Guest Post: New Year's Revelations

Amanda Chatel at thegloss.com said, Forget New Year’s Resolutions. Do revelations instead—what did you learn in 2012? So, here goes.

1. I can go to Africa

I’ve wanted to go for over a decade, but first I had to get into medical school. Secondly, I wanted to stay close to my then-boyfriend, now-husband. Thirdly, I wanted to pay the mortgage and have kids. And in 2012…hey, I made it to South Africa and Swaziland!

Now I’m dreaming about traveling with my family to Asia and Africa. Because it’s doable, right?

2. I can muscle my way back into the emergency room

I started back in October 2011, but I increased my shifts after my trip to Africa. And it was fun. Also challenging, irritating, and exhausting, but mostly fun.

3. I can do yoga every day

Maybe just a few minutes. Maybe an hour. But I tried, every day. For a few weeks, I gave myself a sticker every day that I showed up at the mat. Why? Well, partly because I gained a few pounds after I weaned my daughter. Note: I plump up when I’m pregnant, but breastfeeding sheds it all and then some. Unfortunately, once I stopped nursing her to go to Africa, I couldn’t eat like a linebacker anymore. But I still wanted to eat like a frat boy, at least. So I did more yoga, which I truly enjoy and need to make more time for anyway, and at least I can wear my skinny-cut pants again. Some of them better than others.

4. I can write a new medical thriller

Okay, it’s just a draft. Terminally Ill is not ready for prime time, or even a beta reader. But I’d told myself I couldn’t plot out a medical thriller while my brain cells were torn between my work and family—until I decided to just do it. And that was fun, too.

5. We can do a fundraiser for rhinos

We raised almost $1500, splitting the money between reducing demand (WildAid) and groups actively protecting rhinos on the ground (Wildlands Conservation Trust, SanWild, WWF-SA, all of whom sent me audit reports), with a small amount to WWF-Canada/TRAFFIC. In 2013, we will send an SLR camera to CPIN to spy on poachers and I will send a donation to Helping Rhinos as well.

Will it do any lasting good? I don’t know. But when I hear about poachers paralyzing rhinos, hacking their faces off, and leaving them to suffer and die, I think, At least we did something. We didn’t just shrug or wring our hands.

6. I can relax.

I almost forgot this one, and it’s a biggie. My mother is the kind of person who never sits down. While the rest of my family watched a movie, she’d make a great show of resisting before ironing AND watching the movie. But I’ve been the same way, working maniacally—until this year. On Sex and The City, Carrie once said, “In New York, they say you're always looking for a job, a boyfriend, or an apartment” I was always working hard! hard! hard! on school/medicine, having kids, and writing. If one or two out of three was going well, I’d just go nuts on the missing link, most recently the writing.

Now that I know a few thousand people have paid for my words, I can relax a little. Bestseller Jennifer Crusie says you should write like a rat with an island, like you have faith you will be rescued, i.e. published. Well, I struggled to make myself have that faith. Didn’t work. But now that I know my books are out there and people buy them sometimes—hooray. Elizabeth Gilbert wrote, “My goal was to publish something (anything, anywhere) before I died.” I guess my subconscious goal was to have people around the world read my words before I died. So now I can just lie down and watch Neflix sometimes. Which I like, even if I feel conflicted about it. But, like Ray Bradbury wrote, “Learning to let go should be learned before learning to get. Life should be touched, not strangled. You’ve got to relax, let it happen at times, and at others move forward with it.”

What were your New Year’s Revelations?

Melissa Yuan-Innes (ACLS) is an emergency physician who runs codes and writes prescriptions in Eastern Ontario, Canada. She also prides herself on her life outside the hospital: her two kids (6 and 2 years old), her high school sweetheart-turned-husband, and her nascent writing career. www.melissayuaninnes.com

MiM Mail: MCAT prep; osteopathic vs allopathic schools

Hi MiM,

I am currently a 25 year old physician assistant that is planning to apply to medical school this spring. I had chosen to became a PA initially thinking that this career path would led to a better work-home balance. And while I do enjoy my job and a great schedule, I yearn to learn more and take on more responsibility. I would appreciate your advice on a couple of things:

1. There are A LOT of MCAT prep materials available!! Does anyone have recommendations that worked well for them? Especially considering I have not had bio, chem, physics, etc for a number of years?

2. I really enjoy the osteopathic philosophy of holistic medicine and patient centered medicine and seem very open to non-traditional students. I have met well-trained doctors from both osteopathic and allopathic schools. However, there seem to be fewer residency programs making it less likely that I would be near family for support. I would really appreciate hearing from you ladies about your opinion on osteopathic versus allopathic!

Any advice on these topics would be appreciated! This blog serves as an inspiration to many including myself and I sincerely thank you for any advice you can share!

Merry Christmas Eve!

This post was inspired by an e-mail from a good friend the other night, who lamented that the posts on MiM lately have been a bit of a downer.  Well, the news has been a bit of a downer, and MiM is a good place to process all of that, but I decided we needed an upswing.

Pathologists are a unique breed.  We lack the romanticism of psychiatrists - we cannot equal the beautiful poetry of Juliaink.  We lack the braniac of neurosurgeons - we can only wish to be as rocket scientist as gcs15.  We lack the adventurousness of OB's - MomTFH, Dr. Whoo, and RH + are in a league of their own.  We lack the sleuthiness (new word!) of internal medicine docs - we can hope and aspire to be like KC, Genmedmom, and MomT, but alas it can never be.  We lack the empathy and sacrifice of the medical oncologists such as The Red Humor and Tempeh.  We lack the finesse of the surgeons like Cutter, and the intellectualism of the neurologists like Artemis.  We lack the heart and dedication of the cardiologists like JC, and the virtuousness of the pediatricians like MommaBee and T.  We lack the blanket aspirations of pre-med students like Kyla - no matter where her path in life eventually takes her, it will be great.  We lack the mystery of the PM&R doc, whose job I still do not understand despite numerous explanations by Fizzy.  All I can say is thank goodness she has her cartoon talent going for her.

We are just lab rats.  But we try to be cool lab rats.  My partner sent a memo last week entitled "The Twelve Specimens of Christmas."  I won't insult you by telling you what Christmas tune to call to mind when I give you the final refrain.  I also won't type the entire song because A) it will take too long and B) you will get the point from the final refrain.

"On the twelfth day of Christmas my P.A. (physician's assistant) sent to me, Twelve Prostates Praying, Eleven Adenoids Ailing, Ten Tonsils Talking, Nine Lymph Nodes Lounging, Eight Tubes a Toiling, Seven Skins a Sweating, Six Hearts a Beating, Five U-TER-I; Four Foreign Bodies, Three Big Toes, Two Colon Segments, and an Ab-scess Ca-vi-ty."

Now you too can entertain your family and loved ones over Christmas dinner.  Make sure you have barf bags handy.

Every year I give my favorite pathologists a gift.  Under $10.00 - it's the thought that counts.  This year I got all the girls a cute mousepad with a cartoon of a chick on it, underneath it said, "Pathology Chick."  The boys got a cool art deco mousepad with repeating microscope pics in soothing browns, greens, and blues.  Everyone got a card.  It was this.

The insert read, "Seasons Greetings to all my favorite pathologists.  All twenty of them - don't worry, I'm not singling anyone out with this card, but I decided we need to change our image.  Someone I write with actually told me a few years ago that she thought all pathologists grew ear hair.  Really?  I'd never heard of ear hair.

So hang up this card in a high traffic area.  I guarantee in a year we will all be more gorgeous for the effort.  Except Brent of course.  Even this card cannot perform miracles."

I enjoyed walking around the lab, stealth-like, watching all my partners palpating their ears with a perplexed look on their face looking for sudden growth.  Thanks for the inspiration, one of my favorite co-writers - you know who you are Fizzy (oops I was trying to keep it a secret that I actually like you a bunch - any readers who believe otherwise be damned.  No, never mind, I wouldn't damn anyone, just setting the record straight.  We give each other shit because we love each other, really).

So there you go.  Pathologists are no longer lab rats.  We are hot.

I hope all of my co-writers on MiM and every reader out there, including aspiring pathologists (good luck H!  I really enjoyed chatting with you the other day) has a wonderful holiday.

A Pause...

I have today (Friday) off from my clinic, in preparation of Babygirl's first birthday party tomorrow and Christmas in general, but I came to work anyways, to drop off Christmas presents for the nurses and office staff. I was feeling pretty good until the NPR commentator announced, "...let us now pause to take a moment of silence to pause in honor of those exactly one week ago. Remember that it was at this time of the morning last Friday December fourteenth that twenty elementary schoolchildren and six teachers were gunned down at a Connecticut elementary school...."

I cried last Friday when I first saw the headlines about this shooting, and I cried again as I was driving in. Every day, I think about those families, and wonder we can do for them.

I can't help but pause for a moment to think about them, and then to be thankful for my own little family, our two beautiful kids, our hectic workaday lives, every day full of small and large joys.

I want to help them. There are things that I can do as a human being, a parent, and a physician, to offer some help to those families... There are things we can all do.

Since last week, I have signed two petitions appealing to our politicians for stricter gun laws, including a ban on all military-style assault weapons. The most effective of these is on the We The People website, an open-access petition site: anyone can start a petition to the government, and any petition that gathers more than 25,000 signatures is guaranteed a response from the White House. In the hours after the Newtown shooting, user David G. started a petition asking for stricter gun control legislation; this gun control legislation petition has now gathered over 190,000 signtaures, in a week, and has received alot of attention as the most popular petition to ever appear on the We The People site.

Guns are a public health issue, and need legislation around them protecting citizens from risk of harm, similar to cars. Try replacing the saying "Guns don't kill people, people kill people" with "Cars don't kill people, people kill people". Hello? Not everyone can have a driver's license- they need to pass a test first. They need to be checked to make sure their previous license was not revoked. We have seat belt laws, we have drunk driving laws, we have speed limits, we have traffic laws, and our driving is regularly monitored by cops on the road.*

Why, for God's sake, do we not have even a fraction of the same legislation and monitoring of guns? We don't shrug and say, " Oh well, no need for laws around car safety, we just need to work on our substance abuse and mental health care system!"*

*I take this analogy - though it is a common one- from Nicholas Kristof's brilliant New York Times Op-Ed piece Do We Have The Courage To Stop This, published after the Newtown shooting, and I recommend it to everyone.

These are my personal thoughts and opinions, as a doctor and a mother... and a rational human being.

Interview

What do you even say on a national blog after last Friday?  How do you start over and talk about normal things again?  How do you pretend that Friday didn't happen, and chat on as usual?

Tonight my group interviewed a resident for a pathology position.  A first, since I've been there.  My colleague Brent and I (aka Dr. Woods - I named him this, as a golf enthusiast, before the Tiger scandal) were hired almost six years ago, and our work family is just now finding a need for new members, based on multifactorial reasons.  We had the resident meet and greet on our home turf for a couple of hours starting at 3:00 p.m, then about a quarter of us, spouses included - for those of us who have them ha ha not me - met him at a local country club two of my partners belong to for dinner.  

His spouse was stellar.  "Don't I know you?"  She said.  I must qualify a bit.  I was born in the same town I currently live in and the wonderful thing about that is that I have major roots.  I can go just about anywhere and bump into someone I know.  Ran to Walgreen's tonight before the dinner and saw a resident below me who now works at the Arkansas Crime Lab.  He relayed a colleague's, one I had met on my resident rotation, sudden and random death.  It was devastating.  I held back tears and apologized to him - not that any of it was my responsibility, but I remembered this man.  How energizing he was, and how he taught me an incredibly cool way to dissect a heart that made a hell of a lot more sense than anything I had been taught thus far.  I told Daniel, "I am so sorry.  My partners are like my family.  That must have been devastating for you."  He looked at me, clearly pleased I understood.  "It was.  We are interviewing too.  Because of the loss.  It's hard."

I did know the spouse of our interview candidate.  When I was taking pre-med courses, post college - I graduated at 20 with a failed attempt times two at Ph.D school for psychology - she was taking the same classes.  She and her husband, our candidate, have four children.  She is a pharmaceutical rep for a hospital.  She was so much fun to talk to.

I dined on lobster cakes and oyster salad.  Most of my colleagues had the fried chicken buffet.  As the evening was drawing to an end, and most of the party had exited to relieve sitters or pick up adult children from airports for the holidays, I addressed our interview candidate.  Told him I had bumped into the crime lab doc, and we commiserated over the death of a great attending.  I wondered aloud if he had gotten to know the head of the crime lab.  Told him he was quiet, and it was difficult but well worth the effort.  He had not.

I said, "He is great.  One of the best advocates I know for abused children.  He gets in there in the courtroom and fights those lame experts on the opposite side who make up stuff about bone disease when it is all really abuse.  No one fights for the toddlers who are whacked too hard by a baseball bat carried by the boyfriend of the mom who is working to make money to support her kids.  No one opposes the blue-haired lady on the jury who says, 'No way that guy, who looks like my grandson, could have possibly hurt that kid.'  Guess what, lady, he did."

Then I looked our interview candidate square in the eye.  "Were you affected by Friday's massacre?  I mean really affected?  Because that stuff happens every day in our country.  And most of it doesn't get this kind of attention.  This just might be a vehicle for change, you know?  Unnecessary, senseless, awful, but still.  Gun change, sure.  Child abuse, everyone's on board for that.  But mental illness in our society, it's so fragmented these days, you know?  Treatment is not available, and everyone advocates drugs, not help and talk therapy.  I know the killer shouldn't be the victim, but he is, in a way.  We are all responsible, especially as doctors."

He smiled back and agreed with me.  He's a candidate for an amazing job, what else is he going to do but agree with me?  We don't talk to candidates, however, without extensive vetting and he made it this far.  Which is pretty impressive - I've got a talented, smart as hell, picky group.  Looking for another family member.  Hoping we just met him tonight.  I think it will work out the way it is supposed to.  Things usually do.  

I try not to look at more than one article a day on the NYTimes, regarding last Friday.  Because it makes me cry.  And that hinders work.  But I think reading about it honors those involved.  I have written my children's teachers personal e-mails, because I think they are heroes.  Sad that it takes Friday to bring that to my frontal lobe/attention.  But it did.  My children's teachers are my, and even more so their heroes.  I wish them well, and hope desperately that they are finding sleep easily these days.  It's certainly eluding me.  Jess said it best, below.  A leaf should fall.  A world should pause.  And we should all hold and honor our children.

Guest post: Compartmentalizing work

I watched a child die.  Literally.  Took his last breath in front of me.  It wasn't an unexpected death, but nonetheless, still very sad.  What do you say when your partner says "How was your day at the office honey"?  What do you say?  How many of you share your bad days with your spouse?  If you don't, how do you assimilate what you deal with into your life?  Life went on that day, as it has to, after his death.  Yet, I couldn't help but think the universe should have stopped in some way, briefly, to mark his passing.  A leaf should fall, or the world should go quiet for 60 seconds.  We lost a child.  Our community lost a child. We lost the promise of his life, the contribution he could have made to our society.  What would his life have looked like?  The impact of watching life slip away was huge, on all the staff, as well as the family.  I found myself wondering, watching his mom stroking his arm just before he died, how do you comprehend that this evening, your child will not be with you? That your family will go from 5 to 4.  How do you tell his siblings that he died?  I watched my colleague go straight from his death to a mundane meeting, wondering how is it that life goes on after this little boy has just died?  I know it must, as mine did, and I know that the family's loss is not mine.  My children are safe and well.  So, my question is, how much do you share with your partner and your friends?  Do you have people in your life that you can share your sadness with, or do you have to deal with this on your own?  Not being able to debrief because you need to protect others is a lonely business.  Are we destined to cope alone, because we chose this path?

Jess


Bio - I live in the South, currently working part time in pediatrics.  I am happily married, with two healthy gorgeous babes.  I stumbled across MIM a few months ago and have been following it avidly since, as it helps me to deal with some of the issues I face, being a working mother in medicine. 

What do you do???

OK, hypothetical situation:

The daycare calls you at 10AM while you are at work, and tells you that your one-year-old has conjunctivitis and MUST be picked up "within the hour."

What do you do?

Clearly this is a situation that comes up with some frequency (five times for me so far) and I'm very curious how other mothers in medicine (and other professionals) deal with it....

Older Parenthood: Upending American Society?

I was at a meeting recently with several female physicians and young therapists. We were discussing a patient who was 45 years old and had a six year old son. One of the therapists commented:

"So that means she was.... 39 when she had a baby. That's so.... old!"

Crickets chirped. Almost every physician in that room had children at 39 or older.

On Facebook this morning, one of my friends posted an article about how families are having children at older ages and the consequences of this decision.

In case you don't to read the article, these are its main points:

1) The chances of learning disabilities as well as certain other problems such as schizophrenia and autism increase severalfold in older parents.

2) Women who have their first child at an older age are less likely to have the number of children they wanted ten years earlier.

3) Reproduction becomes more difficult and costly as you age.

4) Having children at an older age means having older grandparents for your kids.

5) Having children at an older age means dying when your kids are younger or at least being more infirm for most of their adulthood.

At the same time, the article also cites that children of older parents grow up in wealthier households, lead more stable lives, and do better in school.

Ultimately, it's a very personal decision, but I know when it comes to motherhood, we are all wracked with guilt about our decisions, and one of the earliest decisions you have as a mother is when to have babies.

MiM Mail: The what-ifs

Ever had one of those cases where you look back and just wish you'd done things differently? What's your way of handling this feeling? Might you be willing to share your moving forward strategy?

I'm an anesthesiology resident transitioning back to work from maternity leave. While I love what I do, there have been quite a few days when I definitely feel that the transition back to work is not as fast as I'd like. The days where I feel like I'm relearning things I used to know. Yes it's kind of like riding a bike after you haven't been riding one in a while, but when you're training, sometimes you don't feel like you ever really knew how to ride it that well even. And I have many moments where I am mentally kicking myself because I just remembered something I should have done or handled differently.

[The case below has been changed to protect patient and staff confidentiality]

For instance, recently there was a code blue at the hospital. A man who had been undergoing a line insertion was now having massive hemoptysis. A double lumen tube was inserted to isolate the bleed. Some air seemed to be entering one lung. The PAC balloon is inflated and the hemoptysis seems to have stopped for a while. The patient seems relatively stable with good sats and bp and the patient's main physician consults ICU to take the patient for close observation. At the back of my head is this niggling feeling as I am not quite sure whether this tamponade from the PAC balloon will hold - should we consider if we need a surgeon to sew up whatever's bleeding? But soon, the patient is bleeding again, CPR is started, the surgeon shows up but the patient is too unstable and despite best efforts, the resuscitation is unsuccessful. When I get back home, I read up on this, and more questions fill my thoughts. What if we'd gotten a cardiothoracic surgery consult much earlier on? Or heart-lung bypass? But now it's too late for the what-ifs and should-haves. I just wished I had known more at the time to be more useful.

Shortly after, I was in a simulator session. While I was fast on initial management managing a crashing patient and securing the airway, I got hung up on troubleshooting ventilator equipment that had failed, without moving on to switching my equipment. It was one of those how-stupid-of-course-I-should-have-thought-of-that moments - if something's not working, sometimes the best option is not to try and fix it, but to switch it entirely. I know that! But hadn't done it fast enough. In a simulator, it's not a real patient crashing and that's great. But if this was a real-life situation, that patient may not have been as good.

I find it hard not to mentally kick myself, or to look with envy at other colleagues and wonder how they seem so much more confident and competent. When I look at my flubs, I often feel like a Bridget Jones while others seem like a Grace Kelly or better yet a MacGyver - always there with the best plan in the nick of time, executed with calm and grace.

I hope I'm not the only one out there who has felt this way - trying my best but feeling incompetent or stupid at times. Yes it is a learning opportunity, and yes, I hope it gets better, and yes I feel I know more than I used to - but when does one start to feel confident and competent, and bring-it-on-because-I-can-handle-it rather than I-hope-I'm-seeing-bad-stuff-when-there-is-someone-else-on-who's-better-than-me-there-to-guide-me-through-it? When I was a med student, I looked at the residents with awe for their competence and confidence, and now that I'm the resident, I don't know that I feel that way.

Have you ever felt this way? Have you ever had cases that didn't go as well as you'd liked? How did you handle it?

RLMD

11 months in, 42 pounds lost

Hey, remember me? I'm the internist who had two kids in two years, ate everything I wanted throughout both pregnancies, and then  realized I had gotten REALLY fat and out of shape. Like, BMI 30, obesity fat. I started a South-Beach-Style low-processed carb diet and started exercising- which was VERY painful at first. See previous posts on that. I think I wrote that my first time back jogging I felt like a manatee on land.

Since then, I've maintained a basically low-carb diet (with the occasional celebration/ feast), and a basic exercise routine (with the occasional lazy week), and I've continued to slowly burn fat and build muscle.

Now, I've gone from 163 pounds to 121 pounds. At 5 foot 2, this puts me at BMI 23!

I am not yet at my goal, which is for 50 pounds lost, back to my pre-pregnancy weight of 113 pounds. I'm trying not to feel like a failure because I'm not there yet. (How Type-A is that?) But I am proud of what I have accomplished so far, and I offer myself as an example to others, including my patients.

Here are some take-away points and tips:

GET SUPPORT:  Last January, I stated my intentions to my family, and they were enthusiastic to help me. I work part-time, 5 clinical sessions of primary care, which really is a 40 hour week at least. My husband works as a writer and broadcaster so works from home alot but also travels alot. My mom helps with childcare, and we have a babysitter. So, in short, though I work alot and intensely, and hubby works, I have alot of support to help me with logistics/ kid care. But more importantly, my family has been all-in behind my efforts. My husband shares the grocery shopping and cooking; he buys healthy groceries and cooks good food. He eats and enjoys the healthy food I cook. Our family gatherings tend not to be laden with "bad" stuff. So that helps. Everyone is happy to let me have some "me" time to exercise. This is key!

SLOW AND STEADY: I'd go many days of staying consistent on my diet and then have a slip-up day. That's OK as long as you get back on the horse as soon as you have your senses back. Like, when hubby was hospitalized with a diverticular abscess; when both kids and us got sick with some nasty fluey virus; and when we went out of the country on vacation, and several other times, I did not pay much attention to my diet. But as soon as I could get back into any semblance of a routine, I started eating healthy again. So, over time, I had many more low-carb calorie-restricted days then I did "bad" days.

PICK A DIET YOU CAN LIVE WITH: I'm doing a South-Beachy-Style diet where I eat 3 meals and 3 snacks a day, so I eat SIX times a day. I aim for 1200-1600 Kcal daily. I like my eat-six-times-a-day-low-processed-carb diet because I like eating every two or three hours, and I like fruits, veggies and lean proteins. I don't miss cake, bread, pasta, cereal, cookies etc. because I feel pretty good on berries, yogurt, apples, cheese, big salads, grilled veggies, seafood and chicken, and nuts. It also makes the occasional really good hot bread slathered with butter that much more special.

WRITE IT DOWN: I got a 79 cent spiral bound notebook and write down everything I eat over the day, aiming at 3 small meals and 3 snacks, eating 6 times/ day, and calculated out to about 1200-1600 Kcal total per day. At first this involved looking up calories a it, but after awhile, I had all the calorie counts memorized. Clementine or small apple, 50 Kcal. Yogurt, 150 Kcal. 2 small hardboiled eggs, 160 Kcal. et cetera. I didn't stick to 1200-1600 Kcal all the time, and I didn't write it down all the time, but doing this most days really helped me stick to it. It also felt SO good to flip back over the pages after a few months, with the occasional weigh-ins recorded, and see the pounds just going down, down, down.

EVERYTHING IN MODERATION: It's OK to have the occasional slice of hot buttered good bread. A diet is not "ruined" by a big treat, or even a week of treats. You're in it for the long haul.

GET IN ANY EXERCISE YOU CAN WHEN YOU CAN: You don't have to go to the gym to get exercise. In the beginning, there were many nights when all I did was some core exercises on the floor by the side of my bed. I've worked up to at least two days a week of either running, or a gym workout, like Stairmaster and light weights. I try to walk with the kids, or even take one or the other out with the baby jogger. I try to use a basket instead of a cart at the grocery store, and switch arms like I'm lifting weights. I try to get out and rake, or shovel, or just fill the birdfeeders. Whatever, whenever.

GIVE IT TIME: Quick results tend not to be lasting results. The goal is fitness and health for life!

Orienting Hemorrhoids?

Last week I was covering our cytology rotation, which can be very demanding.  There are a lot of diagnostic radiology needles.  We are also responsible for junk surgicals, as we nickname them - gallbladders, tonsils, breast reductions, hemorrhoids.  We call them junk because they are easy to look at and sign out, most being very routine cases with only one or two slides.  Occasionally there is a surprise tough case (gangrenous toe chock full of melanoma, for example) but overall they go quick.

One day I had a tray full of hemorrhoids.  They are usually easy cases, normal sign out being "Dilated submucosal vessels, consistent with hemorrhoids."  You have to check out the overlying epithelium to make sure there is no dysplasia, being ever vigilant.  Some breast reductions have carcinoma in situ.  It happens.  Some hemorrhoids have overlying HPV (Human Papillomavirus) changes.  Whenever I have a surprise like this, I generally contact the clinician.

I usually have a hemorrhoid or two, but a whole tray?  I spoke to a friend.  "Either the surgeons are having a blue light special or there is an epidemic of which I am unaware."  I have written of hemorrhoids in the past.  Gangrenous hemorrhoids, to be exact.  I won't rehash that in this post, but you can read about it here, if you want. I thought that was the most interesting hemorrhoid case I would ever see, but then I came across one that was oriented.

Orientation is necessary in pathology for many cancer cases.  Here's a good example.  In all breast excisional biopsies, the techs will ink the margins according to the surgeon's marks.  Sometimes the surgeons use long and short pieces of thread tied to the tissue.  "Long superior, short lateral."  Since a breast biopsy looks like a technicolor version of a lump of scrambled eggs, this is helpful to us in the gross room.  The tech inks the margins according to the surgeon's notes, and describes it to us in their gross description.  "Black anterior, blue lateral/posterior, green medial/posterior,"  for example.  That way, when we see the slide the next day, if the cancer is plowing into a margin, we can see the green ink and note it in our report (invasive carcinoma transected at the medial/posterior margin) so the surgeon can go back and get a clear margin.

But I was very surprised to see a case of oriented hemorrhoids, my first.  There were three different specimens.  The first two were "left hemorrhoid" and "right hemorrhoid."  Left and right hemorrhoids?  Are you the surgeon looking at the person?  Is the person supine or prone?  Or are you the sitting person?  And the third one was the kicker.  "Left posterior hemorrhoid."  Really, posterior?  Aren't all hemorrhoids posterior?

And why does a hemorrhoid need to be oriented?  If you don't get a clear margin on an invasive cancer, sure, you need to know, because it can recur.  But a hemorrhoid transected?  I imagined a transected hemorrhoid, dangerously spreading and growing out a patient's ears.  Ha ha.  Doesn't happen.

So I'm wondering if any surgeons out there can enlighten me.  Or maybe it was the surgeon's joke on me.  In any instance, I enjoyed wondering why on Earth a hemorrhoid needed to be oriented.

Dear Moms, How do you cope?

I'm currently doing the dreaded stint as the chief resident in the burn unit.  Its a particularly grueling rotation, lots of getting called in from home, crazy sick patients and lots of terribly sad stories.  It is taking an emotional toll on me, and I've been missing out on seeing by little peanut.  For the first time since I've come back from the lab I've gone two full days without seeing her.  I have cried a record number of times after countless family meetings at the end of hours of doing everything we could.  Thankfully, I've had a fabulous and amazing team of interns, nurses, chaplains, social workers and support staff to be on this journey with me.  However, despite the support, the one thing I haven't managed to cope with very well is the non-accidental injuries.

I have always found child abuse unbelievable horrifying, but as a mom, my horror about this has reached new levels.  In particular, a recent child I operated on, who is very similar in many ways to my own, has left me having nightmares every day in which I see her injuries on my precious daughter.  I wake up gasping and anxious and immediately go hug my daughter or go to her room and stare at her while she sleeps.  I've talked to other moms with similar experiences, a pregnant NICU fellow fighting the nightmares about her unborn child mirroring the illnesses she saw each day, the burn unit nurse manager who I sat and chatted with in her office about how this unit makes you so hypervigilant about protecting your kids, but the one thing we fail to come up with is a solution.  How do you make the nightmares stop?  I even talked to my own mom, who doesn't need to be in medicine to understand the disturbing fear a parent feels anytime they see another child harmed.  (My mom is awesome by the way, just want to throw that out there because she is my greatest mentor as I navigate this crazy journey of motherhood!)

So, tomorrow I will go to the spa, and try and lose my thoughts and replace them with relaxing calm.  I will continue to listen to my mindful meditation CD's as I drive home from a particularly horrifying day of work.  I will continue to delight in my beautiful, amazing blessing of a child each moment I see her.  And, I will pray for the beautiful children who have endured hurt and pain and pray that they someday receive the love they deserve.

Selah.

MiM Mail: 2 countries, 2 doctors, 1 baby girl

Hello fellow doctors,

I stumbled across your blog while searching for resources for single moms who also happen to be resident physicians. Currently, my girlfriend (Dr. B) and I are in a somewhat unique condition and I was wondering if anyone out there had any similar experiences and any advice for us.

Our situation is as follows: my girlfriend and I both graduated from an offshore medical school this past June. Neither of us are from the US and I actually attended medical school on scholarship from my country's government. In return, I am supposed to give them 4 years of service following graduation and as such, I did not bother to apply for the match in my 4th year since I planned to go home and fulfill my obligation. My girlfriend, who is from a different country and who has no such obligation to return to her homeland, obtained a residency position in a small Ob/Gyn program (only 3 interns/year) in New Jersey where she is currently halfway through her intern year. 

During our 4th year of medical school, we became pregnant unexpectedly and despite the challenges we both faced in the future we decided to keep the baby and this past August, only 40 days into her internship, Dr. B gave birth to our beautiful daughter Princess Peach. Unsure of what she was entitled to in terms of maternity leave for residents and how it would affect her ability to finish her residency on time, Dr. B took 2 weeks vacation following the birth of Peach which served as her maternity leave. Before she began her residency, I had decided to defer the start of my service in my home country to January 2013 in order to be free to care for Peach while mom continued to work, with the thought that I would take Peach with me back to my country since I would have family to help support me in taking care of her since Dr. B does not have that kind of support here in NJ. Her hospital doesn't offer childcare either so that is not an available option.

As such, since August I've been Dr. Daddio, stay-at-home father, which has been an absolute blast to be honest. I had no idea I had the capacity to love someone as much as I love my daughter and I cherish all the time we have together, even more so when her mom actually has a little free time to spend with us. However, as we near the end of the year, my time here is drawing to an end and Dr. B is freaking out at the thought of Peach and I leaving her here alone. She is already guilt-ridden about the very little time she gets to spend with Peach and she is dreading the day when Peach is no longer here for her to hold and kiss and love when she gets home from the hospital. As a result she is reconsidering letting Peach go home with me, however neither of us can see any feasible alternative. At this time, we cannot afford to pay for the kind of flexible care that Peach would need which would also accommodate Dr. B's crazy work schedule.  Our apartment, which we share with Dr. B's full-time student brother, is not big enough to accommodate a live-in nanny either. The situation in my home country is less than ideal as well since I would also have to be working crazy hours as an intern, and I am unsure of who among my family and friends can realistically take care of Peach while I work, but at least I would have options there that Dr. B doesn't have here in NJ. One option is to let Dr. B's mother and grandmother take care of Peach in their home country but neither of us wants our daughter to grow up without either of her parents.

So here's the conundrum: I have to leave the country for 3 reasons (a. to fulfill my contractual obligations with my government; b. my visa only allows me to stay up to 6 months at a time; and c. my brother's wedding on January 1st), so there's no chance for me to stay here beyond the end of the year. Currently, Peach and I are booked to leave at the end of December but I know at any time Dr. B can change her mind and say that she won't let Peach go with me. If Peach leaves with me as planned, Dr. B won't see her again until the end of March when she takes her next vacation. As far as I can see there is no ideal situation for the foreseeable future as we both have commitments to work in 2 different countries for at least the next 4 years and although we are committed to each other and to our daughter, it will take at least that long for us to be a nuclear family unit again after I leave. This prospect is daunting to say the least! Neither of us want to be away from the other or from Peach, but our situation necessitates the separation. I'd like to explore the option of Peach splitting her time between the US with her mom and my country but that would have to be after we have saved enough money to afford to pay a carer regularly.

Does anyone out there have any experience in such a situation where both parents are doctors and one has to live and work far away from the other? Are there any options for childcare that I am missing? What advice can you guys offer us as we prepare to face this extreme parenting and relationship challenge?

Thank you for your blog and any and all comments are appreciated.

Sincerely,

Dr. Daddio

Clerkship Preference

In light of my post last week, about people with special considerations (i.e. kids) getting preference for the holidays, I wanted to post this story. A version of this was originally on my personal blog:

During second year of med school, most schools have a lottery to decide on what the third year rotations will be, both the order and where we would have those rotations. There were four main hospitals we rotated through, two of which were nearby and two of which were about an hour and half away.

Prior to our 3rd year clerkship lottery, we voted on special considerations for the clerkship lottery. Basically, students emailed in their special needs, and an email was sent to the class with the anonymous requests and we could vote on them. These were some of the requests I remember:

--A few students who had children asked for all their rotations at one particular hospital so they wouldn't have to move around.

--A couple of students asked for an elective during a certain month so they could get married.

--Two male students asked for an elective month during their wives' due dates

--One student asked for an elective month when his father was having cancer surgery

--One student asked for rotations at a certain location because she only had one car and she carpooled with her husband

Out of our class of 100+ students, 12 anonymously asked for special considerations. Out of the 12, 10 passed through majority class vote. (Notably, the car one didn't pass, the one with kids/births did.) I actually voted yes for all of them, mostly because I felt if they believed it was important enough to get special consideration, they cared about it a lot.

Anyway, the day after we found out which requests passed, one woman in our class sent out the following email:

This is ridiculous! Many of those reasons were absolutely silly. What was the percent of votes needed to pass this anyway? I can't believe the votes passed with those stupid reasons these students gave.

Because for one thing, if your parents are ill, get a visiting nurse, since there is nothing you can do while you are studying anyway. Secondly, all these people that want to take care of their family or assist with their wife's pregnancy or take care of the children or see your children and all that... well, we all have loved ones we would like to see as often as possible, but because we chose such a demanding profession, we simply don't necessarily have that luxury. We just make it work without having to subject our colleagues to it. If it matters so much, have your family member move to where you are or you can commute or hire a baby sitter that can pick your children up from school.

I easily could have said something equally lame, but I sacrificed and let people with more important reasons have their say. But all these crazy reasons, I tell you, is unfair to the class as a whole and it is especially unfair to people that had good reasons but took the initiative to find solutions to their issues.

We generally all thought this particular person was being extremely selfish. What do you think?

Role Reversal

I was once at a pancake breakfast for my kid's school.  Cesilly was 5, Jack was 3.  Jack was in a dance class, pre-Taekwondo and Boy Scouts.  I was feeling pretty savvy, my son in a dance class!  How liberal and against the grain.  He had to wear a uniform for the performance - a black suit with a spangly sparkly bow tie.  He looked like a flim-flam man.  I was a little confused by the attire.  I wandered over to another mom to ask her about the logistics.  She was a gyn-onc at the University - a transplant who was trained in California.  Her son was my son's age, her daughter the same age as mine's.  I didn't know her well, but was itching for companionship, especially from another doc/mom.  I walked up to her and took a deep breath.  Wanting to be her friend.

"So what are they supposed to wear for the recital?  Do you know?"

She looked at me, puzzled.  "I have no idea.  My husband takes care of all of that."

I think he was a stay at home dad, or at least had a very flexible laid back job.  I had gathered that much, from observing them over the past few months at the school.  I also saw them at the grocery store on Sundays, all of them, the entire family shopping together, while I was on my own doing the weekly shopping.  I admired that about them.

My reaction to her statement was complex.  I was awed that she gave up those duties to her husband, and also jealous that he was available enough to take charge in that arena.  I also felt angry at her, probably projected anger redirected away from myself.  Angry at her for not knowing about the mundane details of the children's lives, since that was my primary role in our family at the time.  I was a resident, busy with work and two small children, and I would have never imagined relinquishing that knowledge or responsibility to my husband.  It would not have worked, in our relationship.

I am divorced, two plus years now.  My ex and I get along better now that we are co-parents, and not married.  He is remarried to a wonderful woman who has taken the role as stepmother to my children, not stepmonster.  She calls my kids her "bonus children," and read such a beautiful passage to them at her wedding last March, about there being room in her and their hearts for everyone, that I got teary.  As my daughter Cesilly said at breakfast one day, "Mom, Dad sure does some things really well.  He picks good women.  He picked you, and he picked Miss Rachel."  I laughed.  I agree.  I love Miss Rachel, and so do my kids.  I maintain a respectful distance, but will be eternally grateful for the structure and emotional support she provides to their household.  My marriage issues are water under the bridge.  But there was definitely a large gap in childcare division back then, me taking on most of it.  I don't think this is uncommon, especially when the children are young.

My primary reason for writing this blog is about roles and delegations in marriage, traditional and otherwise.  Did I have any right for feeling judgmental about the gyn/onc's lack of knowledge about her son's dance outfit for the recital?  Or was it all a reflection of my own situation?  Would I have reacted the same way if she were a man, and he didn't know?  I could not have imagined approaching any father at the pancake breakfast to ask about dance recital outfits.  Part of my frustration in my own marriage was the one-sidedness of it all - I saw other friends whose husbands were much more involved in the day to day of the kid's lives.  I take some responsibility for this, in retrospect.  If I had a stay-at-home dad back then, and not a physician husband, would it have been so weird to me that she had no clue?

My kids have moved on to two different schools since that pancake breakfast.  The gyn/onc and I earnestly tried to make some play dates, but I am sure the readers in medicine can guess how that worked out - busy lives move forward without much room for pause.  I last saw the gyn/onc a couple of years ago at the grocery store.  She was expressing frustration with her academic career, the challenges of it, and I listened sympathetically.  Told her about Mothers In Medicine, it being such a great outlet and community for me.  I haven't seen her since.  I sometimes wonder if she is still at the University, or if she has found another job.  I hope she is happy in her career and life.  I don't feel as judgmental of her now as I did back then.  Maybe that speaks well of where I am now in life.  I guess it ultimately takes a working balance in a relationship to make it all work, no matter how the roles play out in the end.  As long as everyone is happy and on the same page, that is what matters more than individual responsibility.

I am curious to hear about how other women, all women - working and stay-at-home, negotiate these treacherous waters in their relationships.