adversely interact with their chemo in ways I cannot predict.

I am on maternity leave right now, so it is perhaps strange that I have spent the morning googling Dr. Burzynski (although truthfully quite helpful as I really do get asked about the Burzynski Clinic often). I started thinking about this issue when I noticed the tag on the "Mother's Milk" tea I have been drinking two or three times a day -

That says "Traditional Medicinals". My first reaction was "Oh no you don't. It's me, being a practitioner of "westernized" medicine, that is the "traditional" one here. You, my homeopathic tea, are the "alternative". In my world, tea is no more medicinal than the vinca alkaloids are natural. And for the record I don't talk to my tea.

I started drinking this tea "just because", and more as novelty than because I worried about my milk supply. That being said, in the last few weeks my milk has been "coming in" more frequently than I remember it doing when I was nursing my daughter. I really don't know how proven a galactagogue fenugreek is, but in my case (the worst kind of evidence - anecdotal...) it certainly seems to be working.

And so I find myself in the odd position of feeling both snarky towards the makers of this "medicinal" tea and yet not able to go an hour without the need to nurse or pump. Of course, the answer could be as simple as it just works, although I would feel better about recommending it should its efficacy be proven in a randomized trail published in a peer-review journal.