Transitioning

I've been back to residency after my time in the lab for a full three months now.  This transition has been quite a roller coaster.  Here is my reflection of transitioning.

#1 Our lives have totally changed.

Positives:

• I have managed to keep breastfeeding and actually making milk.  I have no idea where my body finds this milk reserve, and I can no longer breastfeed in the mornings because I leave before she wakes up, but this has allowed me to maintain a very precious part of my relationship with my daughter.  With all the change in our lives right now,  I cherish being able to continue our "bu bu" time.
• I truly LOVE surgery.  I love operating and as a more senior resident, it is even more clear to me how much I truly LOVE being a doctor to my patients.  I now get to see my patients in clinic, operate on them, make decisions about their post operative care, and meet with families in a much more meaningful way than I did as a junior resident.  
• Being a mother has CLEARLY made me a better doctor.  I have an additional way I can relate to my patients.  It has enhanced my empathy.  There are so many intangible, hard to describe ways in which I have become a better person, and I can already see this reflected in my work.
• My husband and I have become CLOSER!! Yes, I said closer!  We were struggling post baby.  As my love was exploding for this little perfect human we had created, my husband and I were having a hard time relating to each other in these new roles.  The strain on our relationship was significant.  This is another thing on the list of stuff people never tell you about having a baby (up there with peeing when you sneeze).  One of our issues was me feeling like he didn't respect the work I was doing in the lab. Well, his support of what I do as a resident is unquestionable, he is constantly building me up and teaching our daughter that when I'm away I'm doing something that matters.  We also appreciate each other more because we are both working so hard to make this work.  I appreciate how he takes care of our daughter and our house when I can't be helpful. He appreciates how hard I work to contribute when I am at home.  This has been probably the best outcome of me going back to residency because I seriously worried what would happen to our relationship as I got busier.  

Negatives

• I MISS my baby SO MUCH!!!  I MISS HER, I MISS HER. I MISS HER!
• It is such a struggle to balance.  Trying to study, prepare for work while maximizing my home time with my family involves lots of juggling and making choices to do something less well.  I'm developing strategies.  I sometimes come home after work, have family time, and then set a certain time where I do back to work to finish paperwork and notes and prep and study.  I also have times where I choose to spend time with my beautiful girl knowing that I will suffer tomorrow.  Evidence - this Friday, I BOMBED my case conference presentation - BOMBED IT! But the night before I let my husband stay at his work function because he already gives up a lot for me. And since I hadn't been home before 9pm all week, my daughter literally refused to sleep.  She wanted to play princess with me, watch Dora with me, read books, you name it.  She was literally forcing herself to keep her eyes open.  So after hours of fighting it.  I just let her hang out with me while I tried to prepare for conference.

Transitions

One of the harder things about transitioning back to residency is managing the daily transition from home to work.  With less quality time with my family, I want to try to be the best version of me that I can be when I'm at home.  This can be hard to pull off after a crazy day.  It requires a mind-shift.  It requires me pushing out of my mind the patient who I watched realize his own mortality as he prepared to go to hospice for what will likely be his last few weeks, it requires pushing out of my mind the berating I received at the end of the day from my least favorite attending, it requires forgetting the young moms with cancer, letting go of my mental step my step operating in preparation for tomorrows cases.  It requires me realizing the importance of princesses and shapes and coloring and bath time.  Sometimes I go to Dunkin Donuts, buy two munchkins and sit in the parking lot in silence for 10 minutes just to clear my head.  Sometimes I stop by Krogers on the way home and walk around aimlessly until I feel like a grocery shopping mom (that's when I know the switch has occurred).  Sometimes I listen to breathing exercises on the way home.  And sometimes I fail, and I come home all revved up and worn down and I feel like a bad mom.  

This is hard.  Being a working mom is hard and rife with guilt.  But we have to do it.  We have to find ways to do it our way.  I receive encouragement all the time which gives me the little push I need to keep going.  Yesterday, the coffee cart lady who brings coffee to patient families on the floor just randomly tells me I'm setting a beautiful example for my daughter and that I'm a good doctor, just because she overheard me talking about my beautiful girl.  I had never even really spoken to her before this.  It can be hard to find role models, but occasionally I do and they keep me going, and encourage me to be a role model for those that are to come. 

Thats all for now.

Cutter 

When Does The Doctor Get To Call Out Sick?

We've seen posts on this before... But I struggle every time I'm ill. This week, it's not so much my own illness that's been the major problem. It's the kids'. Because they can't sleep. And if they can't sleep, we can't sleep.

It started last week with this upper respiratory bug that's going around. Cold viruses mutate just enough over time that every few years, I get hit hard. I call it the "Three Year Cold". This one was really bad as it hit me on top of my undertreated seasonal allergies and having a 9 month old who doesn't sleep through the night. (I'm just not getting to the Neti pot.)

So no surprise that after a week of this virus, I started to get an earache. Within an hour the earache went from kind of annoying to consistently throbbing. I had a colleague look at my ear to confirm that there was a dull, red, bulging TM there. By the time I got to the pharmacy to pick up my antibiotics, it was screaming, pulsing, popping. I kept putting my hand to the canal expecting to feel pus and blood.

This is on top of a toddler and a 9-month old with copious nasal discharge and coughing. The baby HATES having her nose aspirated, but is used to sucking her binky as she falls asleep. With all the green mucous, she can't suck the binky and breathe at the same time. Thus, misery, for her and us. It's been over a week with this struggle to clear her little nasal passages so she can soothe to sleep...

Our toddler is a bit better off, but still cranky, clingy, picking at meals, whining... And waking up during the night coughing. A cup of juice and some quiet rocking lulls him back to dreams, but meantime, either me or hubby is up, again.

Night before last, it was midnight, and neither child had been able to fall asleep yet for more than a few minutes. Stuffy snotty noses, coughing, diarrhea poopies, fevers, et cetera et cetera, and we had spent hours trying all the tricks... Steamy shower, nasal aspirator, saline wipes, Tylenol, juice, singing, reading, cuddline, cartoons... And I had to be up at 5:15 a.m. for a 7:40 am start time in clinic.

I admit that I kind of lost it. I was personally miserable with my own symptoms, exahusted from several nights in a row of this sort of shenanigans, and I knew I would have only a few hours' poor sleep before I had to truck it to the city and take care of people.

"You have to call in sick," insisted my husband.

"I CAN'T," insisted me.

And I didn't. The kids eventually drifted into snoring/coughing but sustained slumber. My alarm went off at dawn. I hauled my sorry drugged-up ass into the shower, and made it to work alive. I popped Phenylephrine, chugged Dextromethorphan, snorted Afrin, gulped a whole lot of coffee, and tucked a full bag of Ricola into my white coat pocket. I saw my full panel of patients. I got some looks from people, colleagues and patients alike, for my red, swollen, flaky nose, and this wet cough. I kept assuring people, "I'm at the tail end of a cold, I doubt I'm contagious. It's my own misery."

I've commiserated with colleagues. Everyone's been through this before. But we all agree. You SHOULD call in sick for this stuff.... But we all feel like we CAN'T call in sick for this stuff.

So when can the doctor call in sick?

I remember as an intern on a busy overnight call, one of the senior residents started the evening with GI bug symptoms. It was severe, coming out both ends. By 1 a.m., he was laid out in the call room, and the nurses hooked him up to IVs. Still, we interns were coming to him for all the usual overnight precepting: running admits by him, reviewing labs, discussing cases. There was no question of, could he go home sick. We knew that he was febrile and dehydrated and not thinking straight, but it was like, there was no choice. And in the morning, the attendings heralded him as a hero for sucking it up and holding down the fort, despite having active nausea/ vomiting and diarrhea... that was contagious. That left a strong impression on me. Today, I think that was INSANE.

More recently, I had to fight with a patient of mine who also happened to be a surgeon. She had developed flu symptoms and wanted Tamiflu, but didn't want me to test and confirm Flu, so she wouldn't have to call out sick, as is mandated by Occ health. "I'm on the schedule, I have to operate," she explained.
Those are extremes. More common, I think, is our family's situation. We're all miserable, but can't justify calling out.

What would you do?

Mommy track

I was just thinking the other day about whether there can or should be a mommy track in medical training.

There are other fields where you can have the option of training part time while building a family. Why not in medicine? And this would eliminate resentment aimed at mothers who might need to leave early or call in sick more often due to obligations at home or pregnancy during residency.

I'd imagine residents would take longer to graduate and get paid half salary. If the residency was primarily inpatient, that might be a little trickier to manage, although in outpatient rotations, I'd imagine the resident could just work half days. In a field like PM&R, I could definitely envision how it might work.

What do you think? Is parttime residency a good idea or a bad idea?

Guest post: Bitten by the green bug

I never thought I would meet someone who is jealous of a med student. Not the kind of "Oh, I wish I got in to X school" type of jealous. The real "wow, you are so busy and love what you do and I want that" kind of jealous. Unfortunately, it isn't a friend or former classmate who was bitten by the green bug; it is my husband. Since we moved to a new city in July once I got into med school, he only had a few months to find a job before the financial and family pressure set in. Now, 2 months later, he is 3 weeks into a job- what he did think was his ideal job, but he HATES it. Hates it to the point he regrets moving, I feel like a cheerleader every day trying to make him happy at home, and this whole situation stressing me beyond the point of what I thought was stress-able. The fact that I LOVE school but also need to study all night doesn't make it too much better. Has anyone else had a spouse/domestic partner who had trouble during training/after? Any ideas?

-SmMommy

I am a mom of a beautiful, smiley 5 month old daughter, wife to a wonderful (if not too happy at the moment) husband, and first year medical school in the school of my dreams somewhere near a coast.

Having kids "young"

I felt very young when I had my first child. There were times when I felt like a knocked up teenager. Mostly because most of my friends and colleagues didn't have kids yet (there were, in fact, no parents at all amongst all the residents in my program) and seemed to be waiting for some undisclosed time in the future.

In actuality? I was 27 years old. Two years older than the average first time mom in this country. Six years older than the average first time mom in 1970.

More and more, it seems like women are waiting until their thirties or even their late thirties to have children. In medicine, I think it's a function of trying to get difficult training out of the way first, which I can certainly understand. There are times when I question my own decision to have kids so young. But ultimately, I think it was a good decision. I've written here before about how I think that career advancement can always be postponed, but having kids is the one thing that's time sensitive for a woman.

Here's why I'm glad I had kids "young":

--Pregnancy was much easier in my twenties than my thirties. The difference was actually surprising, and my glucose numbers were even worse the second time. I had zero complications in my first pregnancy. And since I was so young, I didn't have to go through any invasive testing like amniocentesis.

--Caring for a newborn was easier in my twenties than my thirties. My body was much more amenable to it when I was younger and I had far fewer aches and pains.

--Presumably I'll continue to have more energy to do stuff with my kids throughout my thirties, compared with parents in their forties. I've heard a lot of older dads complain about this.

--My parents are younger and have more energy to help than they would if I had waited till they were in their late 60s to have kids. And similarly, I'll have a greater chance of being a young grandma, who can help with and appreciate my own grandkids (*fingers crossed*).

--I never had to go through the pain of trying to conceive while all my friends were having babies and posting photos of them on Facebook. If I did have trouble TTC at 27, I would have had more time to work on it.

--Arranging coverage was amazingly less burdensome as a resident than it was as an attending.

--At this point, since I feel "done" with childbearing (IUD willing), I can expand my career and take on new obligations without worrying about another pregnancy and baby interrupting things.

--Kids are awesome

Of course, I'm sure there's a similar list of benefits to having kids at age 40.

I dread/ hate "Family-Centered Rounds"

* I apologize in advance for the number of times I use the word “hate” in this post, but it’s gone beyond dreading into the realm of hating. Let me explain:

I have a background in Health Promotion and I always try to find ways to incorporate patient understanding and literacy in to my interactions. I realized early in medical school that I dread and now hate rounding. Absolutely hate it. As I have often seen it, it is Team-Centered with the patient/ family on the periphery. It is not health promoting. The literacy level is directed to professionals. All big no nos.

After a week on the Wards, I realized yet again that I hate “Family Centered Rounding” for pediatric patients due to the following reasons:
- way too much information is being spewed at parents who have probably just woken up
- way too much detailed information is being reported; if medical students and Interns have trouble keeping up how do we expect families to?
- there are way too many people in the room who have only minimal involvement with the care of a particular patient
- it is unprofessional and unappealing when folks with minimal involvement are only half-present (ex. the other Interns working feverishly to complete notes and orders on other patients)

And my biggest concern is are we hurting patient care when we list detailed and often scary differential diagnoses and mention lab tests that we probably will not perform?

I could go on and on but I won’t. I think Family-Centered Rounds has the potential to be a wonderful educational tool for families, a way to increase engagement in the medical decision making process. At least as I have seen it (at a large urban tertiary care center and at a medium size community hospital), it falls short. Rather than complaining without taking action, I am very interested in helping make these rounds better at my hospital, for our patients. I am motivated, selfishly, to at least work toward making the process less dread and hate-inducing for myself so that I don’t completely omit becoming a Hospitalist from my list of possible future careers.

Questions:
1. How do Family-Centered or Patient-Centered Rounds work (or fail to) at your institution?
2. If you could change this process and make it better given time constraints, what would you do?

I think I see a Quality Improvement project simmering . . . .

Oops Babies

It seems like there are a lot of "oops babies" out there.

I know a bunch of other people who said they only wanted one or two kids or no kids, but then "oops." It seems like everyone I know either had an oops baby or knows someone who did.

I question the concept of oops babies. I wasn't trying to get pregnant either time I did, but I know I wasn't trying very hard not to. (Mistimed natural family planning.) One of my friends in residency got pregnant "by accident" twice, although one time it sounded like she wasn't using any protection. A friend of mine who got pregnant in high school wasn't the result of a broken condom but no condom at all. I do know a woman who got pregnant on birth control pills, and I have to wonder if she was taking them correctly. I wonder how many genuine oops babies there are, or if they're really "should've known better" babies.

Right now, I feel like 99% sure that I don't want any more children and I certainly feel like the stress of another child would be unbearable right now, so I got a Mirena IUD. It's supposed to be greater than 99% effective and as effective as sterilization procedures. But the more stories I hear, the more I worry about an oops baby.

I let a patient do my hair.

Oh yes, I did.

This is not a level of intimacy with which I am that comfortable, but when it became apparent within minutes of starting our appointment that she was not going to Let This Go, I acquiesced.

I was running late, and the messy braid running down my back was obviously going to be a barrier to our getting through a few important issues in this otherwise routine follow-up visit. Before you go thinking this is terribly creepy or whatever - she identified herself as a "trained beautician" who wanted to make me look "as beautiful as the pastor's wife".  Fine. Fine. FIX ME.

I doubt very much any of my male colleagues would have allowed this to happen. I speculated as to if female physicians in other fields would have consented to an exam room "make over". Do patients ask to re-do the surgeon's hair? The psychiatrist's? Surely not. Eventually, as she was still twisting my hair this way and that, I rounded my way to the realization that few, if any other female physicians would find themselves in this position.

This might, in other words, be a me-specific problem. And I am wondering if I should be bothered by it, because, aside from feeling a bit bashful at the time, I'm not. I just hope years of medical training and motherhood aren't eroding an occasionally whisper-thin sense of self-preservation.

But hey, even if they are, I still got a new hair-do that earned me some compliments later in the afternoon. Self preservation? Ah, just FIX ME.

the other parents in medicine

Just got to thinking, is there a fathers in medicine group blog? 

Fathers in medicine who are reflecting on their careers, their choices, their balance or perhaps lack of it, their children, their partners and families, their co-workers, their time off, their time on, their weekends/evenings/late/early meetings, their yearning to breastfeed or pump (!), their commute, their biological clocks, their practice, their burnout, their paycheck, their research year, their struggles, their stresses, their joys, their tears, and...   

reflecting on us mothers in medicine, of course.

What else might they reflect on?