Saturday, October 30, 2010
Friday, October 29, 2010
Socks on Stairs
(The latest in patient educational materials, written after one too many such injuries came through my office...)
I like my socks.
I have 12 pairs.
I wear my socks
Upon the stairs.
1 step, 2 steps...
That's not all!
3 steps... Oops!
I slip and fall.
Bump! Bump! Bump!
I bang my head.
Thump! Thump! Thump!
Ouch! "Help," I said.
I wish my socks
Were not so slick.
My low back hurts.
I'm feeling sick.
I have to see
My surgeon now.
My spine's messed up.
Those socks, that's how
I hurt myself.
I couldn't wait
To put on shoes.
Now I'm prostrate
Upon the floor
Below the stairs.
Will need repairs.
Be more cautious
Than I have been.
Those socks on stairs
Will do you in!
Wednesday, October 27, 2010
Join me in my journey to 50K!
In case you didn't read my post last year, NaNoWriMo is "a novel-writing program for everyone who has thought fleetingly about writing a novel but has been scared away by the time and effort involved." Yes, you too can write a novel that will never be read by anyone ever.
I think it's especially aimed at us workin' folk, who are too busy to write most of the time. This kind of forces you to sit down and write. And it's FUN. All the cool kids are doing it, including yours truly.
I would love to have more "writing buddies" so that we could have some fun competition. If you want to friend me, go here to read my brilliant title and the compelling description I wrote.
I "won" (= finished 50K words) last year, but this year is going to be a much bigger challenge. First, I've got a real job instead of a "research" "fellowship". Second, I'm losing an entire weekend to a conference. Third, Thanksgiving is gone because I'm going to relatives. And fourth... well, you don't need to hear my whole life story, but trust me, I've got stuff going on. But I'm determined to stagger in at the finish line.
Will Fizzy succeed? Can a mother/physician write 50K words in a month? Friend me to find out!
Tuesday, October 26, 2010
AWOL: Waiting for baby
A 38 week and 4 day little boy. Inside my uterus threatening to make his big arrival. Oh the places this little guy has gone (conferences in distance cities, organ procurement midnight travels) things he has seen (dying patients, miracle recoveries) and the drama overheard (dying great-grandmother, father unexpectedly unemployed). I could feel the strain of the pregnancy. In my hips and pelvis. On my mind. Being the wholesome expectant mother was inconsistent with my reality of 12 hour work days, two week blocks of call and Saturday and Sunday rounds.
It was time for me to move on. To move away from my office. To enter the parking garage and drive away. To pick up my two year old at day care in the middle of the afternoon. To arrive home in time to make dinner.
Really I had made it. Worked beyond emotional and physical pain. Accomplished professional milestones that I felt would justify my absence for maternity leave. But on that day instead of high fives on my way out- I felt a strong sense of disappointment. Despite all that I had done. Despite my sacrifices of health and happiness. To my (mostly male) colleagues at the end of that day I was still leaving. Taking a three month "vacation" where my work would need to be done by someone else.
Is it simply a scenario of wanting the cake and to eat it too? (And let me tell you I have indulged in my share of cake eating over the past nine months.) Honestly it would have been my preference to continue working up until my due date. To ease out of the most grueling work and ease into my transition home. Ultimately I had to call it quits. I needed a physical separation. I needed a vacation.
In my first days home I completed my patient charting, painted/organized the nursery, caught a matinee and napped in the mid-morning (and afternoon). It has been an active process of turning off my role as doctor, grappling with this guilt of desertion. What I have been able to do is sit and find my voice (hence the blogging). A week ago I feared that labor would come too early- leaving me to scramble and find a replacement for my hospital duties. Now I find myself, thank goodness waiting patiently, staring over at an empty bassinet as I type.
What I also found is strength. Strength that I was using every day, but somehow managing only to get by. Following a day at work too exhausted to climb the stairs to bed and overwhelmed to the point of tears. Now physical strength to attend a fall festival and join the family for a hike in the woods. Emotional strength to participate in the hospice care of my grandmother occurring five states away. Finding myself in the quiet and recognizing that there is plenty of me for this baby, my son and my husband.
Yes I do have a problem with work/ life balance. Partially to blame is my chosen specialty, but also to blame my own ambition. Achieving a sustainable effort is something I will continue to pursue- but for the time being I am the wholesome expectant mother. Hmmm, I wonder if there will be time for a pre-natal massage before my OB visit tomorrow afternoon?
Monday, October 25, 2010
We enrolled in med school anyway. We would become the physicians that knew nothing other than evidence based medicine, that would trade in our pharmacopias for epocrates, and see a work hours revolution change how patients are cared for in the hospital.
As an impressionable first year medical student I had a wonderful course called Medical Humanities. In a series of lectures we explored the philosophy of doctoring, and received our assignment. To preserve our humanism despite the rigors of training. To see each patient as an individual. To ask open ended questions. To respect cultural and racial diversity. To evolve beyond the paternalistic model and embrace the world where the patient is a partner.
I took this assignment on as a mission, reminding myself as years went by that smart and skilled was only part of the equation. That acting patient and compassionate was ultimately important. Years later I find myself in a field caring for extraordinarily ill patients, where astronomical efforts are made to save a life. Where more often than not this falls short and the best we can offer is a good death.
Over time I sense something that is just not right. It began with overwhelming frustration as a patient arrived with a ream of "medical information" downloaded from the Internet. Later it turned to disbelief as I found that my patient who cannot afford their rent is buying $100 per month of vitamins and supplements. As I find myself explaining why their information and supplements are bunk I find myself tip toeing in order not to offend and alienate. With so many new sources of medical information I think perhaps the grumpy old physician was on to something, the role of the physician has changed. Not necessarily a lack of respect toward doctors, but certainly a fair dose of skepticism that perhaps is deserved.
In my opinion the partnership model became derailed as the physician embraced the evidence and at the same time grew fearful of litigation. Informed consent then became central to the patient- physician relationship, a legal document. The conversation turned to odds of this and that, alternatives A and B, and finally the decision is up to you. The physician no longer answers the age old question, "If I were your mother/ child/ spouse what would you tell me to do?" Instead the doctor deflects a personal stake in the matter and ensures that in case of a bad outcome it will all be supported by the evidence, guidelines and paperwork.
Emerging from my medical training I began to feel an alienation at the bedside of my sick and dying patients. Witnessing their struggle with fear and uncertainty I felt like the care was falling short. The paces of a typical hospitalization includes selection of the proper evaluation, declaration of the correct diagnosis, and the discussion of treatment (with risks and benefits)- by the book. All of this done with the physician as the advisor and patient as a partner. When tackling the toughest issues- for instance at the end of life this series of discussions and decisions became just too much.
Grandma is too ill to speak for herself and there is a 80% chance that she will die. Would you like for us to do? Continue to try to save her? Should we treat the renal failure/ pneumonia/ UTI? Place a feeding tube? Continue lab work? Continue IV fluids? Turn off the ventilator?
My attempts to impartially advise and educate about all options grew in conflict with an urge to protect. To comfort. To spare whatever suffering could be spared for the patient and their family. But to step in and dictate what should/ could be done would be adopting the age old Paternalism we were raised to leave behind.
Perhaps there is a better way. May I be bold and call it "Maternalism". A way to provide compassionate care and resume part of the burden that we were taught to deflect. Partnering not as an equal but as a nurturer and comforter. For dying Grandma, first to help the family understand the situation, then to articulate what Grandma would have wanted. If that is go down fighting, they get a fight. But prevent the fight gone awry where Grandma suffers years as a vegetable with a feeding tube. If Grandma wanted to die naturally, then we allow nature to take its course. But spare the family from the agonizing series of discussions, where the family feels that at each step they are actively bringing the death of their loved one.
I find myself in a struggle to practice with excellence but also to sleep at night. Perhaps what we need is a sound clinical trial- or perhaps a meta-analysis to investigate the most effective role of the physician- in the post-Paternalistic era?
Sunday, October 24, 2010
The Newest Angel
Normally, it is a loud, busy place. The staff and surgeons are almost like a big family; we chat with each other and banter cheerfully with patients to help get their minds off the imminent ordeal of surgery. Chaplains pray with patients and families. Sometimes there are disagreements, as in any workplace. But everyone cares about everyone else.
Because of that caring, it was hushed. Instead of talking, people touched hands or embraced. The chaplain's prayers could be heard more clearly than usual.
Thursday night, a colleague's daughter had died. She was 4 years old.
She had been diagnosed with a childhood cancer over a year ago. We had followed her progress through treatment on a Web page her family set up. At first, we thought things would be fine; so many children can be cured these days. The survival rates were encouraging. Her dad, a talented young surgical subspecialist, carried on as usual after the initial shock.
Then the cancer spread. It stopped responding to treatment. One morning we came in to find her dad's cases cancelled at the last minute. Word spread surreptitiously: "She's had complications, and she's comatose now. It's not looking good." In the following weeks, hope slowly evaporated.
Strange; we all live with the presence of death every day. Patients code in the hospital. We make critical decisions about patient management; we do brain death exams and organ harvests. We live with its inevitability and yet find ways to go on. How unexpected, then, the pain when it happens to one of us, even when we know it's lurking just around the corner. No matter how much we know, we are never prepared for its intimacy when it comes. When it's a child, it's so much worse.
This is why I couldn't do pediatric neurosurgery. They see the worst of the worst; head injuries, abused children irretrievably damaged, malignant brain tumors that can't be cured. When I did that rotation in residency, my son was 18 months old. I couldn't help superimposing his face on patients about his age. It was unspeakably difficult. Admittedly, it can be very rewarding, because children do have such amazing capacity for healing. But many don't, and they broke my heart. I have such respect for those who can do this work, and for pediatric oncologists, too.
There must be a way to offer comfort to parents who have lost a child like this. I still don't know what it is. All I can do right now is hug my own son, smell his hair, and watch him sleep as if he were small again. I'll go back to the OR this week wishing I could repair my colleague's wounds like those of my patients. I'll be thinking about his daughter's Web page, purged of all the news of suffering.
Last Friday morning, that page had just one sentence: "There is no cancer in Heaven." Seeing that, we knew the newest angel had arrived.
Meaning this: We ALL get judged all the time. For everything. Whether people mean it or not. Do women get judged more than men? Possibly. Do female physicians get judged more than non-physicians? Actually, I doubt it. And no matter how much you protest that you do not judge others, we ALL do it.
One person commented that we "must be supportive of all women." Supportive of all women? What about a female patient who comes into our clinic pregnant and drinking vodka? Obviously we wouldn't support this decision just because she's a woman. I know that seems like an extreme example, but there are lots of crunchy internet moms who think giving your baby formula is just as bad as guzzling vodka during pregnancy. We judge any decision that we don't agree with, that we think is potentially harmful.
So after that lengthy introduction, I'd like to present some actual REAL judgments passed upon me over the last several years by family, friends, and nosy people on the internet:
You should go to medical school. You're never going to be happy if you don't.
Why are you going to medical school? You're going to be in debt forever.
You're going to sleep now? The final is tomorrow! Are you really done studying?
How are you going to do well on your exam if you don't get any sleep?
You're going to do a residency in internal medicine? You're going to be miserable and never make any money.
If you drop out of internal medicine, you'll never find a new residency.
If you do PM&R, there won't be any jobs for you when you graduate. And what IS PM&R anyway?
You shouldn't have a baby in residency! You're going to be exhausted!
You should have all your babies before residency ends because the coverage is better.
If you get an epidural, you won't be able to feel your labor and you'll end up getting a C-section.
Don't try natural labor. You're just going to end up begging for the epidural and by then, it'll be too late.
Don't give your baby a bottle too early! She'll get nipple confusion!
If you wait too long to give your baby a bottle, she'll refuse to take it.
You let your husband give your baby formula so that you could sleep? You're a terrible mother. I don't care that you had a fever of 102 and had just come back from the ER.
You have to swaddle your baby or else she'll never sleep.
Stop swaddling your baby, you monster!*
Everyone does a fellowship after residency.
If you do a fellowship, you're wasting your time.
Having a second baby will quadruple your work, so make sure you're ready for that.
If you don't have your kids two years apart, they won't be friends.
I could probably think of more, but I think you get the idea.
The point I'd like to make though is not that we should all try to be less judgmental and more supportive of each other, because let's face it, that's never ever going to happen. The one thing I've learned though is that you must try to be happy with your own choices. The judgments that really hurt me were the ones where I wasn't sure I was doing the right thing and already felt guilty about it (i.e. giving formula).
So while it would be great if we could all support each other, what I'm really trying to say is that we should try to support ourselves.
*This is my absolute favorite. I posted a video of my two month old daughter in a Miracle Blanket on youtube just for my parents and in-laws to see (because she was making sucking motions in her sleep and it was cute). I thought it was unsearchable, but somehow some nosy woman found it and started yelling at us for swaddling her.
Friday, October 22, 2010
I've been following along for a couple of years, occasionally putting in my two cents' worth. It's exciting to be joining in as a regular contributor. This is an amazing group of women, all great writers with a lot of stories to tell. I look forward to being a part of it all.
Thursday, October 21, 2010
Guest post: New mom in an unsupportive environment
Right now I'm on a lax 2-week radiology rotation consisting of half-day lectures but on November 1st, I return to the surgery department for 2 months of Q3 30 hour call. Board exams are in January. It's beyond daunting to even think of it right now.
After a struggle to establish successful breastfeeding with my baby, we have finally done it! But now I'm facing going back to work in an unsupportive environment. I questioned the possibility of pumping at work (very loosely suggested the topic to the head admin) and was told I could probably pump in the bathroom. I really don't think I'll be able to sneak off to do it anyway, but the fact that there is really no place to do it at this facility besides a dirty bathroom is even more frustrating. I've been torn up over making the decision to try to pump some or to just switch to formula.
As I have not met anyone who has had a baby during intern year, let alone in surgery, I would love to meet anyone who has been in a similar position. Even other moms in surgery practice.
Anyway, this has been a very emotionally draining and physically exhausting month "off". My medical school debt load is so insanely large that I could never fathom taking time off or not pursuing the paths I have taken so far. So, here I go...
Tuesday, October 19, 2010
My Experience With Infertility, Part 2
I got pregnant for the first time after three nervous tries when I was just 29. I went to my doctor and I remember him saying when my pregnancy test was positive, "You saved us a lot of trouble." I was to find out just how much trouble less than ten years later.
My husband wanted to have another baby right away, but I was never satisfied with my career as a teacher so I decided to instead go back to medical school first. I assumed the myth that if you can have the first child, you have all the time in the world to have the second. This was wrong, wrong, wrong. Not only does fertility decline 50% from age 35 to 40, but I didn’t count on other unforeseen things like my first husband leaving me when I was 33. At this point I was in a sheer panic to find someone else fast and have a second child.
The infertility spiral began slowly. I was remarried at 38 and immediately even before formally getting married, tried to get pregnant again. At first I was really excited about trying and finally having a new baby, now that I had a new husband and had a stable job as an attending physician. This time when I didn’t get pregnant on the first try, I went back to the same doctor and he started doing tests. I had to have an x-ray of my tubes which initially showed that my tubes were blocked. I had to then have a surgical procedure which showed that they actually were not blocked. I had several other tests and each month would go by and I wasn’t pregnant. Finally after what seemed like forever, I started getting injected with a massively potent drug called perganol which not only did not work, but left me with a disabling tinnitus that cut my infertility treatments short. The tinnitus was so bad that I couldn't sleep and nearly lost my job as a result. As if that was not enough, the perganol caused me to get uterine cancer about 15 years later.
I became miserable and bitter and the worst part about it was that it all didn’t have to happen if I didn’t just wait too long for no reason at all. I wasn't infertile when I was 29. What was I doing that was so important that I had no time to have a second baby? What about my work was so important that I had to do that instead of having a second baby? There is no job on earth that is worth giving up having a baby. I was horribly envious watching all the women on the street pregnant and with baby carriages wheeling young babies. It got so that I couldn’t watch people on TV who were pregnant, even if they were dead and in reruns like Lucille Ball. I could not go to any family functions or have anything to do with anyone who had more than one child, which was practically everyone.
I hated knowing that there was no way my daughter would even think of having a baby herself until she was done with medical school. I just worried that she would have to go through all the misery and dangerous treatment that I went through. If there was one good thing that came out of my infertility, it was hoping that she would learn from my mistakes.
In answer to your questions, she was serious about the Lucille Ball thing. She has been really bitter about this for the last 20 years and this is really how she talks. Perhaps you can now understand how much I want to avoid turning out that bitter and angry.
Monday, October 18, 2010
Guest post: The "art " of medicine and getting along with others
I trained at a major academic institution, where residents would impress attendings and each other with detailed discussions about scientific studies and their merits and flaws. Over a few years, we all become indoctrinated with the importance of evidence based medicine and more than that, the fact that it was the gold standard of practicing medicine. There’s a sense that practicing according to evidence is the RIGHT way, and everything else is morally reprehensible.
Fast forward then to my first job out of residency. I was in a small rural community in a group practice with a nurse practitioner whose husband was her supervising physician. After a few months of working there, I started becoming really incensed at some of the practices she had, which to me, were questionable in some instances, and in others, outright harmful. They were not supported by any kind of scientific evidence, and in some cases, even actively discouraged by the evidence. I printed out guidelines and papers for this nurse practitioner to review, and in return, she gave me a book written by a layman which supported her practices. Feeling helpless and outraged, I vented to other staff members and was ultimately confronted by her husband, who called me rigid and inflexible for not being able to accept that there were different ways to practice medicine. They threatened to fire me, and “demoted” me to a separate office location in another part of the medical building.
I did apologize to the nurse practitioner just to make peace, but have always maintained that her practices are wrong and detrimental to patients. I have even contemplated reporting her to the board of nursing and him to the medical board, but have been afraid of repercussions (which is a separate discussion in and of itself). I established my own patient base and kept my practice separate from hers. With that separation, I was able to regain a sense of sanity.
After a period of time, I was finally able to move to a new job. In this new job, I work with a couple of physicians who do some things that are not evidence based, although it’s nowhere to the degree that the prior nurse practitioner does. I had a run in with one of the physicians who got very upset when we had a disagreement over a patient management issue. Not wanting a repeat performance from my former job, I apologized to him for any hurt feelings, reiterated that we should have the freedom to practice the way we want, and stated that I wanted to have a separation in our patient population. He was pacified, and the relationship was repaired.
At the end of the day, I realize that there really is an “art” to mastering relationships. At the heart of being a physician is this fundamental conflict. On one hand, we are supposed to tell patients what to do, because quitting smoking is the right thing to do, getting a flu shot is the right thing to do, going for the stress test is the right thing to do. On the other hand, we are supposed to maintain an encouraging and positive relationship with patients when they don’t follow our recommendations, and we are supposed to respect their choices. It can be hard to let go of the sense of what’s right and overlook that in treatment of the patient.
In the same way, when it’s been drummed into your head that practicing evidence based medicine is the right thing to do, it can be hard to accept other physicians disregarding that tenet. It’s like what a young woman physician said to me about another physician, “I hate to tell him that he’s wrong, but… well, he is!”
Regardless of our position on evidence based medicine, we still need to be able to work together and get along. We need to be able to depend on each other for backup and allow for differences in practice styles without getting too upset about other doctors not practicing according to guidelines or evidence. After all, we’re not perfect ourselves and have to constantly strive to improve our own knowledge and habits.
Have you had conflicts with your colleagues about patient management issues? How do you resolve it? Do you think being a woman or being young has any impact on this?
Sunday, October 17, 2010
My Experience with Infertility
You might ask why I know such a thing. Believe me, I'm not some kind of encyclopedia of what celebrities had kids at what ages. But in 1992, when Susan Sarandon was 46 and give birth to a son, my mother was 42 and trying to get pregnant for the last three years.
I don't know if you've ever known someone having problems with infertility. Or if you have, you may not have lived with them. It's pretty painful. When my mother found out Susan Sarandon was pregnant, she cried. Cried! Let me tell you, there are a lot of people in this world procreating... probably, like, millions... and it's really difficult to shield your mother from all of them. We weren't even allowed to watch television shows involving fictional pregnancies or babies.
It went on for years. Years of pregnancy tests, ovulation kits, fertility drugs, and mostly just a lot of crying. And eventually, she really was too old and then there was the "trying to adopt" era, which came with its own set of heartbreaks.
I had my daughter when I was 27 and was probably the youngest of all my friends and colleagues to have a baby. Although interestingly, that was still above the average age to have a first child in this country. But then again, that includes people living in huts in Wyoming, where I don't think birth control has been invented yet. (Kidding!) In any case, I felt a little awkward at times having a baby so early. Some of my friends thought I was nuts. And now, almost four years later, some of them STILL haven't gotten started on their first.
The thing is, when you've watched someone so close to you go through the heartbreak of infertility month after month, it's really hard to wait for something you know you really want. I knew I had to be a mother, that my life would seem empty if I didn't get to experience that, so how could I do anything to risk that not happening? And I did wait for quite a while. It's not like I got knocked up in high school... I made it through my entire intern year.
That's why I feel a bit perplexed when I see my female friends waiting through all of med school then all of residency, and even though they're married and in their early or even mid thirties, they still continue to wait. And the truth is, I'm sure they're all going to get pregnant. People seem to get pregnant pretty easily. But then again, what if you're the one person who can't and you didn't even start trying till age 35? I had a talk about this with an OB/GYN attending and she said that most of her female co-residents decided to wait until after residency to conceive and some were less successful than others.
That's why, despite the fact that I'm only 31 and in many ways I like my life how it is, I feel compelled to start thinking about having a second baby sooner rather than later. My husband tells me I'm being silly, but if I know I want a second, then how could I risk not having it?
Note: This is my 100th post on MiM. Definitely a sign I've got too much time on my hands.
Friday, October 15, 2010
Seriously, I wanna know...
Thursday, October 14, 2010
MiM Mailbag: Need some help (urgently)
I need your help. I am in a sudden mid-training crisis and after years of being absolutely sure of what step comes next… I now have choices and that leaves me in a panic. I’ve been reading this blog for about a year now and I respect and enjoy reading the posts that go up. So I need your help in the form of unbiased opinions about what to do with my life.
I’m an internal medicine resident in my second year, with a 19-month-old son and a loving husband. I’ve been interested in Endocrine casually for a while now but recently I’ve decided that I would like to specialize in it. The unfair thing is that the match application for fellowship occurs in December of the second year of residency… for a spot after the third year is over. So after the whirlwind of intern year, it seems like this crossroads comes up way too quickly. This is also the time that my program sends out the call for Chief Medical Resident applications (there are 4 chiefs every year for my program), again, for the year just after I graduate. I’ve been asked twice by one of the associate program directors to apply for CMR, which is both flattering and shocking to me. I want to stay at my current program for fellowship, but this is a year when 5 of my colleagues also are applying for Endo and 2 out of the 3 spots have already been promised to people. Basically, no reason to apply for the match this year. I’ve been told that if I did do CMR that I would be guaranteed a spot when I was done. I literally have to make a decision in 2 days (deadline for CMR). So I made pro/con list (or, sort of a stream of consciousness) for the jobs that I’m considering.
Endocrine Fellowship +/- Chief Medical Resident vs. Primary Care Internal Medicine
Pro: Focused on limited problem set - thyroid, pituitary, diabetes, PCOS... Overall nice colleagues. Maybe a little better salary than primary care... Don't have to deal with musculoskeletal issues or runny noses. Get to potentially see some really crazy pathology and treat thyroid cancer.
Con: Have to apply for fellowship, including a personal statement, letters of recommendation, trying to start and somehow make sense of a research project. Being stuck in a fellowship for 2 more years while not making a full salary. Possibly having to end up doing primary care anyway after 2 years of training (the market in my area of the state is completely saturated and full time endocrine jobs are extremely hard to come by from what I’ve been told).
Pro: Tons of jobs available. Weekends off, no more overnight call in-house EVER. Making a decent salary in less than 2 years. Happier husband. Potentially really nice patient-doctor relationships with the sane and reasonable patients.
Con: The overwhelming amount of follow up labs, etc. MSK complaints that I never know what to do with. The fear of missing a big diagnosis. The awful gyn complaints (though I think outside the VA where my continuity clinic is at, internal medicine primary care is probably a lot less gyn since women usually have their yearly pap by an OB/Gyn).
Chief Medical Resident. This is an esteemed position that comes as a bitter-sweet combination of administrative work, no clinical time, teaching, politics, and pretty much an 8-5 M-F schedule, and a few more bucks than a regular resident. It would be one more year past my 3 years of residency and would essentially guarantee a spot in my institution's Endocrine fellowship after I'm done. On my curriculum vitae it would be a plus for any future job application. What's one more year out of my life? Well, I think I'm hesitant for two reasons: 1) my husband is not a fan of making 1/2 the salary of an attending for one more year of delay to a real job 2) I don't want to have to deal with all the politics and new ACGME rules that are coming down the pike, i.e. the new rules of interns only working 16 hrs in a row (which is ridiculous, but I'm sure all the new interns for next year are happy about that). I think I would be a good chief and I've always liked mentoring along my younger colleagues (mainly medical students, at this point), teaching, realizing that I actually do know some medicine.
Here’s the rub… My husband has been in his career for 10 years. He is making great money… but he hates his job. He has stuck by me for years now… moved with me to medical school, moved back for residency, supporting me through the overwhelming debt I have from medical school and college, being the primary caretaker for our son last year when I was an intern. He would like nothing better than for me to finish IM residency, get a job in Primary Care, and start having a regular salary and consistent schedule. He’s sure, now more than ever, that he needs to change his career drastically for the sake of his happiness. I want this for him too. After all, he has been supporting me this whole time… when is it his turn? How long can he wait? We will both be in our late 30’s by the time I am really done if I continue onto fellowship.
So. Here I am. I feel like there are a few ways this could play out… and any of them I would find a way to be happy. That’s just who I am. That’s what makes this decision so tough… In any of these, I think I could be happy.
1. Primary care – as a career
2. Primary care for 4-5 years, then apply for Endocrine fellowship - my fear is that I become too comfortable in my current salary/job and just bag the whole idea of going back to training
3. Chief year, then Endocrine fellowship directly after – this is what I would choose in the alternate reality where I’m not a wife or a mom
Any comments or ideas I would greatly appreciate!
Monday, October 11, 2010
A Letter From Your Doctor
*All patients are fictional.
Sunday, October 10, 2010
The Colorful Cupcakes
About a month ago, my seven-year old Sicily came home from school.
Saturday, October 9, 2010
Welcome to Metablogging Topic Week
Scroll down to find the posts...
To Blog or Not To Blog
When I was blogging regularly, I thought it was "secret" - but kids (especially teens) know everything, and I'm pretty sure my sons read my blog routinely. I haven't shared my blogging with this site with too many; in part, I'm frustrated by my lack of output. Like many of the other mom-docs who share in this site, life too often gets in the way of trying to put together a post.
My goal is to discover a better way to incorporate writing (this blog, NaNoWriMo, crazy ideas like "Elena Kagan Effectively Kills the Exercise called Kegel in Early Court Decision") into my daily life - much like exercise, time for family, and everything else beyond that black hole called work. I'm happy to be a part of this group, even if my contribution remains small. But trying to figure out this whole life-in-balance-thing was part of the reason for this blog's existence, right? Let's keep figuring it out together - one post at a time.
After publishing that first post, I got three comments...from STRANGERS; warm, compassionate, kind strangers. The simple act of writing the post had made me feel so much better, but the responses were icing on the cake. You know how the story goes from there, I visited their blogs, we made a connection...I visited new blogs, those bloggers visited mine...and I found myself in the midst of a beautiful, supportive community. I didn't feel isolated anymore, I was a part of something. I met people that I never would have had the privilege of meeting in my daily life, people scattered across the nation and world. Some of them had similar lives to mine, some were very different. When it came time for KayTar to get her g-button, it was a few of my blogging friends with personal experiences in this area who talked me through it, three long distances phone calls made all the difference in the world in those moments. When KayTar was inpatient last week for the worst test in the history of tests, the controlled fast, many of these same people were virtually cheering us on. Blogging has never simply been words on a page for me; it has provided support, information, and understanding when it was hard to come by in every day interactions.
Blogging has also afforded me interesting opportunities. When my daughter lost health insurance and could not be accepted into a new program because of her pre-existing conditions, I blogged about it. It was picked up by Johnathan Cohn, who was working on a piece for SELF Magazine. They also flew KayTar and I (and my mother) up to NYC for a photo shoot. I never thought I'd pick up the phone and have a magazine editor ask me when they could fly me out to New York! It was pretty amazing, and without blogging, I never would have been a part of something like that. I've done a lot of advocacy work for children's health insurance reform in my state and at the national level, and my blog has aided in that as well.
What started as a secret blog has remained a secret blog. My husband knows that I blog, but he never reads it. I told him that he can read it, but I never want to know if he has and we certainly cannot discuss it face to face. My parents don't know, my best friends don't know, my classmates don't know. That is how I want it for now. Proportionally speaking, my blog is still mostly about KayTar, but I recently changed the name to Life with the 'Tars because I feel like that dark, stressful portion of our journey is over and the blog is lighter now and more accurately represents what our lives are really like. A good portion of it is about me now, not as a scared, uncertain mother, but about my own journey as I my pursue a career in medicine. I also like to dabble in photography and I find it is a wonderful way to share that, as well. Sometimes I think about telling people about my blog, but I'm not ready to sacrifice that privacy yet. I find it hilarious when I am telling people stories about the kids (especially KayTar, who is incredibly hilarious) and someone will say, "Oh Kyla! You HAVE to start a blog!" I just laugh and nod. Maybe one day I'll tell them, but I'm not ready yet. I don't blog as frequently as I once did and I don't always have the time to comment on all the blogs that I read, but I an definitely not ready to step away from it yet. I don't need it like I did when I first started blogging, but I enjoy it and setting aside that time to write, purely for enjoyment, is important to me.
I was thrilled when KC invited me to start writing here, because once again I've found myself a little on the outs with my real-life community. People look at me like I'm speaking a foreign language when I start talking about medical training and everything that goes along with it, just like they did when I would start in with therapy regimens and IEPs and ARDs and MRIs and LPs...but here at MiM, discussing those aspects of my life feels perfectly normal. I think that is the true beauty of blogging, it makes it possible to find or build a community in way that can't always be easily accomplished in your day-to-day life. There are no support groups, or book clubs, or Sunday school classes, or any other sort of easily accessible form of community for mothers of perpetually undiagnosed medically-needed children who are also insane enough to decide to go back to school for a career in medicine...but out here in cyberspace, I've been able to piece that together for myself and it is wonderful.
Friday, October 8, 2010
And I fear that I am guilty most of the (blogging) time of not revealing enough about that with which I wrestle.
I self-censor in a few ways, mostly thinking about whether or not something that I've experienced, thought about, struggled with, is, well, blogworthy.
I also ask if this is a topic MIM-worthy. Is my online journal post-to-be just about being a mother (or a parent for that matter) or is it just about being a pediatrician, rather than the interdigitating of these two major roles in my life (plus SPOUSE, daughter, sister, and all that).
Often at the laptop in the evening my husband chides me with a gentle "are you blogging" (kind of like the "do you like clogging" line from some Jack Black movie). I want him to want to read what my fellow MIM bloggers are writing, to be as into the fun, the heavy, the sad, the puzzling as I am. But mostly I just pull up the latest doccartoon and we laugh, cringe, and reminisce together over those.
Then I think about professionalism, over-sharing, living in the moment instead of blogging about it, and basically I go back to overthinking it all anyway. Blogging IS one form of reflecting, of which I'm a big fan. But it is also doing so publicly, whether or not "out." I am guilty of posts that are real, but maybe read too much like they've been put through an IRB???
In life I am a person who is not afraid to emote, to tell it like it is, to feel, to cry. I don't know if I am that blogger however.
Driving home from work one June day, I began to think of all the bad advice I got as a resident. I wished I had had a reference, like this blog, during my training. So I came home and wrote this post. With some trepidation, I submitted it to the site. Surprisingly, I was asked to join. I was excited to participate, but there was only one problem: I was most definitely not a writer. Hadn’t written anything before, hadn’t ever really ever had the desire. But the initial post was so cathartic to write, and it was so encouraging to see how others responded, that I decided to give it a try. Hey, it was anonymous!
I’ve tried to just speak from my heart. Endeavoring to share words of encouragement or hope when I can. The struggling med student, who is wondering if all the work is really worth it; the resident, who hasn’t slept for weeks between baby and call; the attending, who is trying to create balance without appearing to shuck responsibility: for you, I share insight into my life. My wish is that maybe in our shared experiences you might find some comfort or humor.
The other thing that the site has done, is give me insight into the lives of other physicians. From Physiatry to Pathology, I have developed more empathy towards other specialties. As OB/GYNs we sometimes think we have it the worst, from scheduling to malpractice; but seeing others perspective, has helped me realize that every specialty has its challenges and rewards.
I’ve also started writing for a blog, as myself, which I find to be much more difficult. I overanalyze every post thinking what will my patients or colleagues think if they read it. It’s hard to be entertaining, informative, HIPPAA compliant and not controversial. Despite my angst, for the most part, I’ve found that most people don’t really care.
Only my husband knows that I write for this site, and he’s supportive. He said that he liked my anecdotes and my posts seemed pertinent to the readers. As an aside, he also said that my writing isn’t so much “writing” as me just dictating how I talk. Initially, I thought this was not a flattering comment, but I realized that essentially it was true. I’m not a writer, but I am a talker… and most definitely a great story teller. So, essentially that’s what blogging is for me: my chance to tell my stories. Thanks for listening.
Thursday, October 7, 2010
That's So Meta...
Life often gets in the way of blogging for me, and so many times I am struck with the urge to spill all of the thoughts from my head onto the screen. I love blogging. I love that it brings patients and physicans to a common ground, so the better to communicate as people, rather than 'doctor' and 'patient.' I also love the community of blogging physicians, it is so nice to share stories, laughs, and frustrations with those of us in the trenches, and it is also great to provide information and guidance to upcoming residents and medical students alike. Sometimes, however, I feel obligated to blog. I feel as though I am letting people down when I don't write. Then, if I feel obligated to write, sometimes the ideas don't flow as freely.
Ultimately, blogging has changed the way I think about people, patients, and medicine. In many ways, it reminds me every day to think of my patients as real people and not just problems to be solved or diagnoses to be made (or numbers to force through the treadmill). I try to keep in mind that even though it may be my 9th delivery of the day, it is *the* delivery of the day for my patient. I am thankful to be part of this blogging community, and hope to be blogging for many more years to come!
Hate mail, non-anonymous blogging and a favourite comment
I knew that if my blog attracted any kind of readership, I could expect hate mail. I prepared myself by deciding that when the first nasty comment arrived, I would see it as an accomplishment, a marker of an ever-widening circle of readers. Then someone called my kids f***ing ugly and interpreting that as a mark of success proved more difficult than I had anticipated.
All posts are vetted by Pete. On more than one occasion he's responded with, "I'd actually file that in the Who Cares Department." I post those ones anyway and invariably they're particularly well-received.
I've never blogged anonymously. For one, I wanted to take responsibility for what I wrote. I also wanted full credit for it. When I write, I consider that anyone could be reading: patients, employers, ex-boyfriends, my mother, my child's teacher. This keeps me cautious, and keeps blogging from landing me in any sort of real trouble. That also means that out of respect for family, friends and even institutions, most of the very best fodder for writing is off-limits.
For example, I won't write about:
- being actively discouraged from pursuing medicine by family
- being raised in a small, religiously and ethnically homogeneous community wherein women pursuing careers was rare and having a child in formal daycare was unheard of
- the refining of my Christian views as medicine affords me glimpses into human hearts, lives and suffering
- the complexities of relationships with friends who home birth, don't vaccinate and seek medical advice through Facebook status updates
It seems to me that it helps to write thoughts and things down. It makes the unworthy ones look more shame-faced and helps to place the better ones for sure in our minds.For another, I value having records of events. I am certain I would not remember the small details of my son's radial/ulnar fracture had I not documented it. I'm grateful I made the effort to describe what my typical day looks like. For me, writing captures memories far better than photography does. It also feels like the most authentic me; my writing represents me much more accurately then my CV, or my wardrobe, or my library.
But what I enjoy most about blogging is having others derive pleasure from my writing. The best blog comment I ever received was from someone who wrote:
When I saw that you were gonna describe each of your morning patients I got so excited I actually got a bowl of chips and some coke to thoroughly enjoy the read.When I tell a story face-to-face, the response is immediate. When a piece is published in a journal, that very fact is affirmation enough. But a blog audience, for the most part, reads in silence, and that inscrutability can be unnerving. Learning that someone out there is settling in with a snack to enjoy a post is a huge incentive to continue.
Wednesday, October 6, 2010
When I first started blogging in November of ’08, I didn't really understand what it was, I was just following a suggestion from someone I know. I felt kind of vulnerable, and my now ex voiced his opposition to being subject matter - I honored that as best I could. I chose an anonymous name, and made up names for my kids. Occasionally I would weave him into a tale involving a great parenting moment with the kids.
Blogging became an emotional release for me. Although being anonymous felt somehow protective, I was still cautious about what I blogged about, understanding that when you are putting yourself out there on the web you are never truly anonymous. I had my mentor from residency read my first few blogs and give me tips about what to include and exclude. When I compose stories about work, I often bend the encounter to a point beyond recognition and make sure the time frame of the blog is far removed from the interaction. It was frustrating at first, because I am a stickler for details and precision, but eventually it became fun to fictionalize.
Positives about blogging:
A sense of community. Something to do besides reading after the kids go to bed. I have met a lot of incredible women, and made some amazing friendships through e-mail. Having people read and comment on my own blog makes me feel a little less alone. I do not keep my blog secret from my friends and family, and it has pulled me closer to my brother and his wife, who live pretty far from me, and my other brother who is in law school in another state. Local family generally doesn't read it, because they get enough of me as it is. I was honored when KC asked me to join MiM last fall, and my presence here has widened my blog social horizon significantly.
Knowledge. These girls are smart! I get tips on mothering, doctoring, books, politics, history, and life. When you are a professional and a mother, especially single, there is little time to nurture relationships with other moms at school through activities and play groups. Blogging, following blogs, and commenting on blogs supplements that. Some of my favorite blogs are SAHM blogs. It's great getting mothering tips from those who get to spend 24/7 doing just that (a sometimes escape fantasy for me, on my bad days).
Entertainment. Smart=funny. Nowhere is that more true than our own Fizzy’s cartoon blog. I remember when she started I was instantaneously enamored. Now she has a million more followers than me (not jealous!). Recently, her hosting of Grand Rounds led me to a lot of other blogs that I enjoy following.
Negatives about blogging:
Well, there really haven’t been any.
I’ve been blogging a little less lately, because moving and divorcing are stressful life events - both occurring for me in the last two weeks - but I also made partner Friday, which almost outweighed the negatives. Instead of blogging at night, I’m unpacking boxes. But I was off Monday to meet the U-verse man, so that should change.
I read a fabulous book last week called The Year of Wonders by Geraldine Brooks. The author was a Middle East correspondent for The Wall Street Journal when she happened upon a small town in England that lost 2/3rds of its population to the Plague (Yersinia pestis) in 1666. She was drawn to the history of the town, and studied all patterns of 1600’s sociology from witching to farming to medicine to personal accounts in her research. The tale she wove about a handmaid to the preacher was exquisite. I especially recommend it to Mom TFH, Dr. Whoo, and Rh+ because a midwife passage was one of the most incredible I have ever read - I don't want to spoil it but my eyes got a little shiny and the words blurred. The main character, Anna, lost her whole world in a year, but instead of folding into depression she worked and created a new life for herself. I’m not sure where this book came from, but I found it last weekend in a box when I was desperately looking for an escape, and the story I encountered made me feel the find was serendipitous. We always look to others to buoy us in hard times, and that certainly helps, but the strength we need usually resides within ourselves.
That is what blogging has been for me. An escape, an emotional outlet, and a way to find myself. I’m not tending plague victims, but it has been equally important to me. A couple of years ago, I was desperately lost. Was blogging my only savior? No. My family, my kids, my friends, my partners all helped. But blogging has been invaluable in getting me from there to here, where I'm much happier.
Blogging ad infinitum
I soon thereafter discovered blogs, well, mommy blogs (as unappealing as that phrase is to me), and realized what I had been missing. Here it was, the richness. I particularly recall coming across Dooce's blog and being captivated/jealous/inspired by her monthly letters to her daughter which captured the essence of that month in her daughter's development.
I want to do that, I thought.
So, I started a personal blog, mainly intended to be devoted to my daughter. I wanted our family and friends to know about what she was doing, learning. And, I wanted to write (again). I (also) started a monthly tribute to my daughter on my blog, but instead of a letter, I decided I would post her developments in the form of a software update, complete with new features and known operating failures: Version 14.0 was the first release.
At first, the only people who knew about my blog were my husband (who would always be the first to read my posts no matter what) and a few friends and family. I soon discovered a whole community of supportive bloggers whose writing I admired - I'd post comments on their blogs and they would on mine. It was like having a cheerleading section with you - along for the ups and downs on your life ride.
Pretty soon, I was writing on a regional moms blog, freelance writing a blog for Disney (long story, but short version: they found my personal blog and asked me to write for them), and blogging was suddenly a very big part of my life. My husband has always been my number one reader-fan and despite my writing for multiple outlets, always made sure to read my posts and murmur supportive things about them. He sometimes would half-joke that everything - every funny conversation we had -might make it onto the blog. I tried to be sensitive about that since he's more of a private person than me. He once actually guest-wrote about what it was like being the husband of a blogger (me) on one of the blogs I was writing for. I loved reading his perspective.
My family knows about my blogging (even though it still weirds me out when I can see that my retired Dad has refreshed my blog page 20 times or more in one day) and my co-workers. In fact, a whole lot of people who know me know, apparently, sometimes catching me off guard. Mothers of friends have mentioned certain posts to me, and the other day, a former intern of mine stopped by my office to talk about a mutual patient when he mentioned HE was reading Momicillin and wanted to congratulate me on my pregnancy. (In my mind, I manually closed my jaw with my hand. In real life, I smiled back and said, "Thank you!!!")
Over time, I've tended to mask the identity of my family more and more while unmasking my own- I guess I'm making it more about me than about them which I think has more to do with giving them more privacy and exposing myself than about narcissism. (Hopefully.) Personally, I have come to believe in taking ownership for my words and my thoughts and standing behind them, for better or worse.
Blogging invaded my academic life and I started using private blogs for reflective writing with medical students and in 2008, this blog was born. I've had to give up some of the other blogging gigs along the way, but this blog, with its community of readers, with its writers, with its stories, is still one of my proudest bullets on my CV. I owe MiM for producing some of my most valued IRL friendships. These women I write with here are simply amazing.
And the versions? They continued on until Version 42.0 when I thought my daughter was getting old enough that it was becoming less my stories to tell in so much detail. Like Fizzy, I went back and published all of those old posts in a book, to give to her eventually. Now, I'm up to Version 33.0 XY for my son (although these have become far more sporadic like hers did at the end and plan to publish his own book of posts one day. In a few months, I guess I'll be starting all over at Version 1.0 XY(2)...and so it goes.
Tuesday, October 5, 2010
Fat Doctor, Versions 1-3
In October of 2005, I struggled with emotional adjustment to a health crisis. Because I needed to write to heal, I Googled "online journal", found Blogger and decided my blog's title should be The Fat Doctor, because that's what I am. I chose the username bigmamadoc. My first post was brief, raw and full of anger. I still believe it's the best I ever wrote.
I thought the blog would be just for me, but after a week or so, I realized that taking my blog public would give me more "reason to write." I'm the type of gal who loves an audience. I signed up on medlogs and eventually a few people started to comment on my posts. After I hosted a couple of Grand Rounds, the readership increased. Somewhere along the line I started thinking about my blog as a brand and renamed it "Fat Doctor" and changed my username to that as well. Readers addressed me as FD.
My blog friends became increasingly more important to me. TBTAM, Doctor Anonymous, all sorts of bloggers felt as real to me as the friends I met for movies and dinner. During my hospitalization in San Francisco in April of 2006, Husband printed out the comments on my blog and bring them to me every day. In the heyday of my blog, which was probably Fall of 2006, I was getting about 800 hits a day.
In May of 2007, I was outed at work. Too many personal details...it was bound to happen. My department chair came to my office and said that he was particularly dismayed to read my comments about a recent faculty meeting. He did not ask me to take the blog down, but I did just that. I moved to WordPress and my posts changed tone. Fat Doctor Lite, if you will. It wasn't that much fun anymore.
After changing jobs in July 2007, which probably was a result of the embarrassment I felt about being outed (and the lure of twice my salary), I kept that boring blog going. When I was laid off in 2009 and I needed to find a new job, I took it private, allowing only usernames I trusted to see it. Fat Doctor still exists, and I post there a few times a month, but only a handful (if that) of the 100 or so registered users read it regularly. I believe that blog has started the agonal breathing that signifies impending death.
Meanwhile, it seems a lot of bloggers have outed themselves. What a refreshing concept! I started a new blog as just plain old me. It, too, is extremely boring. I won't discuss work at all. I'm not sure this blog will work out, either, but it feels good not to hide behind an eponym.
Funny, but I don't seem to need blogging anymore. It really served a role when I was worried about dying, but I'm now convinced I'll live forever. Similarly, blogging served a role when I was miserable at my first two jobs post-residency because I could "safely" complain, but that kind of backfired. Now I love my work and want to stay where I am until retirement.
I need a new addiction, perhaps, but I certainly won't choose anything related to exercise. After all, my blogs may come and go, but I'll always be Fat Doctor.
Monday, October 4, 2010
Mom, Are You Blogging About Me Again?
My secret life of blogging
When I was about eight years old, my grandmother bought me a little pink diary. With a lock and key! And multi-colored pages! I was so excited, I started writing in it immediately. However, I recently rediscovered this diary and found it was a mish-mosh of entries every 3-6 months, mainly focusing on either my latest math test or my latest crush. I guess grade schoolers don't have that much to say.
During college, the internet was becoming pretty big (although clearly just a fad), and I found a few interesting blogs online. In the midst of studying for my midterms during sophomore year, I decided to give it a go.
Everyone I knew was informed about this blog, which was how I found readership. My parents would make comments like, "You sound a lot more bubbly and happy on your blog than you do in real life." (In real life, I'm apparently chronically depressed.) My blog was also a good way to inform my boyfriend that I was pissed off at him. But for the most part, the entries were shit: brief random musing that had nothing to do with anything. This is a sample entry, that I presumably wrote after learning about Mendel and Martin Luther:
Monks have made a lot of important contributions in history. So I don't want any more monk-bashing, ya hear?
But somehow knowing people were reading kept me going and I wrote in the blog all through college. Then in med school, I took my blog offline, but I kept writing. And now I wrote in-depth entries about my experience going through the oft-times fun but mostly pretty horrible training process. (Anyone who says "I love med school," just know that I hate you. You and med school should go get a room.)
After med school, I discovered Livejournal, and I moved my blogging over there. It has a great format in that not only can you lock individual entries, but you can filter entries so that only a handful of trusted people can read the more personal, gut-wrenching stuff. I've been blogging there for the last five years, with all entries locked. That way I don't have to worry about that thrill of fear in the pit of my stomach when a colleague or family member discovers my blog.
It's nice to have a public web presence though, which is why I like blogging for Mothers in Medicine. But does my family know about it? Other than my husband, no. There have been tons of times when I wrote an entry that I would have loved my mother to see, but then I realized that if I showed it to her, I'd have to constantly be censoring myself here.
I do censor myself somewhat though. It's a mistake to think that anyone on the internet is completely anonymous. Whenever I write an entry, I ask myself if I would be in any trouble if everyone I knew saw this entry. If the answer is yes, I don't post it. A few times I've complained about resident colleagues on here, but I was secretly hoping they'd find the entry and realize what a dick they'd been.
When I started my cartoon blog, I fully intended to tell my parents about it. However, I showed my father, a psychiatrist, this cartoon and he declared it "not funny." I decided that I'd prefer to stay anonymous than deal with any more negative critiques. My husband reads the blog though and he says he appreciates my "really immature sense of humor."
I think the best thing about blogging is looking back on old entries. After my intern year, I went back and collected all the entries into a book, which I published on Lulu for myself:
Recently I was having lunch with some friends and one of them mentioned the idea of starting a travel blog and was looking for advice. I kept my mouth shut, not mentioning that I contribute to three blogs. If I go around telling people that, I may as well tattoo a big L on my forehead. So really, it's my little secret.... not so much because it's scandalous, but more because it's a little embarrassing.