MiM Mailbag: Shared residency

Hi all!  I love your blog, and have already utilized so much of what I've learned from your posts.  I'm an M1 with a seven month old.  Although I am very far from making any decisions regarding specialty options, the fact that I will be deciding in the next couple years has been on my mind lately.  And while I know it shouldn't be the only factor I consider, I would be lying if I said that lifestyle wasn't an important player for me.  So, when I heard about the possibility of a shared residency, I became very curious (and even, yes, a little excited).  I am sure these things are few and far between, as well as incredibly competitive, and chock full of faults of their own, but what do you ladies think about them?  Anyone do one, or know someone who did?  I would love to know more about them, but am hesitant to ask people at my school, for fear that they'll make assumptions about me. Thank you!

Hello There MiM!

Hello everyone! I am new to MiM and looking forward to learning about everyone here. My name is Laurie Marbas and I am a family doc in rural Colorado. I just finished a stint in the USAF and now my family and I are adjusting to the civilian world. We are loving every minute of it, especially the part of no more deploying!

Just a little bit about my family and I. I am married and when I started medical school (go Texas Tech!) my kiddos were 5, 3, and 10 months. Well, now they are 16, 14, and 12. Needless to say I have a few more wrinkles and not sure about the gray hair because I feel compelled to keep the local beauty parlor in business. During med school my grandmother also lived with us. She suffered through breast cancer my 3rd year and a stroke my 4th so I have learned some tough lessons and am looking forward to sharing these with you all. I also have my own blog at http://laughingdoc.com.

Again, thanks KC for the opportunity to share.
LaughingDoc

Friendship and Female Physicians II

Over a year ago I wrote a post about the challenges of making friends as a female physician. I cross-posted it on my own blog, and the comment boards on both blogs were pretty interesting. I'm back for a visit here because the topic has generated a lot of reflection for me lately, once again.

One of my best friends in med school was an O.B. nurse. Though she has moved almost all the way across the country and I haven't seen her since I was in school, we're still in touch and expect to be seeing each other at last in a couple of months.

By some coincidence one of my best friends now is also an O.B. nurse. I'll call her Ziva (yes, I watch a lot of NCIS). Ziva is from Israel. She is smart and funny, a lover of books and movies and good music and good food, talented and competent, and above all a great and generous person I would entrust with my children's lives. Ziva and I can talk about just about anything - silly "girl stuff," deep intellectual stuff, spiritual questions, moral/ethical dilemmas, work stress, kids, comic moments from day-to-day life, worries about tough problems, faults and failings, embarrassing secrets, cultural differences, things that inspire us or bring us joy.

For some reason, her colleagues are very uncomfortable with our friendship and underhandedly persecute her for it with snide comments and not-so-veiled criticisms. One time I arrived to provide a spinal for a C-section. Ziva was already in the room counting instruments, and one of the other nurses said, "Oh, are you happy now - your friend's here." Another time she happened to mention that she and I had recently discussed the mechanics of intubation, and in front of all the other nurses one of her other colleagues made some critical remark about her being friends with me. When Ziva called her on it, saying "What's wrong with that? T. is SO nice! She's totally adorable," the other nurse said, "I have no desire to be friends with T. I have my OWN friends." Ziva found this nurse's comments and the tone in which she said them disrespectful and hurtful. Many of the other nurses can barely conceal the clouds of disapproval and resentment that darken their looks when Ziva and I greet each other cheerfully at the nurses' station.

"They feel threatened," my husband said.

"But if I were a single, tall, good-looking MALE doctor it would be FINE for a nurse to be close to me, right? Isn't that totally self-demeaning of these women? Sure, it's ok to befriend a man in a position of authority, but it's somehow wrong if it's a woman?" I was totally frustrated and irritated that the culture in this workplace wouldn't tolerate a genuine close friendship between a female doctor and a nurse.

Ziva and I do not flaunt our relationship in professional situations. I feel I am just as business-like with Ziva while delivering patient care as I am with any other team member, and conversely, just as nice with the other team members as I am with her and with the patients and with any colleague. But there's a lot going on here. Gender issues. Cultural issues. Xenophobia, or, even worse, maybe some anti-Semitism. And perhaps status issues. Maybe they think nurses and doctors can't or shouldn't be friends (unless, of course, it's a dating situation between a male doctor and a female nurse). Or maybe they feel Ziva's smarter and more highly trained and better educated than they are and they just can't stand it.

I am feeling exasperated and a little angry. This type of collective attitude is completely stupid and unnecessary. I don't know that there's much I can do about it. I'm certainly not going to change this blessed friendship for the sake of a few small-minded harpies who aren't comfortable enough in their own skin to show some tolerance, respect, and support.

-T. from Notes of an Anesthesioboist

MiM Mailbag: Pumping intern

Hi there,

I'm glad I found this blog. I have learned a lot from the posts, and I suppose I'd like to ask everyone's advice if that's okay.

I am working as an intern next year in Melbourne, Australia, and my baby will be 8 months when I start. I am planning to continue breastfeeding him. I get some ideas about expressing whilst working but to be honest, I am still very nervous about the whole thing: Will I be able to fit pumping into a hectic internship work? What should I do if I get paged in the middle of pumping session? I have a relatively slow let-down reflex, what if I cannot pump much at work? (I tried manual pump --it's hopeless, havent tried electric one yet though). Which pump should I use --Medela handsfree style or just normal one? (can you actually realistically do some intern works while using freestlyle breastpump?)

If you have some tips or experience to share, I'm all ears :)


-internmama-

Dressed to Kill

Several months ago, when I was still a fellow, I had a totally embarrassing interaction with my attending:

I had just finished seeing a patient with him and when we were done, he ushered me into his office, closed the door behind him, and instructed me to sit down.

"Listen," he said. "There's something I need to tell you."

"Okay," I said, perplexed.

"Now I know this is going to sound hypocritical coming from someone who badly needs a haircut," he said. At this point, I was starting to panic. I was wondering what the hell was wrong with me. Was there some odor I wasn't aware of?? "But when you're an attending, you have to be very professional about the way you dress."

"Oh," I said. Now I was confused. I don't exactly dress classy, but I don't walk around in jeans or anything. I thought I looked okay.

"A patient made a comment to me in the past," he said, "that he could see your stomach under your shirt."

I was shocked. Trust me, I don't dress racy. I wasn't walking around in a midriff, if that's what you're thinking. At that very moment, I was wearing: tan khaki slacks that were probably at least two sizes too big, an off-yellow polo shirt that fell well below the belt-line, and a "granny sweater" that I inherited from my great aunt (my mother put it in my closet and it's ugly but warm). If I were dressed any less sexy, I could have joined an Amish community.

I had no idea what the offending outfit was, but I suspect what happened (on analyzing and overanalyzing the situation and mostly being pissed at the patient) is that the pants I was wearing were too big and the belt I was probably wearing to hold them up was too big. (I have stomach issues and thus feel sick when I wear pants that fit snugly around the waist.) And perhaps the combination of that and a normal-length shirt created a temporary gap when I raised my arms to examine the patient. A similar thing happened to me when I was pregnant, because all maternity shirts show off ridiculous cleavage.

However, it's true that I don't know how to dress. My mother, also a physician, was a notorious bad dresser who wore sneakers to work and got called out several times by her boss. But she loves to buy me clothes and I think may be under the misconception that I'm still growing, so she only buys me insanely colorful shirts in Large for my 110 pound frame.

And of course, through most of my medical training, I was desperately poor and clothes are expensive. When I shop at a non-discount clothing store, I feel ill and wonder what sort of person can afford to pay $50 for one shirt. So I shop at places like Target, where the clothes are still more expensive than you'd think. I bought the majority of my wardrobe when I started my MS3 year and had been clinging to it till it got so worn out, a strong breeze might have rendered me naked. (Take that, prudish patient!)

After my attendings comment, however, I did make some changes:

1) I got all my pants hemmed. I'm not sure what sort of gigantic Amazon woman pants are constructed for, but my pants were all several inches too long and I was wearing them rolled up. Now I just automatically add $10 to the cost of pants for hemming costs.

2) I got new shoes. After spending the year walking two miles to work and back in my loafers, I had a dire situation going on. When you look into your shoe and see sunlight peeking through, you know it's time for new shoes.

3) I invested in a few new shirts. The finest garments Target had to offer.

I still don't feel well dressed though. Some women always seem to look classy and chic, but I might need some sort of Tim Gunn intervention in order to get to that level. I guess as long as nobody is complaining, I'm happy.

Open door policy

My office sits on a busy hospital corridor. Most times when I'm inside, I keep the door open. Not just open a crack, but widely ajar. I don't know. It feels neighborly. And, I like being accessible to my ward team whenever I'm on service - my interns, residents or students just pop on by with questions, my office only being a short walk down the hall from their team room.

Of course, my open door policy means that I might be slightly less productive while working at my desk (and also puts me at risk for being exposed to ambient noise and...fragrances), but this connectedness I feel with the hospital around me - my colleagues, other hospital staff, the patients- seems worth it. (On the introvert-extrovert scale, I tend to score down the middle. Maybe that explains it. Need interaction, just don't have to be in the center of it.)

Last week, one of the dieticians on the floors (someone I've had only minimal interactions with) stopped in my office and proceeded to sit down in one of my office chairs facing my desk to tell me of the headache she had a few weeks ago. It took me a few seconds to realize she was seeking my medical opinion. Over the years, I've had multiple staff come in to tell me about their bodily discomforts - all casually entering, taking a seat, and launching into their personal stories without much warning. I've always found these encounters slightly touching that they would feel comfortable enough to approach me and trust me to render them an opinion.

I've had interns (who are not on my team) come in to vent and end up crying about a stressful situation on their team. I've had students (who are not on my team) come in to vent and end up crying (note to self: bring new tissue box to work), and have also had students come in to talk about life, their career plans, balancing motherhood and career, you name it. People just walking by, seeing my door open, and coming in.

I've had lots of patients or visitors asking for directions. Lots of patients or visitors stopping to ask what a "Hospitalist" is. I've been a loan center for pens, chairs, and paper. Recently, one of the support staff stopped in and asked to charge their cell phone in my office. No kidding. That was a new one. Apparently, my office is a one-stop shopping extravaganza.

It's full of surprises, occasionally chaotic, at times downright odd, and, just sometimes, something deep and meaningful that could only happen by leaving the door open.

It reminds me of my favorite part of Thanksgiving. For many years, I've been hosting a crew that has often included my parents, my in-laws, my brother and his wife, cousins, lone friends, anyone wanting to join in. It's having a busy and full house, feeling the joy that comes with caring for others, of being there together.

It's all about the open door.

Please hold

Nothing like seeing an old picture of yourself to serve up a big plateful of truth. You might thing I'm talking about aging, and I've certainly had my share of those moments--wait, I DID once have a waist, and other favorites--but no, I'm talking about delayed gratification. We went on vacation this summer to the beach near my sister's home. While we were there, we spent a day at her place. I wandered through her house, looking at pictures of us together from 7 or 8 years ago. And then, it hit me. The clothes. I had packed light for our weeklong trip since the kids had oodles of things they wanted to bring and we were driving. I had brought only 4 shirts. I was wearing 3 of them in the pictures on my sister's table. I suddenly realized: I HAVEN'T BOUGHT ALMOST ANY NEW CLOTHES IN 8 YEARS (maternity clothes excluded).

Now at least part of the reason is that I hate to shop. For anything. Truly hate it. I think clothes are fine, and occasionally I have been known to fall in love with an article of clothing, but I just cannot bear shopping, especially for clothing. Maybe it's the unforgiving dressing room lights. Maybe it's the chafing of taking on and off 2 dozen dresses. Maybe it's frugality, knowing that I will one day fall out of love with whatever I just spent that money on and will regret that I ever bought it. I don't like it much better online than in person, so maybe it's all sorts of things. As I looked at the pictures, I told myself, it's just that you don't like to shop. But here's the big plateful of truth that I grazed on as I drove home to our beach house that evening: I have come to think of delayed gratification as a way of life rather than part of life.

I think this problem began when I was a medical student. After 22 years of living largely in the moment, I was suddenly having to wait to satisfy even the most basic needs. Need to go exercise? Big exam in 48 hours, I probably should focus on that and exercise this weekend. Need to pee? Well, unfortunately I'm on the far end of a retractor in an abdomen, so I'll just hold it for about oh, 4 more hours. It only got worse as a resident. Need to eat? Oh, I have to pre-round, I'll just wait until lunch. Need to rest? Oh, 3 more admissions for in the ER, I'll sleep when I get home post-call...in 30 hours (this was pre-work hour restrictions). Want to go home for Thanksgiving or Christmas? Oh, I'm on call for Thanksgiving and taking every other night over Christmas, maybe next year. And on and on.

And then came kids. Suddenly there was a whole new set of things to postpone and a whole new set of reasons for the delayed gratification. I gave birth to 3 children in rapid succession, which meant that I was pregnant or nursing or pregnant AND nursing for literally almost 7 years. Want to get back in shape (not getting back to the original number on the scale, which has never been a problem for me fortunately, but REALLY back in shape...as in NOT looking like a mom)? Why bother? Hardly worth busting my butt for 6 months to get sixpack abs only to stretch everything out all over again a few months later. I'll wait. How about new carpet? Well, the toddler is potty-training. And the baby spits up milk every time she is vertical and sometimes when she's not. We'll do it in a few years once the kids are older. Maybe a nice bra purchased this decade? Oh, I'm nursing, so I'll just stick with this worn out one that I can pull down to nurse or pump and wait to get something pretty until I'm done and know what size I will end up. Ok, well, you can at least have some lunch. Hungry? Yep, starving, I'll eat in a minute...right after I nurse the baby and put her down for a nap, unload the dishwasher, switch the laundry to the dryer...

I have come to the conclusion that medical careers and mothering represent the perfect storm for training women to put off their own needs and desires eternally. Are you living in a state of delayed gratification? Is it necessity? Or habit? And if you're not, please tell the rest of us your secret!

Seriously, I wanna know....

Is there a dress code for primary care physicians?

Some back story... a new drug rep came into my pediatric office to promote the latest asthma inhaler. I can't remember the name of the drug because she I was preoccupied with her purple maxi dress. Floor length knit dresses seem kind of appealing - comfortable, cover up all manner of figure flaws, easy to move in (until they get caught in the wheels of my rolling stool) and no ironing, but are they appropriate attire for a pediatrician?

MiM Mailbag: PA student thinking about med school

Hi Ladies,

I am currently a physician assistant student and needing some advice.  I would like to remain annoymous and would appreciate you putting up my post!  While I am not married yet and don't have kids but chose PA school so that I could have a good family life.  I also worked very hard in undergrad and was worried I would greatly struggle through med school (which was a big thing that pushed me to PA school).  Now that I am in PA school (second semester of didactic year), I love what I am learning and want to learn more and have started to re-think med school.  I would like to finish this program and work a couple years and would be around 27 yo when starting med school if I chose to go back.  I was wondering if I could get some advice from former pa/np's who went back to med school at a slightly older age and from the other women if it is able to still have a good life when in med school, residency, and of course after.  Thank you for your help! Please don't post my name, I would hate for someone at school to see this.

Thank you!

Premed shadowing

I had a whole 'nother post planned in my head, but after I read Kyla's post, I thought of a story that I had to write about.

The story takes place way back when I was just a little premed. Well, truthfully, I was never really premed in the precise sense of the word. I was a math major and chemistry minor and I fit the rest of the premed classes in as electives. My biology major roommate reacted with shock when she found out I was considering medical school, because I was "much too laid back." In fact, among my friends in my chem classes, "premed" counted as dirty name-calling:

"Oh my god, you're studying on a Saturday?! You're such a loser premed!"

"I'm not a premed! You are!"

Of course, then it turned out they all got PhDs in chemistry or became i-bankers (?) and I was the only "loser" who really went to med school.

Anyway, when I declared that I was applying to med schools, I was assigned a premed adviser. Because I expressed an interest in pediatrics, I was assigned the chief resident of pediatrics at our university's hospital. Since he was going to be writing some kind of letter for me, he told me I should come shadow him one day in the NICU. I enthusiastically said sure. (That's how you knew I was a real premed: my ability to act enthusiastic about something I was dreading.)

He told me to come to the NICU what seemed like insanely early at the time, but was probably something like 7AM. I failed to get to sleep before 3AM the night before and was thus exhausted when I dragged myself to the hospital. I accompanied my adviser on rounds, meanwhile throwing a pity party in my head because my feet were killing me from standing so long and I was so tired from getting so little sleep. I was miserable. Then to top it off, when he was giving the history of this baby with retinal attachments, I started getting queasy and had to excuse myself (I had this "thing" about eyes).

All in all, it was quite the disaster. I had lunch and got the hell out. He invited me back but I said I was too busy.

In retrospect, it puzzles me that in light of that truly awful experience, I didn't for a second question my decision to go to med school. Maybe it was because I'd had experiences shadowing attending physicians in the past and found those experiences enjoyable. But this was my first time working with residents and I feel like I should have paid more attention to how unpleasant this was for me, and not just blown it off as a one-time thing that had nothing to do with my future career.

In actuality, med school was much more like that experience in the NICU than any of my other shadowing experiences. I hated waking up early, I hated standing for long periods of time, I hated giving up my weekends. Okay, yes, nobody likes those things. But I HATED those things. Enough that nothing else mattered except my own discontent.

As a result, I spent a lot of my clinical years being miserable. I spent a lot of the pre-clinical years being miserable too, actually. When I got into PM&R, things were considerably better and I'm light years happier now, but I think if I truly knew what was ahead of me when I started med school, I would have taken another path. I think there were other careers that could have made me happy without making me miserable for years first.

As for the moral of this story, but I'm not entirely sure what that is. Maybe it's that shadowing a resident might be the best way to figure out if med school is right for you. Maybe it's that you shouldn't go to med school without making a careful pros and cons list (using different colors and fonts for pros vs. cons).

Or maybe the moral is just: for god's sake, don't be an idiot like me.

A Day in the Life: Pediatrician Edition.

I spent the day yesterday shadowing our fabulous pediatrician. Beforehand, I worried that it might be a little awkward, following someone around all day without contributing anything, but it turned out to be a really enjoyable experience! I'm looking forward to doing it again next month.

We saw a lot of kids, of course...kids who were there for well-checks, URIs, EIs, rechecks, and one patient who came in for a rule-out of a fairly rare condition...kids who loved the doctor, hated the doctor, and were ambivalent about the doctor...and they were all adorable. I got a lot of smiles from all of those cuties. It was a busy day, though not unpleasantly so. It was a nice pace. We spent roughly 10 minutes (my guesstimation, I didn't pay attention to the actual time) with each patient which seemed the perfect amount of time, and from 9:30am until about 1:30pm there were not any lulls. Then we went to lunch, visited a baby in the NICU at the hospital, and came back to clinic and saw a few more patients before I morphed back into a parent when BubTar arrived for his 3pm appointment.

Things I learned, in no particular order:

1. I am not used to wearing heels all day. Ha! Obviously, I was on my feet all day and we did a lot of walking and took the stairs quite a bit. It didn't bother me a bit until I was OFF of my feet for a while...then, OUCH. Gotta work on that. ;)

2. Primary-care pediatrics is a lot of repetition. We saw many kiddos that were there for the same well-check, and so you basically repeat the same thing over and over. It isn't a BAD thing, just something that hadn't really occurred to me previously.

3. 4 months old infants are particularly adorable patients.

4. I need to learn more Spanish and get brave enough to utilize what I already know.

5. I can see myself being happy with this sort of career.

6. (which is not specifically related to yesterday) I can survive a week with roughly 3 hours of frequently interrupted a sleep per night, two sick kids, feeling mildly under the weather myself, while keeping up with my coursework and responsibilities, and still manage to enjoy myself.

Cross-posted at The Journey.

Little Wonders

I sat with my patient, a new mother, in the examination room. She was there for her first post-partum visit and we were discussing the events of the last few weeks. We chatted about breast feeding, birth control, lack of sleep, how annoying it is that men can sleep through *anything*, and then, I asked, as I always do, about how she was handling things emotionally. I always make it a point to screen for post-partum depression, many times, if you don't ask, they will not tell you how they are really feeling. This time, though she passed the screening for depression, she gave a laugh and said, "For the first time, I know why my mother is the way that she is." She went on to elaborate how she always made fun of how emotional her mother is, and now how she couldn't watch Kleenex commercials any more without bawling like a baby. It is so true. When we become parents we are forever changed, not only do we understand our parents better, but the way that we look at the whole world is different.

For me, it was the same. Before I became a mother, I loved to watch scary movies. The scarier the better. Imagine my surprise when, not long after Cindy Lou was born, and Mr. Whoo and I settled in to watch a horror flick when I realized that I had changed. I could not watch it, couldn't even get past the first 30 minutes. Why? Because there was a little girl child in it who was missing, and I couldn't handle thinking of a child (my child) being lost, scared, and alone. I never realized how many horror films use disturbing images of children before having a child of my own. It changed how I watch movies even now, far removed from the emotional lability of the immediate post-partum days. The same holds true for news stories involving children, footage of the 2004 tsunami devastated me, same for Katrina the summer after. The tears flow more freely now, happy, sad, and wistful. Most of all, music speaks to me, and often moves me to tears. There are certain songs I associate with different stages of my children's lives, and find myself tearing up just thinking of the lyrics. For Cindy Lou, it is "Baby Mine" and "Return to Pooh Corner." For Bean it is "Sweet Baby James" and "Little Wonders." Especially these lyrics:

"Our lives are made, in these small hours, these little wonders, these twists and turns of fate.
Time falls away, but these small hours, these small hours still remain."

So now I know how my mother felt when I was younger, when Cindy Lou turns to find me wiping away a happy tear or two and says, "Mommy, if you are happy, then why are you crying?" Perhaps it is because the transformative joy and wonder of having a part in creating these precious lives fills up our hearts until they break, just a little, from the magic of it all. How have your children changed the way you see the world?


***Cross Posted at Ob/Gyn Kenobi***

To all who have gone that way before

I am staring down the barrel of the residency match. Yes, I still have a year and a half until my match day, but there is a lot of planning that goes into the process ahead of time. I know it was a topic day here once. (Covered beautifully, I might add!) But, I have a specific concern, and a specific question.

The concern: I already have kids. I am a single mom.

The question: What is more important, what is inside the walls of the hospital, or outside?

Before I got separated, I was looking at programs based on certain factors: geographical location - was it a cool city where I've always wanted to live? (Like Portland, Oregon). Was the program a progressive program that seemed woman centered? (Like OHSU in Portland, Oregon.) Was it an academic program? (Like OHSU in Portland, Oregon...see where I am going with this?) Was it a program that had a reputation for being a happy place to work with reasonable attention paid to resident work/life balance? (OHSU again).

But, Portland is across the country from my family and my support base. About as far as you can get and still be in the continental US. Yes, I have friends there. A lot, actually. Some of them are mothers. But, my kids' dads and grandmas and friends and schools are all here.

I was OK with moving the kids out of the area when my younger son's dad was going to be moving with us. Now that we're separated, I am having serious second thoughts. Not only would there be legal wrangling and custody issues, but I would be starting a residency in a new city as a single mom. It was hard enough arranging child care and new schools for both of them here in Miami. I can't imagine trying to do it in a new, unfamiliar city without two grandmas helping me out. I also don't know if I can justify moving to a new place and then disappearing, for up to 80 hours a week.

Peers in medical school have told me to go for the residency of my dreams, and if mama's happy, the kids will be happy, and it will all fall into place. I am not so sure that is the case. My kids are happy and well adjusted, but there is only so much even happy and well adjusted kids can take.

Throw in the uncertainty of whether I can even get into the local program, the recent uber-competitiveness of ob/gyn and whether I can get into any program at all...sigh. And, if a closer program that I do get into is malignant, and I am stuck there for four years, am I really better off?

Any thoughts?

MiM Mailbag: Give up the dream?

Hi,

I just love your blog, from the touching to the funny, all of it real.

I have a question I'd love posed to your readers (feel free to edit it down if I'm so lucky as to have it used, I tend to get wordy):

I have wanted to be a doctor since I was a young teenager. I entered undergrad taking courses that would prepare me for the MCAT and med school, I met with advisers. Then I either got scared or realized I was too immature (the answer depends on how you look at it) and switched to a major in the liberal arts school. Graduated, then looked into taking the MCAT again, but then my boyfriend (now husband) and I moved, married and had kids and I put my dream on indefinite hold.

Every six months or so I spend time looking up medical school prerequisites and local post-bacc programs and read message boards and blogs of moms who have done medical school with children. Crazily enough, I am not entirely daunted by the tales of long hours, pressure and scant family time.

However, I am in my early 30s and I have four kids. Four kids under the age of 8.

Every bit of sense I have tells me, "Don't even dream it, give up before you start, you can't possibly make it work and keep your family intact." And yet I keep reading stories of people who've done just that.

So I want to ask some questions of those who went to medical school after they had kids. Do your kids resent the time your training takes? How did they take it if you had to move? Would you do it again at the same stage in life? Will you have enough time to pay off your student loans if you don't start practicing until you're 40 (or older!)? Is it worth it??

I am so torn. I really, really want to do this and think I could do it, but I worry about the kids.

Thank you!

Signed,

Anonymous, so my friends don't think I'm crazy before I've even jumped into the crazy pool

The empathy toggle switch

In our clinical years, our medical school has instituted a program in which we do learning modules along with our in hospital experience and didactics. I was happy to see a module on empathy for my second month of surgery. The last question to be answered in this module was: "Although the studies on empathy are very consistent other authors have indicated that medical students are really not losing cognitive empathy, rather they are learning to engage in a “toggle switch” approach to patients where one side of the switch is “associated with the patient” and the other is “disassociated from the patient” which is necessary in order to perform medical procedures. Please discuss this and use example which you have seen or in which you have been involved."

Here is my answer:

I am not sure if I agree with this. Yes, there is a certain amount of disassociation that may have to happen in order to get through the day, and I guess I felt a “toggle switch” moment when I was first in the OR, and the patient was not a patient but more of a sterile field surrounded by drapes. But, I think there are complex layers of desensitization, not just an on/off switch situation that happens.

I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it. I knew I would have plenty of opportunities to do pelvic exams on awake and aware patients whose humanity I would face directly and whose informed consent I would be able to directly assess, and I was willing to wait for that opportunity.

I did promptly forget about the patient and what she was going through when I was observing the procedure with the physician. I was more fascinated by the tools I had seen used in other applications and in workshops, but never used in a real D & C. I was eager to listen to the physician and thrilled that he was a willing and excellent instructor, and wanted to explain everything he was doing in great detail. I suppose there must have been some sort of toggle-switch moment where the patient was no longer a patient, and I was only cognitively aware of dilators and an os, and the integrity of a previously scarred uterine wall that was attached to a nameless, faceless body.

After the procedure, I happened to come across the patient in the holding room immediately post op. She was not doing well. She was feeling incredibly nauseous, and felt like the room was spinning. I was saddened that she was alone. I summoned the nurse, and the nurse tended to her needs medically by getting some anti-emetics on board. Still, I stayed with her and talked to her about how she felt, emotionally, about what she was going through. It is hard enough to feel nauseous and dizzy, but it has to be even harder when one just definitively ended a much desired pregnancy. Also, her family was not with her in this recovery area, and I felt bad for her for being so alone. I guess if I was ever switched off, I was definitely empathetically switched back on at this point.

I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.

Cross posted at Mom's Tinfoil Hat