How medicine changed me during the snow and ice

I am in medicine, where I must get out of bed and leave home on a “snow day” after arranging care for my own kids, to de-ice my car, commute through snow, sleet, and freezing rain, so that I can be available in person for my patients.  Before medicine, I would have probably lounged around, woken up late, and perhaps taken a walk just to enjoy the snow.

As a medical professional, I have responsibilities rain or shine. Just like a post officer, "neither snow, nor rain, nor heat, nor gloom of night stays these couriers [read: medical professionals] from the swift [read: caring and comprehensive] completion of their appointed rounds." The mother portion of me as a mother in medicine feels particularly bad leaving my family on a snow day. The medicine portion of me as a mother in medicine feels good, to be in a service profession, indeed.

(And maybe we'll get out early, in time for some twilight sledding.)

Medicine Made Me the Person I Am

As someone who went directly from college to medical school, I have spent most of my life in medicine. Medical training morphed all the areas of my life. I have no idea what I would be like if I wasn't a doctor, but I know medicine has made me a stronger, more appreciative person.

Medicine made me stronger. Its 3 a.m. and the baby's heart beat drops into the 60's. It's my patient's third baby. I check her cervix and she's a good 8 cm. The nurses and I give her oxygen and change her position but nothing helps. As the bradycardia approaches 5 minutes the tension in the room begins to rise. I am the doctor. Likely the only one at the hospital, at this hour. It's a tough decision, but this is my call. My pulse starts to rise, but I take a deep breath to calm myself down. I'm bone tired, but that really doesn't matter because I've done this so many times; I know I am strong enough to push through the fatigue, the stress and pressure. I have to be. This team needs be to be a calm, confident leader. As the bradycardia passes 10 minutes, I communicate the seriousness of the situation to the patient but not try not to scare her. We must proceed with an emergency C-section. A chaotic symphony of orders, instruments and bed pushing ensues. A healthy baby is born moments later.

Moments like these have given me some wrinkles and grey hair over the years, but  have also given me nerves of steel.

After surviving residency, two kids and private OB practice not too much scares me. I know that I can tackle most any challenge whether emergency surgery, bodily fluids or board meetings. I am afraid at times, but neither fatigue nor feces make me flinch.

Medicine taught me to appreciate the little things. Life contains so much sadness; too much cancer, drugs abuse and loss. Beauty and miracles abound, but around the next corner you find stupidly ridiculous tragedies. Life in medicine becomes a daily decision not to become jaded. I'm stronger and little rougher around the edges but I refuse to be jaded.

One small way I do this is to purposefully enjoy the happy moments of my day. When I deliver a baby, assuming mom and baby are happy and healthy, I take a moment to soak in the moment. I simply observe the mother's face light up as I place her baby in her arms for the first time. I watch the expressions of astonished love and the happy tears rolling down dad's face. I remind myself that THIS IS WHY I do it. All the late nights,emergency c-section and all the sadness ARE worth it. I get to make a difference in this family's life. I get to play a small but integral part in helping make their family.

This goes to my home as well. I appreciate my own children's health. The little moments of hugs, giggles and homemade cookies are stored away in my memory for safe keeping. Many bedtime stories are missed but the ones I'm there for are cherished.

Medicine made me a scientist. Medicine teaches you to reason. I look to randomized controlled studies to help make decisions for my patients. I follow the standard of care for my specialty. I know my strengths and limitations. I find these principles spilling over into other areas of my life as well. I have consumer reports and google ratings to help decide on appliances or any other purchase. I rarely make a decision without research to back it up. If only there was a published standard of care for parenting toddlers.

As a premed college student, I was nearly bursting with enthusiasm over my chosen profession. I could rarely wait for the point in an introduction when I would get to declare my plans to "be a doctor." But medicine is more than a profession, it's really become a large part of who I am. Medicine has made me a stronger, smarter, better person and I'm thankful for the privilege of being a physician.

Guest post: How has medicine changed me

Since the age of 22 I have been entrenched in medicine-went right from college to medical school and residency. The formative years of my 20s have been busy dissecting bodies, studying dense medical textbooks, giving case presentations, rounding, taking call, eating bad cafeteria food, searching Up To Date, and learning how to adapt to different classes/teams/attendings/colleagues every month. I also took A LOT of tests. Looking back now 4 years post-residency, I am simply not sure how I did it!

Medicine has changed me in ways that could be viewed as “good” and “bad.” Medicine has given me more empathy; it has showed me the importance of compassion and hope; it has made me a better listener; it has given me confidence and the strength to be vocal; it has given me a career to be proud of. Medicine has also given me my husband! (We met, married, and couples matched in medical school.) It has shown me the value of wonderful friends and family, which many people do not have. It is a privilege to help people in their times of need and share intimate details of their lives. I trained in emergency medicine and have a valuable breadth of medical knowledge from excellent training. The knowledge helps me daily both on the job and off.

On the flip side, medicine has changed me in some negative ways. I am more judgmental-there is a need for quick (instantaneous) decisions when talking to a patient in the ER. I am cynical-while practicing medicine is considered a privilege, it is also a burden, and we usually see people at their worst. I take frustration out on my family because I know they will always be there (I hope). Medicine has been consuming and I have missed out on a lot of experiences….like family birthdays, funerals, weddings, parties, leisure, travel, holidays, and such. These missed experiences have caused me to be resentful and bitter at times.

I am not sure about you, but I feel like one of the most important things medicine has done is make me a better mom! I have 2 young kids and am grateful everyday for my medical knowledge. I know how to observe, study and treat my kids. I also know where to look for the answers I need for them. This medical knowledge helped immeasurably with my son’s near-death from kidney failure when he was 2 weeks old and all the subsequent care he has needed. Some mommy physicians complain that they “just know too much”....but I would never trade in that knowledge for ignorance.

No field or career can only have positive impacts on a person, and overall, I am proud and grateful to be a physician. Being a ‘mommy’ physician is an even bigger badge of honor in my mind. There have been a lot of challenges/walls/ceilings to break through….and a huge inner struggle to conquer the mommy guilt and “just keep swimming….” (Thanks, Dory.) Time out of training has brought more clarity with this issue and the compromises needed to make work and life, work. I wish all of you luck with making medicine work, as well.

AW

How Has Medicine Changed Me?

KC suggested this topic, and I have had to think and think about it. How HAS medicine changed me? 

As an uber-idealistic practically socialist gunner med student, I had a vision of myself in the future as a doctor completely devoted to the poor and disenfranchised of the world. I was going to work for Doctors Without Borders or something like that. I was going to deliver skilled medical care with aplomb, to the suffering and forgotten. My vision was pretty vague, but definitely included basic field hospitals, palm trees and grateful patients.

I held onto this vision well into residency, shrugging off questions about how I would finance my dream, seeing as I paid for med school with loans, and would end up about $120,000 in the hole, before interest.I shrugged off those questions, figuring where there was a will, there was a way. I did every international elective I could. I ended up in crazy places (and I have many crazy stories) from Guatemala, Nicaragua, Peru, Ecuador, Sri Lanka...

As the end of residency approached, along with those ever-increasing loan statements, I started looking for a job in my dream field, which was, in my head, basically "International Health". Of course most medical jobs in this area don't pay much; and though many allow loan payback deferment, the interest still mounts... I considered going for an infectious diseases fellowship, but I had signed on for Primary Care loans, and would take a penalty if I broke my commitment to primary care.

I tried some things; I did work in HIV research and thought about pushing that work into something more... international. I struggled. I got kind of depressed, trying to reconcile my vision with the reality of life, and finances.

But then, something else was happening. I was in my mid-thirties, and I was starting to have other visions... Visions of family. Of settling down, raising kids, of community, of stability.

There was a transition, a positive one, and I ended up here, in a very nice suburban home, with my wonderful rock-stable husband and two healthy kids, working in a small practice at a respected academic institution, providing primary care to decidedly American patients. I'm really very happy.

A lovely patient of mine, someone who has faced many medical adversities, told me once that "it's the kindness of caregivers that gives a person courage." I do try to remember that, even when faced with an angry patient... Be kind. It matters, whether it's with first-world or third-world patients.

So, I try to be kind. And it's all good. What's so funny is that I feel like I'm a nicer person now than I was when I was supposedly devoted to saving the world...I seriously think that's how medicine has changed me. It's made me a nicer person, though not in the way I anticipated it would.

Guest post: The Things We Carry

Tim O’Brien’s “The Things They Carried” begins with a list of items carried by a platoon of soldiers during the Vietnam War:

First Lieutenant Jimmy Cross carried letters from a girl named Martha, a junior at Mount Sebastian College in New Jersey….  Henry Dobbins, who was a big man, carried extra rations; he was especially fond of canned peaches in heavy syrup over pound cake.  Dave Jensen, who practiced field hygiene, carried a toothbrush, dental floss, and several hotel-sized bars of soap he’d stolen on R&R in Sydney, Australia. Ted Lavender, who was scared, carried tranquilizers until he was shot in the head outside the village of Than Khe in mid-April.  

In a writing class, you might learn about O’Brien’s use of repetition, about how he uses the list to reveal something about each man’s character.  But I’ve been wondering lately, what do the things that we carry through life reveal about each of us?

My husband and I have too many possessions, this I know; more than we need or can even use.  I am also aware that this is a developed-world, middle-to-upper-class problem, and that such complaints are at best insensitive and petty.  This is not a war zone and our possessions are not strapped to our backs; instead these are the clothing and household items that pad our comfortable lives.  Acknowledging these facts, I still believe that things deserve some examination.

There are the hand-painted margarita glasses that we purchased in Mexico and that have followed us, cloaked in too much bubble wrap, from apartment to apartment.  Each time they settle onto a new shelf where they sit undisturbed until the next move.  There are the clothes that get passed over each time we dress for work or a special occasion, but that remain in our closet because they might be perfect for an event that just hasn’t happened yet.  There is the chair reminiscent of the one that sat in my parents’ vacation home when I was a child, the one that brings back memories of hours spent reading novel after novel.  Except neither my husband nor I has sat in the current chair since at least two apartments ago.  Instead it holds stacks of books, clothing, and anything else temporarily without a home or that we are too tired at the end of the day to put away. 

Why do we keep all of these things?  Is it emotional attachment, fear of loss, just plain inertia (of the staying-at-rest variety)?  And how might our lives be affected if we were able to detach from our possessions, declutter, simplify?

I recently came across an article written by a woman who, along with her husband, had decided that it was time to do exactly that.  They sold or donated many of their possessions, making it a point to buy only what they truly need and will use.  In the process, they paid off a large chunk of debt, but the benefit that interested me most is somewhat surprising, something that I crave more than anything: “We're finding more time for the things we gave a lot of lip service to but didn't always make time for: health, fitness, reading and each other.”

Over time I’ve started to realize that, at least in my own life, carrying around a lot of physical stuff can feel just as burdensome as carrying a lot of emotional or psychological baggage.  All of that stuff demands management – cleaning, storing, organizing, or at least sifting through as you search for something else – and thus time, energy, attention.  If I had less stuff, if I limited my possessions to those that were really important to me, would I use them more?  And would I discover more time to devote to the things that I really want to do in life?

It certainly seems possible.  My husband and I have decided to give it a try.  We are not emptying out our home by any means, but we are parting with a lot of the extras, the things that we had previously kept around on the basis of “what if” or “someday.”  Already in our lives it feels a bit easier to move and to breathe.
  
Except there is one complication.  A large part of the impetus for our decluttering is the fact that we are expecting our first baby in February and we desperately want to maximize the time that we are able to spend together as a family, as well as to grow even more fiscally responsible in order to provide for the baby’s future.   But with a baby comes stuff.  A lot of stuff.  And how easily the line between the things we need and the things we need becomes blurred.
  
When we made the obligatory trip to Babies “R” Us to set up a registry, my husband paused before scanning our first item and warned, “Let’s just stick to the basics.  Let’s not go overboard like we did for our wedding.”  I paused and recalled the hours we had spent perusing china, crystal, and every isn’t-that-neat-looking kitchen gadget that caught our eye, ultimately adding several of each to our wish list.  With this approach in mind, we braved the first overstuffed aisle.
  
This, I suppose, will be our first test.  It is one thing to purge one’s home of a few belongings; it is another to retain the patience and thoughtfulness to avoid reflexively refilling it just because there is space available.  And while we have no desire to raise a child or children with rooms overstuffed with rarely-used and under-appreciated toys, neither do we wish to impose on them a stringently spartan lifestyle.   The answer for us, it seems, lies somewhere in the balance.  And for the first time, we feel ready to set out in search of it.


Becky MacDonell-Yilmaz is a pediatrics resident at Brown University/Hasbro Children’s Hospital in Providence, RI.  Her work has been published in the Annals of Internal Medicine, The Writer's Circle, and The New Physician. She blogs about her experiences in training at The Growth Curve: ruminations of a pediatrician in training.

Guest post: Fidelity

I achingly relate to other doctor mamas each time I read this blog. It is not an easy path that we have chosen. There are a myriad of challenges and rewards on this journey. Some challenges and rewards will be generally the same between us, such as becoming mothers, graduating medical school, and starting practice. Yet even those general similarities will be experienced differently by each mother, each doctor, each wife, each partner, each daughter, each sister, each aunt, and each of us women, under the many hats that we wear.

Lately there has been something on my mind. Not the usual things, like medicine and professional development and children's needs and schedules, though those are all still there. My career as a military physician has taken me away from home a lot this year. The time away from home has presented many challenges (which I would love to discuss with other military doctor mamas), but there was one that I did not anticipate: what do you do when you are attracted to someone else?

We have all had chemistry with someone as soon as we meet them. An instant attraction. Some people are just destined to get along. This chemistry might be with someone of the same or opposite sex, and is probably a prerequisite for those great friendships that sustain us all. I have many friends of both sexes with whom I enjoy a lovely chemistry. Have I found other men attractive since I got married? Of course I have. But I have always considered the question of fidelity (and consequently the topic of unfaithfulness), to be an issue of uncontained sexual desire, and therefore, not applicable to me, since I can "control" myself.

However, now, as a human being and wife and mother, I find myself struggling with thoughts and questions that never occurred to me before. My marriage is actually quite wonderful. I love my husband. Yet, we are separated by so much time and distance lately, that sometimes my life at home takes on that same wispy feel as a dream lost on waking. I miss it and I want it so badly, but it is frustratingly inaccessible. I'm certain that many women in medical training or practice can relate to this feeling. I remember longing for my husband and family even when I was home, because I felt like I was never there. However, I also have always felt that my connection to my home life is more real and tangible than any other connections I have.

Realistically, many of us in medicine will see our colleagues, on an hour-for-hour basis, more than our own families. We can and should expect to form strong bonds with those people at work whom we genuinely connect with. But what happens when one day, you find that the bond is something deeper and stronger than you anticipated – and you don't know what to do?

I know that I am committed to my marriage and I do not ever, ever want it to end. I know that I want to share my life with the wonderful man that I married. I do not foresee that changing. How then, can I struggle to realistically and honestly address the question of fidelity?

Given the sensitive nature of this topic, I hesitate to divulge too much, but I would like to explain this: the person I am attracted to is also married. He is not a patient. He is not in the military. He has a family. He loves his wife and kids. Our attraction is mutual. We genuinely like each other and respect each other, but we are not in love. We have discussed it. We have vowed to not "act" on it. It seems so simple on paper, but I never could have imagined how hard it would be. Even as a write and re-write this post in hopes of "getting it right," I see that nothing I write can convey the frustration, loneliness, doubt, guilt, and confusion that I feel.

I have no doubt that some people will judge me for confessing to these feelings. I recognize that this post might make some people uncomfortable. It makes me very uncomfortable. I write in order to open the door to genuine discussion on a very taboo and (I believe) common topic. I don't know if anyone will post on this other than in a safe, generic way, since many of you have an online presence which may preclude you from writing honestly as yourself. I understand that. I want to be anonymous, too. Yet my own sense of shame bothers me. What exactly do I have to be ashamed of?

I hope that some of you will reply. I sincerely want to ask – what do you do when you are attracted to someone else? How do you cope? Especially when you are away from your home and family? How do you answer those haunting questions that you never, ever thought would be in your head, such as: Is it wrong to be attracted to someone else? If so, why? Is it only wrong if you "act on it" by crossing some sort of physical or sexual line? If so, why? Is it therefore less wrong to "only" have an emotional connection with someone? Why?

Perhaps KC would be willing to post comments for those who are not comfortable doing so.

Guest post: An unconventional couple's match

Match Day 2012 was supposed to be the best day of our lives. Or one of them, at least. But it was so, so not. Monday morning my husband and I left our respective rotations around 11:45am and hopped into our SUV in the hospital parking lot in anticipation of the noon email saying we had matched. We wanted to celebrate that together. My email came: "Congratulations! You have matched to a one year preliminary position." I was devastated. But it got worse. My husband's email came: "We're sorry, you have not matched to any positions."

Can that happen? Did that just happen? I didn't think that was possible. Our numbers were right. We had plenty of interviews. We were matching Emergency Medicine (him) and Surgery (me). A difficult match, but not an impossible one. Right?

He was the better candidate, but we thought Surgery was the harder match. So at match choice #18, after all of our same city match choices, we listed a match-no match option. The thought was that in this certain city we chose, surely he could find something to do for a year. A big city, close to my family, lots of options. We assumed he would at the very least be able to find a preliminary surgery spot at one of the four hospitals in the area. Prelim surgery spots aren't hard to find, right?

We drove straight from the hospital parking lot to a McDonalds and hooked up the laptop and filled out his SOAP application. He applied to all the Surgery Prelim spots in my city (the NRMP will tell a couple, in a match-no match situation, the city of your match). Tuesday, Wednesday, and Thursday came; no interviews, no offers. Match Day came and went, we "celebrated" at home with our baby boy and my parents, and occasional tears.

Then we looked for research positions for the year for him. And... Nothing. We tried, we weren't even picky. But he was over or under qualified for anything we found.

Then one day, out of the blue, he got an email inviting him to interview across the country for a position in Emergency Medicine. He got the position. And yet we struggled with it. Was this a temptation that he should pass on? Was this a blessing? Was it great for his career at the expense of our family? Would we be able to survive without each other? Could I be a surgery intern, with our BABY, without him?

Ultimately, he took the position. We're tough. Yes, he and I are tough. But what I also mean is that we women physicians are tough. We're a different breed, I think. No one can tell us no. No one can put anything in our path too great to achieve our goals. No one can tell us we can't love our job and love our child. No one can tell us we can't do it without certain features of our home life lined up. We can do it.

It's hard every day. That I won't deny. It's hard being away from my best friend and confidante; the person I want to vent to and hug and go on dates with and share in our son's new milestones and that he finally says "Mama." It's hard being a "single" parent. It's hard knowing my son is not with his mom or his dad 24-7. It's hard when your child reaches for their grandmother for comfort when they fall and you are both standing there. And oh yeah- it's hard being a surgical intern, period.

But I'm blessed. We're blessed. Training looks different for everyone (we went to a school where our basic sciences were in the Caribbean; more on that another day). Life looks different for everyone. Just because it's different doesn't make it wrong or weird or not doable. We've learned a lot along the way, and talk about it a lot (when our shifts don't overlap, that is). I'll sum it up for you, in case it would help anyone else along the way . . .

1. Don't be too proud to apply to different locations if you're couple's matching. You'd rather be a doctor in a different geographical location than not-a-doctor in the same location.

2. Surgical preliminary spots aren't as easy to get into as you might think. I think that's the going rate for almost any residency these days.

3. There's lots of spots outside the match that you don't hear about unless you look for them in the right places. Look on your specialty's program director website (a good place to start) to see if there are open positions outside the match.

4. Don't panic if things don't go how you saw them. Where there's a will, there's a way. Don't let anyone tell you something isn't possible.

5. Family comes first, but deciding to be apart doesn't mean they don't still come first. Don't feel bad for choosing it. It doesn't mean you ranked them of less importance. It just means your story looks different.

6. Speaking of stories: Life looks different for everyone. You can use yucky situations for learning and growing, or for being miserable. It's a choice.

7. When you rank programs, go where you love. The rest will fall into place.

Of note- at the time of publication of this blog, my husband has an interview for an open PGY1 EM position that came available in late July right down the street at a phenomenal academic center.

Either way, we know what we've learned through all this.

Either way, we're good.


I am a PGY1 general surgery resident with a husband who is a PGY1 emergency medicine resident and a 2 year old son. I live in the South (Texas). I wrote this originally here.

Next MiM topic week: How has medicine changed you?

Our next MiM topic week will take place the week of December 9. The topic: How has medicine changed you? Not medicine as in drugs, but medicine as in Our Chosen Profession. During the week, we'll feature posts written by our writers and hopefully you, on the process of becoming a doctor and how we feel that has changed us (if at all).  We're excited about this one and hope you'll join in on the fun and reflection by submitting a guest post. If you'd like your piece to be included, please send it as a Word document to mothersinmedicine(at)gmail.com by Sunday, December 8.

As always, thank you for reading and for being part of this community.

Are We Allowed a Break?

It's genuinely not my intention to call anyone out or shame them, but the truth is, there was a comment on my last post that I can't stop thinking about:

"I'm reminded somehow of a lady I knew that took vacation from work but continued to drop her child off at daycare at the usual time every morning the entire week. He knew she was on vacation - he was only a toddler but he knew his mother was going to be hanging out without him. I think the attitude or message probably made him feel less valued and I have wondered how that turned out."

My thoughts are:

1) That is one smart toddler if he really understood that.

2) Are we really not allowed to take a week off all to ourselves once we have kids?

3) Is taking short periods of time to ourselves something we should worry will scar our kids for life?

4) If we do take that week to ourselves, should we expect that all other mothers are judging us for it?

Food for thought.

Do you have 5 year plan?

When asked this recently, I fumbled.  Actually, I tossed back the answer, asking the asker to mentor me through getting such a plan.  It wasn’t even someone who knew me well and it had been asked in a fairly casual way.  Regardless, I was not able to answer the question.  But if I were to answer it, the answer would be, “No I do not.”

I feel like my personal plan is on track, I have some goals which essentially these include some family fun and fitness.  But in the professional arena, I don’t have a 5 year plan like others do.  Do others have a 5 year plan? 

I have quite an accurate 5 day plan.  My calendar is reasonably organized.  I'm a list writer, whether on paper or on a smartphone (actually, both) and an avid list crosser-offer.  Sometimes I'm tempted to add things just so I can cross them off again once completed.

Flash back 5 years ago, I don’t think I actually had a career plan to get to where I am now, though I am where I want to be.  I was "finished" with the relatively more well-defined years of college, med school, residency, public health school, educator-leadership program, (can you say "perpetual trainee" or more generously "life long learner"?).  Career-wise, I think that mostly things have come to me through plenty of hard work, but admittedly with some luck, good timing, and strong collaborations.  Now I’m trying to think about what will come next.  Not that I’m at a mid-life crisis per se, but just that if I try to map out what’s coming up, what should happen, what I’d like to do or explore professionally, I’m just not sure.  I feel like I can (and do) help others along with theirs, but not sure of my own at this point.  In academia there are peaks, valleys, plateaus and mountains to climb.  I am hoping I can find the right trail.  The journey is still interesting, made more interesting by taking part in mentoring others, even as I continue to pave my own way.  I have a vision of what I might want to do but I'm not sure how to get there or if it's feasible.  I continue trekking onward. 

Do you tend to let things happen and see what unfolds along the way, or do you have a plan?

Guest post: Are we doing the right thing?

The opiate post segues into something I’ve been grappling with periodically - the ethics of medical intervention when the outcome for the patient might be terrible, or even futile.  Cases such as patients with massive heart attacks, who then end up with severe brain injury.  Or the trauma victim who lives, but in a vegetative state.  The one pound neonate born at the edges of viability, who survives as a severely disabled child.  I do not know the answers, and I don’t know how we make such a decision about outcome when most of these scenarios present as an emergency with no time for considered thought.  It’s troubling me more of late though.  I have a colleague who ran into an affected family member of a patient for whom she’d cared, during such an event some years earlier.  The family member recognized her, and asked if she was proud of herself for what she’d done. The patient involved was only saved through advances in modern medicine - not so long ago, such a patient would have died.  At the time, this family wanted nothing more than for their relative to survive.  Now, they carry the burden of caring for a patient with no meaningful quality of life.  Their marriage has broken down and future dreams shattered.  Although I ached for my colleague, having such anger directed at her, I could understand the place from whence it came.  The problem is, there will always be that success story, the patient brought back successfully from a devastating injury, the neonate born at 24 weeks who is now a happy, functioning, bright child.  There is no pause between the presentation and the decision to treat in which to make a choice, no crystal ball to guide us.  The principle of non-maleficence is very hard to apply in those precious moments of a resuscitation.  We have statistics, as to who might fare poorly and who might do well, but how do statistics help if you are the family member burdened with making the decision to discontinue treatment, or in the case of a very premature neonate, to never start treatment?  How do we as doctors guide them?  As we sit by the patient who looks to have a dire outcome, how do we advocate for that person and family, when we can never be sure which statistic they will be?  We can quote the statistics, but how does a parent or a relative choose to not treat, how does one choose to let another person die, when the numbers are not black and white?  What would you do if it was your family member, your neonate?  Are we doing the right thing, saving such patients, just because we can?

Jess

2 (Parody of Taylor Swift's 22)

It feels like a perfect night to dress up in mom's clothing
And spill juice on it, uh uh, uh uh.
It feels like a perfect night for breakfast at 5AM
Wake up and make me Cheerios!, uh uh, uh uh.

Yeah,
We're happy, crying, confused, and noisy at the same time
It's exhausting and magical.
Oh, yeah
Tonight's the night we clog the toilet with baby wipes
It's time

Uh oh!
I don't know about you
But I'm feeling 2
Everything will be alright
If you catch me and wipe my poo
You've barely slept all year
But I'll bet you want to
Everything will be alright
If we just keep coloring on the wall like we're
2 ooh-ooh
2 ooh-ooh

It seems like one of those nights,
I want my socks off,
Now I want them on again uh uh uh uh
(Now I want them off again)
It seems like one of those nights,
We ditch the bottle and end up screaming
Instead of sleeping.

Yeah,
We're happy, stinky, hyper, and sleepy in the best way
I'm going to rip my hair out.
Oh, yeah
Tonight's the night when we climb into your bed and kick you in the head all night
It's time

Uh oh! (hey!)
I don't know about you
But I'm feeling 2
Everything will be alright
If you find my little pink shoe
(Where is it???)
You don't know about me
But I'm the one who spilled that glue
Everything will be alright (alright)
If we just keep bouncing on the bed like we're
2 ooh-ooh (oh, oh, oh)
2 ooh-ooh

It feels like one of those nights,
We run around the house naked
It feels like one of those nights,
Then pee on the carpet
It feels like one of those nights,
You look like scissors
I gotta have you,
I gotta use you.

Ooh-ooh
Ooh-ooh, ye-e-e-e-eah, hey
I don't know about you (I don't know about you)
But I'm feeling 2
Everything will be alright
If you bring me back that toy I threw
(again)
I haven't napped all day (haven't napped all day)
But I'll bet you want me to
Everything will be alright
If we just keep watching Elmo like we're
2, ooh-ooh
2, ooh-ooh
2, ooh-ooh, yeah, yeah
2, ooh-ooh, no, no, no, NO!


(My daughter and I composed this yesterday and I had to share)

Note: Cross posted to my blog

Does it get easier?

I keep putting off taking on extra responsibilities at work, saying, "I'll do it when my life gets easier." I figure having a kid in her terrible 2's is some sort of peak of difficulty. It's got to get easier than that, right?

However, this weekend it was my grade schooler who managed to:

1) Burn her finger and injure like three other body parts

2) Wake me up WAY before I was ready on daylight savings Sunday (daylight savings is meaningless when you have little kids)

3) Not allow me to have even ten minutes to rest after a several hour excursion to the mall

Plus, whenever I make comments along the lines of that it will get easier when they're older, people are fond of telling me, "Oh no, it just gets hard in a different way."

So which is it? Does it get easier ever?

Book Review: The Devil Wears Scrubs by Freida McFadden

I love to read books written by other doctors. I think doctoring can be kind of isolating sometimes, but reading about the experiences of our colleagues can be so... validating.

This book, which was written by Mothers in Medicine blogger Fizzy McFizz under the second pen name Freida McFadden, is a humorous account of an intern's first month in an internal medicine residency. It's light, it's a quick read, and it really is funny.

The story follows newly minted Dr. Jane McGill as she tries to figure out how to survive and thrive on the floors at a county-style hospital, with little to no instruction or guidance on what, exactly, to do (sound familiar?), and all the while being picked on by a seemingly sadistic senior resident. The senior, however, has a human side as well, and a few good lessons to teach.

While this fun little book is fiction, I get the sense that it's House Of God-style fiction, meaning, alot of it is likely sort of true. I don't know this, I'm just guessing, and it made the book so much more interesting to me, as this intern's experience is largely miserable, and it reminded me of my own miserable intern experience (and I blogged about those memories in a post titled "How a fun little book dredged up buried memories of my intern year" ).

I was again reminded of this book at a recent medical conference, a Virginia Mason seminar (all about running a more humane, efficient practice) and one of the speakers was describing how setting basic work protocols and standards is so key to a positively functional work environment. She asked us how we can expect people to do tasks if they have no formal instruction in how to do them, saying: "Asking people to do things that they have not been trained to do is an exercise in frustration: theirs, and yours. Most people want to do a good job, and if you repeatedly put them in a position where they are likely to fail, they become demoralized, angry, and difficult."

I sat there thinking: Well, that's medical residency in a nutshell.

And Dr. McGill's experience in this book exemplify this: An experience so miserable, it's funny.

The book is available on Amazon.com, here is a link.

The Opiate Epidemic And Us

Our 25-year-old nephew passed away last week.  He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.

His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.

When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.

We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.

There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or  left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).

Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew.  In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time  dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.

Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.

Because we are in an epidemic.

All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.

Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.

Opiates are extremely physically addictive. And lives are crushed by addiction.

Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.

Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.

Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.

In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.

I'm curious to hear what are the thoughts and experiences of other physicians on this issue...