Too swamped to write

Well, I have been meaning to post here for months and after several good-natured nudges by our organizer I finally made it! I am amazed that you all have been able to share so much and maybe that's what I am here to share- that I've felt so swamped the last year I haven't even felt I had time to write about it. I have definitely found that as our 3 children get older I have felt that although there is a certain freedom that I appreciate in them having independence like getting bathed and dressed alone, keeping track of homework, playdates and sleepovers and reminding me about birthday parties, I also dread other aspects of their independence- like my nine year old daughter insisting on walking a mile to school without a parent when I have to race out the door to work, leaving me feeling very unsure about her safety and wanting to hold her hand all the way to school. Another whammy that came recently was when she cried so hard at bedtime saying "why do you always have to go to work and just leave us with babysitters our whole life"-- wow, that one was unimaginably painful! Like many of us I presume, I alternate between periods when I feel quite happy and satisfied w/ work and home life and then others when I feel I am drowning- this is one of those drowning times so I'll spare you all any more of this debbie-downer post and look forward to returning when I'll have something more cheerful to write about :) Go moms!

Pretty girls don't need to be doctors!

On my last rotation, I was sharing an office with a former beauty pageant winner. She was gorgeous. And you can imagine how terribly attractive this made me feel, what with my wrinkled white coat, my shirt stained with baby food that didn't come out in the wash, and shoes that are probably similar to the ones your grandma wears. But she was such a nice girl, it was hard to feel too badly about it.

Anyway, Miss Beauty Queen was interested in going to med school.

Over the course of the rotation, I did my damnedest to talk her out of it. Every single day, I told her a different true story, some titled "Med School Sucks", others titled "Being A Doctor Sucks", most under the general heading of "I'm Really Tired". Some of those stories were lifted right off this blog. Also, she would be a little older than the traditional students and I reminded her that OMG, your biological clock is ticking! Babiezzz!!!

She was very surprised by some of the things I told her. She said that most people were really encouraging when she told them she was thinking of going to med school, especially when she told them she had doubts about it. (I was surprised by that, because I thought all doctors were bitter.)

Whenever I meet a pre-med, as a rule, I always try to talk them out of going to med school. It's not so much that I think nobody should go to med school. Clearly, there are people who are born doctors and love it. And if nobody went to med school, I'm pretty sure everyone would end up getting diagnosed and treated by Dr. Wikipedia.

So I'm not against med school. But I figure if there's something that I can say that is enough to talk a person out of going to med school, they're probably better off changing career paths now than when they have negative $200,000 in their bank account. Because medical training is damn hard and most people just don't understand that, I mean really understand that, until they're in too deep. I feel like if I can keep even one person from making a mistake, it's worth it.

On the last day of the rotation, Miss Beauty Queen told me she was going to business school.

WAKE UP CALL

Okay, I'll just come right out and say it: I was T-boned by a bus on Tuesday and have a type III odontoid fracture. I am now in a neck brace for 6 months but lucky to be alive and not paralyzed. I cannot even begin to explain all the thoughts and emotions that one goes through - from the coldly rational (wow, this is what it's like on a backboard, in a collar, in MRI) to the wildly emotional (DAMN DAMN DAMN, there goes the concert I was going to give, there goes the clinical study that was going to make JAMA, there goes the dressage show I'm ready for, and there goes vacation with the kids in the Carribean). But the one thing that is the MOST heartbreaking: not being able to scoop my kids up into a big bear hug.

Trying to be the optimist I'm struggling with what to do with months of non-physicality. Go ahead I think, perfect that Spanish, read all the library books, type up my diaries, catch up on all the movies - but somehow it pales in comparison to the dreams I was already embarking upon and achieving. And although I'll be home (always), I'll see the kids less because I won't be taking them to piano and swim and school and birthday parties like I usually do. But it's early yet - perhaps as a result, the kids and I will have more bonding time with the hubbie and our nuclear and extended family as well as friends may become closer still.

The weirdest thing is (harkening back to psych) that my schema of myself is slow to change. I keep having to remind myself that IF I move my neck the wrong way, or trip and fall, it could be disastrous. But it still doesn't seem real until in moments of sobbing I realize it is. Now excuse me while I go cry.

Guest Post: You're Fired!

Today a patient returned to my office for followup of my treatment of her spinal problems. She has back pain that clearly will not do well with surgery, so I’ve been trying to treat her with other modalities. She has been through PT, medications, and (most recently) 2 epidural injections. I do most of my own patients’ injections and did both of hers, spaced several months apart. She’s not a candidate for surgery, but I’m trying to help her.

At her first visit, I spent 45 minutes with her, evaluating and discussing her problem, showing her the MRI films, explaining what the options were. We discussed her anxiety and depression and talked about how that fed into her chronic pain. She did well with one injection, and seemed fine at that 20 minute followup visit. Now she returns after the second injection:

“Why didn’t you make me numb for this shot like you did the first time?” Tears. “It hurt so bad!” Tears. “Why did you let me be so anxious in the recovery room?” Angry stare. “I have some QUESTIONS.”

Now, I do the same protocol with every injection, including IV Versed for sedation. I know I did nothing different the second time, but no matter what I say, she gets more upset. Finally, after accusing me of telling her at her first visit that she needed surgery, and now telling her something different, she announces, “You and I are done, then.” I offer to refer her to another physician, and she snaps, “My own doctor can find me plenty of doctors who will care more!”

Fine.

As a professional, I’ve been here before, and I know not every patient is going to get along with me. It’s her choice, and I’m fine with that. My brain tells me I shouldn’t let it bother me and that this patient has issues I’m not going to be able to solve anyway. *You can’t make everybody happy all the time.* I can’t even make the fixable problems better 100% of the time. The studies confirm that.

My heart tells me that I went into neurosurgery to fix people’s problems, and I should be able to help every patient I see. Because I do care so much about every patient and because I try so hard, every patient should understand that and be happy and grateful. If a patient doesn’t get better or doesn’t like me, that’s my fault. I’ve done something wrong or not done enough, been supportive enough.

No matter how much my brain tells my heart to shut up and be realistic, I can’t reason it away. This will bother me for days. It always does. The 29 patients I saw back today doing great, who’ve thanked me for my help, don’t make this better. I love the successes, but I wish the failures wouldn’t hurt so much.


gcs 15 is a 39 year old full-time neurosurgeon in private practice in a beautiful Southern state. She has a 10 year old son who plays travel soccer and ice hockey. Her wonderful, Type B husband is a primary care MD who quit medicine to be a college professor and loves teaching premed students. She adores her job but hates the politics involved in the practice of medicine. She's always struggling to find ways to get more hours in the day.

Next Topic Day: Things we wish we knew in medical school

Our next Topic Day will be on Wednesday, November 12. We'll be sharing the advice we wish we had while we were in medical school.

As always, we welcome guest posts from readers. What would you tell entering women medical students concerned about future work-life balance? Career choice? Residency? Being an attending? Being a mother? What would you tell the younger you, if you could time travel, about life on the other side?

Please send any submissions to mothersinmedicine(at)gmail(dot)com and include a brief bio if you'd like.

Burying the message

We recently had an ant problem at home. After getting through the hot months without any real indoor ants, which are usually a summer problem in this area, we began noticing during a couple ants on the floor in late September, a little trail marching by the patio door, a few appearing under the sink...then full-on ant explosion. They were everywhere. Major ant problem. We made a valiant effort with the Trojan horse model, the little environmentally-sound childproof baits that are supposed to result in poison being carried home to the grand matriarch, then watched as our ants consistently walked a wide circle around them to get to the food remnants my 10 month old is eternally throwing on the floor. After a week or two, we gave in and called an exterminator.

A nice fellow came out, looked around, sprayed some stuff inside and out, then rang the doorbell again to give me the receipt. I thought the transaction was over, but it was just beginning. He also had a very long verbal list of suggestions of things to do to keep the ants from returning. It included removing all of the flowers from the beds adjacent to our home and sidewalk and replacing them with stone (or nothing), taking out all of our bushes whose roots might contact the home, removing the vines and other random vegetation touching our foundation, cleaning out the dishwasher filter twice a day and promptly cleaning crumbs, drips of juice, etc up when spilled, recaulking our kitchen counters and every other little gap in the kitchen, installing quarter-round moulding in several areas of the kitchen, emptying out our sandbox on the deck and powerwashing the desk, and "ideally" redoing our relatively new deck floor so that the gaps between the boards would not be so small as to provide a place for the ants to set up shop and build their nests. I'm sure I've forgotten some of them, but those were the biggies. When he started talking and told me that just spraying wouldn't be enough, we would also need to do a little work around our house, I thought, "Sure, of course, that's reasonable. He's going to tell me to try to mop the kitchen every day--I can do that, in fact, I'd like to anyway." Then the list started and went on and on and on. At some point in the list, I was amused, then kind of annoyed, and eventually came to a complete and final stop at hopeless. There was nothing to be done. We would have ants forever. So be it.

The next day in clinic, I heard myself giving a patient the list. It was a woman with cancer and a number of other medical problems, many of which were caused or exacerbated by lifestyle choices. I sensed that we had a strong connection, she was really listening for the first time ever, she seemed motivated and invested, and I had my in. This was my chance to really change her behavior. So I went for broke. I said she had to stop smoking, period. Her chemo wouldn't work as well if she continued smoking. Her breast reconstruction was more likely to be unsuccessful, from a vascular standpoint, if she continued smoking. If she survived the cancer she had, she'd be far more likely to develop another unrelated cancer if she continued smoking. She needed to eat less fat and lose some weight because we know that obesity is associated with a worse outcome, and a low-fat diet has been shown to reduce the risk of recurrence in a large randomized trial. And she should stop taking phytoestrogens--there were lots of them among her lengthy list of supplements. If she could manage to do an hour per day of exercise, that would be helpful too, and ideally, the program would include a half hour per day of the most vigorous exercise. Oh, and the other thing is...on and on and on. I saw her eyes glaze over the way mine did with the exterminator. I had her for a minute, then she looked vaguely amused, then she got a little irritated, and then she just got the zombie eyes and nodded in completely non-genuine assent. She had no intention of doing anything I asked. The requests were too numerous, too overwhelming, too unrealistic. The message--that she had the power to change her lifestyle and really impact her health in a positive way for the first time in her life--had been buried. In my enthusiasm, I had slammed shut the window of opportunity.

I saw another patient later that day who admits to smoking 3 packs a day, which probably means 4, and has for over 40 years. She also has a long list of medical issues related to lifestyle choices. At the end of the visit, I said, "I'd like to see you try to smoke less. Do you think there's any way you could cut your smoking back by one cigarette per day each week?" She said, "One less per day? That's it? Sure, I could probably cut out 2 or 3 without even missing 'em. You really think that matters, a couple cigarettes less per day, when I smoke 3 packs a day? Yeah, I can definitely do that. You watch, doc, I'll be down to 2 packs a day when I come back to see you in a couple months."

Sounds like a plan.

A full day's work by 9 AM

I start work at nine. I get up at six.

Even though we make lunches and lay out everyone's clothes the night before, we need that much time to get all five of us packaged and delivered to our respective places of work and play in good spirits.

I shower, dress and oversee the kids pulling on play clothes or school cardigans while Pete makes breakfast. There's a flurry of smoothing hair into pigtails, stowing rain boots in backpacks, pouring coffee and hunting for library books. We drive Saskia to before-care at her school. Then we head over the bridge and into the city, where we bring Ariana to daycare and Leif to preschool. Finally, Pete swings by my clinic and drops me off on his way downtown. I use the half hour before my first patient to review lab results and catch up on work email.

At two minutes to nine my colleague flies through the door, unstrapping his bike helmet. He's forty and single. His hair is a mess, he's out of breath and he seems exhilarated. "I woke up ten minutes ago," he announces. "I just rolled out of bed and out the door!"

Watching him hang up his reflective jacket and rummage in his briefcase for a granola bar, I vaguely recall a life where my only real responsibility between waking up and presenting at work or school was to put on clothes.

Now, I can hardly remember what it's like to show up at the office without feeling like I've already done a full day's work.

Lifestyle specialties

I work in a field called Physical Medicine and Rehabilitation (PM&R), which means that I'm pretty much constantly explaining what I do...

"I'm a PGY4 in PM&R."
"You're a what in what?"

Basically, we deal with sports and other musculoskeletal injuries, as well as the subacute medical management of patients with neurological injuries, including brain and spinal cord injury. It's supposedly a "lifestyle" specialty, which is illustrated by the joke that PM&R stands for Plenty of Money and Relaxation.

Of course, it's not all money and relaxation, especially during residency. But considering I had no in-house call, even during my first year after internship, I can't complain too much.

Lifestyle specialties are usually popular among all applying med students, not just women who want to have kids. That or skin is just SUPER interesting. It's definitely a lot easier to have children if you're in a specialty where the hours are manageable. I won't lie and say that lifestyle wasn't a significant part of my decision.

PM&R is somewhat like psychiatry in that it's a lifestyle specialty that isn't terribly competitive, probably because people don't want to do what we do or don't know about it. The more competitive lifestyle specialties are dermatology and radiology. Family medicine is another favorite among women who want to have kids (it's got "family" in the name, so it MUST be family-friendly). There are some internal medicine specialties that seem to attract more women, like rheumatology and endocrinology; cardiology, not so much.

Anesthesiology was extremely popular among women in my med school class. I never quite understood that, because the hours in residency seemed pretty rough, and it's one of those residencies that tends to get harder as you progress, with more responsibility. But apparently, the jobs after residency are great.

As everyone knows, the field that is probably most dominated by women is OB/GYN, which is decidedly NOT a lifestyle specialty. But I guess you have to do what you love, even if it doesn't necessarily have hours you love.

To Infinity..... and Beyond!!!!

“Bob the builder! Can he fix it?
Bob the builder! Yes he can!
Scoop, Muck and Dizzy…….”

So today I sang the entire theme of Bob the Builder….. while doing a pap smear. My patient was a stay at home mom, with no one to watch the kids. She attempted to keep the pacifier in her baby’s mouth while I did my best to “entertain” a four year old boy. Which entailed singing, while I inspected his mother’s nether regions. Later, I had to push him away from the biohazard trash with one hand, while hold “specimen” in the other. This is pretty much the norm. I guess this could be one of my multitasking skills.

My patients often have to bring their small children to their appointments. I have great sympathy for this having hauled my own boy genius around a few times. So I often find my self trying to help them entertain their children while I ‘m doing their exam. Whether it letting the kids hold the Doppler to listen to the baby’s heart beat or in depth discussions about Thomas the Train.

Recent interaction:

“I see you like Thomas?”

“Yes, my favorite engine is James”

“No that ‘s not Thomas your holding, that’s Gordon”

“No, Thomas doesn’t have a coal car, and he’s #1 Gordon’s #4”

“Yes, I’m sure I’m right”

I hope my patient ‘s appreciate the effort … and don’t find it creepy that I’m singing the theme to Elmo's World while checking their cervix.

"The health of the mother"

Considering that most of us probably have an opinion about a certain upcoming national event taking place on Tuesday, let me applaud us for having shown surprising restraint when it comes to talking politics on this site. A usual TV non-viewer, I know that I am dashing down from bedtime books with the kids to the couch every night now, eating up CNN with a spoon. I am off in la la land as I sit in boring meetings, wondering what the latest polls show.

But as a doctor-mom of 3, I am hopelessly behind. I frequently gush over movies I have seen over the weekend only to have people say quizzically, "You mean 'Walk the Line' that came out like 3 or 4 years ago?" Yeah, that's the one. I have made my peace with the fact that I will never catch up.

Anyway, I am ashamed to admit that I did not see the last Presidential debate (which took place over 2 weeks ago for those of you who are also 3 weeks behind on dictations and looking at 6 loads of laundry next time you can bring yourself to go to your laundry room) in real time. I recorded it to watch the next day--ha, ha, right! Anyway, I finally watched it tonight, before the election at least, and holy mackerel!

There is a moment in there where Obama and McCain are discussing abortion. Obama says, "I am completely supportive of a ban on late-term abortions, partial birth or otherwise, as long as there's an exception for the mother's health and life." McCain proceeds to offer his rebuttal and says IN AIR QUOTES "health of the mother", not once but twice. Here's a link to one video on youtube that shows just this brief exchange, rather than having to sit through the whole debate for those of you who were together enough to watch it in real time: http://www.youtube.com/watch?v=SGZOyxfiNoU

Whether you are Republican or Democrat or Independent, pro-choice or pro-life with or without conditions/exceptions, can any woman, particularly a woman in medicine, watch a potential future leader of this country put the "health of the mother" in air quotes during a mainstream media event watched by tens of millions of people without falling off the couch? I managed not to hit the floor, but just barely. And I'm posting at 1:30am because I cannot sleep for wondering the implications of such an attitude for the women of our nation.

Planting Bulbs

I love autumn. It's always feels like a time of regeneration and new starts, even more than springtime does. A lot of this probably has to do with school beginning in the fall - we get used to a cycle of starting again each September.

Fall is also a time of planting for me; while many look to the spring to sow seeds and plant annuals, I prefer to put in the bulbs that will become the crocuses, daffodils and tulips that I love to look at in the spring.

It dawned on me as I was planting the bulbs that this is very similar to raising kids. What?

I can prepare the beds and make sure the bulbs are as protected as possible from the environment, including harsh weather and rogue squirrels, but ultimately I have to have the faith that the bulbs will grow where I planted them.

Isn't it the same with our kids? We feed, clothe, nurture them, read to them, snuggle and play with them, and love them. We offer the best environment that we can - but ultimately have to recognize that the final outcome may be out of our control. As someone who is used to directing her environment, this is a tough realization to come to grips with. But, I'll sprinkle a bit of fertilizer and nourish both my bulbs and my boys as best I can. And wait for the outcome.

A

P.S. Have a happy and safe Halloween!

Stains

Pete and I were getting ready for work when he set down the iron, inspected his pants, and said, "Not these ones too! All of my pants have grease stains across the thighs."

"So do mine!" I told him. "Grease stains, mid-thigh."

We puzzled over the consistent appearance and placement of the marks for a few minutes, and then it dawned on us. The range of the stains exactly matched the heights at which our two- and four-year-old plant their little hands when they grab us.

I've been a mother for seven years, and I don't think I've ever gone into work wholly clean in that time. I've had breast milk spit up on my shoulder, crusted rice cereal on my shirt cuffs, teething biscuits cemented to my pant legs, apple juice splash marks on my shoes and now a tideline of grease across my thighs.

Maybe I should go back to wearing a white coat. Do they come in floor-length?

(Cross-posted at www.freshmd.com)

Dr Unicorn

In late September, daughter age four mentioned casually (about 20 times), without pediatric parental coaching, that she wanted to be a doctor for Halloween. Yeah! Not only were there the salient and loving implications of role modeling at play, but also, EASY costume! Perhaps an old adult medium scrub top as a full length dress, my stethoscope around her neck, a reflex hammer in her pocket, an ID tag, a fake chart (no EMR's yet), and we're good to go. But late October (just in time, really) she made a more rational decision, to change her Halloween costume and perhaps future career choice. Why be a doctor when you could be a unicorn? Okay, we can do it. A horn, a mane, a tail, lots of purple and pink fabric paint. And rainbows, an abundance of rainbows. It hadn't occurred to me why she changed her mind, but shall I assume it had something to do with the long hours?

(Fortunately, like RH+'s post, I was able to get time off for Halloween, because you've just gotta go to that pre-school costume parade!)

Mommy Awards

"You did it! CONGRATULATIONS! World's Best Cup of Coffee! Great job everybody! It's great to be here." -Will Ferrell as Buddy the Elf in Elf


One thing's certain: I won't be getting any "World's Best Mom" awards any time soon. "World's Most Embarrassing Mom," maybe - we're getting to that age.

Some people might even wonder - ESPECIALLY if you scour the American Academy of Pediatrics recommendations, or talk to parenting-book authors/readers - how conscientious I could possibly be as a physician when one considers that I have, at various times in the past,

-occasionally co-slept with my kids when they were babies (right in line, I must interject, with, like, 90% of the rest of the world's cultures)
-used Disney's Fantasia and the like as a babysitter when I had to cook dinner
-let my kids jump on backyard trampolines
-let my kids eat raw cookie dough
-skipped back-to-school night
-let them eat apple pie for breakfast (just once - and it was homemade and yummy and we all did it)
-made them memorize their times tables BEFORE explaining multiplication conceptually
-been physically and emotionally unavailable to them due to an excess of call
-let their father take them through a carnival house-of-horrors when they were WAY too little to laugh it off
-been way too permissive about TV-watching and video games/Wii playing
-missed some performances / special days
-failed to nurse at least one of them for the recommended period of time
-used phrases like "Because I said so" and "Don't do that"
-taken them out of school for trips
-required them to stick with certain academic or extracurricular activities against their wishes
-been impatient and snappish when tired or preoccupied
-let them eat a sickening amount of Halloween candy all at once.

Then I think, all those nitpicky little recommendations in the books and guidelines are nice, but they're not gonna make or break our parenting "success." I was sitting around comparing notes on the subject with some colleagues once when I was a resident.

"I watched TV all the time when I was a kid, " said one. "Violent stuff, too - martial arts movies and everything."

"We didn't even own a TV," said another

"We only ate food from local growers."

"We subsisted on chips and soda."

"I read TONS when I was younger."

"I barely read anything before college."

"And look - we all ended up in the same place, with 'M.D.' after our names, being fairly good people, for the most part, right?" someone finally pointed out.

That one conversation enabled me to avoid beating myself up too hard for all my faults and failings. Here's my bottom line: my kids are happy. They are healthy. They are curious. They have a sense of wonder. In general, they are kind. They read lots. They ask lots of questions. They know we expect them to work hard for their learning, to do not just "good enough" work but their best work always, and to accept the fact that they can't have every material thing they want. They have an abundance of what they need, and much more besides.

Most important, when they see our faces greeting theirs, they see us light up at the sight of them. They know they are immeasurably loved. They know we intend to be there for them no matter what.

And despite all those years of medical training, we have family memories to cherish. A brass band concert heard from a picnic blanket one balmy July night. Making s'mores in the wood stove one New Year's Eve. Dressing up as a medieval family with a Power Ranger to trick-or-treat one Halloween. Stolen moments, when I was either post-call or, miracle of miracles, actually off duty. Precious, warm, treasured moments.

So when the kids run to the door exclaiming "Mommy!" and throw their arms around me in big bear hugs every time I arrive home from work, or come home after a long night of call, I take heart. I may not be the world's best mom, or the world's best doc, for that matter, but I've had more than my share of the world's best moments.

EXERCISE AT 4AM??

Okay, I think I finally figured it out. Last year I remember talking to a colleague who told me he exercised at 4 in the morning before work. I looked at him like he was crazy. Turns out he wasn't so crazy after all. I discovered if it's something you love to do (dressage horseback riding) AND you don't want to take time away from the kids and the husband, it's a PERFECT time to do it. Not only that but you get there quicker since there's no traffic - and no one is there so you get the whole place to yourself!! It has completely eliminated the guilt I felt when I rode post call because I was either missing picking the kids up from school, or missing eating lunch with my hubbie. Not only that, the post call days weren't even that predictable and progress with riding was haphazard. This way it's 4 days a week guaranteed (Thursday is staff conference at 6:20). PLUS there's the extra added benefit that I come to work completely happy and relaxed, so no matter how bad the day goes I just remember my ride in the morning and I automatically get that meditative wash of "yah, but I got to RIDE this morning!"