Thursday, December 10, 2009

A day in the life of a part-time medical oncologist

Note: I am a medical oncologist who works part-time, two full days and one half-day at work and the rest of the week at home with my kids (almost 2, 4, and almost 6). We have a part-time nanny who comes on my 3 workdays. This is my half-day, which probably captures a little bit of both of my worlds.

5:10am Wake up to sound of husband opening drawers as he gets dressed. Open eyes briefly to see gorgeous man a few feet away. Too tired to appreciate him aloud, I smile blissfully and fall back to sleep. I'm married to that guy!!!

5:55am "Mama, milk please. Milk, Mama!" on the monitor. Go get my youngest from her crib who greets me with a toothy grin and nurse her in my bed. Wonder if I am still nursing her (usually once a day, either morning or bedtime, but occasionally both) because I am tired and this gives me a few minutes of snooze or because she likes the bonding or because I like the bonding or all of the above. Fall asleep wondering how I will wean her--she will be 2 in a couple months.

6:15am Wake up to youngest saying "Shhhh! Listen...mourning dove!" She's right. How does she know what a mourning dove cry sounds like? Aren't they supposed to fly south for winter? "Read Tick-Tock, Ears Hear a Clock!" Hop up, make the bed, change diaper, get her dressed for the day, and read her about 15 board books in her glider under a pile of blankets.

7:10am My 4 yr old wanders in with bedhead and slides under the blankets with us. We reread half of the stack of books, as well as two Fancy Nancy books she brought with her. Kids finally tire of reading and start to play together. I pee and brush teeth.

7:50am My 6 yr old wakes up to the sound of his sisters playing together very loudly. He is grumpy because he's still tired. He needs 12 hours of sleep per night or more and seldom gets it because he is such a night owl. Vow to do better at coaxing him to bed early. Start his Pulmicort neb.

8:00am Big kids use the potty and get dressed while I supervise. Dispense kids' Calcium chewables and son's asthma medicines and ask them to identify the pattern (my son's latest kindergarten task): "pink, purple, purple, orange...A, B, B, C" the older two shout in unison. Brush 3 sets of teeth. Start washing machine, loaded up and forgotten at bedtime last night.

8:15am Cook oatmeal while big kids decorate Christmas cards for friends and classmates at kitchen table and baby drives her doll and Curious George around downstairs in shopping cart. Empty dishwasher and finish packing lunches for preschool and school. Think it would be better if I emptied dishwasher and packed lunches the evening before.

8:30am Breakfast with kids. Baby insists on sitting at table, not in high chair.

8:40am Baby dumps bowl of oatmeal and raspberries everywhere. Clean up floor and notice that there's also a LOT of dried-up dinner remnants from last night and random fuzz down there, too.

8:45am Load dishwasher up, then chase kids around downstairs with the Swiffer Vacuum (incidentally, they love this and don't realize that I'm actually doing housework since I run with it like a maniac...try it.)

8:55am Walk 6 yr old son to bus stop for kindergarten. Kiss goodbye. Nanny arrives and drives 4 yr old daughter to preschool with my 22 mo old daughter along for the ride.

9:00am Grab charts, work papers, laptop, gym bag, lunch, cell phone, and wallet. Check email. Move clothes from washer to dryer. Get into car to head for the gym.

9:05am Back at home. Forgot my glasses. On the way to gym again.

9:15am Pilates.

10:20am Surprise preschooler by joining her preschool class in the pool for last half of their rec swimming time (preschool and our gym are adjacent and share a pool). Asked nanny to bring the 22 mo old up to the pool, too, so we all swim around together.

10:45am Shower, dress, dry hair quickly, no makeup (which is the rule rather than the exception lately, though I try on workdays...). Drive a mile to my son's elementary school.

11:15am Help my 5 yr old son and 22 of his classmates stamp snowman shapes onto t-shirts using glitter paint and potatoes.

11:45am Eat a sandwich in the car while driving to clinic. Conference into a meeting about clinical trial design issues, listening through the car's speakers via Bluetooth. Feel glad that we did not trade in our Prius for a second giant family truckster when we had our third child.

12:05am Sign clinic notes, bill outstanding visits, discuss patients with fellows, review two abstracts on which I am a co-author, read and respond to work email. Overhear fellows talking about the new breast cancer screening guidelines. They ask what I think about them. I explain that I can see both sides. Note that all of the female fellows are somewhat sympathetic to the pro-screening side of the argument; none of the men are. Interesting. Wonder how that impacts our counseling of patients. Note that inbox is now over 2000. Wonder what would happen if I just emptied it. Nurse asks if I had exfoliation or something. Thinks I look younger today. I tell her thanks but no. Remember that I'm not wearing any makeup. Look at my reflection in the exam room mirror--maybe she's onto something. I do look younger without makeup.

1:00pm-5:00pm New patient consultations, all breast cancer, often alone, occasionally with fellows. A representative sample:

32 yr old woman with high-risk early stage breast cancer. Recommend a clinical trial. She will need to travel to participate. Could also do aggressive chemotherapy outside of a trial, but not my first choice. Offer tissues to her as she cries periodically and entire tissue box, flashlight, reflex hammer, tape measure, and rolls of gauze to her 13 month old son who is toddling around the room and holding it together remarkably well for the lengthy visit. Mother, also in attendance, expresses outrage over the new breast cancer screening guidelines, which could have killed her daughter. I explain that her daughter is only 32 and wouldn't have been affected by these guidelines, which refer to women age 40 or older. That her tumor was palpated and not visible on the diagnostic mammogram even after the mass was felt. That these very aggressive tumors, such as her daughter's, tend to develop over months, not years, and often appear between annual screenings anyway. Cases like her daughter's are part of the case AGAINST mammograms in young, premenopausal women. She reiterates that no one seems to care that the guidelines could have killed her daughter. I decide I am not being a very effective communicator.

43 yr old woman with a smallish focus of ductal carcinoma in situ. Has had genetic counseling and isn't a BRCA mutation carrier. I recommend lumpectomy with radiation and tamoxifen for 5 yrs, which will reduce her risk of recurrence or a new breast cancer by nearly half. She wants bilateral mastectomies to save her life. Tell her that her prognosis is excellent, that there is no data to suggest mastectomy will improve her survival, and that bilateral mastectomy is absolutely overkill. She has two small kids and doesn't care. She wants them off. Wonder if I might not make the same irrational decision if I were in her place. Print out a patient education sheet from one paper showing no survival benefit for mastectomy. She shrugs and I give her the name of a good reconstructive surgeon. She declines the tamoxifen.

78 yr old woman with a recently resected very large, node-positive neglected breast cancer. Really, really, really don't want to have to give her chemotherapy. Wonder why she ignored this thing for so long. So I ask her. I was hoping I'd die before anyone ever told me I had cancer. Does she want to die? No, of course not. Does she want treatment for cancer? Of course. Recommend chemo in addition to hormonal therapy. Hold breath and hope chemo will do more good than harm. Think it will but never know how old a 78 yr old really is until she gets chemo.

35 yr old woman with stage 1 breast cancer, no family history, diagnosed by screening mammogram. Recommend chemo and hormonal therapy. Talk about fertility preservation and the chances of having a successful pregnancy in her 40s after chemo and 5 years of tamoxifen. She is angry about the new breast cancer screening recommendations. Her life has likely been saved by a screening mammogram, at age 35 no less, that her GYN recommended based upon several years out-of-date guidelines. She asks what I think about the new guidelines. I can't tell if it's a challenge or not from the tone. I spend 15 minutes explaining how there are valid points to both sides of the debate. Again. She seems unsatisfied. I think she was hoping I would agree with her or disagree with her but not both.

42 yr old woman with locally advanced breast cancer that was diagnosed by a screening mammogram, but must have been palpable months before. Wants a second opinion about the choice of preoperative chemo. Also asks what I think about the new breast cancer screening guidelines for women in their 40s. Think maybe I should put what I think on a shirt and wear it to clinic. I tell her that it's kind of like playing the lottery. You'll probably buy a ticket every week (i.e. get a mammo every year) and nothing will come of it. It will definitely cost you, but probably not that much. If your number gets picked and you win, you will think you clearly made the right choice to play. If you don't, maybe you'll regret all those tickets you bought and maybe you won't--that's kind of a personality and values thing. It's the shortest and least meaningful commentary I have made on the breast cancer screening guidelines (which I have discussed about a dozen times a day at work and socially) since they were released. I am tired. "That's the clearest, most thoughtful way of summing it up that I've ever heard," she tells me. Sigh.

5pm Grab charts and rush out to Tumor Board. Run into (literally) an out-of-town patient in her early 40s I had seen almost two years ago with a very high-risk, inoperable triple negative breast cancer. She had flown down to see plastic surgery about reconstruction and decided to stop in to surprise me. When I saw her in 2007, I had recommended that she go on a clinical trial that involved traveling hundreds of miles from home frequently. It would take her away from her school-aged kids. I had agonized about whether it was the right choice--it was a long shot--given all the time away from her family and her potentially short survival if it didn't work. She had been lost to follow-up at our institution. She had done the trial, had the preoperative chemotherapy, had an amazing response. At the time of mastectomy, she had a pathologic complete response (no tumor left in the breast or lymph nodes). PET scans every few months had all been clear. It is likely that she is cured. YES!!!! She hugs me and cries, cries, cries. Tells me that's the first time she's cried since the original call from the surgeon telling her she had breast cancer. I think I might cry too--a combination of joy, exhaustion, and hypoglycemia.

5:10-5:45pm Slide into Tumor Board 10 minutes late. Eat a disgusting pastry left over from some conference earlier in the day. Regret it. Think I should really plan better and bring a healthy snack. I am always famished after clnic. We have plenty of food in our fridge. Why is that so hard to pull off? Discuss my and my colleagues' challenging cases. Surgeons are running the show and have little patience for the medical oncologists yapping on and on, so we end 15 minutes early.

5:50pm-6:10pm Commute home. Listen to NPR for a few minutes and then call my best friend, who also commutes home at this time, via Bluetooth stereo speaker. Love the Prius again!!

6:10pm Enjoy the hero's welcome at the front door by all the kids and hubby. (Incidentally, no hero's welcome for me from the kids on the days I stay home with them!)

6:10-6:30pm Make black-bean pumpkin soup with 5 minutes of prep and quick-steam string beans in the microwave. (Love Aviva Goldfarb's Six O'Clock Scramble website for fast, healthy meals that everyone in our household will actually eat--check it out!) Mix up banana bread from scratch (6 yr old has food allergies, so no mixes for us) and put it in the oven. While dinner cooks, sit down at our kitchen table with a family-sized bowl of strawberries. Help 6 yr old with his phonics homework, congratulate 4 yr old on being selected "Top Dog of the Week" at preschool, and collect a few dozen random items on my lap, brought to me by my 22 mo old.

6:30pm Dinner with the whole family.

6:45pm Chase kids with Swiffer Vacuum again (they could do this all day) while husband loads up and starts dishwaser.

6:55pm Bath time!

7:10pm Everyone in PJ's. Back downstairs to have a bedtime snack of banana bread and apple cider. Love the fall treats!

7:20pm Help son with a Lego dragon he is building. Girls come into the room wearing dress-up clothes and costume jewelry (pajamas off). Make up a story that incorporates princesses AND dragons. Agree to tell the exact same story a second time, by popular demand, if girls will get back in pajamas. Make this request about 10 times. It eventually works.

7:45pm Everyone BACK in pajamas. Teeth brushed. Play Tickle Monster, also by popular demand. The baby old slips in her footie PJ's and falls. Big tears, overtired tears. Boo-boo buddy and special blankie. Evening saved.

7:55pm Husband starts reading bedtime books to all 3 while I fold the laundry on the floor in the room with them. As I finish up, little one comes over to sit in my lap with her thumb in her mouth and a longing look.

8:05pm Nurse 22 mo old in her room. Wonder if I am nursing her because it gives me a chance to sit down and unwind in a dark room or because she likes the bonding or because I like the bonding and decide it's all of the above. Wonder how I will wean her--she'll be 2 in a couple months. Fall asleep wondering. Jostled into the land of the living by my son, who wants me to read the last book.

8:15pm Put little one in crib and tiptoe out. Read the last book. Put my 4 yr old in bed and sit in her chair, her nightly request, for 10 minutes to talk about her day. Kiss her good night.

8:25pm Flop on my son's bed and beg him to join me. He draws portraits, dinosaurs, robots, all the items he would like at his next birthday party (including details of the party favors, pinata, cupcakes, and juice boxes), and does math problems standing at his dresser. I get snapshots of his day with answers to every third question.

9:00pm I tell him I will give him math and spelling problems if he will get in bed. We lie there together in the dark. Ok, how about CHICKEN? Um, C-H-I-C-K (it's CK, right, Mommy?)-I-N. Close, it's E-N. What about THICKET? T-H-I-C-K (it's CK, right, Mommy?)-I-T. Close, it's E-T. Ok, try CRICKET. C-R-I-C-K-I-T, no wait C-R-I-C-K-E-T!! Hey, is this a pattern, Mommy!! Let's do more patterns. Ok, try 2,4,6, blank, 10? He yells out 8. How about 10, 30, 50...? He says 70, 90, 110, 130, 150...I fall asleep while he's still counting. Apparently counting sheep works even when there aren't sheep and even when you count by 20s. At some point, I notice that he has gotten back up and turned the light on to draw again. When he sees me wince, he dims the light but keeps drawing, standing at his dresser. We should get a desk for his room, maybe for Christmas, I think. On second thought, maybe not--he'll never go to bed again. I fall back to sleep.

9:50pm Wake up in my son's bed to my son, now back in bed, asking me to scratch his back. I do and he falls asleep. Vow to get him to bed earlier tomorrow.

10:00pm Find my husband flipping between sports channels and playing Scrabble on computer during commercials. Sit down to watch 30 minutes of stand-up comedy (Brian Regan, totally hilarious). Laugh really hard, but fall asleep at the end of it.

10:25pm Husband shakes me awake, and I get in pajamas, brush and floss my teeth and wash my face. This wakes me up. I decide to go downstairs to pack lunches for the next day, notice that we need their thermoses which are in the clean dishwasher which I then unload, notice that we are out of yogurt and napkins so start a list for the store, sift through the day's mail and notice two bills that I need to pay. Too busy to let them wait, we might forget. Get online to pay the bills and realize that I also need to do our bi-monthly nanny payroll, which I do. Notice on our office desk a receipt for Motrin and Benadryl and fax it into our FSA. Look on travelocity at plane tickets for Christmas, which are now too expensive for the 5 of us...guess we'll be driving. Speaking of Christmas, I still haven't written our Christmas letter or done almost any of my shopping. Get on Amazon.com and order gifts for the nieces and nephews since they all have to be mailed, as well as a few things for the kids. Try to figure out what to get my husband (don't know) or what I want (keep getting that question from my family, don't know). Send my sister pictures for a calendar she is making for my dad for Christmas. Spend 20 minutes on Facebook reading about who is still eating their kids' Halloween candy and who says The Gentleman from Connecticut had better not filibuster, buster and who has found a lonely cow on their farm.

12:05am Join sleeping husband in bed.

12:06am Realize it's cold in the house. Go cover up the girls and put my 6 yr old, who falls out of bed every single night, including tonight, back in bed.

12:08 am Join sleeping husband in bed. Look at the window and realize the Christmas lights are still on. Go down and turn them off. Feel pretty awake again. See New England Journal and Real Simple on the chair by the door. Decide to read Real Simple for just 10 minutes. Read for 15 minutes. Feel guilty. Start reading "Case Records..."

12:30am Wake up when my head jerks forward. Re-join my husband in bed and fall asleep.

6 comments:

  1. Oh my gosh - your post is wonderful!

    I was laughing and shaking my head towards the end. Your nights are just like mine - those last few paragraphs are gold!

    Thanks!

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  2. Loved it! Thanks for sharing.

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  3. hmmm you made me miss my kids as little ones :)

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  4. You are making me dream about working part time.

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  5. Love your post! I am considering oncology... sounds like everything I am interested in... and your post made me more sure of that. :)

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