My Brain Doesn't Work Like This: chronicles of an aspiring primary care provider in the PICU

I am in the throes of my first Pediatric Intensive Care Unit rotation. I was shocked that by Day 2 I wanted to run away and hide under my covers. Shocked that soo early into the rotation, I was hitting  the snooze button soo many times that my husband who sleeps through anything (except my occasional snoring and Zo crying) ordered me out of bed.

I am NOT that Resident. I’m not the one who hates residency. On most days I am so excited to serve patients and work with amazing colleagues. But I fear I have become THAT Resident. The grumpy one. The one who doesn’t want to be here. The PICU and its acuity has brought it out. Stealing the “oomf” from my life. Encouraging family members and friends have given me pep talks as I weep into the phone about how draining dealing with such critically ill children and their families has been; children with devastating neurologic damage or those with genetic syndromes with abysmal prognosis.

And top off the emotional heaviness with the fact that my brain just doesn’t work like this! The Attendings and Fellows are amazing. Without a single written note, they can recall doses of infusions from the prior week, what the Neurologist or Infectious Disease Consultant said 8 days ago, what I and other Residents said at every moment of the day, and various other details that I cannot ever imagine myself being able to recall without very detailed notes. Ventilators and infusions and cardiac physiology after a specific surgery, my brain screams out, “give me 5 minutes, 5 more minutes with the Peds In Review or Up-to-date and I promise I’ll have a detailed explanation!” but no, I have 2.5 seconds before I get the “you are dumb, hush up now” look. And of course I am now tachycardic and sweating and feeling hypoglycemic in the third hour of rounding.

I have tried to somewhat let myself off of the hook. I will never be a great PICU Resident, but I’m getting better and might even be pretty darn good by the end, nor do I endeavor to become a great PICU Attending. As an aspiring primary care provider and maybe even a Nursery or part-time ER Attending I will know how to keep critically ill patients alive until the Intensivists arrive. And even now, I am keeping my patients alive. I am learning how to more efficiently and effectively manage their acute issues and prioritize. I have come up with some good ideas and my brain works really well sometimes. But feeling adequate most of the time, just doesn’t feel good. And then my brain screams that it just can’t work fast enough to be excellent in this setting. And I acquiesce because it’s right and this is something I’ll just have to come to terms with as I snuggle even more under my covers while pressing snooze one more time. Because now more than ever, my brain needs its rest.

Night Float - The Bad Beginning

A few years ago my family medicine residency program, realizing that duty hour changes(*1) were coming soon, decided to start a night float system (*2).  The new duty hour limits were not in place, so residents worked 14 hour shifts for 14 nights in a row (*3).  (Then we got one day and one evening off in preparation to return to work - on day shift.)

In case you were wondering, this was a horrible idea.

Just a few generalizations about night shift - when you work nights, you never, ever feel good.  You always feel tired, like you need to go to bed, or like you just got up from an ill-timed nap, or like you desperately need a nap regardless of the timing.  You feel disconnected from society – just as people are going to work, you are headed to bed, and just as the kids are getting home from school, you’re trying to wake up again and get ready for another workday.

I know that six nights in a row can be difficult and taxing but 14 were just monstrous (*4).  By the second week, I started to lose perspective.  I was crying every night on the way to work.  I left home with my child in tears as well and my husband frustrated at being thrust into single parenthood with a very angry roommate.

I was angry – initially at the program directors, but gradually at the nurses, the other residents, and ultimately the patients.  I wondered why I was getting so many stupid pages, and why none of the other residents could do their own work without dragging me into it, and mostly why all these stupid people had to choose tonight for their shortness of breath/chest pain/drug overdose.   Not a good attitude.  Add to that the directors’ insistence that no one ever, EVER nap on nights even if all the work was done (“Because you have all DAY to sleep”) and their refusal to consider putting a day off in the middle (“Because it would disrupt the sleep schedule” (*5)).  By the end of that two weeks, I honestly hated my program and was wishing heartily that I’d gone with my second choice.

Then I reverted back to days and life improved tremendously.  I still had a chip on my shoulder for a while, though.

*1) No longer allowing interns to work 30 hour shifts.
*2) “Night Float” means that a handful of residents take care of the hospitalized patients all night so that no one has to work a 30 hour-shift.
*3) Yes, this means a 98-hour work week.  As long as they averaged the first week of night float with the week before it and the second week of night float with the week after it (and each of those weeks were electives), we still satisfied the ACGME requirement of <80 hours per week average.
*4) I don’t want to sound like I think I had the most difficult job in the world –  I just want to make a few points about how badly it went for me personally.
*5) By this logic, no one should ever take weekends off, because most people sleep in on those days thus disrupting the sleep schedule.  However, the program directors did not forego their own weekends off.

MiM Mail: Regret going into medicine?

Dear MIM,

Hi there,

I am a 2nd year medical student, and I have a question for all the MIM's out there: Do you regret going into medicine?

The statistic has been steady around 50% for several years. This seems like a large percentage to me! I know that as humans, we tend to minimize challenges that we have overcome. For example, I remember there were so many times in first year when I felt like my world was collapsing, and that I would just never get through it. But when I did, I oftentimes found myself unjustly minimizing the past, saying "It wasn't all that bad."

So, I'd like to hear your authentic thoughts and reflections:  Do you regret going into medicine, why/why not?

Sincerely,

Andrea C.

Guest post: Struggle

I struggle with it every day. Every day that I get into my car, turn it on and drive up my driveway. Every day that I drive away from my baby to go take care of other’s babies.

I am fine after I arrive to my office and get into my day….after I see the faces of my patients whom I adore and after... I deliver a new life into this world.

But, still I struggle. It is constant. The feelings of guilt that I tackle on a daily basis are at times overwhelming.

I never anticipated this. I adore my career, my life, my husband.

I find myself playing “what if” scenarios as I drive to work. I glance over at a minivan and see what I imagine is a “stay at home mom” with her children in tow. I think to myself, that could be me. My husband tells me, quite frequently, that he would support whatever decision I make. That, if I wanted to leave work as an OBGYN, that we could figure things out. So, when I see that mom in the minivan, I put myself in her shoes. I imagine a day where there is no call, no missed bedtimes, no missed story time , no missed bath times and no missed kisses and hugs.

Oh, what a glorious day that would be. Nothing but memories of day after day with my sweet Joseph.
Then, my cell phone rings. Labor and delivery comes across my phone. Catapulted back to reality I answer it. A favorite patient of mine is in labor, I delivered there first and now she is getting ready to deliver her second. I smile.

I realize that no, I am where I need to be. God has put me in this place for a reason. I love my job, my patients, my staff, my partners. I love delivering life. I love being an OB.

But still I struggle. I struggle when my mind slowly lets the thought…”he knows his dadda more” creep into my mind. I struggle when I hear him call his Nanny “momma.” I struggle when I am home with him for a day and feel clueless in regards to his daily routine.

It is a balance that I have to work every minute of my life to achieve.

My heart aches when I start thinking about Christmas and Halloween and being on call. He is little now and these holidays mean little to him. But, being a momma, I sometimes dread ..the future ..of perhaps missing a costume or a present because I am at the hospital.

So yes I struggle. I think to myself will it always be this way? Unfortunately, I know it will. It will only become more difficult. But, I will make it. I will be Joseph’s momma, John’s wife and Dr. Watkins the OBGYN.

The doctor problem

As other bloggers have mentioned in the past, it's always hard to tell new moms you meet that you're a physician. I worry about the reaction, that it will make people uncomfortable, that they won't want to be friends with me anymore.

But lately I've hit on a solution:

Other mom: "What do you do?"

Me: "I'm a physiatrist. Do you know what that is?"

Mom: [likely thinking: physiotherapist, podiatrist, etc] "Oh! Yes!"

And she has absolutely no idea I'm a doctor.

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."