My aptitude for family medicine: poor, apparently

I did the University of Virginia medical specialty aptitude test purely for sport recently and was startled to learn that of 36 medical specialties, the one I am least suited for is family medicine.

I'm not surprised that family medicine did not rank first. I chose it only partially because of any natural inclination toward it, and mostly because the training and practice of it meshed best with other priorities in my life, particularly raising a family. What did take me aback was that it occupied the very last spot on the list.

Pathology and radiology ranked at the top.

From time to time I flirt with the idea of returning to residency, but what it comes down to is that I would rank my current job satisfaction as a family physician at a 9/10. Is a chance at boosting that to a perfect score worth three more years of residency, a massive reorganization of family roles, a significant reduction in my time spent with the kids and a hefty kick in the pocketbook? I don't know.

William Maxwell, fiction editor of the New Yorker from 1936 to 1975, said upon retirement: "For nearly forty years I have shaved with pleasure in the thought that I was about to come to this job." How I love that quote. What a gift, such perfect happiness with one's work.

Of course, while he was shaving his wife Emmy was likely frying up the breakfast bacon, readying their daughters for school, preparing for a day of housework and granting him the enviable ability to be single-minded.

That is what I find most difficult about mixing medicine and motherhood: the diffusion of focus.

My work in refugee medicine is profoundly rewarding; raising three little ones even more so. The two have proven to be compatible. And yet at some point the efforts put into one require sacrifices made of the other. There simply are not enough hours in the day for me to invest what I wish I could into both spheres. I have erred on the side of mothering, and while I do good work at the clinic, my career trajectory has been modest.

I say this cheerfully. So far, I don't regret any decisions I've made. And every day presents an opportunity for new and different choices. Maybe one day, when the kids are a little older, I'll alter my career track or return to residency.

But for now, and maybe forever, a 9/10 is good enough.

(Cross-posted at my personal blog.)

Hello, unemployment!

In less than three months, I will be graduating from residency.

I can't tell you how much I've been waiting for this over the last four years, especially the last two years since I had my daughter. I didn't get to take as much maternity leave as I would have liked and all I could think about was how wonderful it would be to have a few months off with my baby. About a year ago, I made a list of all the things I wanted to do when I graduated. I lost the list, but I think "healthy cooking class" was on it somewhere.

Now my dream of finishing residency is so close that I can touch it. And instead of being thrilled, all I can think about is that I wish I had a job lined up. I wish I were doing a fellowship. Anything.

Part of it is that being unemployed is no longer cute or funny now that the economy is in the crapper. Not finding work is a real fear for me. I waited longer than my colleagues and continue to not look aggressively because I'm making a big geographical move after residency and interviewing would be difficult and pricey. So instead, I sit and worry.

I'm hoping the job situation isn't as bad as I fear. After all, I get daily calls from recruiters.... SIX of them emailed me last week to wish me a Happy Doctors Day, whatever that is. I just need one person to give me a chance. I'm not picky. My back up plan is to simultaneously apply for fellowships, since at least I'm only competing with graduating residents for those spots.

I just wish I could enjoy this break that I've been waiting for so long.

once is enough, apparently

Very recently, my son did what most of us all do eventually. He peed in the potty. In an effort to encourage him to continue with this exciting new development, I gave him a gentle prompt. Before tub this evening, I asked him if he wanted to pee in the potty, and he said "that's okay, I already peed in the potty yesterday."

Finding my net

My husband deployed 3 weeks ago today. Before he left, I said a silent prayer that the following 3 things would not happen while he was gone:

1. Sudden demise of a major, cannot-live-without-it household appliance
2. Vomiting illness
3. An ER visit for me or my kids

In those 3 weeks, we have had 2 distinct vomiting illnesses tear through the entire household. One of them, in my 3 yr old, was severe enough that we wound up in the hospital with a very scary clinical situation: dehydration, distended tender belly, anion gap metabolic acidosis, elevated LFTs, and alarming lethargy. Fortunately, after lots of fluids and antibiotics, she is now back to normal. Oh, and did I mention that our washing machine began a slow, spiral of death within 12 hrs of my hubby's departure and ultimately took its last breath in the midst of wave two of vom-a-rama, leaving me to wash about 2 dozen loads of vomit-soaked bedding and clothes in total in our tub, wring them in the washer (which would still spin until close to the end), and then dry them...ALL NIGHT LONG on more than one occasion.

Deployment is really not going so well for us. Or so I thought.

But today, I had a fantastic day. Why? I bought a new washing machine over the weekend, and I did four loads of laundry today. Ordinarily, that would not be cause for celebration, but today I felt like whistling a little tune as I watched our clothes gyrating around. Even they looked happy in there. I could have sworn my sweater was flirting with my jeans. And no one vomited. In fact, no one has vomited for 4 days now. And, although I was in a hospital today and my clinic ran hours late, I was on the right side of the stethoscope. Amazing how a little badness can make a whole lot of ordinary look pretty fantastic.

But the real reason that I am feeling on top of the world is that I have found my safety net when I was beginning to think I was flying without one. In the midst of illness and household crises,not to mention general deployment sadness, we were invited to dinner by other Navy families (thanks, KC!) and preschool families we didn't know especially well before. I had acquaintances who heard about what was going on show up unannounced at our door, asking to take our vomit-soaked laundry to their house to wash and dry and return it to our home (!). I watched in awe as our clearly exhausted nanny stepped up with a smile and came to the ER after working a full day with vomiting kids to take my non-sick kids home for dinner and bed so that I could focus on taking care of my desperately sick one without guilt or distraction. And I had busy family members volunteer to drop everything and get in the car or on a plane to come to us as fast as modern transportation would allow if I said the word. Suddenly, I feel strangely lucky that my husband is deployed. Surely these kindhearted, generous friends and acquaintances and relatives were out there all along, and I could have seen them if I had looked hard and long enough, but it took deployment and all the minor crises that ensued to bring them into focus for me. It has dawned on me how much a little nugget of goodness can resonate with someone who is in a crisis, however defined.

Today in clinic, I saw an elderly woman with newly-diagnosed metastatic breast cancer. Through a series of unfortunate self-fulfilling medical prophecies, including misreading of a CT scan and erroneous interpretation of pathology slides, she had been told that her cancer was widely metastatic, required urgent, very aggressive chemotherapy, and that she would almost certainly die within 6 months regardless. I had the distinct pleasure of telling her that while she does have metastatic cancer, it involves only a few spots on her bones, appears biologically quite indolent, and should be easily treated with one pill a day that won't cause nausea or hair loss or any of the things she fears terribly. As she teared up for the first time, about 30 minutes into our visit, I took her hands and said, "Listen to me. It is far more likely that you will die WITH this cancer than OF it. You are going to live for many years to come." It was one of those moments that every cancer patient coming to a large medical institution for a second opinion (and every oncologist seeing such a patient) silently dreams and prays will come to pass, but which very seldom does. Today, she and I shared a moment of joy that was like nothing I have ever experienced in my life except at a birth. In a way, it was a kind of birth. It was her life, unwittingly stolen by a devastating comedy of medical errors, being dusted off and handed back to her. At the end of our visit, she said to me, "I have had people coming out of the woodwork since this diagnosis making such offers of help to me and my husband...you wouldn't even believe it, if I told you some of stories. And now, I feel on top of the world even though you confirmed I have metastatic cancer. Who would have thought such bad news could sound so great? Weird. I know that probably doesn't make sense to you at all."

Actually, today, it makes perfect sense.

Vote for a future colleague! Vote for love!

Mothers in Medicine, our help is needed. Kirby is a MS3 who is a dedicated reader of this blog. She and her fiancee are finalists for a free wedding...but needs votes to win! You can read about their story and vote on the right sidebar for "Kirby and David" at the website. It takes only a minute to vote but could mean making the dreams come true for a future mother in medicine. Voting ends the morning of Sunday, April 5.

I just voted. It took me all of 0.2 seconds.

Good luck, Kirby and David! You'll have to promise to post pictures of the wedding here if you win.

Mother of the patient

I thought maybe my 14-month old son woke up on the wrong side of the crib from his afternoon nap. He wasn't acting like himself. He had no appetite. He was burning up. And he was breathing noisily. I had thought he was getting better from his cold that started several days ago but now he looked sick.

I took out my stethoscope and listened to his lungs. Coarse breath sounds, rhonchi, and wheezes. It sounded awful in there. In my little baby boy. My sweet, angel of a boy. It seemed so wrong that such sounds would be coming from his lungs.

I grabbed his sister's albuterol inhaler and spacer and gave him a couple of puffs. Which did nothing appreciable to his breathing. He also wasn't the most compliant of patients.

It was Sunday afternoon. Of course. It would be the ER. Now, or in the middle of the night, I thought.

I made the executive decision to have him be evaluated in the ER. We should go. Now.

At the front desk, I insisted to be the one to fill out the triage paperwork (as opposed to my husband, not in lieu of the nurse!) Reason for coming: wheezing, tachypnea, fever. I needed to "sell" him as someone who needed to be a priority. I needed them to know I knew.

Rectal temperature in triage: 102.9 F. Pulse 180s. O2 sat 93% (!) RR 42/min (!)

It wasn't very busy and we got into a room right away. They set up a neb for him right away and had me administer it to him, knowing that I was a physician.

JL did NOT like the nuisance mist machine all up in his business all the time and fought it sadly, crying, twisting. I watched as the nebulized mist battled his thumb that was firmly planted in his mouth. He was burning in my hands.

I told the ER physician right away that I was an internist. We needed to be on the same page. Because of that, her way of dealing with me changed, giving me a lot more power in the physician-parent relationship. She told me her thoughts, but then wanted mine, and ultimately left certain choices up to me. X-ray or not (no). Antibiotics are not (yes). I couldn't bear the thought of his little body soaking of radiation - and for what? To definitely know he had a pneumonia? Would I be satisfied if it was negative to not give him antibiotics (no)? But, I worried about some focus of bacterial infection since he was getting better from his cold and then turned for the worse. Bloodwork or not (no). Ceftriaxone IM x 1 (no).

I appreciated having the chance to weigh in so heavily, although I do wonder if I was completely clinically "on" given my duress having a sick child in my arms. Not any sick child. My sick child. But we decided this would be our management. He would be given an acute follow-up appointment in the peds clinic the next morning.

At the follow-up, the pediatrician examined his ears and saw a very clear-cut ear infection in his right ear. This was never done in the ER. I had wondered to myself if someone was going to look in his ears for the sake of completeness, and even entertained the idea of taking a look myself with the otoscope in the room, but quickly brushed the thought aside when JL had pried open the red biohazard container of the floor exposing some kind of urine hat. Plus, the ER physician didn't think it was necessary.

Perhaps I led the ER physician down a diagnostic pathway due to my own suspicions, and maybe coming from me, was persuasive enough not to veer her too far off that path. I know how to give a compelling story for whatever process I think is going on. Isn't this only natural? But, I'm wondering whether she would have done exactly the same with a parent who wasn't a physician. Would she have been more complete? Would she run more tests?

Anyway, JL is doing better, on antibiotics. He's defeveresced but still with a "junky" chest exam. His antibiotic dose was increased since apparently the dosage is higher for an ear infection than pneumonia (wow, peds was that long ago).

And I'm left wondering how much I help and how much I complicate when it comes to the health of my own children. I hope it's heavily weighted towards the former.

No, Mom, Billy DOESN'T want to stay for dinner

While sitting at the dinner table, someone brought up maggots (I know! – but such is life with two boys of a certain age; disgusting subjects at dinner are the usual fare alongside the main course). Eldest quickly mentioned how skeeved he would be if a maggot were to touch him. Of course, I had to jump in with all of the medical uses for maggots, especially when used to treat decubitus ulcers or other poorly healing wounds. I casually discussed the role the maggots played in debriding the dead tissue and how most patients would likely consider maggot therapy rather than dismissing it out of hand, especially if faced with a potential amputation. I buttered a slice of bread as I chatted about how maggots stayed away from healthy flesh; concentrating on my broccoli, I failed to recognize how quiet my dinner companions had become. As I started in on the medical uses of leeches, I looked up from my plate to see three faces staring at me in horror. Mouths agape, eyes wide, silverware down; my family finally burst out as one: “That’s revolting!”

Er, yes, I guess some might view it as such. Apparently it’s time to brush up on my sense of acceptable dinner conversation, which has at this point been warped by too much discussion around the themes of farts, boogers, loogies and the occasion poop.

Baseball, anyone?

Seriously, I wanna know...

Do you have a favorite season? Does your favorite have anything to do with work/school? Winter for Pediatricians is like tax season for accountants - busy! In the spring, we are starting to pull out of cough, cold, flu season, but the days in the office can be unpredictable. Having just had a run of influenza at our house, I'd say home is unpredictable, too. Fall was my perennial favorite for many years - still some daylight when I left the office, boys in the groove of school, family vacation during Fall break. Our school system changed their schedule a few years back and did away with the Fall break - shattering it into several teacher work days scattered through the semester. Vacations shifted to Spring break to compensate. I've found myself looking forward to summer more and more - the more free-form home schedule, warm weather, flip flops (wish I could be OSHA compliant in them at work!) and lighter schedule at the office even with partners on time off. So my answer: Summer!

photo credit: seseo.wordpress.com/2009/01/

"Match Day" book give-away follow-up

In a highly technical method of randomization (comments printed, cut into slips, and picked blindly from a bowl), ten readers of Mothers in Medicine were contacted last week to receive their prizes. Amazingly, quite possibly all of the commenters whose name is "Katie" got selected by some strange twist of bowl-drawing fate. What are the chances? (Okay. Could calculate but...)

Thanks for joining in on the fun.

(Shout out to Jenny, MS2 in NYC: claim your book! Email us with your address!)

Mom's Apple Pie

I have a confession to make - but first, a little story.

Last Friday my husband and I got to do one of our favorite things: walk our son to school, a lovely, small elementary school set amid tree-lined streets in our peaceful neighborhood.

That day we went bearing pie - home-made apple pie, to be exact, by special request, for an open house during which we would get to peruse all the kids' family history projects and enjoy culinary delights from the various cultures represented in the class.

My son had been worrying (needlessly, despite reassurance and encouragement) about this project for weeks. He was worried about getting the work done on time. Worried about messing up the illustrations. Worried about revising the final draft. Worried that I wouldn't have time to make the pie and he'd be the only little boy whose mommy was a dismal, neglectful failure.

Well, by golly, I was determined not to disappoint him, even if I had to stay up late post-call or get up early pre-call to do it. As it happened, not only was I able to make the pie at a reasonable hour, right on time for the open house, but also my call schedule was such that I didn't have to be at work till mid-afternoon on open house day, so he was able to have both parents there.

My son visited me in the kitchen while I was preparing the apples. He sometimes tries to keep me company because he's concerned I might get lonely (he hasn't quite grasped the concept of enjoying time for oneself).

"I told all my friends you make the best apple pie in the whole world," he said.

How cute is that?

"Well, that was very kind of you," I replied.

"It's the best pie ever."

"I'm so glad you like it."

Peel, peel peel.

"Is it hard to make?"

"Not especially," I said. "Once you get a feel for when to add water to the dough, and how much to add, it's not a hard recipe to follow."

Dice, dice, dice.

"Do you like making apple pie?"

Hmm. How to answer that?

"Parts of the process can be a little tedious, to be honest," I said. "But it's not bad - I don't mind," I said quickly, to reassure him.

"I love your apple pie," he said.

I never did learn in anatomy class where exactly the "cockles" of my heart might be, but they were definitely warmed.

On the day of the open house, as we approached the front lawn of the school we caught sight of other parents coming from different directions on foot with their children, carrying covered dishes and trays and plates, all heading toward the front entrance. There was something so village-like about it. A pleasing aroma of book paper and crayon drawings wafted over us as we entered the school building, making me nostalgic for my own elementary school days, when I could focus my attention, as these kids were doing, on things like "daily life in colonial times" and haiku.

The atmosphere at the open house was one of friendliness mixed with the pleased-as-punch pride of children who have done well at something. There was so much food the teacher had to set up a second table. We ate, visited the desk exhibits, mingled with parents, mingled with children; some families even visited their friends' open houses in other classrooms.

We opened our son's Family History Book and smiled as we read his tell-it-like-it-is descriptions, written in his painstaking scrawl. On the cover he had drawn a Philippine flag and a French flag, as well as maps of both countries. In the upper left corner there was a small, muffin-like item with steam rising from the top.

"That's a pie," he explained.

Several pages into the booklet it appeared again: a little pie in the margins.

My confession is this: making my husband and children happy with pie is the "accomplishment" that brings me the greatest satisfaction in life.

Even their deeply appreciative inhalations as they enter my kitchen filled with the smell of baking pie make me feel like I'm on top of the world, like I've made their day a little better. Yes, I graduated with honors from an Ivy League university. Yes, I got a medical degree. Yes, I am reasonably successful in my practice of medicine. Yes, I've had the chance to travel, learn languages, study music, get advanced degrees, receive a little recognition for things I've written, and all that. But nothing brings me greater joy than those moments when my husband and kids are eating well, savoring with relish a pie I've just made. Am I crazy? Perhaps. Crazy about them.

It's funny - cooking is, by definition, the creation of gifts that can't last. The moments we take to enjoy meals together are fleeting, as are the meals themselves. But those moments are worth the world to me. And somehow the gift does last, I think - I hope - in ways I'm sure I can't see or predict. I'm hoping that somewhere in the margins of my children's lives there will always be a little pie sketched in - an unquestioning, nourishing trust in their parents' love, a capacity for sharing and for happiness, a corner of freshness and warmth.

I hate boys!

Sorry, I need to vent:

A resident I know recently came back from maternity leave with her second child and happened to mention to another resident (a single male resident) that she was tired.

His reply: "Why are you tired? You just had a vacation!"

Hearing that story really made my blood boil. Of course, all women who have kids know that maternity leave is not a vacation by any stretch. I still remember mine as one of the most exhausting and stressful times of my life.

But what really got my angry about this was not the thoughtlessness of the comment from a single guy who really has no idea, but it drew attention to the fact that the most unreliable residents in our program are the single guys. The female residents with 2+ kids are always on time, considerate, hard workers, etc. The punctuality and attendance issues we have at our morning lectures are 100% attributable to the single male residents. Or "the boys", as I call them.

You would think that with no family to worry about, the boys should be able to be Super-residents. They should be the first ones into work in the morning and always willing to stay late to help out. They certainly shouldn't need to whine about covering an extra clinic here or there. Yet I'm finding that the opposite is true. The boys tend to be incredibly unreliable and the first to complain about coverage issues.

Of course, I'm generalizing. I know there are a lot of single guys who are great residents. But it really makes me angry when someone who can't even show up on time in the morning belittles a working mother of two for being tired.

Welcome to Match Day on Mothers in Medicine

Welcome to our 5th (!) Topic Day at Mothers in Medicine: Match Day. Today, we'll be featuring posts about our experiences with the big day.

As promised, we are also giving away 10 (!) copies of the book "Match Day" by Brian Eule. (See reviews by myself and Fizzy earlier this week). To enter, leave a comment to this post with your email address and we'll select 10 random readers to receive a free copy sent to them! You have until midnight tonight to leave a comment, so spread the word, tell your friends, score a copy!

And, good luck to those going through the actual match who will be finding out tomorrow at noon EST!

Posts will be publishing regularly throughout the day. Scroll down to see the posts....

Match Day: Part 1 and 2

My match day was March 17, 2005.

Our match day was done in a "let all hell break loose" kind of fashion. The envelopes were at different tables organized alphabetically, and we basically trampled each other in an attempt to get our envelopes.

Inside the envelopes, was a tiny strip of paper. That 1 cm high strip of paper had our whole future on it.

I matched at my first choice on my rank list, at a primary care program close to where my husband would be working. I was so thrilled that I cried (well, a few tears) and hugged my friends. Ironic, considering I wanted to drop out of that program within two days of starting. It took me six months to get up the nerve to tell my program director that I wasn't coming back next year. No way, no way, no way.

Match #2 for me took place a year later. I didn't do it through ERAS because I was already a resident. I was on evening cross cover and as I sat in my scrubs on the couch in the empty resident lounge, waiting for the other residents to sign out to me, I got a call on my cell phone. It was the program director at the PM&R program where I had interviewed a few weeks earlier.

"We've decided to offer you a spot for next year," she told me.

No fanfare, no trampling, no hugs, no tears, no green Hawaiian leis. But there it was: a spot for me in my dream program.

Now I'm nearly three months away from graduating from this program. I feel blessed that I had the opportunity to train in a field that I love. And I don't throw around words like "blessed" very often.

Pediatric Match Day

“Should I stay or should I go now?”
The Clash

I don’t think Mick Jones or Joe Strummer knew anything about the NRMP or National Resident Match Program – but their words echo in my head as I think about my journey from medical student to pediatric resident in the early 1990’s. The decisions I made that late winter were many but they boiled down to remaining in my medium sized southeastern hometown, or venturing to a bigger pond. St. Christopher’s in Philadelphia, Emory in Atlanta, Children's National Medical Center in Washington, DC were three of the several pediatric programs that I interviewed and interviewed me. The big city had an allure for me, and each successive site convinced me that I could swim in a bigger location.

But I had my doubts. Could I learn to draw all the labs on my admissions? Would that be educational or just scut? Would I be safe as I headed to my car after 30 hours (these were the pre-mandatory work hours days) in the hospital? Would the traffic overwhelm me? Could I afford to live on a resident’s salary? How would I find a roommate if I needed one? Did all the “perks” of a program really matter? Would I have chemistry with this program or that one? Maybe that seems like an odd question, but I was about to spend the majority or my life inside the walls of a hospital. I needed a sense of connection to this team I was about to join. For the next three years, I would be guided by physicians who could determine some part of my professional future with their advice and evaluations. In return, I would be expected to be a team-player with my fellow residents in the care of patients. Could all of this come down to a gut decision? For the one time in my life – footloose, unbeholden and young, my decisions affected only me.

Despite some early interests in triple board programs (Pediatrics/Psychiatry/Child & Adolescent Psychiatry), I interviewed in and ranked only categorical Pediatric programs. Writing that rank list was one of the hardest career moves I’ve had to make. (Taking my first job in the rural Southeast over the chief residency was a close second) All indications were that my home program at a children’s hospital would welcome me into their fold.( Reassuring smiles & nods from attending physicians) No guarantees, though. That would be against the rules of the match. The alternative was to take a risk and rank St. Christopher’s Hospital in Philadelphia number one – a program where I’d had a second interview and hopefully made an impression. Again. No guarantees. No assurances. Pick my home program and have familiarity and the acquaintance of at least two thirds of the residents. Or, pick the unfamiliar, riskier choice that could potentially jettison me into a fellowship or academic medicine.

My own Match Day was anti-climatic after I submitted my list. Most applicants for Pediatric residency positions get their first choice. I was no exception. Yet I was still jittery on that Wednesday. My class had spawned five couples who were trying to match as couples. My nerves felt their anxiety and my own. What if some computer glitch matched me in Philadelphia or Washington, DC? Was the decision really about location or was it more about envisioning the future of my career? Was it about having a high-powered pediatric career or a more balanced life that included pediatrics? Guess what? I’m still working on that balance, and some days I have thoughts about the fellowships I could have applied for, but I wouldn’t have written that rank list any differently.

(match day) - which day was that?

Not sure why but I can hardly separate out in my mind my own match day (in the 1990's) and my husband's a few years later. Earlier today I asked him to remind me about the circumstances surrounding our opening those fateful envelopes. I don't think it's post-traumatic stress-induced amnesia, since we both were happy with each of our matches, despite the hurdles coordinating the geography and job prospects without a true couples match. Perhaps my MIM status has resulted in a loss for specific details; I now more holistically just remember that it ultimately all worked out for the best. Then again, my coffee cup is usually half full.

What's coming back to me now is how silly I felt mentioning "my boyfriend" during interviews leading up to match day, since we'd actually been (living) together for many many years prior to actually getting married. Sometimes I mixed it up by saying "significant other." We did become domestic partners so we could co-habitate in the med school dorms, us and a few thousand gay New Yorkers. In any case, most of the hard part was us figuring it out beforehand, crafting the list, and then once we met our match we planned accordingly. After all, the culture in medicine is to train for 3-4 years, and then make a decision to move or stay. Then you train for several more years and then make a decision to move or stay. And so on. Fortunately for us, the "move or stay" has always involved staying in love.