I Care About You, But I Hate What You're Doing: The Internal Struggles of a Primary Care Doctor

Gizabeth, a pathologist, just wrote about needing to maintain a "poker face" when she did a patient's biopsy, because she knew the diagnosis was metastatic cancer, and she knew it wasn't the right time or place to deliver that diagnosis.

This hit on something I've been struggling with for some time, now, and what I suspect many doctors struggle with (unless they've become completely detached):

Over these past five years as an internal medicine attending, there have been patients who have broken my heart, who have made choices I strongly disagreed with. Of course, as long as the choices are legal and not harming anyone but themselves, they can do that, and the point of my writing about these cases is not to debate these choices. It is to learn how to manage my emotions as both a physician and as a thinking, feeling human being.

How do other doctors deal in the immediate moment, and then in the long-term, when a patient follows a path you believe is wrong?

 I'm thinking of several cases (all details obscured or altered to protect true identities):

Several years ago, I took care of lovely, vibrant, fifty-ish year old woman, who in addition to living extremely healthfully, also saw a holistic provider. One appointment with me, we reviewed some test results that suggested she had cancer. I arranged for immediate referral to a wonderful specialist. The specialist confirmed cancer, and outlined a reasonable treatment plan that involved surgery and chemotherapy. About a week later, the specialist sent me a note that the patient declined all of it, and instead chose her holistic provider's plan of herbal remedies.

I was horrified. I called the patient and asked her if this was true. She said yes, that she thought of cutting and chemotherapy as worse than cancer, and would take her chances with the herbal tinctures, powders, teas, cleanses and energy healing offered by her holistic provider.


What would other doctors say to that?

I said, something along the lines that I respected her decision, but felt that I, as her primary care doctor, needed to inform her that she was choosing untested and unproven treatments, treatments that were not likely to help her at all. She said she would take her chances, and we hung up. That was the last I ever heard of her.

The above case is actually a combination of a few similar cases... It's not unusual for patients to turn down the 'Western medicine' treatment plan. Again, of course, the choice is the patient's, that is not debatable. What I struggle with is my own feelings. Because I know that when this situation comes up, when I KNOW the "Western Medicine' plan, though imperfect, is the patient's best shot at extending their life and quality of life, I know my heart beats like crazy, my palms sweat, and I have to work very hard to control myself, to NOT stand up and scream: "ARE YOU CRAZY?? You're planning on taking all kinds of potentially toxic and useless herbal crap when you have access to the best treatments in the world for this, and suffering people in every developing country would give anything to be here in YOUR place with the chance YOU have at a cure, and YOU are turning it down???"

Then, there's the opposite scenario.

I once took care of a lovely and also quite seriously ill man. He was extremely elderly and debilitated, with some dementia, enough dementia that all of his finances and logistics were managed by family members, though with enough insight and judgment to contribute to his own medical decisions. He had a terminal cancer diagnosis, on top of multiple medical problems, making his care quite complex. He was feisty at times. He had been asked to consider his palliative care and hospice care options on several occasions, and always became quite angry, usually ending up by shouting things like "I'm not going to let you kill me!".

He was admitted for serious, life-threatening complications related to his cancer. It was very likely that he would end up on life support without a chance of any meaningful recovery. He was asked again if he would consider hospice/ comfort care. He refused. His family, who had power of attorney, chose to abide by his wishes. He ended up near cardiac arrest and was sedated and intubated, and stayed in the intensive care unit on a ventilator for a very long time before he passed away, without ever having regained conciousness.

I don't need to tell many people in healthcare that this scenario is so common, I've seen in many many times. It plays out every day. It's just as heartbreaking to me, to see someone choose the cold, often prolonged ICU death, when they could have had the chance to go a homey hospice - or even home!- with the comfort of a morphine drip, holding hands with family members all around them, saying goodbyes or telling stories, until a naturally peaceful end.

Again, the choice is the patient's. But how do you deal with seeing this over and over again, trying to convince yet another human being that the choice they are making really, really sucks?

There are many other situations where my heart breaks. I hesitate to write about it, such a huge can of worms is the subject of abortion. It's with a heavy sigh that I even type this, as I know it stirs strong feelings and stronger words, pro- and anti-, either way. My point in writing is, again, not to debate the choice. In this country, thank God, the choice is up to the woman.

But I struggle, sometimes, to contain my own emotions when I am counseling a patient through her options.

I am pro-choice, and do believe that someone needs to provide safe pregnancy termination services to those who choose that. But at this stage of my life, I am personally, for my own self, pro-life. I did not choose to have any early risk assessment in my pregnancies, despite my own advanced maternal age. It wouldn't have changed mine nor my husband's decision; we agreed to carry on with any chromosomally imperfect fetus. We had even agreed to carry on with a pregnancy if it happened before we were married. We agreed that we have the financial resources and family support to care for a child, any child.

So, I struggle when I am counseling women who, like me, are financially stable, partnered, educated... who, in short, I perceive as having the resources available to care for a child, any child, special needs or not... and yet, they choose to terminate a pregnancy. In the room with them, I am professional; I smile kindly; I hand them the list of termination clinics; I counsel on birth control; I often see them after a procedure for followup.

But it is not uncommon that I tear up. I often need some space after one of these sessions to recover before I can go into the next patient's room. And I take it home with me. It makes me very, very sad.


How do other doctors deal with this? Especially, doctors who are mothers?

So many situations in medicine can affect us. We are all different in our beliefs and actions... But there must be situations that affect all of you, as healthcare providers. What are they? What touches you, and what do you do about it?

MiM Mail: Pathology vs General Surgery (long-term goal: breast surgery)

I have been following this blog for the last 3 years. I am currently a fourth year medical student who is about to apply to residencies … and I am a confused fourth year student. I am also a 33 years old mother of a 3 year-old boy. 

I applied to medical school thinking about becoming a pathologist. It was my mother’s dream and had some exposure to pathology when I had worked at a clinical laboratory as a phlebotomist and a lab assistant during pre-med years. During the third year clinical clerkships, I fell in love with general surgery and scheduled all my sub-I’s having surgery in mind. Now finishing up my first sub-internship and having taken a couple of 30 hour trauma calls, I start to doubt my decision for the first time.  I am now torn between pathology and general surgery for the first time since the middle of the 3^rd year. Feeling physically tired contributes to it but what I have recently realized is that I do not know much about neither residency schedules in either specialty nor about lifestyle of neither general surgeons nor pathologists. I am worried that if I choose pathology I will work just as hard during residency but would be thinking about how would my life be if I chose surgery. I heard that it is best to choose what you love the most and the schedule will work out at the end. Would you agree with this statement? I also heard statements about applying to general surgery only if one can not imagine doing anything else but surgery, but I also find it hard to believe that the general surgeons, especially mothers,  never doubted their career choices.

Here are my questions, and I would appreciate input from Cutter and Gizabeth.

-       What are the approximate work hours in residency (pathology and general surgery)?

-       Do the hours in residency depend more on a specialty or more on a type of a program?

-       How will my schedule look like when I become a breast surgeon vs a pathologist?

-       What is an attitude towards family in pathology and a general surgery residency?

-       My husband would really like us to have another baby.  Would it be feasible to combine internship, 2^nd or a 3^rd year residency with a pregnancy / new baby?

-       If my marriage does not work out, would it be possible to continue residency and take care of my kid as a single parent?

-       I am shy about asking my current residents and attendings about their schedules since I am on an audition rotation. Do you have any ideas whom I should ask and what else I can do to try to figure it out within the next few weeks? (Ideally, I should be submitting my ERAS application between September 15 and October 15).

how did you celebrate?

My dad cried loud, heavy tears on the day I graduated from medical school. My mom cried too, although not as intensely as my dad. My parents, sister, in-laws, and two closest friends came to my graduation, one of whom had flown cross country to be with me for the event. We had dinner together at a Thai restaurant after the ceremony. My husband gave me a pair of emerald earrings. 

I don't remember crying. I remember feeling happy that I graduated and glad to be with my family, but as I had correct anticipated residency to be more difficult than medical school, I didn't feel overly celebratory about the milestone itself. 

I felt differently about the completion of residency.  When I walked out of the hospital for the last time, I looked back at the inpatient towers, thought to myself I never have to go back, and was surprised by the wave of relief that flooded over me. I'm glad no one was around to see what must have been the biggest, dopiest smile pulled across my face. 

But there wasn't time to celebrate. I graduated from residency on a Friday, moved over the weekend, and started fellowship on Monday. If I bought myself something to commemorate the occasion, I don't remember what it was. Although this achievement meant more to me than med school graduation, it's significance was eclipsed by the need to move and instability of my first few weeks of fellowship. 

Now I am graduating again, this time from fellowship, a milestone that will finally mark the end of my  medical training. 

Memory is an imperfect tool, a shortcoming I appreciate when trying to appraise the individual steps and aggregate of my medical education. To the best of my recollection I was happier in medical school than I was in residency and happier in fellowship than I was in medical school. But then again, my life outside of training was significantly different during these periods that it is difficult to assess them based on just the training itself. I had good friends in medical school. During my fourth year we all lived in apartments close by and spent weekend nights drinking so much wine that it gives me a headache just to think about it. I realized shortly after starting residency that I didn't much care for inpatient medicine. I had fewer friends in residency, a husband who traveled, and an unplanned pregnancy that affected my emotional health during what felt like an unending string of thirty hour shifts. In retrospect, I think I was suffering from postpartum depression where I told myself it was "just the blues".  Thankfully, it passed. Or maybe resolved when I completed residency.

And perhaps it is strange that consider myself happier now, in fellowship, than I was in medical school or residency even though, at the end of my first year of fellowship and just after finding out I was pregnant for the second time (yes, this one planned), I called one of my attendings (a female and the only remotely "mommish" of the faculty) crying. I told her I worried I wouldn't make it through another two years if they were as bad as the first. Even though I hated parts of medical school and residency, I never occurred to me to quit. She told me it gets better. And it very much did. (I am also fortunate that she never held this episode against me nor told anyone about it.) 

I started medical school just before my 22nd birthday. I am through five years of medical school (I did a research year between my 3 and 4 years), three years of residency, three years of fellowship and, last week, turned 33.  I am married with two kids and feel good about the job I have lined up and the career  ahead of me. 

In other words, I want to celebrate. 

And need some ideas. I have a friend whose husband through her an elaborate party (doctor themed) at his family's restaurant. Another friend put a trip to Jamaica for her family of four on a credit card and took off for a week after graduation. One of my (child-free) co-workers is spending six weeks in Europe. 

I don't think I will do any of these things. Although I am feeling indulgent, we are hoping to buy a house soon and will be moving. I don't need another big expense. 

So what did you do? Memorable dinner? Earrings? Party? Trip? Nothing at all? 

Guest post: A quarter-century moment

I turned 25 in May and my life started to shift greatly. Somewhere over the next couple months many of the things I thought were most important in life: education, career, financial stability, settling down with a partner, started to change. It’s not that they became unimportant, it’s that they hopped about my order of priorities and importance like jumping jelly beans. Here I am: living in Thailand, single, 6 months away from closing my Peace Corps service, with an English degree, and no real career or graduate school education under my belt. Fair enough. That’s a pretty standard place to be at my age. However, it doesn’t jive with the reality that blindsided me one day: “Holy moly, Batman. The thing I want most in life is to fall in love, get married and have children.”

Okay, so you say that’s a pretty normal thought for a 25-year old woman. No, not this woman. If you’d met me 1 ½ years ago at the beginning of my service you would have laughed hysterically if I told you that. I ran out of rooms full of children with an ice pack on my head and aspirin in hand. Not really, but I ran into hiding. Before you call me an evil monster, read on.

Maybe because my uterus has a mind of its own that nature bestowed it with, or maybe there are actually hormones in my body that function normally, or maybe Darwin was on to something when he talked about our biological drive to carry on the human race, I don’t know, but suddenly the only certainty I knew about my future was that I wanted a settled-down life that involved family, children, and a loving supportive wife. For years I had been in this mechanically-like driven determination to get to medical school. And here I am now reduced to smiles and tears in a classroom of adorable first-graders.

As a side note, other life influences surrounded this quarter-century crisis. At the beginning of June I went through a painful breakup with a woman I thought I was going to marry and settle down with. We dated for 3 years. I naively assumed it was a certainty because we’d planned our lives together and done everything short of propose. Many nights, what got me through each difficult day away from home was knowing that she’d be there waiting for me at the end of my service and we could start a family together. We were each others family. However, life and whatever Higher Power there is other that ourselves has a funny plan for us, so I had no choice to let go of all that when she decided I wasn’t the one for her. At first I felt devastated because I thought what I lost was this woman I loved more than anything and my hopes and dreams of settling down, getting married, and having children until one day it dawned on me: I haven’t lost the chance to get married and have children, it just means it isn’t with her. It’s at that exact point that I realized how incredibly important it is for me have that life for myself. I want those things, for me. Ladies and gentlemen, this was just short of a miracle (Dramatic you say? Talk to me about what I used to think about these things. Better yet, talk to my friends).

And then, I do believe, the first-grade girls I teach changed my life. Every morning I walked into the classroom and these young, 5-year girls screamed my name, walked up to me and wrapped their arms around my legs. My heart felt pretty raw and bare on those days and their sweet, simple love for me caused me to tear up a bit. Here I am, a foreign teacher they barely know, we hardly speak the same language (culturally or natively), and yet they are so eager to have me in their lives. All they want is to love and be loved. Yes, that sounds cliché, but its true. We try to over-complicate things in life when that’s what it all comes down to. I found myself just as eager to receive Monday morning hugs from these girls every week. They brightened up my life. I thought to myself, “I want this. Why did I resist so much before? What was I afraid of?”

Fast forward to today. I’m successfully 3 months and 3 days into my 25th birthday and life is strange. One day, after pursuing medical school since I was a junior in high school, I asked myself, “Is this what I want?” Ever since I can remember I have written the ending to things far before they even happened. I had a burning desire to figure everything out light-years before it actually happened. We call this living in the future. Part of me was afraid of living with the uncertainty of everyday life and seeing where it takes me, part of it was feeling the need to control everything so it doesn’t fall apart or fail, part of me was afraid that if I didn’t plan then I wasn’t headed anywhere in life. Until one day I realized that I MUST live with the uncertainties of everyday life because the present is where life happens. I also realized that I have to let go. Let go of control, let go of trying to fix things and settle into the way things are at this moment. As far as the last one, I have enough years of life under my belt to know that I never need to plan a thing and I’ll never allow myself to fail, no matter what. “If you can dream it you can do it,” may as well be my philosophy. However, this notion calls into question one small thing: the dream.

I reconsidered my final decision to go to medical school and turned it into an option instead of an absolute. I realized that I’d do myself justice to pursue experience in the healthcare field, seek out shadowing opportunities, and volunteer with hospice to see if this really was the life I still wanted for myself. The one big looming question, “Can you do it? Can you go to medical school, be a doctor, a wife, a mother?” Or maybe the real question is, “Can I do it?”

You know what, actually, I take that back. The question is not CAN I go to medical school. The question is not doubt. Of course I can; there are thousands of women before me who have shown us that it’s possible. The pivotal question, and the more terrifying one is, “Do I want to?” That’s what I’m struggling with. It’s “Do I want to be a doctor, a wife, and a mother? Is that the life I want for myself: being pulled in so many directions?” To answer this question begs me to let go of whatever plan I may have for the future. No really, Julia, let go. To take each experience everyday and let it shape me on its own. To live in the moment and follow what my heart says to me when the time is right. When it’s time to act, I’ll know it. If I don’t know it yet, I’m not there yet and I’d do myself a favor to keep enjoying the little things and following the path (as blindly as it may be).

I’m the only one who can answer this question. And maybe even then, there’s a bigger plan for me out there. I better just breathe, take a look around and enjoy this quarter-century moment. That big stuff? Careers, family, children, love, it will all turn out as it supposed to. I just have to have a little faith. For now, if you need me, you can find me in the present.

I’m Julia. I am 1 year and 8 months into my Peace Corps service in Thailand. I admittedly have no more answers to life than anyone else. Each day I wake up, go to one of two village schools and teach a mix of elementary kids and high school kids. They’ve taught me more about life than I have them.

The Devil Wears Scrubs

I did it! I wrote that book about my intern year!

It's fiction. But it kind of isn't. You know? In any case, if you enjoy my writing, I feel certain you'll really enjoy reading it. Here's the blurb:

Newly minted doctor Jane McGill is in hell.

Not literally, of course. But between her drug addict patients, sleepless nights on call, and battling wits with the sadistic yet charming Sexy Surgeon, Jane can’t imagine an afterlife much worse than her first month of medical internship at County Hospital.

And then there’s the devil herself: Jane’s senior resident Dr. Alyssa Morgan. When Alyssa becomes absolutely hell-bent on making her new interns pay tenfold for the deadly sin of incompetence, Jane starts to worry that she may not make it through the year with her soul or her sanity still intact.

Please buy it!

It's available for the Kindle. For now, I've kept it at the low, low price of only $2.99, although that is subject to increase in the future.

Also, you can get it in paperback!

It's short, it's fun, it's deliciously evil, and if you buy it, you'll make me really happy. And it also does involve a mother in medicine. What other incentive do you need?? :P

If you're not sure, you can read an excerpt.

(Cross-posted to my blog)

MiM Mail: Going from 1 child to 2 during residency

I'm a pediatric intern, wife, and mother to a wonderful 3-year-old daughter. My daughter was born the summer between M1 and M2 year of medical school. I originally thought I might spread the M2 year out into two years, but ended up powering through and graduating on time. In retrospect, everything worked out fine although it seemed hard at the time. I managed to breastfeed her/pump for her first 18 months of life and relished in the flexibility of my M4 schedule to spend lots of time with her. I have a wonderfully supportive husband who works from home and does essentially all the day care drop-offs/pick-ups, middle of the night bed sheet changes when she wets the bed, bath time on evenings I'm working late, most of the household cleaning, etc. We are in a new city for residency. We left a setting with more extended support for one with some but significantly less extended family support in the area.

We are thinking about having baby #2 (have been thinking about it for quite a while)…but I'm scared. We want to have a second child and I'm kind of wishing we had just had #2 during my M4 year and have been done with it. The pregnancy itself scares me. I remember being sooo tired while pregnant as a med student and can't fathom being that tired while working 13-hour intern shifts (or 26 hour senior resident shifts). There are days when I don't have an opportunity to pee the entire day--how does a pregnant resident who has to pee every hour handle that? What if I get nauseous from morning sickness on morning rounds? I'm terrified of the new-mommy fatigue on top of resident-fatigue. And is it actually feasible to pump as a resident? While in medical school, I could lecture-capture from home while pumping and call in sick in childcare emergency situations, I know I won't have those luxuries in residency. I'm also scared of stirring the pot with my daughter, whose world would be turned upside down with a new baby sib and that added element of stress of having a regressing toddler in the mix.

I don't want to wait until after residency to have #2 because my daughter is already three years old and don't want there to be too large of an age gap. Any words of encouragement or advice on when to have baby #2 and how to get through the transition? Are my fears well-based, or should we just take the plunge?

Wanting to grow my family,

H

Poker Face

As a pathologist, I am one step removed from the patient.  This is comforting for the most part.  I render my diagnosis and another clinician communicates it to the patient.  It is best this way - I have no treatment options in my own doctor toolbox to give meaning to the words I communicate.  I learned this the hard way - in fellowship training.

Once I was doing a fine needle aspiration on a small sub centimeter mass behind a patient's ear.  The patient had a history of melanoma, and they were very anxious.  After I aspirated some cells I looked at them under the microscope.  I had a good sample.  It was pretty obvious, despite needing stains to prove it.  Metastatic melanoma.  I sighed internally and turned around.  The patient asked, "Well, what is it?  Is it melanoma?"  I was nervous, still in training, and I hesitated a second too long.  The patient melted into tears, guessing the answer by my lack of words.  I communicated some soothing words and did not hesitate to ask a nurse to call the oncologist two floors above.  Wisely flaunting routine the doctor arranged to meet the patient immediately to discuss treatment.

I learned from that experience.  Now I tell the patient up front that we won't have results for at least 24 hours, although at least half the time I have a pretty good guess at the results when I triage the sample on site to see if it is good enough material for a final diagnosis.  The clinicians appreciate our discretion, and as I said, it is best overall as we usually need special stains or additional material from a cell block for a definitive diagnosis.  And most importantly, we cannot offer treatment options.  This leaves us and the patient at a huge disadvantage if we jump the gun.  Giving a diagnosis without a next step is mental torture.  I sure wouldn't want to be on the receiving end of that.

As a long time member of the community in the hospital where I practice, I encounter situations, not infrequently, where a family member of a patient will text me or facebook message me and ask if I can look at/triage/let them know when the results are out/ of a biopsy of a family member.  I am always happy to help but at a loss for many reasons I mentioned above, not to mention that to communicate results to someone other than the patient, even a family member, is a major HIPAA violation.  I try to offer support and information but fall short of giving away any information about the actual diagnosis - letting it fall naturally in the clinicians hands to communicate themselves.  I know this is for the best, and appropriate, but when your friends are in need diversion can't help but feel deceitful.  I have actually called clinicians, during working hours, letting them know that my report is out and I have a patient or family member calling me.  The clinicians are always gracious and helpful, despite my natural reticence to add to their workload.  I have usually fielded many calls from them about patients in their office - wanting a preliminary diagnosis or a personal phone call when the final results are out - so I understand it works both ways.  And once the diagnosis is out, I am more than happy to discuss it with a patient.  Although that doesn't happen very often it is a rewarding experience.

Sometimes I wish I was back in college when a poker face was just that.  A poker face.  Texas holdem.  Seven card stud.   I wasn't good at it then, bluffing is not my strong point, but I have developed a fantastic one in my field.  It's a skill I didn't anticipate having to master when I chose pathology.

MiM Mail: OB vs. Peds....25 days left to decide

Hello All,

 

I am an MS4 with seven months left til graduation, and more importantly perhaps 25 days left before I hit the send button on ERAS.  I have a serious problem.

 

I am in love with OB. Absolutely in love.  I like Peds, but I love Neonatology.  Who says you can be in love with two different niches? 

 

The problem as I see it is three fold.  1)  I am in my late thirties with a nine year old child that has some emotional issues, and a husband who is not really a husband (ie, he cheated...habitually, horrible husband, great father to our son and we have agreed to co-parent peacefully up until this point.  With such a predicament, I am wary of embarking the OB path with the fear that I will not be as available to my son as he is going to need me to be, that I will miss out on his growing up in lieu of delivering the loves of other peoples lives.

 

2.) I keep hearing how miserable OB/GYNs are, how they don't make any money, and how they all stop doing OB and are doing GYN now for lifestyle purposes (but OB is the part I really like!).  Not to mention I constantly hear OB residents are straight biotches (present company excluded Im sure).  I have a bit of it when pushed, but I don't want to be miserable all my life!

 

3.) I did not care for office pediatrics, but I did enjoy my neonatology clerkship with relish!  And I felt it was truly more thrilling to be handed a brand new baby and tend to it than to pull one out and walk away.  And to add to that, Ive never heard nor seen a miserable pediatrician....a tired one, a broke one, but never a miserable one.

 

How do I make the right choice?  How do I do this without being an absentee mom?

 

Any advice would be quite helpful. 

 

The clock is ticking.....

 

Sincerely,

 

The Phoenix

Guest post: No fun

A few years ago, my husband and I got together with a man and his wife that we had known as young adults.  This man is now a prominent figure in our community, and is well known by most of the people in our small town.  After an evening with this couple, my husband remarked, "It was nice to see them, but it's almost like he can't relax - like he's always on.  He's just not fun anymore."

Fast forward to the last few weeks.  A dear friend of mine came thousands of miles to be "back home" for the summer.  We had several opportunities to go out to eat, take the kids swimming, etc.  As we talked, I found myself noticing something -

I'm just not fun anymore.

Before mentioning a tidbit of interest I would have to think - is this person a patient?  Would I have even known this information outside of the practice of medicine?  When I'm in public, I feel that I am always "on."  When I'm at the store I might be greeted by the dad of a baby I just delivered, or be questioned about a new medicine, or be updated on a cough.  I know, though, that this is to be expected, especially as I take care of many people that I've known since before I started medical school.

In a community this size, being a doctor is like being a minor celebrity.  I'm not exaggerating when I say that hundreds of people know which day I have off, or where I went for vacation this summer and when.  Often it seems that just when I am starting to relax or spend time with my family, I will hear the call, "DoctorGrace!"  I find I can't be anything less than pleasant and professional when I'm "on duty," and I feel that I'm on duty nearly all the time that I'm physically present here.

Now, I realize that I signed up for this;  I know that this is a tremendous privilege, this look into the lives of others.  I honestly love my career, and there is no other life that I would have chosen.  I had another career before medicine and I really feel that I walked into this with my eyes open - as much as is possible, anyway.

I knew that medicine would demand my time and energy.  I knew that I would sacrifice time for my family and myself.  I just didn't realize until now that my spontaneity and sense of fun would be a casualty as well.

DoctorGrace is a family practice doc in the Midwest practicing full-spectrum family medicine.

A fun question

I was just having this conversation with some work colleagues so I thought you might want to throw in your answers:

What were your children's first words?

My two kids' were:

"Bye bye"

And, more heart-achingly, "Mama."

MiM Mail: Leave the Marines for medicine?

Successful ladies, mothers and driven achievers-it was so refreshing and motivating to come across this website and read your posts.  I am a mother of a beautiful 2.5 year old son, happily married for nine years now and currently deployed in Afghanistan missing it all.  However, being away has offered me time to reflect on my life goals. I find that yet again the desire to pursue a career in medicine springs to the forefront of my mind.  Shortly after starting college I uncovered a fascination and curiosity for physical science and the mechanics of the human body.   I was already obligated to military service so I didn’t follow this dream but kept my options open through completion of most pre-required course work (except organic chemistry). Now, after serving 10 years in the Marine Corps I still cannot stop thinking about this deep rooted desire-the idea of studying medicine just excites me!  I find studying the body and how it works to be a fascinating journey.  I feel very passionate about it.  Aside from observing a few surgeries and working in a physical therapy clinic, I have not done much volunteering in the traditional sense but I have certainly been exposed to medicine much more than the average non-health care provider.  I work long hours with my current employment and hope to find at least a few hours a week to clock some candy striper hours in the near future.  The purpose of my post today is to voice some of my reservations and look for advice from those who have already completed the journey or are currently on their way.

I have three big concerns holding me back from my pursuit: 1- As a mother, will I sacrifice the young years of my son’s life and miss out on milestones and memories if I am in school or residency?  Will I be able to have more children and nurse and nurture them or will I resent always having to leave them in the hands of another?  Certainly I am a woman who enjoys balancing motherhood with work; and I need to feel a sense of purpose from my work, but I am trying to determine how much is too much.  2- Am I smart enough?  I have never failed at anything, but it is not from natural abilities-it is from sheer will power.  Long after the gifted are done I continue to study, read and try to synthesize the day’s lessons.  I view myself as an average scholar-I have never been a great test taker (I only performed average on the ACT/SATs) but my grades have always been very good (Cum Laude with a BS in Physiology from Ohio State University).  This compounded with the fact that I am 10 years post-college has me concerned.  I don't want to get in over my head and succumb to overwhelming stress that reduces my quality of life.  3- Do I want to leave the Marine Corps?  It is a career I am good at and that is now familiar to me.  I resent so many hours away from my family though and am not sure that I can do anymore 6-8 month deployments.  I know it may not be much better with medicine, but I would be following my life’s passion.  Please help!  I would value any and all thoughts as I indecisively stand a fork in the road-both leading to two very different ends.

Hopefully submitted,
Emma

Taking Advantage

I've talked about how flexibility is really important for a female physician with young kids, and fortunately, it seems like more jobs are willing to provide it. However, I feel like if you're granted this flexibility, you have to be extra careful not to take advantage.

I don't work with anyone now who I feel takes advantage of this flexibility. But I've seen it in the past and I've heard a lot of stories. For example:

--Calling in sick excessively... like, every Friday

--Leaving early frequently if that's not part of your schedule

--Using your kids as an excuse to get out of just about everything

I'd like to think most women are responsible enough not to do this, but I'm not so sure. What do you think?

Guest post: Swimming

Becoming a mother and becoming a doctor were, in many ways, remarkably similar processes. They both required a radical redefinition of my sense of self. I thought that I had perfectly planned and designed my transition into each of these new identities. But after jumping, eyes closed and breath held, into each new role, I found myself unexpectedly struggling. Option one, the easy route, would have been to softly sink into the newness, absorbing it into myself without question, seeing in it something that had been there all along. Option two (the one that I chose), consisted of frantically splashing about to keep my head in the old world, fighting as if my life depended on not assimilating…and then, in the end, enjoying what I had known that I’d wanted all along.

First: doctoring. For so many years, I had resisted the desire to be a doctor. I did so for many reasons. I’d watched my dad (a surgeon) miss so much of life, and knew that I didn’t want mine to center on work the way that his did. I’d “learned” in college all about medical sociology and the way that new doctors get indoctrinated; I was horrified to think that I too would by necessity fall prey to this ideology if I went to medical school. I saw the passionless lives of professionals and knew that I DID NOT want that for my own – I wanted excitement and happiness and time and craziness and all the things that were not contained, by definition, in medicine. And of course I wanted to change the world.

But in the end medicine won out. I got convinced that I could in fact change the world as a doctor. And I sat down to learn the language, the cadence, the perspectives. Of course I spit and struggled in its face: first I broke up with my boyfriend for convincing me that med school was a good idea; then I refused to study “too hard” because doing so would be legitimizing the establishment; all throughout, I held myself apart, insisting that I was somehow “different” from my classmates. And yet one day, before I knew it, I had become one – a “doctor.” I thought like one, talked like one, was passionate like one. I think my real wakeup call came when I got engaged, and realized that I was no less of a woman for being a physician. And that I was, in fact, better at making informed decisions about my future life than I would have been without medical school. I had fought being submerged by medicine. But I surprisingly realized that I had learned how to float.

And next: motherhood. Equally planned, complete with lists of pros & cons. Once again, I tried to “take lessons” – attended classes, read books, and so on. The difference was, this choice was irrevocable. For the first time in my life, I entered into something that I could not take back. Motherhood happens so quickly, and there is no trial period! People have described the first year of motherhood as being something of a chrysalis. Now that I am on the other side of that year, I understand the poignancy of this description. But I think that a better metaphor that becoming a mom is like jumping in off a diving board. There is no shallow end.

Oh, how I struggled in that first year of my first child’s life. I insisted that I was not “really” a mother. I was not “one of those” who would pay exclusive attention to her child. I didn’t obsess over things the way that “stay-at-home” moms would. I was different, special, not fully subsumed in the role. And yet… now, Being a mom is part of my being.

In the first years, I constantly argued with my husband about who would take on various tasks. I had to realize that fight as I might, no one would take these tasks away from me; there was no one to hold me up. But I wasn’t really sinking. Indeed, I refused to dip below the water line for long. I learned how to manage all of these new movements to keep my head up. And one day it became… dare I say it? Not effortless, but thought-less. Five years later, I find that I now longer have to think about the day-to-day tasks of being a mom. Just as I tread water automatically, so I manage schedule, lunches, playdates, without thinking.

But then the final challenge: how to meld these two roles? Can I kick and float at the same time? I think I’m getting there. After all, I’ve found that my mothering skills help immensely in the Emergency Department. When they throw tantrums, I understand that it has nothing to do with me. When they are whining I know that they really just need a cup of juice and some crackers. When they cause trouble I understand that they’re just looking for attention. When they break down crying I know that they just need a hug. (And I’m not talking about my residents!!)

Conversely, I’ve found that my medical skills are helpful at home. As much as I try not to be a doctor with my children, I can’t help judging their scrapes, rashes, and fevers with a medical eye. I look at how much they’re eating, how they’re drinking, what they do after they tell me their belly hurts… and I make what I hope are somewhat more educated decisions. I also know when to not freak out – something that too many people these days, scared by everything from BPA to H1N1 to thimerosal, are prone to do.

Each transition has contained moments of tremendous frustration, fighting, anger, unwillingness to capitulate, and yes, feeling like I was drowning. But I think that I may finally be learning how to swim through life.


Emergencymom is an academic emergency physician and public health researcher on the East Coast.  She is proud mother of 2 (aged 4 & 1), and wife of a small-business-owner.  Her work-home balance is precarious, but generally enjoyable.  She still can't believe that she gets to do research for half her work-week!  She welcomes suggestions on how to get 4-year-olds to stop whining, how to have dinner cook itself, and how to not be perennially 1 hour shy of a good night's sleep.

First Call

It's my first overnight call in the hospital. It's 7pm and I've been at work for 13 hours. There are 16 more hours to go. My arms are halfway through the portholes of an isolette and my hands are cradling the tiny hand of one of my patients who needs a blood culture and screening labs. I am shush-shush-shush-ing the baby as I choose my spot, swab it with alcohol, and pierce the skin quickly and definitively, trying to cause as little pain as possible. My pager phone is buzzing and beeping against my hip, the nurses are mobilizing, talking, helping each other do all the things this sick baby needs done, but for the moment it is just me and this hand and the artery that is hidden a few milimeters beneath the skin. After a few adjustments of the needle, the red arterial blood flashes into the needle, travels up the tubing, and begins to fill the syringe. My shoulders start to unknit themselves and I take what feels like my first breath in a while. Thirty seconds pass as the syringe slowly fills. There's nothing else I can do for the moment but stand here. I haven't stopped moving and doing and thinking and worrying for the past 13 hours, so this feels like a break. The baby is chewing on his pacifier, looking around for the source of the sting, and our eyes meet for a moment before the blood hits the 2cc mark and I retract the needle into its hub. "Thanks, little man," I whisper to him softly, grateful to have gotten the blood, grateful that I don't have to cause him more pain with a second stick, grateful that I don't have to call the fellow to come and help me, grateful for the couple of breaths I took and whatever small thing passed between us. In the time it took for the stick -- no more than three or four minutes -- four new pages have come through and I am needed in four places at once and I don't breathe again until well after midnight.

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The most recent change in the ACGME medical training rules happened when I was a fourth year medical student. At the time, all the protest over the limitation of interns to 16 hour shifts seemed silly to me. How could anyone protest a seemingly more humane schedule? What was the big deal? Then I got to intern year and began to understand the widespread dissent. The day-float, night-float system featured constant signout -- on long call days, I would spend 2-3 hours of my day signing out. I worked 13, 14, 15 hours six days a week, enduring the pain of long separations from my child, often staying up late working on notes and discharge summaries -- and still there was never enough time to see patients, with rounds and conferences and notes and sign out and the endless to-do lists. Most disturbingly, I felt like I wasn't learning as much as I expected. Admitting a patient was more a matter of administrative work. There was never the opportunity to travel with the patient through the process of diagnosis and treatment. At best I would put in the initial orders, then sign the patient out to the night person. Nights were a little better, with more opportunity to actually see patients and think about them, but six consecutive 15 hour days left me feeling exhausted and was hugely disruptive to my family. I began to feel resentful all the time. Worse, I began to forget why I went into medicine in the first place.

As second year neared, I was filled with both apprehension (would I actually be able to function for 30 hours in a row?) and excitement for the switch to a Q4 overnight call schedule. What was I looking forward to? The time to actually see patients. The chance to spend at least one out of every four afternoons with my daughter. The chance to admit and then follow my own patients instead of picking up overnight admissions and shuffling patients when one or another team member switched to nights. The sense of mastery that would come with being able to manage patients by myself overnight. I was hoping to fall in love with medicine again.

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It's 3:30am and even though I should be trying to catch a little sleep during a lull, I am worrying about sodium. One of my patients has a sodium of 129. It's not low enough to panic, but it's not normal. It's not low enough to call the fellow who has probably already gone to lie down but it's low enough to make me lie awake in the dark, wondering if I should intervene or not intervene, wondering if I should call the fellow or not, feeling like this is the kind of problem I should be able to solve on my own. I get up and turn on the light in the small call room and set about reading about neonatal hyponatremia, which confirms that the baby is not in danger. I could go down on his fluids, but he is losing more than the typical amount of fluid through his unrepaired myeloschesis and there has been concern all day for poor urine output. On the other hand, it's hard to imagine that he is fluid down with a sodium of 129. I go around and around in my head, weighing the sodium level against the risk of insensible fluid loss. I decide to recheck a level in the morning and leave the fluids where they are. It's a small decision but it keeps me tossing and turning for the interrupted hour and a half I have to rest before the morning work starts. When the BMP pops up at 6am, my heart catches in my throat for a moment. What if his sodium is 121? It's 130. On rounds later in the morning, we decide to leave the fluids where they are. For the team it's a small decision -- no one even notices -- but for me it's the end of an arc of learning: how to tolerate the anxiety of uncertainty, how to make a clinical decision when there are no protocols to follow, how to think through a problem and come up with a safe solution. If I had been there with a senior resident, I would have just asked them and they would have changed the fluids or not changed the fluids. I would have slept better. But I would have been no farther along in my ability to take care of patients independently.

Post-call rounding is a whole new experience. I know all the patients and what has happened to them over the past 24 hours. I was there yesterday when decisions were made on rounds and I watched these decisions play out. I have listened to these lungs, stared at these monitors, felt these bellies all night long. I am the one who was here. For the first time, none of the patients on rounds are new to me -- they are all mine. I have the opportunity to get feedback from the attending about my overnight decisions, learning that will stick with me forever. Even though I am exhausted, it is exhilarating. I go home, sleep for a few hours in the afternoon, then have the incredible treat of going to pick my daughter up at day care, something I could almost never do on the intern schedule. I have a normal evening with my family, full of all the quotidian details of dinner, bath, and bedtime that are my secret paradise. By the next morning, I am ready to dive back in.

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The new duty hour rules were well intentioned, designed to keep patients safe and minimize the ill effects of sleep deprivation. But I think there needs to be some consideration of what may have been lost. The danger of sleep deprivation has to be balanced again the the burn-out associated with the relentless march of long days without the high-yield learning and sense of connection to patients bourne of the shared journey of an entire day. Being awake for 30 hours is hard. But feeling like a mediocre doctor while seeing my family for an hour a day for most days every month was much, much harder.

I'm curious to what other people think about the "new" (now not so new) duty hours.

How's your summer?

Since you asked...  If it weren’t for her dose of chemotherapy q 3 weeks and some iatrogenic wbc-boosting induced bone pain, it’d be fine.  And yet, my mother and I are still having a reasonably good summer.  Slowing it down a bit and being together.  Even if the togetherness is while we have a picnic in the chemotherapy suite, or while we walk to the local pharmacy to pick up a medication refill. 

Because nothing says bonding with your mom like shaving her head.  She reminds me that early on I’d wanted a career as a hairdresser.  Alas, now there is no hair. But to my pleasant surprise she is the same strong, smart woman with or without her hair. 

Hats abound.  Tennis caps, floppy sun hats, indoors or outdoors.  They suit my athletic mother --who scheduled her first chemo treatment around her tennis game-- better than a wig.

So how’s your summer?

Taking it one day at a time.   Fortunately or unfortunately, I can conjure up that old car commercial ("this is not your father’s Oldsmobile") and say this is not my father’s chemotherapy.  That was another summer 20 years ago, a different regimen, and for an incurable disease.  This time around it’s like cancer 2.0 with a better chemo concoction and a much better prognosis.

And how do you like this summer heat?

I’m trying not to sweat the small stuff, but sometimes I have trouble figuring out which is the small stuff.  Even now, when I should have perspective on what matters most in life.  Sometimes when I’m stressed about the big stuff, the small stuff makes me sweat too.  I’m working on it.  And overall, it’s been a good effort in rebalancing.   It’s mid-summer and there are lots of balancing acts, being here in the middle.  As I am a doctor but not her doctor.  As I care for mom and am a mom.  As my mother cares for her mother and for her daughters and for her grandchildren.  Chemo more than halfway done and yet other treatments still ahead.  So we try not to sweat the small stuff.  Unless it’s while on a jog or on the tennis court.