Friday, July 31, 2009

Time flies

We measure time in seconds and minutes, hours and days, weeks and months, years and decades. Sometimes seconds drag. Sometimes days and weeks fly by.

I see patients with chronic conditions, so my relationships with them are typically measured in chunks of three to six months. It’s often a surprise to me to see a certain name on my patient list – is there a problem? Why is she back so soon? Then I check the chart – there’s nothing wrong, just a routine six month evaluation. Where has the time gone?

In my home life, too, I frequently feel like I’ve been in autopilot mode: Get up. Make lunches. Go to work. Get the laundry done. Then, like a submarine which has been submerged for too long, I have a hard time adjusting to my surroundings when I finally surface. How did Eldest get so tall? When did Youngest grow those shoulders? Is that a mustache? Two mustaches?

If I were a stay-at-home mom, would I see these changes while they were occurring? Or does every mother experience the sudden realization that her children have been quietly, efficiently, growing up? Perhaps the daily changes are so gradual that we can’t see them. Like the movement of the hour hand on the last analogue clock in the house, after a certain amount of time has passed the change becomes obvious to even the most casual observer.

I want to stop time. No, I want to be more aware of time. Any ideas how to make this happen?


Thursday, July 30, 2009

6 words

There was a contest at SMITH magazine (now ended) where women were asked to describe motherhood in a six-word "story." It made me wonder how I'd describe being a mother in medicine in a six-word "story." Here's my six-word story about being a resident mama:

3AM, a noise... pager or baby?

Feel free to contribute your own!

Monday, July 27, 2009

Deadline for worthwhile work: age 40?

Take the sum of human achievement in action, in science, in art, in literature—subtract the work of the men above forty, and while we should miss great treasures, even priceless treasures, we would practically be where we are today . . . The effective, moving, vitalizing work of the world is done between the ages of twenty-five and forty.

Sir William Osler, "The Fixed Period", farewell address at Johns Hopkins Medical School, 1905

I came across this quote by renowned Canadian physician William Osler a few months ago and found it disconcerting. Not because I disagree with it, but because I wonder if there might be truth in it. And because I am a thirty-five year-old mother of three who has been treading water career-wise, working two days a week, with plans to truly launch myself professionally in another five years or so.

Then I watched In the Shadow of the Moon last week, Ron Howard's documentary on the moon landings, and was struck by the fact that Neil Armstrong, Buzz Aldrin and Mike Collins were all 38 when they flew to the moon in 1969. Arguably at the pinnacle of their careers, they were three years older than I am.

So I find myself wondering - have I already peaked? Have the opportunities for my best professional work slipped by while I've been laundering onesies and making homemade chicken stock? Or have they simply been postponed, with the next decade being my professional hurrah, as hoped?

My twenties were characterized by energy and optimism. My thirties have seen an indisputable downturn in both, but gains in insight and creativity. I thought perhaps each decade would burnish some new qualities, culminating at age . . . fifty-five? sixty? I don't really think that far ahead. But I was certainly counting on having more than the next five years to make my mark.

So - if you are at the end of your career, at what age did you make your greatest contributions? If you have passed forty, do you feel that your most productive years are behind you? And if you aren't yet forty, what years do you expect will be your best?

Thursday, July 23, 2009

Day in the life of a SAHM

If you asked me two years ago what I thought about Stay At Home Moms (SAHMs, for those of us in the know), I would have said that I was intensely jealous of them. How could someone be so lucky as to get to just stay home and play with your kid all day?

Residency ended for me on June 30 and since then, I've been playing SAHM for the month. This is my typical day:

7:30AM: Melly wakes up screaming for her stuffed animal that she went to bed with, which is likely just lost in the covers

8AM: I shower while Melly washes her hands in the sink. She can wash her hands for like five hours in a row. Is this early OCD?

8:30AM: I beg Melly to use the potty. BEG her. She laughs at me and runs around the house diaper-less.

9AM: Breakfast. I discover that Melly dropped a bunch of food on the floor last night and now there are ants. She gleefully points them out and calls them "cute." I kill them with my bare hands like in the olden days.

10AM: We go to the library. At some point, she gets away from me and runs amok in the "quiet" section. We get shushed a lot.

11:30AM: We head back home for lunch.

Noon: Lunch. (She's actually a really good eater.)

1:00PM: I attempt to get Melly to nap. This results in swearing, crying, and occasionally, napping.

2:30PM: We go to the park. This will kill at least an hour. Except where are her F#$^%ing shoes??

4PM: Trip to grocery store for odds and ends. Melly wants to eat everything in the store RIGHT NOW. I yell at her to wait and feel like a horrible mother/person.

5:30PM: Daddy gets home. I cry with relief.

So yeah, right now I'm feeling like SAHMs deserve a medal. (Although it's probably still better than surgery residency.)

Seriously, I wanna know...

Sally: I'm difficult.

Harry: You're challenging.

Sally: I'm too structured. I'm completely closed off.

Harry: But in a good way.

When Harry Met Sally (1989)

Are you a magnet for difficult patients? By difficult, I mean patients with threatening or abrasive personalities, who come to the physician encounter with 5 or more complaints, use health services extensively, or have a mental disorder - the criteria used by Dr. An, et al in Burden of Difficult Encounters in Primary Care: Data from the Minimizing Error, Maximizing Outcomes Study. Archives of Internal Medicine 2009; 169(4): 410-414. According to their data, if you are young and female, you are more likely to have encounters with difficult patients. Is burnout responsible? What about multi-tasking? Does our training leave us prepared to deal with medically complex patients but not emotionally, demanding complex? Does the difficult encounter impact outcome?

Tuesday, July 21, 2009

Day Dream Believer

After writing for Mothers in Medicine for a year, I took a short sabbatical from writing. It wasn’t planned or intentional. I have been carrying around this gnawing feeling that my kids are growing up so fast, and I need to spend whatever time I can eek out with them.

With six months of planning, I scheduled an extra day out of my office to spend with Will & Harry for the summer. I’m really liking my three day a week schedule, and I don’t think the extra day has put undue burden on my partners.

My fantasy about this summer with my sons was a glossy mirage of day trips to pick blueberries and find adventure together. As with most of my fantasies – going back to residency to do pediatric dermatology, starting a bead/jewelry company, surf lessons, decluttering my bonus room – reality has a way of smacking me between the eyes with either lack of skill, lack of time, or just lack of motivation.

So the score mid-summer for these idyllic trips:

Lovely Day trips with sons: 0

Loud action movies with popcorn/soda/candy in sedentary repose: 4

Afternoons spent with neighborhood boys running through my house: TMTK (too many to count)

On realization of the above score, I made the command decision last Thursday, to have an adventure and seek out our new IKEA store. (Can you hear the boos in the background? Sheesh, house wares, mom, what kind of adventure is that?) We set out for the twenty minute trek to the blue and yellow Mecca with promises (read bribes) of treats. So ninety minutes later, lost in 91 degree southeastern summer heat with limited AC in my station wagon, I discover that several “friends” have joined our trip:

Howie Mutch Longa

Tutantired Togo

Ima Lousie’n Mya Mynda (my BFF)

Dewie Hafta Ngo

Fortunately, bouncing on display beds and opening a myriad of drawers in the IKEA showroom once we found it disbanded our unhappy group of travelers. The strategic placement of the concession stand at the end of check-out taught me the power of Swedish Fish. And I have a plan to streamline our multipurpose bonus room – otherwise known as home office-guest room-exercise equipment storage-Lego & X Box central clearinghouse. I can also smile to myself when one of the boys starts a sentence “Remember the time mom dragged us to…” because I know time has a way of sugarcoating these memories as we age.

Wednesday, July 15, 2009

Yes, we said Facebook

Mothers in Medicine now has a Facebook page, kind of like an adjunct virtual water cooler to the main virtual water cooler (this site). If you're on Facebook, please come by, become a fan, and feel free to post questions/thoughts/links on our Wall. We'll be linking to our blog posts, as well as other interesting links we come across for fellow mothers in the link we recently posted about part-time academic medicine careers --a great resouce with relevant bibliography, considerations, etc --taken from the Society of General Internal Medicine site.

If you're not (yet?) on Facebook, maybe now's the time to take the plunge?

And if you've vowed to never, ever be on Facebook, we understand that too - been there, done that.

Monday, July 13, 2009

Guest Post: On the lack of women mentors

None of my mentors have been women. It saddens me to say this. In fact it outrages me. The women I met in medicine prior to medical school warned me away from medicine - "Its not too late," they said. "You can quit now and find something easy." I had been bitten by the bug and there was no way I was doing anything else but medicine.

We had had real tragedy in my family and at that point I wanted to be a trauma surgeon or a neurosurgeon working 100 hour weeks, hopefully saving some lives, and the idea that I might want to do anything else with my life was so foreign.

Then at the end of 3rd year I got pregnant. We had been married 7 years. This was a planned and hoped for pregnancy and though I had thought that making the work-life balance would be difficult, I was definitely living a fantasy. Reality set in 9 months later when I held my child in my arms the first time. The responsibility weighed on me. I almost picked my specialty just on the fact I could have an easier residency. But I decided not to sell out my dream.

I am lucky and have an incredible husband who can (and will) be doing the parenting by himself next year. I chose to stay in town at an academic but not abusive residency. I've got a long road to go, but I realized long ago that it is about the journey and not the destination.

I wish there had been a woman around who had made the same decisions I made who seemed genuinely happy about them. Maybe I'll find one as an intern/resident. There are definitely some women out there who could use some guidance other than "Don't do it."

A reader left this comment a few weeks ago on a post that was part of our Topic Day on "Our Mentors." We hope this site can be a source of support and encouragement for those who need it. (I think all of us contributors here agree that it is worth it, and our lives are richer for our decision to be physcians and mothers.)

Saturday, July 11, 2009

I Didn’t Join the Circus, So Why Must I Jump Through These Hoops?

One of the things that troubles me most as a teacher is watching medical students’ enthusiasm and curiosity deteriorate during medical school. Within about three months, I see them going from thinking about what they are learning to trying to pare down the material to what is likely to be on the next test. The competitive habits that got them into school provide a deeply debased motivation for studying—without knowing why, they fret about being AOA or getting into a competitive specialty . Few of them live in the present—as preclinical students, too many want only to survive to move to the clinical years. As clerks, they worry about buffing up their records to get into residency. Once in residency, I wonder if they ever recover the vitality that comes from being fascinated and engaged in learning something, thinking a new thought, or enjoying the unfolding of a new relationship .

Given the deadening effect of our current way of educating— or to be precise, training—doctors, I understand why the competing challenges of mothering appeal so strongly. With children, we have to live in the present (though we do also eventually transmit to them worries about their future and risk turning high school into nothing but a springboard to college). We can’t stop to study them for the next exam. Their development and our relationship to them propels us forward, and it is only in looking back that we see how much we may have learned in the last few days, weeks, months or years.
A lot of paper and ink is currently wasted by people pontificating about “adult learners,” postulating that they learn differently from children—because they have to incorporate new information into older structures and because they need to learn by doing rather than by rote. I often find myself doubting whether any of these theorists (mostly men, I might add) have actually watched children explore the world, puzzle out new information to figure where it fits with what they already know, and joyfully practice new skills.

I wish that I could be creative and persuasive enough as a teacher who draws on experiences as a mother to enlist others to think differently about how to engage and encourage students . Rather than spice up our lectures with video clips to entertain them, we should think about creating relationships with patients, peers, and mentors that both stimulate their felt need to learn things and reward them, immediately, for doing so. I know that a medical student will never learn the complexity of our profession in the unselfconscious, apparently effortless way that our children learn in their early years, but I think they long for it to be so, and I long to able to make it that way for them. But even if that is not possible, we need to think more about motivating them by stimulating curiosity rather than fear of failure, rewarding learning immediately rather than in the distant future, and engaging with them as teachers so that they in turn will engage with patients and be the doctors we would want to see when we get sick.

Thursday, July 9, 2009


I made a post a couple of months ago about how impossible it is for a mother to do a fellowship. I feel a little embarrassed for acting like Whiny McWhinerson, especially since it turns out I landed a fellowship after all. Apparently, after residency it's all about the connections and I had the right one. Woo, I get to continue being an impoverished trainee! (Just kidding, I'm actually really psyched.)

A large component of my fellowship is supposed to be "flexible research time". This really appeals to me, not because I intend to spend this time taking my daughter to the park, but because I love doing research. Many eons ago, during college, I participated in quite a few serious research projects, but the mice in the lab weren't my bag (baby). I love proposing a project, collecting data, analyzing data, writing the paper, and especially seeing the article in print... but I hated sitting in a lab with test tubes and/or rodents. Ugh, and PCR.

So the idea of doing clinical research really appeals to me. People all tell me I seem like an academic. And it's in my blood (i.e. both my parents).

I also think that it's ideal work for a mother in medicine due to the flexibility. I never want to give up seeing patients or lose my clinical skills, but I think I'd lose my mind seeing patients full time. Research grants seem like a nice way to add to your income while not working yourself into the ground. Also, you have the opportunity to contribute something to your field as a whole.

I haven't seen any other MiMs on here discuss research as part of their job. An oversight or does it just not exist?

Wednesday, July 1, 2009

Ladies, don't panic!

Just a couple days ago, I posted about the decision my husband and I are struggling with about whether to try to have a fourth child. The piece got a lot of comments. The one that struck a chord the most, though, came from an anonymous reader who commented:

"At the risk of being the Cassandra here, how well would your life work with a fourth child who has Down's?? You know how high the odds are climbing for you at age 37. Your family size is clearly not my decision, but in my family of origin I was the youngest by a large margin, and my parents wanted a sibling "for me" close in age. My un-named baby sister had Downs and its most severe cardiac manifestation when she was born via emergency C/S to my then-37 year old Mother. She never left the hospital, and her death tormented my Mother the rest of her life. And selfishly, I know if she had lived MY life would not have been the same. Just some food for thought...."

First, let me say that I think Anonymous' intentions were good, and I appreciated the willingness to share a personal story to provide the devil's advocate viewpoint to the general tone of "Keep the love goin'" comments I was hearing. But the truth is that that comment struck fear in my heart. I immediately thought "She (or he?) is right! We have been so fortunate to have 3 healthy kids. We should quit now." And then, "Actually, no, I don't know 'how high the odds are climbing' for me at 37." I know that 37 is advanced maternal age, but I had no idea what 37 really meant for my risk in cold, hard data. So I did what I always do in moments of personal medical crisis--I did research and I called my baby sister (not an MD, but a pediatric physical therapist and a voice of reason).

From a career standpoint, I wear two hats--one as a clinician treating breast cancer patients and one working in a public health role. For both, I spend a lot of time thinking about risks and how we convey them to patients and people in general. What is most understandable by a lay person? How do we shape perception of risk, and in turn behavior, when we express risks one way versus another? It is fascinating and, at times, disturbing.

Note that, due to some formatting challenges for my elderly brain at 12:30am, I am indicating risk of Trisomy 21 in bold and risk of any chromosomal abnormality in italics rather than figuring out why my tables come out garbled in the post.

Maternal age Risk of Trisomy 21 Risk of any chromosomal abnormality
25 1 in 1250 1 in 476
30 1 in 952 1 in 384
33 1 in 625 1 in 286
35 1 in 385 1 in 192
37 1 in 227 1 in 127
40 1 in 106 1 in 66

For any of you who aren't 25, I am guessing this looks pretty scary. I know I can feel the sand slipping (or more accurately, gushing) out of my hourglass when I look at that table. But now what if I put it like this instead? (Same formatting convention with the bold and italics, but note the difference in the headings)

Maternal age Chance of NO Trisomy 21 Chance of NO chromosomal abnormality
25 99.92% 99.78%
30 99.90% 99.74%
33 99.84% 99.65%
35 99.74% 99.48%
37 99.56% 99.21%
40 99.06% 98.48%

Kind of takes the zing out of it, doesn't it? For those who don't know, 35 is called Advanced Maternal Age because that was the age (historically...amniocentesis is a bit safer now than it used to be) at which the risk of fetal loss due to amniocentesis was approximately equal to the risk of detecting a chromosomal abnormality, and therefore, the benefit of prenatal detection was felt to justify the inherent risk of the procedure. The fact is that, at the large academic medical center where I practice, they now consider advanced maternal age, for those purposes, to be 32 and routinely offer amnio to women who are 31 or older at the time of conception. This has caused all sorts of angst and dismay amongst the female residents and fellows who feel that they are now somehow at higher risk because of this change in definition. One physician even lamented to me: "It's not fair. How come advanced maternal age changed to 32 for us? I thought I still had 4 years, and now I only have 1!?!" Ummm...because amnios are safer.

Now, don't misunderstand me. I am not on a soapbox to get everyone to delay childbearing willy-nilly into their 40s and 50s. That is the terrain of Hollywood stars. For every successful story you hear of someone who had all 3 of her kids in her 40s with her own eggs and got pregnant in a month each time (and those people exist, for sure), there are also many, many often untold stories of women who endured multiple miscarriages or fertility treatments, who tried to get pregnant unsuccessfully for years with all the heartbreak that involves, etc. But the fear of Down's syndrome, or any other chromosomal abnormality, should not be what drives someone to get pregnant (or not).

So, as I said, I also called my sister to get her take on all of this. Wise as always, she said something that really hit home for me. She has a clinic brimming with children who have physical and cognitive challenges of every variety, including Down's syndrome. But, far and away, the most common cause of the disabilities she sees are things that happened after birth: near-drownings, meningitis, head injuries from biking without a helmet, car accidents. Patients with Down's or other chromosomal abnormalitites represent a minority of her practice. Which brings me to my next point: there are no guarantees in life or in parenting. To be clear, I am all for prenatal testing. I think it is critically important for couples to have the opportunity to know before birth if their baby has a chromosomal abnormality, whether that allows them to make the agonizing choice to terminate a pregnancy or to prepare for how their lives will change with the addition of a special needs child. But it's not a guarantee of a "normal" child. There are plenty of things that can't be tested for prenatally, and there are plenty of things that can go wrong--both diseases and accidents--after birth that will change the life of a child...and his siblings...and his parents forever. One of my own best girlfriends from college is currently struggling to come to terms with how their lives have changed since her previously healthy and incredibly athletic 7 yo son had several catastrophic strokes for which no explanation has been found. That uncertainty comes with life and with parenting, and if such uncertainty is too much for an individual to bear, parenting is going to be a very long, very hard road.

Everyone always says that pregnancy prepares you for being a mother--the sleepless nights of back pain and leg cramps and inability to breathe and peeing and rearranging closets during pregnancy are training for waking every 2 hours to breastfeed ad infinitum, to comfort the colicky baby who cries half the night, etc. The truth is that the lost sleep of pregnancy is just the tip of the iceberg compared to the lost sleep with a newborn. Worry is no different. You will no doubt worry as a woman trying to conceive and as a pregnant woman, but I can tell you from experience that you will worry a thousand times more once you are a mother. It is understandable. It is probably evolutionarily conserved so that our species will survive. But it cannot be all that you do, or it will become all that you are.

So ladies, don't panic!

The Other Side of the Gurney

What happened?
I feel wet grass and mud on the back of my head and a searing pain shooting through my body.
Where’s my son?
I feel a sense of relief when I call out to him and he says he’s fine.
Can I move my legs?
Do I have to go to the ER?
How am I going to get there?
Husband’s not home.
Can’t believe this happened.
Can’t believe I don’t have disability insurance yet.
I remember my neighbors were outside a minute ago.
NEIGHBORS!!!! I need help!
They rush over.
I’m not sure if I can move.
They help me up.
Throbbing headache, but everything works.
Neighbor takes me to ER, other neighbor keeps son.
Head injury gets me quickly into ER bed. I lie there lonely, thinking of worst case scenarios. Praying. Husband is on his way home, will be here in an hour. Call up to Labor and delivery to see how busy they are, they sound slammed… I don’t tell them why I called (hoping they were slow and someone could come down and sit with me while I wait)
ER doc is really nice. I recognize his voice from many phone calls.
So what happened, he asks.
Fell off trampoline, landed on the ground, on my head. The “safety” net broke.
Let’s get a collar on you and a CT scan.
I tell him the irony was we have scheduled to get rid of this trampoline the next week. It had came with the house and was getting old.
He chuckled.
I didn’t.
Then the orderly (I think they call them ‘tech’s now) wheels me through the hospital to radiology.
The whole thing feels surreal. I’ve walked these halls hundreds of times, but I’ve never looked at the ceiling. It’s a normal ceiling.
Strange to be on the other side. I fell anxious and embarrassed.
More than anything I feel vulnerable. Being pushed around the hospital. Flat on my back. Unable to move. Wearing only a hospital gown and underwear.
The tech tries to make small talk, but no one explains anything because they assume I know.
I see people doing double takes out of the corner of my eye. Is that Dr. RH+? Why is face tear stained and her hair wet and muddy?
The CT doesn’t take long just a few minutes.

Another trip through the hall and hubby arrives.
We’re both relieved to see each other.
ER doc gives a good report.
Headaches and neck pain for a week, but luckily no long term injuries.
Hug son extra hard when I get home.
I feel blessed.