Poker Face

As a pathologist, I am one step removed from the patient.  This is comforting for the most part.  I render my diagnosis and another clinician communicates it to the patient.  It is best this way - I have no treatment options in my own doctor toolbox to give meaning to the words I communicate.  I learned this the hard way - in fellowship training.

Once I was doing a fine needle aspiration on a small sub centimeter mass behind a patient's ear.  The patient had a history of melanoma, and they were very anxious.  After I aspirated some cells I looked at them under the microscope.  I had a good sample.  It was pretty obvious, despite needing stains to prove it.  Metastatic melanoma.  I sighed internally and turned around.  The patient asked, "Well, what is it?  Is it melanoma?"  I was nervous, still in training, and I hesitated a second too long.  The patient melted into tears, guessing the answer by my lack of words.  I communicated some soothing words and did not hesitate to ask a nurse to call the oncologist two floors above.  Wisely flaunting routine the doctor arranged to meet the patient immediately to discuss treatment.

I learned from that experience.  Now I tell the patient up front that we won't have results for at least 24 hours, although at least half the time I have a pretty good guess at the results when I triage the sample on site to see if it is good enough material for a final diagnosis.  The clinicians appreciate our discretion, and as I said, it is best overall as we usually need special stains or additional material from a cell block for a definitive diagnosis.  And most importantly, we cannot offer treatment options.  This leaves us and the patient at a huge disadvantage if we jump the gun.  Giving a diagnosis without a next step is mental torture.  I sure wouldn't want to be on the receiving end of that.

As a long time member of the community in the hospital where I practice, I encounter situations, not infrequently, where a family member of a patient will text me or facebook message me and ask if I can look at/triage/let them know when the results are out/ of a biopsy of a family member.  I am always happy to help but at a loss for many reasons I mentioned above, not to mention that to communicate results to someone other than the patient, even a family member, is a major HIPAA violation.  I try to offer support and information but fall short of giving away any information about the actual diagnosis - letting it fall naturally in the clinicians hands to communicate themselves.  I know this is for the best, and appropriate, but when your friends are in need diversion can't help but feel deceitful.  I have actually called clinicians, during working hours, letting them know that my report is out and I have a patient or family member calling me.  The clinicians are always gracious and helpful, despite my natural reticence to add to their workload.  I have usually fielded many calls from them about patients in their office - wanting a preliminary diagnosis or a personal phone call when the final results are out - so I understand it works both ways.  And once the diagnosis is out, I am more than happy to discuss it with a patient.  Although that doesn't happen very often it is a rewarding experience.

Sometimes I wish I was back in college when a poker face was just that.  A poker face.  Texas holdem.  Seven card stud.   I wasn't good at it then, bluffing is not my strong point, but I have developed a fantastic one in my field.  It's a skill I didn't anticipate having to master when I chose pathology.

MiM Mail: OB vs. Peds....25 days left to decide

Hello All,

 

I am an MS4 with seven months left til graduation, and more importantly perhaps 25 days left before I hit the send button on ERAS.  I have a serious problem.

 

I am in love with OB. Absolutely in love.  I like Peds, but I love Neonatology.  Who says you can be in love with two different niches? 

 

The problem as I see it is three fold.  1)  I am in my late thirties with a nine year old child that has some emotional issues, and a husband who is not really a husband (ie, he cheated...habitually, horrible husband, great father to our son and we have agreed to co-parent peacefully up until this point.  With such a predicament, I am wary of embarking the OB path with the fear that I will not be as available to my son as he is going to need me to be, that I will miss out on his growing up in lieu of delivering the loves of other peoples lives.

 

2.) I keep hearing how miserable OB/GYNs are, how they don't make any money, and how they all stop doing OB and are doing GYN now for lifestyle purposes (but OB is the part I really like!).  Not to mention I constantly hear OB residents are straight biotches (present company excluded Im sure).  I have a bit of it when pushed, but I don't want to be miserable all my life!

 

3.) I did not care for office pediatrics, but I did enjoy my neonatology clerkship with relish!  And I felt it was truly more thrilling to be handed a brand new baby and tend to it than to pull one out and walk away.  And to add to that, Ive never heard nor seen a miserable pediatrician....a tired one, a broke one, but never a miserable one.

 

How do I make the right choice?  How do I do this without being an absentee mom?

 

Any advice would be quite helpful. 

 

The clock is ticking.....

 

Sincerely,

 

The Phoenix

Guest post: No fun

A few years ago, my husband and I got together with a man and his wife that we had known as young adults.  This man is now a prominent figure in our community, and is well known by most of the people in our small town.  After an evening with this couple, my husband remarked, "It was nice to see them, but it's almost like he can't relax - like he's always on.  He's just not fun anymore."

Fast forward to the last few weeks.  A dear friend of mine came thousands of miles to be "back home" for the summer.  We had several opportunities to go out to eat, take the kids swimming, etc.  As we talked, I found myself noticing something -

I'm just not fun anymore.

Before mentioning a tidbit of interest I would have to think - is this person a patient?  Would I have even known this information outside of the practice of medicine?  When I'm in public, I feel that I am always "on."  When I'm at the store I might be greeted by the dad of a baby I just delivered, or be questioned about a new medicine, or be updated on a cough.  I know, though, that this is to be expected, especially as I take care of many people that I've known since before I started medical school.

In a community this size, being a doctor is like being a minor celebrity.  I'm not exaggerating when I say that hundreds of people know which day I have off, or where I went for vacation this summer and when.  Often it seems that just when I am starting to relax or spend time with my family, I will hear the call, "DoctorGrace!"  I find I can't be anything less than pleasant and professional when I'm "on duty," and I feel that I'm on duty nearly all the time that I'm physically present here.

Now, I realize that I signed up for this;  I know that this is a tremendous privilege, this look into the lives of others.  I honestly love my career, and there is no other life that I would have chosen.  I had another career before medicine and I really feel that I walked into this with my eyes open - as much as is possible, anyway.

I knew that medicine would demand my time and energy.  I knew that I would sacrifice time for my family and myself.  I just didn't realize until now that my spontaneity and sense of fun would be a casualty as well.

DoctorGrace is a family practice doc in the Midwest practicing full-spectrum family medicine.

A fun question

I was just having this conversation with some work colleagues so I thought you might want to throw in your answers:

What were your children's first words?

My two kids' were:

"Bye bye"

And, more heart-achingly, "Mama."

MiM Mail: Leave the Marines for medicine?

Successful ladies, mothers and driven achievers-it was so refreshing and motivating to come across this website and read your posts.  I am a mother of a beautiful 2.5 year old son, happily married for nine years now and currently deployed in Afghanistan missing it all.  However, being away has offered me time to reflect on my life goals. I find that yet again the desire to pursue a career in medicine springs to the forefront of my mind.  Shortly after starting college I uncovered a fascination and curiosity for physical science and the mechanics of the human body.   I was already obligated to military service so I didn’t follow this dream but kept my options open through completion of most pre-required course work (except organic chemistry). Now, after serving 10 years in the Marine Corps I still cannot stop thinking about this deep rooted desire-the idea of studying medicine just excites me!  I find studying the body and how it works to be a fascinating journey.  I feel very passionate about it.  Aside from observing a few surgeries and working in a physical therapy clinic, I have not done much volunteering in the traditional sense but I have certainly been exposed to medicine much more than the average non-health care provider.  I work long hours with my current employment and hope to find at least a few hours a week to clock some candy striper hours in the near future.  The purpose of my post today is to voice some of my reservations and look for advice from those who have already completed the journey or are currently on their way.

I have three big concerns holding me back from my pursuit: 1- As a mother, will I sacrifice the young years of my son’s life and miss out on milestones and memories if I am in school or residency?  Will I be able to have more children and nurse and nurture them or will I resent always having to leave them in the hands of another?  Certainly I am a woman who enjoys balancing motherhood with work; and I need to feel a sense of purpose from my work, but I am trying to determine how much is too much.  2- Am I smart enough?  I have never failed at anything, but it is not from natural abilities-it is from sheer will power.  Long after the gifted are done I continue to study, read and try to synthesize the day’s lessons.  I view myself as an average scholar-I have never been a great test taker (I only performed average on the ACT/SATs) but my grades have always been very good (Cum Laude with a BS in Physiology from Ohio State University).  This compounded with the fact that I am 10 years post-college has me concerned.  I don't want to get in over my head and succumb to overwhelming stress that reduces my quality of life.  3- Do I want to leave the Marine Corps?  It is a career I am good at and that is now familiar to me.  I resent so many hours away from my family though and am not sure that I can do anymore 6-8 month deployments.  I know it may not be much better with medicine, but I would be following my life’s passion.  Please help!  I would value any and all thoughts as I indecisively stand a fork in the road-both leading to two very different ends.

Hopefully submitted,
Emma

Taking Advantage

I've talked about how flexibility is really important for a female physician with young kids, and fortunately, it seems like more jobs are willing to provide it. However, I feel like if you're granted this flexibility, you have to be extra careful not to take advantage.

I don't work with anyone now who I feel takes advantage of this flexibility. But I've seen it in the past and I've heard a lot of stories. For example:

--Calling in sick excessively... like, every Friday

--Leaving early frequently if that's not part of your schedule

--Using your kids as an excuse to get out of just about everything

I'd like to think most women are responsible enough not to do this, but I'm not so sure. What do you think?

Guest post: Swimming

Becoming a mother and becoming a doctor were, in many ways, remarkably similar processes. They both required a radical redefinition of my sense of self. I thought that I had perfectly planned and designed my transition into each of these new identities. But after jumping, eyes closed and breath held, into each new role, I found myself unexpectedly struggling. Option one, the easy route, would have been to softly sink into the newness, absorbing it into myself without question, seeing in it something that had been there all along. Option two (the one that I chose), consisted of frantically splashing about to keep my head in the old world, fighting as if my life depended on not assimilating…and then, in the end, enjoying what I had known that I’d wanted all along.

First: doctoring. For so many years, I had resisted the desire to be a doctor. I did so for many reasons. I’d watched my dad (a surgeon) miss so much of life, and knew that I didn’t want mine to center on work the way that his did. I’d “learned” in college all about medical sociology and the way that new doctors get indoctrinated; I was horrified to think that I too would by necessity fall prey to this ideology if I went to medical school. I saw the passionless lives of professionals and knew that I DID NOT want that for my own – I wanted excitement and happiness and time and craziness and all the things that were not contained, by definition, in medicine. And of course I wanted to change the world.

But in the end medicine won out. I got convinced that I could in fact change the world as a doctor. And I sat down to learn the language, the cadence, the perspectives. Of course I spit and struggled in its face: first I broke up with my boyfriend for convincing me that med school was a good idea; then I refused to study “too hard” because doing so would be legitimizing the establishment; all throughout, I held myself apart, insisting that I was somehow “different” from my classmates. And yet one day, before I knew it, I had become one – a “doctor.” I thought like one, talked like one, was passionate like one. I think my real wakeup call came when I got engaged, and realized that I was no less of a woman for being a physician. And that I was, in fact, better at making informed decisions about my future life than I would have been without medical school. I had fought being submerged by medicine. But I surprisingly realized that I had learned how to float.

And next: motherhood. Equally planned, complete with lists of pros & cons. Once again, I tried to “take lessons” – attended classes, read books, and so on. The difference was, this choice was irrevocable. For the first time in my life, I entered into something that I could not take back. Motherhood happens so quickly, and there is no trial period! People have described the first year of motherhood as being something of a chrysalis. Now that I am on the other side of that year, I understand the poignancy of this description. But I think that a better metaphor that becoming a mom is like jumping in off a diving board. There is no shallow end.

Oh, how I struggled in that first year of my first child’s life. I insisted that I was not “really” a mother. I was not “one of those” who would pay exclusive attention to her child. I didn’t obsess over things the way that “stay-at-home” moms would. I was different, special, not fully subsumed in the role. And yet… now, Being a mom is part of my being.

In the first years, I constantly argued with my husband about who would take on various tasks. I had to realize that fight as I might, no one would take these tasks away from me; there was no one to hold me up. But I wasn’t really sinking. Indeed, I refused to dip below the water line for long. I learned how to manage all of these new movements to keep my head up. And one day it became… dare I say it? Not effortless, but thought-less. Five years later, I find that I now longer have to think about the day-to-day tasks of being a mom. Just as I tread water automatically, so I manage schedule, lunches, playdates, without thinking.

But then the final challenge: how to meld these two roles? Can I kick and float at the same time? I think I’m getting there. After all, I’ve found that my mothering skills help immensely in the Emergency Department. When they throw tantrums, I understand that it has nothing to do with me. When they are whining I know that they really just need a cup of juice and some crackers. When they cause trouble I understand that they’re just looking for attention. When they break down crying I know that they just need a hug. (And I’m not talking about my residents!!)

Conversely, I’ve found that my medical skills are helpful at home. As much as I try not to be a doctor with my children, I can’t help judging their scrapes, rashes, and fevers with a medical eye. I look at how much they’re eating, how they’re drinking, what they do after they tell me their belly hurts… and I make what I hope are somewhat more educated decisions. I also know when to not freak out – something that too many people these days, scared by everything from BPA to H1N1 to thimerosal, are prone to do.

Each transition has contained moments of tremendous frustration, fighting, anger, unwillingness to capitulate, and yes, feeling like I was drowning. But I think that I may finally be learning how to swim through life.


Emergencymom is an academic emergency physician and public health researcher on the East Coast.  She is proud mother of 2 (aged 4 & 1), and wife of a small-business-owner.  Her work-home balance is precarious, but generally enjoyable.  She still can't believe that she gets to do research for half her work-week!  She welcomes suggestions on how to get 4-year-olds to stop whining, how to have dinner cook itself, and how to not be perennially 1 hour shy of a good night's sleep.

First Call

It's my first overnight call in the hospital. It's 7pm and I've been at work for 13 hours. There are 16 more hours to go. My arms are halfway through the portholes of an isolette and my hands are cradling the tiny hand of one of my patients who needs a blood culture and screening labs. I am shush-shush-shush-ing the baby as I choose my spot, swab it with alcohol, and pierce the skin quickly and definitively, trying to cause as little pain as possible. My pager phone is buzzing and beeping against my hip, the nurses are mobilizing, talking, helping each other do all the things this sick baby needs done, but for the moment it is just me and this hand and the artery that is hidden a few milimeters beneath the skin. After a few adjustments of the needle, the red arterial blood flashes into the needle, travels up the tubing, and begins to fill the syringe. My shoulders start to unknit themselves and I take what feels like my first breath in a while. Thirty seconds pass as the syringe slowly fills. There's nothing else I can do for the moment but stand here. I haven't stopped moving and doing and thinking and worrying for the past 13 hours, so this feels like a break. The baby is chewing on his pacifier, looking around for the source of the sting, and our eyes meet for a moment before the blood hits the 2cc mark and I retract the needle into its hub. "Thanks, little man," I whisper to him softly, grateful to have gotten the blood, grateful that I don't have to cause him more pain with a second stick, grateful that I don't have to call the fellow to come and help me, grateful for the couple of breaths I took and whatever small thing passed between us. In the time it took for the stick -- no more than three or four minutes -- four new pages have come through and I am needed in four places at once and I don't breathe again until well after midnight.

*          *          *          *          *

The most recent change in the ACGME medical training rules happened when I was a fourth year medical student. At the time, all the protest over the limitation of interns to 16 hour shifts seemed silly to me. How could anyone protest a seemingly more humane schedule? What was the big deal? Then I got to intern year and began to understand the widespread dissent. The day-float, night-float system featured constant signout -- on long call days, I would spend 2-3 hours of my day signing out. I worked 13, 14, 15 hours six days a week, enduring the pain of long separations from my child, often staying up late working on notes and discharge summaries -- and still there was never enough time to see patients, with rounds and conferences and notes and sign out and the endless to-do lists. Most disturbingly, I felt like I wasn't learning as much as I expected. Admitting a patient was more a matter of administrative work. There was never the opportunity to travel with the patient through the process of diagnosis and treatment. At best I would put in the initial orders, then sign the patient out to the night person. Nights were a little better, with more opportunity to actually see patients and think about them, but six consecutive 15 hour days left me feeling exhausted and was hugely disruptive to my family. I began to feel resentful all the time. Worse, I began to forget why I went into medicine in the first place.

As second year neared, I was filled with both apprehension (would I actually be able to function for 30 hours in a row?) and excitement for the switch to a Q4 overnight call schedule. What was I looking forward to? The time to actually see patients. The chance to spend at least one out of every four afternoons with my daughter. The chance to admit and then follow my own patients instead of picking up overnight admissions and shuffling patients when one or another team member switched to nights. The sense of mastery that would come with being able to manage patients by myself overnight. I was hoping to fall in love with medicine again.

*          *          *          *          *

It's 3:30am and even though I should be trying to catch a little sleep during a lull, I am worrying about sodium. One of my patients has a sodium of 129. It's not low enough to panic, but it's not normal. It's not low enough to call the fellow who has probably already gone to lie down but it's low enough to make me lie awake in the dark, wondering if I should intervene or not intervene, wondering if I should call the fellow or not, feeling like this is the kind of problem I should be able to solve on my own. I get up and turn on the light in the small call room and set about reading about neonatal hyponatremia, which confirms that the baby is not in danger. I could go down on his fluids, but he is losing more than the typical amount of fluid through his unrepaired myeloschesis and there has been concern all day for poor urine output. On the other hand, it's hard to imagine that he is fluid down with a sodium of 129. I go around and around in my head, weighing the sodium level against the risk of insensible fluid loss. I decide to recheck a level in the morning and leave the fluids where they are. It's a small decision but it keeps me tossing and turning for the interrupted hour and a half I have to rest before the morning work starts. When the BMP pops up at 6am, my heart catches in my throat for a moment. What if his sodium is 121? It's 130. On rounds later in the morning, we decide to leave the fluids where they are. For the team it's a small decision -- no one even notices -- but for me it's the end of an arc of learning: how to tolerate the anxiety of uncertainty, how to make a clinical decision when there are no protocols to follow, how to think through a problem and come up with a safe solution. If I had been there with a senior resident, I would have just asked them and they would have changed the fluids or not changed the fluids. I would have slept better. But I would have been no farther along in my ability to take care of patients independently.

Post-call rounding is a whole new experience. I know all the patients and what has happened to them over the past 24 hours. I was there yesterday when decisions were made on rounds and I watched these decisions play out. I have listened to these lungs, stared at these monitors, felt these bellies all night long. I am the one who was here. For the first time, none of the patients on rounds are new to me -- they are all mine. I have the opportunity to get feedback from the attending about my overnight decisions, learning that will stick with me forever. Even though I am exhausted, it is exhilarating. I go home, sleep for a few hours in the afternoon, then have the incredible treat of going to pick my daughter up at day care, something I could almost never do on the intern schedule. I have a normal evening with my family, full of all the quotidian details of dinner, bath, and bedtime that are my secret paradise. By the next morning, I am ready to dive back in.

*          *          *          *           *

The new duty hour rules were well intentioned, designed to keep patients safe and minimize the ill effects of sleep deprivation. But I think there needs to be some consideration of what may have been lost. The danger of sleep deprivation has to be balanced again the the burn-out associated with the relentless march of long days without the high-yield learning and sense of connection to patients bourne of the shared journey of an entire day. Being awake for 30 hours is hard. But feeling like a mediocre doctor while seeing my family for an hour a day for most days every month was much, much harder.

I'm curious to what other people think about the "new" (now not so new) duty hours.

How's your summer?

Since you asked...  If it weren’t for her dose of chemotherapy q 3 weeks and some iatrogenic wbc-boosting induced bone pain, it’d be fine.  And yet, my mother and I are still having a reasonably good summer.  Slowing it down a bit and being together.  Even if the togetherness is while we have a picnic in the chemotherapy suite, or while we walk to the local pharmacy to pick up a medication refill. 

Because nothing says bonding with your mom like shaving her head.  She reminds me that early on I’d wanted a career as a hairdresser.  Alas, now there is no hair. But to my pleasant surprise she is the same strong, smart woman with or without her hair. 

Hats abound.  Tennis caps, floppy sun hats, indoors or outdoors.  They suit my athletic mother --who scheduled her first chemo treatment around her tennis game-- better than a wig.

So how’s your summer?

Taking it one day at a time.   Fortunately or unfortunately, I can conjure up that old car commercial ("this is not your father’s Oldsmobile") and say this is not my father’s chemotherapy.  That was another summer 20 years ago, a different regimen, and for an incurable disease.  This time around it’s like cancer 2.0 with a better chemo concoction and a much better prognosis.

And how do you like this summer heat?

I’m trying not to sweat the small stuff, but sometimes I have trouble figuring out which is the small stuff.  Even now, when I should have perspective on what matters most in life.  Sometimes when I’m stressed about the big stuff, the small stuff makes me sweat too.  I’m working on it.  And overall, it’s been a good effort in rebalancing.   It’s mid-summer and there are lots of balancing acts, being here in the middle.  As I am a doctor but not her doctor.  As I care for mom and am a mom.  As my mother cares for her mother and for her daughters and for her grandchildren.  Chemo more than halfway done and yet other treatments still ahead.  So we try not to sweat the small stuff.  Unless it’s while on a jog or on the tennis court.

Beautiful complexity

Every time I talk to a friend whom I haven’t talked to in a while, they ask, “How is it?” Referring to my newfound life as a mama-doctor-wife.

Although it changes depending on the type of day I’ve had, my response generally goes something like this: It is the most beautiful, scary, complex, overwhelming, inspiring, difficult, challenging, heartbreaking, soul-stirring thing I have ever experienced.

Words escape me. How do you explain what it’s like to run a code on an ex-premature infant with bronchiolitis? How do you explain being the ranking Pediatrician in house overnight at your community hospital? How do you explain the multi-layered thought process each treatment change entails? How do you explain the sheer joy you experience as you FaceTime with your husband and toddler before their bedtime while on a break in the hospital? How do you explain what it’s like to work with folks that you find absolutely, positively inspiring and others soo ridiculously frustrating? How do you explain how one second you are “Dr. Mommabee” writing orders and making decisions about who to transfer to the PICU and the next you are “Mommy” who is taking orders and making decisions about dinner options that your toddler won’t spit out and throw on the floor?

Some days I am beyond exhaustion. Others I am bouncing to upbeat tunes in my head. Some days I am extremely efficiently. Others I am crumbling into a puddle in the call room paging my Resident-friends and calling my husband for support.

Serving patients while being a wife and a mother is the most beautifully complex reality. I live it. I breathe it. It keeps me up some nights. It wakens me renewed and optimistic.

One of my favorite quotes by the poet Nikki Giovanni is, "i wanted to be an inspiration in the dreams of my people, but the times require that i give myself willingly and become a wonderwoman." This is what we do every day. We give ourselves mostly willingly, sometimes begrudgingly. We are wonderwomen.

limbo

I'm in a strange limbo. I have another three months of fellowship, but I've finished all my major requirements. I go to clinic a few times a week, study for my boards (which aren't until November), work on a manuscript, and try to muster the courage to ask all those "dumb questions" during this last period before my professional training wheels come off.

I have my nights and weekends off. I pick the kids up early most afternoons and on hot days we go to the pool for a few hours before dinner so that my husband (who works at home) won't be disturbed. I've been baking, which is something I hardly ever do, and we (husband sans children) just finished a two week binge of Breaking Bad. I'm also moonlighting to mitigate some of the financial damage I've done with so much free time.

It's a sweet time, but it's also a strange time. I've wasted too many of my unstructured hours perseverating on the looming change to come. The Move. The Job. I can feel this change near me like the warm heavy breathing of a sleeping animal that's soon to wake up. I'm not scared of it, just aware of it being there.

Perhaps that's a little melodramatic. We've moved a lot in the last fourteen years, got married, had a few kids. Most people I know have undergone at least one, if not a few, major changes during the same time period and more often that change included a cross country or international move. We aren't moving that far and someone else is going to do the actual move for us.

But, for the first time time since I left for college, that move is home, rather than to a city I (correctly) anticipated to be a 3 or 4 year pit stop along the way to... well.. somewhere else I guess.  

While I wouldn't call it a regression, "going home" has, until just recently, entailed a component of just that. I stay with my parents in the house where I grew up. My mom cooks. My dad and I watch reruns of Law & Order with huge bowls of ice cream. We talk about the neighbors, high school sports, and the weather. I don't usually venture far from where they live, which is fairly suburban and removed from the "hipster-chic" elements that have birthed stereotypes of the city- unrecognizable to me- in the time since I've left.

I am unsettled by the idea of living as an adult in a city I've only known as a kid, especially as now, at the completion of my training, when I am expected to act more independently than I have at any previous time in my life, professional or otherwise. I wonder if I will ever feel grown up in a place that reminds me of being 17.

Moving home. More complicate than I had anticipated.