If you're a mother, you've done a lot of research

You're drawing on the literature, you're weighing the risks and benefits of various protocols of parenting, and you're conducting the all important experiment called being a mom, confirming hypotheses and identifying new areas of uncharted territory for exploration.  I'm co-parenting a middle schooler presently, so you can imagine that the data is incredibly hard to interpret.  And the participant has many questions about the plan.

And then there are the other people in my life, the medical students.  They have a lot of (great) questions too.  One thing that many medical students universally ask is why, whether or not, and if so how should they do research in medical school.

This weekend I was at the American Academy of Pediatrics national conference (a local national conference, and so I shall at some point post about the ups and downs of big annual conferences that happen to be in one's own home town).  Before a packed house of medical students from around the country and the world, I served on a panel where we were asked question after question about preparing for residency.   

In the ramp up to the panel, the AAP's young peds network launched a new forum for tackling these kinds of questions and I was asked to write about research during medical school.

• Why is research looked upon favorably by residency programs?  (Is it?)
• Why would it be a good thing to gain research experience? 
• How do you go about getting started?   

Should you get involved in research on the way to residency?  For my take on these questions, see Research for Residency here.  Bottom line, whether you are in middle school or medical school, it's great to search for answers, to delve into a given topic and set about to gain a systematic understanding.  Especially if you are enriching yourself and serving others.

That parent: you know the one who makes the front desk staff have nonepileptic seizures?!?

For those that don’t know - nonepileptic seizures also known as pseudo-seizures are a phenomenon when a person does not have a real seizure, but they just mimic the movements of a seizure. Sometimes it is for secondary gain such as getting out of school and getting attention or sometimes it is a manifestation of underlying psychiatric illness.

Well, this is a post about patients that really stress providers and staff out and cause us all kind of angst.

I will take a moment to perform some serious self-reflection: I love me some difficult patients (yes, “love me some” as my Granny would say), blame it on my mother being a Social Worker, me being an interdisciplinary major who took a ton of medical anthropology and ethics classes, and me being extremely committed to social justice. Add to that the fact that most of the difficult patients come from places where my cousins still live and culturally I just feel connected to the loud, passionate, trash-talking patients. And finally, blame it on the fact that I have read countless accounts of the biases we providers have for folks we relate to and have against those who aren’t like us. I continually find myself being the only person bringing these biases up. I get it, I'm usually the only person of color in the room and to me these are issues I deal with every day and most of the time these biases harm folks that look like me and come from where I come from (see references below).

In spite of the very real and significant way we providers treat patients differently based on how we perceive them (see references below), what to do when a parent crosses the line? When their own mental health disorder gets in the way of their interactions with care providers? What happens when a parent only knows how to speak in a way that is viewed as overly aggressive to my colleagues and other staff but is culturally tolerable to me (loud, hands waving, maybe with a few expletives)? What happens when essentially an entire staff is overwhelmed with these interactions. There has been at least one time when I felt like the only one still advocating for a family but even I began questioning if I was really helping at all? What happens when we collectively have nonepileptic seizures when a parent comes in the door because we know the ish is about to hit the fan? I'm just wondering. What to do about "that parent"? The one we all want to avoid but who we still want to find a way to work with?

References:
1. Association of Race and Ethnicity With Management of Abdominal Pain in the Emergency Department. http://pediatrics.aappublications.org/content/132/4/e851.full
2. Problems and barriers of pain management in the emergency department: Are we ever going to get better? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004630/
3. Unequal treatment. https://iom.nationalacademies.org/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx

Call for Topic Week submissions: Thankful

MiM is having our next topic week November 16-20. Topic weeks are weeks where we feature posts by both regular contributors and readers all centering on one common topic or theme. We have had topic weeks on "A Day in the Life," "Work-life balance," and "How medicine has changed me," among many others (check our sidebar labels). This next topic week is "Thankful." 

Please join us by submitting a guest post on anything related to the topic.  Some ideas include: What are you most thankful for? How do you cultivate gratitude in your children? How do you stay thankful? What role does being thankful have in your life?

To be included, please send your post by November 15 to mothersinmedicine@gmail.com. Please include a one-line bio that includes your level of training and specialty.  Feel free to write anonymously. Thanks for reading and sharing!

A Doctor-Mom Day Off With The Kids: Halloween Baking Project

Genmedmom here.

I don't know about other doctor-moms, but I have very little "free" time with my kids. Too often, a day off with them gets spent running errands or from scheduled activity to activity. I've found that I treasure unplanned, sort of spontaneous fun stuff, and I think they do, as well.

One recent weekend day, I found myself with both kids and a few free hours. Some groceries and sundries were desperately needed, so we piled into the car and headed to the nearby super-uber-market that sells everything cheap.

Before we entered the store, I laid out our basic ground rules:

No yelling, no fighting, and no running away from me.

If they could do all that, we would do a fun project.

So we did our shop, and I spied some halloween cookie cutters. They were purposefully displayed alongside theme sprinkles, food coloring, and decorator frosting. Hmmm...

I asked the kids what they thought. Two thumbs up! They excitedly helped pick out what they wanted to use.

When we got home, I made the kids wait until all the other stuff was put away, and then, we started. Babyboy only took part until the dough was made, and then he left with the spoon to watch "It's The Great Pumpkin, Charlie Brown". Babygirl owned this project.

Want to try this at home? Below, see our recipe, and photos of all the steps. Enjoy!

(And yes, the kitchen will be an ABSOLUTE MESS, there is no way around it. Flour, sprinkles, colored frosting fingerprints... and, it will have been totally worth it.)


Sugar Cookies Basic Recipe
Let the kids do as much as they can/want!

2 sticks unsalted butter
3/4 cup sugar
1 large egg
2 teaspoons vanilla extract
2 1/4 cups white flour, plus extra for rolling out the dough
1/4 tsp salt

Preheat the oven to 350 degrees. Line 2 baking sheets with parchment paper, or, even better, those nonstick silicone sheets, they are awesome. Soften the butter, but don't melt. Beat the butter and sugar together with an electric mixer until really smooth. Add the egg and vanilla and beat again. Add the flour and salt and just blend slowly until no patches of flour are visible. Squeeze the dough together as best you can and plop it onto a piece of plastic wrap. Wrap it up and place in the fridge. While it is chilling, make the base frosting.

Frosting:
3 cups powdered sugar, plus more if needed
1 stick butter
up to 1/2 cup milk
food coloring

Soften the butter. Add some of the powdered sugar and beat. Add a bit of milk and beat. Keep alternating until the sugar is gone or mostly gone, and the consistency is creamy and very easy to spread. Leave it out until the cookies are ready to frost.

On a flat clean work surface, sprinkle some flour so the dough doesn't stick. Divide the chilled dough into thirds or fourths, and place on work surface. Flour up a rolling pin, and roll away. When about 1/4 inch thick, cut into shapes using cookie cutters.

When first sheet is full, place in oven and bake for around 6-8 minutes, until golden. These burn really easily. Repeat for the rest of the dough.

Cool completely. We decorated like this: We made several base colors from the creamy frosting, orange, gray and white. I spread the base frosting onto the cookies with a plastic knife, and my daughter then decorated the cookies, for the most part.

(FYI: We also had bought one bottle of liquid black decorator frosting, which we used for the black bats. We tried to use it for drawing and writing, but it was too liquidy. In addition, it tasted funky, and made the kids' poop greenish. Will not use again! I'm sure there are better homemade versions out there.)

Rolling out the sugar cookie dough and cutting out shapes

Yes, our kitchen is a disaster.

This girl is FOCUSED

I hope this black frosting isn't toxic.

Ta-da! (and yes, that is our cat's butt on the counter)

Season finale of “As the Residency Turns”

* DISCLAIMER: I meant to post this back in June as I finished residency but it got put aside as I filled out my umpteenth credentialing application. Here it is now. I wrote it 2 days before finishing my last primary care rotation of residency:

After 3 years of residency I have had some amazing interactions with patients. Amazing in the wonderful way the 9 month old whose well child checks you have always performed smiles and babbles when you walk in way and reaches out for you to hold her. Your heart opens wide, the parents are at ease and you think to yourself, “yeah, this is why I do this!” Or amazing in the way things go when a developmental delay I picked up is being addressed by Early Intervention and we can all see how the affected child is flourishing. Or when you talk that sexually active teen into being more assertive in communication with partners and you get her to get a Nexplanon.

Then I have had some intense interactions of the other kind. Intense in the I was so concerned that I called Child Protective Services and now a CPS worker is here with you and you are yelling at me and I am crying and I want to work with you so much but you hate me right now and won’t listen to anything I have to say kind of way. Intense in the way things go when a parent has what appears to be bipolar disorder and splits on providers and one minute says our hospital saved his/her child’s life and the next is cursing about how several of our providers did them wrong.

During the amazing ones, my heart soars, during the intense ones my heart plummets and I often get palpitations. I have been having a few day run of extreme highs and pitiful lows. I have 2 more days in clinic before my last day of residency at the end of June and there are so many loose ends. I realize that clinic is the only part of residency that resembles continuity; we do other rotations for a month at a time and are essentially visitors but in clinic you are like the cousin who comes home regularly for major holidays and family gatherings.  The end is in sight and I feel like I need some closure - so much so that I helped draft a letter to our patients from the graduating seniors updating our patients on where we would be going and now parents come in and say “Dr. Bee - you’re really leaving us?!?”.

There are so many amazing patients who will continue to grow and I will miss their new developments. And I have a few difficult patients who once I’m gone will literally have no one else who wants to work with them. 2 more days. What can and will I do? Why does it feel like such a huge deal? I think I’m scared and sad that things are coming to an end, it’s for the best, right? Why do I feel like a success and a failure all at the same time?

Meat panic

In case you haven't heard, the WHO recently said that processed meats are in the same category of carcinogens as smoking cigarettes and asbestos. Popular processed meats include sausage, jerky, bacon, hot dogs, and kebabs, along with everyday lunchmeat such as ham, salami, corned beef, pastrami, and bologna, as well as canned meats and packaged meat-based sauces. Also, red meat "probably causes rectal cancer."

Granted, I haven't done a ton of research on this. But I'm a little confused about how big this risk actually is. And how panicked should I be?

If it were just me, I wouldn't panic. I eat very little red meat or processed meat. But my younger daughter eats nothing but processed meat. All she wants to eat are chicken nuggets, hotdogs, or ham. If those things weren't available, I'm pretty sure she would just starve. One article suggested making my own chicken nuggets, but not only will she not eat my homemade chicken nuggets, but she will only eat chicken nugget from Tyson and they have to be circle shaped. God forbid we get chicken nuggets shaped like a dinosaur. They are inedible.

So my question is, how much is it worth panicking? Is anyone making any real changes to their diet? Or should we all just go about our lives as usual?

Meta story

I have always been a big fan of stories. I love listening to NPR's StoryCorps although I do take issue with those segments playing during my morning work commute since they inevitably make me cry. Heck, this whole blog is built around sharing our stories: finding community and support through our stories. So when the opportunity came up last spring to participate in a live storytelling event, there was no way I was saying no. 

The publisher Springer launched a program to "empower authors and humanize research" called Springer Storytellers. They hold live events where authors tell their personal stories about science and research. This past April, one of these events was tied to one of the big medical meetings I usually attend: Society of General Internal Medicine. I was one of five physician researcher authors who took the stage.

It was difficult for me to decide what story I wanted to tell. It had to be a story related to my work, but a lot of latitude was given about exactly what. I love telling funny stories, and I originally thought I might tell a story about pumping madness while attending a medical conference. In the end, I decided to tell a very different story that I had never told before. The story of how my husband's deployment helped me understand my patients better, and how I became attuned to the stories we can't always, but need to, tell. How it led to a curricular intervention centered on witnessing patient stories. A story about stories.

The setting was breathtaking that evening in Toronto. 

Design Exchange, Toronto


I was fourth out of five in the line-up. Each story I heard that night was unique but equally powerful. I fell a little bit in love with each of my co-storytellers. Something about sharing things so deeply personal and meaningful on stage, owning our vulnerability before a live audience, bound us.

One behind the scenes moment took place as I was walking up the four stairs to the stage. As I took the final step onto the platform with my right foot, my left python-print pump remained on the last step. As in, I walked right out of my shoe. Hello, audience. I had to backtrack and try to replace my shoe as gracefully as possible. The emcee came over to give me an arm to assist. This was not quite Jennifer Lawrence's stair fall, Oscars 2013, but not exactly the entrance I imagined.

With both shoes on

The podcast of my storytelling was recently released.  I couldn't wait for my husband, in particular, to hear it for the first time. I tried to listen to it myself, but between hearing my own voice (don't particularly enjoy) and reliving those emotions, I couldn't quite do it. Maybe with some more time and space. (And now, my first words will make a little more sense knowing my shoe incident.)

To stories that need to be told, and to those who choose to listen.

10 lessons learned in 10 years of Private Practice

This summer marked two major milestones in my life: My 40th birthday and 10 years in practice. Both have prompted some serious reflection on my part. As I thought about the most significant lessons I've learned over the years, I realized some were grasped the hard way and others came from great advice (some of which I got from this blog). For those of you in residency or just getting your ears wet in practice, here's a bit of what I've learned, hopefully it might help a little.

1. Make friends

When I first started practice I would often ask senior physicians what advice they would have for a new kid starting out and I was surprised to hear from several colleagues (male and female ): make time for your friends outside medicine. Several remarked that the felt lonely and isolated as they got older having devoted most of their effort to their career with what little time they had left over to their families.

Quality friendships require the one thing I hold the most precious: time. However, thanks to this early advice, over the years I have been very purposeful about making an effort to make time for relationships. Now I have a community of close friends who truly enrich my life and offer me a reprieve from the drama of the medical community. This year I unexpectedly lost my father and I'm not sure how I would of have survived without the support of my girlfriends.

2. The sky is not falling

Since the day I started medical school in 2001 I have heard how the sky is falling. Managed care, EMR, meaningful use, ICD 10 these were all going to send us to the poor house and ruin medicine. Yes, they have caused me some headaches and I may not make as much money as doctors did in the glory days, but I still can pay my bills, take care of my patients and enjoy my job. (see #10)

3. Lean in (but don't fall in the damn lake and drown)

I hate self help books, but if you haven't yet read Lean In then stop reading this post and go to Amazon right now and buy it. In medicine many committees may feel like pointless wastes of time. I would encouraged you to attempt to find one you can be passionate about and get involved. (If not "passionate" than at least one that doesn't make you want to bang your head against the wall out of desperate boredom) By being willing to say "yes" and giving a little bit of your time to get involved in the processes of your organization, you can learn a lot about hospital administration and make valuable networking connections.

I can always find time for a least one committee, but sometimes I can get a little carried away with my ambitious projects. Recently, I found myself on 4 major committees (all volunteer) at my hospital. That was a little too much. I'm still learning to find the balance between leaning in and falling in.

4. I can't please everyone

In medicine, there is a lot of emphasis on patient satisfaction. It's not enough to provide good care, you must be nice as well so the you and the hospital get good grades on our score cards. That's not to mention internet ranking sites, blogs and facebook. If someone hasn't written something nasty about you that wasn't true, then you haven't been doing this long enough.

Of course, we all want to be liked, but in medicine, sometimes you have to be the bad guy. At the end of the day you must be kind and compassionate to all your patients. They will not always like you and that's OK.

5. Know my stuff

Some of the best advice I got as a resident was that you can't know everything, but the key is to know your bread and butter conditions, learn what's normal, know your emergencies and you can look up everything else. I remind myself of this advice when I begin to feel overwhelmed with keeping up to date in my field. I focus on knowing the basics inside and out and keeping references handy.

6. Find my own version of work life balance

To me my work life balance is a combination of having a fantastic SAHD husband, living 8 minutes from my office/hospital and the flexibility of being my own boss in private practice. When I first started practice I would frequently fret during slow office weeks that I would never make my overheard and equally fret during busy office weeks that my children would grow up never seeing their mother. I slowly learned to enjoy the slow season and embrace the fact that the busy season would help me pay my kids tuition.

{In my opinion no one has ever explained work-life balance better than FreshMD right here on this blog.}

7. Be kind

Be kind. Treat the janitor with the same respect you treat the CEO. Treat the cokehead patient with the same care you would your best friend.

Especially in surgical specialties practitioners tend to yell and pitch fits to get their way. I've seen nurses chewed out for pulling the wrong size gloves for a doctor. To be a confident, respected female physician you do not have to be a bitch. The only excuse for yelling is emergent situations where patient safety is being compromised. I'm not saying to be a pushover, but you can be assertive without being mean. When you are characterized by levelheaded kindness, your true complaints will be taken much more seriously by your supervisors.

8. My kids will not be scarred for life because I missed a few bedtimes

I've missed a lot of bedtimes over the years. I still hate the fact that I have to miss out on important events in the lives of my littles because of my job. But at age 11 and 6, they are doing fine and I can already see that the missed bedtimes are harder on me than them. And I promise all you resident mamas out there: LIFE DOES GET BETTER!

9. Have a financial plan

Again, I hate reading non fiction, but one of the best financial book I have read is The Millionaire Next Door. The title is rather misleading, seeming to be yet another "get rich quick" book, but the actual point of the book is to learn to live well below your means and focus on avoiding the traps of debt. I wish I had read it as a resident.

10. I love my calling

There will be rough days. Patients will die, you will get sued, many nights you won't sleep but through all the crap, try your hardest to focus on the times you made a difference. Don't let yourself become a bitter and filled with self pity. This isn't a job we have, but a calling. Concentrate on the moments you saved a life, provided comfort to the grieving, eased someone's pain and changed their lives. If you find the grey cloud of negativity hovering for too long, then make a way to cut back your schedule and refuel your soul.


I'm not vain enough to believe that what's worked for me, will be the answer to all. I tried to leave out all the obvious things like eating your broccoli, exercising and maintaining your marriage. Hopefully even if my advice doesn't apply that much to you, it may make you pause and think.


Anybody else have some lessons to share?

The Gauntlet

We have entered the time of year I call The Gauntlet because I feel like I am running through one. Historically, this refers to two rows of men with sticks and other weapons that who beat the person who runs in between rows. In my house, it refers to early October to late February. During that time, we celebrate Halloween, Thanksgiving, Hanukkah, Christmas, New Year’s Eve, both Blurs’ birthdays, the Super Bowl (yes, it is as important as these other holidays), Valentine’s Day, and my birthday. It seems most of the kids in Blur1’s kindergarten class were born in the fall. We have soccer for both Blurs in a fall and basketball for Blur1 in the winter. In addition, holiday schedules for me and the busy season for Hubby where he works many Saturdays. Between now and December 1st, with normal activities of school, work, and religious school, we have something every day except the seven days I took off for Thanksgiving to travel to my parents’ house; everyone knows this kind of vacation is no vacation.

By the time, we hit February, I am sick of cake, having made and eaten several because the Blurs’ birthdays are 10 days apart and want cake on their actual birthday as well as at school celebration and at their party. For Valentine’s Day, I ask for flowers only as we still likely have Christmas candy (and to be honest, Halloween candy too, if I didn’t go on a rampage one day and throw it all away) still around. For my birthday, I ask for dinner at my favorite local restaurant and I make my own cake (not sad, as I love to bake and am ready for cake again after 3 weeks of no cake) which we eat with the Blurs before going to dinner without them.

I cope mostly by overplanning. I have a Word Document that keeps me organized - presents bought, menus from prior years, locations for birthday parties, etc. I make great use of my freezer and pantry and have already started buying for special dinners and foods. My Halloween costumes (this past weekend), candy (the minute it was put out) and plans (annual party) are all set. I start looking for Hanukkah-Christmas presents in July, start buying August and currently, I’m mostly done with that shopping for the Blur1 (Blur2 being the 2nd kid is always harder to shop for). I know what I’m doing for Thanksgiving (traveling or not) in July and if I’m not traveling, my Thanksgiving dinner is bought the week they put those turkeys out in the grocery store. I have a gathering on trick-or-treat (kid friendly dinner with a couple families at my house and then the kids trick-or-treat in my awesome neighborhood) so that I can decline all other Halloween parties. I buy birthday presents at Christmas sales, usually the week after Christmas but sometimes before. The birthday parties are booked around Thanksgiving but actually take place late January. If we do something for New Year’s Eve (rare because I usually work), it has to be low-key and kid-friendly and in years past has involved the same families as the Halloween trick-or-treat party.

I am somewhat envious of those of you who can just go with the flow and buy Christmas presents on Christmas Eve and “let traditions happen”. I get anxious. I had all these wonderful traditions and my mother made it look so easy. Like my father, it never crosses Hubby’s mind what presents the Blurs should get or what to serve for Hanukkah dinner or even to buy groceries for said dinner. Hubby, for his part, does a lot of the day-to-day home stuff - laundry, dishes, bathtime, bedtime - so it’s not like he doing nothing. The Blurs do get time with us, which I know you’re thinking they want more than a fancy dinner, but they do have to eat.

So if you see me in the store this week, buying Hanukkah supplies (or lamenting my uber-Christian area has Christmas stuff out but not Hanukkah stuff), buy me a Starbucks, because you know I need one.

Hormones and shots and procedures, oh my! What is it like to undergo IVF?

People are having children later in life, whether the reason is pursuit of career aspirations, travel, or riding the asymptotic curve to financial security. This truth is never more evident than in the field of medicine, where more and more women are taking the long road of training to become physicians. Some of us (like me) even choose this training as a second career, rendering us older from the start. You've heard saying such as "40 is the new 30", etc., but the reality is that a woman is born with all of her eggs and those eggs age with her. She may follow a perfectly healthy lifestyle and appear younger than her real age in many ways, but her eggs are as old as she is.

As eggs age, their quality declines in the form of DNA damage, which negatively effects their ability to make a healthy embryo that will grow into a healthy baby. By the age of 40, the percentage of eggs that have DNA damage incompatible with healthy embryo formation is approximately 75%! On top of this immutable fact, aging brings the possibility of medical issues that can affect fertility in both a mother and a father. The chance of a naturally-occurring pregnancy during any given monthly cycle of a 40 year old woman is approximately 5-10%, and due to the DNA damage I already mentioned, the chance of a live birth resulting from that pregnancy is even lower. It is truly a miracle in my opinion that women over 40 have spontaneously-conceived, healthy pregnancies.

Enter in vitro fertilization (IVF). IVF is a long and detailed process, requiring lots of resources, money, time, and patience. The first stage of a typical cycle involves, ironically, taking oral contraceptives to reset the hormone milieu and force all eggs into a senescent, follicular stage. The second stage involves stimulating the ovarian follicles with daily doses of a hormone cocktail. It is usually some combination of FSH, LH or an LH inhibitor depending on timing, and possibly GH. There is quite a bit of monitoring at this stage, including almost daily ultrasounds and blood draws to evaluate the growth and maturation of the eggs. The third stage is egg retrieval, in which all fluid-filled cysts within a certain size distribution are aspirated for the contained egg. The eggs are then fertilized with the intended sperm (by various methods depending on the presence or absence of male-factor infertility) and are allowed to grow for 3-5 days into multi-celled embryos. The last stage is embryo transfer, in which selected embryos are injected back into the uterus for implantation. This may occur using the aforementioned, freshly grown embryos approximately 5-6 days after the transfer, or the embryos can be frozen for testing and/or later transfer. Once an embryo transfer occurs, it's up to fate (and continued hormonal supplementation)... after the dreaded "two-week wait", it's time for a pregnancy test!

As you can imagine, the process is not for the faint of heart, nor is it for the person with no flexible time and no extra money. I had to do IVF to get pregnant, and these are my experiences.

Time: If a fresh embryo transfer is planned, all of the steps mentioned above take approximately 6-7 weeks to complete (not including the two-week wait). If the embryos are intended to be tested or frozen, the first three stages themselves take 5-6 weeks. After the egg retrieval, the ovaries must rest and the enlarged follicles must resorb over time. This is achieved by having a period and going back on oral contraceptives for at least 3 weeks. Then the uterine lining is augmented with estrogen supplementation for another 3 weeks prior to the embryo transfer. During this time, other testing may take place for the patient (such as a hysterosalpingogram, hysteroscopy, or endometrial biopsy) and/or for the embryos (such as preimplantation genetic screening for aneuploidy or diagnosis of genetic diseases).

Not only does each pregnancy attempt take a significant portion of a year (during which time a woman's eggs undergo further aging), but each cycle also requires quite a few appointments for monitoring, lab draws, procedures, etc. Although I sometimes had to apologetically make my schedule requests after my practice group's time deadline, I was lucky to have enough vacation time built into my yearly clinical commitment that I could take as much time off as I needed. Not everyone would need to take the entire day off for an hour-long morning appointment, but as an anesthesiologist I found that it was the only way to make things work. A physician who sees patients in a clinic might be able to shift her clinic hours back a bit to make morning appointments - which occur every other day and at times every day during the stimulation phase of a cycle. And at my fertility clinic, the egg retrievals were conveniently performed on the weekends.

Money: With some exceptions, IVF is commonly not covered under health insurance in the United States. That said, I found that certain ultrasounds, lab tests, and medications would occasionally be covered by my insurance based on the fact that they were recognized as appropriate interventions for my preexisting infertility diagnosis. Prices for IVF vary slightly depending on the part of the country where the fertility clinic is located, the medications prescribed, etc. A typical cycle including the stimulation period, monitoring ultrasounds, and the egg retrieval procedure runs $12,000 on average, not including medications (another $3000 - $5000). A frozen transfer at a later date is approximately $3000 - $5000. Preimplantation genetic testing of embryos adds approximately $5000 - $8000 to any particular cycle. A portion of these costs can be offset using "batching" techniques or multi-cycle discounts, tax deductions (in some cases), and an FSA; however, IVF in its many forms is undoubtedly going to present some financial stress for any patient.

"Heart": Egg retrievals are performed across the country using different modes of anesthesia. At the IVF clinic I used, it was treated as a moderate IV sedation procedure with fentanyl and midazolam; however, there are some clinics that do deeper sedation or even general anesthesia. An embryo transfer, regardless of whether it is fresh or frozen, is usually done with oral diazepam, and the patient does not need to be NPO. Prior to either of these procedures, an IVF patient can expect to have many transvaginal ultrasounds, which can be uncomfortable for some women. There are other diagnostic procedures that may figure into an infertility workup or IVF journey treatment plan as well, such as hysteroscopies, biopsies, hysterosalpingograms, etc. In addition to these procedures, the patient must receive daily injections of hormones during the follicle stimulation phase and sometimes additional daily shots after implantation. Most of these shots are subQ, but some of them are IM. I must admit that I myself am somewhat squeamish when it comes to being a patient, but I found the invasive nature of IVF to be tolerable. The mental aspect of the uncertainty, the waiting, the rescheduling of life so that appointments and cycles can be completed, etc. was much more difficult. But if you are a person who does poorly with procedures, this may be an important factor in your IVF decision path.

Speaking of decisions, IVF can take a toll on personal relationships - friendships, family bonds, and romantic relationships. This usually presents in the form of differences in opinion on direction of care, number of IVF attempts, or ethical issues with genetic testing/embryo selection/possibility of multiple gestation/etc. Going through IVF can also impact your feelings about yourself; many women complain of feeling unwomanly, and I was not immune to this myself. It is difficult to accept that you need assistance achieving something that is so basic to human life as reproduction. I dealt with this through therapy, quiet time/meditation, and journaling, but everyone differs in terms of what works for them to manage such stress. I recommend to every woman undergoing IVF that she at least attempt to get therapy for herself, if not couples therapy for her and her partner.

IVF is a physically and mentally involved endeavor. Copious time, financial allocation, and mental fortitude are required. But for many patients with complex infertility issues, it is their only path to genetic parenthood (as it was mine). I'm 32 weeks pregnant now and I am very happy with the path I took to get here. As a "success story" with a little girl on the way, it was all worth it!

Mothers of mothers in medicine

Hi mommas- I've really struggled to write about an issue that has been a gray cloud hovering over us these past few months. We talk so much about our relationships with our significant others and medicine and how they change once little people enter the picture, but what about our relationships with the rest of our families? How has your relationship with your own mother changed after becoming a mother? Have you had to deal with tension and seemingly irreconcilable differences between your own family and your significant other?

A blog post can't begin to succinctly describe the history and multi-dimensionality of a mother-daughter relationship in a nutshell. To those of you familiar with the Tiger Mom stereotype, this is a good starting picture to have in mind (well... maybe highly risk-averse and conservative Korean Tiger Mom on steroids haha... although this really does do her injustice, as all stereotypes do). Rather than try to paint a picture of our relationship and events, I will ask: how did your parents respond when you told them you were starting a family?

We decided to start our family in my 3rd year of medical school. I should preface this by summarizing that I am the eldest of three and always dreamed of going to medical school, however, mostly beginning in college, my mom deeply disapproved of all my decisions, which in her eyes were obstacles to finishing medical school. First, she disapproved of my significant other (now husband), especially when I decided to move overseas with him to work in a start-up company straight out of college rather than go directly to medical school. During medical school, I did research for 2 years, which in my parents' minds, was a distraction while my husband finished his PhD. When I told my parents we were expecting, I knew they wouldn't be happy, but I did not expect that they wouldn't speak to me for 2 months. When my mom finally called, there was extensive lecturing over mainly the financial aspect- how irresponsible were we to bring a child into the world on a post-doc salary while paying medical school tuition? How could we pay for day care when we were already net negative? (Valid point). How could we deal with the exhaustion when I was entering residency? (Another valid point). Did I have any idea how much of the burden a woman carries when children come into the picture? (Umm) How could we know what we were getting ourselves into? (Who does??) And how in the world could we expect her to be happy for us? Why did we have to do this under these circumstances and why couldn't we have waited? 

She came around of course as my due date came closer. But ironically, after my daughter was born, after years of a tumultuous relationship, I felt like I could finally begin to understand from where her fierceness and seemingly extreme irrationality arose. And shockingly, for the first time in my life, I felt like she was the only person who understood me. Like her, we had no outside family help when my daughter was born and it was just so so hard (with my dad in the military, we were living out of the country when my brothers and I were born). I felt like she was the only person to whom I could really express my feelings of utter exasperation and exhaustion- I entered the newborn period after a 50+ hour labor, needing to basically to be left alone and sleep for 2 weeks straight to recover- frustrations dealing with the sudden extreme gender inequity that having boobs and a vagina lead to, and struggles being at home and navigating a new identity as a mom. Despite always adoring kids and feeling very maternal, I really did struggle with having a newborn and it took me several months to settle into becoming a mom. My mom was the only person I could really speak with about these feelings openly when I felt like all I could hear was "enjoy every precious moment!" at every turn.

Fast forward a year. Moved cross-country for residency to be an hour away from my parents and on the same coast as my husband's family. My parents are an enormous support to us and we love seeing our daughter spend so much time with them, we see them every week or every couple of weeks. My husband, for the first time in our ten year relationship, feels genuinely accepted by them. But then we decide to expand our family and I get pregnant. This time, though I still tell them with trepidation, I expect that the reaction will be different from my parents- however, no such luck. A complete repeat of the previous episode with silence for weeks followed by yelling about financial irresponsibility, exhaustion, being unable to handle two, etc etc. However, there is also, why couldn't you "find someone" who can provide for you? (my husband is a PI in academia) This devastates and infuriates my husband, understandably, who by now has been made to believe that the disapproval drama was a thing of the past.

I had a miscarriage. But serious damage had been done. It's been maybe 6-7 months since then. I made amends with my parents a few months ago so that I feel comfortable visiting them on my own, in large part for my daughter. No, they are not perfect, but missed them and love them and grateful that they are close by and healthy. And I have been through these episodes so many times with them, I don't really take it personally. But my husband is different. These are not his parents, he does not have the loyalty I feel towards them. He feels like he never wants to see them again, that enough is enough. They have made no effort to apologize to him, because they feel like they have nothing to apologize for. It is like a Cold War and I am stuck in the middle. Again, number two is on its way, and I still haven't been able to bring myself to tell my parents... I keep hoping somehow things will be resolved between my parents and my husband before then. I am now solidly into the second trimester and won't be able to hide it much longer. I want to be optimistic but I do dread sharing the news. Isn't that unfortunate? I know it's not a big deal in the grand scheme of things, but I really wonder what it would feel like to not have these life events overshadowed by negativity. Any advice/thoughts/sharing of your own experiences are welcome.

This child and his sensitive skin

It all started out as a little papule on his left buttocks. In the middle of a busy week of relatives visiting and make-up clinic days, what started out as a small papule morphed into something worse. Zo has had exceedingly sensitive skin since he was 1 years old. Hyperkeratotic plaques behind his knees that sprout up in the span of 2 days if he isn’t slathered in a thick mixture of shea butter and petroleum jelly twice a day. Diffusely itchy maculopapular rashes if we miss his nightly dose of cetirizine. That type of sensitive skin.

I thought I had things under control. But I didn’t.

Monday - I see a little papule on his left buttocks. I put on a thin layer of triamcinolone 0.025% on it. Later that night, I see a few more papules. I put him in the bathtub and then put on more triamcinolone and begin our twice a day ritual for exacerbations.

Tuesday - I see more papules. He is itchy. Is that a ring? Nahhh, I’ll just step up the emollients.

Wednesday - I return home and notice him scratching. How was swimming? His response, “it was fun” as he continues to scratch. Bathtime. Is that a 2 centimeter scaling ring-lesion?!? Oh goodness! He’s got tinea!!! I don’t have time to get clotrimazole and I forget to text my hubby what medicine to get from the pharmacy.

Thursday - satellite lesions. After clinic I run to the local CVS and wait in line for 15 minutes to purchase clotrimazole and by the time I arrive home he's asleep. That peaceful sleep where you know not to interrupt them or all hell will break loose so I let him sleep as I fret about his tinea outbreak.

Friday morning - we begin twice a day clotrimazole use.

Weekend - more lesions. Lower back, posterior and anterior thigh. Areas I won't mention for fear of him one day reading this. But seriously who knew tinea could spread so quickly and that toddlers can get jock itch! Major fail!!! Quick consult to my doctor friends with pictures of all of the lesions minus his groin. Definitely tinea. Definitely spreading; it’s all of the summer camp fun and splash park play dates. Primary care friend KJ says just go ahead and suck it up and put him on griseofulvin too, it’s already too out of hand and you'll stop it before it spreads to his scalp.

And just like that, I have written my first prescription for my son. Too ashamed and time-pressed to bring him in to my new clinic for tinea corporis. I knew the liquid wouldn’t go well as he is now 16 kilograms and our last go round with amoxicillin ended in us making daily smoothies. Based on my calculations, he could do one-half of a 500mg tablet daily - and after all of the pill swallowing for kids I observed due to an awesome program one of my co-residents did, I knew what to do.

Tuesday - I took him to the pharmacy to get him excited about his new medicine to help with his itchy parts. He shook the bottle to a nice beat and did a happy dance. We got home and I cut the pill. Hubby says “shouldn’t you crush this, it’s huge.” I say “nawww, we’ve got this.” Equipped with 1 tablespoon of honey and half of the pill, I say, “okay, you’ve got to swallow this without crunching it up.” Zo smiles, says okay and then hubby offers him some extra water and then VOILA!!! My almost four-year-old swallowed his first pill!!! Proud doctor-mommy moment in the midst of a crazy week.

Last day of September

September is National Suicide Awareness month. With this last day of the month, I want to bring awareness to this heartbreaking issue.

You might be thinking: how does this relate to Mothers in Medicine? Unfortunately, it's a topic that has impacted me.

Most of you will remember Superstorm Sandy, right? Well, not only did it destroy billions of dollars in property...it destroyed lives, too. My cousin (we'll call him Bill) was living in NYC, had 2 kids and a wife, had a couple of businesses that seemed to be going well. Then the storm hit--Bill lost several properties and his car to the flooding. His wife left him, and she took the kids. He was despondent. Little did I know at the time that Bill was also abusing alcohol. He even tried to get help from a counselor.

Bill moved in with my aunt and uncle, living in their basement, until he could get back on his feet. One day my uncle came home from work to find that his son, my cousin, had committed suicide. My dad went to be with the family and had to identify the body in the morgue. Bill's suicide was the most devastating event in our family's recent history.

Since Bill's death, his parents have struggled with all the stages of grief, as one can imagine. Now three years hence his mother is ravaged with anxiety. It's hard for me to conceive of anything more tragic than losing your child.  And losing them to suicide: a potentially preventable cause. Well, that's the kicker.

As a mother and a doctor, I think it's in my nature to be concerned about the welfare of others. I mean, that's part of those jobs, right? But since Bill's death, I really try to listen *intently* to the answer when I ask someone, "How are you doing?" I try to read the body language. But despite our best efforts as mothers, doctors, friends, etc. I am sure we miss the subtle hints of people who feel they are on the precipice, without hope to carry on. When I see people I know or patients I see with depression, I am insistent that they get treated. I impress upon our housestaff the importance of treating depression, for it affects a person's self-management of their other comorbid conditions.

So to our community of mothers in medicine: we must try to reach out to others, lend an empathetic ear, connect people with medications, counseling, other treatments for depression. Let us work to prevent losing more of our children, our loved ones, our colleagues, our neighbors to suicide.

MiM Mail: Looking for a part-time pediatrics residency partner

I am a mother of soon to be three boys in search of a part-time residency in Pediatrics. I am willing to live anywhere in the continental United States to make part-time possible. I read encouraging comments from mothers on your blog who did part-time or know someone who did. I was also encouraged by an article I read from the AAP on part-time and how open programs are to it. It listed benefits of mental health, productivity and job satisfaction. However, I seem unable to find a program amenable to it. I applied to all of the programs that advertise having part-time/shared positions. I've been offered a few interviews but when I ask about part-time, I don't get very encouraging replies.

One woman wrote that she similarly got denied until she found a partner willing to split time with her. I am looking for such a person and would love it if we could find each other. My dream is to be a doctor but I do not feel the sacrifice of three solid years of working horrific hours is fair to my family. I hope there is another person out there seeking the same and we can help each other fulfill our dreams and personal goals in this way by sharing a position. If you would like to discuss further, please send an email with your contact information to mothersinmedicine@gmail.com.

Thanks in advance,
J

Tackling My To-Do List

I have always been a maker of to-do lists.  Ever since childhood, I enjoyed making to-do lists and checking of completed tasks.  But somewhere between residency and motherhood, my to-do lists got out of control. 

As an intern, I had a clipboard with a to-do list that a) ridiculously long and b) my life (i.e. if I lost the list, my life as an intern might end). 

Motherhood (which began when I was a third year resident) brought a whole new set of to-dos.  My home to-do list started to rival my work to-do list.  In the ten years I’ve been a working mother, my to-do list has become a monster that I lives a life of its own and now controls me more than me controlling it.

Some bad things were happening.  First, I would look at my list and feel a sense of panic.  Second, I felt totally unaccomplished because I could never actually get through my list or even make a dent in it. Third, I was always late because I was always trying to eek one more task into my day.

A few months ago, I decided to reevaluate my to-do list process.  I had read lots of productivity books (in fact, I’m a bit of a productivity book junkie). I had tried making a four-quartered square to prioritize tasks. I had tried to dedicate time to finish tasks at the end of the week.  But nothing was working. 

Here’s what I did.  I made a list of the domains of my work and life and created one monthly goal in each domain.  For example, I have an ongoing list of things I have to work on in my apartment. Instead of keeping an enormous anxiety-provoking list of a million tasks, I pick a room of the month and focus on it. 

My work involves a lot of writing, teaching, and administrative tasks.  In each of these domains I created one monthly, practical goal.  In the writing domain, my goal is to prepare a final version of a research paper and to start a draft of a new manuscript.  Nothing more, nothing less. 

After I set monthly goals, I create daily to-do lists that contained about five to six tasks.  These tasks work off the monthly goals (e.g. finish my MIM post) and a few other things that are more routine (e.g. clean my office desk) or just come up (e.g. buy last minute party favors for my son’s birthday).

The shorter list is a huge change from my previous lists. It takes a lot of effort to keep it short. With the barrage of emails every day, it’s very tempting to add one more task. But the vast majority of these tasks don’t need to be done today and instead can be done in a few days when I have an emptier list with more room.  The key habit it to write down the task on another day’s list so that I don’t stress out about forgetting it.

My to-do list experiment has been really insightful.  A few expected things that came up:

1. My stress level dropped.
2.  I feel a sense of accomplishment at the end of the day.
3. I’m much more connected with my kids and husband (i.e. when I get home and I am not trying to get 80 more things done and actually focus on my family).
4.  I’m on time (ok, not always but more frequently).

These were all things that I expected and was pleasantly surprised that they came true but something unexpected came up.

I became much more productive.  I did not expect this.  I thought that with a shorter list, I would get less done. What I found was that with a shorter list, I actually got more done.  I especially got things done that I had been dreading or putting off for months. 

In the course of three months of my experiment I finished three manuscripts, started drafts on three more, wrote five blog posts, and cleaned out my kitchen cabinets (this task had been on my to-do list for two years). I also watched several movies with my family and did not pull out my laptop to-do work during them (this is unheard of for me).  

As mothers in medicine, we are expected to-do an almost superhuman number of things in our lives.  Ladies – let’s take back our sanity and tackle our to-do lists!