In between promise and fatigue: here's to the end of residency

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams.”

“Before a dream is realized, the Soul of the World tests everything that was learned along the way.”

“Every search begins with beginner’s luck. And every search ends with the victor’s being severely tested.”

I can see the end of residency. My schedule is set. I know that June 23 is my last official day of my pediatric residency. I am standing on the edge: the edge of my time as a “trainee” and the beginning of my time as an Attending Pediatric Physician. As one of my closest mentors says, “Medicine is about delayed gratification,” and she is so right because I can feel the end of training, it’s palpable. It stands looming in the distance. I see the promise - the chance to continue to create the career that I have envisioned for so long. One committed to the underserved, adolescents, and new families. One committed to medical student education and helping to forge a path in medicine where the marginalized student feels less alone. One committed to enhancing trainees understanding of health literacy, compassionate care, holistic care. One committed to clinical excellence and rigor.

I can feel the promise of creating a career where I can share more of the child-rearing responsibility with my husband. We have had the chance this year to experience up to 2 consecutive months of me having a “regular” or non-Ward schedule and it has been amazing (family dinners, weekend outings, dates, sleeping in). My Attending friends tell me that this is how life can be post-residency and that I have to work hard to get a schedule that allows us to feel more like a regular family. Interviews have been going very well, but none has felt quite like “the one.” I can feel “the one” coming though and am giving myself until April to keep searching and networking.

But I can also feel my fatigue. It also stands looming and sometimes sneaks in for a jab or two. The tight pull of my neck as I continue to type into our electronic medical record. The beginnings of a tension headache as I work on licensing applications during Zo’s nap time. I can feel my strain and my friends’ strain as we begin conversations about our final residency rotations with “I am soo over this!” Invariably all of our texts, phone calls, and in person conversations include our “being over” being on call, covering in the wards, and Interns doing crazy things. Then we laugh and talk about how a friend who is a new Attending has told us something wonderful about his or her life.

As my Residency Director said, “You’re not supposed to love residency” because it’s not a permanent job, it’s just a big hulking stepping stone.

As I always do when I am straddling a new transition, I have begun to re-read selections of "The Alchemist." This book has been with me since the first time I read it in 2004 as a fourth year undergraduate awaiting medical school acceptances. This road has had its share of suffering. Times where I felt failure was imminent. I fought on. In spite of a few very low points, I have experienced joy beyond what I ever could have imagined. Providing excellent patient care, figuring out diagnoses, being hugged and hugging amazing families and assisting them during their lives’ lowest points. I have experienced the joy of getting married to an amazing man that I now call my own and together we welcomed to the world an outgoing, rambunctious little boy that amazes us every day. There isn't a day that we don't pause, smile or laugh out loud and shake our heads at his silliness and love for life.

As I stand on the edge of my most recent life’s transition, I foresee some suffering, some testing, and a whole lot of joy. While I welcome luck, I also know that I have been fortified by life’s challenges and know that you can experience fatigue and promise simultaneously and it still bring so much joy.

Here’s to the end of residency!!!

Quotes above are from Paulo Coehlo's "The Alchemist," 1993.

I Just Want to Dance!

I recently had an idea that I wanted to sign my Doll up for some dance classes.  She is old enough for them, and with a quick google search I found >10 studios in the area! (And many more with a little driving.)  I called all of them.  Each one.  Not one has any classes available on the weekends for children that young.  All of the classes are offered on weekdays, right in mid-day (11AM-2PM).  There is no way I could make that work.  ::Working Mom guilt explosion::

Thought:  My child will just have to be deprived of life's pleasures such as dancing, her life is ruined!!
Feeling:  Guilt and sadness
Restructure to:  My child has many pleasures in life, but dance class will not be one of them at this point.

CBTing myself didn't quite work...I am still writing this blog, feeling deflated.  Oh well, life goes on.

Divorce

I recently recommended my mother read a book called big little lies by Liane Moriarty because I thought that was one of the best books I have read all year, and dealt with a lot of important issues. One of the issues was that the daughter of a woman who had been abandoned by her husband when the daughter was a baby comes back into their lives, and now the daughter suddenly likes the father better.

My parents got divorced when I was a toddler, and my relationship with my father always frustrated my mother. She always told me when that I was older, I would "get it" and suddenly despise my father, yet now I'm older and I apparently still don't "get it." 

This book has gotten her all riled up.  Her latest email to me says that it's better if the father dies than if the parents get divorced, because then there's no bitterness. It's better not to have a father at all than divorced parents.

Right now, I'm older than my mother was when she got divorced. I've been married for over a decade. I've see many of my friends get divorced. I've struggled with my own marital problems. So I really do think that I do "get it." These are my feelings on divorce when you have children, based on my own childhood and everything I have seen:

1) sometimes divorce really is better. If you stay with a person that you hate just for the sake of the children, the children will notice this and they won't think it's better.

2) if you do get divorced, maintain an amicable relationship with your ex. Don't make the children pick sides.

And this is the hardest one of all…

3) if it all possible, don't leave your spouse for another person. If you're having an affair, presumably you're not happy in your marriage. Don't wait for the affair to be the impetus to leave, because it sucks to be left for another person. It's a lot easier not to feel bitter if you don't feel like you were discarded for a younger or better version of yourself. 

My hero is fellow MiM blogger Gizabeth.  She's written about her divorce here, and she's had an exemplary relationship with her ex-husband.  A divorced person should use her as a role model.

Obviously, it's better to have a marriage that is all sunshine and lollipops.  But sometimes (often) that can't be the case.  Sometimes divorce really is what's best for both the children and the whole family. 

MiM Mail: Missing life before kids

I am a family doctor in southern Ontario but previously worked in remote northern Canada for 3 years. Up north, I worked in full-scope practice, including OB, ER, home visits, hospitalist, fly-in communities, medivacs and nursing station phone support. When I became pregnant, I could not have my job modified to have a healthy pregnancy. I was concerned about extremely bumpy boat rides to get to and from clinics, helicopter transfers, working in very cold environments, nearly being flooded, stray dog attacks, dust, bugs, and not having safe shower or tap water in certain fly-in communities. I had asked to not work nights but was told this was not an option due to lack of staffing.

Sadly, I left the community I had intended to stay in all my life. I moved near my extended family in southern Ontario. We bought a farm, and my husband stays at home with the baby and farms. We have the wonderful support of 4 grandparents. We now have a very happy toddler and another baby on the way in the summer.

Down here, I run my own clinic four days/week. I am doing walk-in clinics on the weekend. Although I enjoy it and have a very reasonable schedule, I am growing antsy to do more. I find that down here, even the simplest issues are referred to specialists. Compared to the north, people are not very sick when they see me. I enjoy being home with the baby, but only for a few days a week. I am happier working as a physician the rest of the time. I miss the action and adventure of northern medicine. I keep looking at job openings in the north and trying to figure out how this could work. What I always seem to conclude is what is best for me isn't best for my family.

The things that are keeping me from going back up north? Well, for one, I am 16 weeks pregnant. I plan to have two kids, so after this one, pregnancy won't be a limiting factor, but breastfeeding will. My husband doesn' t want to move north, as there are no farming options for him there. He has farm animals that require daily care, so even doing locums and bringing him with the kids isn't possible. I could go alone, but that would be very stressful on a baby and toddler.

Maybe I should just stay put and accept the current situation. I just feel like my skills are being lost for every year I don't use them. I would love to hear some advice or suggestions from others.

Early Morning Musings of a Snowbound and Homebound Primary Care Physician

Genmedmom here.

Here in Boston, we've been experiencing winter weather conditions never before seen in modern times. I'm not exaggerating. A series of intense winter storms and an unusually prolonged stretch of extremely cold temperatures have combined to create a Pompeii of snow and ice, rather than ashes. The region is near-paralyzed. Frankly, I'm getting bored of writing about it.

But the fact is, weather disasters unite us, forcing us all to realize that we are weak, small, and, well, only human, compared to Mother Nature.

As a primary care doctor, this weather has also forced me to realize some humbling truths.

One: as a 100% outpatient attending, I am not an "essential worker".

Two: I can do alot of my job over the phone, safely, and with greater patient satisfaction.

For the first two of these last four major winter storms, I was home alone with my two children under five years old. It was not physically possible for me to shovel out in time for work, and I had to cancel some clinic days. For the third, my husband was home, but the weather was so bad that between us, it was still not physically possible to shovel out in time for clinic. I cancelled again. Then, as mass transit was also shut down, and most staff had no reasonable way to travel in, our office ended up closing for a day as well. The hospital announced that basically, only employees essential to inpatient services needed to report to work. The Governor of our state announced that only "essential employees" in general needed to be out on the roads.

All of these weather events equaled alot of patients whose appointments had to be bumped. For all of these days, I reached out to most of my folks directly, and offered to handle their medical issues over the phone to the best of my ability. I felt bad, and so I made myself as available as was reasonable using our secure messaging system, email (many of my patients work at the same hospital) and my cell phone.

Everyone I contacted was thrilled that they didn't have to figure out how to get to my office; most were going to cancel anyways. What I found was that most acute issues were handled safely without a visit; physicals, pap smears were rescheduled.

Examples of issues that were managed successfully included UTIs, candida vaginitis, mild asthma, URIs and sinus infections. I've been following some more complex cases, and we were able to determine stability and plan next steps; these are folks undergoing workups for more serious symptoms.

My internal medicine colleagues described similar scenarios, diagnosing and treating everything from shingles to migraine to flu, over the phone. One of these colleagues commented that "it didn't feel good" when she realized that she was "non-essential".

It wasn't always this way. As a resident, and then a fellow with inpatient responsibilities, calling out for bad weather just wasn't done. Later, as an attending with inpatients to round on, ditto. But our practice has since turned to our hospitalist service to care for our inpatients. This was done with the encouragement of the hospital; almost all practices have done the same. Inpatient medicine is now its own animal.

Still, the idea that I'm an M.D. and also "not essential" feels odd. I feel guilty for staying at home with my kids.

A reader then introduced me to a wonderful doctor-mother blog written by surgeons called: Hot Heels, Cool Kicks, and a Scalpel: Trauma Mamas Balance Fashion, Fitness, and Family. One of their trauma surgeons has also been writing about the snow, and I was so glad to read her posts, as they alleviated my guilt, substantially. Two particularly relevant posts:

Rants of a Snow Beleaguered Trauma Surgeon

A Plea For Snow Days and Common Sense

I am learning to make peace with being non-essential. I am also considering offering telemedicine visits to my patients on a regular basis; though reimbursed at a much lower rate, the patient satisfaction would pay dividends. This may also free up visits for more acute illnesses and/ or physical exams.

My thoughts and prayers go out to the essential healthcare providers and hospital support workers who have to get in to work or stay in the hospital through weather like this, and I would be interested to read more about the experiences from "the other side"....

Guest post: Trust me, I am a mother

I never went into medicine to become a better mother. I never became a mother to become a better doctor. But, the two journeys merged in 2013 when I knew something was seriously wrong with my almost six year-old son. My son is like any other boy his age, other than occasional mild irritability that is slightly over the average and incredible creativity. He usually springs out of bed ready to tackle the day, excited about all the projects he is going to do. For about ten days, I noticed that not only was he not interested in any activities, but he was incredibly irritable at even the most minor setbacks. He has always had a high pain threshold, yet we started noticing an increase in his frequency of "got hurt" episodes. There were no focal deficits on physical exam. I sent an email to his teacher asking if she noticed any limitations at school. She said no. I didn't know if I should go to a pediatrician or a psychologist. Then, he developed a minor unprovoked pain in the shin. I jumped on it as now I had a reason to take him to the pediatrician. I reasoned with the pediatrician that given the irritability and mild low grade temps at night time for two days, his shin pain may have been an indicator of something systemic. After an exam, she ordered some blood work and X-rays which came back normal, other than a slightly elevated WBC and platelet count. She told me to trend the fevers and to come back if there was no improvement.

The same night, I noticed a slight temperature and called the on-call doctor. I explained that I was concerned about the low grade temperatures without an obvious source, and that the shin pain might point to a musculoskeletal or neurological issue. She also told us to "trend" the fevers and call her back in the morning. Completed unreassured, we took him to the emergency room. A full day waiting in the emergency room led us again to blood tests that were mildly abnormal but not convincing for any diagnosis. An MRI of the leg was done which was read as normal. I pulled the pediatric ER physician aside and told her my concerns: was there something systemic? As an adult critical care physician, I was not the kind of parent to seek attention unless I was truly concerned. I alerted her that I was concerned regarding the elevated white count and thrombocytosis without an obvious source and even more concerned that the MRI was normal. We were told to "trend" the fever, and if it became more than 101.5, to seek attention. We were also to give scheduled ibuprofen to suppress any synovial inflammation that may be happening in the hip from a viral infection two weeks before. After a dose of ibuprofen, they tested his walking, and said that it was noticeably better, so it must be Transient Synovitis, a diagnosis of exclusion. One caveat to this "give the drug, and see if this gets better, if then, it must be this" argument is that it is absolutely flawed. If the participant knows that "he or she is supposed to get better" then the free will overcomes any pain and of course, he is going to walk better. It may or may not have anything to do with the drug. We walked out of the Emergency Room still concerned.

I continued to give him ibuprofen over the next day. He continued to limp. The ibuprofen suppressed the fever, so now we had an afebrile child who couldn't walk. After no significant improvement, we took him back to the pediatrician office the next day and asked for a neurological exam and, bingo, over the course of a few hours my child developed cerebellar ataxia, clonus, and inability to stand. All of this happened within the time we saw the pediatrician, got him back to the emergency room, and a MRI was scheduled. That night as I sat at the edge of the MRI machine holding his leg, I had never been more frustrated with the fragility of the human body. I loathed hospitals. I never wanted to step foot in the hospital again. The doctor inside of me put the differential diagnosis of "epidural abscess, brain tumor, meningitis, encephalitis" on the list, while the mother inside of me put "something really bad" at the top. While the initial scout films started coming up, my husband, who is a body radiologist subspecialized in MRI, stood by the MRI technician with a solemn look in his eyes  -- one that I had never seen before. As he drew his finger in a vertical line across the computer monitor, the heart of the mother inside of me sank, while the doctor inside of me said, "Wait, that could mean it is not a focal tumor or an epidural abscess, but could it be a diffuse tumor? Maybe, it is meningitis."  With one hand on my child's leg amid the deafening noise from the machine, I kept waving to my husband to see if he could tell me something. He asked me to come outside and knowing my child was already asleep in the machine, I stepped out and could immediately notice the flair abnormality that swept across the spinal cord. As the axial cuts were pouring in, we could see the flair signal lit up like two snake eyes pointing to the diagnosis of Transverse Myelitis, which we knew only held very good prognosis one third of the time. There was no Brain MRI ordered as the ER staff wanted to "focus on one thing at a time," and it  seemed that the spine was the problem. Thankfully, the neuroradiologist who was examining the scout images, and who was about to leave in thirty minutes for the night, noticed the transverse myelitis throughout the spinal cord and asked the technician to add a brain MRI. Within minutes we found her and discussed with her and confirmed the diagnosis of Acute Disseminated Myeloencephalitis with Transverse Myelitis, a disease that occurs in my child's age group, typically after a viral infection or a vaccine.

During the hours in the emergency room, my son went from being able to walk with a limp to being unable to move both legs and becoming tachypneic. Prior to returning to the emergency room from the MRI, I told my husband that knowing the diagnosis, they will for sure want to do a lumbar puncture to rule out active bacterial/viral meningitis and this will of course delay steroid treatment if the lumbar puncture was not done in an expedited manner. We were already in the emergency room for twelve hours by the end of the MRI and given the progressive course of his symptoms, further delay could have caused him to progress into a coma and the risk of hemorrhagic encephalitis existed. Upon return, we asked the team to be present at his bedside, and we made our concerns open to them. The on-call ER physicians were skillful and quickly performed the lumbar puncture. We soon knew that there were no alterations in protein/glucose/gram stain and that we had the right diagnosis. The ER team hung the bag of 600mg of IV solumedrol before we were transferred up to the ICU and every successive day resulted in more return of neurological function. Within five days, we were at home recuperating after this nightmare of an illness. The neurologists repeatedly told us that they have never seen a child with such degree of MRI severity not have the physical signs to reflect the changes; it is likely because we sought attention right in time. The mother inside of me was strong during the five days, and the doctor inside of me was quick to decline any unnecessary blood draws and made sure that he got out that hospital as quickly as possible. For if anyone knows how deadly hospitals can be, it was the doctor inside of me. We were welcomed at home by a supportive community and his return to school and activities was a breeze because of the love and support from family and friends. When I bought my son a couple of youth basketballs to help his recuperation phase, he jumped out of the sofa, ran to me, gave me a big hug and said, "Mommy, how do you know me so well?"

I said, "Trust me, I am a mother."

"You're full of it"

I have read countless articles about how medical trainees have been berated and belittled, yelled at or pushed. I have never in my years of training felt that way or been treated that way. Yes, I’ve been questioned strongly. Yes, with lines of questioning sometimes called “pimping.” I have felt like I needed to study for 40 more hours and have gone into the bathroom afterward to cry, but I’ve never been berated. I’ve never been pushed. I never even thought of what I would say or do in those situations. I have heard my share of racist and sexist remarks and have found ways of addressing it directly and highlighting to the team why it’s unacceptable. But what would I do if someone directly belittled or disrespected me? Would I cry? Would my knees buckle? Would I yell?

Well, that all ended when a Pediatric Surgery Attending told me, “You’re full of it” in front of my staff while I was working in the Pediatric Intensive Care Unit. This particular Surgeon has a history of yelling at Resident Physicians that I learned of after the incident. That night, I was caring for a postoperative patient who had just left the operating room. During interdisciplinary sign out I asked for clarification of a medication dose as I was preparing to enter routine orders such as for PCA-administered pain medicine. The Surgeon turned and said, “No, we will enter the orders” meaning the Surgery Residents. I told him that in my experience PICU Residents enter the orders and manage the PICU patients. He said, “No, who trained you, this is my patient?”  I looked around and of course, everyone was staring at their feet. I was in my second month of PICU service and had heard countless times how our unit was a “closed unit” and that we managed our own patients, but this gruff, aggressively self-confident, tall male Attending with salt and pepper hair and a fresh tan was staring me down. I said, “You will need to speak with my Attending because this is not what I have been trained to do.” He turned, stomped away, and snuck in a low, yet completely audible, “You’re full of it.”

I stopped in my tracks and said more audibly, “Excuse me, but you just said ‘You’re full of it.’”I paused, collected myself and continued: “I feel very uncomfortable, and that was disrespectful. It is not appropriate to speak to trainees that way. I only want to provide excellent patient care.” He froze. When he turned around he had a look of utter contempt and disbelief; it was like no one had ever told him he cannot speak to people that way. His eyebrows furrowed and he spit out, “Well, I’m sorry,” and turned around. At that moment, my Attending arrived and my Fellow said, “Well, I’m glad you said it because I was about to.” I quickly excused myself as my hands began to shake and the pounding in my ears began to dull everything else out. I exited the unit, and sank onto the bathroom floor and cried. Big crocodile tears as my grandmother would say. I was anxious and nervous, but I was damned proud of sticking up for myself.

My PICU Attending found me later and asked me what had happened. I explained the facts and he shrugged and said, “I’ve heard worse,” and told me something about how that Peds Surgeon had cursed at him during his Residency. I told him that I hadn’t heard worse and had never experienced that type of behavior but that I thought it was unacceptable to speak to any member of the team that way. He shrugged and said he would address it with the Surgeon later. As I entered the Unit, the Nurses individually applauded me for speaking up the way that I had. I asked a trusted Nurse mentor if she thought I handled it well and she said I nailed it, and my Fellow echoed the sentiment. I didn’t get emotional, I said what I needed to say, and kept it focused on the patient. One of the Peds Surgery Chiefs came up to me later and had heard about it and gave me a quiet nod of support. She agreed that Surgery Residents who did not spend the night in the hospital should be consulted but they shouldn’t be the ones putting in orders since the PICU Residents are the ones who stay in house overnight. It’s a patient safety issue.

Many thanks to a different fabulous PICU Attending who a week earlier coached us on working in uncomfortable situations. She told us to use words such as “uncomfortable” and “unsafe” and keep things focused on the patient. Without her words, I probably would have shut down, my knees buckled and I wouldn’t have been able to say things in a way that would have gotten any response from that Peds Surgery Attending. I still believe, “You’re full of it” has no place when we are caring for patients.

I spoke on a panel earlier this year sponsored by the Student National Medical Association. They asked a group of underrepresented minority Attendings and Residents to discuss discrimination in medicine. I shuddered as I listened to the horror stories the Black and Latino Attending Physicians recounted. I think I would have quit if I had to endure the downright hostile environments they practiced in in their early careers. I don’t discount the real experiences highlighted by other trainees around the country and applaud them for their candor in sharing. I hope that we all are continuing to work so that abuse and disrespect are not allowed, and when they do occur can be apologized for and learned from.

That way you talk

I was in the office speaking with a parent and her kids at some point in the past year (how's that for sufficiently anonymized).  The mother was gazing at me for just a little too long.  She could have been pondering my most recent question, or may have been lost in thought, but at that moment I opted to ask her gently if she was okay.  And she simply said, "I'm sorry, I just love the way that you talk with my kids."

Oh how that made me feel that I'm right where I should be and doing what I should be doing.  She saw the way I really ask, really listen, and aim to motivate. It's working, at least in this case. 

You've probably heard similar positive comments from time to time about how you communicate with your patients.  And yet, if I could only do so at home!  I can be ever so calm and motivating, building partnerships, and serving as a measured and informed voice of reason at work.  And while I want to consistently do the same at home, I CAN'T HELP YELLING. AT MY KIDS. SOMETIMES. GOT TO WORK ON THAT.  You?

moar veggies

My older daughter has always been an amazing eater.  She eats her fruits, her vegetables, her meats, her starches, and of course everything in the baked goods food group. One of her favorite foods? Scallops.  I was a terribly picky eater as a child, so I always wondered what I did to deserve such a great eater.

Well, the second time around, I got what I deserved.

My youngest daughter is a terrible eater. The only thing she wants for dinner every night is chicken nuggets. And even then, I sometimes have to beg her to eat them.  And God forbid they have the wrong shape, like if I gave her the circular ones when she wanted the dinosaur ones, or vice versa. (I'm never going to know which one she wants until it's actually in front of her.)

Recently, she suffered a really pathetic bout of constipation, and my husband asserted that she needs to eat more fruits and vegetables. (He already slipped through some of his fiber cereal in with her Cheerios in the morning.) Well, maybe fruits are possibility, but how do you get a kid who won't even eat the yummy stuff to eat more vegetables?

And furthermore, I have to wonder if it's really worth it. If she has to be coaxed to eat french fries or chicken nuggets, I can't imagine what I'm going to have to do to get vegetables in her mouth. It would probably have to involve a slingshot. So what if she doesn't eat her vegetables? Is it really so awful?

Do Female Physicians Need Female Chaperones?

Genmedmom here.

Our department is considering a policy that would require female chaperones to monitor every pelvic exam. This would include pelvic exams performed by female providers.

As a primary care women's health doc who performs pelvic exams every day, I felt vaguely insulted by this.

But, as both a female physician as well as patient, I understand the reasoning behind this potential policy. In our department's case, it was apparently proposed in response to a complaint involving a female physician; we have no idea what the issue was. Of course, historically there have been cases where there was abuse of the doctor/ patient relationship in this context. Also, cases of perceived abuse. To have an official "observer" present can help to prevent any abuse, or false claims.

My own OB/GYN office uses chaperones. But it always strikes me as odd and impractical. My own OB/GYN is an excellent physician with superior bedside manner who has overseen both of my pregnancies; she even guided me safely through a VBAC. But even she has to leave the exam room and go fetch a medical assistant, who may have never met me and is not involved with my case, so that they can stand there and observe what is basic, routine office care. I've considered requesting that she NOT go fetch the superfluous eyeballs, as I think it's kind of weird, and it would save time, too. But I haven't wanted to rock the boat.

So, as I have myself experienced, having an additional person present for this exam can also in and of itself be uncomfortable, and can make routine medical care feel weird. It may not help many women to feel more comfortable at all.

Are there things we providers can incorporate into practice that can help minimize discomfort and prevent abuse, or perceived abuse?

I really try to help patients through what is generally considered, at the very least, an uncomfortable and awkward examination. For many women, a pelvic exam can even be a traumatic experience, either physically due to atrophy or inflammation, or psychologically due to past rape or sexual abuse.

I think there's some basic things that we can do to help women feel more comfortable and in control when a pelvic exam is necessary. These include explaining why we are doing the exam and what we are looking for before we even start. Does she need a Pap smear, or STD screening, or both? Is she complaining of pain during sex, abnormal discharge, abnormal bleeding? Is there a strong family history of GYN cancers? Is there a family or personal history of melanoma? Then we'll discuss whether the exam will include a speculum exam, or a bimanual exam, or just an external exam, and why. Not everyone always have to do have all of these.

It's important that the patient knows what's going on at all times. I think it's better if the back of the exam table is slightly elevated and the paper drape is pushed down, so that the patient can easily see the provider. I also try to explain everything I'm doing in real time. I don't even touch the patient in that area at all, without saying what I'm doing and why immediately beforehand. I'll hold the plastic speculum up, and explain that it's the same diameter as most regular tampons, that we use plenty of lubrication with this, and it's usually cold. I tend to talk through the entire procedure, Rachel Ray-esque. Often I'll suggest yoga breathing, letting the pelvic muscles and buttocks relax.

In some cases, urinary incontinence is a problem. If Kegel exercises may help, I ask women if they know how to do these. Then, I either test their Kegel, or ask if they want to learn this. What I've seen is that many women who think they're doing a good Kegel squeeze will actually be tightening their buttocks, or simply tilting the pelvis. So I add pelvic floor physical therapy here: a lesson in isolating the pelvic floor muscles, and a test to see if the patient is able to do a decent Kegel. I think if someone walked in as I'm saying "Squeeze!" they'd wonder what was going on. But since Kegel exercises are effective for preventing and treating urinary incontinence, we'd better make sure patients can do them before we recommend them.

Sometimes, a patient is extremely uncomfortable with some part of the pelvic exam. Then, the exam must be halted. I usually pull the drape back down and discuss, ask if they would like to try again, or hold off. I really don't think a provider can proceed in those cases without a time-out and discussion. It's okay, and sometimes absolutely necessary, to just skip the exam. It can be rescheduled; special arrangements can be made as well, as in cases of extreme physical or psychological discomfort, such as exam under anesthesia.

I've had patients tell me that the pelvic exam "really wasn't that bad", or even that they learned something useful. I take this as positive feedback! I'm sure I can do better; we all can. I'd be interested to know what techniques other providers have found to be useful.

If we are required to institute this female-chaperone-for-pelvic-exams policy, it would mean significant logistical hassle. In our office, we work one-on-one with the medical assistants, and several are male. Would the guys need to be let go, transferred to other practices? In addition, our medical assistants perform the phlebotomies on the patients they've checked in. Were this policy to be put in place, we would need to reorganize our whole system, and likely need to adjust the operating budget to include additional staff. And, of course, if we're required to go fetch a chaperone before every pelvic exam, that will add time to all of those patient visits. Either we'll all run even more behind, or we'll have to restructure our scheduling, and likely need to institute longer days for us and our staff, to accommodate. Again, this could mean a budget problem.

In summary, I don't think that requiring a chaperone to stand there and observe every single pelvic exam is a good idea.
But, I'm very curious what women physicians think about this, both as providers and as patients.

What better place to ask, then the physician-mom blog? What's the vote: Yay or nay?

For those docs that perform pelvic exams, what have you incorporated into your practice to help women feel more comfortable and in control?

-Genmedmom

Guest post: Fewer patients, more friends

On the face of it, a day at the clinic seems very social. I see patients, one after the other, from nine until four, with a break for lunch. Most of my patients I've known for a while now. I get caught up on their their lives - school, family, work. "How are your spirits these days?" I ask almost every time, patting my right hand over my heart, using the most effective cross-cultural mood elicitor I know.  It doesn't get much more personal than this. It's just me and the patient, our knees almost touching, in a small exam room with the door closed and an interpreter behind my left shoulder.

I leave work after a day of this, drive the five minutes to pick up my three-year-old from preschool, and begin the commute home to Deep Cove. Suddenly I'm ravenous. I ask Ilia what's left in her lunch box and she hands me some carrot sticks and cubes of cheddar from the back seat. Ten minutes later, around Grandview and Nanaimo, I bottom out, utterly exhausted. The idea of having to shepherd four kids through meal time and bedtime chores after this feels impossible.

If Pete's not away on business, I come home to sous-vide salmon and curried cauliflower, and we divide up the after-dinner work. If he's traveling, we eat the lasagna my thirteen-year-old put in the oven when the big kids came home from school. Then I oversee homework and lunch making, brushing teeth and laying out tomorrow's school uniforms.

I cut corners. I pick the bedtime book with one sentence per page. I move up the bedtimes of the kids too young to notice. I want the noise to stop, even the singing. They're getting shortchanged, I think, but  I'll make it up to them later in the week.

Where I live. And why I live here. © Martina Scholtens. Deep Cove, BC

For years, I've seen patients Monday, Tuesday and Friday. Mid-week I'm home with my youngest, grateful that Deep Cove is off the beaten path. We can't see our neighbours from our place. Looking up from the laptop now, I see a stand of waving cedars, the gunmetal grey winter waters of Indian Arm, and the dark bulk of Belcarra rising from the opposite shore. The solitude is perfect. No play dates, thanks. No community centres or meeting up for lunch, either. I might be up for something on the weekend, but it'll take until Saturday evening to recover from Friday's walk-in clinic.  I need a respite from human contact, and I prefer as much solitary time outside the clinic as four kids will give me.

I forget, though, that seeing patients isn't at all a substitute for catching up with friends over drinks.  At the clinic, the topics of conversation, the confidences, the complaints - they're all one-sided. It often strikes me that family physicians are professional friends: non-judgmental, accessible, reliable, skilled listeners and excellent secret-keepers. There's pleasure in seeing patients, but really, it's business.

If you had told me that I'd have four kids and eight hundred patients, and feel lonely, I'd never have believed you. But my work drains me to the point that all of my spare time is spent trying to recuperate. Pete would love to have people over more, and vacation with other families. I always imagined a noisy, boisterous home with friends and family coming and going, but with my work commitments, I don't have the psychological reserves to make it happen.

Then I had an epiphany. Clinical work exhausts me with the people lineup, and my social life is extremely thin because I need stretches of alone time to recharge from work. I ought to reverse this. I need to implement more solitary time at work, and more people-time in after hours.

I've started on this. In October I gave up my Friday clinic. I've worked Fridays since I finished residency in 2003. Now I finish the week with administrative work and other projects instead, alone in my organization's secret library. Just me, a row of computers with access to our clinic's EMR, shelves of journals on paediatric nutrition, and a yellowing poster on Boolean operators. I can do this very happily for much of the day, and still have the energy to go out with Pete at night. It's been life changing.

I knew from residency that I couldn't see forty patients a day, five days a week. I find it hard to do half that. Maybe it's that my patient demographic, refugees with trauma histories and multiple barriers to care, are particularly challenging. Or maybe it's the demands of four kids. Maybe our clinic needs to use a different model of care. Maybe an office with some natural light and a view of the North Shore Mountains would help. There are probably other changes I could make to bolster my psychological fortitude and soldier on, even thrive, in this setting. But for now, I've reduced my work hours devoted to direct patient care.

Three months in, and no regrets. Before, I felt like I spent everything at the office. Now I've got this feeling of having a bit of pocket money. There's the promising jingle of spare change.


-Martina Scholtens, cross-posted at www.freshmd.com

Guest post: Loneliness

Cross country move to start a second residency, otherwise known as a long fellowship. Getting pregnant in residency. Health issues in the family. Yearly in-service exams. Patient care. Having a baby. Board certification for the first residency. Learning curve. Conference presentations. And now there is job search. I get by in most of these situations. I must say I have excellent family support, but a physician spouse can also only help so much. I find myself exhausted, sometimes nervous, mostly looking forward to the days going to work and coming home. But I also find myself extremely lonely. There is no time or energy to go meet other mommies. No time to hang out with your single or non-parent colleagues. (They don’t invite you anyway) No time to form new friendships. Hardly some time to hang on to the old ones you have left behind in another city and another country. I love my husband, who is also a hus-friend! But, a girl needs some girl friends.

I find myself making awkward attempts at trying to set up playdates with other moms, who apparently have their baby’s social life all dialed in.

Do any of you other mothers in medicine experience this loneliness? Or is it just me? Should I even allow myself to feel lonely when I have a lovely child and husband. Can you be busy and lonely?

Older

I'm sure almost every physician has experienced patients complimenting them, or more likely complaining about, how long young they look. I've been told that I look like I'm in college, in high school, ought to be suckling on my mama's teet, etc.  you know what I'm talking about.

As I get into my mid 30s, these comments are becoming more seldom, which is what I would expect. I've spent my life wearing a sun hat to protect my skin, despite years of ridicule, I don't smoke or drink, but no matter how good care I take of myself, I've never met a 40-year-old who looks like they could be in high school.  So like it or not, these comments are sure to stop in the next few years.

It's not like I feel young. I've been a doctor for nearly a decade, and I am the mother of two children. I certainly don't feel like a high school kid. So I don't know if it's terrible to not look like one.  I would rather be respected for my wisdom.

Before I run out and buy 10 bottles of concealer, share with me what you think the best things about looking older are for a woman.  There's got to be something!

MiM Mail: Starting medical school, need encouragement

Hi MiM,

In six weeks I am supposed to start my first year of medical school. It's been a long time coming. I trained as a nurse, worked as one for a while, and then decided to pursue medicine. I finished off the prerequisites I needed, applied and got in (to a medical school in New Zealand - where I am from originally). My husband and I had a surprise pregnancy right before I was supposed to start medical school so I deferred for a year. I now have a gorgeous six month old and have been enjoying working casually as a RN. However starting medical school beckons, and I find the idea now terrifying. The unknowns of how to manage it all with a baby. I have an extremely supportive husband but he is also studying a PhD so is busy. We have great childcare sorted - our baby will be at the university day care right around the corner from the medical school. I'm not really struggling with the idea of leaving my baby as I'm not the full time stay at home type, but I am afraid I will find school all consuming and miss out on her. Also from a financial perspective having us both studying sucks - my husband gets a small stipend we can survive off but it's hard when our friends are buying houses and taking dream vacations, and we can only afford meat once a week! I suppose I am using this post and community as I imagine many others do - to seek out encouragement and to hear stories from those who have gone on before. How did you do it with a baby? Any ideas on how to manage financially? Is it worth it in the end? Etc. Would love any encouragement, inspiration, advice you can spare.

Thanks so much,
A.

Every Bite is a Victory

In the last month or so, it seems that my Doll has absolutely rejected all forms of foods, at all hours.  She will take maybe a bite of something new, then immediately spit it out.  This has led to many hours of distracting her with toys, which hasn't worked.  Her left hand is always up and ready to push away any spoon or fork of food, and she has learned to swing her body from side to side as far as it will go in her high chair just so she does not have to eat.

When my husband is home, together we are able to get a few bites of food in her mouth--eggs, crackers, cheese, fruits, what have you.  Whenever she takes a bite (that she actually chews and swallows), I often feel relieved and frequently say, "Every bite is a victory."

One day, hubby was post-call and tired, but because of nanny drama, had to watch her all day while I was at work.  As a result, he did not fight with her to eat, he just put food in front of her and as a result, she didn't eat anything all day.  By the time I got home, she was hungry and ate an ENTIRE dinner!  I was so ecstatic, I told him he should babysit her more often when he's post-call.

This leads me to think:  am I just overfeeding her, so she doesn't want to eat?  I don't know, doesn't feel like she eats anything ever!  Is she just being a normal toddler who is refusing food?  Don't know, she's my first toddler!

The past week especially, I've been growing so frustrated with all of this, that this past weekend, I vowed to not care if she doesn't eat.  I'll just keep putting food in front of her, and if she doesn't eat, must mean she's not hungry.  (Right? I don't know...)

She started daycare this morning after a few months of nanny-ing... so we will see if this changes her eating habits at all.  I know they won't baby her the way I do at home, so it shall be interesting to see!

Does/has anyone else struggle/d with toddler mealtime?  I know it's not just me!