My ideal medical practice - I opened up shop!

House call doctor tools of the trade. I have since gotten another rolling bag.

Over the last few years I have slowly been inching toward establishing my own practice. And this January, I did it, I incorporated my practice, Healthy Home Pediatrics! It is a house call based concierge, or direct primary care, practice serving Washington, DC and the surrounding Maryland and Virginia areas.

In my first blog post as a new business owner, I wrote:

It feels so good to work hard for my own vision. For the last 5 years I have worked extremely hard for visions that were established by hospital administrators or the organizations that I worked for. Too often, these visions fell short of what I knew my colleagues and I were truly capable of and far short of what patients really wanted and needed.

During times like this, when I am venturing into the unknown, I often go back to one of my all time favorite books, The Alchemist, by Paulo Coelho. I have read this book countless times. In it, Coelho shares the story of a young shepherd boy who leaves home and goes in search of his dreams. Along the way he is tested and experiences both profound joy and deep disappointments. One of my favorite sections of the book shares a conversation with the boy, his heart, and the alchemist:

“People are afraid to pursue their most important dreams, because they feel that they don’t deserve them, or that they’ll be unable to achieve them. We, their hearts, become fearful just thinking of loved ones who go away forever, or of moments that could have been good but weren’t, or of treasures that might have been found but were forever hidden in the sands. Because, when these things happen, we suffer terribly.”

“My heart is afraid that it will have to suffer,” the boy told the alchemist one night as they looked up at the moonless sky.

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams, because every second of the search is a second’s encounter with God and with eternity.”

“Every second of the search is an encounter with God,” the boy told his heart. “When I have been truly searching for my treasure, every day has been luminous, because I’ve known that every hour was a part of the dream that I would find it. When I have been truly searching for my treasure, I’ve discovered things along the way that I never would have seen had I not had the courage to try things that seemed impossible for a shepherd to achieve.”

This is my dream. To practice medicine in the way that feels good to my heart, in a way that I know will help families and my community. To be unhindered by traditional systems such as hospital systems and clinic administrators. To collaborate directly with my patients and their families. To build sustainable relationships with families that help prevent disease and suffering. To be there for my patients when they need me.

Many thanks to KC and others for encouraging me and supporting me. A gentle nudge from her is what prompted this post. Even though it is scary, sharing such a personal detailed account on MiM, I want to share this new phase of my life because I have already received countless messages from colleagues, friends and family saying how much my business has inspired them to pursue their own dreams. I want to take you all on this new path with me. Let me know if there are particular topics about entrepreneurship and balancing work and life that you would like me to write about.

Thanks Mothers in Medicine for inspiring me!

Please follow my journey on social media:

https://www.facebook.com/pedsdrj

https://www.instagram.com/pedsdrj/

https://twitter.com/pedsdrj

To OB or not to OB...that is the question

Career advice wanted

I’m having a mid-residency crisis. I’m halfway into my three year family medicine residency, which means in a year and half there will be much more independence but also much less of a safety net below me.   I want to practice in primary care - so I know that it won’t be hard to find a job, however will be much more difficult to find the right one. I’d like to continue doing underserved medicine of some variety - but not sure if that means staying in the city as I am now or moving to a rural area, possibly closer to family now that Baby is here. I’m currently ruminating on whether I’d like to continue practicing OB or not.

It was a surprise to me how much I liked practicing OB as a resident. I liked it as a med student enough (although I will forever hate ORs - I’m too clumsy with too little body spatial awareness) but doing deliveries of my own clinic patients has been so rewarding and energizing. When I find that precious time to devote to independent learning, I find myself reading OB literature (and staying awake through it) more than any other kind.

Today was the first call for a delivery I’ve had since our own Baby was born. As timing goes, it was perfect for me. I was called at 6 am, ran to the hospital, and was back after a beautiful delivery by 9 am. It was great for me - but maybe not so much for Husband. When I left at 6, Baby was just starting to wake up and Husband had stayed up late working the night before, was already awake and was very much looking forward to a morning nap. He didn’t say anything negative, but his expression was less than pleased.

...and this is a best case scenario when I got called in. Our residents are continuously on call for our own patients with lots of back up as with residency schedule we may be working nights or a hospital shift elsewhere that we may not be able to leave. My husband didn’t realize it was a possibility that I would be going in today, but the reality is it’s pretty much always a possibility as I’m usually within 2 weeks of a patient’s due date and babies don’t always come on schedule. And I think as an attending, I’ll likely be much more responsible for my own patients’ deliveries - although having adequate back up is something I am definitely evaluating as part of my future job.

So my question is... can we do this? Or more accurately, will it be worth the effort to do this? We don’t have family close. We don’t really have an emergency contact nearby who can watch Baby if plans change quick. I think I can handle the lack of sleep and unpredictable hours, but is it fair to ask my family to do the same? What about when we want to leave town and spend time with our family? Husband and I have had several conversations and will continue to do so over the next 6 months as my patients continue to deliver and we’ll see how it goes.

 I just really wanted the advice of some moms who have been practicing outside of residency for awhile. Spoiler alert: this likely won’t be my last post asking for career advice. Are you doing what you want in your careers despite a somewhat demanding call schedule? Or did you find that giving up a bit of call was worth it for a little more overall family stability?

MiM Mail: How to ask for part-time?

I'd love for advice on the topic below. Thanks MiM!

I recently started my first attending job (anesthesiologist). I interviewed at many hospitals and ran the exhaustive lists of pros and cons with my husband before accepting a position at a large, academic tertiary care hospital near extended family. My reasons for picking this position were many, but a large part was the better work/life balance it seemed to offer over the private practice model (some private groups were regularly working 80 hours/week!).

Fast forward to now, when despite this being my best option, I'm still working 60 hours a week, my husband is still working full time, we are struggling to manage the day-to-day shuffle of having two kids. It's just as exhausting as residency! I need to cut back my hours for my own mental health and for my family, but how? I'm the newest attending. I'm the youngest attending. I'm female. I fear the "mommy track" label that will come with it, despite the fact that I will still be working more than 40 hours/week. I also resent the massive pay cut to work what any other professional would call full time.

I can get over all of my misgivings, but I'd love advice from people who have had this talk with their bosses. When is acceptable to ask? How long do I have to wait? How did you do it?

Thanks, ladies!

You're a part time mom

What was the worst thing anyone has ever said to you?

I found the answer to that today. It was an eventful weekend. It's been about 2 months since I've started my new job as a first time attending (more on this on another post!) but since then, it's been non-stop with the move from San Diego to Los Angeles, getting little C adjusted to her new school, starting a new job, studying for boards (which is next month!) and furnishing a new house! I have to say we got pretty lucky and everything is going fine with of course a few bumps in the road but that's expected.

My in laws, including my mother in law, father in law and two aunts came to visit for the weekend. It was a stressful but happy weekend! Moving on to the topic of this post, my brother in law (big C's brother) and his wife and I don't get along. The primary reason being that he doesn't like the fact that I'm a physician and how often I talk about it, which with him, is mainly limited to group emails and text messages amongst my husband's side of the family.

If you guys remember my story, I did not live with little C for the first 2.5 years of her life as she stayed with my parents in Irvine, an hour away form San Diego. Afterwards, I was a single mom with little C for 2 years while I did long distance with big C. During those times, we didn't have much time to visit his side of the family in northern California. I look back at these emails and I do realize I talk a lot about what I do, career wise, but often times, it was out of guilt and my way of explaining as to why I was so sorry that they aren't able to see their granddaughter that often.

Moving on, my brother in law and I had an argument today about the fact that he cancelled plans on us this weekend and he didn't offer an explanation. (Reason being--he just didn't feel the need to tell me.) But regardless, in this argument, he said that I needed to know my audience. The fact that his wife (stay at home mom) is at home with his daughter all the time with no help makes me inadequate to talk about my struggles as a working resident mom when I had help from my own mom. He said I was a "part time mother" for 2.5 years and that his wife is a "super mom" because she doesn't ever use a nanny or house cleaner. Wow. Those words really got to me. It took awhile to process. Little C is already almost 5. She's been with me over 2 years now. I an her favorite person. She is 100% sure that I am her mama so why did I feel like I couldn't breathe?

I did my best to hold it all in during the conversation but when it was done and over, I couldn't' even process it. I had to excuse myself and go the bathroom. I locked myself in a stall and I was brought back to my first week of residency after maternity leave. My boobs ached. I was still pumping and bringing milk back to C at the time. I was experiencing all the symptoms of post-partum depression but didn't even realize it. People asked how little C was doing and I could barely hold in the tears as the insurmountable guilt of leaving her with mom came back to me with every mention of her name. The mom guilt was so strong and with just that statement--it came all back to me.

It made me question am I bad mom? Is C going to be okay? Am I selfish for wanting a career and motherhood? I turned into that insecure first year radiology resident in the bathroom at the VA hospital with tears streaming down my face only to bite my tongue so hard as if the physical pain could take the emotional pain so I can back to fluoroscopy suite to do the next upper GI study that was on the schedule.

But I am not that little girl. I am not a part time mom. It takes a village to raise a child. Even as an attending, I have a wonderful village that includes a nanny who helps me with morning drop offs, a house cleaner, a dog walker, a grandmother who is willing to help out whenever she's needed and a wonderful husband, who despite his own busy work schedule, will watch little C in a heartbeat if he is free.

I will not apologize for my village. They make me the mom and physician I am today. I will not apologize for being a doctor. I will not apologize for being an example of what a woman can accomplish to my daughter. And most importantly, I will not let your words doubt my ability as a mom ever again.

I am more than a part time mother. I am her mother. And the only opinion that should matter is hers. And tonight before bed, I asked little C, do you wish mommy could stay home with you? She said, "no mama, I go to school because I'm a kid and you go to work to help sick people because you're a doctor."

Don't let people like him bring you down. As Taylor Swift will say, haters going to hate hate hate but I'm just going to shake, shake, shake, shake, shake I shake it off, I shake it off...

Looking back, looking ahead

As I hang up my short white coat after my last clinical rotation of medical school, after the celebrations of commencement week subside (I have had more than my fair share of these), and before the reality and terror of starting as an intern starts to set in, I find myself looking back and looking ahead. What a wild ride these past years in medical school have been! Spending all these years preparing for the first day of internship. Along the way, also learning on the job of raising a child. As I enjoy the lull of these last few carefree days between completing medical school and starting internship, every now and then I feel like I should brush up on my clinical knowledge to allay intern year anxieties. Then I remind myself that no amount of preparation could have really "prepared" me for being a parent or a medical student, and nothing will really make me feel "ready" for intern year. Best to savor this time with family and friends.

Recently I came across this article in the New York Times titled "The Gender Pay Gap Is Largely Because of Motherhood". It goes on to discuss not only the impact of motherhood on income, but also career decisions made by mothers to give up job opportunities, inequitable distribution of household and parenting responsibilities. Looking back at that experience of mixing parenting and medical school, I have reflected on how things would have been different if I didn't have my baby during medical school? How would things have been if I had gone through this experience without being a parent? I may have done better in some rotations, or gotten better grades on some tests. In the end, those things didn't matter as much as I thought they did. I ended up matching to what and where I wanted to end up for residency. Even if I had a perfect application for residency, my desired outcome wouldn't have changed.

I am pretty early in my career to measure the impact of motherhood on my career and quantify it in terms of lost opportunity or income. In some ways, I can't imagine the alternate reality of going through the medical school experience without my son, my experience as a medical student is so completely intertwined with being a new parent. Sleepless nights dealing with baby eating into precious few hours to sleep during clinical rotations. Being in a perpetual rush to pickup or drop off my toddler from or to daycare. Dealing with meltdowns in the morning struggling not to be late. Preparing for tests while distracting my toddler without distracting myself from studying. However dealing with the responsibility of raising a little human taught me patience, empathy and humility, which I like to believe, made me a better human being and will make me a better doctor.

On Family Medicine

I wondered during undergrad if I could do medicine and "have a life". I didn't have a lot of first-hand contact with physicians, and had just started to consider a career in medicine, so I really didn't know what a medical lifestyle was like. I knew it could be incredibly demanding and busy, but I wasn't sure how much flexibility there would be. In the end I suppose I still didn't really know, but I figured if others did it, I could figure it out too.

We had the chance to get early clinical exposure at my medical school. I had always planned to do family medicine, so every Wednesday afternoon in my first year, I would take the bus to the family medicine clinic of Dr. B. Dr. B's patients adored her. She truly listened to them, and was clinically excellent too. Seeing patients -- real people with real problems! -- was thrilling. I get a reminder of this from time to time in my office when I have early medical students join me. Looking at a tympanic membrane is exciting to them! It's a great boost. 

During medical school, I went through the "cardiology! neurology! infectious diseases!" rotation in my mind, until it was clear that being a generalist was what I wanted. Internal medicine was tempting, as I actually enjoy learning minutiae, but I loved women's health, pediatrics, and doing preventative care. The flexibility of a career in family medicine was unmatched in my eyes. So from clerkship onward, I continued to feel that family medicine was the right fit for me. 

I now have a family practice of about 1200 patients in a small group practice, and see patients for about 30 hours per week.  Charting, results and other paperwork takes about 8-10 hours a week.  I block one day off every month for self-care or catch-up time - with young kids, if I have to cancel a clinic due to their or my illness, it’s nice to have a day available to re-book patients. I can book off in advance for appointments for the kids or myself, or fit in local CMEs or meetings related to some community health work I do. The demands of my practice - and of home - fluctuate from week to week, but generally it feels like a good balance. 

I ran into a lovely, well-meaning non-medical friend a little while ago. "How's work going?" she asked. "Ah, it's been a long week." I said. "Lots of coughs and colds?" she mused. "If only!" I thought. I tell this to students a lot: family medicine can be very challenging, medically, and very draining, emotionally. So rather than things like a chest cold or plantar wart being boring and mundane, they can be a very welcome break from the challenging things we see at times.  The medically complex cases are invigorating, and the emotionally draining cases, highly meaningful; the "mundane" cases act as a much-needed foil. And above all, when you know your patients like you do in family medicine, it becomes much more about caring for the person in front of you than about the particulars of their issues. 

Help with attending job interviews!

T minus 8 months until I join the real world.

I am now 4 months into my breast imaging fellowship. It's about that time I start looking for my first attending job!! As someone who went straight through in my medical training, I have no idea what a job interview truly entails. Yes, I've done plenty of interviews. I know what it's like to sell myself as a medical trainee but as for joining the real world, I have absolutely no idea.

My experience looking for a job might be a little different than some because I am geographically limited. My husband started his (first) attending job in a city 2 hours away from where I am doing fellowship. On a side note, this situation is so much better than our west coast east coast marriage while he was doing fellowship last year! As much as I am looking forward to joining the real world, I am really looking forward to our family of 3 to finally be living under the same roof!

I went on 2 interviews so far. The first one was not the same location but same group as my husband's place of work. Given that it's part of the largest managed care organization in the United States, questions outside of who I am, what I can offer were really not asked. Details of what the contract would entail, how much I would make, what my benefits were and etc. were not discussed. Mostly because I already knew the answers to these questions and the fact that I was told that there was no need to go over a contract from this place as it was standard across the United States. I came back from this interview thinking it went well and that it wasn't much different from a fellowship and residency interview. A downside to this job is that it will be a 45 minute commute to where we will most likely settle down.

The second interview I went on was a large private practice group in the city where my husband practices. It's a group of approximately 80-90 radiologists. We talked about my dual boarding in radiology and nuclear medicine. We discussed the possibility of working within my preferred subspecialties (breast imaging and nuclear medicine. We discussed the possibility of working part time, which got me really excited. I also met some of the radiologists in the group, who all seemed very nice. However, I came back after my interview most of my conversations with my attendings at work went like this.

"How was your interview?" "Good. I really liked the practice"

"What is your base salary?" "I don't know..."

"What is your retirement?" "I don't know..."

"What benefits are offered to you?" "I don't know..."

"What about maternity leave? " "I don't know..."

"Do you get paid overtime for call?" "I don't know..."

"How many years until partnership?" "I don't know..."

Basically, I felt like an idiot. And now, I am waiting to hear back from both jobs but I feel like I cannot really compare and contrast since I don't know the answers to these questions!

How do you go about asking these questions during a job interview? Do you ask right away? Do you wait until there's a proposal? Is these anything else I should be asking? Do you need a lawyer to review your contract?

Thank you in advance for your help!

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.

Surprise! Female physicians are paid less.

I am sure many of you have seen this recently published article about physician wage gender disparity in the New York Times. The original research article was published in JAMA Internal Medicine, and received a lot of popular press with mentions in the New York Times, Time magazine, Boston globe, Marie Claire and many others. I am always a little wary of science/research reporting. I sometimes try to read the primary research paper behind the news item, especially if the topic interests me. Pay equity for physicians is certainly a topic of interest for me.

This article put a specific number on the gender pay disparity: female physicians make roughly $20,000 per year less than male physicians. This is after adjusting for age, experience, faculty rank, specialty, scientific authorship, NIH funding, clinical trial participation, and Medicare reimbursements. This news came up in a non-work context with a male resident physician. He told me that the problem with these types of studies was that they don't account for the amount of work put in. According to him, "female physicians work less than male physicians". Well how do you mean sir? Do you mean more female physicians work part time? He said, "In my experience, women complain more and work less, period. They always have to go pick up their kids or some other excuse and they dump their work on me". Ugh! Alright then Dr. Curmudgeon.

The paper is well written and the research is pretty well done, I highly recommend reading. Sad statement, but female physicians being paid less won't come as a big surprise to anyone. Safe to say, I was being ironic in the blog post title. Gender based pay disparity occurs in the rest of the US workforce. The dicey question, which Dr. Curmudgeon raised, is the pay disparity unfair? It maybe unfair from a social standpoint. Women ending up with more childcare or household responsibility and not being able to match male productivity. But is it unfair from an economic standpoint? Are they truly being paid unequal amount for equal work? Is there is an inherent bias towards them? This paper suggests that there maybe a component of both social and economic unfairness.

Comparing unadjusted salaries, i.e. without taking into account specialty, faculty rank etc., the difference is even larger, $51,000 per year. It may be true that more women than men make choices that lead to being paid less, such as working in certain specialties or working part time. But women don't choose to be overtly discriminated against. The authors adjusted for a lot of factors that could explain the pay disparity and still found a gap of roughly $20,000. The authors lacked some information, most importantly, full time vs part time status. They did two things to counteract that. One, they used Medicare reimbursement in their multivariate analysis to adjust for clinical volume. Two, they eliminated bottom 25th percentile of income data, with the assumption that it would eliminate part-time workers from analysis. They are imperfect measures, but the best that could be done with the lack of available information.

I am pretty early in my training, and from my own limited experience, I do believe that there is at least some inherent bias. Dr. Curmudgeon is not an exception, there are more people like him inhabiting the medicine world. They may be outspoken about their biases, or maybe not, or maybe only in certain contexts. They may be aware of their biases, or maybe not. I suspect, a lot of Dr. Curmudgeons are even in positions where they can influence factors, like promotions and pays. If you have encountered one of these Dr. Curmudgeons, I'd be interested in hearing your stories in comments.

All of the ways I forget

I had my 90-day evaluation in my new position today. I left the clinic I was working in, one overrun by burnout and toxic management, in order to remember why I went into medicine at all. I love my patients and this work, but I love my family more. I now work 3 days a week in health care administration and quality improvement. I sleep well at night now that the main cause of my insomnia has ended. My family is happier. My evaluation went very well.

Immediately after my meeting, my husband reached out and said he needed to talk. I needed to talk too. He is finishing his dissertation this week, we just bought a new house, and my parents came in town for the weekend. We have been passing like ships in the night. Both busy and not really checking in enough. With moments of hugs and kisses and simple appreciation. But overall, we haven’t been checking in frequently enough and we definitely haven’t been having the weekly meetings that are my bookends at work.

I feel lonely. He feels unappreciated. Why didn’t I offer to help with his appendices? Why didn’t I read the chapter he asked me to read so many months ago (honestly, he gave it to me and I forget and he never mentioned it again until today and now I feel like dirt). He feels that my work has taken priority in our family for years (medical school, residency, the toxic job took so much of our family’s energy just to stay afloat). And now I’m studying for my Boards again after I failed them last year (more about that later, I have a lot to say about it but it's so raw and traumatizing). And he’s finishing his dissertation and starting his first job as a professor at the state university.

When we get busy I forget that my marriage needs check-ins, scheduled ones, on purpose because they are priorities. And when we are busy, we both have to go the extra mile to make sure that my needs, his needs, and our family’s needs are met.

And I’m sitting here at work, dragging my feet because at home I am reminded of all the ways I forget. I need to go home and start remembering again. And I need to be gentle with myself because we are juggling plates and though many of them are scuffed up I pray that none of them are smashed and destroyed. I’m going to head home now in order to remember that I love him immensely. And loves me. And we can't forget.

Are You Suffering from Overcare?

Dear MiM,

This is my first post, so I will introduce myself. Thank you so much to KC and all of you veteran MiMs for this opportunity. I've been a reader for years, since residency, and found MiM so helpful when thinking about my future career. I'm a family physician in a mid-sized Canadian city. I've been in practice for seven years, which still feels very "early career" to me. I work full time - 35-40 hours/week counting clinical plus admin time. I call it full time but always somewhat sheepishly around other physicians! I have a three year old son and one year old daughter, and a work-from-home husband. I'm involved in refugee health work and am community faculty for our medical school. For me, some amount of "big picture" work has always helped me maintain enthusiasm and appreciation for the clinical work. I look forward to reading your stories, and sharing mine!

N.

---

A few months ago, I was getting bogged down by excessive self doubt and perfectionism at work. The main way it manifested was in ruminating and worrying over decisions once I'd made them, but there was also over-thinking clinical choices, triple- (quadruple?) checking, and asking for advice when I really didn't need to. I try to take a pretty balanced approach to life, accepting the "good enough" principle and refraining from placing unrealistic expectations on myself. But "good enough" never seems to fit with medicine. I can accept vulnerability and imperfection in other areas in my life, but medicine? There's no room for it. I think our patients and society echo this as well; after all, it's comforting to think that physicians are the ultimate authorities in health and it's disconcerting that we are inherently flawed humans. We are socialized and trained in this mindset as well. Of course, we must be conscientious physicians. I'm not talking about being sloppy or less than thorough. But, recognizing that we are human, even when we are conscientious, careful and keep our knowledge and skills up-to-date, we'll falter.

During this time, I came across an excellent article on the topic of Overcare, written by the late Dr. Lee Lipsenthal and adapted from his book "Finding Balance in a Medical Life". Overcare was a new concept for me, and a useful one. Dr. Lipsenthal talks about overcare as a chronic emotional state that physicians can get into, and it involves agonizing over decisions we have made, and at the core of it, wondering "Am I a good enough doctor?" There are several factors at play. Our personalities tend to be perfectionistic, and we do carry a lot of responsibility. He talks about our addiction to being needed and how the intermittent positive reinforcement we get from patients can lead to us doing more and more, hoping and waiting for the "reward" of a satisfied patient. The perfectionism expectation in medicine is often instilled into us during training, and also informs how we judge others; we in turn also fear being judged harshly by our colleagues. This is especially true for me as a family physician. Any time one of my patients is seen in the Emergency Room or by a specialist I've referred them to, my care will be under scrutiny. I find that Impostor Syndrome often tags along with this overcare and perfectionism. If your expectation is that a "perfect physician" is the default, yet you witness your inherently imperfect self, impostor syndrome can creep in.

How can we counter overcare? Personally, it helps to remind myself that I am competent and doing the best that I can. And that I am human. I try to consciously make a decision, and make peace with the inherent uncertainty. I ask myself a useful question from cognitive-behavioural therapy for anxiety: am I problem-solving, or worrying? If the latter, move on. Do I think about patients after hours or change my mind about decisions? Of course, but I have a better sense now of what qualifies as being conscientious, and what is actually overcare.

Do you struggle with overcare? Are there any strategies you've found helpful?

MiM Mail: RN considering medical school

Hi MiMs,

I would first like to say thank you for sharing your stories and your day-to-day experiences and challenges of being mothers and physicians. Your stories have been helpful to me as I consider making a change in career paths. I am 25 years old, unmarried, no children at this time. I work as an RN in an ICU in the south. Prior to becoming a nurse, I studied biology and psychology and then obtained my MSN to become a nurse. I'm considering returning to medical school and becoming a physician. One of the reasons for this is that I question whether I will live up to my potential academically by remaining a nurse, and I have a thirst for greater knowledge than what I currently have. On the flip side, I enjoy my work as a nurse, taking care of patients, leaving work at work when I come home, and having a flexible schedule that allows me free time to travel and have a life outside of work. My sister is married and is in her intern year of IM and most of the time seems miserable and can attest to the strain placed on a marriage by residency. Although I'm not to the point of motherhood currently, being a mother with multiple children is something to which I have always aspired. My concern is that if I become a physician I wouldn't have the time to spend raising children and taking care of them like I hope to. I would love to hear your thoughts on this. Thank you!

Sincerely,
Laura

MiM Mail: Turning Back

Dear MiM,

I was first introduced to MiM 7 years ago when I was on the path to do a clinical psychology PhD and considering changing my career to medicine. A great mentor was trying to encourage me in both my dream to someday have a family (I was single at the time) and to practice medicine. Fast forward and I am sitting in a "How to make a Match rank list" meeting, fighting back tears.

The problem is, I'm not sure I want to Match. Don't get me wrong, I love medicine and I don't feel that anyone led me astray. I can see myself practicing (probably part-time) in the future and being able to love my work. I am not discouraged by the notion of having a family in medicine. I simply do not think I have three more years in me. For months, I've been interviewing and trying to envision how my life would fit into each residency program and I've become increasingly discouraged. I am envious of my friends with their 8-5 jobs that support their lifestyle and am disheartened by the concept of spending a lifetime trying to make my lifestyle fit my career. My partner - who still loves me dearly and who has patiently supported me through a post-baccalaureate program and four difficult years of medical school (and poverty) - has talked about us splitting because he does not believe he can survive three more years of bending to my schedule and being alone so much of the time. (As an aside, I do not blame him for considering this, and I ask that you do not blame him either.) Add to that, there are no programs where we currently live. We have just begun to fall in love with where we live, we have many non-medical friends, my partner has a fantastic job (that is not transferable), and our families are within a reasonable drive. When I started down this path, a partner and a family were merely figments of my imagination. Now, I am the worst half of a relationship, the partner who is never available to be spontaneous and when I am, is exhausted and out of shape. I am the person who is hindering my partner's career and tying him where I need to be. And, perhaps even worse, I owe him everything because I could not have made it thus far without him. Plus, I have some health issues that may impede my fertility, and the clock is quickly winding down to when the risks of pregnancy far outweigh the benefits. Add all that to $400k of debt and I feel terrible while all my classmates around me excitedly making their Match lists.

So do I pack it all in now, graduate with my MD and move on with my life, ashamed but being free of the struggle for balance in medicine? Or do I go through the Match, probably lose my life partner and simply cross my fingers and hope that a) I make it through with my mental health relatively intact and b) I can overcome my resentment and still enjoy medicine? This is such a sensitive topic that I am afraid to reveal my reservations to my mentors and I have valued the fantastic insight of the MiM community thus far. Thank you, in advance, for your support!

Sincerely,
Struggling with the Match

The Three Mentors You Need

A lot has been written about mentorship. In medicine, we are often assigned mentors based on our clinical or research interests.  Sometimes we get guidance on how to cultivate these relationships, sometimes we don’t. 

In 2013, the author and expert on gender and workplace issues wrote a book called “Forget a Mentor, Find a Sponsor” where she argued that in the workplace we don’t need mentors who just give us advice but we need sponsors who will pull us up, get our names out, and have our backs. 

I whole-heartedly agree that everyone in medicine, especially working moms in medicine, need sponsors but I have also found that we need more than that.   Over the course of my career I have found that three mentorship groups make a huge difference in my career and my life. 

Here’s what I have:

1. A  Sponsorship Team

I spent some time last year formally identifying sponsors and now have a team of them.  This team includes people who traditionally fill the role of a mentor such as more senior faculty at my institution but also come from outside this traditional role.  For example, I identified someone who has a career path that I admire and contacted him.  In some settings, there is a formal process to meet with your sponsorship team as a group but often the meetings are one-on-one and casual.  The key component is knowing who your sponsors are so that you can cultivate long-term relationships.

2. Peer Mentors

I can’t overestimate the value of peer mentors.  A few years ago, a colleague and I started organizing monthly peer mentorship lunches where we discussed topics that were relevant to us.  It was a safe environment and a huge success. The format was informal: one person picked a topic and everyone chimed in. Topics ranged from delegating tasks to staff to negotiating better pay to saying "no" when you have too much on your plate. The connections I made from this group are amazing and very valuable to me professionally and personally.

3. Outsider Mentors

I have a group of family and friends who don’t practice medicine and aren’t in academics but know me as a person. I’ve often discussed career challenges with them.  For example, I have a group of college friends in different industries that gets together periodically to do life assessments.  I am so close to these women and value their opinions tremendously. They are the people to whom I turn to when I need a reality check from someone outside my industry or when I am thinking about change.  I find that the outside perspective helps me keep things in perspective.

That’s it! These are three (groups of) mentors who have helped me.  Keeping up with these groups may sound daunting but often the maintenance of these relationships can be weaved into your lives and often they bring tremendous value to your career.

MiM Mail: PCP to PM&R?

I am an older mom to a one and only, fabulous, wonderful little boy. I had a career in human services before medical school. I completed my internal med residency. I have worked as a PCP for about a year and, frankly, it's awful! I like my patients. I chose to work in an underserved area with a lot of folks who are newcomers to the United States and I really like this part of the work. I feel like all I do is tap on the computer instead of really dealing with the human being in the room with me.

I had never heard of PM&R in med school. The more I hear about it and read about it, the more I feel like it might be a good match for someone like me. (You know, someone who likes to talk to patients, take a history, do an actual physical exam, maybe have time to do a procedure....)

Does anyone have any suggestions about residency training? It doesn't sound like the PM+R residency would be that much worse than the schedule of an attending PCP. I am able to sacrifice salary due to a very type A doctor dad in the picture. (In that way, I am very, very lucky.)

Thanks!

Attending Status: let's go!

I woke up to the sounds of the birds chirping and then “Mommy!” as my almost 4-year old tried to start his day at 6:45am. Quick detour for a potty-break and then promptly back in his bed because, “It’s still too early. Time for sleep.”

As I sit at our desks, I double and triple check that my Epocrates app is up to date so that I can quickly calculate drug doses. Today is my first official day as an Attending. I am returning to my dream health care system to work in the pediatric clinic I did my third year community pediatrics rotations in. The Attendings and many of the front desk staff remember me back when I was a medical student and they, like me, are super happy that I have returned.

We had an all-day orientation yesterday that was truly inspirational - yes, I’ve drunk the Koolaid as they say and am already one of those super happy people to work where I work. Providing care to children in our nation’s capital is truly an honor and one that I do not take lightly.

During times like this I refer back to my favorite book The Alchemist (Paulo Coelho). I was tested immensely in these last few years, but every second of the journey brought me closer to the realization of my dream. Every struggle. Every triumph. And I’m here. In this moment. Feeling the immensity of years of pre-medical studies, MCAT struggles, public health school, medical school, biochemistry challenges, clinical year excellence, pregnancy during USMLE Step 2, birth, and being a mother in medicine.

I am totally ready for this aspect of my journey. I vow to do great things. So let’s go. Let’s get it. Pediatric Attending status 2015! (happy dance, happy dance, happy-praise dance!)

Girls Don’t Cry

I have been following the response to Sir Tim Hunt’s incredibly sexist comments on women in science and thinking about how it relates to a working mother in medicine. If you haven’t heard of Tim Hunt, he is a Nobel prize winner who made headlines earlier this month for saying “…three things happen when [girls] are in the lab…You fall in love with then, they fall in love with you and when you criticize them, they cry” at a lunch for women journalists and scientists in Seoul.

Not surprisingly, the response has been overwhelming.  Some of my favorite tweets:

and…

and my all-time favorite…

But all joking aside, sexism still exists in science and medicine.  And as a working mom I’m very sensitive to issues of sexism, ambition, and differences between men and women.

This may be because I am constantly pulled in two directions (career versus family) and wonder if my ambition is ever questioned. On the one hand, I don’t want to draw attention to the fact that I am very much pulled in these two directions and must balance work and life.  But on the other hand, I do want to draw attention to this struggle to help support other women and help others understand decisions working moms need to make.

The fact is that I make very conscious decisions that incorporate both my work ambitions and my motherly ambitions. No, these decisions do not involve being distractingly sexy or crying in the lab but they do involve taking a slower and, sometimes, more convoluted paths.

I have rejected significantly higher leadership positions because they would squash my flexible schedule, I consciously avoid travel, and I am not willing to move my entire family for my career. To some of my male colleagues, these decisions may seem crazy, but, for me, these decisions are very calculated. 

I’m very conscious of burnout and hope to keep a level of balance that helps me work full time, find satisfaction in what I do, and keep me on an ongoing trajectory so that when I am no longer in the weeds of motherhood, I will still have interesting and meaningful career opportunities.

That being said, there are times when keeping the reins on my career is hard. I wonder whether I am being left in the dust when I see male colleagues make different choices and move up the ranks faster than me. And as a working mom, I never want to compromise other women by having my ambition questioned. 

But even with these doubts, I am incredibly proud of the difficult career decisions that I and every working mother have to make.  I know I will only have a short time with my kids at home and I want to cherish that time.  I’m sure there will be time in the future to turbo charge my career if I want.

In terms of Tim Hunt, I’m not sure if #distractinglysexy and #crybaby necessarily come up as issues for my career but ambition, choices, and timing certainly do. I think if we keep open dialogues and try to respect for each person’s decisions then I think we can push the conversation.  What do you think?

The Do-it-Again Equation

Cutter’s excellent post and the comments to follow really got me thinking. What factors go into our thoughts about whether we would do it again (become a doctor)? Can this change?

This is just my way of thinking about the question (one way of potentially many), but I think the simplified, general equation may look like this:

Outcome - Sacrifice    =    DiA
                    time

If DiA = positive, you would do it again. If negative, you would not.

And where Sacrifice = time, money, family relationships, moves, etc , thus far

Outcome = present level of satisfaction with career, may include work-life balance (or work*life product), income, career-related meaning, work-related aggravation

And time, because I do think time is a factor because time attenuates sacrifice/hardship. For instance, if you asked me whether I wanted to have another child while I was sleep-deprived and breastfeeding my newborn Q2 hours during those awesome early weeks of being a new mother, occasionally crying in the shower if I was fortunate to have a shower, my answer may not have been a resounding Absolutely! Not that I didn’t think my child was a magical gift, but wow. My pregnancy/labor/post-partum period were not easy. Fast forward a couple of years and that hardship didn’t seem quite as insurmountable relative to the outcome.  That was kind of a terrible analogy (along with math, not my forte), but I think in general, distance makes the heart grow fonder and the memories fuzzier.  Alternatively, maybe the Sacrifice was way too much and no time in the world would make that value small enough.

For me, my Sacrifice to become a doctor was relatively small and feels smaller with time. I met my husband during medical school. I was really fortunate to finish training with minimal debt, and besides being very tired and on-call during multiple holidays (Thanksgiving dinner with my co-residents in the physicians’ dining room; watching fireworks on July 4 through the 8th floor hospital windows), it wasn’t so bad. My Outcome, on the other hand, has increased over time. I now have more control over my schedule (compared to being junior staff right out of residency), higher income, more clinical knowledge, have engaged in new areas that keep me excited (teaching, research, mentorship, leadership) and after working with all different members of the healthcare team, value the role of physician as leader more than ever. Don't get me wrong- there are parts of my job that are the mental equivalents of how I imagine a root-canal would feel, but on the whole, my career is rewarding beyond what I could have imagined right after my pre-duty hours residency. My DiA started out positive from the start and only has grown more positive with time.

It goes without saying that this equation and its variables are individual, and there could be a fatal flaw that I have not considered in forming this equation. But, it’s not an easy path to take, no matter how you compute it.

To be or not to be.....a generalist

Hello MiMers!

I'm nearing the end of my Family Medicine residency and am struggling with the age-old question: To be or not to be?....a generalist.

I've always loved the variety and scope of FM. To me, there is such great appeal of being a jack-of-all-trades kind of doctor. I love being the first point of care, collaborating with specialists, seeing new and unfamiliar problems, and flying by the seat of my pants. Growing up in Canada and being surrounded by a culture of Family Medicine has undoubtedly shaped my love for general practice.

That being said, after countless hours of studying, rotations, patient care, and hard work, I am sometimes weighed down by the questions, "What am I GOOD at? What's my area of EXPERTISE?" Sure, there are the things that I see everyday and feel pretty comfortable with: Diabetes, high blood pressure, back/shoulder/knee pain, asthma, preventive care to name a few. But this always comes with the knowledge that I'm not necessarily an EXPERT in those fields. Can I really be giving my patients the best care for their problems if I'm not an endocrinologist (diabetes)? orthopod (shoulder pain)? pulmonologist (asthma)? Could I give a thoughtful, professional-level lecture on any of those subjects?

I've been seduced many times during residency into doing a fellowship. At one point, I've seriously considered a fellowship in geriatrics, OB, EM, sports med, palliative care, dermatology and HIV/AIDS (to name a few). But I can never seem to commit myself to narrowing down to one subject. I find myself getting back to the same fear of getting pigeonholed into one area and losing my ability to be a generalist. It is quite a humorous mind-loop that I get into time and time again.

Ladies, lets discuss. What do you love about being a specialist? Or a generalist? I'd love to hear your thoughts.

Sincerely,
HulaMed

Hurtling toward the next phase

I have searched but I cannot find the flying trapeze story I read a few years ago that explains my life, so I’ll paraphrase and add to it here:

I swing back and forth preparing for my next take off. I have prepared, but I know that this leap is longer and more challenging than ever before. In spite of a long line of successful jumps, there have been some near-misses, some full on misses, some blood, scrapes and even some still healing deeper wounds. This time I jump, my husband is watching and waiting readying himself for his jump into dissertation land and as we prepare Zo waits by ready to take off with us.

Well MiM friends, it’s official, I have accepted a position as a Pediatrician in my dream clinic. I’ll be back in DC working at an academic center-affiliated community clinic. I did my community pediatrics rotation there as a medical student and so many of my respected supervisors and medical school friends are still there.

Interviews were a whirlwind. I met so many nice people, got lost countless times, learned even more about what I need, want, and will compromise on.  

And now onto school finding. Every day I have a mini-freak out when I think about Little Zo starting pre-k. Our cherubic toddler has been replaced by an almost 4 year old hilariously funny and extremely sweet rib-protruding knock-kneed ball of energy. And then I freak out more about making pick up and drop off work and I pray so intensely that we find the right environment for him and that we will find balance so I can rock my boards and O can finish his dissertation expeditiously. I wish I could transplant his daycare to DC.

And house hunting on a single income in a very tight housing market is not my favorite thing to do but I guess house hunting without the beloved Property Brothers will always be lackluster. We have several leads on promising houses and are heading up next weekend prepared to make an offer. Can’t wait to have our first home secured and then on to do-it-yourself projects for years to come.

This jump seems epic. Push-pull-push-pull, forward backward forward backward, take off.