The Massage

For special occasions, my husband likes to get me creative presents. No chocolates and roses from this guy. He claims it's because I don't like chocolates or roses, but I do actually like chocolates and would be fine with receiving them as a present (not so much roses). Some creative presents he's gotten me have included a membership to the Lobster of the Month Club and a hammock for our tiny one bedroom apartment:



(Unfortunately, the hammock came to life during the night and tried to bring us back to its home planet. We had to destroy it with fire, its only weakness.)

Last year, he bought me a gift certificate for a massage at a spa. Sounds like a great gift, right? Unfortunately, I've never had a massage before and I'm a little bit terrified of them, mostly because I vasovagal kind of easily. When I was having a one on one yoga demo session, the instructor did some kind of massage-like manipulation and I almost fainted, and felt lousy the rest of the day. The same thing happened when an osteopath in my class did some kind of manipulation on my shoulders.

So I traded the massage for a pedicure and a wax, and I was happy. Yes, I preferred having hair yanked out of me by the root rather than get a massage.

I guess I didn't emphasize to my husband my feelings about massage because this year for our anniversary, he again bought me a gift certificate for a highly rated spa in our area. Except this time it was a spa that basically ONLY does massage and variations on massage. And it's a $200 gift certificate, so it's not like I can just toss it. I have to get a massage.

I feel a little stupid about the whole thing, because really, what woman wouldn't want a massage at a nice spa? But I'm seriously worried about fainting during the experience or something along those lines. And isn't part of the fun of a massage looking forward to it? I feel like this is going to become a self-fulfilling prophesy.

So here I am, dreading a massage (and also playing the world's tiniest violin).

Guest post: Top 5 Unexpected Discoveries While on Leave of Absence

As a rising 4th-year medical student, I took an extended maternity leave after giving birth to my youngest daughter, Starlight (for many reasons, mostly practical ones, but some sentimental).  While the obvious reasons (a proper recovery, extended breastfeeding, family quantity time) were readily apparent, there were a few unexpected discoveries on the way:

1. Making new friends, and keeping the old. During medical school, and especially during the in-hospital clerkships, my life choices were made for me: either school or family, often in that order.  There was little room for anything else, especially not friends.  (Have you been friends with a medical student?  They are never around, and if they are, they are talking about exams or sneaking peeks from flash cards.  And planning get-togethers? Forget it--they're at the mercy of the next clerkship schedule.)  So a few months into my leave, when someone asked to set up a play date after a La Leche meeting, I was dumbfounded.  That there are other people out there who can relate to me outside of my profession and are willing to rehabilitate me back into the world of non-familial human attachment, was--and still is--a wondrous thing.  I am forever grateful for those friends who ask to socialize despite my terrible track record at reciprocation.

2. Time to....think.  Don't get me wrong, in school I was thinking all the time.  But the thinking that came with school was strictly medical (normal pressure hydrocephalus or early dementia with BPH?).  Left to my own devices, I started to think about my medical thinking (metadiagnosing?) and how I was taught.  I reflected on what I would do for a career, what kind of thinking I liked to do.  I read JAMA for fun, and went to a writing workshop for medical students.  I feel...more resolute now, more introspective.

3. Hobbies.  While I didn't revive my favorite hobbies with nearly the gusto I intended, it was nice to dabble in them here and there, even if it meant that time-intensive knitting was replaced with beadwork, or jogging was replaced with chasing kids in a park.

4. Kids--they grow!  Once Starlight was born, I lived in this fog of sleep-deprived, perpetual kid-tending.  Starlight never slept more than 40 minutes at a time, and she constantly needed to nurse.  Unlike Sunshine, she wanted to be held all the time.  Sunshine (my oldest daughter), being barely two, still needed intensive mothering--I was clothing her, diapering her, and cutting her food in little pieces.  She couldn't be left alone more than a few seconds.  It didn't occur to me then that this state of being might be temporary.  Over the last few months, I've watched Starlight nap longer, learn to explore on her own, and try all sorts of finger foods.  Sunshine can now put her own clothes on, play quietly by herself, and use the potty.  This was definitely one of my favorite discoveries.

5. I'm the same person I always was.  When I started my leave, I had grand ideas of remembering everyone's birthday with personalized cards, preparing elaborate dinners, and finishing all sorts of household projects.  The truth is I'm not an apple-pie mom.  I'm a doctor-mom, and if my heart and my mind are ever not with my family, they are with medicine.  My house never got to immaculate status these last months, but it matters more to me that I was able to tutor medical students and perform experiments.  My cooking will never make anyone's life a little better (Mr. Scrub can probably attest to this), but hopefully my skill and empathy as a physician will.

Tomorrow is my first day back.  I should be wistful (and probably fearful), but right now I'm full of anticipation.  New lithium AA in my pager, and a fresh set of bound notecards to pair with my pocket reference book. 

The air is hardly crisp, and the leaves are far from turning, but back to school, here I come!

-scrubmama

Reverse Sexism in OB/GYN

From the moment I was accepted to medical school, I began to get unsolicited advice about which specialty I should choose. The most common recommendation was OB/GYN. “Female OB’s are in such demand!” I was told on a regular basis. However,I had ZERO interest in becoming one of THOSE women. As I began my rotations, I realized that there was more to the specialty than pap smears and stereotypes. In time I embraced it as my calling.

The year I graduated (2005), 75% of OB/GYN residents nationwide were women. I don’t know today’s numbers, but some recent journal editorials have brought attention to the fact that there are fewer and men going into OB. As more and more practices are marketing themselves as “women only,” some male OB’s are beginning to cry, “Foul!” To some extent they are right.

When I made my appointment for my very first pap smear, I called every female doctor in our town, only to find them all on a 6 month waiting list for new patients. I begrudgingly went to see my male FP, and he was fantastic… well as fantastic as the person giving you a pap smear can be (not THAT fantastic). Some of the kindest and most compassionate OB/GYNs I know are male. Many of my mentors in residency were older male physicians, who would really take the time to teach, while the female attendings often hurried home to their families.

At the end of the day, when starting with a new physician, a lot of women just feel more comfortable with a female OB/GYN. I am part of an all female practice, and honestly that is beneficial to getting new patients in the door. A significant majority of our obstetrics patients will ask to confirm that there is no possibility of a male physician delivering them. I answer in the affirmative, but the answer makes me a little uncomfortable. "I prefer to see a woman because you KNOW what I'm going through" they will often tell me. As women, the ‘been there, done that factor’ can cut both ways. Yes, I do get pap smears and understand the discomfort of putting my junk in the literal spot light every year. I also worked 12 hours the days I delivered my baby, and find it hard to muster up compassion for the multiple complaints of my term pregnant patient who work a part time desk job.

Being a MIM is not easy, but honestly in my field it is an advantage. Is it in yours? These men are saying the current situation in OB is rife with discrimination. What do you think?

Home vs. Hospital Birth

When a woman I know in real life or online tells me they are interested in giving birth at home, I am never entirely sure how to react.

While I am a physician, I'm not an obstetrician or pediatrician or someone who works regularly with childbearing age women. When it comes to the statistics and research about home vs. hospital birth, I know very little. All I can really offer to an expecting mother is anecdotes from my brief experience on L&D. I can share a story about a severe postpartum hemorrhage that might not have made it to the hospital from home, or the newborn with unexpected heart problems whose life was saved only by immediate medical care. Based on that experience, I would never consider giving birth at home or advising anyone else to do it. But anecdotes don't equal evidence-based recommendations.

In contrast, a lot of women having home births have done tons of research on the topic. Something I recently discovered is that some women who are pro-homebirth not only feel that it's safer to give birth at home, but that this is an undisputed fact supported by solid medical evidence.

There are probably women who read and write on this blog who know the evidence back and forth, but I'm not one of those women.... which is why I'm writing this post. I am not entirely sure what to make of women who proclaim that they're giving birth at home because it's safer, then try to convince others to do the same. Yet I feel like as a physician, I have to speak out on behalf of my profession.

The readers of this blog are generally medical professionals of one kind of another, or at least people who likely respect physicians. So I ask this specific community for the sake of my own (and the readers') curiosity and knowledge: what are your thoughts on home vs. hospital births?

Triggers

The first time it happened I was an intern. I was starting the first day of a week of vacation after a 6 month straight spell of no vacation and few full weekends. I had just finished one of our more demanding services and had been up until 1am finishing up notes. I woke up late Monday morning - after the sun was up - and got in the shower. It was a bright, beautiful sunny day! Then, about 5 minutes into this glorious long shower I started BAWLING!!!! Just the day before I heard about a patient that I’d taken care of off and on all year - she had died in hospice earlier that week. She was a patient who I got to know well. I got to know her family. I was devastated but never really felt it because I was just way to busy. Well, five minutes into my vacation shower I started to feel it. I started to think of all the patients who had died - oncology patients who fought hard to the end, sick kids in the PICU, bad trauma patients, EVERYTHING!!! I cried for like an hour! Then I got myself together, and went out for breakfast.

Well, this morning, I was driving to work. I had just dropped my super cute daughter off at daycare and I was having a good morning. Then, on npr there was a story about poet Dean Young who had just received a heart transplant. In the interview he talks about what it means to receive a heart from someone - in his case a 22 year old college student - and suddenly I start crying. A patient I took care of died over a year ago suddenly and very dramatically after being totally stable from his heart transplant. It was a heart I helped procure. He was one of the kindest patients I had ever had. He was young and so happy about the new life he was about to begin. I had a hard time with his death last year but I thought it was behind me. However, here I was, in my car, crying for this patient. I knew I needed to write about this, the thought of writing it out is part of what got me to stop crying so that I could get out of my car and go to work. How do we deal with the crushing losses we are a part of? How do we stay human and also stay sane?

When Your Patient Can't Get Pregnant- And You Are

Now that I am again expecting, I am wondering how to approach potentially difficult clinical situations in my Internal Medicine practice. It’s too early right now for my pregnancy to be obvious, but I know that it will soon be very obvious to my patients who are struggling with infertility issues or pregnancy losses. Not only that, but I am struggling with my own emotions when I counsel patients through miscarriages or pregnancy complications.

Last pregnancy, when I walked into the exam room at 6 months to see my patient with a cough, it was painfully, massively obvious that I was pregnant. This patient is a lovely woman, about 42 years old. She and her husband had been trying to conceive for several years. She had tried Clomid, in utero insemination (IUI), and several cycles of in vitro fertilization (IVF). They had used up their infertility treatment insurance benefits and a large chunk of savings on the project. We had spoken of her issues before, and I had provided referrals for her to a new fertility center, to try again. But that day, she was only in for her cough.

When I was at 6 months, almost anyone who saw me commented on my pregnancy. Patients would almost invariably enthusiastically ask: A query as to how it was going, how I was feeling, did I know if it was a boy or a girl, etc. I welcomed this banter and enjoyed the opportunity to chat with patients, as most times the banter led to some memories from the patient on their own pregnancies, or expressions of hopes for future pregnancies, or descriptions of beloved nieces and nephews or grandchildren. In short, a pleasant time was generally had by all.

But this patient was clearly pained by my state, and the visit was strained to the max. As soon as I walked into the room, she seemed shocked, silenced, and took some time to get composed. It did not occur to me right away what the issue might be, so I asked her some questions about her illness. The visit progressed, I took care of her cough, but she never once commented or said anything about my state. She kept looking at me as if I had somehow betrayed her. She fairly fled the room at the end of the visit, clutching her prescriptions. I felt terrible.

Afterwards, I asked colleagues how I could have handled this better. It had seemed as if there was an elephant in the room- and at my size, there literally WAS an elephant in the room. They suggested that I acknowledge the elephant, say something like, “It’s possible that my state is upsetting to you right now, and it’s no problem at all for me to find another provider to care for you, if you like” type of thing. I think that with this pregnancy, I’ll be more sensitive to these situations, and likely offer something like that. I’m curious as to what other providers do, especially the OBs, who much encounter these situations far more often than I do.

Now, I am 9 weeks along. I’m exhausted, emotional, and a tad nauseated, but other than being various shades of green during exams, I don’t think anyone would know that I was pregnant. However, it comes up for me, on my end, with the emotions I have in caring for my patients who are having pregnancy issues. Two weeks ago, I counseled one patient through an early miscarriage. She had had a hard time getting pregnant, and the loss was such an overwhelming disappointment to her and her husband. I couldn’t help imagining what it would be like for me, for us, to go through the same thing; as a result, it was difficult for me to contain my own tears in front of them.

I have another wonderful young patient who is struggling with a complicated early pregnancy, right now. She has numerous health issues, and hers is a very much desired pregnancy that has been a long time in the trying. Our LMPs were close to the same date. She does not know that. My pregnancy has progressed pretty normally thus far; hers has been fraught with vaginal bleeding and erratic HCG levels; an early ultrasound showed a small gestational sac with no heartbeat, and she was counseled to hope for the best, but prepare for the worst. This week she has had more vaginal bleeding, and a followup ultrasound showed a fetus, alive, with a heartbeat, albeit a slow heartbeat. She was again counseled to hope for the best, but prepare for a possible miscarriage. I cannot imagine the limbo she must be in. I worry that I will run into her at the OB’s, as we both are going to the same OB office for care. I wonder what I will say, or what I should say, what I need to say.

How do other physicians cope with these difficult situations? I do not believe that a complete dissociation into professional identity is possible here. These issues hit the deepest emotional, irrational parts of us. For so many women, being pregnant or trying to get pregnant can represent a whole future; hope and loss, life and death, and is life-CHANGING, regardless of the outcomes.

What do people do?

Is There a Doctor in the House?

Last week, I had a kid-free weekend coming up. Trying to decide how to spend my time, I googled volunteer opportunities in Little Rock, AR. I came across a website called volunteermatch.com, or something like that, and signed in to look for opportunities.

There were lots of chances to mentor kids, or host exchange students, but I have two kids of my own that I am currently trying to mentor, so I am reluctant at this point to take any others on. It seemed serendipitous that a big event was happening on Saturday, called Take Steps for Crohn's and colitis. They were looking for 50 volunteers to help set up. My brother has Crohn's disease - he is in Boston. I decided to go for it. I e-mailed the coordinator, explaining that I was a physician and touting my personal interest in helping out. She e-mailed me back.

"We had a nurse running the First Aid tent, but she had to back out due to family obligations. Could you man the tent between three and seven o'clock?"

I cursed the fact that I told her I was a physician. I am a pathologist, for crying out loud. I could do someone's autopsy, if they died? I was counting on setting up tents, or maybe hanging up balloons, but running the First Aid tent? Yikes.

I decided well, maybe I'm a pathologist, but I'm also a mom. I don't keep up with my ACLS certification, but I am pretty good at bandaging boo-boos. I told her yes, and hurriedly and desperately recruited my friend Ramona Bates, a surgeon, to help.

Ramona and I arrived promptly at 3:00, and despite our attempts to help in whatever capacity, we were relegated to the First Aid tent. There was a plethora of Central High School students doing chalk art and any manual labor that was necessary. I was worried (Ramona was not), but my worries were to no avail. In four hours, we passed out two band-aids - to the same person - one who was trying to protect a blister during the walk. MEMS was present - it seemed a little silly considering the short walk required after the provision of massive amounts of Bar-B-Q, freebies, and pizza, but I was still comforted that if anyone needed a "real doctor," I had back-up in Ramona and MEMS.

As a pathologist, I worry about my little exposure to the "real world" of medicine. Here I am, a bona fide M.D., and what do I have to show for it? Sure, I make a decent living, and am proud of what I do, but why do I have heart palpitations when I am on an airplane and I worry about hearing an overhead announcement, "We have an emergency and we need a doctor - are there any on board?" Will I be able to perform? I was recently discussing this with an OB - she voiced the same concerns. She was on a plane recently where they asked for a doctor, and after realizing she was one of two on board - her and an ENT - they both reluctantly volunteered to help, wondering if they could do anything for a geriatric stroke victim.

I was talking with one of my partners Monday about my weekend volunteer experience. She empathized. She said, "I think we should have a yearly workshop. Call it, "Is There a Doctor in the House?" And we should be updated on how to respond, as M.D.'s, in emergency situations. We were trained to help, and we should keep up the training, so we can perform in these situations.

One Friday night a couple of years ago, I was triaging bone marrows and lymph nodes that were rolling in mercilessly while I was on weekend call. I had just finished a platelet apheresis on a patient with Essential Thrombocytosis. She had been done for a couple of hours, and for all I knew, she was on her way home. I got a call from the dialysis nurse. "She is on the floor, seizing." Shit. I told her to call the heme/onc. He was climbing a local mountain for exercise. I told her to call the on call hospitalist. He told her to call me. As I was rushing upstairs to get labs and try to stabilize her, with my limited microscope medicine, I got a call from an internal medicine doctor. "Her electrolytes are out of whack. We are fixing it. It is all under control."

We are so subspecialized, in medicine, that the very thing we start off trying to be good at (dealing with these emergency situations) we end up being abysmally afraid of. Maybe it is just pathology. I am a general pathologist. I presented three disseminated fungal infections at a hospital-wide Chest Conference today. I did three fine needle aspirations in fast-track ED. I handled two inpatient needles in radiology - making spur of the moment decisions with limited tissue to benefit the patient in the CT scan, under the needle. I feel like I am so much, but also not enough. Does anyone else feel this way, as a doctor?

What do we owe?

I recently had a discussion with fellow residents, their spouses and friends at a dinner party. We ended up discussing the difficulty of balancing family and a surgical career which brought us to a discussion about two recently graduated female residents who both have young children. They both started out residency very similarly. I had the pleasure of working with both of them and they were awesome leaders and had great technical skills. Both were ironically interested in the same very demanding subspecialty and had done everything necessary to secure top fellowships. Then they both had kids during residency. One went on to pursue her very demanding fellowship and is currently doing well and loving her job. The other finished residency and is now a stay at home mom and also very happy. When we brought up these very divergent career paths it started a discussion about what doctors owe society. One person commented that there is a significant societal costs of training a doctor. In addition, there is a surgeon shortage and therefore a responsibility of those trained as surgeons or any type of doctor, to actually practice medicine. I was surprised by the strong feelings about this issue and felt that personal and family decisions are based on more than these large scale societal issues. Yes - the resident that is not currently practicing as a physician represents some loss to the society. But, I didn’t feel she owed anything to society. She worked hard through medical school and 7 years of residency. She took care of many patients during that time and devoted much of her life to it. In my opinion we all have a right to choose.

What do you think?

Guest Post: My biggest fan

My mother is almost inappropriately proud of me. At parties or social gatherings she will announce unsolicited that I am a physician (or was a medical student, or was planning to go to medical school, etc etc). She will go on, to whoever hadn't made an excuse to refill their drink, about whatever particular detail makes me fabulous, the word "doctor" coming up repeatedly. And although I find her rosy accounts to be both flattering and endearing, I have had to pull at her arm and mutter in her ear “Mom, come on” when I sensed our crowd is not interested.

I would of course like to think that my dazzling success, tireless benevolence, and deafening charisma has deemed me worthy of her immoderate praise. But I recognized that part of her pride stems from the fact that until she made a huge mid-life career change (into social work) never derived much pleasure or satisfaction from her own work. She raised my sister and I to “reach for the stars and let the rest shake out where it will”, and with the expectation we would have our own careers, earn our own money, and generally live as independently as possible.

My mom is very bright; however raised in Latin America as part of a family whose hopes and expectations for my mom did not extend beyond that of marrying "well". Her education and personal development were not valued to the same degree as those of her younger brother, who was sent to boarding school in Italy when no satisfactory local school could be identified.

Despite, or perhaps in reaction to, being presented with so few options, she spent her twenties partying in night clubs around the world, working in generally low paying jobs, and becoming engaged to six different men. I find the motley anthology of my mom’s travel and love trysts almost painfully exotic, especially in comparison to how I spent the same decade of my life. She strongly disagrees with my characterization, insisting that she would have spent her twenties very differently if she had known how to get herself on a different course.

Last month my mom lived with me while my husband was out of town and I was on our busiest inpatient ward service. With my pager going off starting at 7am six days a week, I needed help with everything, including but not limited to getting my daughter ready for school, making her lunch, dropping her off, picking her up, dinner, and all the other small tasks that can become monumental when I am on my own.

I am unfortunately now accustomed to the constant distraction of my pager, so it was interesting to see my mother’s frustration grow each time it went off. She watched curiously as I had to leave the dinner table to get on the computer. She worried that I was too tired to work. She wondered aloud how I was suppose to attend to so many people’s needs without being able to meet my own.

Slowly, she started to understand that which I realized soon after my daughter was born - I can still do anything, but I can’t do everything.

Her rudest wakening came during a conversation we had about the upcoming plans to “transition” my daughter from the toddler to the preschool room at her daycare. When my mom inquired as to my “strategy” for said transition, I stared at her blankly before replying that the great plan was to drop her off, as I would any other day, and go to work, again, as I do every other day.

My mom looked at me as if I had just said I was going to kick her out of a moving car on a cold and raining morning, with the hopes that fear and hypothermia would drive her into her new classroom. She immediately started planning a return trip so that she could oversee the "transition".

I would like to think my mother is still proud of me, but as she realizes how much I have missed, and will miss, of my daughter’s early years, she seems less enthusiastic about my choice in career. She has become almost bitter about my inability to be in two places at once, and would like to hold the "male-dominated world of medicine" responsible for this failing.

And now we both wonder to what degree we will encourage my daughter to pursue a similar career pathway. My mom might never have been satisfied with her career, but she was at every soccer game and running event. She was there when I got home from school and on weekend mornings. And she never left in the middle of the night.

I owe a great portion of my accomplishments to my mom, who was always by biggest fan and believed in me when I didn’t believe in myself. But, armed with only the best of intentions and an incomplete view of the consequences, my mom inadvertently overlooked the cost of this success.

With the full appreciation of its benefits and limitations, how I counsel my daughter in this regard remains an unanswered question. I love what I do, but I love my daughter more.

And I think that will be only contribution I can make over that which my mom gave me; do something you find meaningful, but know that nothing will mean as much as your children.


s

s is a Hematology/Oncology fellow in California. She lives with her husband and two-year old daughter. She blogs at http://www.theredhumor.com/

Pregnant in the cath lab

There is no harm in being protective of your unborn child. There is no harm in speaking up for yourself when you have strong feelings about any subject. For heaven sakes we are in a healing profession- we should take care of one another too. We should make a pact- all MiM and MiM followers to steadfastly protect and promote the (physical and mental) well being of our gravid counterparts.

There is potential harm in overstating the risk of x-ray in pregnancy. At least from my perspective. Sorry for additional post Fizzy, I have too much to say for comment section. I really think you are on to something here, and I appreciate this discussion.

First to get this out of the way, there is a major difference between therapeutic (or diagnostic) radiation exposure vs. occupational radiation exposure. All physicians would consider using x-rays to examine or treat a pregnant woman. As long as the benefit outweighs the risk. Do you need dental xrays while pregnant- probably not. You have a serious condition during pregnancy, attempts will be made to use alternative imaging or minimize fetal exposure. The risk to the fetus is based on amount of exposure (may vary based on type of exam) and week of pregnancy. It would be a mistake to x-ray a pregnant woman without considering the fetus (therefore the questions and signs in radiology). Just because there are signs and attempts made to avoid exposure in no way means that it is absolutely contraindicated.

Here as Mothers in Medicine we are discussing occupational exposure. A classic intersection of personal responsibility and professional obligation with undercurrents of gender discrimination. We would all take a bullet (literally) for our children, our own safety/sanity is only a secondary concern. What are we willing to expose our children to- now that is a hot topic.

Fifty percent of Internal Medicine residents are women, yet only 14% of all cardiology fellows and a mere 7% of practicing cardiologists are women. We may be few, but as women in cardiology we are a serious bunch- and are concerned about why more women do not consider careers in cardiology. It is likely women are deciding not to pursue cardiology early- as med students or interns. Concern over lifestyle and radiation exposure during mothering years is likely a key issue.

Tackling the subject head on, two important papers are published in cardiology journals. The first published in JACC in 1998 (http://www.ncbi.nlm.nih.gov/pubmed/9525565) is a consensus statement for radiation safety in the cath lab. This year another consensus statement (http://www.ncbi.nlm.nih.gov/pubmed/21061249 ) was published by a group of women interventional cardiologists (now these are women who I seriously admire). I recommend that you read both if this issue affects you directly.

Here are important points I would like to make:
1. Fizzy's initial post upset me a great deal, it felt like a personal attack (unreasonable I know). I think this points to how intimate and heart wrenching pregnancy related issues can be.

2. Fundamental radiation science: exposure is proportional to energy emitted, inverse to distance from source, and subtracted by protective equipment. When pregnant I wore two layers of lead (my usual apron) in my first trimester then special pregnancy apron (even though it weighed 12 lbs-or maybe a TON) the rest of the time. I never let the fellows control the fluoro pedal and when able always took an extra step away from the camera. On occasion I took it as an excuse to stay far far away from the table, on a stool in the corner where I could rest my feet too, a bonus.

3. When I was a fellow one of my female attendings was pregnant. It really helped me to see her in this role. She gave me the best advice. Meet with the University Radiation Officer- this really helped to balance my fears with what is known about the risk.

4. The female fellows in my current program are not allowed to work in the cath lab during pregnancy. This takes the decision making away from them. I am not 100% behind this, only because it is really hard for them to find coverage for maternity leave already.

5. X ray is not the only source of radiation exposure. I learned from the Radiation Officer that my greatest risk would be during my nuclear cardiology rotation. Patients dosed with isotope emit radiation, and despite high standards areas of radiation can be present in the department. Always wear your badge when reading nucs, do not leave your lunch in the reading room and for heaven sakes do not do injections for stress tests or PETs.

6. The total amount of radiation allowed in pregnancy is 0.5 mSv per month and 5 mSv for entire pregnancy. This is 10% of the amount of radiation defined as negligible by ACOG guidelines (Obstet Gynecol 2004;104:647–651 ). Studies from diagnostic radiology in pregnancy show exposure below 50 mSv is not associated with fetal loss or anomaly. Other population studies suggest that exposure to 100% of the allowed radiation during pregnancy will increase the risk of having a child with congenital anomaly from 4.0% to 4.01%. The chance your child will develop cancer will increase from 0.07% to 0.11%.

7. It is difficult for me to compartmentalize my role as mother and cardiologist. It all runs together in an overwhelming way. Eight weeks pregnant, while taking progesterone for a fetus at risk I was inches away from the camera while doing CPR on a woman while my partner inserted a temporary pacemaker. I had lead on, but had not yet declared my pregnancy and did not yet have a fetal badge. That woman celebrated Mother's Day with her children last weekend. During my 2nd trimester I was exposed to acute viral myocarditis, amazingly 3 times where two of the three patients were killed. Suspected viruses can cause fetal hydrops. The surviving patient was a miracle and my ability to cure him was instrumental. My team knew I had ID consultation and special tests by Employee Health. They did not know I took a "time out" in the call room where I sobbed uncontrollably for 20 minutes.

I carried two pregnancies and worked in the cath lab both times. I checked my fetal badge religiously every month. Under my lead, over 18 months of pregnancy my fetal badge (s) summed total radiation exposure of <0.01 mSv, below the measurable limit, ZERO.

It is probable that women avoid their true calling into cardiology due to concern over the occupational hazard. It is possible those who do pursue cardiology still face additional obstacles based on current maternity policies (I think this is true of most of medicine). My experiences thus far have been challenging, and I hope we can make things better for the next generation.

Okay so you may now jump in to discuss. So let me have it, I imagine being crucified and accused of child endangerment. For the sake of full disclosure in addition to exposing both of my boys to radiation I also ate lunch meat, non-pasteurized cheese and even drank a glass of wine (or two) during my 3rd trimester. And if anyone corrects my writing/ grammar I will kick your ass.

Radiating Yourself in Pregnancy

Last week, I wrote an entry about things that bugged me from my pregnancy during residency. One thing that ended up being a bit of a topic of debate in the comments was the issue of radiation during pregnancy. Basically (in case you didn't read the original post), when I was in my second trimester, an attending asked me to hold a patient's head while they were getting spine X-rays, then seemed shocked when I was reluctant to do so.

I certainly didn't expect all the readers to be on my side, and I wasn't disappointed. A couple of people commented that they didn't understand the big deal, since I would be covered by lead. One person went so far as to say that she would never ever consider covering for a pregnant women who wanted to avoid radiation.

I don't think I'm a weirdo for worrying about radiation during pregnancy. Most attendings never asked me to do such a thing. When we were taking an X-ray at the patient's bedside, they immediately stepped in and ordered me out of the room. On another occasion, when I wasn't pregnant, I went down to hold a patient's head, and the radiology tech grilled me about whether or not I was pregnant, even going so far as to ask if I was on birth control. Another resident in my program had her schedule for the year arranged so she could avoid a radiation-intense rotation during her pregnancy, and I don't think anyone questioned this.

Of course, there isn't a lot of conclusive research about radiation exposure during pregnancy, since it's not like they're going to be doing any double-blinded randomized controlled trials any time soon. An X-ray, I've read, provides about as much exposure as a cross-country plane flight. I spent a minute doing a PubMed search before writing this and it seemed like the only thing they knew for sure is that radiation during pregnancy causes a lot of anxiety in mothers-to-be.

I think it's an important topic for women in medicine though. After all, a lot of fields do have radiation exposure. And a lot of us get pregnant. A friend of mine is currently pregnant and working as a Pain physician, performing injections under fluoroscopy. I know she wanted to get pregnant and deliver prior to that job in order to avoid the radiation exposure, but things didn't work out that way. Sometimes you can't avoid radiation during pregnancy. But if you can, should you make an effort to try?

At the risk of causing an argument in the comments, which y'all know I really hate, I'd like to ask the readers what their feelings are about radiation exposure during pregnancy. Do you think the anxiety is unwarranted? If you were pregnant, would you have held that patient's head during that X-ray (and the 3-4 other times it came up during my pregnancy)? Would you work as a Pain physician doing injections daily with an X-ray machine? Would you agree (or better yet, volunteer) to help a pregnant co-resident who wanted to avoid radiation exposure?

Mothers who lie

Okay, someone I hold in high esteem (basically one of the most intelligent women I know) is a philosopher by profession and recently wrote a chapter in a book. But not a chapter in a book that is too hard for us non-philosophers to read, but one we can all get into. I wouldn't say it is dumbed down, but just that it is very readable. It essentially delves into the philosophy of motherhood. Please believe me that this is not a "buy this book" post (no link to Amazon here); I'm telling you the truth. And therein lies the issue. That's what it's about. The chapter is entitled "Lies and the Lying Mothers Who Tell Them." With proper mention of Kant and Bok and Augustine and Mill.

What lies have you told to your children, as a mother and/or as mother in medicine? Perhaps some creative mothering? Maybe:

• If you jump on the couch that way you will crack your head open.
• That's a beautiful drawing.
• Your little brother did it by accident, I'm sure.
• You will grow nice and tall if you go to sleep right now.
• It's very late.
• The tooth fairy _______ (fill in the blank).
• Don't touch that! It will make you sick and you will have to miss your party tomorrow.
• You will literally turn into macaroni and cheese if you have that for dinner again tonight.
• There are no monsters upstairs in your bedroom closet (okay, that one is true), but if you don't get dressed right now they might start wearing your clothes.
• We are leaving this store right now.
• This won't hurt.
  
• I'm almost done (with this email, post, tweet)
• I'll be home soon.

Is it okay to lie to your kids? Is it for their benefit? Wishful thinking? For the greater good? What lies have you told to your children, as a mother and/or as mother in medicine?

Happy Mother's Day

My Mother worked.

She spent her formative years in the convent to escape a rough home environment, and became a nun.

She left the convent in her early 20's and worked three jobs, including running an EKG machines, running errands for a lady in exchange for a room near her college, and working in a cafeteria at the local University where I eventually went to medical school. These jobs, in addition to a scholarship, helped put her through nursing school.

She met my Dad while dishing up grubby fare in the cafeteria line. He was in medical school. She likes to joke that she divorced God to marry my Dad, but really the timing wasn't right. When she came down to Arkansas from the convent in New York to visit her Dad (she quickly discovered in her 20's that he hadn't changed much in being able to offer her support), she couldn't get bus fare back to New York, and never got an answer when she wrote them for help. So she wrote to a local college instead, detailing her desire to be a nurse, and they hooked her up with the aforementioned jobs.

After going through nursing school, she took various jobs including helping organize and run free clinics, becoming the director of nursing at the Health Department, getting her masters in Public Health, doing school nursing, and eventually volunteering her skills in orphanages in Russia and Thailand. Did I mention I am the oldest of four children? My sister has her P.A. in anesthesia, my brother has a Ph.D. in food science, and my youngest brother is finishing law school at the top of his class. Needless to say, none of us were neglected.

Today she is a proud grandmother of four and devotes her time volunteering and traveling around the country visiting her four kids and grandchildren. She also keeps my Dad in line - he is still working as a neonatologist and when she leaves town all the flowers in the house die, the food pantry becomes appallingly stark, and he becomes a recluse (no offense, Dad!). We call her Babcia, the Polish word for grandmother.

I hope I am half the Mom to my kids as she is to all of us, and can touch half as many lives as she has throughout hers - I would then be more than whole.

Happy Mother's Day to all!

Twitter to Tenure: My (parenthetical) story

I'll soon be heading to the 2011 Society of General Internal Medicine's annual meeting. As prelude to a workshop called "Twitter to Tenure," I, and several fellow academicians are blogging about how social media has helped our academic careers. See bottom of post for the other posts in this series. And if you'll be at SGIM, please come and say hi!


If I had known that starting a personal blog in 2006 would eventually result in such great things for my career, I would have started one a long time before that. The truth is, I was simply trying to capture the moments of new motherhood that I didn't want to forget. (Also, before 2006, I was like, what's a blog?)  In the process, I unknowingly set wheels in motion that would eventually help shape my future personal and career pursuits. (Bonus!) This is what you call a win-win. Win-wins in life are the best.

Writing leading to...
In my early days of blogging, I posted feverishly, to my 3 readers, one of which was my husband. We're talking practically everyday (I sigh when I think about how much more time I had when there was only 1 child to contend with). In the process (of talking to those 3 people), I developed my writing voice. It became like nothing to write a post- I could whip one out in 5-10 minutes, honing my story-telling, organization and my writing got better. (Please do not use this previous sentence as an example.) Malcolm Gladwell talks about this 10,000 hours phenomenon to achieving excellence in anything--I haven't come close to that but blogging so frequently was a start.

Writing opportunities...
An amazing thing happened in the midst of blogging feverishly (now over 3 readers): people found my blog and offered to pay me to write about parenting --humor writing. Paid! To write! This was a huge boon since it felt like I was an actual writer who could (occasionally) make people laugh. Meanwhile, the blogging (on multiple blogs now) continued, more hours under the belt. I networked with other bloggers, went to blogging conferences (after at first scoffing at them--who would go to a blogging conference??? Lame. I've realized, since, how much I love eating my words, or at least, embracing being lame.). I am not sure when my affinity for using parentheses developed.

And medical education applications...
I now appreciated what blogs could offer (discussion, community, feedback, support, to name a few) and while studying adult learning theory and the theoretical underpinnings for reflection in medicine, started a reflective writing blog for internal medicine clerkship students. Students' writings blew me away as they wrote frankly (amazingly frankly) about professionalism, doctor-patient relationships, empathy, and the struggles and anxieties of being a medical student. This led to workshop presentations at conferences, a paper in an academic journal, and networking with some pretty awesome collaborators.

And research....
Having had a blog where I occasionally mentioned issues that I saw in the hospital, as well as developing a (vaguely, on good days) humorous writing voice, I could appreciate the line that physician-bloggers had to manage between privacy, humor, disclosure, and professionalism. I became interested in the intersection of professionalism and physicians on social media and had an idea for a study on medical students and unprofessional online content. I also got involved with other forms of social media - Facebook and Twitter - and more ideas for studies came. This research has led to plenary talks, media interviews, grand rounds invitations, national conference workshops, and has defined a career path. Not to mention it's just fun to do these studies. Note: I would have never imagined I would be doing research when I was a resident! Thoughts of doing research in the past had always been accompanied by images of pain and suffering, like having a fork stuck in an eye.

And staying up-to-date with news from my field...
I've become a Twitter convert, thanks to Twentors (sorry) like Vinny Arora, an amazing academic rock star and Star Tweeter (ST). It has become my go-to source for breaking news and keeping up with my areas of academic interest --medical education and social media in medicine. I do not follow anyone like Paris Hilton ("I'm sooo tired! Need a nap!"), and instead follow those who have similar interests (as me, not Paris--pretty sure our interests don't overlap) or provide interesting perspectives and links. See Vinny's post for more resources about how to use Twitter professionally.

And Mothers in Medicine...
And of course, blogging led to the birth of Mothers in Medicine. Enough said.

So, social media has been good to me. It might also be good to you too.


Also see the following STs:

Alex Smith's (@AlexSmithMD) intro post on Geri Pal.
Vinny Arora's (@FutureDocs) post on FutureDocs.
Bob Centor's (@medrants) post on DB's Medical Rants.
Eric Widera's (@ewidera) post on Geri Pal.

Patient Negotiation

Over the course of any given day I sometimes find myself either pleading or negotiating with patients to take steps to improve their health. Am I the only one who has found this to be the case? It is becoming increasingly frustrating. Sometimes I just want to say, “Listen, you came to me for help. I am telling you to do ____ it is up to you to do so. Please feel free to come back when you are ready to listen to the advice you paid for."

Sometimes I think parenting has prepared me more for medicine than medical school. Raising teenagers has taught me the skill of listening and then collaborating to reach an agreement without inciting a rebellion. These can be tricky, shark infested waters, one must tread lightly. The last thing I want is a patient stopping his medications or a teenager sneaking around. Unfortunately, I did not raise my patients from infancy. Their previous doctor relationships could have been positive or negative. Their perception of the doctor-patient relationship could be completely skewed from what I would want to instill.

Or maybe this phenomenon is a result of an American culture that encourages instant gratification and looking for the easy solution. Yes, you must give of your liter of soda a day to get your blood sugars under control, and yes, you must exercise to lose weight and feel better and no I don’t have a pill that will fix all of your personal problems. What is a doctor to do? Give up or continue to chip away at a brick wall with a wet noodle? When these patients start to bother you, is this the beginning of burn out?

Don’t get me wrong though. I have many patients that are more than willing to do the work that is needed. They may grumble and tell me I am ruining their fun but they make some changes for the better. I usually thank these patients for doing the right thing and tell them I am going to brag to the other doctors what “good patients” I have. Oh my, I feel like I am bragging to the other mothers in the play group.