A day in the life of X-ray vision...

Disclaimer  #1: most days aren't like the one I'll be talking about but few are as noteworthy as the past couple days that I feel compelled to share.

Disclaimer #2: most days really aren't that bad and as my little C has adjusted to pre-school and I've been somewhat juggling this whole residency, husband on the east coast doing fellowship and raising a daughter and our toy poodle (did I mention I also am crazy enough to add a dog into the mix?-- but of course, the dog did happen before the baby so I am not that crazy right?) okay. I have my good days and my bad days.

But I think I may have just experienced the worst one yet!

I'm from California so please forgive me when I complain about the weather for those who experience much worse! But we have been experiencing the hottest summer ever! I've lived in California all my life and I've lived in the city where I'm doing residency since 2003! (Yes, I am one of those people that has done undergraduate, medical school and residency all at the same institution!)

The past couple days my little C has not been sleeping well due to the heat. We don't have central AC at our place but we do have a portable one but due to the usually pretty awesome weather we are used to experiencing we do not need to use it very often. However, we've been experiencing weather in the triple digits with unusual humidity so it's been a very uncomfortable situation.

So bad actually that I moved us all out to the living room where the portable AC is located and the 3 of us, me, little C and our toy poodle have been "camping." On top of this, my little C is in the midst of potty training. She's been doing a great job with #1 but #2 not so much. She has a huge fear of pooping on the toilet but she's been holding it in until she comes home from school and I put her in a pull-up. After 4 days of not pooping, I was very worried. I spent all evening yesterday trying to get her to poop---ranging from pear juice, green smoothies and grapes and finally, she did it! I was feeling pretty great until then my dog P decided to go diarrhea everywhere. I still don't know the cause of the diarrhea but either way, pretty darn gross!

It seemed like she was done after we took her outside and let her do her business some more so we went back in. I gave little C a bath. I gave P a bath. And then as I'm giving myself a shower, of course with both of them staring at me, P decided to go diarrhea again! I run out of the shower, clean up the mess and P.

As I'm putting little C to bed, I touch my hair and notice that there is still shampoo in my hair. Great. I fall asleep too tired to notice. But of course, I wake up intermittently all night worried about P making another accident. I thought I was smart by keeping her in a secluded area so if she did make a mistake, I would be able to find it.

I wake up and I find P on our couch. She escaped. I search the house frantically but luckily, I found only 1 small mistake. As I clean that up, of course, little C wakes up and I have to get her ready for school and get myself ready for work as well.

We're also potty training so I put her on potty and she goes! yay! (minor victories...) I make her breakfast of grilled cheese. She screams and yells she wants bagels. Usually I comply but this morning, I just couldn't. Lo and behold, she eventually finished the grilled cheese.

I give P another bath to wash her up and notice that the hair around her butt area keeps getting soiled when she goes diarrhea so I said screw it, I'm just going to cut it off. I find a pair of scissors and while little C stares at me, I start trimming my dog's butt hair. I sat there and could not believe what I was doing. As I disinfected the scissors, I cut myself in the process. Great!

We're about to leave and I decided to get rid of P's dog food. Great again. I notice that the heat has made the ants find refuge in P's dog food. I find a trail of ants. I panic and then of course, I had to kill the army of ants in P's food.

Okay at this point, I am just super late. I'm done. Oh shoot, I notice that little C is still in pull-ups. I try to get her in underwear but then all hell breaks loose. She just started wearing underwear all day at school. She loses it and refuses to wear underwear. I'm about to lose it too. I let her wear pull-ups.

We finally make it out of the house but oh no, we forgot blue doggy (she has to bring to him to school!). I run upstairs and grab blue doggy and we finally make it to school. I tell her teacher about the pull-up situation and her teacher says that's fine. I yell thank you and run out the door.

I finally made it to the hospital. I park. I lose it. I cry and laugh at the same time in my car. I wished someone could have filmed us this morning. The meaning of a chicken running with his head cut off has a whole new meaning.

I calm down. I walk in. I open up my work list. I check my e-mail. My attending has sent back edits on my abstract. I submit it. I start dictating my studies.

If only anyone else knew about the morning I just had...

I felt compelled to share this day in particularly because in the light of social media, people see snippets into our lives not the full picture. I get asked constantly how I balance it all and make it look so easy. I wanted to share the truth. It is not easy. I'm a hot mess majority of the time. But that's life. That's motherhood. That's residency. It's the life I choose and I wouldn't have it any other way! (most of the time anyways! I did have my moments of doubt this morning)

How I Studied For The Boards...

Genmedmom here.

I saw Mommabee's September 1 post asking for practical advice about how to study for the boards, and I felt compelled to post the link to an article I wrote on this very topic! This was written for the New England Journal of Medicine Knowledge+ blog as a humorous, but essentially accurate personal account: I Studied For The Internal Medicine Boards On The Stairmaster

Mothers

This blog is about mothers in medicine, but most centrally it is about mothers.  I considered many times over the past few weeks telling KC that I was going to resign from writing.  But, I would stop myself because I so love this community of women.  I felt I didn't have much to give.  I'm drowning a bit right now.  To catch you up, I've started a new, amazing, super supportive fellowship.  I feel like I have my life back after 7 years of residency servitude.  I've passed the first part of my boards.  I have some exciting job prospects that may be materializing soon.  My daughter is in a wonderful school and thriving, and my husband just landed his dream job.  I get to hang out with my siblings on a regular basis.  I'm writing grants with my baby sis (so amazing).  But most importantly, and most poignantly, my mom has treatment resistant aggressive metastatic breast cancer.  On the bright side I get to see her nearly everyday, her doctors are my colleagues and we have far from exhausted every option.  But on the other side - I feel like I am drowning.

My mind is constantly thinking about my mom.  I constantly fight to push some medical knowledge out of my head while using other parts of my medical knowledge to help.  I feel quite ineffective at this.  I strive to bring her grandbaby to her side every day because my baby girl is a beacon of joy in the midst of this.  To busy myself I cook and clean and organize - thankful for my siblings and my dad as we all share these tasks together.  I yearn to just lay in bed and talk to my mom for hours, but I am so unstill.

At work I try to bury my constant thoughts so that I can excel, so that they see me as an asset.  Most days it seems to work okay, other days - like the day we realized it had spread to the liver on therapy - its hard for me to stand.

There is a centrality of mothers in a childs life.  This is the beauty of this blog and certain groups on facebook.  We realize that we have two awesomely important jobs.  Well now my mind is on the one who was so central in my life and how I can't envision a life without her.

So, I don't have lots of MiM specific insight or questions.  Just that this blog is about mothers.  So, I thought I'd talk about mine.

My mom quit her Economics PhD program when I was a baby.  My dad had to travel for work, so she chose her family.  She was a stay at home mom until I was about 12.  Then she started doing economics work for the state and selling real-estate.  It wasn't until I had my own child that I realize that she must never have slept or ate when we were little!  3 active kids in a million activities and she essentially worked two jobs.  Despite that she seemed just as present then as when she stayed at home.  She has always found a way to always make us feel that she is right there.  I never really had teenage angst with my mom.  She has always been my best friend and my cheerleader.  She never made me feel like I was anything short of the best and she is crazy proud of any and everything we do.  She told so many of her physicians that I was a surgeon that I'm pretty sure they flagged her chart.  She rescued me from my post partum depression.  She is the one who made it okay for me to get help.  She taught me that I could do anything, that I could be fierce and accomplished and made me feel like I deserve it.

So now, I can't bear the thought that my sweet baby girl (who wants to do everything with grandma) might forget her.  If I'm ever blessed to have another child I can't bear the thought of that child never meeting her.  My siblings are younger, they have weddings and pregnancies in future that she will likely never see.  I always thought that choosing oncology as a career was my calling, because with cancer people have time to prepare, unlike the immediate finality of trauma for example.  But, now that we're in the middle of this "time to prepare," I can tell you it sucks.  It is hard to make the most of it/treasure every minute/make happy laughing videos and everything you see on Hallmark movies.  My mom is tired and worn down from chemo right now.  She needs rest and pain medication - not a montage.  What we really want is the time before this all started.

Thats all for now.  Make life count.

When is enough, enough?

Much of the past few years, I have regretted decisions I've made... The decision to stay in medical school, the decision to... Well, mostly that.  I knew about a week into medical school it wasn't for me.  I looked into PA school, and transferring to dental school, but was too afraid to make any moves.  So I kept on with the flow, and eight years later I am a fellow.  I have thought about the decision not to quit many times, and have wished I could go back and shake myself and do what I was so afraid of doing:  disappoint my parents, not become a doctor, do something different, not become a doctor, disappoint my parents.  I was young and living alone and terrified, and if my parents were more supportive I maybe would have quit, but that's no excuse and I have absolutely no doubt that I definitely should have, because here I am on a random weekend night, still regretting my decision not to take action then.

What makes me really think about this again, you ask?  No, I don't drive myself crazy on a daily basis; but as I mentioned, I'm now in fellowship and I don't like it.  The field isn't what I thought, the program isn't what I thought, and really, I just don't need it!  Since I've matched and committed to the year, I'm willing to complete the year (to be a responsible adult, but really so on my resume I don't have to say I quit fellowship after two months).  But I don't want to stay for next year (it's a two year fellowship.)  My husband supports me no matter what I decide, but he says, "But it's only one more year!  Then you can be board certified in another field and be even more marketable!" True, true.

My big hesitation again with quitting after this year is:  I'm still afraid to disappoint my parents.  And boy will they be disappointed if I end up practicing just psychiatry.  Eight years later, and that young, scared girl hasn't grown up much.

I wish I could have quit then, and I want to quit now.  When is enough regrets, enough?  When can I just make decisions for me, and not for others?  When can I do what I want?  When can I just be happy with my job?

Disclaimer:  This post is not meant to discourage anyone looking to go into medicine.  Just like some people like chocolate and some vanilla, everyone's desires are different.

Attention all gunners

I met with my small group tutor today who leads our case-based learning sessions. I knew she was going to say I need to take more risks during our sessions and throw my ideas out there even if I'm not totally sure they are correct. I am admittedly suffering from some form of imposter syndrome; given my finance background I sometimes feel inadequate among my gunner science major peers who have spent years in the lab. I know I just need to get over it and I'm making a conscious effort to do so. My tutor did bring up a good point though, that now is the time to get all these insecurities and hesitations out of the way before the clinical years, residency and so on and so forth. She mentioned that she's seen many students, especially quieter females, miss out on various opportunities because of this. I think I'm a true ambivert; extroverted in most social situations, but especially introverted in academic settings when I feel like I don't know every single thing I need to know. And while I don't think I'll ever be that person who loves to contribute anything and everything even if not particularly relevant, I definitely do not want to lose out on opportunities because of it.

I know medicine is about being comfortable with some uncertainty because it's impossible to know it all. And I realize some of this will come with time, but all you lovely aggressive types, please share your ways. And those who had to work at it, how did you eventually get there?

What in the world?!?

I was supposed to be much farther along in my studying goals and there are 6 weeks until my pediatric boards and every week I realize how much further off track I am.

I thought my schedule was “made for” studying. Four-day work week with Fridays off. And then my clinic closed for 2 days and I’m making up those days on my off days because I don’t have enough comp time yet.

And then the fancy, super detailed Google calendar study plans that I worked so hard on are being utterly obliterated. The first 2 weeks I was solid, but that was when my patient load was only at 50%. Then when I got up to 75% things got real. And now that I have a full patient load there is literally not enough time in the day to sleep, eat, see patients, work on notes, call patients back, read consult notes, spend at least a few hours with my family, and finish the notes that I didn’t get done earlier in the day.

I hadn’t even realized I had gotten to the 6 week mark until one of my study partners mentioned it. What in the world?!? She said “it’s time to go to PICU hours?” And she’s totally right. Something has to give and I don’t have $2,265 nor the time to retake these Peds boards. My husband is super supportive and tells me to take the time that I need but after so many years of missing out on tons of family related activities it just breaks my heart to be at this coffee shop doing Med Study questions on a beautiful Sunday morning while my family is at the park but hey - it’s going down!!! (well right after I write this pity-party of a blog post)

I’ve got this, right?!? I just remember how grumpy I was during the PICU because of the sleep deprivation. At least I don’t have to calculate TPN (total parenteral nutrition) or ventilator settings.

Alright ladies - I need your support. Your encouragement. What did you do? (I scratched that because I have all of the resources I plan on using and don't really want general info about how you studied cuz' we all study differently and I know me - I'm all about practice questions). How did you do it? How did you balance it? Did you study as much as you'd planned? Did you get up at 5am? When did you do your notes? When did you study?

The End of Summer

When I was a little girl, the last few weeks of the summer were filled with mixed emotions. It was still summer vacation but I knew that fall and school were looming around the corner.

In some ways, I feel like that little girl except now I am a mother and instead of summer vacation, I feel like I am in the summer of motherhood. And like that little girl, I don't want summer to end.

Summer has felt like the best season of motherhood. Sure, the spring of motherhood was spectacular. I experienced motherly love for the first time and the miraculous growth of my babies to become toddlers. There were so many delectable moments: first smiles, first steps, bear hugs. There were so many moments when I wished I could freeze time and capture the delight, innocence, and charm of my babies.

But like springtime, with it cold days intertwined with perfect days, mothering babies and toddler was exhausting and difficult, at times. There were sleepless nights, fussy eaters, double strollers, and truly terrible twos.

The summer of motherhood is exactly what you’d expect – it is relaxed and calmer and truly amazing. My sons are now ten, eight, and six, and I have experienced so much joy at these ages that I wish I could make time stand still.

Life is easier. My children dress themselves, brush their teeth by themselves, and read themselves to sleep. This summer involved no strollers, no separation anxiety, and no fear of pools and beaches. Instead it involved a myriad of camps where my sons learned, grew, and had fun. This summer included two kid-free weeks when my boys were with my parents and a myriad of weekend adventures.

I watched my six year old son learn to ride a bike. I watched my ten year old son play electric guitar for a Beatles cover band. And I watched my eight year old son learn how to play improv jazz on the piano.

The highlight was a trip to Italy. We saw art, we relaxed in the Tuscan countryside, we enjoyed great food and card games in the evening. I would never dream of going without my children.

Summer has been amazing. So it’s no surprise that I’m starting to feel the pangs of sadness that I felt as a child - that sense of sadness that a wonderful time is ending. But at this point in my life, it’s more than just this summer. I feel pangs of sadness that my summer of motherhood will soon end and I just don't want it to.

Sooner than I think, I will be in the autumn of motherhood. My kids will be teenagers. I suspect they will want to spend less time with me. They may dread family vacations. And they will, no doubt, be sassier.

I feel like a broken record when I say that motherhood just flies by. There are so many moments when I wish I could stop time - keep my kids exactly as they are and never let them change. This is a moment when I really feel that way.

Unfortunately, I have no way to stop time so I am trying my hardest to enjoy every moment that I have during this amazing summer of motherhood.

2 year olds say the funniest things...

Considering my first 2 posts were a bit on the serious side. I just wanted to share the funny things that little C have said to me recently. Motherhood is a curveball. You never know what's coming at you but you really do live for moments like these. Recently, I've been feeling very nostalgic, reminding myself that little C is only this little for so long! Perhaps because my husband is on the east coast doing fellowship and missing out on these adorable moments! But this is a list that I've made for him that I wanted to share with my fellow mothers in medicine as well.

Little C has been saying the funniest things lately. I feel like I need to document them so I don't forget. Here's my top 10 fave from this week! 

1. When P tries to lick me, she yells "No Po!! C's mama!!" (P is our toy poodle)
2. She told her teacher "mommy is a doctor!" Her teacher asked what does she do? And she said "oh she gets to drive an ambulance!"
3. When shes in trouble, she grabs her toy phone and says "mom! I'm calling grandma!" And she talks into her phone and says "grandma, I want to live with you!"
4. When someone isn't sharing with her, "Be nice!! Share with C!"
5. First thing she says when she wakes up--"Mister Sun!!!! Where are you Mister Sun!! Mom! We have to go say good morning to Mister Sun!:
6. I lost my hospital ID badge last week. (Super annoying by the way! Considering it lasted me a good 4 years and 2 months and now I'm only 10 months away from graduating residency). She noticed. "Mommy, where's your badge???? Did you get fired?"
7. When she doesn't want to go to school--she grabs her toy stethoscope and say "okay C go to hospital too. C doctor too"
8. When she doesn't want to play with P or another kid during a play date-- "Okay bye P (or insert kid's name). See you tomorrow!!" (as if that will make the dog or kid disappear...)
9.  When we're going up the stairs, she doesn't want to hold my hand anymore. She goes up first and yells "Wait for C! Mommy!!!!" and when she makes it all the way to the top "Mommy's turn!"
10. And my favorite that she's been doing for the past week! Every morning she says "bye mama! I'm going to miss you!" And today she added "I love you!"

X-ray Vision 

P.S. On a side note, after 7 weeks of crying and making me feel miserable at pre-school drop offs, little C has done a 180!!! She is very happy at her pre-school, made lots of friends and loves her teachers. We are slowly but surely adjusting to all the changes in our lives. 

Pregnant in the OR: Potential Hazards

Regardless of your position, occupational hazards exist when working in the operating room. Normally these things aren't given too much thought, but when my choices suddenly affected another developing life, it caused me to pause and contemplate these hazards on a deeper level. Unfortunately, studies on pregnant healthcare workers (and other occupations) are difficult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting:

Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.

Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.

Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement... I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).

Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.

Stress. This is the most difficult "hazard" to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.


I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.

For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!


References:

Keen RR et al. Occupational Hazards to the Pregnant Orthopaedic Surgeon. J Bone Joint Surg Am. 2011;93:e141(1-5).
Fowler JR and L Culpepper. Working During Pregnancy. UpToDate, 2015.
Radiation and Pregnancy: A Fact Sheet for Clinicians. http://emergency.cdc.gov/radiation/prenatalphysician.asp

MiM Mail: Paediatrics training vs. family medicine

To the mothers in medicine team!

I'm a doctor working as a second year paediatrics registrar with a new baby and was hoping you might be able to give me some advice- I have struggled with choosing a career path for the last six years since I graduated from medical school- I generally don't like very stressful jobs but on the other hand, have always really enjoyed complex, interesting patients I've seen whilst working in hospitals.

At the moment, I'm a second year paediatrics trainee (and have yet to sit the exams for the college of physicians). I have a twelve week old baby and am contemplating going back to work where I will need to do three more years of training after my exams, of largely shift work (nights, evenings, weekends). If I do the training part-time, I would need to spend six years (and thats without having more children, which my husband and I would both like).

For these reasons, I'm considering changing careers to general practice (family medicine where I will be able to finish training in 18 months (or 3 years part-time and can say goodbye to shift work forever!). I think I will miss hospital-based medicine (and just getting to see children) but I think it might be more family friendly? Any advice from people with similiar dilemmas in the past, and how they decided what was best, would be really appreciated!

MPAS

Urinary incontinence

During the last couple of weeks, I’ve been on a urology elective, and I have seen soooo many patients with urinary incontinence, so I’ve been thinking about it A LOT.  

I don’t know how many of you had issues with urinary incontinence during your first pregnancy - I definitely did.  I tried to do pelvic floor exercises to strengthen my pelvic muscles, but almost every day in my third trimester, I managed to leak urine when laughing, sneezing, or coughing, and I frequently was running to the bathroom, hunched over, hoping that I would make it.  I know some of you know what I’m talking about ;)

Now, I am pregnant again (I know, I know, I haven’t told you yet - that is for another post), and, although I am just in the early second trimester, I am already having worsening incontinence.  I say, “worsening,” because I continued to have mild stress incontinence even after my first pregnancy.   As someone in my mid-to-late 20s, this has been difficult to accept.

The worst part is that I feel as if there is little that I can do.  Sure, I can do my Kegels every day, I have adopted a voiding schedule that is q2-3 hours (which kind of interrupts work), and I have eliminated caffeine from my diet, but I fear the future.  Based on what I have seen in the urology clinic, it seems that I may be doomed to be incontinent.  Any other mothers with urinary incontinence out there? How do you deal with it?

MiM Mail: Why the disparity in advice to prospective doctors?

Dear Mothers in Medicine,

There seems to be a disparity in the advice given to prospective doctors. Sometimes the tone is tense, heavy, and almost bitter. Warning people of the commitment, the intensity, the sacrifice of medical school and residency. And other times the thread takes a completely different tone and instead offers encouragement and suggestions for making it work, and the reassurance that more and more people are finding ways to get through those grueling years with a family.

As I try to work out the cost benefit analysis for myself, I'm curious how much of these perceived sacrifices and other costs are specialty based or otherwise dependent on the choices of the student. For example, yes, the financial cost of medical school is significant, but there are scholarships, there are repayment for service programs, and there are ways to mitigate the costs. What impact does the choice of specialty have on the stressors of residency?

How often are medical students able to get a residency near their medical school so they do not have to move their family?

Currently, my kids are 1, 4, and 5. To put the next 10 years into medical school means my kids may pay a steep cost during their childhood, and I'm not sure how much benefit they will receive. From their standpoint, I'm concerned this next step for me could be particularly hurtful. But I want to focus on primary care, which I suspect could be a milder journey, and therefore ask less of my family.

My husband is 100% on board. Wholly and completely. His work allows significant flexibility but insignificant pay. So he's happy to move with me and make this work. I just need to figure out what we'll be asking of the kids before we move forward.

Any insight for me?
Thanks.

Guest post: How hard things can get

I am a more than full-time family doctor. I manage my own office and do extra urgent care shifts on weeknights and weekends. I have a very busy, demanding and wonderful two year old son. I am paying off my mortgage and helping my husband get started with a farming business. I am struggling to keep up all my medical skills, applying for continuing education grants and trying to stay healthy and balanced...

I thought my life was chaotic enough... then...

I find myself pregnant with my second baby. 8 months of a very difficult pregnancy follow, forcing me to eliminate night and extra shifts. I don't sleep and suffer from severe heartburn later found to be due to polyhydramnios.

My baby is born a month early and at 24 hours, I find out he has a major birth defect, undiagnosed through the pregnancy, an extra connection between his trachea and esophagus with no connection to his stomach.

I am discharged in the middle of the night, sleep deprived for 48 hours and severely anemic with my son to a children's hospital. I have to drive myself, and it is heartbreaking to leave the hospital with your flowers and gifts but not your newborn baby after giving birth.

We survive intubation, days on a ventilator, swelling, emergency surgery, jaundice, phototherapy, catheters, central lines, ng tubes, countless needles and tests to look for other problems. He still can't swallow and is aspirating. At a family meeting I learn his vocal cord was paralyzed at some point during all his testing and procedures. It should heal but over weeks or months. Otherwise he may need a gastrostomy tube for the next year.

As I drive in daily to visit him in the NICU, nearing his 1 month birthday, I cry. I blame myself even though his doctors tell me it is not known why this defect happens. I blame a sinus infection, not enough nutrition, exposure to farm pesticides I might have had on a hike...the list goes on. I can't let it go.

I sit in the NICU and hold him, wondering what the future holds. Nobody can predict how things will progress with him. All we can do is take it day by day, waiting to see if he stops aspirating and starts swallowing on his own- then his TPN and NG tube can be removed.

As I sit in the NICU, every little thing scares me- an increased heart rate, no weight gain, a rise in temperature, I usually get so worked up within an hour that I have to leave and let my husband sit with him. Normally I am calm in this environment, but that is with other babies, not my own.

And the stress of the situation is affecting everyone around me. My office staff don't know how to book my office, when day by day, I need to be in the NICU and I don't know how long it will last. One staff is billing me for hours she hasn't been at work, another is demanding a raise (could she have picked a worse time)?

My husband is snapping at me for asking questions and his parents are telling him to give up on his farming business for now to devote himself to the care of his two sons. I am the breadwinner for the family, so if we need to bring home a high-needs baby, he needs to be the one to give up work opportunities for now. I feel guilty about this too.

My intent had been to have the baby and return to work the next week, as I had done with my first. I never thought to make a plan B. So I post ads for a locum and a babysitter for my older son, but as of now, no replies to either. And my patients don't understand why the office is closed down-they just want their doctor back.

I look back to all the times I thought I had so much stress in my life, school and residency especially, and they don't compare to this.

Today the first good news in a long time came. I have won two awards for continuing medical education courses. I will also have a chance to work as a locum in a place that I have wanted to work for a long time. This hint at my past organized life as an FP is so reassuring when the rest of my life is so chaotic and the future so uncertain.

I tell myself to focus on the positive and not worry about what can't be changed. This is what I have told past patients and this is what I do. I am learning a lot just sitting with my son in the NICU. I am donating milk to other babies. I am spending more time with family. I am learning empathy and how it feels to be a patient's mom. I have some of the best night-time babysitters around- the NICU nurses. Most of all, I know that in another time or place, my son would have died from this now corrected birth defect.

If this is how hard things can get, I hope that eventually things will swing back just as far in the other direction. Once they do, I will have to write again.

MiM Mail: PCP to PM&R?

I am an older mom to a one and only, fabulous, wonderful little boy. I had a career in human services before medical school. I completed my internal med residency. I have worked as a PCP for about a year and, frankly, it's awful! I like my patients. I chose to work in an underserved area with a lot of folks who are newcomers to the United States and I really like this part of the work. I feel like all I do is tap on the computer instead of really dealing with the human being in the room with me.

I had never heard of PM&R in med school. The more I hear about it and read about it, the more I feel like it might be a good match for someone like me. (You know, someone who likes to talk to patients, take a history, do an actual physical exam, maybe have time to do a procedure....)

Does anyone have any suggestions about residency training? It doesn't sound like the PM+R residency would be that much worse than the schedule of an attending PCP. I am able to sacrifice salary due to a very type A doctor dad in the picture. (In that way, I am very, very lucky.)

Thanks!

From premed to med

So in the last two months I managed to do most of the things on my list. We moved nearly all our stuff down and unpacked while I was 37 weeks along. SK's birthday bash went smoothly. Our house is rented. Baby #2, SE arrived and is happy and healthy. We waited until she was two weeks old, packed up our remaining items in a U-haul and made the ten hour drive to our new home. (It's really only supposed to take six hours, but every 30 miles someone either needed to be fed or had to pee.) And now we are here, adjusting to life with a new family member, in a new city, with new schools and jobs. Everyone I've told about our moving experience has thought we're completely nuts, which we are, but we had a plan, stuck to it as much as we could and anything else that came up, we decided to just roll with it. In fact, these last four words have really become my motto as of late, so much so that I can basically take a picture of our crazy lives at any moment and have #justrollwithit be a fitting caption.

My first week of school was packed with such moments. No one to drop off or pick up SK from school on Monday? Just stay home with grandma and do some crafts, eat lots of treats and watch too much TV (#justrollwithit). Get to school and realize I brought my pump but forgot all my pump parts at home? Use the lactation room's backup pump and try to ignore the idea that others have used the same pump (#justrollwithit). Motion-sensor lights turn off in lactation room while pumping, leaving me fumbling around in the dark? Dance like a mad woman in the chair, still attached to my pump until the lights turn on (#justrollwithit....ok there might have been some expletives here and there).

I'm starting to realize that my med school experience is going to be a little bit different than what I had envisioned. I missed out on most of the socializing opportunities my first week because I had to run down to the first floor lactation room to pump while everyone else ate lunch. In fact, it is lunch time right now as I write this and I'm being serenaded by the gentle pff pff pff of my lovely pump. When our social calendar first came out I foolishly rsvp'd to several different events which I'm now realizing was a tad bit ambitious. I guess having a preschooler made me forget what newborn schedules are like; I forgot about the eating every 3 hours thing and the getting up multiple times at night routine. I am feeling a little bit left out, but I know the social aspect of med school will come with time, especially when the little one is a bit older. My biggest struggle right now is trying to figure out when I'm going to find time to study and I'm hoping with some trial and error I'll figure it out. Yesterday an assignment took me 5 hours...maybe 1 hour of actual work in total, 1 hour playing DJ for SK so she could perform dance routines in the living room, 30 minutes of reading Fancy Nancy books, 30 minutes of redirection, timeouts and talks, 1 hour of snuggles and cuddles, 45 minutes of breastfeeding and 15 minutes of accidental sleeping. By the time everyone else is actually in bed and I can study without distraction, I'm about to face-plant into my laptop.

I am loving what I'm learning though and I'm thankful to be in a great program. It's the logistical part that's scaring me right now. I can feel the dreaded "what have I gotten myself into" question creeping into my mind sometimes, but I'm pushing it aside for now. I'm rolling along and I'll be rolling with it for the next 4 years and probably thereafter.