MiM Mail: Career impasse in academic medicine

I was so pleased to come across this blog while trying to research career options. I am currently at an impasse in my career and looking for some insight.

I am currently two years into my first position as a full-time medical oncologist at a major academic center. As a bit of background... I have been at the same institution for medical school, residency, fellowship and now as an attending. I am specialized within oncology, but did complete my board certification in IM, hematology and oncology so as to keep my options open in the future. I chose my specialty with no consideration of future family planning, but because I love these patients and find the work very rewarding.

I met my (now) husband in medical school and we have since married and have a 6 month old baby at home. He (my husband, not the baby) is also currently embarking on an academic career.

I am only now realizing the extent of sacrifice that will be required of both of us to have successful careers in academic medicine. I find that my priorities may be shifting now that we have a child and plans for future children and I am struggling to decide how to juggle my career and family. I am no longer sure I am willing to sacrifice so much time with my child for work obligations.

I am trying to see what opportunities may be out there for both clinical and industry work if I were to take some time off or switch to a part-time position for a few years or permanently. I am just not sure if I can take time off at this point in my career and expect to be able to find a position down the road.

What I do know is that my child will only be little for a short time and I want to be with him as much as possible.There are also certain financial issues to consider given that we are both in academics and have a pretty sizable amount of debt from med school.I would love any feedback from those of you who have been in a similar position. Particularly to those of you who have found part-time work.... is this a common situation? I know that at my current institution, it is unlikely that I would be able to stay on faculty part-time, so I would need to find something elsewhere.

Thank you so much for providing this blog as it reassures me that I am not the only one struggling with these decisions.

Guest post: When the Pediatrician Calls the Pediatrician

I was changing my daughter’s diaper the other night when I noticed some spots. There was a cluster of six or so around her belly button and a line of them tracing her bottom rib on the right. They were reddish-brownish-purple pinpoints and when I pressed on them, they did not blanch. She did not seem bothered by them at all. I, on the other hand, began to quietly freak out.

I am currently rotating on the pediatric hematology service where reddish-brownish-purplish spots that do not blanch are the opening line in a number of slow-motion tragedies involving such things as leukemia and bleeding disorders. Then again, they also play a part in a number of totally benign and boring stories like heat rash and bruises. Infant skin is like one of those word searches that looks totally random from a distance: a lot of what goes on there means nothing, but every once in a while you need to pay closer attention.

So I saw the spots and I wanted to call the doctor right away. It was 7:15pm, a totally reasonable time to call the on-call pediatrician. But I felt sheepish. When you are a doctor, calling the doctor can be awkward. You know all the questions they will ask. You have completed the physical exam that they would have completed if your child were in the office. You have your own differential diagnosis in your head, and you have a rational sense of when or if your child needs to be seen and what if any further evaluation they might need. Why, you wonder, are you calling someone else when you know the answer already? But then there is also a loud voice in your head that is screaming, “WHAT IF SHE HAS CANCER? WHAT IF SHE HAS BACTERIAL MENINGITIS? I KNOW EVERYTHING IS OK BUT WHAT IF IT ISN’T?! ACCCCKKKKKKKK!!!”

I called my partner, C, up to see the spots and she said, “Hmmmmm. Looks like she might have fallen against a toy.” I had to agree. I could almost make out the shape of said toy, a rectangle with one corner at the belly button and the other corner up near her rib. Still, I was not reassured. My partner doesn’t even know what petechiae are. “She’s fine,” C said and went back downstairs. Once again, the rational part of me had to agree. She was not sick. She was totally 100% well-appearing. This was a problem that could wait until the morning. This was likely a problem that was not even a problem. I resolved to let that be the end of it. I put my daughter to sleep and then got ready for bed myself. (Yes, I have the same bedtime as my one-year-old. This is what it means to be an intern).

As I lay there in the dark, it became clear that I would not be able to sleep. I worried about the spots. I thought about my patients and the day ahead. Then I worried about the spots again. That very day on rounds, our attending had told us about a case from his residency, a boy who presented to the ED with petechiae, eating his McDonald’s lunch, and was dead twelve hours later from overwhelming sepsis. Sure, he had sickle cell disease, and a fever, but I couldn’t put it out of my mind. I checked on my daughter and tried to palpate her liver without waking her up. I went back to bed. I stared into the dark. Nine o’clock became ten o’clock became eleven o’clock. I snuck downstairs and called the pediatrician’s after hours line, hoping my partner would not hear. I needed to sleep in order to function the next day, so I rationalized that it was for the benefit of my patients.

A nurse called me back thirty minutes later. We talked through the situation. “I’m worried she has petechiae, but she’s totally well-appearing.” The nurse paused. “If you’re telling me she has petechiae, she has to go to the Emergency Room.” “I don’t know if they are petechiae! They don’t blanch.” She paused again. “Well, lots of things don’t blanch. Are they more red or more purple, because if you’re telling me she has purple spots, she has to go to the Emergency Room, but red spots are fine.” I could tell she had sized up the situation and was trying to reassure me, but she was sitting in front of a protocol book and protocol books do not care about over-anxious intern mothers in the middle of the night. We went around and around a couple more times. “Why don’t I call the doctor on call,” she said.

As I waited for the return call, I sat in the dark in my office chair. I thought about my little girl. I indulged in some worst case scenario rumination. I imagined her having to go through the heinous trial of chemotherapy, the endless sticks and vomits. How would we even get her to sleep in a bubble-top hospital crib? I couldn’t imagine a hospital room containing her, so active and curious and on the move.

My thoughts turned to "R", a toddler who had died of leukemia while in my care. There are patients who travel with you forever, and R is one of those patients for me. Time does not make my memories of him less vivid. I was a sub-intern in the PICU at the time, a medical student in my last year of medical school. R had been transferred to the PICU in the middle of the night, gravely ill. I was out of my depth caring for him -- his oncologists were still talking about treatment while the PICU doctors intimated that he would likely pass away soon. I did not know who to believe and I didn’t have my own experiences to guide me. His room scared me, but I was also drawn there. I could sense that the work of love was being carried out there, despite or perhaps because of the terrible inevitability of his death. R was pale, almost colorless, and swollen from the chemotherapy and the cancer. He had lost all his hair and he was sleepy most of the time, but still comforted by the presence of his parents. He was so beautiful and I felt a tenderness toward him that I could not explain to myself. Every morning as I went through the familiar steps of the physical exam, I touched him as I would my own child. I wanted my touch to if not heal him, at least bring peace and rest to his suffering body. R’s heart stopped an hour before the end of my last shift and he was coded for close to an hour before his parents asked the team to stop. I hovered beside them the entire time, not knowing what to say or do. His mother sat in a rocking chair crying and his father stood behind her with his hands on her shoulders and there was so much in that gesture about their love for each other and their helplessness and their strength. After R died, they went into his room to hold him and everything became quiet. I had a flight to catch, so I had to leave, and I never had a chance to talk to them again. I think about him and them often, though I have never spoken about him to anyone.

The phone rang. It was the nurse. “I talked with the doctor on call and she thinks it’s probably nothing. Wait until the morning and if they are still there or you are still worried, call the office and make an appointment to be seen.”

“Thank you so much,” I gushed. “Thank you so much.” I wanted to convey to this person how grateful I was to her and to the doctor, whoever she was. “You have no idea what a gift that is.” I was crying, embarrassed and euphoric. The safe over-the-phone answer would have been to send me to the ER, but one of them or both of them had understood that if my daughter had truly needed to go the ER, I would have already been there. They understood that what I needed wasn’t medical advice, it was reassurance, and they had the courage to reassure me.

By the morning when I woke up, I couldn’t believe how scared I had been. In the light of the day, the spots were clearly a bruise. Two days later, they were gone, with only me to remember them.

I wonder how the situation would have played out had I not been a doctor. Either I would have made nothing of the spots, or called about the spots and ended up with a long and fruitless ER visit. Either way, I think the quality of the terror would have been less acute. The average person does not have a repository of worst-case-scenario images to match every sign and symptom. As a pediatrician, I didn’t need reassurance less, I needed it more.

I did not realize before the spots episode how much effort I expend maintaining a separation between the reality of illness that I inhabit during the day and the reality of wellness that I inhabit at home. Sometimes the one intrudes on the other in ways my rational self cannot prevent. I hope this will not negatively impact my daughter (or my partner, who relies on my medical judgment and was understandably shaken by this false alarm). On the other hand, I never take my daughter’s health for granted. The possibility of illness sits on my shoulder and reminds me to be humble and present, both for myself and my family and for all the parents like R’s parents who are suffering the unimaginable. It makes for a state of parenthood that is more anxious but also more alert and sacred. I am grateful in advance to all the pediatricians who will care for me and my family over the course of my daughter’s life, who will allow me to be afraid, who will give me the gift of reassurance, who will hold my anxiety in confidence and allow me to be a parent instead of a physician. 

Miriam Stewart is a pediatrics intern and lives in the Philadelphia area with her partner and thirteen-month-old daughter. She blogs about the joys and challenges of juggling motherhood and medical training at whatbeginswithm.wordpress.com. Details about "R" have been altered to protect patient and family privacy.

Part-time

I work part-time.

Some people think that women who work part-time are ruining medicine and contributing to the physician shortage. So I want to present my very reasonable list of reasons why I work part-time in a flexible job:

1) I am sick constantly. Constantly. My kids are Petri dishes. And it always lasts forever. Even as I'm writing this, I'm coughing and my left ear really hurts and keeps popping. Is it easy to work under these circumstances? Not particularly. Maybe mothers of small kids who work full time have better immunity than me. Or maybe they're just better at working while very sick.

2) I don't have family members who can quickly cover for me in a pinch. Like when the daycare calls, saying my daughter has conjunctivitis and must be picked up NOW NOW NOW. (Literally, I am required to show up within an hour. OR ELSE.) Ideally, I would have a babysitter who waits by their phone, constantly on call for just this situation. Do those exist?

3) If the workday "ends" at 4PM, that's the only way to guarantee making it to the daycare by 6:30PM. I have no back-up if I can't make it.

4) I kind of like having two days off to recover from the week. It's called a weekend. It probably seems crazy luxurious to you, but believe it or not, it's actually sort of normal to most people.

5) When I feel like I'm rushing around and getting pulled in too many directions and expected to do three different jobs at once, I actually get kind of stressed out. And depressed. I don't like feeling that way.

6) There are things I enjoy doing that don't involve medicine OR my kids. And if I work part-time, I get to actually very occasionally do some of them. It's important to me. I feel guilty saying it, but it's true.

7) When I am really stressed out, I am not super pleasant to be around. I start screaming at the top of my lungs and then burst into tears because my daughter won't put her sneakers on in the morning. I'm sure I have inferior stress-compensation (likely genetic) compared to full-timers, but I just hate being like that.

8) I have trouble with night call. I never liked it, but at some point, between waking up for my baby's cries and waking up to a beeping pager, my sleep became very dysfunctional and a major source of stress. I've seen professions to address it, and it's better, but I can't deal with working at night.

9) I don't have the physical stamina you do, apparently. After working a very busy 10 hour day, I am too tired to play with my kids. I was never a high energy person. Somehow, I didn't realize how important this was when I went into medicine. I wish I had the energy, but I simply don't.

10) I am not a Type A personality. I just can't do it all at once. And if I tried, I wouldn't do it well. Does that mean I shouldn't be a doctor?

Trust me, I feel guilty that I can't work the hours some physicians work. Sometimes I wonder what's wrong with me, that I can't seem to juggle the same number of balls as some other women. But I have found a balance of career and family life that seems to work for me.

I'm sorry I'm ruining medicine.

The Little Itty Bitty Ones: a.k.a. premies in the NICU

I didn’t think it would happen but I fell in love with my Neonatal Intensive Care Unit babies. Here’s how it went down:

Sign out prior to the beginning of the rotation: From the Intern finishing up her rotation: “everyone just survives this rotation, be prepared to write lots of total parenteral nutrition orders (TPN).”  Sign out ended with me congratulating myself that I hadn’t started crying just hearing how sick some of my new patients were.

Day 1: Examining those tiny babies had to be the scariest thing I have done in my life. I’m used to 6 pound babies in newborn nursery, not 1 pound babies who are ventilated and in incubators. I made it, my patients made it. I’m used to talking about urine and stool counts and giving breast feeding advice. I’m not used to talking about glucose infusion rates, assist control ventilation, bubbles CPAP, and making split second decisions based upon arterial blood gases and urinary output.

Weeks 1 - 2: struggled with patient management, presentations, note writing (many nights I finished around 10pm), and TPN. Struggled with missing Zo’s bedtime.

Weeks 3 - 4: started getting used to the routine and began enjoying deliveries (dry, stimulate, and ventilate). I also began enjoying the daily mechanics of managing my “feeders and growers” and even got to do a really cool creamatocrit to assess the nutritional content of a patient’s maternal breast milk. Surprisingly, I also started to really like managing my complicated patients and the daily brainstorming that goes on with our consultant specialties. Establishing relationships with the parents was really the best thing about this time and the staff who work in the unit are outstanding and know their trade exceedingly well. On the homefront, I still had not gotten used to the lack of sleep and was really started feeling badly about how junky our house was becoming and how my husband had essentially become a single father.  

Week 5: started feeling the first tinges of confidence or was that my upper respiratory illness superimposed with sinusitis and a head full of medicine? I guess I’ll never know, but I was sad on my last day. Sad that I had to sign out to another Resident (who I totally trust but still they are “MY” patients and families). Sad that I was just starting to become confident and then bam, on to the next rotation. Sad that I wouldn’t see the daily progression of the little itty bitty babies who had surprisingly stolen my heart.

Snowmaggedon/Snowpocalypse/Showers

For some states it takes a hurricane to bring it to its knees.  For Arkansas, it only takes a little snow and ice.

We had a big snowstorm here on Christmas night.  It started with ice, then 8 inches of snow came tumbling down. I had my brother drive me back home from Christmas dinner with my mom and dad, so I could trudge up the 1/2 mile to my car the next morning to get to work.  Well, that's a little exaggeration.  My partner had already texted me to stay home, because there wasn't much work, but I still had to get there on Thursday and Friday.  The power went out on Christmas night around 9:00, and didn't come back on for 5 days.  Luckily the kids were with their dad and stepmom, so I only had to worry about myself.

The first night I slept in my bed, but it was so cold the subsequent nights that I spent time by the gas fire on my son's twin mattress from his bunk bed.  Had the neighbors for lunch the next day - heated up Christmas Eve Chocolate Lightning Chili (thanks again bro!) on the gas stove with a fire starter.  It was fun and adventurous.  And dirty.  I didn't shower until that Thursday when I finally went to work.

My dad suggested I go to the OR - surely they would have a shower there.  He was right and the staff were inviting once I announced my status - they were a little wary of a disheveled woman in bulky sweaters, jeans, and combat boots.  My hike up to my car that morning took me through tangled downed power lines and fallen trees - I dressed for need and not professionalism.  My guide assured me that the shower was clean, and I would enjoy it.  He warned me that no one had used it in years.  I was so excited to get one after almost three days, I didn't care.

The water was tepid at best and the shower pressure was akin to a crappy light massage.  Once I had dismantled my clothing, however, I was all in.  I rushed and shaved and cursed my darned luck.  Swore the next day I would search for a better one.

Someone in flow (cytometry) told me the Baptist Rehab showers were pretty good, so I searched them out on Friday.  The locker room was clean with a surprisingly warm and modern decor.  I bumped into a Chinese woman who was obviously finishing what I planned to start.  We shared stories and empathized about our predicaments.  She lamented, with a heavy accent, about not being able to iron her uniform for work.  I worried about the water temperature based on my experience from the day before.  She said, "I like very hot water.  This was a bit of a disappointment, but it did the job."  As she was leaving I disrobed and assessed the situation.

There were two showers.  One was equipped for handicapped and one was small.  I normally like the larger environments - I'm pretty tall - but the drain was pooled with dark hair and chunks of unnamed stuff and that grossed me out so I chose the smaller shower.  Braced myself for another cold one but it was hot and lovely.  Left me wondering about the the standards of my new friend.  Did she like showers so hot that her skin boiled?

I was so impressed with the Rehab showers I went again on Saturday - I had to finish up a couple of tough cases before calling it a weekend and I needed to get clean.  Scanned the larger shower and it still wasn't clean.  Walked to the smaller one from the day before.  There was a problem.

Something was on the floor of the shower.  Bits - about ten or twelve, I gathered.  At first I wondered if it was dead bugs, but they were all different shapes and sizes so I rejected that hypothesis.  I looked back longingly at the larger shower, but the hair mocked me.  So I decided to grab a paper towel and clean the small shower.  I mean ten paper towels - protected my hands, closed my eyes, and scooped it all up.  Right before I disposed of it in the trash, I couldn't help but look.  The brown casing exposed green underneath.  Yup.  It was puke.  I almost dry heaved, but I didn't.  Kids prepare you for a lot.  I couldn't help feeling sorry for the poor soul that had puked there, and didn't have the energy to clean it up.  I wondered, cancer being treated with chemo?  Did they get a good swim in the pool before the shower incident?  I sure hoped so, and felt a little pride in helping clean up their mess.

I hosed down the shower with lots of body wash and scalding hot water (at least according to me - my friend from the day before would disagree) and jumped in.  As I lathered up, I thought about what my hardship had taught me.  That given the choice, I would choose a shower with puke rather than one with clumps of hair with chunks of unnamed stuff.  And I loved that I was put in the position to have to make that decision.  Life is full of wonderful surprises.

Thanks to all the good folks at Entergy we all had power within about a week.  Some were luckier than others.  Yesterday we had another ice storm.  I worked late, parked up at the bank, and walked down the hill to my street.  Had to crawl up my hilly yard covered in a sheet of ice, purse and computer bag in tow, to get to my front door.  Loved entertaining my kids, again thankfully with dad and stepmom, with that story on the phone.  Mom in adventure movie.  This time we've got power and the promise of a thaw by mid-morning.  There are lots of things in life to get you all in a tizzy, but this isn't one of them.

Hope everyone out there is warm and safe and power-ful, ha ha.

Inner Voices

On Monday my best friend from med school called from her car.  She usually calls me on Monday around noon and if it works we chat and catch up.  She has a drive to go to a smaller town to do clinics on Monday afternoon after working in her ophthalmology clinic in the morning.  It had been a while since we talked because holidays kept us busy.

Lys told me about her five year old daughter, who has amazingly beautiful curly hair that draws a lot of attention, and how she notices that she looks at magazines and seems to admire women with straight hair.  It reminded me of when Cecelia, now 9, was 5, and she used to admire women with blond hair.  I am blond, with the help of highlights in my older years, and Cecelia has beautiful brunette hair.  We discussed talks with our daughters about wishing for what you haven't got, and also trying to give our daughters a taste of what they wanted because we worried that by holding out and shutting down we might create obsession.  I remember buying Cecelia a wig.  Lys, who has gorgeous auburn locks, gets her hair straightened when she goes to the hairdresser, just for the day.  She is planning to surprise her daughter this Thursday by doing this when she gets her hair cut.  I can't wait to see the pictures.

My daughter Cecelia, who has been the same size for about 6 years now, has suddenly grown and blossomed this year.  We have gone through many wardrobe changes, with lots of tears and frustration on her part.  She is not overweight, but beautiful and curvy, without the height (yet maybe) on my side of the family.  She compares herself to taller, twiggier girls in her class and comes up short in her own mind.  It pains my heart.  I focus on healthy eating and mind makes us beautiful but our society makes it a tough battle at times.  I find that it is better to get her clothes that make her look good and feel comfortable so go to great lengths to make this happen.

We are reading a book that my Mom gave us called Iron Hearted Violet, by Kelly Barnhill.  I still do chapter books with the kids at night - one chapter before bed (most nights, anyway).  It is fantastic so far - princesses, dragons, Kings, and Queens.  Lots of adventure.  The young princess Violet thinks she is ugly, and despite her magnificent storytelling capabilities was shut down by the court for telling a story about an ugly princess.  "Princesses are supposed to be beautiful."  In the chapter last night, she is looking in an ancient mirror with carved, writhing lizards on the edge and judging her lopsided face and mismatched eyes.  Both my kids looked at the illustrations and defended her beauty.  Cecelia said, "She has such long, wonderful skinny legs."  Jack said, "Her hair is long and curly and so pretty."  I decided this was an opportunity.

"Well, that's her inner voice telling her she is ugly, but our inner voices aren't always true.  Everyone has an inner voice telling them they aren't good.  What does your inner voice say?"  Jack (7) was a little over enthralled with a recent gift of a lava lamp, so he didn't engage.  But I overheard a conversation he had with his older cousin Joshua at a pizza restaurant in Atlanta last week.  "Well, Joshua, I'd like to play soccer with you, but I'm not very good at it.  I hear from my Mom that you are very good.  I would be embarrassed to play with you."  I rescued him by suggesting that Joshua show him some moves, but our week was busy with cousin fun, so that didn't happen to my knowledge.

Cecelia did engage.  "My inner voice tells me I am not very good in sports."  She is trying hard in basketball this year, and got a goal at her dad's house for Christmas.  She may not be a star, but I love that she is trying.  More than I was capable of at her age.  "It also tells me that I have big cheeks.  Look!  Even when I smile I look weird."  She hammed for me on the bed.  I laughed.  "Cecelia, those are called chipmunk cheeks, and you got them honestly.  They run in my family.  I had them too.  On my first day at private school in 8th grade, the first thing someone said to me as I was walking in was 'Are you the new girl?  Oh my, you've got chipmunk cheeks!'  Good news is, they go away as you get older.  And they are very cute when you are young.  But I understand, I didn't like them much either."

I told her the story of my friend Lys' daughter and she loved it.  I reminded her of her longing for blond hair at that age and she (!!!!) didn't remember.  Last night I watched the Sheryl Sandberg Barnard commencement speech that was recommended in a comment thread, it was excellent.  We women do tend to let our inner voices dictate our lives and bring us down.  Not that men don't have them either, but her statistics are pretty telling.  I never really make New Year's Resolutions, but if I did, I would take that inner voice and toss it out the window.  And Cecelia's.  And Jack's.  But I know I can't do that, so I will keep trying to bring up this conversation about once a year so that they can voice their inadequacies and I can squash them.  Or at least try.  It's my job as a Mom.

MiM Mail: Surgeon versus family

I am so happy to have found this website!

I've been so torn between having a family and becoming a surgeon. All my life, I've wanted to become a surgeon, and I've never imagined myself doing anything else. However, family is super important to me and nothing would make me happier than being able to pass on my knowledge to a child or two. Given my career goals, I probably would only be able to have one child. But I'm still so confused about whether or not I should even have children. I love children but am too young to really gauge whether or not I want one of my own.

I plan on taking a few gap years between undergrad and med school, however even after two years out of undergrad, I'll only be 23 -- I don't know if this will be enough time for me to even find love, let alone a supportive husband and potential father of my children! I don't know if I want to extend my gap from two years to five so I can start a family. I don't know if I should wait until I'm out of residency. I just don't know. And I've found it so hard to seek guidance. Your website helps so much.

It's crazy how much my passion will impact my ability to have a family. But I'm learning so much just going through the blogs, and I'm looking forward to hearing more from you all. I'm so glad I'm not alone.

By the way, I'm 19 and a sophomore in college.

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.