The Soul Condition

The day to day practice of General Internal Medicine can be particularly challenging and trying, but also thoroughly rewarding. I have found that the most incredible moments of privilege and wonder in this profession come in the most unexpected times and places. Especially during this past year, which has been particularly trying for me personally, just when I think I can’t bear any more suffering, there is a surprising glimmer of light that penetrates the darkness. I’m thankful for those moments, and being mindful of recognizing them when they present themselves.

One morning recently, I entered an exam room to see a patient of mine during a busy Tuesday morning clinic. He was sandwiched in my schedule between a lovely middle aged woman with a newly diagnosed metastatic lung cancer (sigh) and a young adult patient with a sore throat. I saw him on my schedule for that morning and smiled – he was a lovely elderly man that had a difficult past few years with depression, obesity, and was ever skeptical of my western medicine approach to his longstanding hypertension. Despite it all, we always found a way to have a good talk, able to cross the chasm of our cultural and religious differences and find a way to speak a common language with each other. I take care of his wife and his adult daughter, as well, so I have a multi-dimensional sense of his life at home.  In the flurry of the day, I closed the door finishing with the patient across the hall and stepped in the doorway of his exam room to say a big hello. I looked up and barely believed my eyes – “Oh my goodness, how are YOU?!” I said. There he was, big sparkling smile, bright eyes, “Hello there, doc!” He looked twenty years younger than his 74 year old self, and strong and happy.  This was such a stark contrast to our last meeting, about year ago. “Well, doc, I thought you’d be proud. I lost 70 pounds.”

I smiled. I paused. I looked at him lovingly and proudly and then squealed with excitement as I gave him a hug. “How did you do it? And how do you feel?”  He went on to tell me how he feels terrific, both physically and mentally.  When we last saw each other about a year ago, he was sad, lacking motivation, irritated with his wife who was ‘nagging’ him, and about ready to move away to a warmer climate.  He was morbidly obese, had aching knees, and just didn’t feel like himself. I recall distinctly (one of these moments that just are quite captured in the EMR documentation!) at that visit we talked about “why are we all here?” –I had referenced a friend who had recently passed away at the age of 49 and I was feeling great loss at the time – he too was feeling loss and disappointment about moments in his life and was reflecting on his 73 years, having an existential crisis of sorts. We hugged at the end of that office visit. And now here we were, a year later, and he is bright and happy and has lost so much weight. 

A year has changed so much of who we both were. I was about to hear about his year long journey. Over the last year, I had seen hundreds of patients while I tried to keep my own tattered life afloat. My marriage broke up, I sold my house, I moved, and have tried to weather the storm of a messy divorce while parenting two little kids who were trying to understand it all. I couldn’t help myself as these thoughts rushed in--the year since we saw each other last had affected us both so profoundly. And here we were, again. And I think we found unspoken strength in each other.

“Well doc, this is all about my ‘Soul Condition’.”  I looked up, saying nothing, but my eyes gesturing ‘tell me more.”  He went on to tell me that he thought a lot about his life after our last appointment. He realized that his poor health habits, for him, were about failing to care for himself and his ‘soul’. He realized at some point he is worth more than his poor health habits, so slowly he started eating better and exercising. He said “Doc, you told me to go for a walk. So, I’ve gone for a walk everyday ever since I saw you last.”  Wow! I admit I had a moment that I couldn’t believe someone actually listens to me!  We went through the rest of the visit, me with genuine joy for him, him with the pride of a child reporting back a good deed to a parent.  And then we finished, as he and I somehow always do, sharing tidbits of our lives and hopes, and he teaching me more about the Soul Condition. He said “Doc, if you are unhappy, just work on your soul. You should tell your other patients that. I’m not even tempted to smoke or drink alcohol, or eat ice cream. Why would I now that my Soul is so happy in this body?”

I’ve thought of him a lot since that day. I could certainly learn a few tips from him – or at least my Soul needed a new kind of condition after all I’ve been through this year.  I couldn’t help but wonder if he saw it in my eyes, if he knew I needed this advice.  Divorce is ugly and bitter and deeply devastatingly sad – it does break a soul as it breaks a family.  I bear witness to so much human suffering on a daily basis in my role as physician, and sometimes the only thing I can do is sit with a patient and listen and hold his or her hand, offer a supportive word or a hug.  I have found it an incredible burden to also carry my own suffering into the room with my patients as I listen to their stories, offer kindness, support and advice. I’ve often wondered over the last year if I’m good for any of them and if I could possibly bear any more. During that 20 minute appointment, I earnestly rejoiced in his improved health and happiness and learned from his wise counsel. 

Just like my patient worked to make his Soul happier, I’ve learned I need to deliberately take steps to do the same. I savor my kids’ giggles, and give more hugs, and spread more love, and have learned my own needs count.  I have long taken care of others, and I’m just now learning the skills to recognize my own Soul Condition, and tend to it.  Today I went out of my way to spend time with a long lost friend, take a walk, and bake banana bread. I went slowly through my day, took note of how I felt, and listened to what my Soul needed today.  I also held my son, as he cried in my arms for a half hour after coming home from a weekend with his dad. He wanted to know “why can’t mommy and daddy just live together?”  And so I hold these things, some so difficult, some so beautiful, and think about what we all need to care for ourselves and our Souls. In this moment, my heart ached wide open for my sweet child, and was also warmed by his earnestness and his openness and his absolute softness in my arms.  My Soul has a little farther to go to feel healed, but I’m listening and trying. My patient is a beautiful man and a special, special Soul. May both our Souls triumph in a beautiful year ahead of us, until we meet again.

Childcare Options for Doctor-Moms

Genmedmom here.

Childcare is such a huge issue for working parents. It can be so expensive, and it is so important. With me in outpatient primary care and my husband traveling for his work pretty frequently, we needed to figure it out.

Thankfully, we have my mom who lives close by and provides the bulk of childcare for our little ones. We have also used daycare, as well as nanny services, both to give her a break and to provide socialization for our kids.

Family help is the best, but it can't always work, for many reasons. Daycare has the advantage of providing key socialization, as well as building relationships with other working parents, a bonus that I didn't realize would be until it was. However, if we didn't have my mom to pick up our kids at the end of the day, we'd be pretty miserable. It probably wouldn't work at all.

I found nannies to be the most difficult. It was almost a part-time job to find a decent nanny, even with Care.com. And, they weren't always decent. Plus, that option can be very expensive, prohibitively so. Upwards of twenty dollars an hour in the Boston area, for a nanny with experience.

Other docs have written about au pairs, and that options sounds wonderful, but one has to have a place for the person to sleep, and we just never had that. It's a small house, barely enough room for us and the two kids. Au pair, sadly, was never a possibility for us.

What childcare options have worked best for others?

Help with attending job interviews!

T minus 8 months until I join the real world.

I am now 4 months into my breast imaging fellowship. It's about that time I start looking for my first attending job!! As someone who went straight through in my medical training, I have no idea what a job interview truly entails. Yes, I've done plenty of interviews. I know what it's like to sell myself as a medical trainee but as for joining the real world, I have absolutely no idea.

My experience looking for a job might be a little different than some because I am geographically limited. My husband started his (first) attending job in a city 2 hours away from where I am doing fellowship. On a side note, this situation is so much better than our west coast east coast marriage while he was doing fellowship last year! As much as I am looking forward to joining the real world, I am really looking forward to our family of 3 to finally be living under the same roof!

I went on 2 interviews so far. The first one was not the same location but same group as my husband's place of work. Given that it's part of the largest managed care organization in the United States, questions outside of who I am, what I can offer were really not asked. Details of what the contract would entail, how much I would make, what my benefits were and etc. were not discussed. Mostly because I already knew the answers to these questions and the fact that I was told that there was no need to go over a contract from this place as it was standard across the United States. I came back from this interview thinking it went well and that it wasn't much different from a fellowship and residency interview. A downside to this job is that it will be a 45 minute commute to where we will most likely settle down.

The second interview I went on was a large private practice group in the city where my husband practices. It's a group of approximately 80-90 radiologists. We talked about my dual boarding in radiology and nuclear medicine. We discussed the possibility of working within my preferred subspecialties (breast imaging and nuclear medicine. We discussed the possibility of working part time, which got me really excited. I also met some of the radiologists in the group, who all seemed very nice. However, I came back after my interview most of my conversations with my attendings at work went like this.

"How was your interview?" "Good. I really liked the practice"

"What is your base salary?" "I don't know..."

"What is your retirement?" "I don't know..."

"What benefits are offered to you?" "I don't know..."

"What about maternity leave? " "I don't know..."

"Do you get paid overtime for call?" "I don't know..."

"How many years until partnership?" "I don't know..."

Basically, I felt like an idiot. And now, I am waiting to hear back from both jobs but I feel like I cannot really compare and contrast since I don't know the answers to these questions!

How do you go about asking these questions during a job interview? Do you ask right away? Do you wait until there's a proposal? Is these anything else I should be asking? Do you need a lawyer to review your contract?

Thank you in advance for your help!

How Do You Do It All? (i.e. The Art of Being Imperfectly Perfect)

Genmedmom here. 

Let’s face it: working moms have alot on their plate. A patient recently complained to me how guilty she felt because she couldn’t be a perfect mother, wife, accountant, and friend, all at the same time. If she felt really good and strong in one area, she was slipping in another. “No matter how much I try, I’m a failure!” she declared. 

Okay, look, despite the expectations on us, no one can achieve perfection 100% of the time. No one is going to excel in all of the areas of their life always. But we can manage. We can do our myriad jobs well enough. And we can be happy. 

On a weekly basis, I usually manage: four clinic sessions a week (approximately twenty hours seeing patients), one morning precepting in the firstyear medical students’ interviewing and communications course, co-parenting our two school-aged kids (with lots of family help), regular blogging on three separate blogs, kids’ dinner/ bathtime/ bedtime virtually every night, about three good workouts per week, church and big family dinner on Sundays. 

Is it all done perfectly? Hell, no. I wish I could get to all the patient phone calls, emails and lab results every week. It would be great if I could do the reading before the medical school course. Our kids are late with homework probably at least once per week. We never seem to know what's going on at school until the last minute. My blog posts often have typos, and could have used a little more editing. My workouts are sometimes really short. We don't get to church or have family dinner every Sunday.

But I can say this: We fit in what we need to fit in. We do what we feel needs to be done. It's not perfect, but, for us, it is. Imperfectly perfect. We, as a family, are happy.

I am often asked “Geez, how do you do it all?” 

Well, if what you're aiming for is happiness rather than perfection, then I’ve thought about this. It will be different for everyone, but generally, I suggest: 

Identify your time-wasters and eliminate them. What time-consuming things in your life do not help you to achieve your goals, and do not serve a healthy purpose? For me, that’s television. I do not watch television unless there is a really good reason. I’ll watch a Disney movie with the kids once in awhile, all snuggled on the couch. And, of course, once a week our whole family watches my husband’s football team play. Other than that? No sitcoms, no news, no movies. Social media can also easily become a time-sucker, so I limit that to my train commute.

Hire cleaners, if you can. Yes, we all know that we are capable of cleaning. But how much is your time worth? You are an M.D., and if you were paid by the hour, you would earn $100, at minimum. Multiply that by a thousand- no, a million- and that’s how much your hour is worth to your kids. Though we couldn’t afford it when we just started out, as soon as we could, we hired a cleaning service. They are worth every penny.

Order anything online that can be ordered online. We have groceries, pet supplies, clothes, shoes, furniture, books, et cetera delivered right to our front door. 

Stay local. Need to run an errand? If possible, avoid driving time, and support local businesses to boot. 

Schedule carefully. There are so many options for kids’ activities around us. It would be very easy to slip into driving-everyone-all-over-the-place-for-this-or-that-thing. We were forced to hold back quite a bit, as our son with autism doesn’t handle a busy schedule very well, and doesn’t do drop-off events at all. So, we have a music teacher who meets them in my mom’s home after school one day. And we choose family activities like hikes, trips to the farmer’s market, and scouting (Boy Scouts), rather than kids-only classes like dance and tae kwon do. We’ve realized that this quieter, easier, more familiar approach results in less hustle and bustle, and doubles as “family time”. 

Identify toxic relationships and avoid them. Okay, I'm wandering into therapeutic territory here, but the truth is, people who make us feel bad are a real drain on our precious time and energy. Conflict and negativity are distracting. We can't be our best selves now if we're re-living an argument or re-thinking that weird conversation from yesterday. If there's a person around who consistently brings conflict and negativity into my day, I avoid them as much as possible. Likewise, if there are good, psychologically solid people who support me and boost my mood, then hey, I want to spend more time with them.

Keep reasonable goals. I’m not striving for crazy achievements in any area. I’d like to take good care of my patients, be a solid teacher for my students, raise emotionally well-adjusted kids, keep on writing until it goes somewhere, stay as healthy as possible, and be actively engaged in our community. Like I said, it's not perfect, but, for us, it is. Imperfectly perfect. We, as a family, are happy.

What about other mom-docs? How do you "do it all?" What do you do to save time? How do you keep you and your families happy?

[Watching our friends get] Married... with [our] Children

Let's bring the boys to the wedding, we said.

It will be fun, we said.

We were so cocky. Bean had been to several weddings and loved to dance, we reasoned. And Teeny, though young, was just so chill that it wouldn't be a big deal. An outdoor, afternoon wedding of a laid-back couple with tons of family medicine and pediatrics residents in attendance. It would be like a weekend away without needing to pay for a baby-sitter. What could be more perfect?

We rented a house through Airbnb so that we would have plenty of space and the boys would have their own rooms. We beat traffic on the way there and spent the next morning exploring the cute town. We stumbled upon a farmers' market and ate ice cream for lunch. The boys even went down for a pre-wedding nap.

On the way to the wedding, we talked about how we would need to be very quiet. (We had no illusions that we would actually sit down for the ceremony, but planned to watch from a safe distance.) As we rounded the side of the beautiful inn where the festivities were being held, the bride was just starting to walk down the grassy aisle to the strumming of a guitar. Bean pointed to the musician and began shouting, "Man playing 'tar!!!!!"

We retreated. A staff member inside kindly pointed out a large picture window overlooking the lawn where we could watch without disrupting things.

At that point Teeny let us know that he was hungry, so I settled into an armchair in the corner to nurse him. My husband headed to the window with Bean, but there was a problem: the parlor of the inn was filled with so many nice things and Bean needed to investigate all of them. There was a large birdcage containing actual birds and a stone fireplace and so many trays of seashells and trinkets and shiny objects. In other words, it was a room we had no business entering.

"We really need to rethink whether we bring the boys to weddings," my husband noted a few minutes later in a tone that struck me as irritable, though he adamantly denies having felt annoyed. I sighed and internally (or maybe externally) rolled my eyes. We were in another state and the celebration that we had traveled here to attend had just begun. There could be no second thoughts.

As soon as Teeny had finished nursing, my husband pounced. "My turn to hold him!" he exclaimed, which was code for it's your turn to chase the toddler. But Bean was in great spirits, happily occupied by tracing the contours of the stone fireplace with the car key that my husband had handed him to play with. I relaxed a bit and began to really take in the gorgeous setting. On the other side of the fireplace, I noticed a basket filled with books and a plush stuffed lobster. As Bean began to edge too close to the hurricane jars lining the hearth, I lifted him up, intending to plop him down by the [unbreakable] lobster. While in the air, he started to protest: "Hold key! Hold key! Hold key!"

Which is what he says when he wants to hold something that he is not holding.

I looked down at his empty hands. "Key? Where's the key, Bean?" I asked in an urgent whisper, not wanting my husband to hear. "Bean, what did you do with the key?"

"Hold key!!" he wailed, and I left his side, hurricane jars be damned, to retrace my steps, scouring the floor.

"What does he mean, 'hold key'?" my husband asked, because of course he was right there and had heard and now realized the predicament.

"Don't worry, I'm sure it's here - " CRASH!!!!!! 

I spun around, expecting to find my family covered in shards of glass. My husband, with Teeny in his arms, had sprung to action trying to find the key, but in doing so had knocked over an end table. An end table that had held a glass dish of beautiful, fragile seashells.

Of course that was the moment that the inn's manager entered the room.

"I'm so sorry! We're so sorry!" my husband yelled, frantically gathering shells in one hand while cradling Teeny in his other arm. 

"Hold key! Hold key!" Bean continued to wail.

"Just let us know how much we owe," my husband huffed, still scrambling to scoop bits up off the floor. "And also, we're missing a car key."

Outside, the ceremony came to a close. The bridal party and guests began to make their way back up the lawn toward the inn. Having already crawled along the floor to peer under the couch, I stood up and spied the key nestled behind a throw pillow. Somehow the glass and shells and whatever else were picked up off the floor. My husband and I gathered our things and, each taking a child, stepped out onto the back porch where guests were now mingling over cocktails. In the kind of frustrated yet silent agreement that comes from more than a decade and a half as a couple, we parted ways, each joining a separate section of the throng.  

By the time dinner started, Teeny was napping contentedly on my shoulder and Bean had begun to make his presence known on the dance floor. We had caught up with old friends and made new introductions around the table. And for the rest of the night, our family was happy and smiling.

I had thought that some time would need to pass before we could speak of - and certainly before we could laugh about - the scene at the inn. But as he pulled our car out of the parking lot at the end of the night (well, the end of the night for a family with small children), my husband grinned. "Well that will make quite a story."

Since that time, I have referred to it as "The Wedding Where We Almost Got Divorced," though he swears it was never that serious and he was never that annoyed. And as for bringing the boys to weddings? We haven't done it again. 

At least not yet.

Money and mothers in medical training

Children are expensive. So is medical school. Children take up a lot of time. So does medical school. Unfortunately time and money are two things in considerable shortage during medical training. Mixing children and medical school can be an unhappy combination. We had our baby halfway through medical school (me) and residency (the Mister). There has been lots of discussion regarding the timing of procreation in medicine (eg here and here and on this blog). My general takeaway can best be summarized with this license plate.

I have found some serious life wisdom on vehicle license plates.

My general takeaway 1.1 regarding the subject of timing babies in medical training is that there is no perfect time. Each time is good in some respect and not so great in others. Having spent my 20s in pursuits of other advanced degrees, I didn't want to wait until I had a "real doctor job". But that meant that financially it was not such a great decision. Residents stipend is not enough for supporting a family, especially when one member of said family is incurring expenses of medical school. More than a third of our income goes to childcare expenses, and that's not even including food, diapers, and a multitude of other child related expenses. We are always worried if we'll be able to pay all our bills at the end of each month. I am in debt up to my eyeballs. Financial worries are always lurking in the background of my thoughts, and money has been on my mind even more as I am looking into taking out more loans for upcoming residency interviews.

A friend offered me wisdom from her interview experiences, telling me about some common interview questions, one of them being "Tell me about a difficult experience you had in medical school". I said (almost half jokingly), urrmm pretty much the entirety of medical school since having a baby has been one incredibly difficult experience. It is difficult to separate the experience of being a parent from that of being a medical student, and money has been one of the connecting threads between the two.

Daycare was the only affordable childcare option for us, and we are lucky to have hospital subsidized daycare. It was amusing (not really) when one of my classmates thought that "hospital subsidized" meant that all costs were covered by the hospital and it was free of charge. No, it just means there is a small discount. Though it is a "hospital affiliated daycare", but like most other daycares, it is not a 24/7 facility. Having both spouses in medical training means that both of us have very little control over our schedules. There are plenty of times that we are both working outside of daycare hours. And trainees may have an 80 hour a week work limit, but a child requires care 168 hours a week.

This same classmate who thought that daycare was free, was also surprised to learn that I hired baby sitters to study for medical school exams. "Wait, so every time you have to study, you have to pay someone to watch your kid? Can't you just put him in a playpen and do your studying?" Before I had a baby, I envisioned this picture of getting home from the hospital and spending daily finite hours of "quality time" with the little one and then he would, I don't know, put himself to bed or maybe I'd read him a little bedtime story at the end of which he'd dutifully doze off and sleep through the night, and I'd get more hours of "quality time" studying. Or just like my classmate I assumed that I would be studying while the baby/toddler would be happily playing by himself on the side with his toys, of course, without interrupting me. Those fantasies/assumptions disappeared pretty fast when a real baby (who is now a toddler) showed up.

Talking to other people in our situation (two medical trainees with no family close by) most options I heard of were not financially viable alternatives for us. I have heard people say to not worry about money and keep taking out loans because when I have a "real doctor job", I'll be able to pay it all off. Maybe there is truth to that. But when I look at the enormous amount of debt that I have already accumulated, and when I think about the uncertainty with future physician compensations, I don't feel comfortable taking out loans to whatever amount.

Things haven't always worked out great with this whole arrangement. I have less than perfect grades in medical school. I feel like if it was just the hours in the hospital and then I could come home and eat, pray, love or something, it would be fine. But because work just gets started after getting back home from work, is what makes it so hard. After a particularly rough rotation that had lots of nights and weekend shifts (read: "when daycare is not open" shifts) and an end of rotation exam, I bombed the exam. The course master told me that he was really surprised about my exam performance because the clinical portion of my grade was stellar and there was such a discrepancy between the clinical grade and the exam grade. I didn't know how to explain that for me studying for exams cost money. Whatever little savings we had, had recently disappeared after a family emergency, and as interview expenses had drawn closer, I had scrimped on getting sitters to study for tests.

As a minority it is sometimes difficult to explain or convince people even in the face of overwhelming evidence that social factors control how you experience your life and the color of your skin can change the opportunities and travails you encounter. At some point it is tiring to keep going through the explanations over and over and knowing that unless someone has actually been there, they really won't know what you are talking about. I feel that way about the experience of being a mother in medicine too. I could go blue in the face with my explanations but it is exhausting.

The Woman in Scrubs

Now how's this for stereotyping:

Sometimes when I drop my youngest off at school, I've seen another mother dropping off her daughter in the same class.  And she always shows up wearing scrubs.

I've had a couple of conversations with her.  And of course, I'm dying to ask her what she does for a living that she's always wearing scrubs.  But I don't want her to tell me that she's a nurse.  And then I'll have to tell her I'm a doctor.  And any possibility of friendship will be vanquished.

There are probably a few things wrong with this:

1) My certainty that there will be awkwardness upon discovering that she is a nurse and I'm a doctor.

2) My assumption that she's almost certainly NOT a doctor herself.

As for the first one.... it's likely predicated on the fact that I've never had a nurse friend.  And I can't even get any of the nurses I work with to call me by my first name.  As for the second one... well, just going by the numbers, I'm probably right.

Yet another case of my career feeling like a detriment in my quest to make friends.  Recently, a mom I met at a playgroup asked me if I was a nurse and I was sooooo tempted to say yes.

Would You/ Did You Deliver In Your Own Hospital?

Genmedmom here.

I could not have imagined going anywhere but the OB/GYN office down the hall from mine. My lovely OB was a clinical instructor in the same course as me, and I ran into her at the medical school from time to time, in between my prenatal appointments. She'd seen my cervix and God knows what else was going on down there, and yet we would find ourselves standing around pleasantly chatting about curriculum changes while sipping lukewarm coffee. I didn't care.  

Just take good care of us.

Still, with my first, I went a little psycho around delivery. I created an annoying three-page natural-no-epidural birth plan with all sorts of stipulations: no med students, minimal residents, no male anybody.

Ha. When the meconium hit the fan, there I was being wheeled into an O.R. crowded with every level trainee and both genders well-represented, and I didn't care.  

Just take good care of us.

Babyboy had to be rapidly and forcefully extracted: hauled from above and pushed from below. But he was born and he was healthy and all was good.

For my second, I had no plan. I was so traumatized by how violently OPPOSITE everything had turned out from what I had envisioned the first time around, I couldn't make any decisions at all. So my lovely O.B. firmly (but nicely) guided me through a successful VBAC.

I've seen her around since and we are very friendly. I've probably also run into multiple nurses, residents, and students who were witness to my howling hysteria in one or the other delivery, but I can't remember who was there from either so who cares.

Personally, I'm glad that I delivered with a physician I know professionally and admire. I could never have managed going to any other hospital but my own anyways, too inconvenient. 

But not everyone feels the same way. The question occurred to me: Where do OB/GYNs deliver? Do you guys generally prefer your own or a different hospital?

How about other specialties- OB anesthesia, what about you? Does it vary at all by specialty?

Maybe it just has more to do with individual comfort level with the total, supreme lack of privacy, and knowing you will be definitely be observed if not at your worst, then at least, perhaps, not at your best.

I'm very curious about this, as I am covering this topic for a doctor-mom writing project. Please, share your perspectives! Inquiring minds will want to know.

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