Feelings of loss post-partum

by FreshMD | Martina Scholtens

When Ilia was a few weeks old, Pete asked, and said it so casually from the couch where he was reading after dinner, "Do you miss our old life?" The relief to hear it said. I did. I missed the old routine, driving in to Vancouver in the mornings with four-year-old Ariana in the back seat, CBC on the radio and a day at the clinic ahead of me. Yes, there will be a similar routine in a few months, with an infant in the car and a graduated return to work, but those other days, the particular way they were, are done.

"I guess you'll never have another son-baby, hey, Mom?" asked my six-year-old son cheerfully as he ate his after school snack the next week. I could have cried. I saved all my kids' clothes in anticipation of this possible fourth, and now that she's here I have boxes of corduroy pants, sneakers, little ball caps to set afloat. Somehow my daughters' infancies seem preserved through Ilia wearing their hand-me-downs, but I can't kid myself: my son's baby days are over.

And then I overheard Ariana greeting her little sister. "Good morning, Ilia," she said seriously. "It's your medium-sized sister." Saskia's still the oldest, and Leif's still the only boy, but the crown of youngest child has been passed from Ariana to Ilia, by my choice. Then, after church an elderly woman tugged on my arm, admired the baby and confided, "Mothers have a very special relationship with their youngest daughter." At that moment Ariana came into view, long dark pigtails, thin legs in purple boots making their way across the room to the gardens outside. There she was, the daughter with whom I would have had that extra special relationship - except I'd taken that from us and given it to this newest baby.

Those first two months, I missed my bodies. The one before this last pregnancy. The one before I had ever been pregnant at all. The pregnant one, even, that at least looked purposeful. A week post-partum, sitting at the breakfast table, Leif gestured at my paunch with his spoon and asked, "You know why that looks like that? Because all the equipment is still in there."

Most of all, I've struggled with the (temporary) loss of my identity as physician. At the little good-bye party over cake in the chart room in February, I asked the clinic to please just stagnate until I returned. Of course they will forge ahead and do all sorts of interesting things while I'm away, and I hate to not be a part of it. Some of my patients requested six-month supplies of medications to tide them over until my return. I didn't comply, but I understood. I'm grateful for my locum, but I'm jealous of her, too. I miss the collegiality of the clinic, the focus on others' lives, the escape from my own head, the sense of contributing to the community, the academic stimulation. I'm back to work in the fall, but in the meantime, I feel a little unmoored.

This is my daughter:



How I love this little face. I marvel that someone I couldn't have imagined months ago could feel so inevitable, could have an entire family happily orbiting around her.

Don't mistake this for ingratitude. It's simply an acknowledgment that for this new mother, mixed in with the bliss of those first six to eight weeks, were feelings of loss and grief. Surely I'm not the only one.

Must the doctor ALWAYS be in?

First of all, for any of you who decided to read this post because you thought it might be a follow-on to the discussions about whether it's ok to work part-time in medicine, nope, that's not what this is about. Rather, it's about the tendency to wear our doctor hats even when we're off-duty, when it comes to our own health.

It was a Facebook status update, or rather a string of them, that first got me thinking about this issue: the epidemic of medical hypochondriasis among doctors and other folks in medicine. (For my friends in psychiatry, let me apologize for using hypochondriasis in the lay sense, not with any DSM criteria attached, and for my friends in epi, I know it's not really an epidemic.) A friend of mine, who is a mom of three and a critical care nurse practitioner in the PICU of a large academic center, often posts on FB about her anxiety related to her kids' health. One of them has a fever, and she wonders aloud whether she is the only mom checking for petechiae. Another says she's too tired to bike (in the 98 degree weather) and wants to come in and watch TV in the air conditioned living room instead, and she frets about whether she is severely anemic--it could be acute leukemia! It is easy to witness someone else do this and see the absurdity in it, but when it's YOUR lymph node that you think you might feel in your neck or YOUR lumpy breasts or YOUR bone pain, etc, it becomes a lot easier to let your mind spiral off into the crazysphere.

Most of the mothers in medicine with whom I have discussed this freely admit, "Oh yeah, my thing is cancer" or whatever. Everyone seems to have something she is convinced she is going to get, and it's often what she's surrounded by, not what she actually might be at increased risk for due to lifestyle or family history, that seems to drive the fears. My good friend from medical school who is now a pulmonologist in a tertiary care center became convinced that she had pulmonary fibrosis when she found herself out of breath in kickboxing (after taking off 2 mos from it). Another friend who is a high-risk OB attending just about drove herself insane with fear that she would have fetal death in utero. I have seen her on multiple occasions in all of her (3 healthy) pregnancies sitting in the hospital cafeteria with a sugary drink in one hand and the other hand on her gravid belly, brow furrowed, checking for fetal movement. Another who is a rheumatologist is obsessed with developing lupus, and given that lupus can cause any number of symptoms/signs, she gets a near-weekly dose of affirmation that THIS TIME, she really does have lupus. Kind of ridiculous, right? Except when you're in it rather than on the outside looking in.

I find myself worrying about cancer mostly, which I guess isn't shocking since I'm an oncologist. Every patient I see--well, except for a fortunate few who have been misdiagnosed--has cancer, 100% of them. And I see mostly second opinions, so they are usually pretty sick and often complicated patients. Though they all come with a big, thick chart, I always take my own history, and even in patients with several years of metastatic cancer, I always start with how the cancer first presented. I am struck again and again by how subtle the first signs were--that little twinge of pain in the chest that only lasted for a few minutes or noticing that she was slightly winded, just slightly, after dashing up a couple flights of stairs. Or whatever. I don't see the zillions of people who also had little twinges of pain in their chest or mild dyspnea who turned out to have costochondritis or an albuterol deficiency or absolutely nothing at all. I don't see ANY of those people. In other words, I have no denominator to provide me with perspective. Of course, these histories I'm taking are all retrospective, and maybe the "first signs of cancer" patients report were in fact utterly unrelated to their diagnosis, but have taken on significance in the wake of being diagnosed and repeatedly asked these questions by oncologists. All of this, I know, but I can't seem to remember any of it when it really matters.

So, I wonder: does this worry simply come with the territory when one works in a field where life-threatening diseases are the price of admission? Would I still worry if I were a primary care pediatrician, where the majority of my patients are so healthy they are actually labeled "well child"?

Do you find yourself worrying more than you feel is reasonable about your own health or that of your family/friends? Do you worry about the diseases you see in your own practice, or do you have "a thing" like cancer that you worry about, even if it's outside of your usual practice? And if so, how can we do a better job of being a voice of reason to each other? Because we are doctors. And we are mothers. Which means we have more than enough REAL things to worry about!

My Grams, Her Battle Was My Battle

There are some wonderful people that will pass through your life and when they leave it is very difficult to go on at times. Holidays, special events, and birthdays become painful reminders of their absence. I wrote this article a few years ago when my Grams was still alive and I read it at her funeral two weeks before I deployed overseas to the Middle East with the Air Force. 2007 was a tough year for my family but my Grams was a beautiful person who blessed my life.

"When my grandmother, Grams, came to live with us in 1997 she was depressed and a shell of person that I had known in my childhood. She came to us because she was leaving a violent marriage of 20 years. The Grams of my youth was vibrant and energetic, spending many summers with my younger sister and I shopping or playing miniature golf. But that cold day in April of 1997 I saw a sad hunched over figure in a wheelchair being wheeled off the airplane. I almost did not recognize her.

Grams settled into our home, spending many hours with my young daughter, Emily, looking at the stars and discussing what to wish for. Over the course of the next 7 months her divorce was finalized and we moved from Ohio to Texas closer to my mother. By this point I was beginning to see shimmers of happiness and energy from Grams, but on occasion she would fall back into the depths of depression. She struggled with being dependent on us for everything and pushed away opportunities of socializing with others outside the family.

By 2001 I had begun my third year of medical school and my grandmother watched the youngest of my 3 children, Gabriel. In October she called to tell me that her mammogram had showed an irregularity and she was told by her doctor that it would need further evaluation. My heart sank as I had a gut feeling that it was going to be bad news. I spoke to many physicians asking which surgeon they would take their mother to and Dr. Ronaghan's name came up more than once. We had her referred and Dr. Ronaghan gave us the grave news. She indeed had what looked like breast cancer and biopsy would be the only positive answer. Grams took the news as if you told her that she had a simple cold. My assumption was either she was in denial, had completely lost her mind, or extremely stoic. I, on the other hand, was falling to pieces inside. The thought of losing my grandmother made me nauseous, but I knew she was counting on me to be there for her. Little did I know that I was going to be leaning more on my grandmother during this process than she on me.
A few days later she had a lumpectomy which revealed lobular carcinoma and would need further surgery. Grams remained enthusiastic and positive about her outcome, she almost seemed happier than I had seen her in 4 years. I didn't know what to make of it, but then again things flew by so fast that I didn't have time to process it.

She went on to have a bilateral mastectomy with positive lymph nodes on the right side. So, we weren't out of the woods yet, she would require chemotherapy and radiation. Chemo would begin in December, 2-3 times per week for several weeks. By the tenth day her hair began to fall out in clumps and we began looking for wigs. One night she asked me to shave her head so she would not have to deal with her hair falling out anymore. I had cut hair many times, even Grams', but this request made me anxious and hesitant, almost to the verge of tears. It made me feel as though the cancer was winning, she was losing herself to the enemy. It was taking her beautiful thick white mane that made her my Grams. Well, we went to the kitchen and I plugged in the electric razor. I stared at her for a long time until she prodded me saying, "Laurie, it will be alright, don't worry. Anyway, I am hoping that it will come back curly!" At that moment I began to realize that the cancer was not going to win, because my Grams was strong and positive in heart and mind. I was looking at the Grams of many years ago, vivacious and alive! Yes, alive...she hadn't died yet. Wake up Laurie and join the fight! I went on to shave her head of course after we entertained the idea of a mohawk.

She continued with the chemotherapy and had good and bad days of vomiting and fatigue but her optimistic attitude never wavered. The children had adjusted to having a Grams without hair, the boys, Jonathan and Gabriel, loved to run around in her wigs. In preschool Jonathan was asked to draw a picture of his family. He drew his mom, dad, brother, sister, and Grams. We all had hair except one figure had no hair and was holding something in her hand. When asked who this was and what were they were holding, Jonathan promptly replied, "That is Grams holding her wig." As the story was relayed to her, Grams eyes twinkled as she replied, "Well, it's too hot to wear a wig all the time."
Grams went on to have six weeks of radiation therapy that resulted in severe burns across her chest. She was in pain most of the time and we did what we could to make her comfortable. She never cried or felt sorry for herself. She always asked me how my day went, always worrying that I wasn't eating right, getting enough sleep, or working too many hours. All the meanwhile she was in the middle of a life and death battle with an ever imposing enemy. She prayed and read her Bible daily, always reassuring the rest of us that she would make it.

Indeed, 5 years later my Grams is still here without any signs of recurrence of the cancer. She taught me the power of positive thinking, humility, love of family and faith in God. I can only hope and pray to be a fraction of the woman that is my Grams. And yes, her hair came back curly."

I hope you enjoyed this and share it with others. Remember each day is a blessing and there is only a finite number of these! Create an impact on someone's life, and it can only improve yours.

Guest post: No more second guesses

I walked in and out of his room repeatedly during my 30 hour shift, he was the one I was worried about.  It was the same room where, on my first ICU shift, my patient had died in an early morning code.  I feared that the same would happen to this patient, however I did not hope to avoid death of this patient, just delay it enough so that his family could arrive.   The patient was a young man dying of metastatic cancer.  I knew that I had to get him through to the early morning so that his family could be there by his side.  So armed with my lasix and morphine and one of the best nurses I have worked with, we both made it through the night.  I was as happy as I could be in the face of death, to see his family walk through the door.  We finished rounds,  I finished my notes,  and headed home.  I knew it wouldn’t be long.  I later found out that the patient died about half an hour after I left, with his mother and father holding his hands, just about the same time I was arriving home to eager hugs from my own two boys.

I hadn’t allowed myself to think about my kids all night, I had forced them out of my consciousness, so that I could do my job.  I did this to protect myself from imagining what I would do if it were one of my sons in that bed.   I drew the line between hospital and home, and I stuck to it, for better or worse.   At the start of internship I thought I would call home each night I was on call to tell my kids goodnight.  I never did this, in fact, most nights I didn’t have time to sit for dinner, aside from bites while writing notes into the wee hours of the morning.  What bothered me most, perhaps, was that I didn’t even think about doing it most nights.  I can’t count the number of bedtimes I missed or the number of daycare pickups my husband had to do this year.  It is acceptable to me to have to miss a soccer game or a play, it is not acceptable to me to miss most soccer games or most plays.  I can deal with missing a bedtime or a daycare pickup, but I do not want this to be the norm and I certainly never want to reach the point where I feel that it is acceptable. 

I wrote just over a year ago about my mixed emotions on my match and my future career in dermatology.  I felt logically, at the time, that this was the correct choice for me and my family, I just wasn’t sure emotionally.  Now, days from finishing my internship, I am thankful that I made the logical, not the emotional decision.  What a year it has been.  In my professional life, I have performed my first deliveries and pronounced my first deaths, I have treated infants and I have treated senior citizens, I have stayed awake for a 30 hour shift and returned home to stay awake with my children for several more hours, I have made tough decisions and I have made mistakes.   In my personal life, I have uprooted my family and exposed my husband to more call nights than I can count.  I have come to appreciate his patience and commitment to our family in a way I never knew that I could.  And, I have found clarity in my decision to pursue dermatology.  I think it truly hit me that dermatology, had in fact, been the right choice on my ER rotation this year.  I was never as happy as when I was able to fill my day with patients with chief complaints of rash and lac repair.  Or perhaps it was when I reported skin findings while on the cardiology service on a patient admitted for a STEMI.  Or when I noticed all I was teaching my medical students were skin findings and that I actually liked to look at the  NEJM photo quizzes of skin findings for amusement.  Perhaps some of my doubts from a year ago were unfounded.  I am now to the point where, had I to make the choice again today, I could do it with much less angst, knowing that I will enjoy my work and that I will have a tolerable lifestyle.

After this year, I know that I could have been successful in either ob/gyn or peds and I would have been satisfied with my work life.   In fact, in both of these rotations, attendings approached me about why I hadn’t gone into that field.  I give the one liner to these attendings and anyone else who asks, which goes a little something like this: “I love that in dermatology I will get to do both medicine and small surgeries, that I can follow patients across the lifespan, that I can cure cancer in 20 minutes, and that I can be home with my kids at night.”  But the longer answer is that I know myself enough to know that I do not do things half heartedly.  I am there when I need to be, until everything is finished and when I am at work, my mind is completely there. 

I need a career where I don’t have to feel guilty about how much I work or that I enjoy my work so much that I am not thinking about my kids and husband throughout most of the day.  And I need a career where I don’t go home and feel strange that I can be so emotionally distant from the things I have seen that day.  In dermatology I can have all of these things.  I love so many aspects of medicine and I feel privileged to have been a part of births and deaths and to have had patients share with me the most intimate details of their lives on a daily basis.  I will have patients who are as thankful to me for enabling them to control their acne or psoriasis as they would have been had I been there for the delivery of their children.  I will not have to tell another woman that she is miscarrying or tell another wife that her husband has died on my watch.   I am frightened as I move forward, for the sheer mass of information I will have to master, but relieved that I will be able to study at home at night, after putting the kids to sleep, where I cannot forget or ignore my life beyond the walls of the hospital.

Friday the 13th

May 13, 2011 started out like most of my Fridays, with a 5 am jaunt to the YMCA for masters swim class. As I was nearing the end of my workout, the day quickly took an unexpected turn as the receptionist ran into the pool area.

“The hospital needs you to call immediately,” she said. I was instantly in the locker room, digging through my giant bag for my phone. I wasn’t on call, so for the nurses to track me down at the gym, something seriously bad had to be occurring. I assumed that one of my partners must need help with a hemorrhage or some other emergency. Never in my wildest dreams did I expect to get the news I received.

“JB just suffered a cardiac arrest. She was transferred to the ICU. We are not sure if she is going to make it...” My partner’s voice was shaking on the other end of the line.

At this point, I just went numb and everything began to happen in slow motion. This could NOT be happening. JB was my friend. I had delivered her baby just a few days before. She was most likely going to die. I had failed her. She was my patient, my responsibility. I had obviously missed something.

The four mile drive to the hospital seemed to take two hours. My mind raced through all the possibilities: stroke, seizure, heart attack, pulmonary embolus. None of the options were acceptable. I tried to think of what I might have missed. I analyzed every detail of our last conversation. She had called me from home the night before with symtoms of a headache and high blood pressure. I had told her to go to the ER. Being the clever nurse practioner that she was, she tried to talk me out of it, but I had insisted. Later my partner had admitted her, in order to watch her overnight. I had delivered her third baby 10 days earlier, boy number three for her. At the end of her pregnancy she had developed preeclampsia, a fairly common complication that usually resolves with delivery. I kept thinking of what I could have done differently, but as I went back through the case in my head, everything seemed to have been done appropriately.

This can’t be happening. I’ve never lost a mom. Healthy 35 year old women’s hearts don’t just stop. My prayers were brief and desperate. Lord, let her live.

With my hair still wet from the pool and my eyes still puffy from my swim goggles and crying, I arrived in the ICU a few minutes later. She was stable, but still in a coma. I began to have hope that she might make it, but could dare to hope that she would really be OK, to not have a brain injury?

I reviewed the history with my partner and the other physicians. Her husband had stayed with her in the hospital overnight, and heard her gasp and stop breathing. He quickly called for a nurse. She found no pulse. A code was called. After 12 minutes of resuscitation the team brought her back. She was essentially dead for 12 minutes. All the while her husband stood by, holding their newborn son.

I tried desperately to focus on the medical facts and numbers, while pushing the emotions to the side. This became impossible as I walked into her room. My beautiful, intelligent friend lay intubated in the ICU. Her normally tan skin was grey and dusky. Her blonde hair disheveled, while tubes and monitors encapsulated her small frame. The girl who never stopped moving or talking now lay before me unresponsive, with restraints on her hands.

When I saw her husband’s swollen, tear stained face; mt own tears once again began to roll. We hugged.

“Doc, Is she going to be OK?” He asked fearfully.

“Yes, I hope so.” I said, more as a statement of faith, than medical fact.

The morning was a blur of activity. A stream of specialists were consulted to help us search for a cause. More tests were ordered, but no answers were found. We ruled out some dreaded possibilities: brain hemorrhage, heart attack and tumor. I tried to remember if I've ever had a patient fully recover from a cardiac arrest. The only patients who had coded in my care were elderly. The ones who made it, had severe brain damage. The thought of her surviving but in a severely disabled state was almost as frightening as the thought of her funeral.

As all the tests began to come back negative, I began to let go of the guilt over what had happened. None of the things I knew to check for had occurred, so maybe it wasn’t my fault after all. Still the questions lingered.
Being a typical Friday, my office schedule was fully booked. All patients who could be were rescheduled. The rest I saw in short bursts, as I ran back and forth between the office and the ICU. In the office, I attempted to feign interest in the mundane yeast infections and round ligament pain. I tried my best not to be distracted, but it was nearly impossible.

As the morning stretched forward, we got our first bit of amazing news: the neurologist finished the EEG and it showed normal brain activity. He was hopeful for a full recovery. When I told the good news to our office staff they literally cheered. I assumed the recovery would be long and painful, but there was hope.

The afternoon led to even more good news as her oxygen requirements began to decrease. Yes, she was still on a breathing machine, but needing less and less help to breathe. She was beginning to wake up and fight the restraints. The specialist in charge of ICU decided to keep her sedated and let her heal, and then take her off the breathing machine in the morning.

I left that evening guardedly hopeful, praying for a full miracle.

When I finally made it home, I embraced my husband and kids like I hadn’t seen them for weeks. My heart was so thankful. Never would I take my life or family for granted. The usual dinner routine seemed surreal. Then as I was finishing my hamburger helper, my cell phone rang.

“Call from JB,” it said on the display.

My hand was shaking as I picked it up and hit the accept button.

“Hey it’s JB Husband, just letting you know that they took the tube out and she’s awake… and talking!”

“I’ll be right there.”

Within minutes, I was walking back on to the unit. The neurologist had warned us that she would have short term memory loss, likely for a week or two. He felt that she would most likely not remember the cardiac arrest. Still, I wasn’t sure what to expect.

As I walked into her room, she was sitting up in bed, looking absolutely fine.

“Hey, what are you doing here?” JB asked.

“How are you?” I said.

“A little sore…. Why are you crying?” JB responded.

“I was worried I would never hear your voice again.” I replied. Weeping. Again. For what felt like the millionth time, during this roller coaster of a day.

“Really? I don’t understand, I just had a c-section?” JB replied

The room, which now included several members of her family, laughed with relief. She remembered nothing that had occurred since she had her son 10 days before. She just woke up, assuming she was waking up from her c-section.

During the first few days, talking with her was akin to having a conversation with your elderly aunt who is suffering from dementia. It was definitely ‘her’ in there. All distant memories were intact, but during a conversation she would begin to repeat herself every few minutes. This also created the challenge of having to tell her, over and over, what had happened. Each time she would react emotionally as she ‘heard’ the dramatic news for the first time. After about 4 days her memory began to improve and she could remember things that had occurred the day before. Currently, she reports occasional forgetfulness, but has had a full recovery. She required no rehab and has had only minimal discomfort.

With all tests essentially coming back normal, the heart specialist determined that she had an underlying arrthymia. This abnormal heart rhythm was then exacerbated by the stress of preeclampsia on her body, causing her heart to go into cardiac arrest. This extremely rare event just happened to occur at the right time and the right place. He felt she could be at risk for cardiac arrest in the future, so a permanent device was implanted in her heart before she left the hospital. The device will automatically shock her heart back into a normal rhythm should she ever go into arrest in the future.

Since that day, I have thought many times of the ‘what ifs.’ What if she hadn’t called me? What if I hadn’t sent her to the hospital? What if her husband hadn’t stayed with her? What if the code team hadn't responded so quickly? If any one of these elements had not occurred, she would not be with us today. I am so thankful for the prayer chains that were activated, the attentive nursing staff and the many specialists who were involved in her care. I am most thankful to God for allowing her to have a second chance on life.

-The previous story is true and told with the patient's permission. It is cross posted at The Pregnancy Companion

The MiM curriculum

One morning last week, I was standing at the mirror in the gym locker room getting ready for the day. In the corner of my eye I saw a person scurry past. I recognized her immediately. I was excited to see a familiar face, yet she disappeared before I could say hello. When I peered around the corner and she was nowhere to be found, I realized that she was likely avoiding me. Not really a good practice to stalk someone in a locker room, so I turned away. Then as I blow dried my hair the conversation that did not happen played out in my head.

She is a cardiology fellow. Mother of two. I know this because her children are the same age as mine. She breast fed both babies. I know this because her co-fellows teased her about it at the end of the year roast one year ago.

She was hiding from me because I am an Attending. She did not want to be seen at the gym at 8AM on a work day. She fears that she would seem lazy, less dedicated or selfish.

What she needs to know is that I am so proud of her. One tough mama taking all of her call, doubling up while gravid to trade days to allow a maternity leave. Finding a way to be an equal to the guys without being one of the guys.

I would like to tell her that making time to exercise squeezed between early morning mommy duties and full time fellow work is an enviable feat. That what you have done, is perhaps one of the most important tasks you can do to ultimately ensure your success. Yes, I know it is not in the cardiology fellowship curriculum. This lesson really should be Chapter One of the MiM curriculum. Stepping out of the role of mother and physician to see yourself is crucial. By recognizing your need and fulfilling it. Because it means more than just finding time in a busy schedule. It means making time, trading off that early morning conference or sneaking in a little late to read echos. Whatever. Over ruling what is expected of you, to recognize what is actually best for you. A brave move that will make you stronger at the core.

And of course, I would never utter to another soul that I spotted her at the gym. Dear, your secret is safe with me.

Maternity Leave and Psychiatry Residency

I'm not a psychiatry resident, but I have two female friends/acquaintences in psychiatry residency at two different programs who are both going through some issues with their maternity leave and I was wondering if anyone has any thoughts to help them out:

Apparently, one year of psychiatry residency involves an outpatient continuity clinic. Due to the rules of residency, you cannot miss more than six weeks of this year at risk of repeating the entire year.

So despite the FMLA guaranteeing 12 weeks of leave, a woman having a baby that year can only take a maximum of 6 weeks off, or else repeat the entire year. Even if you have a C-section.

I just got off the phone with my friend, who is in tears over this. She was ready to make up any time she missed, but not repeat an entire year. She's gone over the situation with her chief resident and he claims there's no way around it.

Has anyone had any experience with this and has any advice? (Beyond "suck it up"?)

MiM Mailbag: Pumping during fellowship

Hi, I’m so glad to find this group! I’m starting GI fellowship in 10 days and trying to figure out a pumping plan. My husband (a surgeon) and I have a 12 week old son and we’ve just moved across country for fellowship. I have the Medela freestyle, which I love. However, I stored up enough expressed milk to only last us maybe a couple weeks. My program is supportive of my need for pumping, but given the amount of conferences and rounding on a daily basis, my only time to pump is essentially in two 2-hour blocks when I need to see consults and perform endoscopy (unless I’m in clinic). I’m trying to decide whether I should try and pump during the day or just switch to pumping bid (morning and night). I feel like formula supplementation is inevitable. I’ve already noticed my supply go down with changing to pumping 4x/day in anticipation of fellowship starting. Any advice?

Guest post: Major breastfeeding (advocacy) fail!

Heading to Target to do some shopping, I waddled my way (at 7 months pregnant) onto the Metro and found an aisle seat. Sitting behind me, I noticed a couple of very fashionably dressed high school students. Sitting several seats in front of me, a corner of boisterous 1-4 year olds of various ethnicities darted between their mothers/nannies legs to peer questioningly at each other and then dart back to the safety of their own corners. I watched, enthralled by the happenings of these cute little humans exploring the train; a particularly cute Latino little girl wanted to sit on the floor and her mother quickly let her know that she couldn’t. She started getting upset and I quickly averted my eyes and opened my new novel. I feel that when parents have to admonish their children, it’s their business what they do and they don’t need an audience.

Several pages into the book chapter, I hear one of the teenagers behind me say, “That is soo nasty! I can’t believe she’s doing that.” I turned, saw two women in their 60s shaking their heads in disbelief. I raise my eyebrows unknowingly and turn back to the toddlers. The Latino little girl’s mother had started nursing her sans cover to distract and comfort her. My Metro stop came before I had a chance to say anything to the teenagers or to the women.

I smiled at the nursing mother and waddled away. But inside I felt like a major failure!!! Uggghhh. I should have said something witty! I should have said “breastfeeding is more natural than formula” or “what’s nasty about feeding a fussy child?” or “seriously ladies, I’m less offended by her nursing her child than folks feeding theirs salty chips and sugary soda everyday”. But no! I had to waddle off of the train. I was ashamed. Did my unknowing smile make the women think I was agreeing with them?!? I sure hope not!!! I am one breastfeeding-mama-to-be. Forget the old women who may have been set in their ways, but what if those teenagers had never considered the benefits of breast feeding? Again, I felt like a failure.

Becoming a vocal Breastfeeding Advocate (self proclaimed title) in the last few years has been somewhat of a journey. I did not know many mothers who breastfed their babies when I was growing up. My own mother only briefly breastfed my brother and myself secondary to discomfort and lack of resources and support. More recently, when one of my good friends whipped out her breast to feed her son during dinner day several years ago I was a bit taken aback. For me, it took time to realize that breastfeeding was perfectly normal and that I had to get over my hang ups of “modesty” and “privacy”.

The issue has become all the more important now that my husband and I are welcoming our own little baby into the world. Personally, having a supportive husband who doesn’t see the need for formula, several busy friends, sorority sisters, and a mentor who successfully breastfed from 8 months to the 1-year plus mark also helps.  Although I plan to use a cover to be a bit more discrete, I applaud the mama on the Metro who appropriately responded to her little girl in the most nourishing way she could! Next time I hear someone say something disparaging I’ll be ready, no more breastfeeding advocacy failures for me!

Mommabee is an upperclass Medical Student at a mid-Atlantic medical school who is interested in community-based Pediatrics and has a background in public health. She and her husband are pregnant with their first Baby Bee.

Guest post: Happy Father's Day

Confession time. Despite a paucity of evidence, I once lured my unsuspecting husband and daughter into the bathroom and told them to strip. I handed my husband a tube of 5% permethrin cream and proceeded to apply the same cream to our daughter and myself. My husband, well-acquainted with my neurotic behavior, laughed, shook his head in mild disbelief, then willingly obliged. “Jeez”, he muttered under his breath “I give you a car, and you give me scabies” (a reference to our recently purchased vehicle). My decision to call in three scripts for permethrin was based on two intensely pruritic hands and one overactive imagination. My lips were also swollen, but despite repeating over and over in my head, “You have an allergy, not scabies”, the heebie jeebies were welling into a tornado of anxiety that was wrecking havoc on my paralyzed little brain.

My husband puts up with a lot of crap being married to a doctor. And although I would like to think of my neurosis as merely an occupational hazard, I suspect it was likely a preexisting condition, exacerbated by the daily exposure to other people’s illnesses. I am forced to recognize that this career, and the ways in which it has dictated my behavior, can be a hardship on my non-physician husband.

In addition to not having me committed over the permethrin incident, in this first year of my fellowship my husband has shouldered a disproportionate amount of child-related care and chores. When I left for work last Saturday morning, my daughter was naked in the bathtub, in the throes of a wicked GI virus. My husband was at her side, cleaning and comforting her. I wasn’t worried that she critically ill as she had just been eating and running around earlier in the morning, but I still felt horribly guilty for leaving my family at this moment.

And while I am almost certain my husband didn’t mind, much less resented, my departure, I do wonder if he fully appreciated the extent of his parental participation when he married a female physician. Did he know that he would be in charge of daily school lunches, drop-offs, and pick-ups? That he would know the pediatrician better than his physician-wife? I can’t imagine that he did as I didn’t predict (nor wanted) it myself.

Although I recognized how very fortunate I am in my marriage, I sincerely hope that amongst this group of mommy-MDs, I am not unique in the depth of support my husband provides me in my career and our child in my all-too-frequent absence.

So ladies, in celebration of the men whose lives might have been a whole lot simpler had they just married someone, uh, less interesting.... I’d like to say: thank you.

Happy Father’s Day

s

s is a hematology/oncology fellow in California. She lives with her husband and 2 year old daughter. She blogs at www.theredhumor.com

Don't Give Up on Women in Medicine

The Mary Elizabeth Garrett Room lies off a busy corridor on the main floor of Johns Hopkins Hospital. As a medical student and later an internal medicine resident at Johns Hopkins, I often treated the small women’s lounge and adjoining locker room as a sanctuary amid my hectic days and nights of studying and call. Its namesake, a philanthropist who was one of the wealthiest women in the US in the late 1800s, used her financial power to provide opportunities for women to gain independence and autonomy.  She and her friends offered to raise a badly needed $100,000 for the endowment of the Johns Hopkins School of Medicine if the trustees agreed to admit women on the same basis as men.  The rest, for future women in medicine, was history.

In her New York Times opinion-editorial  “Don’t Quit This Day Job” (June 12, 2011), anesthesiologist Dr. Karen Sibert argues that women physicians, who increasingly work part-time or leave clinical medicine altogether to find better balance between work and family life, have a moral obligation to practice medicine full-time. She rightly points out that there are limited medical school and residency slots in the face of a growing physician shortage, particularly in the primary care fields that attract women in high numbers. However, Dr. Sibert’s envisioned ideal would be a great loss to patients and the profession, and a major step backwards for women in medicine.

Historically, the practice of medicine had required a selfless devotion to the profession at the cost of personal and family life.  Turn of the 19^th century legendary physician Sir William Osler is credited for saying, “Medicine is a jealous mistress; she will be satisfied with nothing less.” These roots are evident in the harsh training environment that prevailed for so many years, requiring super-human work hours, rare days off, and expectations to work through personal illness. Slowly, medicine professional culture has made progress, realizing that the care of its members—in all senses of that word—helps physicians (men and women) lead more balanced, healthier, happier lives and helps patients by improving the quality and safety of their healthcare experience through physician work-hours restrictions.

For women physicians, who continue to perform the lion’s share of household duties and child-rearing despite a more progressive society towards the division of household labor, this has meant the increasing availability of part-time positions, job-sharing, and other creative solutions to allow them to continue practicing medicine while fulfilling commitments at home. Achieving work-life balance means greater satisfaction for one’s career and keeps women (and men) physicians in medicine. Indeed, it is this flexibility that is possible in certain specialties such as primary care, dermatology and radiology that makes medicine an attractive career for many women, despite the years of difficult training and medical school debt.

We are, after all, talking about a profession that is built around caregiving, with the parallels between caring for patients and families undeniable.  Women physicians spend more time with their patients, up to 10% more, and have been shown to have a distinct style of doctoring from their male counterparts: more encouraging, supportive and patient-centered. The contributions of part-time women physicians are no less in quality to the lives of their patients; shouldn’t such devotion to caregiving at work and home be traits encouraged in physicians? 

Invoking the predicted physician work shortage as a reason why women physicians should not work part-time or leave clinical medicine places undue guilt and blame on them.  The main factors driving up physician demand is the growth and aging of the US population and health care reform.  While women physicians do work fewer patient care hours compared to men, what kind of profession would we have if women who might decide to work part-time later were denied admission?  More reasonable (and humane) answers to the physician shortage lies in lifting the residency training caps to train needed physicians and creating new models to increase efficient use of the existing workforce.

Besides, women (and also men), who choose to spend a portion of their medical careers working part-time or who take an extended leave, may return to full-time work at a later time, for example, after their children reach a certain age. Thus, there is a need for effective physician-reentry programs that help prepare any previously trained physician to return to the workforce, providing education and re-training as well as portals to reenter medicine.

Let’s not forget about the men. Besides early to mid-career women, men approaching retirement age are the other fastest growing segment choosing to join the part-time physician workforce. Survey data show that today’s medical students and residents, both men and women, say achieving a balance between their work and professional lives will be the most important factor when establishing a fulfilling career in medicine. Medicine mistresses are going out of style all-around, much to the dismay of the medical henchmen: Burnout, Stress and Dissatisfaction.

To be sure, medicine is a public good. Federal dollars support physician training, and certainly, it is imperative that medical school admissions committees select applicants, male and female, who show a strong commitment to medicine. Yet after training, men as well as women may decide not to practice clinical medicine. Is it more problematic when the reason is because a woman wants to raise a family versus a man who takes a job with a consulting firm? I hope not. These are difficult personal decisions, emphasis on personal.  Like everyone else, doctors need to make decisions for the health of themselves and their families. Life happens.

I am a mother, and I am physician.  These two roles are complementary in more ways than they are not. The increase in flexibility for women physicians in recent times has been a boon to those of us who have found a calling in medicine but do not want to sacrifice having a full family life. Isn’t that what Mary Elizabeth Garrett had in mind as well? Independence and autonomy for women to practice what they love, to be empowered by having choices.

Katherine Chretien is founder/editor of www.mothersinmedicine.com.

Rites of Passage

There are the ones you get excited about. Turning 16 – the freedom gained from driving a car. Turning 21 – finally being able to drink legally. And there are the not-so-exciting ones.

When I went to my OB for the first time in few years a couple of weeks ago for a routine check-up, as I was leaving, she said, “Oh, Gizabeth. We need to schedule you for a screening mammogram.” She must be mistaken, I thought. I am eternal youth. I am 37. I informed her of this, and she said, “Screenings are recommended between the ages 35 and 40.” Hitting this particular mile marker is a little depressing.

You might think, since I am a doctor and all, that I had an actual clue about the process of getting a mammogram. I didn’t. Although I spent a week on radiology, quickly determining that me sitting in a dark room for a job might not work since I always wanted to fall asleep, and a week on breast oncology surgery, I have never witnessed a mammogram. I saw one of the breast radiology specialists describe it once, using her hands and her own breast to illustrate (through her clothing), when answering an oncologist’s question about the orientation difference between looking at a mammogram and MRI, but I still didn’t really get it. What would it be like? Since no one other than myself has touched my breasts (for self-breast exams and washing, of course, this is a G rated article, well maybe PG) for quite some time, I even wondered if it might be a little exciting. I was a little relieved, for my own sanity, to discover that it was not – far from it, in fact. I know many reading this have had a mammogram, but for those who have not, let me describe it to you.

They called me back into a cubicle to put on a paper gown. There was an advertisement on the wall claiming that if you went back to the front desk to pay an extra few bucks you could get this foam pad that was statistically proven to make the mammogram experience more comfortable. What about a mammogram experience requires a foam pad, I wondered, since there were no visuals or an explanation provided? Was it something to lay your head upon? I decided not to ask. I was going to go in cold turkey. I’m pretty tough. There was also an instruction card asking you to remove deodorant or powder from your breasts with baby wipes provided. Who puts deodorant or powder on their breasts? Is this something I missed in adolescent hygiene?

I was escorted into a dark room and saw what reminded me a little of a giant vertical George Foreman grill, minus the ridges, at about breast level. It was on a large post and could be manipulated up and down as well as rotate back and forth. The thankfully female tech looked at my breasts. “I think we need to switch out the tray.” She pulled off a large tray underneath the metal sandwich, I mean breast press, and reached down to the bottom rung of a shelf, grabbing a much smaller tray (haha, for the runts, I thought). One at a time, she used her hands to manipulate my breasts into very stretchy shapes I did not know were possible and squished them tightly between the metal plates, which she was closing in on my breast with electronic manipulation. All the while I was being instructed to “angle your head back this way,” “No, wrap this arm around the top of the machine that way,” and “push your shoulder back a little more” and I was oddly reminded of yearly school pictures. At one point she said “No, put your arm over here, I don’t want this to be awkward for you.” I laughed out loud, and told her, “I know you do this many times a day, but there is nothing to me about this situation could not be called awkward.” She smiled, “I guess you are right.”

She was nice. We chatted about kids and concerts throughout the process. When she had each breast sufficiently pan-caked to her preference, she instructed me to hold my breath so she could take a picture. When we were done, she said, “Do you mind if I get a picture of your left breast again? I didn’t get the nipple in profile and it is so much better that way.” I looked up at the radiographic images she had put on a light box, and gasped internally. I see these all the time in conference, but they were mine, and they looked so beautiful. I wanted to ask if I could take one home with me, but that would sound weird, and it’s not like it’s something you can just frame or display on the fridge and not get questions. The one with the nipple profile did look much better – the side without a nipple looked a little malformed, so I agreed.

I got called back for additional images the next day – luckily I was prepared by learning from a friend that this is common, not to worry – they just need to get a really good baseline to establish any asymmetry as most likely benign, and I was glad for her reassurance. But this did not help me from having a tiny panic attack in the waiting room cubicle once again – still did not buy the foam cushion, but at least I understood it now – because I have so much to live for, these days. So I was relieved when after more mammograms and then an ultrasound exam the radiologist, who seemed very surprised to see me as his patient – the name change is still throwing people off – assured me that everything looked all right. “We’ll see you in three years.” Whew.

Finding Balance

Life has a funny way of reminding you daily that you are not in charge. You walk into work after a full night's sleep, thanks to my ear plugs because hubby snores. (Don't tell him I told you!) My energy is positive and I am ready to conquer the day. Then I proceed to look through the files of the patients on my schedule and then I realize there are a few chronic pain patients, crabby COPD patient with new CHF that refuses to go to a specialist, and on and on it goes. I feel the wind go out of my sails and I lean back in my chair trying to decide how to move my mood to a more positive state. Then I take a little mental mini vacay to a winning lottery ticket. Yep, it works every time.

Then after an exhausting day at work, going home to make dinner, started and folded more laundry, discussed the day with the family as we played "Apples to Apples" (Fun game if you have older kiddos.) I soon realized that I really am very vulnerable to my circumstances. Dealing with difficult patients...frustration and fatigue sets in...fun game with the family...happiness and energy abounds. Geez, this is sad realization my mood is so easily shifted. Maybe it is hormonal or maybe I just don't like not being in control...ahh...that is it.

I am a control freak. Yes, type A personality to the core. See when I go on my mental vacations I am in control and decide my fate. In real life, not so much. Not sure how turned into this over the years. Certainly not genetic as my mom is a peace maker and sweetheart and my biological dad never stuck around to change or be in control of anything.

I guess when I figure out how to solve this little personality disorder I will probably become a wealthy person. Any thoughts?

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