Thankful in this moment

I am thankful for this hour of quiet. My father is in town helping us for 4 weeks while my husband is away doing research. I signed up to take Zo trick or treating but the greater than 50 notes I have to finish from the last 2 weeks are weighing on me and I have vowed to finish them this weekend.

I am thankful for the opportunity to care for my patients and their families. There isn’t a day that goes by that I don’t laugh and smile and sing and dance with my patients and think to myself or say out loud how wonderful they are. From the teenagers affected by gun violence who are working so hard to graduate high school and stay out of trouble to the school aged children who get so excited telling me about their dreams. To the new parents whose babies are growing and thriving. There cannot be another job like this!

And I am thankful that my position has just the right amount of joy coupled with dysfunction to keep me motivated but to also remain committed to finding solutions to enhance the work experience of community pediatricians. I cannot imagine how folks continue with this schedule for years and years. I have been practicing full time for less than 6 months and I seriously need a scribe, personal/house assistant, cleaning person, and driver for our son. Out of discomfort comes great things so I will work hard to building a better future for myself and future providers as well. It has to get better. And I have some ideas on how to make it happen.

I am thankful for being given the opportunity to raise my beautiful, outgoing, silly, passionate 4 year old with my extroverted introvert of a husband. I am thankful that my husband’s schedule is flexible enough to accommodate random days off from school. I am thankful that my new salary allows my husband the ability to pursue his research interests. And I am so freaking thankful that at this time next year he will likely have a full time job with benefits so that I can work on a schedule that gives me more freedom to pursue my research and advocacy interests.

In this moment I am thankful. And that’s all that really matters.

Entertaining injury

Just wanted to share a quick story that has made me smile to myself all day today... Last night, I started cooking poorly planned stir fry for dinner while my two-year old daughter was playing with some toys around the kitchen island. While veggies and tofu were sizzling, I started reaching for a few items for sauce, and had the terrible realization that we were somehow out of soy sauce. Ack, I told my daughter! But bad mommy- as I scrambled to throw together some alternative marinade, I didn't keep a close enough eye on her, and in a total of about 5 milliseconds, she managed to pull out a giant glass jar of applesauce from the pantry (when I lamented we were out of soy sauce, she heard "apple sauce" apparently haha). She triumphantly yelled out, "Mommy, I found some sauce for you!!" came over to me, and held it up to me over her head. It slipped out of her hands. ONTO MY FOOT. Mother*%!?!**!!!!!! I fell to the ground in agony. The ensuing events are what have made me crack up and smile to myself all day... she immediately retrieved her beloved comfort cloth/rag, which she calls Addy, and ran back to offer it- "Mommy, here's Addy, here's Addy, feel better?!??" She then proceeded to stroke my back with urgency and say, "It's okay mommy, it's okay, you're okay, feel better? Need a kiss? Let me kiss your foot. Better now, Mommy? Need some ice? Here's some ice. Better now??" This circuit of questioning and comforting went on and on for several minutes in her high pitched concerned voice. I was tearing up and laughing simultaneously- it was like she was doing a condensed/abridged performance of all the things we've ever said to her when she gets hurt, haha...  Despite all the pain and my bruised foot, I'm very comforted to know she's internalized these things and knows how to mobilize to help others. And yes, of course her kisses made my boo-boo better :)

Girl Power

I just finished two of my best weeks as attending on the wards. It’s hard to describe exactly why these two weeks were so great but I think it had to do with a great team dynamic that involved trusting my residents, great teaching opportunities, and interesting patients.

But I also have to wonder if my great experience was because my team was all woman including a resident and a medical student who are both moms.  Here are a few observations from my rotation.

First, resident mom and med student mom AMAZE me.  Resident Mom has two school aged children which means she has had kids during her entire residency.  Med Student Mom has an infant and is on her second rotation after maternity leave.  She drives an hour each way to get to the hospital and leaves her baby for long stretches with her mother. I am exhausted just thinking about her schedule.

What amazes me most about Resident Mom and Med Student Mom is how calm, unstressed, and pulled together they seem.   They work the crazy hours of training yet never seem stressed or tired or cranky.  This is quite different from how I felt (and likely appeared) when I had my son during residency. I cried every morning when I left home and complained a lot about the fatigue and stress I felt.

Resident Mom and Med Student Mom appear quite different.  They are super calm and seem truly on top of everything.   I am in total awe of their dedication and composure.

The second thing I realized is that mothers in medicine need to support each other and the hierarchy of medicine shouldn’t get in the way. There is no question that training will always be grueling and the workload will be heavier for students and residents than for attendings.  

I can’t change this system. But I can create a better culture where people feel safe to talk about the pressures of training, particularly being a mother in training. 

Mothers in Medicine blogger, KC, wrote about a different approach when she became a division chief and met with a new mom who returned from maternity leave.  “We talked about her transition back to work, their childcare arrangements, and where she stood in terms of identifying academic areas of interest,” she wrote. This was a total reversal from her own experience eleven years earlier with male bosses.    

My recent experience on the wards reminded me of KC’s story.  As mothers in medicine start to rise up in the ranks, we can create a culture that supports other mothers, especially those who are still in training or early in their careers.  We are the ones who recognize that it is not easy to be a mother in medicine.  It was natural for me to ask Med Student Mom if she was able to find a lactation room and ask about Halloween costumes and understand that some mornings are harder than others.  

For some of us, showing this support comes in the form of blogging and writing and working for policy change.  But for many of us, support comes in a quieter form – a silent culture revolution. It can be asking questions of how another mother in medicine is doing - whether she’s feeling stressed or guilty or exhausted.  It can be breaking down the hierarchies and treating each other not as students and residents and attendings but instead as adults who share a common thread of motherhood. 

MiM Mail: DO or MD school and motherhood

Dear Mothers in Medicine,

First of all, thank you for being so helpful and encouraging. When trying to decide whether or not to pursue medicine, I read just about every post and every comment on here! Now I am writing to pick your brains about MD/DO. There is a lot of information out there on the residency "merger," and the differences and similarities of the MD and DO approach.

However, I am writing to you because I want to know how getting a DO degree over an MD degree might impact my future specifically as a mother.

Right now I can either apply DO this cycle (the application season is longer) and start school in the Fall of 2016 or wait to apply next year to MD and DO programs and have more options, but start in the Fall of 2017. I am already 27, so starting sooner is very appealing to me, but I don't know how much my age should matter. Either way we will be having children while I am in medical school and residency.

Although I am pretty set on primary care, I worry that I could be wrong. Two years ago when I started this journey, I didn't think I really liked science --- I thought I just needed to get thru the pre-reqs so I could go into pediatrics or FM to provide care to rural and underserved communities. Turns out though, I LOVE science. For a few good hours I considered pursuing a PhD in biochemistry instead of medical school.

Now there is a small part of me that wants to keep my options open incase I fall in love with a specialty I don't even know exists yet, or if I decide to do research. But this --- always wanting to keep all my options open for as long as possible --- is one of my weaknesses and I don't know how much to indulge that part of me!

From reading all the posts on here that mention osteopathic medicine, it seems like a few regret their decision to go DO (momstinfoilhat and RH+) while a few (mostly students) left more positive comments. RH+ wrote in 2008:

"Don’t become a D.O. Right now you are sure that you are going to practice rural family medicine, this will change when you start rotating through different specialties. You are being told that being a D.O. will not affect your ability to get into residency. This is not true. You will seek to match in a competitive specialty, and it will be harder for you to get a spot. It will also make it harder to get a fellowship."

But, this was back in 2008. So I don't know if it is still true? I also saw someone mention that DOs have to do more away rotations in their third year than MDs? With the young children we hope to have, this could be frustrating.

A few physicians on here have mentioned taking time off to care for a newborn and doing research during their time off. Is this an option that is available to DOs? I ask because I haven't heard of any DOs doing it, but I like the flexibility that idea offers.

So, all this to ask, if going the DO route limits our choices later (in terms of a research year to care for a new baby or options for residency locations or job locations... which could limit access to family support), then maybe I should wait the extra year and try for MD while also applying to DO schools?

To those on hiring committees (MD and DO), have you or your colleagues ever passed over DO applicants in favor of MD applicants?

To DOs who are doing their residencies and DOs who are working: Did you feel limited in the match or when applying to jobs? Do you regret your decision to go DO? Do you feel like you have had to work harder to prove yourself as competent as those with MD degrees? Did you feel like your clinical training (years 3+4) was as strong? Can you think of any unexpected ways being a DO might have influenced you and your families lives?

Thank you so, so much for taking the time to read this. I really appreciate any help and advice you can share.

All the best,
Confused pre-med and pre-mom

The End… and the Beginning

When I was first queried about writing, specifically for a blog like this, I was excited, nervous, surprised… would other mothers in medicine actually want to read what I have to say? Would this be an opportunity for me to reflect upon my own clinical and academic practice? Would this enable me to grow as a physician mom? 

Like many things I’m sure you all can relate to, this idea fell to the back burner, simmering. I now find myself at a critical point in which the stew that is my professional and personal life are bubbling, coming to a boil and I find this the opportune moment to jump in. This comes on the heels of a gentle reminder from KC, for which I am thankful. 

I am approaching the final stages of divorce. In order to proceed with finalization, I have been required to attend parenting classes. I won’t go into just how asinine I thought this was given he has no requirement to attend said classes. Nevertheless, I showed up with intent to learn as much as I could that I’ve not already discovered through trial and error in the co-parenting adventure. I was surprised that they started with Elisabeth Kubler-Ross and the stages of grief. I took that with a big arms across the chest eye roll, then softened a bit as I thought more about each stage and the fact that this transition does in fact mark a loss… I’ve since considered my own transition through the stages and thought back on the years we were together. 

It’s taken nearly three years. I asked him to leave almost three years ago with our eleven month old son on my hip, seething with anger and pain. Eight years of emotional roller coasters. Eight years of infidelity. Eight years of me not acknowledging my own value. In that moment, that decision, I chose myself and my child. I chose to remove myself from a relationship and marriage which was so far removed from anything I wanted to model for my progeny. I had finally come to the complete realization that my husband would not every remain faithful and tend to his responsibility and commitment to me as a life partner. I did not want my little one to watch and live in an environment where a person whom is purported to be loved is treated that way. I have come to terms with the fact that I have zero control of half of this equation (my ex), however I have full control of my own actions, behaviors and decisions. 

So, if you will, walk through the stages with me. 

DENIAL 

Every single time I found out about another indiscretion of infidelity, I refused to believe it or give it any power. I denied how devastating his actions and betrayal had been. I denied that he’d made a seemingly meaningful connection with anyone in this world other than me. I denied that he’d violated my trust. I denied that I deserved to be treated with respect, dignity, love and commitment. I denied my value. I denied my intelligence. I denied my sex appeal. I denied everything and assumed it was my fault. I stuffed my emotions and hurt into a little box and told myself he’d be better. I denied my visceral sense that his behavior would never change. I denied my better sense. I denied my friends’ pleas to remove him from my life, over and over again. 

ANGER 

This emotion is incredibly primal for me, particularly in regard to this situation. My instinctual, somatic response was long buried due to a longstanding practice of compartmentalization. The trouble with compartmentalization is that it is both protective and destructive. I put those sad, hurtful, scary, heart wrenching things in a box, I lock each box, then I dissociated from those feelings with the hope to never, ever have to feel those terrible feelings again. I felt comfortable, or at least I felt that I was well enough in control of my life to go about my day to day. Then there come times when I’ve run out of capacity in my emotional compartments and for me, that’s usually when I feel least in control of this primal behavior. On the surface, I perceive myself to be fairly calm, cool and collected. When my fully stuffed compartments start to overload, the anger floods over me, forcing my hand to process what’s in those boxes. This is also the crux of that inherent destructive nature of compartmentalization as well. 

When this happens, my transition to anger is a painfully exhausting one. Each of us experiences it differently, but I can tell you how it feels for me. I develop an ache in my chest, then my heart rate quickens, blood rushes to my head, my jaw clenches, my nostrils flare, my posture becomes more erect and inevitably, my left eyebrow raises. My hair stands on end, my pupils dilate and I coil into position to strike. If it happens too quickly, it blends with the hurt and tears well up alongside my venomous words. At the same time, the sense of power that comes with anger is intoxicating. If it happens more slowly, I can calculate my response, choose my words and actions in a much more strategic way. I feel much more in control and strong. It’s a delicate balance, however, between the primal emotion and the controlled response. My ex, whether intentionally or not, can always find ways of awakening the beast within me. I’m still learning my own triggers and how best to turn each experience into something productive rather than destructive, with particular focus on self preservation. That, however, is for another conversation. 

BARGAINING 

Anger is powerful, but it’s also energy intensive and exhausting. That adrenaline rush only lasts for so long and in general, I’m a big softie. So, let’s get to part of my own challenges with him. The mind is strong, the woman is strong, the flesh is weak. I rationalized that if I reclaimed him, I somehow won. Then I’d turn the blame onto myself. I’d make lists of the things I was or was not doing that must have somehow had an impact on his behavior. If only I wasn’t studying so much, if only I spoke another language, if only I were more exotic, if only I wore more makeup more often, if only I were thinner, if only I were funnier, if only: insert any markedly self-deprecating phrase, he wouldn’t have strayed. I’d consider what I could change about myself to keep him from doing it again, maybe if I were more shapely, or if I colored my hair, or if I wore more makeup, or if I spoke another language, or if I had perfect skin, or if I had perfectly manicured fingers and toes. I was just certain that I could do something to inspire change in him, then in my depression, he’d feed into the bargaining and do bargaining of his own: “I’ll delete her number, I won’t work with her anymore, I’ll delete that email account, I’ll go to counseling, I love you, not her, I don’t know what’s wrong with me.” On and on. Of course, this spoke to the caretaker in me as well. There must be something wrong with him and I can help him! What a poorly rationalized thought which cost me the better part of a decade and emotional scars which will eventually heal, but not disappear. 

DEPRESSION 

I spent eight years ping ponging between denial, anger, bargaining and depression. It happened so frequently that it just became the norm and an expectation. It was just a matter of time until it would happen again, then pieces of my heart would chip away, I’d become furious, buried in anger and wanting to lash out. When he, the person in my life to whom I’d given everything I could possibly think of giving betrayed my trust and discarded me as if I was worthless, I became worthless. I devalued myself. My life lost it’s color. Everything was grey. Tears ran until there were no more tears. The ache in my chest became colder, darker, then numb. I anesthetized and dissociated myself from the situation, from our life together. I ached for connection. I ached to be desirable. I drank, a lot. 

The most marked period of depression in all of this was not actually after I finally asked him to leave. It was when he told me he didn’t love me and wanted a divorce. I packed my bags. I had no idea where I was going. I searched frantically on Craigslist and found a furnished studio which fit into my budget. It was close to the subway. It was close to a grocery store. The grocery store had wine. I could get to work. I could get food, not that I had an appetite. I became a hermit, a one to two bottle of wine per night hermit. One day I woke up and realized that this was not at all in my best interests and pulled back on the alcohol, found a 10 mile race to train for (I’d never run that far in my life) and redirected my energy. Slowly, the depression lifted which softened my heart and he came back into the picture, again. In my softened state, I let him back in, of course, but that’s a story for another time. 

ACCEPTANCE 

This may sound strange to you, but the last time I let him back in, I knew it wasn’t going to work. I had decided that he was not going to change, but I was going to give it one more go. You may be thinking to yourself, “WHAT?!?! Is she crazy?” Maybe, a little bit. We all have our own pathology and demons and this was my path to take. My decision to let him back into my life and my heart was complicated, as these situations often are. As was our cycle, there was wooing and there was romance and of course there was sex. Then one day I realized I was incredibly sensitive emotionally, my breasts were swollen and sore, and GASP! I was late. I immediately ran to the drugstore, bought a pregnancy test, walked to nearest coffee shop and went into their bathroom, and melted into the bathroom stall as two pink lines showed up. Did I forget to mention that I was tapped as a chief resident for the next academic year just one week prior??? 

He never wanted to have children. I could just not tell him. I could cut him out of my life forever. I’d always wanted to be a doctor and I’d always wanted to be a mom. How in the world am I going to do this alone? I knew he was going to completely flip out. It would be so much easier to not include him. Alas, that wasn’t the right thing to do. So I told him. He was livid. “How could this happen?” Ummmmmm, I know you’re not a doctor, but seriously? Remember all those times I reminded you that I wasn’t on birth control anymore because I didn’t think it was necessary given I was alone in a studio apartment drinking my life away and maintaining solitary confinement? Well, we had many conversations about termination, so much so that I went to Planned Parenthood for a preliminary appointment. This was followed by a call in tears to my best friend in the entire world about how there was no way I could do this alone and that I couldn’t count on him for anything, so wouldn’t this just be easier. Thankfully, she talked me off of the ledge. She knew that I wanted to be a mother more than anything and that all of the excuses I was coming up with were silly in the grand scheme of things. I’m a strong woman and I thankfully have a wonderful circle of friends and I would figure it out. I would be ok. We (my kiddo and I, at least), would be ok. 

Then it became clear that he was still involved with tomfoolery with one of the many women from his past. She got involved and there were text messages and emails. I have to say, the level of class demonstrated by all parties is fodder for another time. Ultimately, he cut ties with her, promised to go to therapy for his “sex addiction” read “narcissism.” By the time I was eight months pregnant, he’d demonstrated sufficient amounts of commitment that I finally moved back in and we planned for the arrival of our baby. 

I knew it wasn’t going to work. I. Knew. It. Was. Not. Going. To. Work. I felt compelled to give it one last go for the sake of our little one. I also had an inner dialogue that was determined to figure out how to at least be a parent with this man. We made a small person. I’m stuck with him no matter what happens between us and our relationship. I have to tell my child when they’ve grown bigger and understand more of the world that I did try to make things work. I also had to give my ex the opportunity to be a father, though he never thought he wanted to do that. I wanted to be able to look into the eyes of my pride and joy when they ask why mommy and daddy aren’t together and speak frankly, honestly, that I did everything in my power to make things work… and they just didn’t. I want to say that we both love our child and have our child’s best interests in mind and want them to grow up happy and healthy. 

So, when I was in the midst of my first year as an attending, spending a fair bit of time as a solo parent with our newborn given my husband’s work related travel, and my little was 9 months old and I got a phone call from my father-in-law. He was nearly hysterical as my mother-in-law had just had a CT scan with a mass and mets EVERYWHERE. I knew what this meant. My father-in-law had an inkling, but not a full understanding. He’d tried to call my husband. No answer. I tried to call my husband. No answer. Text. No answer. Another phone call. No answer. I called the hotel where he was supposed to be staying for his work related conference. “I’m sorry, ma’am, there’s no one by that name in this hotel.” Call to his boss. “I don’t think he’s checked in to the hotel yet.” After trying to reach my husband on an emergent basis for two and a half hours, he finally called back. How do you deliver bad news to the love of your life after you’ve been unable to contact them for a prolonged period of time? You don’t ask too many questions about where they were, who they were with and what they were doing… after all, their mom is dying and they don’t even know it. You take a deep breath, tell them you have some difficult news and follow that with as much promise of support as you can. I told him they’d found a mass, it was very concerning for widespread cancer and we needed to figure out how to get him home and us on a plane to see her. I called my colleagues, got shifts covered, booked our flight, headed across the country. 

My husband stayed. I came back to work and essentially be a single parent. I facilitated conference calls with specialists, primary care physicians, hospice providers, and my husband, father-in-law, brother-in-law. I was the tele consult 24 hours a day, while caring for our infant, managing a nanny who left a bit to be desired, managing my board exams and finding my way as a new attending. My mother-in-law didn’t want treatment. She wanted quality of life. Her sons and her husband could not fathom this. My father-in-law understood her desire, but his heart was broken. He was watching his love slip away right in front of his eyes, in his own home. The boys on the other hand were going through their own grief process. My husband was distant. I expected this. I figured it was his process. At the same time, just hours after we celebrated her life in a remembrance ceremony after her death, the text message that came from his paramour, while not unexpected, her timing was audacious. “I think he’s lying to us both. I hope he comes clean with you.” 

That was THE moment of acceptance. I knew it would come. I just needed to go through the whole process. That was the moment our marriage and relationship was over. Now, don’t get me wrong, there certainly followed moments of depression and anger and a sense of loss, but there was no bargaining and there was absolutely no turning back. That was the point of no return. I am worth more than this and my child deserves to learn that I will not accept being treated this way. My kiddo deserves at least one parent who strives to demonstrate the value of meaningful and lasting relationships built on communication, openness and trust. I refuse to accept that life anymore and am moving on with my new life and my little one.

Here's to new beginnings.

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!