Thursday, June 30, 2011
Guest post: No more second guesses
I hadn’t allowed myself to think about my kids all night, I had forced them out of my consciousness, so that I could do my job. I did this to protect myself from imagining what I would do if it were one of my sons in that bed. I drew the line between hospital and home, and I stuck to it, for better or worse. At the start of internship I thought I would call home each night I was on call to tell my kids goodnight. I never did this, in fact, most nights I didn’t have time to sit for dinner, aside from bites while writing notes into the wee hours of the morning. What bothered me most, perhaps, was that I didn’t even think about doing it most nights. I can’t count the number of bedtimes I missed or the number of daycare pickups my husband had to do this year. It is acceptable to me to have to miss a soccer game or a play, it is not acceptable to me to miss most soccer games or most plays. I can deal with missing a bedtime or a daycare pickup, but I do not want this to be the norm and I certainly never want to reach the point where I feel that it is acceptable.
I wrote just over a year ago about my mixed emotions on my match and my future career in dermatology. I felt logically, at the time, that this was the correct choice for me and my family, I just wasn’t sure emotionally. Now, days from finishing my internship, I am thankful that I made the logical, not the emotional decision. What a year it has been. In my professional life, I have performed my first deliveries and pronounced my first deaths, I have treated infants and I have treated senior citizens, I have stayed awake for a 30 hour shift and returned home to stay awake with my children for several more hours, I have made tough decisions and I have made mistakes. In my personal life, I have uprooted my family and exposed my husband to more call nights than I can count. I have come to appreciate his patience and commitment to our family in a way I never knew that I could. And, I have found clarity in my decision to pursue dermatology. I think it truly hit me that dermatology, had in fact, been the right choice on my ER rotation this year. I was never as happy as when I was able to fill my day with patients with chief complaints of rash and lac repair. Or perhaps it was when I reported skin findings while on the cardiology service on a patient admitted for a STEMI. Or when I noticed all I was teaching my medical students were skin findings and that I actually liked to look at the NEJM photo quizzes of skin findings for amusement. Perhaps some of my doubts from a year ago were unfounded. I am now to the point where, had I to make the choice again today, I could do it with much less angst, knowing that I will enjoy my work and that I will have a tolerable lifestyle.
After this year, I know that I could have been successful in either ob/gyn or peds and I would have been satisfied with my work life. In fact, in both of these rotations, attendings approached me about why I hadn’t gone into that field. I give the one liner to these attendings and anyone else who asks, which goes a little something like this: “I love that in dermatology I will get to do both medicine and small surgeries, that I can follow patients across the lifespan, that I can cure cancer in 20 minutes, and that I can be home with my kids at night.” But the longer answer is that I know myself enough to know that I do not do things half heartedly. I am there when I need to be, until everything is finished and when I am at work, my mind is completely there.
I need a career where I don’t have to feel guilty about how much I work or that I enjoy my work so much that I am not thinking about my kids and husband throughout most of the day. And I need a career where I don’t go home and feel strange that I can be so emotionally distant from the things I have seen that day. In dermatology I can have all of these things. I love so many aspects of medicine and I feel privileged to have been a part of births and deaths and to have had patients share with me the most intimate details of their lives on a daily basis. I will have patients who are as thankful to me for enabling them to control their acne or psoriasis as they would have been had I been there for the delivery of their children. I will not have to tell another woman that she is miscarrying or tell another wife that her husband has died on my watch. I am frightened as I move forward, for the sheer mass of information I will have to master, but relieved that I will be able to study at home at night, after putting the kids to sleep, where I cannot forget or ignore my life beyond the walls of the hospital.
Monday, June 27, 2011
Friday the 13th
“The hospital needs you to call immediately,” she said. I was instantly in the locker room, digging through my giant bag for my phone. I wasn’t on call, so for the nurses to track me down at the gym, something seriously bad had to be occurring. I assumed that one of my partners must need help with a hemorrhage or some other emergency. Never in my wildest dreams did I expect to get the news I received.
“JB just suffered a cardiac arrest. She was transferred to the ICU. We are not sure if she is going to make it...” My partner’s voice was shaking on the other end of the line.
At this point, I just went numb and everything began to happen in slow motion. This could NOT be happening. JB was my friend. I had delivered her baby just a few days before. She was most likely going to die. I had failed her. She was my patient, my responsibility. I had obviously missed something.
The four mile drive to the hospital seemed to take two hours. My mind raced through all the possibilities: stroke, seizure, heart attack, pulmonary embolus. None of the options were acceptable. I tried to think of what I might have missed. I analyzed every detail of our last conversation. She had called me from home the night before with symtoms of a headache and high blood pressure. I had told her to go to the ER. Being the clever nurse practioner that she was, she tried to talk me out of it, but I had insisted. Later my partner had admitted her, in order to watch her overnight. I had delivered her third baby 10 days earlier, boy number three for her. At the end of her pregnancy she had developed preeclampsia, a fairly common complication that usually resolves with delivery. I kept thinking of what I could have done differently, but as I went back through the case in my head, everything seemed to have been done appropriately.
This can’t be happening. I’ve never lost a mom. Healthy 35 year old women’s hearts don’t just stop. My prayers were brief and desperate. Lord, let her live.
With my hair still wet from the pool and my eyes still puffy from my swim goggles and crying, I arrived in the ICU a few minutes later. She was stable, but still in a coma. I began to have hope that she might make it, but could dare to hope that she would really be OK, to not have a brain injury?
I reviewed the history with my partner and the other physicians. Her husband had stayed with her in the hospital overnight, and heard her gasp and stop breathing. He quickly called for a nurse. She found no pulse. A code was called. After 12 minutes of resuscitation the team brought her back. She was essentially dead for 12 minutes. All the while her husband stood by, holding their newborn son.
I tried desperately to focus on the medical facts and numbers, while pushing the emotions to the side. This became impossible as I walked into her room. My beautiful, intelligent friend lay intubated in the ICU. Her normally tan skin was grey and dusky. Her blonde hair disheveled, while tubes and monitors encapsulated her small frame. The girl who never stopped moving or talking now lay before me unresponsive, with restraints on her hands.
When I saw her husband’s swollen, tear stained face; mt own tears once again began to roll. We hugged.
“Doc, Is she going to be OK?” He asked fearfully.
“Yes, I hope so.” I said, more as a statement of faith, than medical fact.
The morning was a blur of activity. A stream of specialists were consulted to help us search for a cause. More tests were ordered, but no answers were found. We ruled out some dreaded possibilities: brain hemorrhage, heart attack and tumor. I tried to remember if I've ever had a patient fully recover from a cardiac arrest. The only patients who had coded in my care were elderly. The ones who made it, had severe brain damage. The thought of her surviving but in a severely disabled state was almost as frightening as the thought of her funeral.
As all the tests began to come back negative, I began to let go of the guilt over what had happened. None of the things I knew to check for had occurred, so maybe it wasn’t my fault after all. Still the questions lingered.
Being a typical Friday, my office schedule was fully booked. All patients who could be were rescheduled. The rest I saw in short bursts, as I ran back and forth between the office and the ICU. In the office, I attempted to feign interest in the mundane yeast infections and round ligament pain. I tried my best not to be distracted, but it was nearly impossible.
As the morning stretched forward, we got our first bit of amazing news: the neurologist finished the EEG and it showed normal brain activity. He was hopeful for a full recovery. When I told the good news to our office staff they literally cheered. I assumed the recovery would be long and painful, but there was hope.
The afternoon led to even more good news as her oxygen requirements began to decrease. Yes, she was still on a breathing machine, but needing less and less help to breathe. She was beginning to wake up and fight the restraints. The specialist in charge of ICU decided to keep her sedated and let her heal, and then take her off the breathing machine in the morning.
I left that evening guardedly hopeful, praying for a full miracle.
When I finally made it home, I embraced my husband and kids like I hadn’t seen them for weeks. My heart was so thankful. Never would I take my life or family for granted. The usual dinner routine seemed surreal. Then as I was finishing my hamburger helper, my cell phone rang.
“Call from JB,” it said on the display.
My hand was shaking as I picked it up and hit the accept button.
“Hey it’s JB Husband, just letting you know that they took the tube out and she’s awake… and talking!”
“I’ll be right there.”
Within minutes, I was walking back on to the unit. The neurologist had warned us that she would have short term memory loss, likely for a week or two. He felt that she would most likely not remember the cardiac arrest. Still, I wasn’t sure what to expect.
As I walked into her room, she was sitting up in bed, looking absolutely fine.
“Hey, what are you doing here?” JB asked.
“How are you?” I said.
“A little sore…. Why are you crying?” JB responded.
“I was worried I would never hear your voice again.” I replied. Weeping. Again. For what felt like the millionth time, during this roller coaster of a day.
“Really? I don’t understand, I just had a c-section?” JB replied
The room, which now included several members of her family, laughed with relief. She remembered nothing that had occurred since she had her son 10 days before. She just woke up, assuming she was waking up from her c-section.
During the first few days, talking with her was akin to having a conversation with your elderly aunt who is suffering from dementia. It was definitely ‘her’ in there. All distant memories were intact, but during a conversation she would begin to repeat herself every few minutes. This also created the challenge of having to tell her, over and over, what had happened. Each time she would react emotionally as she ‘heard’ the dramatic news for the first time. After about 4 days her memory began to improve and she could remember things that had occurred the day before. Currently, she reports occasional forgetfulness, but has had a full recovery. She required no rehab and has had only minimal discomfort.
With all tests essentially coming back normal, the heart specialist determined that she had an underlying arrthymia. This abnormal heart rhythm was then exacerbated by the stress of preeclampsia on her body, causing her heart to go into cardiac arrest. This extremely rare event just happened to occur at the right time and the right place. He felt she could be at risk for cardiac arrest in the future, so a permanent device was implanted in her heart before she left the hospital. The device will automatically shock her heart back into a normal rhythm should she ever go into arrest in the future.
Since that day, I have thought many times of the ‘what ifs.’ What if she hadn’t called me? What if I hadn’t sent her to the hospital? What if her husband hadn’t stayed with her? What if the code team hadn't responded so quickly? If any one of these elements had not occurred, she would not be with us today. I am so thankful for the prayer chains that were activated, the attentive nursing staff and the many specialists who were involved in her care. I am most thankful to God for allowing her to have a second chance on life.
-The previous story is true and told with the patient's permission. It is cross posted at The Pregnancy Companion
Friday, June 24, 2011
The MiM curriculum
She is a cardiology fellow. Mother of two. I know this because her children are the same age as mine. She breast fed both babies. I know this because her co-fellows teased her about it at the end of the year roast one year ago.
She was hiding from me because I am an Attending. She did not want to be seen at the gym at 8AM on a work day. She fears that she would seem lazy, less dedicated or selfish.
What she needs to know is that I am so proud of her. One tough mama taking all of her call, doubling up while gravid to trade days to allow a maternity leave. Finding a way to be an equal to the guys without being one of the guys.
I would like to tell her that making time to exercise squeezed between early morning mommy duties and full time fellow work is an enviable feat. That what you have done, is perhaps one of the most important tasks you can do to ultimately ensure your success. Yes, I know it is not in the cardiology fellowship curriculum. This lesson really should be Chapter One of the MiM curriculum. Stepping out of the role of mother and physician to see yourself is crucial. By recognizing your need and fulfilling it. Because it means more than just finding time in a busy schedule. It means making time, trading off that early morning conference or sneaking in a little late to read echos. Whatever. Over ruling what is expected of you, to recognize what is actually best for you. A brave move that will make you stronger at the core.
And of course, I would never utter to another soul that I spotted her at the gym. Dear, your secret is safe with me.
Thursday, June 23, 2011
Maternity Leave and Psychiatry Residency
Apparently, one year of psychiatry residency involves an outpatient continuity clinic. Due to the rules of residency, you cannot miss more than six weeks of this year at risk of repeating the entire year.
So despite the FMLA guaranteeing 12 weeks of leave, a woman having a baby that year can only take a maximum of 6 weeks off, or else repeat the entire year. Even if you have a C-section.
I just got off the phone with my friend, who is in tears over this. She was ready to make up any time she missed, but not repeat an entire year. She's gone over the situation with her chief resident and he claims there's no way around it.
Has anyone had any experience with this and has any advice? (Beyond "suck it up"?)
MiM Mailbag: Pumping during fellowship
Wednesday, June 22, 2011
Guest post: Major breastfeeding (advocacy) fail!
Friday, June 17, 2011
Guest post: Happy Father's Day
My husband puts up with a lot of crap being married to a doctor. And although I would like to think of my neurosis as merely an occupational hazard, I suspect it was likely a preexisting condition, exacerbated by the daily exposure to other people’s illnesses. I am forced to recognize that this career, and the ways in which it has dictated my behavior, can be a hardship on my non-physician husband.
In addition to not having me committed over the permethrin incident, in this first year of my fellowship my husband has shouldered a disproportionate amount of child-related care and chores. When I left for work last Saturday morning, my daughter was naked in the bathtub, in the throes of a wicked GI virus. My husband was at her side, cleaning and comforting her. I wasn’t worried that she critically ill as she had just been eating and running around earlier in the morning, but I still felt horribly guilty for leaving my family at this moment.
And while I am almost certain my husband didn’t mind, much less resented, my departure, I do wonder if he fully appreciated the extent of his parental participation when he married a female physician. Did he know that he would be in charge of daily school lunches, drop-offs, and pick-ups? That he would know the pediatrician better than his physician-wife? I can’t imagine that he did as I didn’t predict (nor wanted) it myself.
Although I recognized how very fortunate I am in my marriage, I sincerely hope that amongst this group of mommy-MDs, I am not unique in the depth of support my husband provides me in my career and our child in my all-too-frequent absence.
So ladies, in celebration of the men whose lives might have been a whole lot simpler had they just married someone, uh, less interesting.... I’d like to say: thank you.
Happy Father’s Day
s is a hematology/oncology fellow in California. She lives with her husband and 2 year old daughter. She blogs at www.theredhumor.com
Wednesday, June 15, 2011
Don't Give Up on Women in Medicine
In her New York Times opinion-editorial “Don’t Quit This Day Job” (June 12, 2011), anesthesiologist Dr. Karen Sibert argues that women physicians, who increasingly work part-time or leave clinical medicine altogether to find better balance between work and family life, have a moral obligation to practice medicine full-time. She rightly points out that there are limited medical school and residency slots in the face of a growing physician shortage, particularly in the primary care fields that attract women in high numbers. However, Dr. Sibert’s envisioned ideal would be a great loss to patients and the profession, and a major step backwards for women in medicine.
Historically, the practice of medicine had required a selfless devotion to the profession at the cost of personal and family life. Turn of the 19th century legendary physician Sir William Osler is credited for saying, “Medicine is a jealous mistress; she will be satisfied with nothing less.” These roots are evident in the harsh training environment that prevailed for so many years, requiring super-human work hours, rare days off, and expectations to work through personal illness. Slowly, medicine professional culture has made progress, realizing that the care of its members—in all senses of that word—helps physicians (men and women) lead more balanced, healthier, happier lives and helps patients by improving the quality and safety of their healthcare experience through physician work-hours restrictions.
For women physicians, who continue to perform the lion’s share of household duties and child-rearing despite a more progressive society towards the division of household labor, this has meant the increasing availability of part-time positions, job-sharing, and other creative solutions to allow them to continue practicing medicine while fulfilling commitments at home. Achieving work-life balance means greater satisfaction for one’s career and keeps women (and men) physicians in medicine. Indeed, it is this flexibility that is possible in certain specialties such as primary care, dermatology and radiology that makes medicine an attractive career for many women, despite the years of difficult training and medical school debt.
We are, after all, talking about a profession that is built around caregiving, with the parallels between caring for patients and families undeniable. Women physicians spend more time with their patients, up to 10% more, and have been shown to have a distinct style of doctoring from their male counterparts: more encouraging, supportive and patient-centered. The contributions of part-time women physicians are no less in quality to the lives of their patients; shouldn’t such devotion to caregiving at work and home be traits encouraged in physicians?
Invoking the predicted physician work shortage as a reason why women physicians should not work part-time or leave clinical medicine places undue guilt and blame on them. The main factors driving up physician demand is the growth and aging of the US population and health care reform. While women physicians do work fewer patient care hours compared to men, what kind of profession would we have if women who might decide to work part-time later were denied admission? More reasonable (and humane) answers to the physician shortage lies in lifting the residency training caps to train needed physicians and creating new models to increase efficient use of the existing workforce.
Besides, women (and also men), who choose to spend a portion of their medical careers working part-time or who take an extended leave, may return to full-time work at a later time, for example, after their children reach a certain age. Thus, there is a need for effective physician-reentry programs that help prepare any previously trained physician to return to the workforce, providing education and re-training as well as portals to reenter medicine.
Let’s not forget about the men. Besides early to mid-career women, men approaching retirement age are the other fastest growing segment choosing to join the part-time physician workforce. Survey data show that today’s medical students and residents, both men and women, say achieving a balance between their work and professional lives will be the most important factor when establishing a fulfilling career in medicine. Medicine mistresses are going out of style all-around, much to the dismay of the medical henchmen: Burnout, Stress and Dissatisfaction.
To be sure, medicine is a public good. Federal dollars support physician training, and certainly, it is imperative that medical school admissions committees select applicants, male and female, who show a strong commitment to medicine. Yet after training, men as well as women may decide not to practice clinical medicine. Is it more problematic when the reason is because a woman wants to raise a family versus a man who takes a job with a consulting firm? I hope not. These are difficult personal decisions, emphasis on personal. Like everyone else, doctors need to make decisions for the health of themselves and their families. Life happens.
I am a mother, and I am physician. These two roles are complementary in more ways than they are not. The increase in flexibility for women physicians in recent times has been a boon to those of us who have found a calling in medicine but do not want to sacrifice having a full family life. Isn’t that what Mary Elizabeth Garrett had in mind as well? Independence and autonomy for women to practice what they love, to be empowered by having choices.
Katherine Chretien is founder/editor of www.mothersinmedicine.com.
Monday, June 13, 2011
Rites of Passage
Friday, June 10, 2011
Then after an exhausting day at work, going home to make dinner, started and folded more laundry, discussed the day with the family as we played "Apples to Apples" (Fun game if you have older kiddos.) I soon realized that I really am very vulnerable to my circumstances. Dealing with difficult patients...frustration and fatigue sets in...fun game with the family...happiness and energy abounds. Geez, this is sad realization my mood is so easily shifted. Maybe it is hormonal or maybe I just don't like not being in control...ahh...that is it.
I am a control freak. Yes, type A personality to the core. See when I go on my mental vacations I am in control and decide my fate. In real life, not so much. Not sure how turned into this over the years. Certainly not genetic as my mom is a peace maker and sweetheart and my biological dad never stuck around to change or be in control of anything.
I guess when I figure out how to solve this little personality disorder I will probably become a wealthy person. Any thoughts?
Tuesday, June 7, 2011
(Unfortunately, the hammock came to life during the night and tried to bring us back to its home planet. We had to destroy it with fire, its only weakness.)
Last year, he bought me a gift certificate for a massage at a spa. Sounds like a great gift, right? Unfortunately, I've never had a massage before and I'm a little bit terrified of them, mostly because I vasovagal kind of easily. When I was having a one on one yoga demo session, the instructor did some kind of massage-like manipulation and I almost fainted, and felt lousy the rest of the day. The same thing happened when an osteopath in my class did some kind of manipulation on my shoulders.
So I traded the massage for a pedicure and a wax, and I was happy. Yes, I preferred having hair yanked out of me by the root rather than get a massage.
I guess I didn't emphasize to my husband my feelings about massage because this year for our anniversary, he again bought me a gift certificate for a highly rated spa in our area. Except this time it was a spa that basically ONLY does massage and variations on massage. And it's a $200 gift certificate, so it's not like I can just toss it. I have to get a massage.
I feel a little stupid about the whole thing, because really, what woman wouldn't want a massage at a nice spa? But I'm seriously worried about fainting during the experience or something along those lines. And isn't part of the fun of a massage looking forward to it? I feel like this is going to become a self-fulfilling prophesy.
So here I am, dreading a massage (and also playing the world's tiniest violin).
Wednesday, June 1, 2011
Guest post: Top 5 Unexpected Discoveries While on Leave of Absence
1. Making new friends, and keeping the old. During medical school, and especially during the in-hospital clerkships, my life choices were made for me: either school or family, often in that order. There was little room for anything else, especially not friends. (Have you been friends with a medical student? They are never around, and if they are, they are talking about exams or sneaking peeks from flash cards. And planning get-togethers? Forget it--they're at the mercy of the next clerkship schedule.) So a few months into my leave, when someone asked to set up a play date after a La Leche meeting, I was dumbfounded. That there are other people out there who can relate to me outside of my profession and are willing to rehabilitate me back into the world of non-familial human attachment, was--and still is--a wondrous thing. I am forever grateful for those friends who ask to socialize despite my terrible track record at reciprocation.
2. Time to....think. Don't get me wrong, in school I was thinking all the time. But the thinking that came with school was strictly medical (normal pressure hydrocephalus or early dementia with BPH?). Left to my own devices, I started to think about my medical thinking (metadiagnosing?) and how I was taught. I reflected on what I would do for a career, what kind of thinking I liked to do. I read JAMA for fun, and went to a writing workshop for medical students. I feel...more resolute now, more introspective.
3. Hobbies. While I didn't revive my favorite hobbies with nearly the gusto I intended, it was nice to dabble in them here and there, even if it meant that time-intensive knitting was replaced with beadwork, or jogging was replaced with chasing kids in a park.
4. Kids--they grow! Once Starlight was born, I lived in this fog of sleep-deprived, perpetual kid-tending. Starlight never slept more than 40 minutes at a time, and she constantly needed to nurse. Unlike Sunshine, she wanted to be held all the time. Sunshine (my oldest daughter), being barely two, still needed intensive mothering--I was clothing her, diapering her, and cutting her food in little pieces. She couldn't be left alone more than a few seconds. It didn't occur to me then that this state of being might be temporary. Over the last few months, I've watched Starlight nap longer, learn to explore on her own, and try all sorts of finger foods. Sunshine can now put her own clothes on, play quietly by herself, and use the potty. This was definitely one of my favorite discoveries.
5. I'm the same person I always was. When I started my leave, I had grand ideas of remembering everyone's birthday with personalized cards, preparing elaborate dinners, and finishing all sorts of household projects. The truth is I'm not an apple-pie mom. I'm a doctor-mom, and if my heart and my mind are ever not with my family, they are with medicine. My house never got to immaculate status these last months, but it matters more to me that I was able to tutor medical students and perform experiments. My cooking will never make anyone's life a little better (Mr. Scrub can probably attest to this), but hopefully my skill and empathy as a physician will.
Tomorrow is my first day back. I should be wistful (and probably fearful), but right now I'm full of anticipation. New lithium AA in my pager, and a fresh set of bound notecards to pair with my pocket reference book.
The air is hardly crisp, and the leaves are far from turning, but back to school, here I come!