Louis Gene Singleton: A Tribute

Gene is from Cherry Valley, Arkansas; somewhere between Wynne and Jonesboro on Hwy 1. As a boy he fished in a creek on Crowley's Ridge. He remembers his mother frying the small fish, bones and all, to feed their family. His rural farm childhood shaped him, and although I don't know much about his service as an officer in the Marine Corps, I imagine that shaped him as well.

I met Gene when I interviewed for my current job. He jestingly boasted to my father, a neonatologist, that I was to be his replacement ten years ago. I felt proud to be set up for that position. I learned that he had three children and 16 grandchildren; a fact that left me in awe. Now he has six great-grandchildren.

When I first started my job after residency, I was naturally fear based. Gene was my rock. I showed him so many cases in the first couple of years I worried for him; but his patience, calm and good counsel kept me coming back for more wisdom. He never gets angry, I heard the gross room physician assistants say. He never gets flustered, I heard the histotechnologists say. If he raises his voice, said the collective voice of the laboratory, then something really bad has happened. He doesn't need to get mad; he just subtly draws boundaries, and you get it. He quietly leads, and people follow.

So I followed, and I learned. He taught me when to dig down deep in the books, and when to send a case out for expert consultation (rarely). He taught me how to subtly and sweetly correct a clinician when he or she was missing the point. He taught me when to let go of my dogged pursuit of righteousness for a greater good, always keeping the patient in mind. That's why we physicians are ultimately here: for the patients. Being right among our peers is less important than being of service to our community. Early in my career one of my diagnoses was attacked by an outside pathologist, and he stood by my side and defended me to show me that this is what the world can be like, and that part of our job is to protect the truth.

There is an art to medicine, one that is lost in our current climate. Gene is the embodiment of that art. I have gathered over the years that he is a religious man, but he doesn't wear it on his sleeve; it is discerned through his actions. He retires tomorrow, and I am heart broken to lose him as a consultant. He went part time a couple of years ago, and I am constantly reviewing the schedule to see if he is here when I am. When I bumped into him in the hall yesterday I realized it is time to let go. He has promised to visit, but he will no longer be a fixture here. Retirement is not just an end, as I learned from my father at the ocean last week. It is the beginning of a new journey.

I've been grieving lately, taking my own stroll through the five steps - denial, anger, bargaining, sadness, and acceptance. I'm finding comfort in the knowledge that his qualities and characteristics will live through myself, my partners, and my future partner joining us next month; our first hire in the ten years I have been here. I need to teach her some of what I learned from him; a job as much daunting as exciting.

The best servants of God leave the strongest imprint on this Earth. Their legacy is the future. A part of Gene's legacy is the countless number of patients he has helped from behind the scenes. While I will  miss Gene's daily presence, I look forward to witnessing his next step in life, and know that he will only be a text away. People have real ages and chronological ages. His visage belies his actual age by about two decades, so I am comforted that he will be around for a long time in case I ever need him.

I wish him well. I wish that he will enjoy his children and grandchildren and great grandchildren. That he will continue to honor and support and enjoy time with his wife in the same way I have witnessed throughout the years. That he will find a way to continue his chosen profession in a new configuration; once a doctor, always a doctor. That he will know that his partners revere him, and that we will continue to be there for him whenever he needs us, as he was there for us in countless ways throughout his career.

Gene Singleton is one of the best fathers, friends, and pathologists. He's the best mentor anyone could ever hope for, and if I can be half of the mentor and pathologist that he was to future members of this group then I will be proud. I'm going to miss you Gene! Hail to the Chief:). Sniff.

Much love, Elizabeth

Guest post: Have baby, will travel

I had my first baby during medical residency, where we were allowed 6 weeks off (including all the year's vacation) without extending leave. My daughter was, ahem, rather "colicky" (read that as "screams for no reason unless being walked on your shoulder for hours a day, or possibly asleep on mom"). I love her but after 6 weeks I was sick of watching Law-and-Order by myself at home (boo hiss lack of US paternity leave support), and starting back into a relaxing research rotation was a relief. Even if it was hard to find a private place to pump. With number two I vowed not to isolate myself so much. To go out and about more with baby, even if it meant breastfeeding in public a bit. (I was just too self-conscious to do it with number one, even with a sheet) So, while pregnant with number 2 during my first year of Oncology fellowship, I realized ASCO (the big annual oncology conference), which I very much wanted to go to, would occur about a month and a half after he was due. Should I go for it?

Being a mom in medicine feels like a mixture of wanting to have my cake and eat it too. I want to work, I LIKE work. I want to have babies, I LOVE my babies. I want to breastfeed exclusively. I hate pumping. I'm going stir crazy after a few weeks of being a stay at home mom. I'm incredibly anxious about the prospect of leaving my baby. It's so nice to be among adults and using other parts of my brain again. Etc.

So, should I plan to go to ASCO?
With a one month old?
While breastfeeding?

First I did a Google search. I found a few articles on graduate students going to conferences, and that people were generally supportive. But nothing specific on ASCO. OK.

Could I keep the baby on me with a sling? Run out if he starts to fuss?

Sadly the answer to that is very much NO. ASCO does not allow any children under 16 in the conference, for "safety reasons." No exception for pre-mobile and breastfeeding babies.

So, I would say it's mostly impossible to attend ASCO if you don't have some kind of secondary childcare arrangement.

However I am incredibly lucky in that my parents are in Chicago, close to where ASCO is held. I was planning to stay with them anyway. My father no longer works and is very supportive. So, I did go with my baby to ASCO, and it was a good experience. Here's how I made it work.

1) Knowing my priorities. For me, my baby and establishing breastfeeding was my number one priority, so if there was a conflict I would choose that. Anything I got out of the conference would be gravy - some conference would be better than no conference, I reasoned. Especially since given the timing of my baby's birth, I was actually still on my 6 weeks of maternity leave while at the conference.

2) Having on-site childcare. In my case, my parents. What we ended up doing was, I went to the conference center with my father and my baby with a stroller full of supplies; there were a lot of common areas we could all go to. I would go to sessions, my dad has a book (did I mention he's tremendously supportive??!). When the baby got hungry and fussy, my father would text me and I would dash out to feed him. There was a first aid station where I could go nurse in privacy. I had my nursing pillow stashed with the diaper bag in the stroller.

3) Only go in-person to the in-person stuff: At ASCO at least, the talks are streamed online! So I could watch those in the luxury of a living room with some water and nursing a baby any time after the talk happened. There's really not much interaction at the talks, in fact sometimes the sessions are so full you end up running from room to room to watch it streamed. The poster sessions, on the other hand, I could read online beforehand then go and talk to the presenter one on one. Bonus, I could run in and out without any issue! I identified which sessions would be most valuable to me and went to those, running out for a half hour here and there when I got a text.

-- I did miss out on the "fellows lounge" as I did not know about it, apparently a good spot to be. Maybe next year!

Things that wouldn't work:
-- not having on-site childcare
-- pumping. Unfortunately the first aid station did not have a breast pump, you have to bring your own. And the site is HUGE. I did try to go one day on my own with a pump, and hauling all the supplies around was just obnoxious. They don't even let you stash them at the first aid station. So I can't recommend that.

Overall, I got to visit my parents, they got to see my new baby, I still breastfed and was with my son constantly, AND I was able to make a few connections and learn about some of the latest data on immunotherapy in different cancer types. I would definitely recommend it if you can find the support.

-Proliferating Oncologist, a first year hematology-oncology fellow.

Witnessing sorrow and grief; taking trauma home.

About a week ago, I awoke to the news of the Orlando mass shooting-that 49 people had been murdered in the Pulse nightclub--for no other reason than that they were gay, and most were Latinx. The mass shooting du jour in America. You know the rest of the story, because unfortunately we've all heard these stories repeatedly. But it made me wonder about something else, tangentially related--but related to us in our work.

I came across a Facebook post by Dr. Joshua Korsa, an Orlando resident who described his experience caring for the surviving victims. Check out his story here (original post) or here (short news story)--. The "tangible reminder" he refers to below? His blood soaked Keens. He writes (about the survivors of the shooting):

"They've become a part of me. It's in me. I feel like I have to carry that reminder with me as long as [those patients] are still under my care. So this is a tangible reminder that the work's not done. That there's still a long way to go" 

Later I read the NY Times' "Orlando Medical Examiner: ‘Take a Typical Homicide Scene, Multiply It by 50" which was just amazing (for lack of a better word)--in less than 48 hours they were able to identify all 49 victims and in less than 72 hours autopsies were done on every single one of them. That's a logistical accomplishment and an emotional....quagmire. I cannot imagine being a part of that. I cannot imagine how hard that must have been. What exceptional work-- bringing confirmation to each of the 49 families and countless loved ones involved.

But wow, logistics aside--consider for a moment about the pathologists and technicians who did this work, who painstakingly photographed each victim, prepared them for transport to the morgue, the pathologist/assistants who later performed the autopsies, cleaned the bodies--these are the unrecognized people behind the scenes in such catastrophic events. How are they doing this week? How are the police officers? The crime scene technicians? Are they ok? How do people that witness such awful mass casualties cope? 

So that got me thinking (this is how my ADHD brain works, one topic to another, bouncing along)...WE deal with some really difficult stuff.  Not mass casualties (I don't think most of us do, anyway) but day to day casualties of life. Car accidents. People losing limbs. Diabetes, heart attacks, cancer, strokes. Kids dying. Homicides, suicides, accidents. Alcoholism. Lung cancer. New diagnoses of leukemia (surprise! you didn't just "have the flu"!). Homelessness. Stillbirths. Domestic violence. And so on. It's a lot to deal with.

How do you deal with the anger, death, violence, despair, stress, grief in your job? Sometimes it isn't even the death that's so hard, it's the sorrow, the daily witnessing of human distress. Death is a separate entity, and varies in it's impact on me--some deaths leave me with a sense of calm, some break my heart and I swear I never want to go back to work again (but I keep showing up.). Some don't seem to affect me emotionally much at all, and that's ok too. Every one is different.

As I walked around the oncology ICU recently, several rooms were empty-- and I realized as I walked around that I associate almost every room with a patient I have cared for in that room--and who has since died. I often think of them as I pass by (Oh, that's J's room...oh, that was D's room...etc).

As I walked down the long hallway to grab lunch, I thought:

• M's room-she was my age--she died in that room over there, overlooking the water. She and her husband were avid skiers and mountaineers and he shared incredible pictures of their adventures together. I swallowed back tears during rounds that day; that was the second time I'd cried that day. M died of relapsed leukemia and candidemia. 
• D's room-she coded suddenly, and died before her daughter could make it in. The chaplain put her daughter on speaker phone so she could say goodbye to her mom as her mom underwent CPR ("Tell her she was a good mom....tell her I love her....tell her she was a good grandma"). D died of advanced lung cancer.
• M's room-an older woman with AML, the same age as my mom. Wonderful family, with a toddler grandchild who liked to sit on the bed and who was fascinated by the sat probe on grandma's finger. That boy lit up the room. M died of a disseminated fungal infection. 

And so on. I remember many. 

We carry our patients in our hearts and in our minds--they are with us/in us, year after year. And sometimes memories of them/their deaths are comforting while at times they are heart breaking and hard to revisit--even years later. Some patients/deaths I look back on and I feel peace, and I smile at the memories that surface. Some patients/deaths I think back on and tears still come to my eyes-and the deaths were years ago. Some I look back on and my heart rate increases--because their deaths were so awful that I still have an emotional/visceral response. 

So I wonder. I wonder how the nurses, doctors, EMTs, police, pathologists-how everyone that helped victims of the Orlando massacres is doing. And I hope they're ok. And I'm grateful they were there to face such horror, to run into a scene that hopefully none of us will ever have to face. And I hope now that they've taken care of so many others, that others are taking care of them.

And last but most certainly not least, may we never forget these 49 people, almost entirely queer people of color, murdered en masse for being...themselves. 

ZebraARNP. 

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In Memory.

June 12, 2016.

Stanley Almodovar III, 23 years old

Amanda Alvear, 25 years old

Oscar A Aracena-Montero, 26 years old

Rodolfo Ayala-Ayala, 33 years old

Antonio Davon Brown, 29 years old

Darryl Roman Burt II, 29 years old

Angel L. Candelario-Padro, 28 years old

Juan Chevez-Martinez, 25 years old

Luis Daniel Conde, 39 years old

Cory James Connell, 21 years old

Tevin Eugene Crosby, 25 years old

Deonka Deidra Drayton, 32 years old

Simon Adrian Carrillo Fernandez, 31 years old

Leroy Valentin Fernandez, 25 years old

Mercedez Marisol Flores, 26 years old

Peter O. Gonzalez-Cruz, 22 years old

Juan Ramon Guerrero, 22 years old

Paul Terrell Henry, 41 years old

Frank Hernandez, 27 years old

Miguel Angel Honorato, 30 years old

Javier Jorge-Reyes, 40 years old

Jason Benjamin Josaphat, 19 years old

Eddie Jamoldroy Justice, 30 years old

Anthony Luis Laureanodisla, 25 years old

Christopher Andrew Leinonen, 32 years old

Alejandro Barrios Martinez, 21 years old

Brenda Lee Marquez McCool, 49 years old

Gilberto Ramon Silva Menendez, 25 years old

Kimberly Morris, 37 years old

Akyra Monet Murray, 18 years old

Luis Omar Ocasio-Capo, 20 years old

Geraldo A. Ortiz-Jimenez, 25 years old

Eric Ivan Ortiz-Rivera, 36 years old

Joel Rayon Paniagua, 32 years old

Jean Carlos Mendez Perez, 35 years old

Enrique L. Rios, Jr., 25 years old

Jean C. Nives Rodriguez, 27 years old

Xavier Emmanuel Serrano Rosado, 35 years old

Christopher Joseph Sanfeliz, 24 years old

Yilmary Rodriguez Solivan, 24 years old

Edward Sotomayor Jr., 34 years old

Shane Evan Tomlinson, 33 years old

Martin Benitez Torres, 33 years old

Jonathan Antonio Camuy Vega, 24 years old

Juan P. Rivera Velazquez, 37 years old

Luis S. Vielma, 22 years old

Franky Jimmy Dejesus Velazquez, 50 years old

Luis Daniel Wilson-Leon, 37 years old

Jerald Arthur Wright, 31 years old

Hello, from Paris; or an utterly disorganized hodgepodge of introductions and Father's Day musings

Now doesn't that sound fabulous? I'm sitting on the terrace of the one-room-with-a-kitchen-and-bathroom apartment we VRBO'd for this week, and writing my first blog while the children and husband sleep off their jet lag. And I'm wearing all black! My former poetry major self rejoices. My surgical ego wants to know: What's next? Is this the right thing for me? For my family?

I'm a PGY 4 in general surgery who took the optional 2 years for research, and this June we are on our transit to Malawi, Africa for the second of those years, where I'll be doing trauma and burns research. First year was an MPH and part-time clinical burns work. We are on a stop-over in Paris to visit my brother in law, who's a French citizen and hasn't met his newest nephew yet. My kids are 6, 4, and 7 months. The oldest worries that she won't make any friends in Malawi; the middle recently confided that he's worried about being eaten by a crocodile; only the youngest continues to smile at me every time he sees me with that untouched, utterly trusting smile of an infant who hasn't experienced any parental disappointments or discipline yet, and who just knows that I'm the best thing ever.

Most people who hear that I'm moving the whole family to Africa for a year divide into two reaction camps: one thinks that I'm crazy, period. The other thinks that I'm crazy, but mixed in is a healthy dose of jealousy for this opportunity. I totally agree with both. I'm so excited to have this incredible chance to travel to a country, make a difference and have it count towards some sort of a career; but it also reminds me that I'm insane and that at this point, that's unlikely to ever change.

But I think the truly insane choice was to have 3 children as a surgical resident in America. Next to that, moving them to a developing country seems small potatoes. As all working mothers do, I beat myself up daily for my inability to have it all and have a shred of energy left; I resent a society that reveres "perfect motherhood" while being unable to define what that is and unwilling to support it with policies that make sense for all mothers, working or not; I sometimes resent myself for my inability to be satisfied with "just" raising the children--why do I have to be a surgeon, of all things?--and then I have to laugh, because for this gender-role bending sworn feminist, the idea that one could be jealous of the stay at home side seems preposterous. But it's there.

Any successful insane person has someone as a rock. My parents have always stood by me, in their way, even though they don't understand how I make most of my choices and don't always support where they lead. But my husband--this is the Fathers' Day part of this post--he's my rock, or some would say, my enabler. When I go to work, he works at home, and faces the same isolation and loneliness as a stay at home dad who's not a "stay at home dad at heart," as I do as a surgical resident with kids who actually enjoys both work and kids. At some point I will unpack that statement but it won't be in this blog. Anyways, he makes me and us possible, and I am forever and utterly grateful to him for always in the end coming around to supporting this craziness that I call my--our--life. I work hard, and I get the credit--but he works just as hard, if not harder, and it's not always appreciated or acknowledged. There are "fathers of the year" who get kudos for making it to their kids' soccer practice--and that's important, and legit, and awesome--but he changes diapers, makes dinner, buys groceries, makes sure the kids are on the school bus in the morning and remembers to pick them up after school--and he never complains. He puts up with a wife who's more like a bad college roommate, who is rarely at home, never cleans up her laundry, eats all his food and sleeps most of the time when she is there. He's the steady to my mercury and the rock to my water, and together we seem to make this circus work somehow, if sometimes only with duct tape, some sticks and a prayer. Here's to all of medical moms everywhere--may you find your rock, or if you've already got one, may you always cherish him or her. Happy Fathers' (or Partners') Day!

On Five Year Plans

This is a throw-back to a MiM post back in 2013 that really resonated with me at the time, and still does, in which T writes about someone asking her, "Do you have a five year plan?"

When asked this recently, I fumbled. Actually, I tossed back the answer, asking the asker to mentor me through getting such a plan. It wasn’t even someone who knew me well and it had been asked in a fairly casual way. Regardless, I was not able to answer the question. But if I were to answer it, the answer would be, “No I do not.”

The comments that followed included other MiMs stating that they too did not have five year plans. People cited living in the present, and checking in periodically to ensure satisfaction and fulfillment, but not necessarily a structured plan. Others did have plans, which they found informed their present-day decisions. I was on maternity leave with my first when I read this post, and was feeling very unmoored. I felt that I should have a very clear path of where I wanted to go in my career.

I remember being asked the same question by a male faculty member during my first week of medical school. I fumbled too, as I entered medical school interested in family medicine but open to possibilities. My surgeon-keener classmate piped in with his plan for surgical specialty x, making me feel even more self-conscious. In retrospect, I don't blame myself one bit. I think some people do well with a well-defined, honed-in focus. Others, like myself, find the goals harder to identify; my priorities have to emerge - they can't be easily forced out.

I have broad goals - community contribution through medicine and beyond, strong faith and family, a healthy lifestyle. I have diverse interests; one is health equity, which has led me to refugee health. Various other interests have led me to different projects over the years.

I do find it helpful to have short-term career priorities; a necessary honing-in to avoid over-commitment and burnout. Dr. Mamta Gautam, the Canadian physician wellness expert, tells physicians that as people who have plenty of interest and enthusiasm about many things, there will always be more interesting things that we want to do, more than we could possibly have time for. So, it is a matter of choosing and narrowing down options.

Right now, I'm focusing on clinical work, local refugee health coordination efforts, and writing - both here, and on a blog aimed at patients. I supervise learners periodically, but have flexibility. There have been other tempting opportunities recently, but I have declined them in order to preserve family and self care time. Personally, I need regular downtime. I schedule a day off every month, sometimes more. I need some "empty space" on the horizon in my calendar, which can involve self care time, and sometimes catch-up work and projects. With two young kids, I've found the regular days off invaluable for recharging.

With the births of my two children, the last four years have been full of transitions. I think motherhood fits naturally with evolving priorities and goals. I look forward to more changing priorities over time. And I'm still OK with not having a five-year plan.

Let’s be like Sweden...or Why doesn’t anyone talk about paternity leave?

Hi everyone, I’m Anna Plasia.  This is my inaugural post for MiM!   A brief introduction: I am a pathologist with a new baby, but I've been reading MiM since long before I became a mom.  I'm married to my best friend who also happens to be a father-in-medicine.  I'm honored and excited to be part of the MiM family!

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I have to admit that I was reluctant to get pregnant.  I was happy, and I didn’t want anything to disturb that balance.    My husband and I are both physicians, and our relationship up to that point had been that of equals.  Obviously there are things at home that one or the other of us has taken over due to interest or entropy, but overall our relationship was egalitarian.  And honestly, I didn’t really see examples around me of parenting relationships that were what I hoped for.    My own parents were both professionals, but it was my mom who stopped working for several years when I was born and it was my mom who managed all doctors appointments, birthdays, shopping, cooking, cleaning, etc.  I was sure that my parents’ relationship must have been similar to ours in the beginning -- but becoming parents made them became so...traditional.  So is having kids just inherently unequal?  Obviously men can’t actually have the baby, but are women really genetically better at managing doctors appointments and birthdays and cleaning, or is there something structural going on that makes things turn out this way….every time?

It turns out that the seeds of parenting inequality may be sown as soon as the baby comes home.   According to a report produced by Boston College Center for Work & Family in 2014:

When we ask why it is the case that most men aspire to be equal partners in caregiving but often fail to meet even their own expectations, there can be many possible explanations for this shortfall. One cause that seems clear from our work and that of other researchers is that this performance gap begins in the very first days following the birth or adoption of a new child, when the disparities between the experiences of mothers and fathers emerge immediately. In our research, the majority of fathers take only about one day of leave time to bond with their new children for every month the typical mother takes….During that time at home, fathers are seldom “flying solo” in caring for their newborns (Harrington et. al, 2011).  

It makes sense - - if mom is the only one home with the baby for the first three months then of course she is the one who knows the most about baby.  She knows what baby eats, what soothes baby, what baby wears.  When dad comes home from work he’s stepping into mommy territory.  When baby needs soothing it’s just easier for mom to do it because she already knows exactly what to do.  And if mom has been off of work for a few months then she’s definitely the one getting up at night with baby.  When she goes back to work she will continue being the one getting up with baby, leading to exhaustion, burnout, bitterness, and curtailment of professional duties.

So the question then obviously becomes what happens when men take off their own version of “postpartum” time? In several Scandinavian countries (see Iceland, Sweden, and Norway) fathers are provided with paid paternity leave that they must use or the time is lost.  In Germany and Portugal mothers get bonus time if dads take their allotted time.  It turns out when men take more time off with their new babies the benefits last for a long time.  A survey of parents in Iceland which looked at how childcare duties were divided both before and after a paternity leave policy was implemented found that “there is a direct correlation between the length of leave taken by the father and his involvement in care afterwards.”

My husband and I both agreed that equality in parenting likely begins in the first weeks...so my husband decided that he would take two months of paternity leave.  We are lucky that both of our jobs were covered by FMLA, and we did not fear permanent professional repercussions from taking time off.  But this is definitely the exception, not the rule for physicians.  This decision came at a significant financial cost as both of us took unpaid leave, but we decided some things are priceless - money be damned.  Because it’s unusual for a man in the US to take off a significant amount of time for a new baby, no one could wrap their head around it.  The reaction was...confused.  “Wait, did you say two weeks - or two months???”  No one had ever heard of a father doing this...especially not a physician with an “important” job.  No one tried to dissuade him from doing it, but it was definitely seen as an unusual request.  I am so proud of him for sticking to his guns...honestly it takes courage for a man to buck the trend.

My husband’s extended leave was one of the best decisions we made about having a baby.  We spent the first month at home together.  I can’t imagine being left at home alone with a new baby a week or even a few days after giving birth.  That first month we woke up together for every nighttime diaper change and feed.  Those first nights are long, lonely, and dark, and I can’t imagine going through them without my best friend beside me.  At the end of my leave, my husband took his second month off, and it made the transition back to work so much easier.  Every morning I left our baby with my husband - who knew what to do since he spent that first month at home.  There was no mommy guilt about returning to work with a 10 week old.   And now I really don’t feel like one of us is the primary parent - we are both just parents.

Unfortunately, our experience is not the norm for physicians.  As a physician, unless you are employed by an academic center or a large hospital, your job is often not covered by FMLA.  Many physicians are employed by private practices with fewer than 50 employees or are self-employed and cannot afford to put their business on hold for an extended period of time.  I was told up-front at several (private practice) job interviews that I would only be able to take vacation time for maternity leave.  If it is this hard for physician moms to take medically necessary maternity leave, imagine how much harder it is for physician dads to take off extended paternity leave.  At the same time I am sometimes surprised when I hear of physician dads who take off less time than they would for a vacation when their partners have a baby.  Obviously there needs to be a shift in both the cultural expectations surrounding paternity leave as well as the law in the US before this becomes a more commonplace occurrence.

I also realize that we are very privileged that we could afford to both take off time from work.  The sad truth is that for many Americans this is not a choice they can afford to make.  Ours is the only developed country in the world whose government does not guarantee any paid leave to new parents (source).  Due to exclusions built into FMLA, only 60% of workers are eligible for the unpaid leave guaranteed by FMLA.   Only around 25% of US employers offer paid maternity leave, and even fewer offer any paid/partially paid gender neutral family leave (which includes paternity leave).  It is the lowest paid members of the workforce who generally have the least access to paid or unpaid leave.  And since family leave is usually unpaid, fathers are even less likely to avail themselves of it as they are often the higher earners (source).   Most families can barely scrape by on one salary for any amount of time, never mind three full months.  Having an egalitarian paid parental leave policy in the US would go a long way toward making parenting a more equitable experience.

Did anyone else’s partners take off extended paternity leave?  How was the request met?  Do you think this is viewed differently in medicine than in other fields?

Doctor Day

Recently, I had the opportunity to teach my younger daughter’s preschool class about being a doctor. Sometimes I think that part of the reason I became a doctor was just so I could get to do that.

I was nervous. I’m not sure why I was quite so nervous, considering in retrospect, I can’t honestly think of anything that could have gone wrong. It wasn’t like I was lecturing to a bunch of Harvard professors--these are individuals who pick their noses and eat it. In public. This was like the least discerning audience of all time.

I started out by introducing myself and asking the kids, “Do you know what a doctor is?”

One kid’s hand shot up and I called on him. “A doctor gives us s-----,” he announced.

I couldn’t make out the last word he said, so I took a guess. “A doctor gives you socks?”

The kids burst into hysterical laughter. He said “shots.” How did I not know that? That is literally the only thing children know about doctors.

I had this brilliant idea to bring in a pile of rubber gloves for the kids, so they could each put on a glove and feel like a doctor. Except this turned out to be the worst idea of all time. Kids are apparently unable to put on gloves on their own. Several teachers had to be recruited to help. This ate up, like, ten minutes.

After that, I had the kids listen to each other’s chests with my stethoscope. They came up in pairs of two so I could help them. Except about a quarter of the class was completely deaf.

Child: “I can’t hear anything!”

Me: [adjusts stethoscope] “How about now?”

Child: “No! Nothing!”

Me: [able to literally feel small child’s heart pounding with my hand on the diaphragm of the stethoscope] “Um… sorry?”

Then I broke out my reflex hammer. You want to hear something sad? I actually bought a new reflex hammer just to use in my daughter’s class. The fact that I was using it on patients wasn’t motivation enough, apparently.

The teachers looked a little nervous about that hammer. Understandably so. It was fine though. Nobody was beaten senselessly with the hammer or anything like that.

Soon after, we ran out of time, which was a shame because I was just getting into it. The teacher asked the children, “Do you have any questions for the doctor that aren’t stories?”

A boy raised his hand: “I went to the doctor and I got a shot.”

“Questions that aren’t stories,” the teacher clarified.

A girl raised her hand: “My mom took me to the doctor and I got a shot.”

And it just sort of went on like that.

In any case, it was a really fun experience. Highly recommended.

Diagnosis

This is a Daughters in Medicine post.

(which really does describe me - I'm a third-generation doc. And that is and isn't relevant to this post.)

When my grandmother was in the last years of her life, she fell out of bed. They took her to the ER, where she was Xrayed, pronounced intact, and sent home (where she lived with my grandfather, the retired internist, and a full-time caregiver.) The next morning my mother called me and said "Your grandfather is upset because your grandmother refuses to get out of bed." This was in the 1990s, before digital radiology and Nighthawk came along. I said "Tell him to call the hospital and ask for the radiologist's interpretation of the film. She might have a non-displaced fracture that the ED doc didn't pick up." Mom called me back several hours later and said - in a deeply suspiscious voice - "How did you know that?" I said "You sent to medical school. I learned stuff."

It's now 25 years later. My mother is the one with dementia, living at home with 24-hour care. No retired internist in sight; my father died nearly ten years ago. Last week Mom fell. The caregivers thought she was OK; a few days later, the pain was worse and she was refusing to bear weight. I said "She needs Xrays; she might have a nondiscplaced fracture." And sure enough. She sent me to medical school. I learned stuff.

Mom doesn't need surgery, thank heavens; we'll get equipment into the house and she'll stay in bed most of the time for a while. She's not having any pain.

But I know what it means when someone with moderate to advanced dementia breaks a hip. I'm a palliative care doc. I know where we're going. She sent me to medical school. I learned stuff. And some days, that stuff breaks my heart.

My cherries are damaged!

Ingenious idea, I thought! Youtube, my trusty friend, came through yet again with a genius how-to video to answer some mundane question of mine. We bought some yummy delicious cherries, and TC, my little Toddler Child, loves fruit. I didn't want him to aspirate a pit in a cherry fueled excitement. Last time he had cherries was several months ago when grandma methodically cut the goodness around the pit. But grandma has time and patience that I completely lack. I needed some quick and easy way to pit lots of cherries. Supposedly such gadgets as cherry pitters exist. But (a) I was sitting with a bag of cherries and a hungry toddler, and I needed something NOW and (b) I hate buying useless one trick pony kitchen equipment. Youtube how-to video to the rescue!

An empty wine bottle. Check. Chopsticks. Check check. So I spent the next 10 minutes pitting a lot of cherries. I may gone a little overboard, but there is something oddly satisfying about excising the pit out of a cherry with precision in one swift motion. Ten minutes later I proudly presented TC with a bowl full of "safe" cherries whose pits he wasn't going to aspirate or break his newly sprouted teeth chewing on. At first, TC let out an excited "Chays!". Yes, TC, delicious chays, dig in! TC picked up the first cherry, and his smile was quickly replaced with confusion. How strange, the first cherry was damaged with a hole. He continued to pick up cherry after cherry and putting them back, now with full-on disgust. I knew it was coming, and there it was! TC tossed the entire bowl of cherries on the floor, laid his head on the table and sobbed his lungs out for half an hour. Because his cherries were damaged.

Anyhoo, with that story as an introduction, I am excited and delighted to be writing for the MiM community! I found MiM a few years ago when I was pregnant and freaking out about how I was going to swing this whole motherhood thing while going through med school. As for all life advice, I turned to Dr. Google, who directed me to this blog. Through the years this blog provided me with some  reassurance that this whole mothering and medicining process doesn't always look pretty but there are others out there in the same boat who are making it work. And they are willing to share those messy stories. I felt that it was time to stop lurking and start giving back and putting my stories out there. You can find more about me in the about page of this blog. I also write my own blog, Mrs MD PhD, where you can find more about me. Feel free to regale me in comments below of how your toddler (or not so toddler) child(ren) laid waste the fruits of your labor and/or cunning.

Fighting back

Oh, the astounding advice that comes to you on a daily basis during a time of crisis. 

I cried in my boss’s office today. Like one of those bad, ugly kinds of cries that you just don’t want to do as a woman in front of your male boss.  Except, in the case of my particular male boss, it’s sometimes borderline acceptable because he is a kind, wise soul. I would never overuse his kindness in this way. I’ve cried exactly two humiliating times in front of him, today being the second.  The waterworks started while we were talking about something I’m struggling deeply with these days -- my professional persona in light of my personal life collapse. See, I work in a leadership position in an academic institution. I’m one of few women in leadership positions, and there is a bit of a propensity at this place, and particularly in my field, for young female physicians-in-training to pass by my office informally and ask questions like “how do you make it all work?” And, in that nonchalant passerby question, they are referencing things like simultaneously juggling knives while also making it work with marriage, kids, teaching residents, and taking care of a panel of primary care patients.  And, so, in a world where I trained with very few female role models who were “having it all”, I took it upon myself to be that kind of path builder. It was a conscious decision to open my life up to the generations of female physicians who were maturing into their multi-faceted roles as women, doctors, mothers, partners, and allow them the freedom to pass by my office and come in when the door was ajar, and ask me what it was all like in “real life”.  I certainly never sugar-coated it -- it’s hard for everyone -- but I wanted to give them faith that a fulfilling life, both personal and professional, was possible. I did have that for a time, until I didn’t.

Today, in my boss’s office, I reflected on my failure to be this person I aspired to be, and who I thought I was. I also talked about my failure to be the role model I wanted to be for my residents.  I humbly asked his advice about how to handle it. It wasn’t so much that I wanted his advice on how to handle my divorce and all of the emotional muck that goes with that (it is so deep), but how to negotiate this space where most of my trainees know me as married, two kids, physician, teacher, academic. At this moment, my new identity is single mom with two kids, physician, teacher, academic. And I’m struggling on every single one of these fronts. And frankly, it’s hard for me to struggle. I’m a perfectionist by nature -- good survival trait for a physician, but it turns out to be a harmful trait when everything in your life goes up in smoke.

Poof.  

I’m noticing that I’m deeply clinging to my sense of self as physician and leader, but I feel this person (or who I thought she was) slipping away. In the last nine months, I haven’t lived to my own standard, nor been the person my residents think that I am. So, am I a fake? A fraud? An impostor?  

Poof.

At one point during this talk with my boss, with tears and eyeliner cascading down my cheeks, and both nostrils completely clogged with snot, I said “I’m fighting my way back. I’m doing the best I can right now (sob, sob), and I know it’s not my best. But I’m really trying. And it’s super important to me that you know that, and you don’t lose faith in me.” He sat there. He nodded. And he sat there some more. And I cried a little more. And, you know, like a good primary care doctor, he just let the silence be the space between us for a while.  And then he said softly “I think, really, if I was going to give you any advice, it would be to let go of the concept of fighting to come ‘back’. You’ll never, ever be back, Frieda. You will be somewhere, but let go of the idea that you will be back where you were before. Nothing is ever going to be the same.”  

Poof.

And, so it was burned in me, under my skin. These words. This wisdom. It was so right. How come I hadn’t thought of it before? In some ways, a liberating thought. In most ways, it deepens my grief.  I’m a fighter. A bootstrapper. A resilient woman. I’ve been putting all my energy into paving my way “back”. Literally every ounce of my soul, strength and breath have been put toward getting one foot in front of the other everyday to get back to where I was -- and I suddenly realize I’ve been deluding myself. It’s so simple, in fact, but I’ve just been unable to see it. It begs the question, so just where am I going? Forward? Then what?

"Why didn't you just go to medical school?"

I'm guessing this is a common question posed to ARNPs/PAs, and one I figured I'd take a moment to answer personally, because I find it irksome. Well, I didn't go (or even apply) because....I didn't want to be a doctor!  I don't think it's a compliment to ask an RN/NP/PA that question, but I'm thinking it's meant to be one (i.e. you're really smart, you could've learned more/done more). But the question presumes that becoming a doctor is The Best Option for those interested in a professional graduate level healthcare career (and that the smartest people in medicine are always the doctors).  But becoming a doctor is one of several medical career options out there, and it's not always The Best One for everyone. So for this post I'm going to recount how I got to ARNPLand, given other possible paths-and how a key factor in going to ARNPLand was motherhood. Doctors are awesome (duh), but not all of us are destined for DoctorLand--for a variety of reasons.

My undergrad education was in liberal arts, which was interesting but frankly not very useful at all (a classic tale). I worked in social work right after I got my degree, and worked in social work/corrections for a while...but I wanted a job where I could DO things, and PROBLEM solve and really FIX things. And not be stuck at a desk all day long shoving paper around.

I knew that I wanted a job where I could do the following:

• Be a big nerd, and be in an environment where nerdiness was celebrated 

  

  What a cute ARNP!

• Fix things or people (or both)
• Make a good living, i.e. to support a family of at least two kids. Oh crap, we have three now; we've debated selling one but the kid market is in a slump. And yes, the third pregnancy was planned. And yes, we had an OB ask us this. We changed doctors. Think about that question for a moment...Anyway, my goal wasn't to be rich but to have enough. Comfortable enough to be like the Cleavers (well, the interracial lesbian family suburban version). Ah, but "enough" is so subjective, isn't it?

The Cleavers, "then"..

The Cleavers, "now"

• Be a mom who could go to choir performances, be home for dinner most nights, have dinner with my mom, go out to dinner with my wife, walk my kids to school sometimes,  have time to email my twins' teacher about schoolwork (and kvetch about common core math, that is a whole different post...), cook dinner on my off days, and so on. 
• Be able to have kids closer to 30, not 35 or 40 (I had twins at 29--overachiever!!). 
• Completely gross out my kids and wife with graphic descriptions of medical procedures, bodily fluids, and so on. 
• I wanted to be able to say nonchalantly, "It's just a flesh wound!" (please click HERE if you understand that allusion...you're welcome!)
• Pay $800 in student loans per month. Actually, this is a heck of a deal-ask a physician (or a lawyer). Gotta pay to play, right?
• Crap my pants as I mumble  confidently say the the words "Call a FREAKING code !!!" as I run to the room, after the RN calls me and I hear the words "EKG changes" and I see the heart rate go from 120--100--90--70--50 in 5 seconds on the tele monitor, while my amygdala fires repeatedly and my brain says "ARGHHHHH!! You totally know what to do, breathe...". Begin CPR....
• Have an unlimited supply of graham crackers to sneak from the nutrition room when the charge nurses aren't around to notice (and peanut butter, oh MAN, that stuff is good).

I also took into consideration how much I'd be able to see my kids, day to day--it was important to me to be around as much as possible...consistency. In some subspecialties (that involve years upon years of fellowship), fellows put in so many hours that it's a real challenge to balance the demands of motherhood and work--and year after year they face these dueling demands--and hats off to these women for taking it on! I see fellows in particular who FaceTime their kids nightly, because they're rarely home in time to say goodnight--especially those with young preschoolers. And sure, it's temporary--because kids grow up, stay up later, and so on--and fellows finish their programs. And fellows do have days off, of course, during which they can love their kids (in person) to pieces. But for me, I wanted more of the day to day mom stuff. The stuff that makes me crazy and the stuff I love.

My point is---to each her own. I have as much respect for the mother who is a general surgeon as I do for the mother who stays home full time. And really, it's great that those of us in medicine can FaceTime now to say goodnight to our kids so that we can maintain the daily connection despite our wacky schedules; I used to do it frequently when my twins were toddlers--I'd leave for work before they were up and get home after they were asleep. It was hard, we missed each other a lot. And it was a lot of extra work for my wife when I was gone, as she'd get through multiple 13-14 hr days on her own. So for any woman who is embarking on a medical career it's incredibly important to consider how one's choice of career will affect one's ability to parent in a way that works best for you, for years.  It's a huge, huge consideration. It's a years long balancing act--how on earth are you going to mix these two awesome things (motherhood and medicine) together successfully and keep your kids alive (and your patients)?! 

I needed the work:life balance that I thought an ARNP career could best provide, and I was concerned that I wouldn't have been able to find had I chosen medical school. Or, I suppose that I could have found it eventually, but I would have had to put off having kids for several years--and I didn't want to do that, for many reasons. I couldn't be the kind of mom that I want/wanted to be had I chosen a different career path. And what about the difference in salary, you might ask? The money is great, I think. The starting ARNP salary in outpatient oncology around here is about 100k. Inpatient oncology at private hospitals around here? Around 130k. That's enough for me, enough for my family to live well. So I'll never be The Boss, I'll never be famous, but it's enough--I'm home over half the month (I work 10-12 12hr days a month), I often pick up the kids from school, I have the time to make dinner frequently (and lunches for school, ugh), I have a challenging/brain stretching/ emotionally taxing job and it's all enough. Score.

So this is my corner in the medical world, and I'm happy in it. And frankly, ALL of us are awesome for making our lives work-however we get it done. So here's a toast to getting by with FaceTime, nannies, dads, moms, friends, support groups, childcare centers, vodka martinis, grandparents, Munchery/Pizza Hut/Whole Foods/Amazon Fresh--we're getting it done--mothering AND medicine.


Later,

ZebraARNP

Trading fake patients for real people

MS2 Terrible Twos here. New to MiM, so here is a quick introduction. I am mom to a sweet nineteen month old boy who is into everything and lacks even the faintest inkling of self-preservation. In a former life I received a Bachelor's of Fine Arts from an art school here in the Bay Area, and worked for over a decade in advertising, marketing, corporate event design, apparel, and retail packaging design until I decided that pursuing a career in medicine was truly my dream. Thanks to a lot of hard work, a loving and patient husband, and tons of emotional support from friends and family, that dream has materialized and I am (as of last week) a second year medical student in the Bay Area in California.

Having just completed MS1, one of the most challenging aspects of the medical curriculum this year has been seeing through the text books, algorithms, power points, Quizlets, acronyms, mind maps, case studies, and patient vignettes and remembering that the purpose of all this learning is to support real, actual people with rich histories and complex emotions. The majority of my patient interactions feel so forced and so awkward – so robotic, scattered, and disjointed. I hear standardized patients describe their symptoms and feel myself responding stoically, without empathy to concerns like, “is this serious?”, or "am I going to die?" as I systematically wade my way through OLD CARTS and FED TACOS and remember what a relevant ROS might include for the few differentials I know to consider.

Throughout every standardized patient interaction, every practical exam, and even every time I have performed an H&P on a "real" patient in my school's student run free clinic, I feel as though what limits me from truly developing any sort of rapport with the patient in front of me, actual or standardized, is the tunnel vision that comes from trying to dot every i, cross every t, and check off each and every box on the syllabus.

I understand that there is a learning curve with all of this. As with many professional practices, the only way to get better at them is by doing them over and over again and I recognize that I'll be working toward that for the rest of my medical career. I suppose that what worries me is the fear that throughout my medical practice there will always be a syllabus to consider, be it a QI evaluation report, an insurance audit, filling in every blank on the EMR, or tending to some other system to which I am held accountable.

I would like to believe that all the the awkwardness of MS1 will start to subside as early as this summer when I volunteer at the free clinic -- that the relief of having completed one full year will allow me to relax a little and try to integrate the systematic thinking of MS1 into just another part of my experience and knowledge. My hope is that the breadth of my other experiences prior to coming to medical school, including being a mother, will begin to materialize within those interactions, allowing me to truly connect.

When did it happen for you? When do patients, even standardized ones, cease to present solely as a collection of their signs and symptoms and emerge as actual people, and what tools have you used to transcend the awkwardness of your early medical training?

Mother duties = father duties

I recently realized something.  Something I don't like, that I've been doing without even knowing it.  I have been thanking my husband for doing fatherly duties.  Example:  He says he is going to pick up our daughter from daycare, and I say thank you to him.

Does anyone else see something wrong with that picture?  He never thanks me for picking her up the majority of the time.  He doesn't thank me for loading/unloading the dishes, or for doing the laundry.  But I thank him when he does anything more than go to work and come home.  

I have friends who have clear division of labor in different ways, where their husbands are actually expected to do laundry, dishes, wake up with the baby, etc.  Mine has never had such expectations.  The tasks are all mine, with him helping out when he sees fit and convenient.  The dishes will not pile up if he doesn't touch them for days, I will put them away.  The food will not run out, I will make sure we are stocked up.  The kids will not go hungry, I will make sure they're fed.  I don't blame him at all for any of this, because it is the precedent I have set in our marriage and home.  But I wanted to ask fellow MiM's:  What kind of precedent do you have in your homes?