Tuesday, July 24, 2012

Join the discussion

We're discussing the article in the Atlantic "Is Medical School a Worthwhile Investment for Women" on our Facebook page. The article is written by the authors of a soon-to-be published study in the Journal of Human Capital (yes, there is such a journal) looking at the financial impact of a woman choosing to become a doctor versus physician assistant. Some interesting and insightful perspectives (international; MD/PhD; MBA, etc) shared so far. Join in on the discussion (or lurk) if you're interested.

Monday, July 23, 2012

the vitamin racket

I try hard not to substitute my medical judgement for that of a pediatrician. Even though I know it's probably a virus and I don't want my kid on antibiotics unnecessarily, when my little mom voice whispers "oh but wouldn't it be nice to just check in with the pediatrician....?" I listen, and usually give the office a call.

The balance between mom and momMD can be difficult to maintain. When my son was 22 days old he developed a low grade fever for which we sought care in our local ER. Two failed LPs and countless futile attempts at IV placement later, the little mom voice that usually serves me so well was screaming Grab your son and get the (expletive) out of here NOW. But I didn't. I thought of countless febrile-but-stable patients I had met in my short training. How, in the span of a few short hours, some of them would be actively dying in the ICU with clear plastic tubes coming out of every natural and man-made orifice. I thought of the two people I knew who had suffered the sequelae of childhood meningitis - one was almost deaf, the other had had partial amputations of all four of her limbs. I ended this internal debate by breaking into loud, messy tears. At one point I started choking on my own snot. For better or worse (and to this day I'm not sure I made the right decision) we stayed and were admitted to the hospital. And my son is fine. 

I tell that rather unpleasant story to make a point - I try to be a good patient. A good mother-of-the-patient. Even when it conflicts with my own instinct. But there is one thing I don't understand - vitamins. My 3 year old daughter was never on infant vitamins. But my six months son has two different vitamin prescriptions. Two. Our first pediatrician told me it was mostly for "vitamin D supplementation". Perhaps I am prejudiced, but as an internal medicine resident who dutifully checked vitamin D levels on most of her patients, I came believe there was something wrong with the test because every single patient had a low or undetectable level. My husband - a healthy 32 year old who eats a balanced diet and works out in the garden - has an almost undetectable level. I guess I'm saying I don't know what to make of the vitamin D hysteria, so I didn't prioritize (or really, remember), my son's infant drops. When my husband admitted to the second pediatrician that we hadn't been very dutiful vis a vis the infant drops,  she appeared quite taken aback. And then wrote a new prescription, this one for infant vitamin drops with fluoride. I hope "poor compliance with medical therapy" wasn't entered into the medical record. In my defense, we've been very compliant with use of iron fortified cereals - an enthusiasm directly attributable to my hematology training. 

I am all for prenatal vitamins and fluoride supplementation in the water, but my son? He doesn't even have teeth yet. 

Thursday, July 19, 2012

Hard, but worth it

I love being a medicine attending in July. It's often more intense work since everyone's in a new role. Bright, fresh interns. Excited new R2s and R3s. And the medical students- the new third-year students who have toiled in the classroom finally get to focus on patient care. Their enthusiasm over hearing a mitral regurgitation murmur, over watching a paracentesis, and, well, their enthusiasm over everything, is infectious. Perhaps it's a bit of a vicarious thrill to be re-living that excitement again  - the realization that we have such a privilege to care for patients and to make a real difference in their lives, of being empowered by knowing and understanding, and being consciously aware of our own growth as physicians. As a medical educator, July is a highlight of the year. Hard, but worth it.

On a recent weekend day, I was rounding with my residents and students. Working on the weekends is my least favorite part of attending on the wards. These are days that belong to the family unit; I always feel an anticipatory dread leading up to a weekend work day. Of course, once I'm there and working, it's all about teaching, about patients, and it goes by quickly.

Well on this day, I had finished rounds with the team, but had something important I felt I needed to do before I could leave for the day and catch up with my family. There was a patient whose struggle with his illness had moved me, and I wanted to make sure he knew I had heard him, that I understood. So, I wrote something for him: his story, as told to me, as received by me. Not his History of Present Illness, mind you, but his real story - his loss of his identity due to his illness. This was his suffering I needed to acknowledge. I asked him if I could read something I wrote him.

That moment, of reading those short few paragraphs, was filled with light. There were tears. There was an opening of wounds. There was sharing - so meaningful and real and deep -that it nearly blew me away. Nine years of being an attending and I am still able to be blown away by the absolute honor of doing this work. It didn't matter that it was the weekend. That I was at work. I was simply filled with gratefulness for this moment and for the job I am so lucky to have.

It's moments like this that remind me it is entirely worth it, weekends and all.  It is a gift.

*This patient gave me his permission to share this moment.

Wednesday, July 18, 2012

Making Friends

I don't consider myself to be a terribly outgoing person, but in high school and college, I had more friends than I knew what to do with. I see these people on Facebook or at random reunions, and while I can't remember what on earth we had in common, I recall we used to be great friends. There was one girl in high school who I considered a good friend, and I'm fairly sure the entire basis of our friendship was that we both watched Melrose Place.

In medical school, it was a little harder, but I still had a group of close friends. In residency, even though I had friends that I used to talk to a lot while at work (I am very chatty, as you may have guessed), I hardly ever socialized outside of work. Between my residency hours and having a baby, I just couldn't find the time or the motivation.

And now I'm just frustrated. I meet plenty of people, but either the friendships don't work out (more likely) or if they do, the person moves away within a year. (I recently discovered the closest friend I've made around here is moving.)

Apparently, I'm not alone. I was chatting with a good friend of mine from med school, who is literally the most sweet, wonderful, and outgoing girl I've ever met, and she told me that she can't make friends. And this article in the NYT confirms what I already knew was true: it's hard to make friends when you get older, especially when you have kids.

One problem I've been finding is that the women I've met who actually have time to have playdates and socialize are all stay at home moms. And it's harder to mentally connect with those women when I'm working full time as a physician. Our problems are so different--it's hard to relate.

Much like the writer of the article, my kids recently had a playdate with the child of a woman I really connected with. We chatted non-stop through the whole playdate. Back in school, this woman might have become a great friend. But I know from experience that we'll be lucky to have playdates every other month. I met a few other women at work that I have really fun conversations with, but I know friendship isn't in the cards if I can't get them to stop calling me Doctor.

Much like that movie, I Love You, Man, I'm trying to approach friend-making the way I'd approach dating:

1) Meet lots of women

2) Don't expect much

3) Don't appear too desperate

4) Take classes or join clubs to meet more people

I also liked what the article said about compartmentalizing friends. I need to realize that my work friends are just going to be friends at work. My book club friends will just be friends at book club. And so forth.

Oddly enough, despite what I consider to be a lack of friends, my social calendar is totally booked with family visits, birthday parties, playdates, etc. Yet another part of the problem.

Tuesday, July 17, 2012

Facebook Good Samaritan

Like most of the civilized world now, I am on facebook.  At first it was fun and exciting, now it mainly acts as a time suck while waiting around at the hospital.  My news feed consists mainly of lovely updates of what my friends from third grade had for dinner or more recently many pictures of car thermometers in Oklahoma.   I, of course, only post extremely interesting things, like cute quotes from my kids or pictures of the XM radio in my car. Obviously everyone wants to know what song I'm listening to.

I do my best to avoid the usual internet arguments.  I skim past  the anti vaccine or homebirth conversations.  The is definitely no “poli-booking’ for me (discussing politics on FB). I’m not ‘friends’ with patients and try to make sure my behavior is ethical online.

Despite these precautions, I have found some grey areas in social media.

What do you do when people are making obvious bad medical decisions online? What is our responsibility as doctors?

A girl I went to elementary school with was recently pregnant. She lives several states away from me and I haven’t seen her since 4th grade.  Every minor detail of her pregnancy was posted in her status updates. Many of these would definitely fall in the “TMI’ category (ie: hemorrhoids ).

Near the end of her pregnancy she began having swelling, and she would post daily pictures of her 'c-ankles.'

One night she posted a status that made my obstetrician’s heart skip a beat, “I have the worst headache of my life, and I’m seeing little squiggly lines.  I just checked my blood pressure and it’s 170/95”

This update, received several ‘helpful’ comments from friends, family and other third grade classmates, such as “take a relaxing bath” or “try Tylenol”.

I quickly sent her a private message recommending she proceed to the hospital.  These symptoms met the criteria for severe pre-eclampsia. She replied that she had called her doctor and her doctor wasn’t concerned.

Now this was a dilemma. Is she lying? Is her doctor an idiot?  What is my responsibility here?  

I tried to go to sleep, but every time I closed my eyes I kept picturing her having an eclamptic seizure.

I posted a comment or her update, encouraging her to go to the hospital that I was worried she had a serious life threatening condition.

She did not respond.

Two days later she posted that she was going to her doctor.  She was promptly delivered.

Luckily she and her baby were fine, but since this incident (which is entirely true) I have been left wondering, what if she had seized?  Did I do enough to just tell her to go?  Should I have tried to track down her phone number and call her?  Should I have ignored the comment all together?   

Technology had introduced many grey areas in our ethics.  Since we have a social media expert in our midst and many of you are bloggers, immersed in the internet, I thought I would toss this out there and see what you think.

Monday, July 16, 2012

Apparently I’m only worth ¼ of a man

This weekend I attended a surgical conference in a beautiful location.  I had been looking forward to bringing my family with me to enjoy a nice weekend getaway.  I barely got out of the hospital on Friday in order to get there, and as a result I felt totally rushed and nervous about the talk I was supposed to give Saturday morning.  I was slated to give my talk right after the big state of surgery update talk by a surgical big wig.  He talked about the health care reform, the surgeon shortage, the effect of hours restrictions on surgeon proficiency at the end of residency and then he talked about the detrimental effect of the influx of all these pesky women into medical school and now SURGERY!!!! Yes, I’m actually serious.  This dude got up in front of an audience at a major meeting and had a slide that said that four female surgeons were required to equal the productivity of one male surgeon .  Yes, these words were on his slide.  He prefaced the slide with a line about it potentially being controversial, but asserted that it was based in statistics and facts that were not cited at any point in his talk.  One of my mentors was sitting beside me and made an immediate rebuttal in addition to commenting again at the end of his talk.  She made it clear that she was a productive female surgeon and that statements like his are what lead to unfair hiring practices.  I whispered to her that I planned to take one more dig at him when I got up to talk.  And she smiled and told me to “go for it!”

I then got up to do my talk after my introduction by a very prominent female surgeon leader.   Suddenly, all my prior nervousness was gone - I’ve always been good at making waves!  So, I loaded my talk, got behind the podium and calmly mentioned that I was never one to shy away from controversy and that as a former economist I was well aware that statistics can easily be manipulated to support your agenda.  I then mentioned that I would now present the research I completed while pregnant in the lab and more productive than anyone else with me.

It is ridiculous that we continue to fight against these types of stereotypes and misinformation.  The only reassuring thing about the entire situation was that so many people came up to me afterwards in support of what I had said.  Women add value to medicine in so many ways, we are essential.  I don’t have to say much about it.  I’m preaching to the choir here.


Sunday, July 15, 2012

The Real Deal: My Intern Orientation Part 1

In my idealized vision of Intern Orientation, my first week would be busy, yet amazing. In reality, it was one part separation anxiety hell and one part meeting really cool new colleagues with a dash of partner arguments.

The hell: knowing that I would miss my baby and then really, really, really missing everything about him. Having spent the last 9 months at home with him full-time, gone are the days of sleeping in, play dates with the other stay-at-home mommies, the almost daily home-cooked meals. The first few mornings have involved me trying to ease myself out of bed without waking the baby or my husband only to have the baby pop up and begin screeching as I brush my teeth. I learned after the first day that the only way to make it out of the house on time is to ignore his cries. I have cried on my way to the hospital on more than one occasion. I have questioned why I chose this path. I have felt like a horrible mother, especially since Zo refused to drink more than 0.5oz of expressed milk for 2 days and morphed from a content, happy baby into a fussy fuss-face in the blink of an eye. Half-jokingly, I have contemplated moving to a country without extradition laws to escape the mountains of student loan debt that I have accumulated so that I can stay at home with him comfortably until he begins elementary school.

The cool colleagues: My Co-Interns are awesome. I was very nervous to meet them. I was worried about the clique-ish, fraternity culture of my medical school repeating itself, but the majority of the group seems very committed to providing excellent care and being collegial with one another rather than drinking it up at bars. Though, I know that I will have to make a point to plan some family-friendly events for everyone to participate in. And some wine and cheese socials for those of us who like things more low-key.

The arguments with the partner who I never argue with: The arguments started on the first day. Prior to orientation, my husband had never spent an entire day alone with Zo. Add screaming fussiness, the heat of Southern living, and a baby who refuses to drink expressed milk and you have a recipe for disaster. By Day 3, hubby and I were pretty angry. By then, Zo had begun eating fruits and veggies verociously throughout the day and we had begun mixing breast milk in everything. We devised banana and milk smoothies, rice and beans with splashes of milk for creaminess, I could go on but some of our concoctions made us cringe while the baby lapped it all up.  Additionally, Zo has altered his schedule and now wakes up 6-8 times a night instead of his usual 3-4. So yeah, the arguments about everything from not having enough veggies to me closing the door too loudly resulted in various heated debates and even one “I don’t want to talk anymore, let’s stop talking right now!”

The mid-to-final-verdict: The first few days of Doctor-mommy being away during the day means less daytime milk, many more night time nursing awakenings, and a fussy family. There will be an end, right?!? I’ll post again once the final verdict is in.

Family and distance

When I was about six months pregnant with my first daughter, I got in huge argument with my father. Because he lived so far away me, he wanted to book plane tickets to visit the baby well in advance, and he decided he was going to come on the day before I was due, and stay for a week.

I was not happy. Since it was my first pregnancy, I fully expected to deliver a week late and he'd miss the whole thing. And then be hanging around me while I was very heavily pregnant, and expecting to go out a lot. Plus I didn't really want my family (other than my husband) around when I was actually in labor.

We argued back and forth. Finally, I lied and said that they'd done an ultrasound and changed my due date to a week later. That convinced him.

I ended up delivering on time, but it actually worked out well having him there a week later, since that was when I was at my most sleep-deprived and grateful for the help.

At the same time, my mother traveled great distance to see her first grandchild for the first time. Unfortunately, she came down with a really nasty cold. I was terrified of having her near my newborn with that cold. I imagined the baby spiking a fever and ending up in the ER, and having to get an LP or something. But my mother was not exactly cool with the fact that she'd spent so much money traveling to see the baby, and now she had to stay away from her. She was angry at me for months over that one. (We still haven't decided who was right.)

I don't think I realized before I had kids how important it is to be near family. Other things that were annoying about living thousands of miles from any family members:

1) They didn't visit often

2) When they visited, the trips lasted for freaking ever until I couldn't take it another minute

3) When there was an emergency, we had no back-up we really trusted

4) No free babysitting

5) When one of us was sick, there was nobody around to give us a break aside from each other.

When I graduated from residency, my number one priority was to move closer to family. Right now, we live less than an hour's drive from my in-laws and much closer to my family too. It's not exactly right around the corner, but boy, does it make a huge difference. This time when I went into labor, I had a family member who came that very day to watch Mel. My parents were able to quickly make travel plans after I gave birth, and still arrived before I was discharged from the hospital.

We have family visiting almost every other weekend, which gives us a much needed break. When one of the kids is sick, I can often call my in-laws to come watch them if I know the night before.

I know other people who live in the same town or even the same house as family members. When I was younger, that would have been unacceptable to me, but now I'm jealous of those people. It's amazing how much of a difference having nearby family can make.

Friday, July 13, 2012


The clock is not the enemy.
Fatigue is not the enemy.
The hospital is not the enemy.
Consultants are not the enemy.
The lab is not the enemy.
Utilization review is not the enemy.
Your patient is not the enemy.

DISEASE is the enemy.

Go forward with courage ladies.

Monday, July 2, 2012

MiM Mailbag: Leave the financial industry for medicine?


I am not yet a medical student or doctor, or a mother for that matter, but I am on the verge of both and am looking for advice! I have been reading your blogs/articles for months and have found so much inspiration and motivation from the amazing women who write and comment.

My situation: I am 29, Canadian, graduated from undergrad in 2006, took a few years to coach alpine ski racing full-time and then got started in the financial industry in 2008. I've worked my way through a couple junior roles and am now an equities trader - reaching my initial goal in 4 years. I'm bored! I have spent the last 6 months trying to determine what I actually want from my career and have  figured out that money is not enough motivation for me to spend my working life hating my job.  Through a very long and thorough process I have come to realize that medicine is the ideal career path for me, for many reasons, and now is the time to pursue it!

The decision is a tough one for everyone, from what I gather from the posts on this and other blogs. The aspects I am struggling with are the same as those of other posters; we are trying (have been for ~6months) to get pregnant - will have a toddler during residency if everything goes as planned, that will be tough. I feel like I am ready to take that challenge on, have a very supportive husband who will make it work. The part that I am struggling with right now, where I need the encouragement to take the big first step back to school, is leaving a job that pays very well (less than 2 years in my current position and at $100k/yr) and going to effectively negative income for the next 6 years...or more.  My current job is one people tend to get into for the money, medicine is not (from my view anyways), there is upside as a physician but its the work and the industry that is so intriguing to me. It's a scary first step for me to take, I know I WANT to and honestly if I were single and not planning to have kids asap I would have left my job months ago. I'm trying to make the right decision, I need to know it is the right one, which is basically impossible. I worry about making this move and regretting 10yrs from now that life is still tough, we have a ton of med-school debt and it could have been so much easier if I had stuck it out in finance for the plentiful income.

Please tell me about your opinion on this; once you have kids, does the value you place on how happy you are in your career fall back? In 10years, would I rather have more money in a boring, unsatisfying job, than be happy with my work but still be struggling to pay down school debts and keep my kids in sports and other activities that I believe are important and of course cost money?

I've heard that priorites really do change alot when kids come into the picture, I am worried that if I don't make this decision now (to leave my career and begin the long/hard path that is medicine) I won't want to uproot once my kids are born and I'll regret not doing something I really wanted. Or, I make the decision to leave my cush job now, and when my kids are a couple years old and I'm spending 24hrs at a hospital in residency that I will regret leaving the boringness for this challenge.