My Favorite Patient of the Week

My last patient of the day was in quite a foul mood.

She had just come from the orthopedist office. He had told her that due to her recent roller blading injury she could no longer snow ski.

"He's a bastard," she said "I'll show him, I'll do my physical therapy and be back on the slopes next year!"

She is 76.

She is awesome.


*details changed to protect patient privacy

When a patient is not a board question

I am really enjoying my Geriatrics rotation. Although my attending preceptor is primarily a geriatrician, he also sees some patients who are younger. I took a history on a patient who was younger than me today, in her early thirties.

She started off complaining about insomnia and headaches, and then said she had some sort of an "attack" earlier this week. She quickly added that her husband died suddenly three weeks ago, and her therapist recommended that she come to see her doctor. I immediately offered her my condolences.

My mind quickly flipped to a frequent practice board question as I gently asked her about other symptoms. A 40 year old man presents to an outpatient clinic complaining of insomnia, poor appetite, and feeling helpless and lonely. He frequently thinks of dying to join his wife. He lost his wife of 18 years five weeks before. Was she suffering from loss of appetite? Was she able to return to work? Had she thought about hurting herself? What did she mean by an "attack"?

Telling the difference between Bereavement-Related Depression (BRD) and Major Depressive Disorder (MDD) is a frequent sample board question that I have come across in various forms as I have been doing patchwork board review. Bereavement is an exemption from a MDD diagnosis for two months after the death of a loved one, while the duration of depressive symptoms only needs to be for two weeks otherwise. Board review questions often dance around this time period. This BRD exemption (and the duration of symptoms for MDD diagnosis in general) is also the subject of some controversy as experts are constructing the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-V), which is the guide to diagnosing mental illness.

I snapped out of my board review musings and continued to question and console the new widow. When I got up to leave the room, I strongly considered asking the patient if I could hug her. Since it was only my third day on the rotation and I was in the room with the physician's assistant, I decided against it. I think if this would be my own patient in my own practice in the future, I would not hesitate to ask. When I left the room and told the other student about it, I teared up.

I guess my empathy toggle switch is still operating just fine.

Cross posted at Mom's Tinfoil Hat

Anger Issues

When I was in my intern year, one of my attendings named Dr. Pasture informed me that I had anger issues.

Dr. Pasture was leading a small group exercise where another intern was playing the doctor and I was playing a difficult patient. I had fun with it and tried to be a difficult patient to the best of my acting ability, laying it on as thick as I could. I was later presented with an Academy Award for Best Supporting Actress. (Just kidding, I only got a Golden Globe.)

I noticed that during the role-playing, the other intern started getting flustered to the point where I felt a little guilty. So after we were done, I laughingly apologized.

Later that day, I had a clinic with Dr. Pasture. While I was in his office, he said to me, "I want to talk to you about something, Fizzy."

That didn't sound good. I immediately started to panic. "What is it?"

"You know," he said, "it's okay to get angry. If you felt a need to apologize for yelling during that role playing, I suspect you never show any anger. I just wanted you to know that it's okay to get angry at people."

That was the last thing I had expected him to say. At first, I was just baffled. But the more I thought about it, the more I realized he was kind of right.

I do get angry, of course, but I never, ever yell. Or even snap at people. I don't even do it in my own home, because both my husband and daughter are exceedingly sensitive. As an example, a few nights ago, my daughter spilled a big cup of water everywhere after I warned her to be careful... all I did was say her name sharply, and she ran crying to the closet and hid in a suitcase. So I've kind of trained myself never to yell.

But what's so bad about that?

My husband showed me some study (I'm too lazy to find the reference) where women who didn't vent their anger at their husbands had a shorter life expectancy. I'm not entirely sure why he'd show me a study that would encourage me to yell at him more, but I guess he felt concerned that I was angry at him sometimes and just not expressing it. I'd argue that while I may not yell, I do other great wifely things, like whine, complain, and nag. I certainly don't walk around constantly feeling angry at my husband. And I vent a lot of my frustrations through writing.

Then again, I do sometimes find it hard to let go of things. Every now and then, I compose rants in my head directed at people who I feel wronged me years ago, thinking about what I wish I'd said to them. ("The jerk store called and they're running out of YOU!") Am I the only one who does that? It doesn't feel particularly healthy.

I'm not sure what to think. I don't particularly like people who yell a lot. I tend to think they have poor control over their emotions. But who's more likely to have the early coronary, me or them?

The month I almost switched specialties

I am finishing up a really great month on outpatient pediatrics. I thought I wouldn't love it. I was scared in the beginning how much I really love it. I had a moment in the first week or two that made me waver, ever so briefly, from wanting to do obstetrics.

I love the babies, even when they are screaming. I especially love the girl ones, since I don't have one of those at home. I love the variety. Sure, there is an awful lot cough, runny nose and fever X 2 days on top of the chart. But, I have been pleasantly surprised by the variety.

I have done everything from a one month well baby visit to STD counseling on a young man. I have seen children living with autism, a child with Fragile X syndrome, one with mosaic Klinefelter syndrome, and a few with insulin pumps. I have seen congenital and developmental variations.

My main fear was becoming too upset by seeing a serious ill child. I cried more than once during my preclinical years during films and lectures about terminal developmental disorders and abuse. I still have to do a month in Peds ER, but my rotation site doesn't do pediatric trauma. I hope I don't end up too emotionally overwhelmed by anything I see. I don't have to do PICU or NICU. I think I would have been fine if I wasn't a mother. Now, I identify with every parent and associate all the kids with my kids.

I think one way we end up picking a specialty is by what we can't handle. Some people can't handle the idea of treating someone who is pregnant. I have an internal attending that always jokes that treating someone under eighteen makes him diaphoretic. I know another who can't face pus. There's a student who dreads the ER.

I still haven't done my ob/gyn rotation yet. I am pretty sure I'll love it, since I trained as a midwife. If not, I suppose I can switch everything over to pediatrics. I really doubt I'll be doing it, though.

Bitter? Well, a little....

For those of you who read my posts, such as my rant about how much it sucks to work weekends and how the bright light at the end of the tunnel is a big fat lie, probably think I'm incredibly bitter and unhappy. That I'm some kind of cranky old doctor who sits on my porch confiscating the wayward baseballs of little children. Some of you have suggested that I switch fields.

Well, really, you don't need to worry so much about Fizzy. The truth is, I kind of like my job. It's not perfect. You're not going to catch me and my job alone in a closet doing unspeakable things (I worry about some of you, really), but I'm quite satisfied. For starters, I don't work weekends. I sometimes really help people. I have a lot of flexibility. I can eat lunch or go to the bathroom any time I want. (I'm not joking. This is huge.) There's a lot of room for career growth and research. If someone told me I'd still be working at the same place 20 years from now, I'd be pretty happy. Like they say in Office Space, it would be nice to have that kind of job security.

So your next question is undoubtedly, "But Fizzy, you're always whining and moaning. If you're happy, why don't you just shut the hell up already?"

Well, that's a good question, although quite rudely phrased. It's sort of like this: say you spent the whole day cleaning your giant house. It sucks but then when it's done, maybe you can finally relax. Except you can't relax because you pulled a muscle in your back and have excruciating pain for the next several weeks. It's sort of like that.

I wish I could say that my training sucked and now it's over, thank god. Except it's not so simple.

All right, my pre-clinical years were not great. My school had a failure rate of something like 10%, which meant that 10% of the class actually had to repeat an entire year. That puts a lot of pressure on you, especially when you're in the midst of a bad break-up and some family medical issues. But I was used to studying hard, so while it was bad, it wasn't that bad. The clinical years were when I started to fall apart. Some people simply don't like waking up at 4AM and working 27 days of the month. Some people start to physically deteriorate. I was in the latter category. I've always had a pretty low energy level (which would explain my impending obesity) and I really struggled with the physical demands of clinical work (e.g. sleep deprivation, standing in place for eight hours, etc.). It was pretty bad, but I got through it.

It was intern year that really got me though. It changed my conception of myself, and not in a particularly positive way.

For starters, my first resident as an intern was a cruel bitch who tore me down on my first day and continued to bat me down every time I tried to recover. (You can read more about her cruelty here.) People like her over the course of my training really brought down my confidence in myself. But it wasn't just that.

I'm a typical oldest child in that I always feel this compulsive need to be responsible. I'm not Type A, but when you ask me to get something done, you can bet it will get done and at least a day early. In school during group projects, I was always the one who quietly did everyone else's work while they slacked off. I am extremely reliable and organized and always have been. Except I discovered during my intern year that after 2AM on a call night, I wasn't particularly reliable. I'm not going to elaborate further, except to say that I'm not proud of my behavior on some of my call nights. (I will at least say that absolutely no harm whatsoever came to any patients.)

That was part of why I switched residencies, in order to have a more regular schedule. Leaving my residency was the most drastic thing I'd ever done in my life, very unlike me, but I was horrified that I couldn't trust myself during call-heavy ward months. I don't think of myself as prone to depression, but I became desperately miserable that year. I was recently reading a journal I kept during intern year, and I wrote one very serious-sounding entry where I said that I wished a car would run me down on my walk to work the next day.

So that's my story. Years later, I still have negative thoughts about myself due to those early years of training. I have trouble thinking of myself as the old reliable person I always was, despite three extremely successful subsequent years of residency. And some of the physical ailments I developed under the extreme stress of my early training still haunt me. But I guess in some ways, I got off easy. One of my colleagues attempted suicide during intern year.

Some of you have applauded me for my honesty and this about as honest as I can get. I don't know how common my experience was, but I've learned it's more common than I thought. I was, after all, a very average intern, as my shocked program director told me when I informed him I couldn't take anymore. I suspect there are people reading this now who feel the same way I did, have in the past, or will in the future.

Guest Post: When it snows, it pours

*All names and potentially identifying information (including some physical descriptions and case details) have been altered to comply with HIPAA regulations, as well as to be nice and ethical.

It was snowing one recent morning when I got up to drive to work. It was supposed to rain. I’m a primary care doctor in Boston, and my commute can be 12 minutes or 60 minutes, depending on the traffic. I was lucky I left early, because the unexpected snow on frozen asphalt created a slippery mess, many accidents, and much traffic. It was pretty bad. I wouldn’t say half my morning session cancelled; rather, I was surprised that half was still on the schedule. Tough New Englanders! I took off my soaking wet boots and pulled on my white coat and waited to see who would show up in the snowstorm.

Part of me was hoping that I’d have the rest of the day off, and I could go home to cuddle with my 6-month-old. Of course, then I would have to make up the day later on… I was here and decided to make the best of it. With oodles of extra time to lavish on my patients, I looked at the schedule. My first patient, Brenda Z., was a 22-year old for a physical. Usually, I only have 20 minutes for these, but today, we would have a whole 45 minutes!

Brenda is only 5 feet tall, but she weighs 244 pounds, putting her Body Mass Index (BMI)(1) at 48. Unfortunately, she is not only one of the 34% of Americans who are obese, but one of the 5.7% who are extremely (morbidly) obese.(2,3) Predictably, she has many obesity-associated problems: asthma, sleep apnea, polycystic ovarian syndrome, and almost-high blood pressure. For the past year, I’ve had her come in every 3 months for weight and blood pressure checks. She comes from a middle-class home, works at a supermarket checkout, and goes to school part-time. She’s a hard worker and a good kid. But best of all, she had lost 11 pounds, by eating mostly fruits and vegetables and Slimfast shakes. I wasn’t at all sure this would stick, but hey, it’s a start.

As Brenda left, I noticed that the medical assistant and one of the nurse practitioners were steering a fairly off-balance woman into my other exam room.

“Um, if you don’t want to see her, I guess we can ask one of the other docs to see her, but this was the closest room…” said the NP.

The M.A. was more blunt: “This one’s drunk. Falling-over drunk.”

It’s not at all common for patients to show up at our office drunk, but this lady, Alexa J., had just wandered in looking for her usual primary care physician, who was out. She was in a bad state, so the staff had taken it upon themselves to make her safe. They checked her in and took vitals, as she promptly passed out face-down on my exam table.

“Hello? Hello, can you hear me?” I rubbed her shoulder, more than a little alarmed. She was dressed well, but absolutely reeked of Vodka. Fumes. I felt dizzy just standing over her.

“I need help, I need to stop,” she garbled.

“Stop what? Are you alright, are you hurt?”

“Alright… I want to stop this, stop drinking.” That much was clearer.

I stood and thought for a moment and then just picked up the phone and called our ER. The triage nurse took the information with aplomb, simply adding “Passed out, eh? Good luck getting her down here.” But the M.A. and I wrestled her into a wheelchair, and with two escorts, off she went to be evaluated and possibly admitted for detox.

I then got a call from a psychiatric hospital. A patient of mine, a middle-aged mom named Jane L., had been admitted with suicidal thoughts, in a background of Bipolar Disorder. I was surprised and pleased to get a callback from the treating psychiatrist, who filled me in: that she was stable, but would need residential placement after acute treatment. I offered some of my take on the situation, but the psychiatrist did not seem all that interested… That’s OK, I’m in over my head with someone who is a danger to herself; she’s in the right place. But I remembered that just a few months ago, after she had come in to see me and had expressed that she wanted to overdose on her pills or crash her car, I had walked her down to the emergency room myself. Just a few years ago, she was working and supporting herself and doing well. Now, she was on disability, in and out of the hospital, her finances in ruins. I so wanted to see her better.

My next patient was new to me, a healthy mom with a cold and a cough, and some mild wheezing. She asked me about Boston Med, the 8-hour ABC-TV documentary series that aired last summer.(4) I was on maternity leave when it aired, but my husband and I watched every episode. It was touching, yet also stereotypical: lots of trauma drama.

She asked, “Are they going to film another series like that? I hope so!”

I didn’t know. But I pointed out that the fact that only surgeons and ER staff were profiled, and that very disappointing to us primary care docs! “Primary care is exciting too,” I said.

She had some mild bronchospasm, so I gave had given her an inhaler. She seemed so reluctant to accept the inhaler, that I had to ask her why. She told me about her son who had been a micro-premie and survived, but with bad lungs. He was 9 years old now and doing well except for asthma. He had been in and out of the hospital with many infections, pneumonias, and was better now but didn’t react well to the Albuterol and they had to keep trying new meds- Pirbuterol, Levalbuterol.

“Will this happen to me?” she asked, really worried. She had equated his long battle, the sequelae of premature lungs, with her new diagnosis of reactive airways, which means mildly “twitchy” lungs that respond well to occasional puff of Albuterol. I couldn’t dismiss her fear, borne of a painful experience… and I couldn’t alleviate her fear with any quick explanation. And so we had a long discussion about it.

“Thanks for spending so much time with me today,” she said.

My next patient probably had the flu. Then I said Hi to my diabetic patient whose sugars are all over the place, and I’m following her along with our diabetes nurse.  Thank God for our diabetes nurse, who can take a good diet history and offer good solid recommendations on eating.

My last patient was Nanette M., a 32-year old African-American woman with a new breast lump. She had no breast cancer risk factors at all, and the lump was round, but it was deep and immobile. We decided to do an ultrasound and a mammogram.  Statistically speaking it’s probably a benign breast cyst. Still, breast cancer is the most common cancer in women (besides skin cancers). Also, breast cancer rates are higher in African-American women than white women before age 45. (5) I wanted to be careful. Though I have seen many women with breast changes that turned out to be benign, one time I examined a patient with breast thickening, and it was breast cancer, invasive but not metastatic. Surgeries and chemotherapy took a whole year from her. Her treatments left her a changed woman. Thankful to be alive, but changed, older. So any breast changes, basically, scare me.

And that was that. I ate a snack, tried to do some paperwork, but then I called home. I spoke to my mom (our nanny) and heard my baby squawking in the background. Then I spoke to my Hubby, who urged me to get home soon before rush hour. Baby just sounded so cute, and Hubby was worried, so I packed it up and made for home, leaving behind some paperwork and a snowy morning at the primary care office.


-MA MD

1. Centers for Disease Control and prevention: Vital Signs: Obesity. http://www.cdc.gov/nchs/fastats/overwt.htm accessed 1/18/11

2. Statistics related to overweight and obesity. National Institute of Diabetes and Digestive ad Kidney Diseases. US Dept of Health and Human Services. http://win.niddk.nih.gov/statistics/ accessed 1/18/11

3. National Heart Lung and Blood Institute BMI Calculator http://www.nhlbisupport.com/bmi/

4. Boston Med, ABC medical documentary Summer 2010: http://abc.go.com/shows/boston-med

5. Breast Cancer Facts and Figures 2009-2010, American Cancer Society

Amnesty Hour

Last Friday I was working at a satellite hospital in a smaller town. The work was light, which was a relief after all of the snow craziness the day before - getting babysitters for kids, arranging for possible overnight lodging which I thankfully did not have to use. I sat down for lunch with some of the lab techs.

I'm not sure how the conversation ended up on kids and discipline, but one of the techs said that even though her kids are almost out of high school, for years they had an amnesty hour every day, usually at mealtimes, where they could talk about anything and not get in trouble. Her kids would talk about things that happened at school, discuss words they overheard but didn't know the meaning to, etc. She started when they were in elementary school. The tech discussed some of the more interesting revelations that came out in teenage years. Then she said that once, when her daughter was eight, she asked her what a "blow job" was - she had heard a kid say it at school. After the mom almost fell out of her chair, she said, "well, that is something for adults and you will learn more about it in a few years." That seemed to satisfy her daughter for the time being, and I think it was a nice, age appropriate response to close the door for a little while.

The idea got me thinking, and on Sunday morning when the kids and I were snuggling in late, I explained it to them. My kids are only 5 and 7 - we certainly don't need a whole hour, maybe not even once a day. When it was Cecelia's (7) turn, after expressing incredulity about being able to say anything and not get in trouble, she talked about a boy at her school and how he was mean to other kids, and what he did. Jack's conversation turned to a couple of the more intense fights he had with his sister over the last year - both I remembered well, when her teasing and torments pushed him to physical retaliation. This was a little awkward considering Cecelia was in the room, but it was nice to hear his side, what stuck with him and his feelings. I think it was good for Cecelia to hear, too - her opinions and words tend to overbear his unless there is someone around to check her and force her to listen. Her teacher tells me that most kids her age need to learn to listen more and talk less, and she is no exception. Most importantly I was there to mediate and comment on their reflections of scary subjects.

Later on that day, we were playing a new card game in front of the fireplace my mom bought us called Spot It! I can't wait until Jack can read - our repertoire of family board games will branch out tremendously. This one is fun because you have to look at both cards, each with about 10 pictures on it, and the first person to spot the match wins the hand. They teamed up against me, and after they narrowly won three games (I know I shouldn't admit this, cause I would never want them to know but I do let them win at this age - I have an unfair advantage of highly developed visual recognition skills - hell I'm a pathologist - and it makes them so happy to beat me - but it shocks me how close I actually come to losing for real as they are getting older), I told them I was determined to win one game before dinner. As I started winning Cecelia completely lost her cool, focus, and her game. She forced me to continue but by the end she melted down in tears of frustration and post losing accusations of cheating - she was a little worn out all weekend from a sleepover Friday night - and when I told her we weren't going to play again since she wasn't having fun, she dissolved in sadness and anger. I sent her to her room to calm down, eventually telling her she'd better go before I lost my cool.

When I wandered back into her room about ten minutes later, we were lying on the bed hashing it all out. She was in a better place, and listened. I was less frustrated, and listened. We talked about the meaning of "sore loser," - she has such a competitive streak we have to do this talk over and over (like mother like daughter). Suddenly, when we were in a good place, I leaned over to her. "Amnesty hour without Jack. Come on. Lay it on me." She talked about how sometimes she hated Jack so much. Then she struggled with something, and I encouraged her, even though she worried aloud about saying it. Finally she said, "Remember just now when you told me you were going to lose your cool? And sent me to my room? I was thinking how you didn't really have any in the first place. You know, cool." I had seen the sway in her backside and the swish of her hair as she marched down the hall and it fit her thought perfectly. I laughed inside, and told her, "Cecelia, you want to know the truth? I'm glad you didn't say that to me when we were both really mad and upset, but if we were kind of joking around? About me losing my cool? The cool I never really had? That would have been a really funny thing to say."

How about readers? Any thoughts, suggestions, remembrances, or ideas about how to get your kids to open up on hard subjects? I can see that as they are navigating rougher waters in school, it will be really important to stay in touch without being too overbearing.

Slowing Down

The kids and I both started our winter breaks around the same time. The first week was full of Christmas prep and holiday fun, but by the Wednesday of the second week I was starting to get that all too familiar urge to climb the walls. It wasn't the kids, they rarely bicker or fight or complain and we were having fun together. It was me...doing nothing. I don't know how to do nothing anymore! Between studying and going to school, volunteering at the hospital and the kids' school, keeping up with the kids' activities and KayTar's medical and therapy appointments, I'm constantly on the go. I realized that I had forgotten how to slow down and simply enjoy a little downtime. So instead of making a New Year's resolution, I made a winter break resolution. After the kids went back to school, I would spend the last two weeks of my break doing nothing. I wouldn't volunteer. I wouldn't prep for my classes. I wouldn't review old material. I decided I would read some books, have lunch dates with friends or my husband, spend some time on my sofa. I would teach myself to enjoy my break, force myself to recharge my batteries while I had the chance.


How did it turn out? Beautifully. It was a bit difficult at first, but I eventually got the hang of it. I had a couple of lunch dates with Josh. I went out with my best friend once or twice. I saw a movie with a friend. But mostly I stayed home, enjoyed the quiet and took the opportunity to read. I read 10 books in two weeks, the most I've read in years. I really enjoyed myself. At the end of break, Josh and I went out of town together, just for a night. He likes to hunt and it was the end of dove season, so we got a hotel room near his lease. I enjoyed the silence of the hotel while he hunted a couple of times, I slept in, we spent some quality time together, went out for dinner and lunch, and got together with some friends who live in the area. It was perfect end to my relaxation challenge. The next time you get a chance for a little downtime, I highly recommend forcing yourself to slow down long enough to enjoy it!

Tiger Mother I am not

I'm a Chinese-American mom, but I'm no Tiger Mother.

I'm almost loathe to start this post as I don't think Amy Chua, and her book, could possibly have more press. I also fully disclose that I did not read this book, having only read (the scary) excerpts and multiple articles and blogs about the book. I did hear her on NPR with Diane Rehm when she defended the "tongue-in-cheek" nature of the book and how it represents an evolution of her own parenting. (Although, it seems that many people who have read her book in its entirety seem to have missed that subtlety.) My friend Joanne wonders whether her form of parenting represents child abuse.

I grew up the daughter of Chinese immigrants who, if anything, were on the permissive side. Sure, they valued good grades and hard work but honestly never pushed me. This might be, in part, due to the fact that I was doing well anyway, but I remember their mantras whenever I called home from college were two: 1) make sure you get enough rest; 2) don't study too hard. In high school, I did cause quite a bit of their concern when I declared I wanted to get a part-time job during the school year. Not out of necessity, I didn't need the money, but, what can I say? I wanted the experiences my friends had. I promised them that I would stop if my grades suffered. (And looking back, the experience of working minimum wage in discount retail was enlightening.) My parents' parenting style was the envy of my circle of friends: I had no curfew (although my dad would nonchalantly stay up, probably developing an ulcer, while waiting for me to return home on Saturday nights). I watched a lot of TV. They allowed me to give up piano lessons when I likened my times with my mid-life-crisising piano teacher to extreme torture.

I did have ABC (American Born Chinese) classmates that had proverbial Tiger Mothers. These women terrified me. Their children were polite, respectful, disciplined and high-achieving, but something was off. There was a hardness to these boys (they were often boys), and, often, a social awkwardness. I felt for them. And very glad I had a different upbringing.

On the flip side, the criticism that American parenting culture is too permissive is interesting to explore. Are we not pushing our children enough (not to TM extremes but isn't some pushing necessary)? I semi-struggled with this as I've watched my 5 year-old daughter beg for piano lessons...then totally lose interest a few months later. Same with dance class. When it got to be a monumental struggle to get her to even pay attention to her teachers or go to class, we've allowed her to stop. The feeling was that maybe she's not ready and when she finds something that she is truly passionate about, it wouldn't be such a Herculean effort to get her to practice. More physical activities, like swimming and gymnastics, have held her attention week after week. We are "following the child" as her Montessori teachers say. This makes a great deal of sense to me. I don't want her to do something for me, or for the sake of doing something. I want her to do something and work hard at it because she loves it and derives happiness in the process (That's possible, right?). But I sometimes wonder if I'm doing her justice by letting things go too easily.

One possible ill consequence of the TM method is raising children where conformity over individuality and creativity is selected. The Chinese have produced a nation of math and science heavyweights, but where are the visionaries? The Apples? The break-out ideas?

Chua, on NPR, wanted it to be known that her book was not a how-to-guide to parenting but a memoir. She clearly has struck a chord with mothers (and parents) everywhere. As much as she's been demonized in the media, I think this comes from a place of insecurity, that we all carry, about how we are doing as parents. Could we not be giving our children the best advantages in life?  Are we doing it wrong? At the heart of the "Mommy Wars, " afterall, is insecurity and wanting to believe that our parenting, one of our most precious tasks --to "successfully" raise a child -- is right.

I hope that her daughters grow up to be successful, as defined by their own beliefs and that this backlash towards her mother's memoir doesn't do any permanent damage. We are all mothers, doing what we think is right, in the best way we know how. After all.

High Level Conspiracy

Last week it snowed in Arkansas. A fair amount. Now when this happens in most states, it is a minor inconvenience, especially when it's under five inches. But when it happens in Arkansas, it might as well be a national disaster. Grocery stores are cleared. Schools are shut down for days. Getting to work is treacherous, since we just don't have the manpower/road equipment to deal with it quickly - I guess it would not be cost effective since it happens to us so rarely.

My kids had a couple of days out of school. They happily played with my sitter and neighborhood kids - sledding down our ideal vertical driveway and front yard, making snowmen, and brewing hot cocoa. A nice extended Christmas vacation. By the time I was off Wednesday, school was back in session, and I was glad because there was much on my schedule to get done. By the time I had carpooled kids to school, finished cling-on cases at the main hospital and a GI clinic, taken Cecelia (7) to her initial 2.5 hour orthodontist appointment (those guys are expensive! And clinics get to take snow days - they were backed up and we had a long wait), shuttled her back to school, grocery shopped, and headed back to the school for afternoon carpool - Cecelia to dance and Jack (5) to haircut - I was wishing I was back behind my scope. I'm telling you - this SAHM business can be as hectic as the craziest needle days on cytology.

Anyway, during afternoon carpool Jack loaded up first and we waited for Cecelia to get out of study hall. He bounded in excitedly, chattering on about his day, luxuriating in the novelty of having me do afternoon carpool. He was showing me all of his work in his folder, moving around the backseat like a spider monkey. Suddenly, he scooted up into the console between the two front seats and leaned toward me, conspiratorially.

He whispered, "Mom, I sneaked something. Want me to show you?"

I looked over at him, a little alarmed. "What did you sneak, Jack?" He hitched up his foot, exposing his ankle between his pants and sneakers. I didn't see anything, so I guessed, "Was it candy? Or a toy?"

He shook his head and smiled his wide grin - the one that always reminds me of an angelic devil. Still whispering he said, voice filled with pride and searching for approval all at the same time, as he peeled back one white cropped sneaker sock to expose another identical one, "No mom, look. It's double socks. I did it this morning. Isn't that sneaky?"

Even though I wanted to double over with laughter, I realized that was not what this moment called for. That is part of our mommy magic - to be able to suppress our mirth and take our kids seriously. "Wow, Jack. That is really cool. Did you think of that all by yourself? To protect your feet from the cold weather?" He looked at me an nodded sagely, pleased that I understood. "Uh huh! Exactly." He shrugged nonchalantly. "It worked."

I told him he was pretty smart, I never would have though of that. Truth be told, I am kind of impressed by this five-year-old's ability to sense the weather and what is needed. A little while back, I searched for weeks for Jack's fireman raincoat. This is one of the side effects of divorce that you don't really think about until it happens - stuff gets lost all the time in the shuffle back and forth between houses. You think your dryer is a black hole? Try your ex's house. Not to be judgmental - it goes both ways, but although he has strengths that I don't, I am certainly more organized. One evening, when my ex took the kids for dinner, Jack appeared at my door afterwards in the raincoat. I exclaimed, "Oh! Did Daddy find your raincoat?" He said, "No, mom. We were walking to dinner and I knew it was going to rain, so I went to Daddy's car and found it." Sure enough, five minutes later they were drenched in a downpour, and when they got home I peeled them out of their wet clothes, Jack's a little more protected than Cecelia's, and got them each in a warm tub.

The double socks continued throughout the week with as much stealth as day one. We were trudging through the yard down to the car every day - it became more slippery as the week wore on, and the driveway ice didn't clear until the weekend. On Friday, my sitter came early to get the kids to school so I could catch a plane to Atlanta for some much needed brother, sister, nephews, and brother-in-law time. I was amused to see this cosmopolitan city in more dire straits than us - they were just emerging on Friday from a week long slumber and ice continued to cause wrecks (not funny) throughout the weekend as cars were getting back on the roads. Before I left for the airport, I was giving my sitter instructions for Jack's show and tell and Cecelia's lunch. I told her the story about the double socks - it had been cracking me up all week. Sure enough, she texted me later that she caught him sneaking his double socks. I'll bet it won't be so funny in a few years when he is sneaking girls and alcohol. I'll be longing for these double sock days.

Which form of Competition is Best?

Just came back from watching my daughter compete in ballroom dance competition. It struck me as a cross between a swim meet and an evening at the theater. I can’t decide if turning an art and a pleasure into a competitive activity is a good thing, or not. 

Which got me thinking about medicine, as most things do. Because what we offer is such a scarce resource, we inevitably select people who are, quietly or openly, highly competitive. Then we continue to rank them, in tiny increments, right through the end of training. At the other end, the money and perks that go with practice, or not, seem to play right into the same attitude. 

On the one hand, competitiveness has made my daughter a fine dancer, and my own competitive streak keeps me pushing myself to accomplish things I might otherwise not. But I do wonder if the drive, not only to excel, but to outshine, is a barrier to learning really important things—like the value of doing something for its own sake, or just being with our families, our patients, the people we work with. By the time my kids finished swimming competitively, they no longer could swim for fun. As a friend, I never learned to hang out; now I only seem able to be friends with people while I am doing something. And much as I try to be receptive with patients, I keep them and myself to a very tight schedule.

What bothers me most is that medical students are so conditioned to rely on their competitiveness for motivation, they can quickly become indifferent or hostile to anything that does not seem to have immediate value for giving them a leg up. The idea of studying anything because it is of intrinsic interest, or might someday be useful, seems to fall away quickly in the first semester of school, and may never return. Since it is especially hard to compete on the basis of creativity, which, by definition, confounds existing standards, this, too, seems to be systematically discouraged in our students. Creative problem solving is an essential element of practice, not just a frill. But to ask “how can we reward creativity?” immediately puts us back in the position of selecting, rating, and favoring, the same dynamic that fosters competition.

Resigning totally from a competitive environment—the ashram approach—never appealed to me. It always struck me as a paradox of people competing to show how anti-competitive they were. I just wish our education—the one we had and the one we offer—allowed us to allow ourselves to freewheel more, and enjoy it. As recent posts and discussions have highlighted, being present in our immediate lives—reading chicklit, not postponing everything in hopes of a future haven, or choosing family time over work--is an important counterweight competitiveness as the root of our motivation, and our rewards.

What It Feels Like for a Guy

*Editor's note: In the spirit of partner guest posts, this post was written by the husband of dr. whoo.

I’m not sure I am worthy of the title of Stay at Home Dad. I don’t have my children all day long every day.

My role to take on more of the domestic responsibilities began in fall of 2008. There was a combination of factors for this decision, but it was largely based on improving the quality of life for our family. Our oldest child had just turned four years old and our youngest, two.

With both of us working beyond full time, we were watching our children grow up in daycare and were limited to an hour or two each evening with them during the weekdays and the weekends were spent catching up on laundry, lawn, grocery shopping and million other items on the must do list. Exhaustion discouraged healthy cooking and exercise, and we ended up eating out or ordering in most of the time. I could continue to list all the reasons, but the truth is we should have done it sooner for fewer reasons. I never thought I would have anything but a long career of continuous development, but my wife had more time and money invested in her career and she was the bread winner. Besides, I have way more patience with children, and all other non-cat related matters.

It has been two and a half years since we made that decision, and it was the best decision for our family. Quality of life for everyone has improved tremendously. Cindy Lou is in first grade now, and we decided that Bean would benefit from the social interaction and academic curriculum at he gets at preschool. I take the kids to school, I pick them up (much earlier than we used to). I cook the meals and clean the house, albeit poorly I am told (seriously, how does dust accumulate so fast?). I pay the bills, clean the pool, and mow the lawn. I also do general repairs, minor plumbing and electrical work and you should taste my stuffed tilapia with white wine lemon butter sauce. During varying times of the day and evening, I work (as needed) to run my unintentionally non-profitable small business with 6 employees. I did get to take a paycheck last January (2010) so that’s good, right?

I now get a lot more quality time….err, snuggling/wrestling/tickling time with the kids which is unbelievably great.

I periodically get a little restless, and send my resume out to test the waters, but every time I get a bite I am forced to reconsider the consequences to my family if I return to the corporate world. Without fail, my decision is swift and clear as to what is best for our family, and that is to stay home. That is to say, stay available. Available for sick children and doctors appointments and field trips and household duties and whatever else needs to be done. My wife’s job as an OB/GYN is stressful and demanding enough, and I cannot help with that or relieve those responsibilities in any way. What I can do is almost everything else, that’s the goal anyway. In reality, she contributes a lot and always has a sense of when I need her help the most.

Anyway, I am unaware of any stigma and indifferent to prejudgments or misconceptions that others may try to attach to me. This works for our family and I am very proud and grateful for this arrangement. I used to think of it as me sacrificing my career for my family, but now I see clearly. We were sacrificing our family for our careers. We’ve both made the necessary changes to end that, and we are a happier family for it.

40 hours

40 hours. Some people put in 40 hours per week at work. It is 23.8% of an entire week. It is also the approximate amount of time I get to spend, in person, with my husband every week. Which makes 40 hours an allotment of time that has taken on new, precious meaning during the past 6 months while my husband has been stationed away from the family, a 6 hour drive (on a good day) away .

That 40 hours includes the time spent sleeping over 2 nights. It includes the time we attend to our own needs: work outs, showers, etc. It includes the time caring for the kids together, at gymnastics and swimming lessons. It sometimes includes the time I spend at work when on-service and covering a weekend. It is time that we are intensely focused on being together, of being a team reunited. It is time I can't wait for at the end of each week, and time that passes all too quickly.

I know this now: we will never take living in the same house, of falling into the same bed each evening, for granted again.

Making each week's 40 hours, from Friday, late at night to Sunday, early afternoon, that much more savored is the fact that soon,  in a couple of months, those 40 hours per week will become 0. 0 x 50 weeks to be exact, the amount of time that he will spend in Afghanistan in active duty. He'll have a total of 2 weeks of "R and R" sometime in the middle.

Working full-time and parenting 2 small kids with 1 on the way (6 weeks and 1 day to go before due date, but who's counting) has only been possible by lots of help at home. Ever since we had nannygate x 2 late last fall, my parents have basically moved in and are a tremendous help. They plan to stay well after I have the baby when another family member has committed to helping for several months. The new nanny search can wait until then.

Despite all of this madness, I'm remembering to count my blessings because they are many. To have retired parents willing to give up their previously enjoyed retired life to come live with us. To have a job which leaves me satisfied, happy, and not (usually) overworked. (Any overworking is my own fault and side projects I've taken on, not expected by my job). I have a wonderfully supportive boss who understands my family situation. I have a rock-solid marriage; we know that this separation and challenging 12 months ahead will only bring us closer. I have the world's best neighbors. We have fabulous friends who have helped so much already this year, both in their actions and their mental and emotional support. We belong to a wonderful church. So, now, 2 months before he is deployed, I am at peace and stand ready to face what comes my way.

One of my Christmas presents this year was a Philosophy set of products from their Amazing Grace fragrance line. If you're not familiar, Philosophy products come with smart names and little blurbs that inspire. The blurb on the Amazing Grace body butter I found especially resonant:

"how you climb up the mountain is just as important as how you climb down the mountain. and, so it is with life, which for many of us becomes one big gigantic test followed by one big gigantic lesson. in the end, it all comes down to one word: grace. it's how you accept winning and losing, good luck and bad luck, the darkness and the light."

My plan is to wear this and live this. Every day. It smells, well, amazing, and it might just help me through the months to come.

The Mythical Bright Light

When I was in my second year of med school, I had kind of a sobering moment:

One of my classmates had a boyfriend who had recently graduated from residency in medicine and had a job in a private practice. Back then, that seemed like the bright light at the end of a long tunnel: someday I would finish med school, finish residency, and then the torture would be over!

Except my friend was complaining about how her boyfriend was working harder than he ever had before. As the newest person in the practice, he took call every holiday and was at the office late every night. She then went on to tell me that this was "typical" of first attending jobs.

I wanted to throw up. So not only did I now have to get through med school and get through residency, I now had to put in my dues in my first attending job for god knows how long? When the hell did it ever end?

When I was doing inpatient rotations in residency, I noticed that my attendings never left work before I did, and actually, were often there later than I was (except on call). I started to have a bad feeling that the bright light at the end of the tunnel was all a myth, and that by entering medicine, I had resigned myself to working hard for the rest of my life.

I do think that, in general, attending physicians work very hard. I know there's going to be some dermatologist who comments something like, "Hey, I work only two afternoons a week, I love my job, and I make half a million dollars a year!" And that's awesome for you, really, you bitch. But I think even physicians like myself, who work part-time and have fewer hours, work pretty hard while at work. And physicians who work full time in private practice generally work their asses off.

The bright light is not entirely a myth. At least as an attending, you earn more money and get to do something closer to the job you want to do. But then again, how many people end up with their dream job right out of training, especially in this economy? I think it's to be expected that you'll need to spend a few years putting in your dues. I think it's a myth to think that you just need to get through seven years of training and then you'll be on easy street. After all, there's a reason Physician ranked only 83 on CareerCast's list of the top 200 jobs of 2011 (I seriously thought we were going to be after the guy who cleans the urinals or something).

I guess my point is that if you think of medical training as something horrible you need to get through before you end up with some cushy, high paying job, maybe you should rethink medicine. I don't think it's a good idea to postpone your life until "the hard stuff" is over, because it might not be over as soon as you think. Or ever.

But as usual, I welcome dissenting opinions. Do you work your ass off as attending? Or did you get a cushy, high paying job straight out of residency?

Doctor chick lit?

I always used to read a lot as a kid, but when I started med school, I decided that anything I read ought to be medicine-related, so I pretty much gave up on reading for fun. ("What, you mean reading Robbins' Pathological Basis of Disease wasn't fun??") But in my last year of residency, I was sufficiently bored that I decided to open myself back up to fiction again.

I'm mildly embarrassed to admit it, but I LOVE chick lit. I don't know why, because I hate fashion and flowers and jewelry and everything else girly. But I love these books. It's especially shocking because I used to be SUCH a little book snob when I was a teenager, and I'm sure I would have mocked Older Me mercilessly for reading a book about a woman who helps her quirky ghost great-aunt find a lost necklace (bonus points if you know what book I'm talking about).

But I don't have anything to prove anymore, so I'm going to read what I want, dammit. I recently discovered a list of the ultimate top 100 chick lit novels and noting that I've already read and enjoyed 7 of the top 10, I've decided to make it my mission for 2011 to work my way through the list. Come on, who's with me?

But you know what bugs me about chick lit? How come none of the female protagonists are ever doctors??

Seriously! On that list of 100 books, you'll find women who are lawyers, teachers, PR reps (a popular chick lit career), i-bankers, and basically tons of great careers. No doctors. There are no chick lit books about doctors.

Why the hell not? There are lots of doctors writing memoirs. There are lots of thrillers written about doctors. (I used to be a big Robin Cook fan, until I realized the villain was always Evil Managed Care.) There are tons of TV shows about doctors, some of which involve doctors hooking up a lot (Grey's Anatomy). There are comedies about doctors (Scrubs). So I don't know why female doctors can't be the protagonists in chick lit? The Devil can wear scrubs, can't she?

You can probably tell this really bothers me. Why can't someone write a novel about a female doctor who's riding on a plane, ends up telling all her secrets to the cute guy next to her, then it turns out he's her new boss and also she has a shopping addiction? What's up with that?