The Versions Revisited

I retired my personal blog a couple of years ago, but at one point, it was a very big part of my life. The importance of capturing the details of my life - with all of their humor, fake drama, and sometimes real drama - loomed large in my priorities. And capturing the details of my children and how they were growing was part of that.

I started a regular series on my blog that took the form of Version Updates. Like software updates, with the latest advancements and continued operating failures. It started with Version 14.0, when my daughter was 14 months old. This, of course, led to some nice creative outlets and photoshop skill development. I eventually felt like my children had "graduated" from having such scrutiny and carried it through until each was around 3 1/2 years old (that's Version 42.0 for anyone counting). I hoped that one day, they would be thankful that I catalogued their journey through the early years of life and didn't think I had exploited them for entertainment and cheap laughs.

I published a book of my daughter's Versions posts to give to her, complete with a dedication in the front. I included that I hoped she knew that I wrote it all down in love and that I was laughing with her, not at her.

Well she's now 11. Almost as tall as me. Her feet are bigger than mine and she borrows my clothes. She's seen the Versions book of her and knows where we keep it in the bookcase downstairs in the playroom. The other day at dinner, she was mentioning the autobiography her class has been tasked to write as an assignment. My husband and I were playfully retelling some of her funnier moments at the table when she leapt up and ran downstairs. She came back with the Versions book and started reading at the table. Every so often, she would read a passage out loud, and we would all laugh. She flipped the pages and soaked up the words. Those words, my words, echoed all around us, delivered with her voice. It all came back - oh yes - you used to say that! The memories tumbled by, and I loved, loved that she was relishing in it.

After dinner as we were cleaning up, and she and I were alone for a moment, she said, "Thank you for writing this. It is very special." After a pause, she added, "Can I do this for my children too?"

My heart leapt. "Of course you can. I'm so glad you like it."

She carried the book off to her room, to later continue thumbing through it while lying on her bed. I'm not sure what I liked more about this: that she'll know herself and how she grew, or that she'll know the eyes her mama saw her with and the humor that narrated her story from the beginning.

Pump Love

A Love Letter to my Breast Pump*

When we accidentally met many years ago, I had no idea how our relationship would become such a central part of my life. As a naïve and very poor medical student expecting our first baby, I scoured Craigslist every few days looking for free baby gear. I remember the brisk foggy morning when I saw the ad for you, the cozy pink oversize shirt I was wearing, how I was rubbing my mini-belly in the breakfast nook in our San Diego cottage. “Near-brand new Medela Freestyle breast pump, accessories, extra bottles, drying rack, etc. FREE to a family in need.” I had no idea what you were, but I knew a breast pump sounded like something I could need. I googled the price. WOW. This was being given away for free??! I quickly responded with my plight- a poor medical student married to a poor postdoctoral fellow (sounds like we shouldn’t be having a baby haha). The poster responded a few days later saying that she chose ME- what luck!- and before I knew it I was driving 45 minutes north to pick up the gear.

She showed you to me- you were surprisingly small and pleasantly yellow. You sat in a shopping bag with a ton of other accessories I had no idea about. With her infant in tow, she patiently explained to me how the pump worked and how she had to switch to renting a hospital-grade pump due to a dwindling supply. I nodded sympathetically and smiled, having absolutely no clue what she was talking about. I felt like I had somehow won the jackpot. We returned home and you sat in that plastic bag in a closet for the next 6 months.

A few weeks after baby’s absolutely chaotic arrival, near-delusional with sleep deprivation/exhaustion and with Step 2 CS around the corner, I remembered you and decided to take you out. What in the world? These funnels go over my tits?!? I googled videos. Ouch! I realized new tubing needed to be purchased. I searched “Medela replacement tubing” on Amazon and a day later new tubing arrived. It most definitely was not the right kind. I started crying and delegated the task of getting the pump sanitized, functional, and figuring out how the *&!@ it worked to my poor husband.

I remember the pride and wonder I felt when I finally tried you and could actually see the milk coming out- it had been such a mystery how much volume was actually being consumed by my little girl. All this fluid is being produced by my boobs?!? Wow! Step 2 CS came and went, with my first taste of what it’s like to pump in a bathroom. I went back to MS4 rotations, and quickly grew to appreciate your portability- your ever-lasting charge was a dream. I could pump in any old closet, exam room, or even in my car in the parking lot, at a moment’s notice. You even fit into my white coat pocket! The real fun began when I started interviewing for residency. I pumped on a crowded Amtrak, on the metro under a coat on the way to an airport, in random chief resident’s offices, and more. We got through it though. You never ever failed me, not once.

When my daughter turned one, you stopped holding a charge. I was sad, because I wasn’t ready to quit you. I had a backup pump through insurance, but when using it, all I wanted was you. With nothing to lose, I called Medela, and a very sweet woman listened to my plight (I left out the second-hand part, haha). Is there any way you could be replaced although I obviously have no proof of purchase?? A week later, a brand-new you showed up on my doorstep, which I packed away for my future baby.

Three years later as a pathology resident, you are still loyally by my side, helping me feed a new chunker. I have the luxury of more day-to-day consistency now, with a wonderful comfortable pumping room at my disposal. But I remember with fondness the crazy times we had. I can never express to you the invaluable gift you have given me, a precious breastfeeding relationship with my babies while continuing my life as a medical trainee. I have you to thank for the memories I will remember forever… ending long nights as an intern while sitting with my daughter quietly in the dark, silently reconnecting with her warmth and memorizing her changing face… being comfort for them when they are sick and need simply to nurse… the little starfish of a chubby hand reaching up for my necklace and resting lazily on my chest. My children have you to thank for all the immunity, comfort, and nourishment you have enabled. And my husband thanks you too for all the extra sleep he’s gotten due to continued nursing, haha. (But he doesn’t thank you for all the bottle and pump parts washing, especially living without a dishwasher.)

So thank you for everything, beloved breast pump. You have your imperfections, but so do I. To many more months of love to come.

*I have no relationship with Medela besides the one described here!!!

**It is NOT recommended to acquire breast pumps second-hand (although I will say that I purchased all new tubing, sanitized everything, and this one was only used a handful of times anyway. Still not recommended, I know!). Pumps are meant to be used for one year and not for multiple babies.

Bloggers block

When KC put out a call for contributors over a year ago, I barely hesitated to respond. MiM was such a refuge for me as I navigated new motherhood as a medical student. Medicine and family have both given my life such richness, so many highs and just about as many lows. I was eager to share my experiences with other trainees and especially to be an ambassador for pathology.

I forgot, however, that despite having the veil of anonymity, writing candidly and sharing is not something that comes easily to me. I am not cut out for this… I cringe at just about everything I write or say when re-visiting it later. Does anyone else struggle with this? We are very private… we don’t post photos of our children (or ourselves really) on social media, no pregnancy announcements, no baby showers, you get the picture… we even eloped at City Hall! I have really struggled to participate but I would still like to. I can’t tell you how many posts I’ve started but deleted. Those of you who are more prolific and seasoned in this forum- any advice for letting go of this paralysis? 

Living Your Questions

I’m sure you’ve heard Sheryl Sandberg's advice to women, "Don't Leave Before You Leave". Well, several years ago, I faced some choices. I had finished Family Medicine Residency the year prior. As planned, I did a series of temporary positions filling in for other doctors - the usual course of action for new grads in my field and location. These experiences were crucial in showing me the kind of practice style and environment I desired. After a year, though, I longed for "my" patients - to be able to get to know people, and follow them over time, both personally and clinically. It was unsatisfying to frequently step into a new clinic environment, never knowing how complete (or legible) the patients' charts would be, and never being able to follow a patient for very long.

Then, I filled in for a colleague's vacation at a great clinic and I didn't want to leave. Another doctor there asked for maternity leave coverage and I happily obliged. It was so refreshing: the clinic physicians were collegial, the staff was efficient and professional, and the electronic medical records system worked like a dream. The great news was that they had room for me to start a practice there. 

This idea daunted me: was I ready to commit to a practice? I wasn't sure, actually, because Family Medicine has its challenges and those that concerned me most were dealing with patients whose expectations greatly conflicted with what treatment I was comfortable providing, as well as assessments of disability for which I felt woefully untrained and unqualified.  I also had interests beyond clinical medicine - in academics, including medical education and research. Wouldn’t it be great not to be tied down? Many of my colleagues continue doing locums for years, and have great freedom and flexibility. Finally, my husband and I wanted to start our family: wasn't it foolish to start a practice when planning a pregnancy? I had uncertainties, and wasn't sure what was the best next step. 

I went for it anyway. I read and reflected on a couple of things: one, that I owe it to myself and potential patients to try practicing "real" Family Medicine. I knew it was the only way I'd find out whether I liked it. After all, having your own patients and directing their clinical care is so different than covering for another physician -- you set the tone of your practice. Further, I came across this powerful statement during that time - "if your next step doesn't scare you a bit, you're not pushing yourself hard enough”, which further reinforced my decision. This, I might add, is quite uncharacteristic for me - I am a very careful decision-maker. And the truth is, for the first few months, I still wasn’t sure that I had made the right decision.

Nearly six years later, I love having my own practice.  I get to establish a rapport with my patients, and partner with them on their journey to improve their health. I have been able to really delve into the problem-solving that makes medicine so engaging. I was also able to serendipitously find and develop an interest in refugee health.  Skill-building in this fairly new, actively growing field added another dimension to my practice, and allowed me to incorporate teaching with medical students and residents and involvement in community initiatives. 

As it turned out, it took my husband and I longer than anticipated to conceive. We are now grateful to have two young children, and I’m grateful that after each maternity leave I looked forward to returning to my practice. The experience of being completely unsure of my decision brings to mind these lovely words by Rainer Maria Rilke, which I first encountered several years before, during another period of uncertainty:

“Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are now written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.”

Goodbye hormonal birth control

It’s kind of hard to say goodbye to hormonal birth control when it’s been so good to you for so long. I started taking the pill as a teenager. My father is a teen parent and my mother instilled in me such a huge fear of early pregnancy that I stayed prepared, mostly to avoid her wrath! Talk about the teen brain in action; birth control was a very concrete option. Avoid pregnancy or be beaten, possibly at school in front of all of your classmates. YouTube videos of parents beating teens wasn’t around then, but if it had been, I’m sure this nightmare would have included my Aunt videotaping and putting it on the Internet. (note: I am totally over-dramatizing this and my mother and Aunt are two of my dearest friends now. They loved me fiercely and kept me from all types of danger including a few college boyfriends who were up to no good.)

I still remember sneaking to Planned Parenthood (it was across the street from a busy metro station) in order to get my first pack of pills. I was sweating, I was scared. But larger than my fear of being seen was my fear of getting pregnant and having to tell my parents. I knew getting pregnant before college would make my dreams of becoming a doctor even more of difficult to achieve, if not impossible. I had my share of providers over the years. I remember one male doctor that tried to shame me by drawing horribly graphic pictures; I wanted to yell at him but was too scared. I remember some outstanding older nurse providers (one super cute grey-haired lady in particular) who were very sex-positive and helped me try various methods.

Methods I have tried to date (in semi-order): combined oral contraceptive pill for years, the patch for less than a month,  Depo-provera for a few months, abstinence, emergency contraception, pills again, the ring for a few cycles, the Mirena IUD for 3 years, a healthy planned pregnancy 3 weeks after discontinuing the IUD, breastfeeding and the mini progesterone-only pill for a few years, and finally my second IUD.

Somewhere around age 30 and my pregnancy, I began to have hormonal headaches each month around ovulation and changes in birth control. Now that Zo is well out of diapers, we are ready for baby number 2. So I said goodbye to my second IUD. Hubby and I decided this would be the end of hormonal birth control for us until we decide to have someone’s tubes tied. I am still holding out hope he’ll see me waddling around pregnant and will decide to get a vasectomy.

I know this country tends to shame sexually active teens, but I was one of them, and I turned out alright in my opinion. I’m a pretty successful Pediatrician, married, with a child. I have friends who used various methods and ended up teen parents and now as an adult I have countless friends dealing with infertility. I wasn’t promiscuous (though I won’t shame those who are), but I always knew that avoiding pregnancy and infection were top priorities for me (referring back to my mother who wanted no parts of being a young grandmother). Now that infection is virtually impossible (if anything goes down hubby will have some ‘splaining to do) and we actually want to expand our family, I say goodbye to my old friend hormonal birth control. Thank you for keeping me safe and allowing me to follow my dreams.

Are Mothers in Medicine Messier?

Genmedmom here.

I suspect that I'm like most docs, when I say it takes alot to gross me out.

And I wouldn't say that I'm messy, rather, I'm highly tolerant of messiness.

But this week, I wondered if maybe my threshold for disgusting is a little too high. Like, maybe there are some things so yucky, anybody should freak out and drop everything to clean it up.

Like this, for example. Check out the close-ups of the wall, soap dispenser and faucet handle:

This is our downstairs bathroom. Last weekend, the kids and I baked and frosted sugar cookies.  And, they also ate melty chocolate bars.

Both kids dutifully washed their  hands in the bathroom sink, which was left grungy with thick purple frosting and chocolate smears that then dried out.

What strikes me is that I used this bathroom every day between then and this past Thursday, and I didn't even notice this nasty crusting. It was right there, on the stupid faucet handle, that I touched, and it didn't even register with me. (Or my husband, for that matter.)

Yes, we are in survival mode most of the work week. Yes, we both have busy careers, and school just started, and our pets are demanding, and no one has a reasonable sleep schedule. But still. Honestly. This is revolting.

Is there anyone else out there who could have this palpable food residue all over their frequently used bathroom and not only not clean it, but also not even notice it for four whole days?

And, to top it off, when I saw this on Thursday, really saw it, I was literally rushing to pee before I had to run out the door to get in the car to pick up my kids from school. It was my day off from clinic, the mess finally registered with me, but I didn't even have time for a rudimentary scrub-down.

Thank goodness our cleaning people come Friday mornings...

10 myths about radiology

Hello MiM community,

It has been awhile since my last blog post. I graduated residency in June and I am currently in month 3 (where has the time gone?) of my breast imaging fellowship. I stayed in the same institution as residency for fellowship. My little C is less than 4 months shy of being 4 (!!). Big C finished his orthopedic spine fellowship on the east coast in July and after a nice 5 weeks of having a stay at home husband, he started his attending job in a city 2 hours from me and little C last month. It has been a busy summer!

I am currently surrounded by medical students applying to residency, which made me want to do this post. And now that I'm a PGY 6 in my radiology training, I think I feel somewhat equipped to dispel some myths about my specialty and I thought it would be a good opportunity to go into the medicine aspect of my life since most of my posts have been about my role as a mom.

1. We are anti-social. A huge part of our job is communication not just with patients but with other physicians. We talk to physicians from all specialties throughout the day. We often present at multidisciplinary tumor boards. I can't speak for all radiologists but the ones I work with and myself included, we are very extroverted and approachable!

2. We never see patients. This may be true if you decide to go into teleradiology post residency. However, during residency, we see patients all the time--whether it be giving results, scanning patients or performing image-guided procedures. As a breast imaging fellow, I spend half my fellowship doing mammographic-guided, ultrasound-guided or MRI-guided biopsies/localizations. In addition, we often have to speak to patients to relay biopsy results. There is the option to not see patients but this will not be the case during residency and the choice is always there for patient interaction post training.

3. We are lazy. Being married to an orthopedic surgery resident, I have the utmost respect for these grueling specialties. We may not wake up the hours of other specialties but we are definitely not lazy. The time we spend having to study plus the time we spend at the hospital would often sum up to 60-80 hours of week during the earlier years of our residency. In addition, our residency is 5 years plus an extra year of fellowship (which is typically not an option as everyone does a fellowship post residency.) Our radiology boards are 2 days--that includes 18 subsections including physics! The amount of reading on top of working in the reading room equals so many hours that we put in outside of work that most people don't realize.

= 4. We love sitting in a dark room all day, every day by ourselves. This is definitely not true especially during residency. Radiology is a unique residency in that we are often one on one with an attending all day, working together and learning from him or her. In fact, this also debunks the fact that we are anti-social as we need to learn to interact and get along with someone we work with all day. In addition, our dark rooms are often frequented by visitors usually in form of clinical teams and occasionally patients.

5. The job market is horrible and no one can get a job. The job market may not be what it was in the past but there's always a supply and demand when it comes to medical imaging. As the reliance on medical imaging only continues to grow with the increase in number of CT and MRI scanners, the job market for radiologists will always be open. As someone who is only looking for a job in one city (one that is super competitive I might add), I have been surprised at the number of listings as well as the number of responses as a fellow in only month 3 of fellowship. In addition, I have only just begun my job search (literally 2 weeks ago).

6. Radiology is boring. I may be biased but I find radiology incredibly interesting. We see different pathologies across specialties on a daily basis. We often get to make the diagnosis and provide a differential. We are not involved in the treatment but for me at least, coming up with the diagnosis is the most satisfying part of my job as a physician. In addition, it is a field that is constantly changing as technology evolves. Imaging utilization only continues to grow and different applications of imaging for both diagnosis and treatment are constantly being researched and incorporated into our specialty.

7. Women should stay away from radiology because it will fry our ovaries. I was pregnant my first year of residency. I have a perfectly normal, adorable daughter. Yes, to be completely honest, radiation can affect a woman's reproductive capabilities but you would need direct radiation to the pelvic area and the amount of radiation would have to in the amount that is used for radiation therapy in oncology treatment. Therapeutic doses are often 1000X more than diagnostic doses (even a CT). Furthermore, as a radiologist, we are shielded from significant radiation doses with the use of radiation equipment and radiation protection practice shields (lead, lead glasses).

8. Radiology as a profession is useless because physicians can interpret their own films. Physicians across all specialties order medical imaging and it should be their responsibility to look at the images they order. However, a formal interpretation by someone who trained in this field for 6 years is completely different. There are many times that the ordering physician has more clinical information that helps in the interpretation of the study. However, when it comes to interpreting the study as a whole that is what we are trained to do--we look to see if its an adequate from a technical point (are there any artifacts on the study? is there too much patient motion?), we look at the entire study (for example, CT abdomen/pelvis is ordered for belly pain and on the few slices of the lung bases, we find a pulmonary emboli), we decide on how to make image quality better (do we need to increase the field of view? what should the slice thickness of the images be?) and lastly, we often decide if the correct study is ordered for the right indication while minimizing radiation dose to the patient (does the study need to be done with contrast? can we do an MRI rather than a CT in a pediatric patient? what study should we order in pregnant patient?)

9. We make too much money for what we do. I can't speak for all specialties except my own but I find it unsettling when I hear this about radiologists. We put in our time with our 6 years of training. We take our boards. We have written reports that cannot be disputed--if we miss something, it is evident that we missed something. Just like any other specialty, we are learning a valuable skill set that helps our colleagues and patients. 

10. We are not real doctors. This one applies more to the general public. We are not the technologists. If I got a dollar for every time somebody asks what I do for a living and I say I'm a radiologist and I get the response "oh yah, I met a radiologist last week when getting my "insert imaging modality" done," I would be incredibly wealthy. However, for someone interested in radiology, the prevalence of this myth one is something to be aware of. I always discuss with my husband who often gets cookies/cupcakes sent home from his patients that as a radiologist you have to be okay with sometimes not getting the direct satisfaction of "saving a life." It's not always "saving a life," but often times we do make the diagnosis but we're not the ones who relay the good news (or bad news) to the patients. I am okay with that. People choose to go into medicine for different reasons and some thrive off the direct acknowledgement from their patients. For me, as a radiologist, the internal satisfaction that I am helping my patients is enough.

Lastly, good luck everyone in their residency applications regardless of specialty!

X-ray Vision

Stop and Smell the Roses Baby

Before we had our baby 11 months ago I couldn’t really imagine how much I could love this little creature.  He is a delightful ball of light ricocheting through the house illuminating our lives.  It is a joy to watch him become a person, and each day I love him more.  But in a dual doctor household, it sometimes feels like we fit him into our lives, not the other way around.

Ever since we started our baby in daycare he’s had a routine.  He always falls asleep on the drive home, and we leave him asleep for the next hour.  And I regard this time as my own adult time.  I know I know, if I was a Good Mom I would be spending this time blending homemade organic baby food or decorating the nursery from some Pinterest inspired ideas, but evidently I’m selfish so I use this time to work out, veg out, or occasionally make dinner.  

So yesterday I finished work early, and on my long drive home I started thinking about everything I was going to get done with the extra hour of time. I was going to pick up the baby from daycare, jog on the treadmill while he slept, and then maybe veg out a bit with my laptop with the afternoon sun streaming through the windows, all before the telltale whimper from the carseat told me it was baby-time again.  It was going to be sublime.

But babies don’t really understand plans.

I picked up baby...check. He fell asleep in the car...check. He stayed asleep when we got to the house...check.  I changed into my workout clothes, and just as I picked up my running shoes I heard that little whimper coming from the car seat.  I was annoyed and disappointed.  But I also felt guilty about being disappointed.  I don’t see my baby that much during the weekdays -- just a few hours in the evening and then it’s time for bed.  I sat down on the couch with him and offered him a bottle.  He was so cranky and tired.  He didn’t want milk, he just wanted to be held.  He curled up on my chest with his chubby marshmallow cheeks pressed against my skin.  His lips opened slightly, inhaling and exhaling warm breath.  I nuzzled his silky hair and smelled his sweet baby scent.  And I thought about how there wasn’t really anything else more important than this moment.  I thought about how now that he’s almost one he doesn’t really sleep in our arms much.  How comforting it must feel for him to sleep wrapped in warm arms, listening to that familiar heart beat again.  The birds chirped outside, and dust floated through sunbeams lengthening on the floor.   The treadmill sat quietly in the corner.  The room slowly darkened.  And we sat in silence, inhaling and exhaling together, doing the only thing that mattered that evening.

Hello from Mooge

A long overdue introduction! This is a post I wrote right before starting internship, but I am just now posting. I thought about updating the content since I've been in the thick of internship for over a month now, but I decided to keep it as is to chronicle this journey.
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I’ve started drafts of this posting several times, but life keeps moving so fast that by the time I come back to finish the draft my words they seem obsolete. So instead, I’ll just introduce myself and why I’m excited to write for MiM. I’m a career-changing mother in medicine, a newly-minted M.D. balancing the excitement of finally getting to be a doctor with the nervousness of starting intern year.

With this excitement comes the realization that the last few months of weekends off and family dinners at home are about to come to an abrupt end. I’m mourning that loss of family time, and I have moments of second-guessing my chosen specialty – not because I don’t love it, but because it’s a time-demanding specialty. The children are already starting to whine about the increased time commitment since orientation started (after 3 weeks of me being home), so I can’t imagine how they will feel starting July 1st. When my oldest asks me why I didn’t choose a different job, my answer of “because I like this job and it helps people” seems unsatisfactory to both of us. I hope getting back into clinical work will help us both remember why mommy does this job, and that we as a family are a great team. I know things will get better, but the unknown of internship looms ahead and unsettles me. I look forward to just getting in it and working!

It’s been a long journey to this point, and I’ve relied many times on MiM to provide solidarity, laughter and spark contemplation. I jumped at the chance to be a contributor this year as a chance to give back to this community and chronicle a bit of the life of an (old) intern with kids! Now, here goes internship with two young children and a busy, traveling husband!

Until next time,
MOOGE

Bits n' Bobs~ Parenting 8 year olds; a fine needle aspirate.

A biopsy (FNA, not core) of  some recent parenting moments.

I have three children, ages 8, 8, and 2. My 8 year olds (girl/boy twins) are about to start 3rd grade next month which makes me feel really old--how did this happen already?! I feel like I was just waddling around HUGELY pregnant, then swaddling them, nursing them, rinsing off binkies dropped on the floor for the millionth time, changing their diapers, having delirium from the sleep deprivation, and all of that goodness and badness. And now we're talking about Big Issues In The World like homelessness, what is a mortgage, why Donald Trump is "not a nice man" (ok, so we're not subtle in our liberal tendencies. We're a West coast gay multiracial family, duh!), why it's better to compost food waste than throw it away, and on..and on. And last week my daughter saw a license plate frame that said "Army Mom" and asked me "Mom, are there any wars going on in the world right now?". What a heartbreaking and innocent question. Cue a conversation about war and conflict in the world, presented at an 8 year old level.

When did parenting suddenly get so complicated for our home? Does anyone just want to read a board book? Sing a song? Wrestle? Be totally oblivious sometimes?! And with two elementary school students, we're now entering into questions about the human body. And these questions usually come up either at dinner or at bedtime (of course).

The other night as I was putting my son to bed I reminded him that he realllllly needed a bath the next day (man, boys can be so DIRTY! Summer boy feet, oh wow); I also asked him if he was still retracting his foreskin while in the tub, to make sure he was cleaning himself properly-such a mom question. It truly astounds me that an 8yo child can get out of the bathtub after having "bathed" as dirty as when s/he went IN. He asked me "Why do I have to pull it back?" and I explained that for boys with foreskins, it's important to retract/clean because blah blah blah. He then says, incredulously "You mean SOME BOYS DON'T HAVE FORESKINS?!". Oh. I guess we never really talked about that specifically--never had a need. So there we were at 9:00 at night discussing circumcision, why we didn't circumcise him, whether most boys are circumcised (around here I think it's 50/50 for new births), penis growth (he said he thought his was "fully grown" by now....um...no, honey...it's not. So we did a bit of teaching there) and so on. It was hysterically funny, all in all.

And at the end of the conversation, my little man, being the budding biologist that he is (his obsession is mostly birds, so ornithology is actually his first love) also reminded me that foreskins are also important because they protect his penis from bad weather, bacteria, and insect bites. Oh right, but of course...

Until the next bedtime,

ZebraARNP

The things we do to succeed

I didn’t want to do it again, but here I go retaking my Pediatric Boards. I can list all of the reasons why I was unsuccessful at my first attempt: I was working too much (50-60 hours per week, getting paid to work 32), I was too stressed (issues with my former boss that I can’t discuss), I wasn’t sleeping enough, I have testing issues but my boss told me she couldn’t adjust my schedule so that I could study more. So here I am hundreds of miles away from home spending close to $2000 to take a 6-day intensive board preparation course. I am doing all that I can to succeed this time. And I refuse to allow the posttraumatic stress of retaking this test overshadow all that I am doing to succeed.

I have met so many outstanding doctors, most of them mothers, who have their own stories of failing their general boards or their specialty boards. These women are some of the best doctors I have ever met and provide exemplary care but they each failed the exam the first time. The stories read just like mine: working too much, stressed, not sleeping enough, family obligations, poor work-life balance. Some have a history of failing other board exams (USMLE or their specialty boards) but others don’t. Why does the cycle repeat? Why don’t we shake our little doctor sisters and say “wake up girl! There is no way you can balance all of this! Cut something back. Cut something out. Or else!”. “You can’t go on like this!”. “You either sacrifice now and focus primarily on passing or you’ll be forced to retake the test after failing!”. “Girl! Don’t do what I did. Let me tell you how I didn’t rock this test!!!!”. Or “Friend! Let me help you pass this test!”.

That’s how I want to recreate my narrative. I’m going to pass this test even if it’s by the skin of my teeth and then I’m going to mentor little sister docs so that they don’t make the same mistakes I did in post-residency auto-pilot mode thinking “well 60 hours is so much less than my resident’s 80 hour work week”. Let me tell you something - it’s not better after all of the years of sacrifice and don’t even pretend like you are not exhausted and burned out. And trying to work that much on top of passing this exam if you have even a hint of testing challenges is a major no-no.

So yeah, please Mothers in Medicine, send me some good vibes because I’m away from my family in this cold hotel room wrapped in blankets giving my all in order to succeed.

SIDE NOTE: In other random news, I just learned that the Peds Boards may become an open book test in 2017. Mwomp mwomp mwomp for me! If I could sit this round out, I would, but my new position depends on me passing this year. I hope the open book re-certification exam doesn’t cost more. Alright, I’m going to block all of that out and keep my nose to the grindstone.

EDIT: I removed the part about the salaries of the American Board of Peds folks because I cannot figure out how to fact-check it so it could be very untrue.

Craving

My youngest is starting kindergarten in the fall. And I kinda sorta want to have a third child.

I currently have two girls, who are absolutely wonderful. They consume a lot of my free time, I can take them to activities outside and they will behave, and I have just enough free time available for other activities that I enjoy. Everything is finally settling down a little bit, I get to sleep through the night most nights, and I'm reconnecting with my husband after some difficult times when the girls were little.

Still. I kinda sorta want to have a third child.

My brain knows that I shouldn't. I've got a laundry list of reasons why:

--my youngest daughter is incredibly attached to me and would undoubtedly be extremely jealous of any time I had to spend with a baby.

--my family has a really strong history of autistic boys. I got lucky with two normal girls, but now that I'm older, the risks are even higher of problems

--I love getting to sleep through the night.

--I have a lot of musculoskeletal issues caused by lifting my younger daughter, which would make a baby challenging

--I am finally getting back to trying to expand my career, and I don't want to give that up

--I like having free time to myself again

--my girls are still quite young, still very cute, and still need me a lot. And they absolutely do not want me to have another child.

--my husband does not like babies. He hates every aspect of caring for babies. He gets incredibly grumpy when he doesn't get enough sleep. I think our last child nearly destroyed our marriage, and now we're finally OK again. But he absolutely does not want another child under any circumstance. Convincing him to have a third child would be…probably impossible.

When I write this out, especially the last one, I wonder why I am even thinking about it. Even my husbands issues aside, the last thing I need right now is another child. The thought of caring for an infant makes me physically ill.

But I still have that pull inside me whenever I see a baby, and I feel sad that that part of my life is over forever.

The Bird Builds its Nest, or Life Lessons from a Liberal Arts Education

I worked out for thirteen minutes today. That's right, thirteen. Not because I'm on some kind of a short-duration, high-intensity workout kick. Because that was the time that I had in between finishing work and getting home at the time I had promised to relieve our nanny. And a little bit is better than nothing.

Not that long ago, I would have scoffed at the idea of such a quick workout. If I couldn't commit to at least thirty minutes, I figured, what was the point? Such a small effort would essentially be equal to nothing. But lately I've had a change of heart. I've been reflecting on the somewhat circuitous route that I've taken to get to this point in my career, and how it began with my undergraduate studies in French.

I majored in French language and literature for two reasons. One was that I loved the phonological beauty of the words and the way they string together to form a lilting song. And the other is that I knew that I would dedicate much of the remainder of my academic and working life to the sciences. I wanted the chance, at least for awhile, to explore the liberal arts and to broaden my general knowledge and appreciation of the world.

One of my professors made a point of teaching us idioms and proverbs, and one in particular has risen to the surface of my recent reflections:

Petit à petit, l'oiseau fait son nid.

Literally: Little by little, the bird makes its nest.
Essentially: Every little bit helps.
A long journey begins with a single step.
Rome wasn't built in a day.

You get the idea.

And in the past few months, as I have returned to work after Teeny's birth, started a fellowship in hospice and palliative medicine, continued to dream of developing a side career in writing, and attempted to maintain my marriage and sanity, all while hoping - though taking little action - to start whittling away at this post-baby-#2 body, I have had many what's the point and all of this is impossible moments.

But then one day, for no reason I can identify other than that I needed it, I remembered the bird making its nest. And I knew that little by little, I could make my own, in whatever aspect of my life I chose to apply that metaphor on a given day. That given the choice between a tiny bit of progress and none at all, I could, should, and now would choose the tiny bit every time.

I'm not able to spend an hour at the gym each day. But thirteen minutes is better - far, far better - than nothing. It's a step forward. It's part of a cumulative effect.

And it's just one more reason that I'm grateful for an education that extended far beyond the confines of the lab.

In praise of skin

Another work post from the burn unit, Kamuzu Central Hospital, Lilongwe, Malawi. I want to tell you about dressing change days, and interject a little ode to skin. I wrote a version of this for my private blog, but wanted to share with you all as well. As always, thanks for reading these ramblings!

Mondays, Wednesdays and Fridays bring dressing changes in the burn unit. This means that every patient—as many as 42, plus the many others who come in from home just to get their dressings changed--line up at the end of the hallway and wait their turn, while 3-4 intrepid nurses unwind and wind miles of bandages, slather ointments, and squirt morphine into their mouths. Except when there is no morphine. Then it’s diclofenac, which is, I imagine, the equivalent of getting a swig of ibuprofen right before you get scalped alive.

Walk with me. From the outside, down a dark hallway filled with people, toward the light at the back and up the stairs, three flights. The staircase is open to the outside and on each flight there's a big window with a view of the city--today it's hazy and hot, so the buildings are distant under a screen of red dirt and smog--but it's not airy or breezy. The stairs are worn from countless people walking up and down it for years, and on the second flight a woman wearing yellow wellington boots is mopping, with a broom that's seen better days and concrete-colored water. On the third floor we briefly bump along behind two policemen, big guns swinging freely, talking exuberantly and walking oh-so-slooooooowly—and finally we arrive on the third floor, and walk down the hallway to 3B, the burn unit.

Before you open the door, take a little deeper of a breath, for you're about to experience that smell. On a good day you manage to take 3 steps inside before it hits--the odor of maize meal cooked into grits-like porridge, or a paste, or a hard cake (nsima); of bodies, urine and boiled cabbage, dirty wounds, feet, doughnuts, and fear--and then you see the mother carrying her five year old daughter wrapped up like a mummy with an IV tube sticking out of her neck--and you feel ashamed for even noticing the smell.

There are six rooms, 4 beds each, lining the hallway to your right. Linking them is the open breezeway down which you’re walking, which opens onto a shared courtyard where people dry their laundry and family members cook their meals. On the other side of the rooms is another hallway, the khonde, or “outside,” which becomes another long communal room during the months when there are more patients in the unit than there are beds. During the cold season—June, July, August—the khonde is full.

Two boys, aged four and six, one with a bulky bandage around his leg and the other with a belly dressing, are playing with a glove balloon, and you toss it back and forth with them for a little while, their smiles lighting up the day.

Are you procrastinating? We have to keep walking down the hallway, to the room at the end, where all those people are queued up, since that’s where all the action takes place. Each mother dons a protective plastic gown and gloves and takes the child—the median age here is 3—on her lap. The mothers hold the children down. The first trial begins, that of forcing the morphine into the children's mouths. Most take it willingly, especially ones who have been here a while, but sometimes they purse their lips, or cry, or swat with their arms. It doesn't matter if the morphine trickles inside or outside of their mouths--there is no refill and the dressing change happens with or without it.

Next, the nurses soak the bandages in saline to help with removal. Since there are 42 patients and 3 nurses, waiting for a complete soak would take way too long. Some of the kids start screaming in the hallway; some when the mothers take them on their laps; some with the morphine; but all of them are screaming by this point. These kids are burned over 10-40% of their bodies, on average; over all possible body parts; in two main ways: they scald themselves or catch themselves on fire. It's the cold season in Malawi, no one has heat at home, and very few people have stoves; cooking happens over open fires, outdoors, and accidents happen frequently. Malawi is burnin', y'all:

 

Skin gets so much criticism. We stare at our pimples as teenagers and wish them away; at our wrinkling faces as adults, and hate their testament of the passage of time. We scrutinize moles and massage cellulite; we want elasticity and spend millions on creams and lotions that promise to keep us looking young. Even as we enjoy skin's gift of touch, in embraces, caresses, and kisses, we resent and focus on its fragility, its ability to hurt, and too often, its color. We don't appreciate scars. Skin should be blemish-less and baby-soft. Not at all like the skin I see in front of me--discolored, twisted, partially healed, in some cases with the tell-tale cheesecloth appearance of a healed skin graft. This is beautiful skin because it works in its intended way: not as pretty packaging but as a barrier to infection and pain, as the selectively permeable wrapper that allows the rest of the body’s functions to proceed uninterrupted and unthreatened, with just enough openings to allow a regulated exchange with our environment.

It's the absence of skin that exposes its absolute necessity. This six year old girl being unwrapped now has full thickness burns (what we used to call third degree) over 55% of her body: anterior and posterior thorax, both legs, both arms, a bit of face and neck, buttocks. Her big, deep brown eyes look at me with tears trickling down her cheeks as her mother’s helper raises the IV bag above her head and arranges it so the tubing is not kinked. This is a bad burn: flame generally causes deeper burns than hot water, and in this case, it looks like her clothes were on for some time, and the contact did a lot of damage. Like countless others, she was playing with her friends and tripped into a fire, where her clothes caught the flame. She cries, but not much: a bad sign. Although we teach that full thickness burns are insensate, since by definition the heat has destroyed the skin's sensory apparatus, not everything burns to the same depth, and partial thickness areas surround most full thickness burns—and those do feel pain. Her name is Chisomo, meaning Grace. She will die in 3 days.

I think about the ones we can’t save, back home, and here. I hold on to them for motivation to keep studying, keep waking up, keep leaving my family, and keep trying—and to honor their memory, although I see them usually only in a dehumanized form, although I know them usually only as bodies wrapped in dressings and not as children chasing goats, eating mangoes or diving into the lake. Knowing what makes a patient human makes me a better doctor but it also hurts more—and many times I don’t want to admit they are people because doing so makes me transiently incapable of returning to work. It’s like this in the States and it’s definitely like this here. The constant blur of activity insulates you from processing both the good and the bad, but both stay with you, and sometimes when you get a breather it all comes out, and it’s very hard to figure out what to do with all of it—so I try to just notice it and not cry, and carry on, because in the end, there are more of the ones who get to be human again than the ones who don’t, and so you keep going. As shown by the parents and patients in this burn unit, every day, with their smiles, their high fives, and their endurance, despair is a luxury. Ain’t nobody got time for that.

Three weeks in

I am three weeks into being an attending and I am writing this to all of those starting intern year (like I was when I started reading this blog), and to all of you in the middle of a long residency and questioning if you can make it through. I am writing this to put your sacrifices into perspective - all the missed recitals and mothers day lunches, the shitty clinic clothes you wear because you can't afford anything else, the many times you leave your spouse to sleep alone at night while you're on call --- I am just three weeks in, but it sure feels really worth it right now.  All I feel right now is joy (Well joy and a fair amount of fear and anxiety!! but mostly joy).  

It feels unbelievable to finally be at this point.  It has been such a long road.  I know being an attending presents lots of new challenges which I am learning about every day.  I know I may not feel so exuberant years from now.  But right now, I'm enjoying it.  I feel thankful to be in a job that I truly love, working with people I respect and feel honored to work with.  I love my patients and feel energized after clinic or a day in the OR.  I also feel very supported by the other faculty.  I feel like that bright eyed, brand new medical student 12 years ago who wanted to "help people." 

Last night, after kindergarten registration, I stared at my worn out sleeping daughter and I was proud of this model of motherhood I have provided for her.  I was proud of our new house, her new house, the house she will grow up in -  I hope one day it will be as dear to her as the house I grew up in just 10 minutes away.  My residency baby - she made me a mother in medicine.  She made me a better person, a better doctor - and every moment of this struggle feels very worth it right now.