evolution

I've been a practicing oncologist for all of seven months, and so was surprised when my chief asked that I take part in our quality review panel. The quality review panel is an internal group that is tasked with the responsibility of looking into allegations that a patient's care was not in keeping with best practice or what is generally considered the standard of care. Cases (often in the form of a complaint) can be submitted by patients or the nursing staff, but more frequently come from other physicians.

Cases are reviewed and scored individually by each member of the panel, and the composite score is used to determine whether corrective action should be taken. Although physicians whose cases are repeated scored "P2" - in which the standard of care was clearly violated - can be forced into remediation, the purpose of the review panel is didactic, not putative. And to that end, the standard is different than that of a legal proceeding - there need not be a bad outcome in order to determine a case P2, only that the expected level of care was not that which was delivered.

Obviously I can't go into the specifics of the cases or the physicians, but what I've been impressed by so far is the recurrent sin of omission. The incidences in question didn't involve the wrong therapy, intended deception, or malice, but the accumulation of small omissions - documentation, timely follow up, etc that morphed into a larger problem. Data management and communication also came up as frequent offenders. 

In one or two cases I felt the problem was that the physician - a few of whom had been practicing medicine while I was still in grade school - couldn't or weren't able to evolve with changing expectations. We are expected to be transparent, thorough, and accountable for what the patient does and does not understand. There's an astounding amount of information to be managed, including but not limited to the electronic medical record, patient email, open notes, and the near-entirely of uptodate and pubmed.  I can speak better to what is happening in my own field - where fifteen years ago there were about that many different types of chemotherapy. Now there's fifteen new drugs coming out every year. 

I started thinking about what it means to evolve and what its going to look like for me over the course of my career. I've found the review experience hugely instructive in that I understand better how physicians get themselves in trouble, but I've also found it unnerving. Twenty years from now the central tenets of"being a good doctor" might be entirely unrecognizable when compared to today. 

I wish I had a note of conclusion on which I could end this post, but I don't. I am just beginning to see how important professional evolution will be, but I have no idea what that really means. 

open notes

Today our electronic charting system was moved to Open Notes, which will allow patients to access their clinic notes online.

This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.

I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.

But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care.  That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.

The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan.  Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.

So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise.  Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.

But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.

The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now.  Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.

And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.

I don’t know. TBD.

landmines

My soon-to-be five year old will do or say anything to delay bedtime. Recently she's wanted me to tell her about my day – what type of patients I saw, where their cancers were, and who was bald. If the patient was female and not bald, she wants to know if the hair was short or long. If the patient was male, she wants to know if he had a mustache or a beard. Hair, who has it and where it is, seems very important in her understanding of what I do.

Because the nature of the inquiry is flattering, I usually linger a while at her bedside and try to recall the patients I saw in clinic. I am careful to choose the details that are not inherently upsetting, but the longer the talk, the more likely I am to stumble into territory littered with the landmines of subject matter unbefitting the ears of preschoolers, especially in the few minutes before bedtime.

When it comes to the question of how to and under what circumstances do we “shelter” our children, I think I fall somewhere in the middle. Although sex and violence might be part of life, I think it’s appropriate to limit my children’s exposure to those themes while they are young. I'm not sure I feel the same about medical illness and problems faced by people undergoing treatment for cancer. I was ten the first time I went to Guatemala and freaked out when children tapped on our car doors begging for money. Even though I remember that experience as a very negative one, in retrospect it was probably a good introduction to the topic of inequality. I share the story to make the point that exposure to uncomfortable subject matter can be an important part of growing up.

But 5 isn't 10 and death isn't poverty, and I am still unsure of what I should and should not share with my preschooler.

She’s quite interested in the subject of death, even more so than the subject of hair, and I wonder if it's precisely this interest that makes me uncomfortable. She knows that “old” people die, but asks questions that would indicate she suspects there’s something more to the subject. I’m not sure if she knows that anyone can die at any time, and, more to the matter, if she poses the emotional intelligence to deal with the obvious implications of that realization. 

I’ve heard before that the best course of action when children ask potentially age inappropriate questions is to answer only the question posed, in as direct and simple a manner as possible. But she asks a lot of questions, and each answer seems to spurn on a new set of inquiries.  I hate the feeling of lying to my daughter, but I do it occasionally to get myself out of discussion I’d rather not have.

How much “real life” do you bring home?

an unsolicited job update

The job is going well. Very well , actually. I’ve been in the clinic for over a month, gradually building my own panel of patients and seeing the patients whose oncologist had left during a recent period of high staff turnover. My scheduled was blocked at 50% for the four weeks, which allowed me to learn the different systems and clinic organization without a lot of stress. There are 2-3 people around at all times to answer work flow questions.  I haven’t rotated inpatient or taken weekend or nighttime call yet.  I’ve been seeing mostly women with breast cancer, and although this is not what I was hired to do, I’m actually enjoying it.

It’s funny to think how different this transition has been when compared to that of residency or fellowship, where “orientation” consisted of being handed a massive stack of papers on “code of conduct”, a pager, a list sick patients, and best wishes on finding the bathroom. Before I started in the clinic I had a week of training, where for the first time I actually learned the EMR program I’d been using (far less efficiently) for the last six years.

I like the people I work with. It’s not a perfect group, and still dealing with the aftermath of a difficult period of painful changes, but the other new (ish) hires seem enthusiastic and hard working. The staff that decided to weather the change are less disgruntled than I had anticipated. I’d been warned that my group’s relationship with the hospitalists (very important colleagues when many of your patients require inpatient stays) was unpleasant if not overtly hostile, and this too seems to be improving.

So, I am feeling optimistic. Optimistic that, with time, the move home and into an uncertain work situation is going to prove the right decision.

as an extrovert without good answers

Though I am loath to admit it, I am, by nature, an introvert. And despite the recent torrent of articles espousing the benefits of being an introvert (also see here, here, and here with funny retort here), it's the part of my personality I like the least. I wish I was better at small talk, better at making friends, more relaxed in a crowd, not so ready to leave a party, and not so frequently told to "smile".

Medicine made me into an extrovert. Or maybe an introvert who can affect the persona of an extrovert with an enthusiasm that actually is genuine. I do smile, a lot actually, and frequently when I don't feel like it. In my white coat I am animated and chatty and quick to introduce myself. Perhaps not surprisingly, I like myself as the extrovert - it's like pretending to be the cool kid I never was. And, again painful to admit, I think patients also prefer Extrovert Me.

On a less frivolous note, I was very much looking forward to this Topic Week, and so am now surprised by how difficult I've found writing on the subject matter. It's hard to collect all the ways medicine, with its messy contacts and daily pressures, changes its practitioners, then analyze and distill that change into a theme confinable to a blog post. I think, after many hours staring at my computer screen, that I can't be complete in the assessment. I will have to focus my thoughts more than I'd planned. 

Please excuse the generalization, but I think oncology, perhaps more than primary care and medicine subspecialties, treats patients whose disease cannot be clearly linked to poor lifestyle choices. Yes there are associations between obesity and breast cancer, smoking and (amongst others) cancers of the head and neck, lung, and bladder, and the various HPV-associated malignancies, but the majority of patients had no reason to think they were at risk for cancer. In plain terms, they never saw it coming. These patients, and particularly the young ones, will spend a significant portion of our initial visit asking and re-asking the question "how did this happen?", for which an abbreviated synopsis of cancer genomics is often emotionally unsatisfactory and scientifically insufficient.

I am just beginning to understand how frequently life lacks good answers to some very good questions. Terrible things happen to people undeserving of an early death or a near lifetime without their spouse. We do not all get what's coming to us. 

I used the fumble the question "Do you like what you do?" because, although the answer is yes, there are times when it's truly horrible.  I can't cure a substantial number of people who walk through the door and my job can involve making people understand something they don't want to understand. But there is meaning to what I do, there is meaning to palliation and prolongation of life, even when the situation itself seems meaningless. Medicine has taught me to find meaning where it isn't apparent and, in doing so, helped me to enjoy this short life that happens to us all. 

did you take his name?

I think I had already decided to keep my name even before my boyfriend-at-the-time told me his (rather long) surname was old German for "caveman", "neanderthal" or "man who lives in a hole in the ground". I would be lying, however, if that bit of information didn't help solidify the decision.

I got married at age 25, while I was still in medical school. No one in either my personal or professional life gave me a hard time about keeping my maiden name. I thought at the time that most people would assume I had changed my name and we would, at least socially, be known as "The Caveman Family", when children eventually came around.

But that hasn't been the case. People are, for the most part, careful to acknowledge that I do not share the same last name as my husband and children. I should also note that my last name is nothing beautiful itself - my sister describes it as a grunt and has vowed that, should she ever get married, changing it would be the first order of business. Perhaps now it is clear why I never really considered hyphenation. One borderline unattractive name is not improved upon by the addition of a multi-syllabic and even less attractive name.

Wedding invitations and baby announcements are addressed to Me Grunt, Husband Caveman, and Children (1) and (2) Caveman. When told I wont be home for dinner, my daughter will reply "We'll have Caveman family night!", the obvious implication being that my last name would exclude me from "Caveman family night", which is too bad because it usually involves movies, ice cream, and late bedtime. 

I have mixed feelings about this. I guess I just care less about my name now as compared to when I was 25. I think my self-identity would just as intact if I were Dr. Grunt or Dr. Caveman. The work I did in undergrad or medical school would not be wasted if I then practiced under a different name. 

I am not sure that I would make a different decision if I were getting married now (at age 33) and I certainly don't care enough to change it at this point. I am, however, surprised by how wistful I feel when seeing my name separated out from those of my family or when my daughter talks about "Caveman family night". Honey, I might not have given you my name, but that chin dimple of yours? That's from me. 

how did you celebrate?

My dad cried loud, heavy tears on the day I graduated from medical school. My mom cried too, although not as intensely as my dad. My parents, sister, in-laws, and two closest friends came to my graduation, one of whom had flown cross country to be with me for the event. We had dinner together at a Thai restaurant after the ceremony. My husband gave me a pair of emerald earrings. 

I don't remember crying. I remember feeling happy that I graduated and glad to be with my family, but as I had correct anticipated residency to be more difficult than medical school, I didn't feel overly celebratory about the milestone itself. 

I felt differently about the completion of residency.  When I walked out of the hospital for the last time, I looked back at the inpatient towers, thought to myself I never have to go back, and was surprised by the wave of relief that flooded over me. I'm glad no one was around to see what must have been the biggest, dopiest smile pulled across my face. 

But there wasn't time to celebrate. I graduated from residency on a Friday, moved over the weekend, and started fellowship on Monday. If I bought myself something to commemorate the occasion, I don't remember what it was. Although this achievement meant more to me than med school graduation, it's significance was eclipsed by the need to move and instability of my first few weeks of fellowship. 

Now I am graduating again, this time from fellowship, a milestone that will finally mark the end of my  medical training. 

Memory is an imperfect tool, a shortcoming I appreciate when trying to appraise the individual steps and aggregate of my medical education. To the best of my recollection I was happier in medical school than I was in residency and happier in fellowship than I was in medical school. But then again, my life outside of training was significantly different during these periods that it is difficult to assess them based on just the training itself. I had good friends in medical school. During my fourth year we all lived in apartments close by and spent weekend nights drinking so much wine that it gives me a headache just to think about it. I realized shortly after starting residency that I didn't much care for inpatient medicine. I had fewer friends in residency, a husband who traveled, and an unplanned pregnancy that affected my emotional health during what felt like an unending string of thirty hour shifts. In retrospect, I think I was suffering from postpartum depression where I told myself it was "just the blues".  Thankfully, it passed. Or maybe resolved when I completed residency.

And perhaps it is strange that consider myself happier now, in fellowship, than I was in medical school or residency even though, at the end of my first year of fellowship and just after finding out I was pregnant for the second time (yes, this one planned), I called one of my attendings (a female and the only remotely "mommish" of the faculty) crying. I told her I worried I wouldn't make it through another two years if they were as bad as the first. Even though I hated parts of medical school and residency, I never occurred to me to quit. She told me it gets better. And it very much did. (I am also fortunate that she never held this episode against me nor told anyone about it.) 

I started medical school just before my 22nd birthday. I am through five years of medical school (I did a research year between my 3 and 4 years), three years of residency, three years of fellowship and, last week, turned 33.  I am married with two kids and feel good about the job I have lined up and the career  ahead of me. 

In other words, I want to celebrate. 

And need some ideas. I have a friend whose husband through her an elaborate party (doctor themed) at his family's restaurant. Another friend put a trip to Jamaica for her family of four on a credit card and took off for a week after graduation. One of my (child-free) co-workers is spending six weeks in Europe. 

I don't think I will do any of these things. Although I am feeling indulgent, we are hoping to buy a house soon and will be moving. I don't need another big expense. 

So what did you do? Memorable dinner? Earrings? Party? Trip? Nothing at all? 

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. 

a tough decision

It's time to get a job. As someone who is far more comfortable when a plan is in place, I feel almost suffocated by the decision needing to be made in front of me.

I should count myself fortunate in that I have options, and they are good options. I had three offers and narrowed the decision down to two.

Option #1 is with a small practice in our current town. I could work 70% for a wonderful boss who was one of my mentors during fellowship. He allows his physicians significant flexibility in how they structure their work days. You have to see your patients, but how you do it is up to you. Call would be frequent, but reasonable and fairly quiet. I would be working with a close friends, who graduated fellowship last year. The facility itself is one of the best run and managed hospitals I've ever seen with a staff dedicated to professionalism and superlative patient care. We could stay where we are, buy a house, and send our kids to the excellent local public schools, one of which offers language immersion (for free!). We could continue in the social lives we've created here and watch our kids grow up with the children of our now-very-dear friends. At 70% I would have one day off and four shorter days, which is going to be important when Munch starts kindergarten next year.

Option #2. Move home. I grew up 600 miles away in a town that I still love. My parents, my sister, and my brother-in-law's family (with the only two cousins my kids have) are all there. My mom is retired and wants nothing more than to take care of her grand kids. The job would be very different. A large group with a strict "no part-time" policy. I would have almost zero ability to leave early for kid-needs, whether they be scheduled or urgent. The group itself is in the middle of a tremendous upheaval and has turned over most of its nursing and support staff. Many of MDs have left or are in the process of leaving, although I liked the "new hires" who I met during the interview. Call would not be as frequent, but busier. I would make more money, but we would probably spend that money on private schools.

Part time work would mean more time for kids, less stress, and less money. Moving home would allow us to access a fully reinforced support system, which could itself make full time work easier.

I also just want to live near my family again. I hate traveling for every holiday and missing birthdays. I want my parents to be a part of my kids' everyday lives instead of the sporadic treat-and-present-filled bursts that now form the basis for their relationship. My husband is equally conflicted. He wants me to work part time but also would prefer to live close to family. Work-wise, it would also be better for him if we moved.

I've come to only one definite conclusion in this week of insomnia-inducing mind contortions - I can't predict what is going to be best for my family 5 or 10 years from now. I can made this decision based only on what I think is the better option for the next few years and hope that if I need to put us on a different path, that path is either available to me or I am capable of making a difficult decision. 

We are moving home.

in the thick

I've been to urgent care three times in five days with two sick kids, one of whom almost got hospitalized for pneumonia.

A few days ago we put an offer on a house (our first ever), for which the payments would stretch us fairly thin during the six months until I start work post fellowship. 

I've signed a job contract that I had planned to mail yesterday. Just before dropping it off, I received one email and one text message, both in regards to two different job opportunities.  I have one week before this contract is due and, even though the other two leads might be better fits for me and my family, the contract I have now is not sometime I would want to walk away from. One of the leads is in another state, further complicating that home offer we made.

It's a strange week when patient care is the least stressful part of my day.

no such thing as perfect

Guilt was one of the first feelings I experienced upon learning I was pregnant with my daughter, now 4 years old.

I had been on a pub crawl the night before, gotten home around 2 am and woke up a few hours later miserably sick. This might seem to be expected after a night out on the town, but had gone to bed sober and hadn't drank that much. I had taken a pregnancy test a few weeks earlier, prompted more by nausea and fatigue than a missed period as stress-induced amenorrhea was not new to me. It was negative.

That morning, not able to shake the fact there was something very wrong, I took a (second) pregnancy test. Positive. I took another. Positive. I took a another. (still) Positive.

Pregnant, drinking, not taking folic acid, and ignoring what my body had been telling me for weeks- which was Have Some More Water. Now Pee. Nap! Eat Some More Bread. I thought about my booze-soaked "intern week", which must have occurred right after I got pregnant.

I was already failing motherhood. It became a recurrent sentiment in my daughter's first year of life. Breastfeeding and pumping were more difficult than I had predicted. We used store bought formula and baby food. She develop a taste for Mac N Cheese. As a resident, I didn't know our pediatrician.

A few years passed. I did some growing.

I have a good friend, an ivy-league educated attorney, who wants nothing more than to home school her children. I have another friend who posts on her FB page links to articles about the treacherous and unregulated world of daycare (the most recent was about a home daycare that burned down) or an admonition to her baby group that, really, if breast feeding was that hard our species would have died out eons ago. These are both woman I like and respective very much.

In my first year of motherhood, these things would have bothered me. Why didn't I want to home school? (And believe me, I don't.) Am I putting my children at risk in daycare? Is my daughter going to be fat, sick, and anti-social because I didn't BF for 12 months? Was she already missing out on activities that would prove pivotal to her future success because I wasn't around to shuttle her from one to the other?

of course not

It took some time to become comfortable in motherhood, which itself has been the most intense and important undertaking in my life. That being said, I've come to realize that, for me, the Perfect Mom is not the Total Mom. I don't have a cohesive philosophy on motherhood save that the vast majority of us seem to be trying as best we can, and how we implement our universally-held good intentions is both personal and family-specific. In regards to home schooling, prolonged BF-ing, nanny-care, organicthisthatandtheother, epidurals, music appreciation class - they are all part of a decision making process that is individual to your family and lacking in any specific moral imperative.

For me and my family, its best that I work. Aside from the obvious financial implications, work is good for me. I enjoy what I do and I choose to believe my children benefit from having a mother who feels this way about her vocation, even if it means daycare and formula and dinners on-the-fly.

I am not perfect. I get cranky, irritable, and short with people, some of them my offspring, who deserve my patience. I don't think this makes me a bad mom, I think it makes me a human being. I gave up perfect a long time ago.

Although, all things being equal, I wish I hadn't drank during the first few weeks of my pregnancy...

the world's longest adolescence

I've been undergoing more frequent bouts of financial incontinence of late. I bought five sweaters in a recent end-of-season sale and a side table from Serena and Lily that is made of carved wooden swans. My husband describes this purchase as the Most Ridiculous Thing We Own. 

I can feel the end is in sight. I am almost done with my training, after which I will be making several times more money than I ever have before.  

Saturday morning I went to a financial planning seminar for graduating medical residents and fellows. After a brief introduction, the speaker guided us through a program he had developed specifically for medical trainees to calculate exactly what income was required to develop and maintain the life we projected to lead with our future salaries. 

I don't know what my salary is going to be next year. I am looking at positions that vary over $130,000 between them, adjusted for part time vs. full time, and private vs academic. So I entered a figure somewhere in the middle. It's even more difficult to project my husband salary as he owns his own company with a salary that varies month to month. He's gone months without a salary at all, which I've always thought taught us to live beneath our means. 

Beneath our means, but perhaps not beneath our expectations. 

It took about 90 minutes to complete the program.  There were a few numbers I didn't know how to estimate - like the expected rate of inflation and expected rate of return on our investments. There were some shocks along the way - the projected cost of a 4 year state education for my 1 year old son is $360,000 if tuition costs continue to climb. I entered the tuition cost for two kids at the most expensive elementary and high schools in the city, the cost for two weddings, and my medical school debt. I figured in the cost for a standard 3 bed, 3 bath house in our community with a 20% down payment. The program included costs I hadn't thought of before, like the cost of an accountant, orthodontia x 2, and home owners' insurance. It calculated the estimated yearly expenditure of feeding and clothing two kids. I felt pleased to enter the amount we've manage to save in retirement and savings accounts. 

I got to the end.

-$118,455

OMG. 

That's the amount of yearly income we lack in order to meet what I thought were fairly modest goals. 

I've heard medical training as the world's longest adolescence. I've never felt it to be as true as I do now, starting down the last few months of my training and still uncertain of what I am going to do next year. 

After a collective gasp, our speaker smiled and admitted to a slight "glitch" in his program - while the program took into account the rate of inflation, it did not adjust the physician salary for that rate of inflation. In other words, the cost of every itemized expense would go up, but our purchasing power would go down with time. 

That didn't seem right. Of course my salary would go up, perhaps to cover the gap between the estimated salary and the projected cost of our lifestyle. And then he made what I think was the most striking point of the presentation. The partners he left in private practice anesthesia in 1993 are making the same salary now as they were 20 years ago. 

OMG x 2. 

It is unlikely that physician salaries are going to go down, but it is highly likely that, with the restructuring in health care underway, salaries won't go up with inflation. I've heard that said before but didn't think too much of it. Now seeing a dollar amount placed on what had seemed like conjecture has given me pause. And in that pause seeped a now recurring frustration. 

How is it that I started med school a few short weeks of my 22nd birthday, I will graduate when I am 33 and I still can't decide what I want to do next year? What is in the best interest of myself, my family, and the longevity of this career I've been working for since I was 21? 

During my ongoing job hunt, I received the unwelcome advice to "not make any decisions based on money alone", which does seem like sound advice and in keeping with the best interest of my young kids, who would benefit from a mother who is around more, and my career should I decide on an academic path over the more lucrative private route. But in that room I started to re-appraise the relative benefit of the options ahead of me. If I work part time in academics, does that mean my kids don't go to college?

The exercise served to broaden what had been a frustration specific to not knowing myself to include the more generalized frustration that I don't know anything. 

And it put to rest any lingering consideration I'd had on the idea of a third child. 

Next Year...

Next year I am getting it right. 

Last year was my first experience as a parent trying to navigate the world of preschool Valentine's Day. I had instructions to deliver 39 Valentine's Day cards, each labeled with my daughter's name  ("Homemade cards welcome!"), to school for general distribution on February 14.  With little thought as to package to package variability, I picked up two boxes of small, brightly colored cards at Target and brought them home. On February 13 I opened the boxes, thinking I would have to do nothing more than write her name on the card, to discover the assembly of each card a five-step process that, in the end, took me 90 minutes and produced a meager little offering. 

That 90 minutes seemed an eternity, and not just for me, but for my 3 year old who, after 5 minutes, wandered off in search of more scintillating activity. Dinner still needed to be made. The house was a mess. But I remained alone at the kids' table to assemble, sticker, and label each card until all 39 were complete.  

I wasn't the only one who misjudged the expectations. In Munch's class are a few children from foreign countries, here for a few years while one or both of their parents complete graduate degree or post bac.  When Munch got home from school that she had a number of artful, standard-sized greeting cards, most written in unfamiliar languages. While I had been disappointed to find myself squandering dinner prep time with Valentine's Day card assembly, I wonder if those other parents were put off by the relatively paltry offerings put forth by their children's classmates. 

This year I bought far simpler cards in early February. 

And on Thursday I realized they were missing. Nothing in this house stays in one place for very long and so, after too long a period spent looking for the cards, I resigned myself to a second trip to Target for replacements. At this late hour, my options were Justin Bieber or origami fortune tellers. 

I strongly considered the Bieber cards. No preparation, not a particularly controversial celebrity, and who-cares-its-just-a-card. But an emotion similar to shame forced me to select the latter and hope dimly they were pre-folded. 

At home I confirmed I was not so lucky. In ground hog day fashion, I found myself alone in the kitchen, the night before Valentine's day, with dinner needing to be made, up against 39 unfolded origami cards and my own expectations. 

I did was I suspected I was going to do when faced with the potential each one of these cards would take me five or so minutes to complete. (Not to mention the time it would take to learn how to fold them in the first place.) Ignoring the multitude of dotted and crossed lines, I folded the cards lengthwise twice over and slid each card into its provided sleeve. I wrote my daughter's name on each sleeve and got on with the dinner preparation. 

Next year I might just distribute an envelop full of candy. Lord knows that is the only thing I wanted when I was 4. 

Time for children

Last weekend I was at my friend's baby shower and making small talk with the mother of a baby boy a few months younger than my own son. His mother was a co-worker of my friend, both physical therapists at the local medical center, and the conversation turned to the topic of child care.

I mentioned that I had just worked with an intern who was 38 week pregnant, had planned to take a 4 week maternity leave (she was a prelim and had to start her second program on time), and had a complicated childcare plan in place that involved a sitter coming over to the house around 5 am - when she and her husband (a surgical resident himself) had to leave for the hospital, the sitter would then drop the baby off at daycare when it opened at 8am, pick the child up when daycare closed, and stay with the child until she came home from the hospital around 7 or 8 in the evening.

"Geez", she said, "Maybe she shouldn't be having children. It doesn't sound like she has time for them."

Whoa. Maybe she shouldn't be having children? I should mention that, although I hardly know this intern at all, I like her and I am worried about this plan for what I think are obvious reasons. Children get sick. Patients crash, usually right as you are about to leave. Daycare closes early on Friday for "Teacher In-service" (like every month it seems). Sitters have "things come up". And what about weekends?

My reaction to her situation wasn't that she shouldn't be having children, but that she needed a nanny to get her though a tough few years. I made what I hoped was a polite excuse and left the conversation. 

I was more fortunate than this intern in both the length of my maternity leave and that I had family that could move in with when my daughter was born, but without those two variables my situation wouldn't have appeared that different. I wondered if the same sort of judgement would be passed on me if my early months and years of motherhood were observed by similarly minded outsiders - even now as my mother lived with us for the last two weeks while I was on the inpatient ward rotation. 

I don't feel bad about how I raised my daughter when I was a resident, I feel grateful to my mother and mother-in-law. But I guess we all have different comfort levels for having other people participate in the care and raising of our children. I've had a lot of help with mine and, for the record, I've been pretty happy with the outcome so far. 

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 vitamin racket

I try hard not to substitute my medical judgement for that of a pediatrician. Even though I know it's probably a virus and I don't want my kid on antibiotics unnecessarily, when my little mom voice whispers "oh but wouldn't it be nice to just check in with the pediatrician....?" I listen, and usually give the office a call.

The balance between mom and momMD can be difficult to maintain. When my son was 22 days old he developed a low grade fever for which we sought care in our local ER. Two failed LPs and countless futile attempts at IV placement later, the little mom voice that usually serves me so well was screaming Grab your son and get the (expletive) out of here NOW. But I didn't. I thought of countless febrile-but-stable patients I had met in my short training. How, in the span of a few short hours, some of them would be actively dying in the ICU with clear plastic tubes coming out of every natural and man-made orifice. I thought of the two people I knew who had suffered the sequelae of childhood meningitis - one was almost deaf, the other had had partial amputations of all four of her limbs. I ended this internal debate by breaking into loud, messy tears. At one point I started choking on my own snot. For better or worse (and to this day I'm not sure I made the right decision) we stayed and were admitted to the hospital. And my son is fine. 

I tell that rather unpleasant story to make a point - I try to be a good patient. A good mother-of-the-patient. Even when it conflicts with my own instinct. But there is one thing I don't understand - vitamins. My 3 year old daughter was never on infant vitamins. But my six months son has two different vitamin prescriptions. Two. Our first pediatrician told me it was mostly for "vitamin D supplementation". Perhaps I am prejudiced, but as an internal medicine resident who dutifully checked vitamin D levels on most of her patients, I came believe there was something wrong with the test because every single patient had a low or undetectable level. My husband - a healthy 32 year old who eats a balanced diet and works out in the garden - has an almost undetectable level. I guess I'm saying I don't know what to make of the vitamin D hysteria, so I didn't prioritize (or really, remember), my son's infant drops. When my husband admitted to the second pediatrician that we hadn't been very dutiful vis a vis the infant drops,  she appeared quite taken aback. And then wrote a new prescription, this one for infant vitamin drops with fluoride. I hope "poor compliance with medical therapy" wasn't entered into the medical record. In my defense, we've been very compliant with use of iron fortified cereals - an enthusiasm directly attributable to my hematology training. 

I am all for prenatal vitamins and fluoride supplementation in the water, but my son? He doesn't even have teeth yet. 

the off-cycle job hunt

I was recently at ASCO and having dinner with a friend from residency. I asked about his post fellowship job hunt and he shared the details of what sounded like exhaustive process that had finally resulted in a position with a large pharmaceutical company. He asked me what networking I had done - or was planning to- do while at the conference.

Networking?

Yeah, like to get a job.

Uh, I haven’t started thinking about it.

And thus ensued a forty-five minute lecture. How could I have not started this process already? I should have a letter of intent and an updated CV. I should have started cold calling large oncology practices. I should have come to the conference knowing who was going to be here and how I was going to introduce myself. The fact I will be graduating late should have spurned me into starting the search earlier.

I sank lower into my chair and, as he continued to berate my lack of preparedness, accidentally finished the massive slice of chocolate cheesecake we had intended to share. I left the restaurant not knowing if the queasiness in my stomach was from anxiety or a butter bezoar.

Although technically I am about to enter my third and final year of fellowship, because I started late due to my first maternity leave (in residency) and owe this program time for my second leave, I won’t finish until October 1, 2013.  The heme and onc boards are in late October, so I wasn’t planning on starting “a real job” until November 2013. Factor in a possible move, I might not be ready to start work until December 2013.

But I have to start the search now? My friend is an intensely driven and consummate go-getter. Both of his parents are successful academic physicians, his older sisters are also physicians, and I suspect he learned about RVUs and impact factors at the family dinner table. He knows a shocking amount of information about the business end of being a physician – how to get grants, publications, protected time, compensation, promotions, jobs, etc. During residency, fellowship, and now, apparently at the start of my job hunt, he was, and is currently, trying to tell me what-I-should-know in order to be successful.  Although I know the constant “advice” comes from a place of caring (and it does, despite the fact I am making him sound like a jerk), he can drive me a bit insane.

But he might be right. I will be graduating off cycle, perhaps almost six months after other fellows are ready to start working. I want to move back to my hometown, a medium-sized city with its own set of fellows graduating from the local university. There are some cities where the heme/onc job market is saturated and if I wait to start the search, I might not be able to find a job at all. He reminded me of a mutual friend who couldn’t find a position until a community oncologist actually died.

I think in the writing of this post I have convinced myself of what I already suspected to be true – as daunting as it may seem, I should start looking now.

A real job. Like a grown-up. Who doesn't procrastinate.

MiM anatomy lesson

Mama: Where's your heart?
Daughter: (points to left chest)
Mama: Yes! And what does your heart do?
Daughter: PUMPS!
Mama: That's right honey! And what does it pump?
Daughter: (thought-collecting pause) BREAST MILK

back to work

Comparing maternity leaves and deeming one the all-out winner feels a bit like comparing the children themselves. I am back at work after my second leave and feeling reflective on what has been the best three months of my life. The same cannot be said of my first leave, but I think I can make a pretty good argument that it was extenuating circumstances unrelated to child A or B that resulted in a very different experience.

First, I wasn’t interviewing for fellowship. As someone accustomed to multitasking long before mommyhood, I mistakenly thought I’d prepare for interviews in the few weeks after my daughter was born. Not surprisingly, this ended up not being a poor plan and I spent the interview season in a state of frazzled exhaustion. In retrospect I wished I had contacted each program, explained the situation, and asked if they could arrange a different day for me to interview while I was still pregnant. I don’t know if they would have agreed, but it never occurred to ask.

As if the pressure of interviewing weren’t enough, the perpetually drunk and/or high man who lived above our apartment flooded us when our daughter was five weeks old. Our apartment was uninhabitable for three weeks, a period during which we were set up with some of our belongings in an apartment close-by.  I had to deal with the agents from our insurance company, his insurance company, and our property manager, as well as itemize and dispose of everything that was ruined.

I was determined that this time things would be different. Obviously there was nothing we could have done about some idiot who decided to make our apartment into a rainforest, but I would make a concerted effort to avoid multitasking if it meant making life more stressful. Formal baby announcements? I decided a Facebook pic was good enough. Baby scrapbook? He doesn’t have one. (Some people are good at the scrapbook thing and enjoy it. I’m not and found it yet another source of stress). Thank goodness I didn’t have any interviews. I told family and friends that if they wanted to see the baby, they had to come to us. I decided to expect very very little of myself on a day-to-day basis.

I am not someone who gets bored easily, so spending an entire day under the weight of my newborn son was pretty close to heaven. I did a lot of reading, writing, and listening to books while pushing the stroller. Dinners were simple.

And I just feel better about the time and attention my son got as compared to what I gave my daughter.

But life moves forward and it is time to get back to work. As a side note, I thought the comment thread after Fizzy’s 4/11 post was fascinating. I guess the question of “how much time is enough” is pretty mommy-and-baby specific.  I myself would love a few more weeks, but I am far from dreading my return.

So lets hear it, ladies – the good and the bad of going back to work. What you did and did not miss about maternity leave.

I’ll get it started-

Looking forward to

More frequent adult conversations. Yes, I miss them.

Being able to eat, drink, check email, and use the restroom on my own schedule

Less back pain

Wearing normal clothing

Eating in the seated position while using both a knife and a fork

Screaming, red-faced men? Not as likely to be my problem

Not looking forward to

Pumping. As a resident I once spilled 4 oz of breast milk on myself at 2am. Arg.

Call nights and weekend workdays

The pager

The everyday drags of medicine that have nothing to do with good patient care

Commuting

I will miss

Being present for every milestone (Gurgling! He gurgles! Brilliant)

Long mid-day naps under a heavy newborn

Blogging! (as frequently…)

Planning the week’s meals around the CSA box’s arrival

Walking my daughter to school in the morning

Mommy and me ballet (on hold at least until the summer)

Lunch with my husband, who works at home

I will not miss

Spending the entire day with no cause to wear a shirt. This gets old.

when are we done with training?

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

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

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

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

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

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

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

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

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

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