What's This Week Been Like For You?

I’m sure we all have an opinion about the election outcome; most likely, a strong one. I was following with intense anticipation as a Canadian. I am utterly despondent with the result. The day after, I met a friend for coffee and together we tried to process the reality. It felt much like the morning after 9/11, where we knew we were facing a ‘new world’ and an uncertain future. 

Our national public radio station’s coverage was filled with interviews with Americans relaying their uncertainties about the future. One gentleman felt a sense of betrayal by his neighbours; that he did not feel he really knew his city as he thought he did. I know that some of you are heartbroken, as I am. Others may be elated, or at least satisfied with the outcome. Some of you may feel conflicted. Still others may be Republicans who feel dismayed that Trump was their candidate. Maybe none of these captures your sentiments. I know many people are struggling to talk to their children about the outcome. Many American citizens and residents of colour and other vulnerable populations are especially worried about the “Trump effect” on their children, and perhaps some of you are seeing its effects in your daily life in medicine. In Family Medicine, it's not uncommon for some patients to bring up political topics, but I try to stay pretty balanced and general.  Personally, I found inspiration here, which cites this great article about talking to your kids about the result. Reading personal accounts and opinion pieces by those who are processing the results thoughtfully is helping me deal with the result. 

I realize that politics in general, and this election in particular, can be polarizing to discuss, and I know this blog does a great job of being a safe space. A refuge from the constant barrage that was so consuming during this campaign, perhaps. I think we can maintain that safe space by respectfully sharing our own personal experiences, fears, and worries. Because no matter your political stripes, I think it’s fair to say that the months ahead are uncertain for the United States, and the world.  

I have great faith in the American people, and the American system, to uphold their democratic values. I believe that most people are decent and that political and social tides ebb and flow throughout history. Let's help one another navigate the best way forward for our families, communities, countries, and the world. 

The things we do to succeed

I didn’t want to do it again, but here I go retaking my Pediatric Boards. I can list all of the reasons why I was unsuccessful at my first attempt: I was working too much (50-60 hours per week, getting paid to work 32), I was too stressed (issues with my former boss that I can’t discuss), I wasn’t sleeping enough, I have testing issues but my boss told me she couldn’t adjust my schedule so that I could study more. So here I am hundreds of miles away from home spending close to $2000 to take a 6-day intensive board preparation course. I am doing all that I can to succeed this time. And I refuse to allow the posttraumatic stress of retaking this test overshadow all that I am doing to succeed.

I have met so many outstanding doctors, most of them mothers, who have their own stories of failing their general boards or their specialty boards. These women are some of the best doctors I have ever met and provide exemplary care but they each failed the exam the first time. The stories read just like mine: working too much, stressed, not sleeping enough, family obligations, poor work-life balance. Some have a history of failing other board exams (USMLE or their specialty boards) but others don’t. Why does the cycle repeat? Why don’t we shake our little doctor sisters and say “wake up girl! There is no way you can balance all of this! Cut something back. Cut something out. Or else!”. “You can’t go on like this!”. “You either sacrifice now and focus primarily on passing or you’ll be forced to retake the test after failing!”. “Girl! Don’t do what I did. Let me tell you how I didn’t rock this test!!!!”. Or “Friend! Let me help you pass this test!”.

That’s how I want to recreate my narrative. I’m going to pass this test even if it’s by the skin of my teeth and then I’m going to mentor little sister docs so that they don’t make the same mistakes I did in post-residency auto-pilot mode thinking “well 60 hours is so much less than my resident’s 80 hour work week”. Let me tell you something - it’s not better after all of the years of sacrifice and don’t even pretend like you are not exhausted and burned out. And trying to work that much on top of passing this exam if you have even a hint of testing challenges is a major no-no.

So yeah, please Mothers in Medicine, send me some good vibes because I’m away from my family in this cold hotel room wrapped in blankets giving my all in order to succeed.

SIDE NOTE: In other random news, I just learned that the Peds Boards may become an open book test in 2017. Mwomp mwomp mwomp for me! If I could sit this round out, I would, but my new position depends on me passing this year. I hope the open book re-certification exam doesn’t cost more. Alright, I’m going to block all of that out and keep my nose to the grindstone.

EDIT: I removed the part about the salaries of the American Board of Peds folks because I cannot figure out how to fact-check it so it could be very untrue.

Girl Power

I just finished two of my best weeks as attending on the wards. It’s hard to describe exactly why these two weeks were so great but I think it had to do with a great team dynamic that involved trusting my residents, great teaching opportunities, and interesting patients.

But I also have to wonder if my great experience was because my team was all woman including a resident and a medical student who are both moms.  Here are a few observations from my rotation.

First, resident mom and med student mom AMAZE me.  Resident Mom has two school aged children which means she has had kids during her entire residency.  Med Student Mom has an infant and is on her second rotation after maternity leave.  She drives an hour each way to get to the hospital and leaves her baby for long stretches with her mother. I am exhausted just thinking about her schedule.

What amazes me most about Resident Mom and Med Student Mom is how calm, unstressed, and pulled together they seem.   They work the crazy hours of training yet never seem stressed or tired or cranky.  This is quite different from how I felt (and likely appeared) when I had my son during residency. I cried every morning when I left home and complained a lot about the fatigue and stress I felt.

Resident Mom and Med Student Mom appear quite different.  They are super calm and seem truly on top of everything.   I am in total awe of their dedication and composure.

The second thing I realized is that mothers in medicine need to support each other and the hierarchy of medicine shouldn’t get in the way. There is no question that training will always be grueling and the workload will be heavier for students and residents than for attendings.  

I can’t change this system. But I can create a better culture where people feel safe to talk about the pressures of training, particularly being a mother in training. 

Mothers in Medicine blogger, KC, wrote about a different approach when she became a division chief and met with a new mom who returned from maternity leave.  “We talked about her transition back to work, their childcare arrangements, and where she stood in terms of identifying academic areas of interest,” she wrote. This was a total reversal from her own experience eleven years earlier with male bosses.    

My recent experience on the wards reminded me of KC’s story.  As mothers in medicine start to rise up in the ranks, we can create a culture that supports other mothers, especially those who are still in training or early in their careers.  We are the ones who recognize that it is not easy to be a mother in medicine.  It was natural for me to ask Med Student Mom if she was able to find a lactation room and ask about Halloween costumes and understand that some mornings are harder than others.  

For some of us, showing this support comes in the form of blogging and writing and working for policy change.  But for many of us, support comes in a quieter form – a silent culture revolution. It can be asking questions of how another mother in medicine is doing - whether she’s feeling stressed or guilty or exhausted.  It can be breaking down the hierarchies and treating each other not as students and residents and attendings but instead as adults who share a common thread of motherhood. 

"You're full of it"

I have read countless articles about how medical trainees have been berated and belittled, yelled at or pushed. I have never in my years of training felt that way or been treated that way. Yes, I’ve been questioned strongly. Yes, with lines of questioning sometimes called “pimping.” I have felt like I needed to study for 40 more hours and have gone into the bathroom afterward to cry, but I’ve never been berated. I’ve never been pushed. I never even thought of what I would say or do in those situations. I have heard my share of racist and sexist remarks and have found ways of addressing it directly and highlighting to the team why it’s unacceptable. But what would I do if someone directly belittled or disrespected me? Would I cry? Would my knees buckle? Would I yell?

Well, that all ended when a Pediatric Surgery Attending told me, “You’re full of it” in front of my staff while I was working in the Pediatric Intensive Care Unit. This particular Surgeon has a history of yelling at Resident Physicians that I learned of after the incident. That night, I was caring for a postoperative patient who had just left the operating room. During interdisciplinary sign out I asked for clarification of a medication dose as I was preparing to enter routine orders such as for PCA-administered pain medicine. The Surgeon turned and said, “No, we will enter the orders” meaning the Surgery Residents. I told him that in my experience PICU Residents enter the orders and manage the PICU patients. He said, “No, who trained you, this is my patient?”  I looked around and of course, everyone was staring at their feet. I was in my second month of PICU service and had heard countless times how our unit was a “closed unit” and that we managed our own patients, but this gruff, aggressively self-confident, tall male Attending with salt and pepper hair and a fresh tan was staring me down. I said, “You will need to speak with my Attending because this is not what I have been trained to do.” He turned, stomped away, and snuck in a low, yet completely audible, “You’re full of it.”

I stopped in my tracks and said more audibly, “Excuse me, but you just said ‘You’re full of it.’”I paused, collected myself and continued: “I feel very uncomfortable, and that was disrespectful. It is not appropriate to speak to trainees that way. I only want to provide excellent patient care.” He froze. When he turned around he had a look of utter contempt and disbelief; it was like no one had ever told him he cannot speak to people that way. His eyebrows furrowed and he spit out, “Well, I’m sorry,” and turned around. At that moment, my Attending arrived and my Fellow said, “Well, I’m glad you said it because I was about to.” I quickly excused myself as my hands began to shake and the pounding in my ears began to dull everything else out. I exited the unit, and sank onto the bathroom floor and cried. Big crocodile tears as my grandmother would say. I was anxious and nervous, but I was damned proud of sticking up for myself.

My PICU Attending found me later and asked me what had happened. I explained the facts and he shrugged and said, “I’ve heard worse,” and told me something about how that Peds Surgeon had cursed at him during his Residency. I told him that I hadn’t heard worse and had never experienced that type of behavior but that I thought it was unacceptable to speak to any member of the team that way. He shrugged and said he would address it with the Surgeon later. As I entered the Unit, the Nurses individually applauded me for speaking up the way that I had. I asked a trusted Nurse mentor if she thought I handled it well and she said I nailed it, and my Fellow echoed the sentiment. I didn’t get emotional, I said what I needed to say, and kept it focused on the patient. One of the Peds Surgery Chiefs came up to me later and had heard about it and gave me a quiet nod of support. She agreed that Surgery Residents who did not spend the night in the hospital should be consulted but they shouldn’t be the ones putting in orders since the PICU Residents are the ones who stay in house overnight. It’s a patient safety issue.

Many thanks to a different fabulous PICU Attending who a week earlier coached us on working in uncomfortable situations. She told us to use words such as “uncomfortable” and “unsafe” and keep things focused on the patient. Without her words, I probably would have shut down, my knees buckled and I wouldn’t have been able to say things in a way that would have gotten any response from that Peds Surgery Attending. I still believe, “You’re full of it” has no place when we are caring for patients.

I spoke on a panel earlier this year sponsored by the Student National Medical Association. They asked a group of underrepresented minority Attendings and Residents to discuss discrimination in medicine. I shuddered as I listened to the horror stories the Black and Latino Attending Physicians recounted. I think I would have quit if I had to endure the downright hostile environments they practiced in in their early careers. I don’t discount the real experiences highlighted by other trainees around the country and applaud them for their candor in sharing. I hope that we all are continuing to work so that abuse and disrespect are not allowed, and when they do occur can be apologized for and learned from.

Self advocacy - why is it so hard?

It’s funny how a few things collide, to suddenly make life crystal clear. It’s job application time for me, and I was lucky enough to receive three offers, strangely enough covering the gamut of work life balance from no after hours to full on subspecialty. After much deliberation, I chose the job that would best complement all my roles – mother, wife, doctor, furry friends owner, health advocate wannabe – you all know the list. I recognised I was burnt out, and at risk of leaving medicine altogether if I didn’t make an active decision to change my hours and where I was headed. Both my husband and I are in high level, full time roles, something I never felt comfortable with for the children. Here was my opportunity to make a change more in line with what I wanted for my family. I’m a firm believer in if-something-isn’t-right-fix-it, don’t just wish or whinge! Fast forward one week - past all the happiness at finally making a decision, the peace that the decision was right for me and mine, excitement of starting a new job, the daydreams and plans to incorporate fitness, walk the furry friends, spend more time with hubby and children - to today. I’m catapulted from a state of contented decision-making bliss into Guilt – guilt I now know is ‘doctor guilt’ (thank you Emily). It deserves a capital G, don’t you think, for the central place it often plays in women’s lives? So what happened?

Well a couple of things. Firstly, taking this new, wonderful job involves resigning from my current job, something that I’ve never had to do before (I’m yet to do this, because I’m waiting on a formal contract). It also means leaving a path I’d always thought I’d follow, and jumping into a reasonably unknown area for me. After making my decision, I had a conversation with the boss of the subspecialty I’d originally planned to follow, creating doubt in my mind that I’d made the correct choice. She wanted me to take her job offer, and I felt like I was letting her down in choosing not to. It was also ‘known’. After the ‘doctor guilt’ came self recrimination – in resigning, I am jumping ship, baling out, leaving colleagues in the lurch. In reality, my position is actually supernumerary at present, so in actual fact, no-one is left in the lurch, but my soon to be old hospital won’t remember that. I’m now the person I never thought I’d be – the one who leaves a post early.

This really forced me to choose what was important to me. I sat down and thought long and hard about my values, what I considered ethical, the life I wanted for my family, the sort of mother I wanted to be, and whether that married with my current workload (no surprises the answer is no). I pictured myself in each of the three jobs, and tried to see how I felt, what my reactions were. I read widely, trying to build a picture of my future career options. I came across an article about women failing to speak up when sexually harassed and why we are all so ingrained to be ‘good girls’, to not create waves, keep everyone else happy. I had many long chats with close medical friends, trusted senior colleagues, and my husband, who all agreed I should take this job. People who, like me, would never ordinarily leave a post early. I was told leaving a post early is common, people do it all the time. Not me though. Never me. In an ideal world, I would ask to start the new job when this one finishes, in five months time. That’s the path of least resistance.

But spending another week, let alone another month, in my current position is too long. My family needs to make a change now. As well as that, moving now saves me time at the end – possibly nearly a year of time (due to retrospectively counting some of this year, something that probably won’t happen if I don’t move until next year). The next five months in my current job is surplus to my training needs. So, for the first time in my life, I’ve chosen to do what is right for me. I’m going to take the community based, no after hours or on call job, and I’m going to start in 4 weeks. All I have to do now, is tell them. Resign. Although I’ve decided, I still question it, and probably will, until my contract arrives, and I have to make the decision final.

So I guess two questions. Has anyone else ever left a post early? Taken a leap of faith? Any advice on whether it turned out ok in the end? Fingers crossed.

Trayvon

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

Maternity leave for medical mothers

The association of directors of residency training in psychiatry has just started surveying program directors about their ATTITUDES toward maternity leave for residents. Years ago, when I was a member, I tried to survey them to find out what the range of actual policies might be, but no one wanted to disclose this for fear, I guess, that women would choose programs with better policies. Still, this punt is a form of progress, and the day may come when young women may have that kind of information, and not be penalized for making use of it.

Since I have changed to medical student education as my professional focus, I have become even more concerned about this issue. My first year in the job, an excellent student failed her clerkship exam about a month after delivering her first child. This led me to research the issue of "motherbrain"--cognitive problems women report after delivery. (I recall my pregnancy friend describing it as "someone took my brain out, administered a few swift kicks, and replaced it rotated 45 degrees.") Although the problem is one women commonly report, the research on it, like earlier research on perinatal depression, has been dismissive. Because the studies all exclude women with depression, severe insomnia, or medical complications, they have not found "objective" evidence of impairment on a limited number of tests.

Research or not, cognitive impairment (poor concentration and short term memory) may be a significant problem for women after delivery, lasting an unknown period of time. While I don't want to discourage anyone from working and demonstrating that mothers can be competent professionals, inadequate maternity leave and too early return to work is not a trivial problems. Students may fail their exams, and the rates of human error, already too high in medicine, may be affected as well. If I thought the information would be used in a non discriminatory fashion, I would be advocating for more attention to research in perinatal cognition. As it is, I try to warn students and residents not to underestimate the impact of childbirth, and to take adequate leave, even if it requires financial sacrifice or prolongs training.

Has anyone else been concerned about this?