Mindful Parenting and a Toenail Drama

It started back in May. She dropped her stainless steel sippy, and the bottom rim landed right in the middle of her big toenail. For hours, she was beside herself. All we could do was kiss and hug her and say, “Yep… it sucks to drop something on your toe.”

It was the first, but it won’t be the last. A week or two later, there was a good-sized, eggplant-colored bruise right under the nail. Welcome to the Black Toe Club. She didn’t seem to care too much about the discoloration, and we went on with life as normal.

Fast forward to a week ago, when I noticed that the nail was starting to unroof itself. It became so… flappy... that it started to catch on things, which resulted in fits of pain and crying. Being the Doctor Mom that I am, I devised a treatment plan involving an epsom salt bath followed by lidocaine ointment and a sharp pair of scissors. But after the bath, she had a freakout.

She WOULD NOT let me cut it. Would not let me even touch it. We fell into a cycle of hugging and talking and attempting, followed by pullback and more crying.

Her: “I’M SCAAAAAARRRRED!”

Me: “This is the best way to deal with this. Otherwise it’s just going to keep catching on things and eventually rip off, which will be even more painful. Trust me! I’m a doctor! You just took a bath! It’s soft right now! Let me cut it!”

Her: [uncontrollable sobs]

This went on and on, extending past bedtime. And repeated for 3 days. The toenail would catch on something, even bleed. It separated further from the nail bed until it was sticking straight up in the air. I got so frustrated… if you’re a physician, you’re likely familiar with the experience of family members not taking your medical advice. All those past memories welled up, compounded by a screaming, inconsolable child.

One night I threatened to rip it off after she went to sleep. One morning I told her we weren’t going anywhere until it was dealt with. We devised different plans, all foiled by her going into a crying fit… and when one involved her dad helping to hold her down, he looked at me with his peircing eyes and said straight up, “What are you doing?”

[long pause]

Um…. What WAS I doing?

I was trying to control the situation. I was worried for her, anticipating the great pain she might experience if the toenail ripped completely off on its own. So instead of letting things take their course, I tried to solve the problem for her. Like lots of well-meaning parents these days, I was coddling.

I was acting on my own aversion to the appearance of her toe (as a self-confessed Picker, if it were my toe I would have cut that flapping nail off immediately despite any pain pemature action might have caused). The sight of it bothered me more than it bothered her.

I was using logic to appeal to an illogical, 4 year old little human. Although I want to respect her as her own person, she’s not a little adult. Yet I sometimes talk to her like she is.

I was trying to control someone else’s body. Someone’s body that is not mine to control. And I was using threats (again) to try to get what I want.

These are all Respectful Parenting fails.

Before even having kids, we decided that respectful parenting was the kind of parenting we wanted to do. I read books like The Gift of Failure and The Conscious Parent. I listened to Janet Lansbury‘s podcast. But like so many things having to do with mindfulness, theory is different than practice. It’s easy to have a plan, but what matters is how you act in the moment of need. Sadly, this time it took me approaching the use of force to realize how far I had drifted off the path I meant to be on.

Defeated but brought back to reality, I admitted I was wrong. This was wrong. My emotional bank account depleted but not quite in default, I was able to salvage the day by taking responsibility.

She put on flip flops with her little nail sticking straight up, I tried not to look at it, and we went about our day. I dropped her off at the gym childcare center, assuming I would get a call about another episode when she caught her toe on the playground or something.

But do you know what happened? When I picked her up, the nail was gone! She hadn’t even noticed it fall off; it didn’t hurt a bit. After all that, leaving it be was probably the best thing to do anyways.

I’m so lucky to have her (and him); I’m always learning from them. Being a parent has been the greatest lesson in mindfulness.

(A version of this post first appeared on the blog practicebalance.com)

On Quacks, and Cold Clinical Facts

Genmedmom here. 

We all have patients, friends, and family members who fervently believe that they have a diagnosis that we know doesn't exist. Or rather, for which there is no current reasonable believable scientific evidence.

I refuse to cite specific examples, because it's useless to refute someone's pet diagnosis. You may have examined a large body of research, read reams of textbook pathophysiology, spoken to respected specialists, but no matter what, if you attempt to disprove the entity they blame for all of their symptoms, and the treatment upon which they have pinned their hopes, they will hate you.

It's unfathomable to me that there are providers out there, some of them medical doctors, who blithely and blatantly practice non-evidence-based medicine on unsuspecting and vulnerable humans.

Infuriating.

And it sucks to sit there and listen to someone you care about describing quacky tests and (at best) useless and (at worst) potentially harmful charlatan treatments. Especially when they are paying dearly, and out-of-pocket.

Of course, I've tried to take down these totally false medical problems many times. It's what you do when you care about someone, right? And I've watched their faces shut down, as they mentally walk out the door. Or, saw them get red-faced and argumentative, unable to hear another word I said.

Sigh. So now, for the most part, I nod and smile and murmur something about how modern science can't answer all the questions and I hope that's working out for them.

After all, I can see why this is happening. Modern day M.D.'s are obviously missing something. Patients aren't getting what they need from us.

It used to be that folks had a local doctor who knew them well (and possibly also their families, neighbors, and friends). Office visits were longer, and paperwork was practically nonexistent. There was more listening, and less prescribing. The pace of the research world and life generally was slower, and slower to change. Hypotheses, explanations, and medications were more stable, things you could get your head around and use for a long stretch of time. The doctor-patient relationship was a real thing.

All that's a fever dream. Now, we docs are SO on the clock. Productivity numbers are in- you need to see more patients! And more! Twenty minutes to address all of your patient's medical problems and questions, examine, order, NEXT! Then, the deskwork. Administrative burden outmatches face-to-face clinical time two to one. It's a team of nurses doing callbacks, if the patient gets a call at all. Nowadays, it's mostly messaging through the "patient portal". The, the general public is fed research study after study after study. Papers and pundits contradict each other, data is manipulated, organizations release conflicting guidelines, medications get pulled. Textbooks aren't even printed anymore because they're outdated so fast. What a mess.

These are the cold clinical truths: There's no time to build trust. Our system prevents real connection. The scientific information world is fast-paced, chaotic, and confusing.

And so people are looking elsewhere.

Our medical system may or may not be headed in a better direction, what with the Patient Centered Medical Home movement and all. We'll see.

But meantime, behind the scenes, I am on a bit of a campaign. I recently wrote a patient-friendly article in support of evidence-based medicine for Harvard Health Blog that was well-received. At least, I didn't get any death threats.

Death threats, you say? Yes! Plenty of qualified critics of particularly trendy fake diagnoses suffer angry trolls throwing cyber-insults or writing letters with intent to harm, or kill.

So I'm trying to educate generally, not specifically. Trying to teach people how to tease apart the "fake news" from the safe news, how to be thoughtful, and consider several sides of a story. Their doctor sees it one way, but the internet says it another way. Okay, let's figure this out.

Doctors, we won't win the battle against the snake oil salesmen using facts and figures. We need to be gentle. Tread lightly. Nod and smile and murmur something about how modern science can't answer all the questions and you hope that's working out for them.

And then, if we can, listen. Try to cut through the requisite logistical bullshit and reach out to our patients. If they are feeling heard, they may trust. And if they trust, they may listen. It will take time, and open minds on both sides. But the patient may get the expert help they need, that the doctor is able to give.

Trading fake patients for real people

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

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

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

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

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

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

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?

Being On Call

When I was a kid, my dad was on call all the time. I am not exaggerating. He was in practice with my grandfather (his father-in-law.) Nat (my Popop) had been in solo practice for years and so when Dad joined him, Dad took over call. Nat was always willing to cover if my parents had plans; mostly Dad was just - on call. 24 hours a day. Seven days a week. My mother finally forced him to take an actual vacation after eight years.

Now, Dad would be the first person to remind me that this was in the 1960s. No ICU. No CCU. No tPA. No push to get patients out of the hospital - people with uncomplicated MIs (if they survived) stayed inpatient for at least ten days. You could admit people for evaluation of new diabetes. No urgent calls on abnormal labs in the  middle of the night. And he genuinely loved his work and his patients, and he didn't need all that much sleep, and of course he had no responsibilities at home because my mother did everything. But still - on call EVERY SINGLE NIGHT. I can't even imagine it.

I'm thinking about it now because last night was One Of Those Nights. I was exhausted after a long and difficult week and I went to bed at 10:00 PM. The beeper went off at 11:00 PM, 1:00 AM, 2:30 AM, 4;00 AM and 5:30 AM. The 5:30 call was from the ED about a patient who needed urgent admission to the inpatient hospice unit, which meant three more phone calls, so I had to get out of bed. I tried to go back to sleep - and then my daughter's alarm went off at 6:10. She's away for the weekend. She didn't turn her alarm off before she went.

I think I'm too old for this. And then I think of Dad and feel like a wimp. And then I remember that he was 20 years younger than I am now, so perhaps I should let myself off the hook.

Am I the only one who has grown to loathe being on call overnight?

The Most Intimate of Jobs

A random Saturday earlier this month marked the first time I provided sedation anesthesia for patients in the same IVF clinic where I was a patient for 3 years. It was surreal and a little emotional driving up the hill to the clinic and thinking about the many times I went there as a patient myself. All the shots, the blood draws, the ultrasounds, the procedures... Also all the letdown and disappointment that was flanked before and after by hope and excitement. I now have a beautiful baby girl to show for my time as an IVF patient!

A friend of mine who is also in the medical field said to me, "I bet it took a lot of courage to do that. Creepy and scary". While I instead had viewed the experience with gratitude and excitement at the ability to give back to a group of people who had given so much to me, I can understand what she meant. As physicians, we are faced with daily reminders of unpleasant things. Things that have happened possibly to us or to our loved ones, or things that are at the very least reminders of our own mortality.

I think these reminders are a gift, one that doesn't come with many other lines of work in this world. They keep us appreciative of what we have, what we've been through. Has anyone else had an experience like this in their practice? Share your thoughts with us.

Saying their names

I don’t have a television but your story flashes across my Facebook feed, my friends tell me about you, my husband the Anthropologist tells me about you, and I look you up online.

You were bullied for being a cheerleader and you took your life (Ronin Shimizu). You went out for a pack of Skittles, a stranger chased you, you were shot and killed (Trayvon Martin). You were selling cigarettes on the streets of New York and you were choked to death as you screamed “I can’t breathe” (Eric Garner). You were playing with your big brother and he accidentally shot and killed you with a gun you found (9 month old in Missouri whose name will not be released). You were born a girl but your birth body was that of a boy, you tried to be your true self but took your own life after not being accepted by your parents (Leelah Alcorn). You were misunderstood, you were playing with a toy gun in the park and you were killed (Tamir Rice). You were with your friends listening to music in your car at a convenience store when a stranger approached you and began arguing with you about your music, he shot you and you died and he went back to his hotel room, walked his dog, and had dinner and drinks (Jordan Davis).

I honor your legacy with my tears. I think about your family. I snuggle my little one more tightly knowing this world is both a beautiful and dangerous place. I honor you with this post; I apologize it has taken me months to find the courage to say your name in this space. This space that is sacred to me but after my last post about Trayvon Martin received some insensitive comments I was hesitant to share some of my deeper feelings since I don’t see much social commentary here at MiM. Why is that? We are mothers and we are providers and don’t we see how unique our vantage point is? We can talk about the intersection of life and policy, public health and personal life from a place most others cannot. I struggle to find the time to read anything besides mindless fashion blogs when I’m not balancing my own needs with full-time medical practice, my husband’s needs and those of my four year old let alone to allow myself the freedom to reflect on society’s transgressions and tragedies.

I thought of you today while looking at my ever growing to do list. And because your life matters to me I put away other thoughts and wrote your name, I am saying your name.

#BlackLivesMatter #ProudLGBTQAlly #MothersInMedicine #2016LivingMyTruth

Guest post: Unexpected gratitude

I love Raymond Carver's poem "What the Doctor Said." The doctor tells the poet he has widespread metastatic lung cancer. The poem ends with this:

I jumped up and shook hands with this man who'd just given me
Something no one else on earth had ever given me
I may have even thanked him habit being so strong

I may even have thanked him. 

I don't have to tell people they are dying. I'm a hospice doc. My patients know they are dying before they meet me. Everyone knows they are dying. They may not want to say it out loud, and they may use a variety of euphemisms, but everyone knows. I don't have to say it. I do have to find a way to answer the question "How long?" I always start and finish my answer by saying "I don't know." We never know for sure. I am frequently surprised - I am surprised how quickly some people die and how long some others linger. I am surprised by so much about this work. I am surprised by the peace that I feel at the bedsides of the dying, and how comfortable it can be in our inpatient hospice unit. I am surprised at the laughter I find when I make home visits. I am surprised by the capacity of family members to do the hard, dirty, physical work of caring for their loved ones.

And I am surprised when they thank me.

Patients thank me for coming to their homes. "A doctor who makes house calls! In this day and age"! Caregivers thank me for the medication that eases the symptoms and makes their job easier (even though it's the nurse who tells me what they need). Family members thank me for clear explanations of the medical system and for signing forms (although most of that credit should go to the social workers who do all the actual work). All of that makes sense. I have done something, given them something, provided an answer or solved a problem.

Then there's the question no on ever wants to ask: "How much longer, Doc?" It's often asked in the hallway of our inpatient hospice unit. Someone is usually crying. Sometimes the someone is me. I am as honest as I can be when I don't really know. I say "I don't see anything that suggests it will be the next few hours...", but I know the patient might be gone when we walk back into the room. I ask what the family needs - what decisions are they wrestling with? Who needs to come in from out of state? Who are they trying to protect? And at the end of the conversation, they say "Thank you." I am always surprised.

I don't really know why they are thanking me. Perhaps it's for some clarity and honesty after the muddle of modern medical care. Perhaps it's for the moment of connection and the respect I hope I'm communicating. And perhaps it's what Raymond Carver wrote about - that I have given them something no one else ever has.

Those moments will continue to confound and humble and amaze me, and for that, I am thankful.


Jay is an internist working full-time in hospice and palliative care and mom to a 15-year-old daughter.

That parent: you know the one who makes the front desk staff have nonepileptic seizures?!?

For those that don’t know - nonepileptic seizures also known as pseudo-seizures are a phenomenon when a person does not have a real seizure, but they just mimic the movements of a seizure. Sometimes it is for secondary gain such as getting out of school and getting attention or sometimes it is a manifestation of underlying psychiatric illness.

Well, this is a post about patients that really stress providers and staff out and cause us all kind of angst.

I will take a moment to perform some serious self-reflection: I love me some difficult patients (yes, “love me some” as my Granny would say), blame it on my mother being a Social Worker, me being an interdisciplinary major who took a ton of medical anthropology and ethics classes, and me being extremely committed to social justice. Add to that the fact that most of the difficult patients come from places where my cousins still live and culturally I just feel connected to the loud, passionate, trash-talking patients. And finally, blame it on the fact that I have read countless accounts of the biases we providers have for folks we relate to and have against those who aren’t like us. I continually find myself being the only person bringing these biases up. I get it, I'm usually the only person of color in the room and to me these are issues I deal with every day and most of the time these biases harm folks that look like me and come from where I come from (see references below).

In spite of the very real and significant way we providers treat patients differently based on how we perceive them (see references below), what to do when a parent crosses the line? When their own mental health disorder gets in the way of their interactions with care providers? What happens when a parent only knows how to speak in a way that is viewed as overly aggressive to my colleagues and other staff but is culturally tolerable to me (loud, hands waving, maybe with a few expletives)? What happens when essentially an entire staff is overwhelmed with these interactions. There has been at least one time when I felt like the only one still advocating for a family but even I began questioning if I was really helping at all? What happens when we collectively have nonepileptic seizures when a parent comes in the door because we know the ish is about to hit the fan? I'm just wondering. What to do about "that parent"? The one we all want to avoid but who we still want to find a way to work with?

References:
1. Association of Race and Ethnicity With Management of Abdominal Pain in the Emergency Department. http://pediatrics.aappublications.org/content/132/4/e851.full
2. Problems and barriers of pain management in the emergency department: Are we ever going to get better? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004630/
3. Unequal treatment. https://iom.nationalacademies.org/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx

When the Patient Brings Presents… or Punishment

Genmedmom here.

This was an odd week. One patient brought me a beautiful bouquet of flowers as a gesture of thanks… and another totally reamed me out. Both are uncommon occurrences in my practice.

The thing is, I didn't feel like I deserved either.

I told a colleague about it, and we laughed. It's so funny, but so often the case, that we're as surprised by the patient who is grateful as we are by the patient who is angry.

Both cases ended up being professional victories for me:

Usually, when I've received gifts from patients, I have felt some pressure to treat them a bit extra-special, overly gently, with kid gloves. Oh, I won't go there this visit. But in the case of the flowers, I approached a touchy subject anyways, and we were able to address it in a positive way during the visit.

In the case of the reaming, which was really a lengthy declaration of my recent deficiencies as a provider, I was able to hear the patient out. They never raised their voice, used vulgar language, or got personal, so I was able to sit, impassive, and take it. I felt it was therapeutic for this particular patient to get it all out… I apologized for the perceived inadequacies, we reflected together, and then we were able to move on to actual medical issues. Usually, when I get criticized, I get heated up, embarrassed, emotional.

I don't know exactly why, but I was able to stay cucumber-cool. Maintain that professional distance. And, best yet, not bring it home with me.

Of course there have been other cases that have found their way into my head and into my home, intruding on the kids' bedtime routine, making their way into quiet conversation with my husband, delaying desperately-needed dreaming…

In our practice, we have a monthly Balint-style group moderated by a psychologist. We often share cases that get in our heads, and these themes have definitely been explored. Be it gifts or criticism, we have all experienced it. It's been very helpful to hear not only what other providers do in response to these challenging situations, but also to hear what they feel.

We're not made of Teflon, and the water sometimes soaks us. How do other physicians respond in these cases? and, more importantly, how does it make you feel?

I'd love to hear!

MIM Intro: Doctor Professor Mom

Hello, I am Doctor Professor Mom.  No, that’s not my real name but it’s a name that makes me really proud.  My oldest son coined it a few months ago when he learned that I am not only a doctor but I am also a professor and I am also a mom.  He seemed genuinely proud when he coined the name and, of course, I was equally proud both at his creativity and at some of my accomplishments.

Even as a Doctor Professor Mom, it’s hard to feel accomplished.  Maybe it’s something about academic medicine where I feel pulled in a million different directions. I teach; I do research; I see patients – it’s easy to feel like a jack of all trades and master of none.  Add on a busy family life and mastery is not in my cards.  But academic medicine has given me incredible flexibility, variety, and satisfaction.  Plus, I get to proudly say I am a doctor and a professor.

Of course my proudest accomplishment is not that I am a doctor or a professor but that I am a mom to three boisterous, energetic, and absolutely wonderful sons.  They are ten, eight, and six (gasp - how did they get so old).  After ten years of motherhood I have a lot to reflect on in managing a household with two equally ambitious working parents and ever changing challenges of parenting. 

I became interested in writing about my experience as a doctor and mother after my first son was born.  I spent 18 months crying every day when I went to work and decided (with the incredible support of my husband) to leave my job and stay home.  Then I struggled trying to find my identity as a stay-at-home mom (I wrote about this experience in an essay called Dr. Mom).  I returned to work and decided to focus on research and a career in academic medicine.  For me, it was an excellent choice.  That being said, the struggles of being a working mom, finding meaning and satisfaction in your work, and all the other challenges of life never go away even when you feel like you’ve found the perfect job.

When I wrote Dr. Mom in 2007, so many women contacted me and thanked me for sharing my story.  I promised myself I would write more, but, not surprisingly, life got busy.  I’m thrilled to have a place to write, to be a part of a community of women in medicine and hope that something I write will resonate with someone else. 

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.

Do Female Physicians Need Female Chaperones?

Genmedmom here.

Our department is considering a policy that would require female chaperones to monitor every pelvic exam. This would include pelvic exams performed by female providers.

As a primary care women's health doc who performs pelvic exams every day, I felt vaguely insulted by this.

But, as both a female physician as well as patient, I understand the reasoning behind this potential policy. In our department's case, it was apparently proposed in response to a complaint involving a female physician; we have no idea what the issue was. Of course, historically there have been cases where there was abuse of the doctor/ patient relationship in this context. Also, cases of perceived abuse. To have an official "observer" present can help to prevent any abuse, or false claims.

My own OB/GYN office uses chaperones. But it always strikes me as odd and impractical. My own OB/GYN is an excellent physician with superior bedside manner who has overseen both of my pregnancies; she even guided me safely through a VBAC. But even she has to leave the exam room and go fetch a medical assistant, who may have never met me and is not involved with my case, so that they can stand there and observe what is basic, routine office care. I've considered requesting that she NOT go fetch the superfluous eyeballs, as I think it's kind of weird, and it would save time, too. But I haven't wanted to rock the boat.

So, as I have myself experienced, having an additional person present for this exam can also in and of itself be uncomfortable, and can make routine medical care feel weird. It may not help many women to feel more comfortable at all.

Are there things we providers can incorporate into practice that can help minimize discomfort and prevent abuse, or perceived abuse?

I really try to help patients through what is generally considered, at the very least, an uncomfortable and awkward examination. For many women, a pelvic exam can even be a traumatic experience, either physically due to atrophy or inflammation, or psychologically due to past rape or sexual abuse.

I think there's some basic things that we can do to help women feel more comfortable and in control when a pelvic exam is necessary. These include explaining why we are doing the exam and what we are looking for before we even start. Does she need a Pap smear, or STD screening, or both? Is she complaining of pain during sex, abnormal discharge, abnormal bleeding? Is there a strong family history of GYN cancers? Is there a family or personal history of melanoma? Then we'll discuss whether the exam will include a speculum exam, or a bimanual exam, or just an external exam, and why. Not everyone always have to do have all of these.

It's important that the patient knows what's going on at all times. I think it's better if the back of the exam table is slightly elevated and the paper drape is pushed down, so that the patient can easily see the provider. I also try to explain everything I'm doing in real time. I don't even touch the patient in that area at all, without saying what I'm doing and why immediately beforehand. I'll hold the plastic speculum up, and explain that it's the same diameter as most regular tampons, that we use plenty of lubrication with this, and it's usually cold. I tend to talk through the entire procedure, Rachel Ray-esque. Often I'll suggest yoga breathing, letting the pelvic muscles and buttocks relax.

In some cases, urinary incontinence is a problem. If Kegel exercises may help, I ask women if they know how to do these. Then, I either test their Kegel, or ask if they want to learn this. What I've seen is that many women who think they're doing a good Kegel squeeze will actually be tightening their buttocks, or simply tilting the pelvis. So I add pelvic floor physical therapy here: a lesson in isolating the pelvic floor muscles, and a test to see if the patient is able to do a decent Kegel. I think if someone walked in as I'm saying "Squeeze!" they'd wonder what was going on. But since Kegel exercises are effective for preventing and treating urinary incontinence, we'd better make sure patients can do them before we recommend them.

Sometimes, a patient is extremely uncomfortable with some part of the pelvic exam. Then, the exam must be halted. I usually pull the drape back down and discuss, ask if they would like to try again, or hold off. I really don't think a provider can proceed in those cases without a time-out and discussion. It's okay, and sometimes absolutely necessary, to just skip the exam. It can be rescheduled; special arrangements can be made as well, as in cases of extreme physical or psychological discomfort, such as exam under anesthesia.

I've had patients tell me that the pelvic exam "really wasn't that bad", or even that they learned something useful. I take this as positive feedback! I'm sure I can do better; we all can. I'd be interested to know what techniques other providers have found to be useful.

If we are required to institute this female-chaperone-for-pelvic-exams policy, it would mean significant logistical hassle. In our office, we work one-on-one with the medical assistants, and several are male. Would the guys need to be let go, transferred to other practices? In addition, our medical assistants perform the phlebotomies on the patients they've checked in. Were this policy to be put in place, we would need to reorganize our whole system, and likely need to adjust the operating budget to include additional staff. And, of course, if we're required to go fetch a chaperone before every pelvic exam, that will add time to all of those patient visits. Either we'll all run even more behind, or we'll have to restructure our scheduling, and likely need to institute longer days for us and our staff, to accommodate. Again, this could mean a budget problem.

In summary, I don't think that requiring a chaperone to stand there and observe every single pelvic exam is a good idea.
But, I'm very curious what women physicians think about this, both as providers and as patients.

What better place to ask, then the physician-mom blog? What's the vote: Yay or nay?

For those docs that perform pelvic exams, what have you incorporated into your practice to help women feel more comfortable and in control?

-Genmedmom

MiM Mail: Types of practices and family life

Hello fellow Mothers in Medicine!

I am a senior resident in a medical subspecialty, about to graduate next year, and am in need of frank advice on different types of practices and having a full family life. I have a child under the age of 1, and plan on having a second child within the next few years. My specialty allows for some flexibility, and I think that either solo practice, small private practice, or hospital employment are all viable options. Ideally, I would like to work part time while my children are young. I am hoping to gain some perspectives on others experiences with the varying different practice types, what worked well for young families and what presented challenges. Thank you in advance for sharing your experiences and thoughts!

Would You Care For A Patient With Ebola?

Genmedmom here.

Last week, a patient with risk factors for Ebola exposure, and who had medical issues, walked into our office.

Kudos to our N.P., who handled this very well. Upon learning of the potential exposure, she called infectious disease at our hospital, and they walked her through the appropriate screening interview questions. It took awhile, but she was able to determine that this patient was extremely low-risk for direct contact with the Ebola virus, and was not exhibiting any suspect symptoms. She was given the all-clear by infectious disease, and proceeded to take care of the patient.

Of course, this drove home very quickly the fact that any of us could be called upon to make a similar evaluation at amy time. I know I opened our hospital-issued Ebola risk stratification and action guidelines and read them over several times.

All day and on the long drive home, I imagined what I would do.

My first instinct was: Of course I would step in and help, no matter what any patient had or may have. I'm a healthcare provider. That's my job.

But.

There are now two nurses who contracted Ebola through caring for an infected patient in Dallas, despite knowing the diagnosis and wearing all the recommended protective gear. This is a virus with a 40 to 50% case fatality rate (now reported as closer to 70% in West Africa, due to lack of resources and care).

I'm a mother to two very special little kids. Could I justify knowingly exposing myself to a highly contagious virus with a grim fatality rate?

I went back and forth in my mind.

There are many healthcare workers in this country... But my kids only have one mom.

On the other hand, I do think that nurses and nurses' aides are at far greater risk of exposure, due to the inherent nature of their jobs and the mode of transmission of the virus. Now that I am an outpatient attending, I am rarely exposed to patients' body fluids.

But.

It only takes one, tiny exposure.

Of course, we have had a providers' meeting about this, and we did review our office protocol again. If needed, we have the "moon suits" and a designated isolation room. We have all the phone numbers to call to arrange transport of a suspected case. We have solid resources, so unlike our counterparts in West Africa. My heart goes out to them and to all the poor people suffering with this. We are lucky over here.

But.

I don't know much about donning layers of protective gear. I would likely screw it up. It only takes one, tiny exposure.

How would I then limit contact with my family, not get too close with my kids, for twenty-one days? I'm always clearing noses, changing diapers, wiping binkies... it would be near-impossible, and nerve-racking.

Ugh.

I don't know what I will do, given the choice.

I know that many hospitals are compiling lists of volunteers, staff who are willing to care for patients with Ebola, including aides, nurses, physicians.... I understand that most of these lists are pretty short. I have no idea what our hospitals' list looks like. I know I am not on it.

I am very curious what others have thought about this, especially the hospitalists and nurses out there, who would likely have more direct and frequent contact with a case should one come in.

Healthcare provider-moms, what are your thoughts?

And if you haven't thought about it, you should....


--Genmedmom, also at www.generallymedicine.com

The Opiate Epidemic And Us

Our 25-year-old nephew passed away last week.  He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.

His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.

When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.

We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.

There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or  left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).

Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew.  In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time  dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.

Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.

Because we are in an epidemic.

All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.

Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.

Opiates are extremely physically addictive. And lives are crushed by addiction.

Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.

Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.

Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.

In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.

I'm curious to hear what are the thoughts and experiences of other physicians on this issue...