Wednesday, November 28, 2012

Clerkship Preference

In light of my post last week, about people with special considerations (i.e. kids) getting preference for the holidays, I wanted to post this story. A version of this was originally on my personal blog:

During second year of med school, most schools have a lottery to decide on what the third year rotations will be, both the order and where we would have those rotations. There were four main hospitals we rotated through, two of which were nearby and two of which were about an hour and half away.

Prior to our 3rd year clerkship lottery, we voted on special considerations for the clerkship lottery. Basically, students emailed in their special needs, and an email was sent to the class with the anonymous requests and we could vote on them. These were some of the requests I remember:

--A few students who had children asked for all their rotations at one particular hospital so they wouldn't have to move around.

--A couple of students asked for an elective during a certain month so they could get married.

--Two male students asked for an elective month during their wives' due dates

--One student asked for an elective month when his father was having cancer surgery

--One student asked for rotations at a certain location because she only had one car and she carpooled with her husband

Out of our class of 100+ students, 12 anonymously asked for special considerations. Out of the 12, 10 passed through majority class vote. (Notably, the car one didn't pass, the one with kids/births did.) I actually voted yes for all of them, mostly because I felt if they believed it was important enough to get special consideration, they cared about it a lot.

Anyway, the day after we found out which requests passed, one woman in our class sent out the following email:

This is ridiculous! Many of those reasons were absolutely silly. What was the percent of votes needed to pass this anyway? I can't believe the votes passed with those stupid reasons these students gave.

Because for one thing, if your parents are ill, get a visiting nurse, since there is nothing you can do while you are studying anyway. Secondly, all these people that want to take care of their family or assist with their wife's pregnancy or take care of the children or see your children and all that... well, we all have loved ones we would like to see as often as possible, but because we chose such a demanding profession, we simply don't necessarily have that luxury. We just make it work without having to subject our colleagues to it. If it matters so much, have your family member move to where you are or you can commute or hire a baby sitter that can pick your children up from school.

I easily could have said something equally lame, but I sacrificed and let people with more important reasons have their say. But all these crazy reasons, I tell you, is unfair to the class as a whole and it is especially unfair to people that had good reasons but took the initiative to find solutions to their issues.

We generally all thought this particular person was being extremely selfish. What do you think?

Tuesday, November 27, 2012

Role Reversal

I was once at a pancake breakfast for my kid's school.  Cesilly was 5, Jack was 3.  Jack was in a dance class, pre-Taekwondo and Boy Scouts.  I was feeling pretty savvy, my son in a dance class!  How liberal and against the grain.  He had to wear a uniform for the performance - a black suit with a spangly sparkly bow tie.  He looked like a flim-flam man.  I was a little confused by the attire.  I wandered over to another mom to ask her about the logistics.  She was a gyn-onc at the University - a transplant who was trained in California.  Her son was my son's age, her daughter the same age as mine's.  I didn't know her well, but was itching for companionship, especially from another doc/mom.  I walked up to her and took a deep breath.  Wanting to be her friend.

"So what are they supposed to wear for the recital?  Do you know?"

She looked at me, puzzled.  "I have no idea.  My husband takes care of all of that."

I think he was a stay at home dad, or at least had a very flexible laid back job.  I had gathered that much, from observing them over the past few months at the school.  I also saw them at the grocery store on Sundays, all of them, the entire family shopping together, while I was on my own doing the weekly shopping.  I admired that about them.

My reaction to her statement was complex.  I was awed that she gave up those duties to her husband, and also jealous that he was available enough to take charge in that arena.  I also felt angry at her, probably projected anger redirected away from myself.  Angry at her for not knowing about the mundane details of the children's lives, since that was my primary role in our family at the time.  I was a resident, busy with work and two small children, and I would have never imagined relinquishing that knowledge or responsibility to my husband.  It would not have worked, in our relationship.

I am divorced, two plus years now.  My ex and I get along better now that we are co-parents, and not married.  He is remarried to a wonderful woman who has taken the role as stepmother to my children, not stepmonster.  She calls my kids her "bonus children," and read such a beautiful passage to them at her wedding last March, about there being room in her and their hearts for everyone, that I got teary.  As my daughter Cesilly said at breakfast one day, "Mom, Dad sure does some things really well.  He picks good women.  He picked you, and he picked Miss Rachel."  I laughed.  I agree.  I love Miss Rachel, and so do my kids.  I maintain a respectful distance, but will be eternally grateful for the structure and emotional support she provides to their household.  My marriage issues are water under the bridge.  But there was definitely a large gap in childcare division back then, me taking on most of it.  I don't think this is uncommon, especially when the children are young.

My primary reason for writing this blog is about roles and delegations in marriage, traditional and otherwise.  Did I have any right for feeling judgmental about the gyn/onc's lack of knowledge about her son's dance outfit for the recital?  Or was it all a reflection of my own situation?  Would I have reacted the same way if she were a man, and he didn't know?  I could not have imagined approaching any father at the pancake breakfast to ask about dance recital outfits.  Part of my frustration in my own marriage was the one-sidedness of it all - I saw other friends whose husbands were much more involved in the day to day of the kid's lives.  I take some responsibility for this, in retrospect.  If I had a stay-at-home dad back then, and not a physician husband, would it have been so weird to me that she had no clue?

My kids have moved on to two different schools since that pancake breakfast.  The gyn/onc and I earnestly tried to make some play dates, but I am sure the readers in medicine can guess how that worked out - busy lives move forward without much room for pause.  I last saw the gyn/onc a couple of years ago at the grocery store.  She was expressing frustration with her academic career, the challenges of it, and I listened sympathetically.  Told her about Mothers In Medicine, it being such a great outlet and community for me.  I haven't seen her since.  I sometimes wonder if she is still at the University, or if she has found another job.  I hope she is happy in her career and life.  I don't feel as judgmental of her now as I did back then.  Maybe that speaks well of where I am now in life.  I guess it ultimately takes a working balance in a relationship to make it all work, no matter how the roles play out in the end.  As long as everyone is happy and on the same page, that is what matters more than individual responsibility.

I am curious to hear about how other women, all women - working and stay-at-home, negotiate these treacherous waters in their relationships.

Monday, November 26, 2012

Some days I’m envious of my Acting Intern

I used to be you. Well rested. On top of things. Bright-eyed. Now I’m the sometimes harried Intern with lots of patients, experiencing lots of sign out and cross-covering. Now I’m the Intern with the baby and husband who you look at and say “wow, I just don’t know how you do it, that’s soo much!” while you run out to your weekly exercise class while I finish my umpteenth note and go home for bath time, dishes, and a glass of wine.

I’m the one with the mommy pouch that won’t allow me to wear the cute new fashion trends (who am I kidding, I can’t even afford those trends) and the hair that needs to be done. I’m the stressed Intern with the significant student loan debt and monthly loan payments. I don’t tell you that if I made just a tiny bit less I’d qualify for public welfare benefits. I’m the one with the job that matters so much that I constantly check and recheck my orders. It hit me hard Day 1, I write the orders and they get done. I get the pages and notifications and make split-moment decisions. I am part of the Code Team. I affect lives. I affect health care costs.

I used to be you, the Medical Student, but now I’m the Intern, I’m Doctor Bee. I used to be scared but not this scared. I used to be tired but not this tired. I used to be happy, but not this happy (in a wickedly complex, exhilarating yet scary all while being fulfilled kind of way). Sometimes I am so envious of you, but more often than not, I’m happy to be exactly where I am.

Wednesday, November 21, 2012

Holiday privileges

Here's a question for the ages:

Should employees with children be given preference in terms of not having to work holidays?

I say yes.

And I say this as someone who will be working on Black Friday. And I worked most holidays during residency without complaining. Before I had kids, I actually offered to work holidays so that other people who had family in the area (I didn't) could be with them. After I had kids, I still worked most holidays without complaining.

The only time I ever asked for preference was when I discovered a couple of weeks before the fact that our daycare was closed for two weeks for the Christmas holidays, and there were just a couple of days when my husband couldn't get out of work, and our usual babysitter was out of town. Basically, I had no options, and my program was super nice about accommodating me, so I appreciated that.

I can see how one might argue against this. After all, just because you don't have kids, it doesn't mean you have no family. And while I agree with this, I do have a few arguments for why I think people with kids should get preference:

1) Schools and daycares are likely closed for holidays and nannies go on vacation, so finding childcare becomes a nightmare. I wouldn't want anyone to put their kids in a potentially unsafe situation just so I could have a holiday off.

2) If a person has school-age children, holidays may be the ONLY time the kids can go on a trip to see family members, since you can't pull them out of school.

3) Holidays are important to everyone, but nobody finds holidays as magical as kids, so I think it's worth it to make it special for them. And they actually probably like seeing their relatives.

Maybe if someone has a big family Christmas event every year that means the world to them and it's a thousand miles away so they have to take off several days to go... well, fine. But frankly, I don't think that many adults feel that way. Most probably appreciate having work as an excuse to get out of the Christmas events.

Personally, I don't care as much, since my husband is usually able to take off days when I can't, and my family is very willing to visit me, rather than vice versa. But I know that's not the situation for everyone.

Monday, November 19, 2012

MiM Mail: Ready to quit

Hello to whoever might be reading this,

I am a 2nd year Peds resident in a grueling program, and I have 10 month old baby.  N'er the twain shall meet.  But they did and they are, and that is why I am burnt out.  I am a zombie from sleep deprivation; being on call q 1 is beyond my capabilities.  And my heart isn't in the residency program like it was a few short 11 months ago, but once my son was born all I want to do is be a mom.  I don't think I want to be a doctor anymore, but I can't decipher between not wanting to be a resident anymore vs not wanting to be a doctor anymore. Oh, and I'm 300k in debt. So I can't quit.  But I want to.  I'm away from my son so much sometimes I forget what he feels like. 
I'm hanging on here but the thread is stretching thin.  I envision, mostly when I'm post-call like I am today, walking into the program directors office and saying, "I quit."  It feels good.
Anyone been in this predicament?  Any suggestions? I love this online community and often read it while at work or right before going to bed to check in with all you fabulous other women doing the combo of medicine and parenthood.
Thanks everyone.

Wednesday, November 14, 2012

I Hate the Library

I love to read.

I have ever since I was a kid. Obviously, I don't have as much time to read these days as I used to, but I've read a good number of books this year. I've found if you really like doing something, you can always make time for it.

Back when I was a mother of one, I used to get most of my books from the library. I used to enjoy browsing through the shelves and seeing what appealed to me. Now that I have a toddler, I haven't been able to make time for that, plus I'm terrified of her destroying a library book. So I haven't been to the library in a while.

Last weekend, however, I got bored and decided to take my kids there.

As some of you who read my personal blog know, I have some issues with the library. But since our local library has an entire floor dedicated to kids, I figured that we at least wouldn't get shushed.

When we arrived, my older daughter Mel was thrilled to discover that there was a train set for her to play with (because you don't actually go to the library to look at BOOKS). She started playing with it while I flipped through books with my toddler. I must have turned away for, oh, sixty seconds.... and the entire train set had been dismantled!

Me: "What did you do???"

Mel: "I'm going to rebuild it!"

OK, well, I don't want to stifle her creativity, right? So rebuild away!

Except she wasn't quite done rebuilding by the time she got bored. I think it ended up being more complicated than she thought it would be to fit everything together, and she couldn't do it. She went about ten feet away to the young readers section and started pulling out books.

"I'm going to read these!" she announced.

And of course, my toddler followed her and we all read books together. Yay for encouraging reading!

Except about ten minutes later, a family of three came into the children's area. It was a mom, a dad, and a girl of about three or four. The mom looked at the area where I was sitting with my kids, where we had a few discarded books strewn about (which I was TOTALLY going to pick up when we were done), and says, "Oh my god, what happened here?"

I didn't say anything, just kept reading and focusing on my kids.

Then they go over to the train set, and now the woman is almost screaming, "OH MY GOD, WHAT A MESS! WHAT HAPPENED?!!!"

Then the couple starts discussing what a travesty this is. The dad especially seems really upset that the train set has been dismantled. He actually sits down and starts grumbling to himself while attempting to put it back together. And I hear the mom say loudly to him, "Can you believe this? I'd like to shame her into cleaning it up!"

Now you don't have to believe me, but I was TOTALLY going to make Mel clean it up before we left. I mean, I was still right there. And when I've got two small kids with me all by myself, it's not the easiest thing to not leave a tornado behind you everywhere you go. Even if I wanted to, I couldn't have put that train set back together without both my kids vanishing on me. And to be honest, they didn't even know it was me who made that mess in the first place.

I fully expected them to come up to me eventually and confront me, but apparently, they just wanted to passive aggressively talk about me behind my back. Still, it upset me, so they did their job.

Is it possible for me to bring my kids to the library without some library patron yelling at me and making me feel like never coming back?

Thursday, November 8, 2012

MiM Mail: Taking a year off from medical school for baby

Hi ladies!

I'm a long time reader/ asker and I've got another question for you guys. I'm an M3 with a 2 1/2 year old and am about 5 weeks pregnant with baby number 2.EDD around early July. I had six months off with my first baby and really would have enjoyed having more time. I'm a crunchy kind of mama (attachment parenting, breastfeeding, etc) and I know how I feel when my baby is new and tiny, and I'm certain I'll want lots of time with this baby too.

So, I'm considering taking a year off when the baby gets here, between 3rd and 4th year. I'm not certain I'll ask for it, or even if I'll get it, but I'm wanting to know what I'm getting into if I go down that path. I'm not sure what I want to do, but right now Emergency Medicine and Internal Medicine are my top two, and we live in the south and I have no Ivy League or academia dreams, so no seriously competitive residencies. Preclinical grades are average, Step 1 was above average, but not shockingly awesome. I don't have any research done yet, and honestly, think that the year would provide some time to boost that aspect of my resume (in addition to making connections in EM, since we don't have much exposure there as M3's). I also think I'll be a much, much better intern with a 2 year old than a 1 year old (and I know, because I have been there!) At my school, M4's essentially have 5 months off, but I'd like more time.

So, has anyone done this? Anyone have thoughts on it?

Monday, November 5, 2012

Onion Skinning

I was at a Halloween party at the kids school on Wednesday, opening sticker packets for a craft.  I noticed a few moms I didn't know, so I wandered over to introduce myself.  It came out that I was a pathologist, and later in the party one of the moms pulled me over to talk in confidence.

"I really hate to bug you about work issues when you are on vacation with your kids.  A significant member of my family was recently diagnosed with probable cancer.  She is incredibly healthy, this is a big shock.  My kids don't know about it yet.  She has had a couple of biopsies, and they can't figure out what it is.  Since you are a pathologist, can you review the slides?  Do you think we need to send it for another consult?  She is in another state being worked up.  We feel so helpless and frustrated!  What do suggest we do?"

I was reminded of a case I had a couple of weeks ago.  Walked into CT - a second biopsy was being attempted on a patient with probable pancreatic cancer.  The radiologist was livid that he did not get the diagnosis on the first attempt.  The biopsy the week previous was called "Atypical."  The tumor marker serum levels were sky high and the radiology was practically diagnostic, but they needed our help to call it and start treatment.  I had a heads up in the morning, and had already reviewed the first biopsy, which was looked at by four pathologists.  It was a tough case.

Sometimes the clinician doesn't get at the heart of the patient's problem the first time the patient presents to the office.  Pathology is the same way.  I don't think people realize this - they think it is all black and white.  We absolutely hate to be wishy-washy, and will often gather our colleagues to try to push the call one way or the other - negative or positive.  I was doing a frozen on a laryngeal biopsy on call a couple of weeks ago.  It was scary and ugly but I couldn't go beyond atypical.  Called a colleague to help and he agreed, so I called the surgeon in the OR and gave him the worst kind of answer - "We don't know."  I was thankful the next day - it turned out to be completely reactive/negative.  It is much easier to look at a piece of tissue that is processed overnight than one that is quickly frozen, sliced and stained for a preliminary answer for the surgeon during the operation.

I told the mom the same story I told the radiologist, in an attempt to assuage their respective fear and anger.  "Sometimes it takes time to get there.  When we have definitive specimen, it is easy.  Once I had a case of a patient with probable lung cancer.  It was exceptionally hard to get the diagnosis.  The pulmonologist did two bronchoscopies with washes and biopsies, and despite seeing the mass, they missed it.  The following week the patient went to CT-guided biopsy twice.  Both times the radiologist missed.  I happened to be on frozen sections the next week, when the patient went to open lung biopsy.  It took the surgeon four frozen sections to get to the bottom of it.  I kept calling it negative, and he was frustrated.  'Giz, I'm standing here staring right at it.  Don't tell me you haven't got good specimen.'  He was speaking to me on the intercom in the OR, I was on the phone by the microscope in the gross room staring at the tissue.  He could see the tumor, as did the pulmonologist and radiologist, but he wasn't grabbing tumor, just reaction around it.  He finally got it on the fourth piece of tissue he sent."  That case was an exception - we can usually diagnose the patient more rapidly.  But sometimes it takes time.

I love the term my partner used once to help me.  She calls it "Evolution of Diagnosis."  I was particularly upset about a muddy specimen.  She said, "Gizabeth, our field requires patience.  It's not always clear from the get go.  It's not a failure on our part if we can't call it right away.  Don't internalize it."  In psychiatry they call this onion skinning.  Peeling the layers away to get to the meat, or the psyche.  The diagnosis.  The answer.  Some onions have thicker skins than others.

I reassured the mom that the doctors would most likely get her family member's diagnosis soon, and gave her my name and number if she had any questions.  Assured her that most pathologists are trained well enough to recognize when they are in their comfort zone, which is 95% of the time, and when they need to send something away to an expert.  I also shared that my kids and I recently lost my mother-in-law, their Nana, to cancer.  Told her about the poem my daughter wrote and read at the funeral.  Empathized about how hard it was for kids to experience loss of that magnitude - mine had to at a much younger age than I ever did.  She thanked me and we served orange ice cream punch.  She and her family are in our thoughts.

The radiologist got good pancreas specimen on his second attempt, and I was able to give a definitive diagnosis to the surgeon the next day so they could cancel the open biopsy and the oncologist could start treatment for the patient.  A lot of times our frustrations and anger, as clinicians and family members, are an expression of the emotion that we have surrounding the stress of getting an answer to alleviate the fear of the unknown for a fellow human being or loved one.  When you can step back and see that objectively, it's a lot easier to let go of it all and focus on the job.  Skinning the onion.  Which is not generally a process that can be performed without burning, stinging and tears.  But the answer is usually well worth the effort.

Thursday, November 1, 2012

Guest Post: Five Lessons Learned on Being a Patient

Last summer, I was enjoying a relatively smooth second pregnancy despite my “advanced maternal age.”  It was a warm, sunny Sunday afternoon, closing a (miraculous) full weekend off of clinical shifts.  I lay down to take a little nap; my then-two-year-old daughter climbed into bed next to me. Suddenly – life changed.   I felt a gush of fluid, and knew that I was either bleeding or had broken my water.  To my dismay, it was blood.  A lot of blood.

At that moment, I made the transition that all doctors will make at some point in their life, but which we all fear:  from physician to patient. 

I was now G2P1, EGA 31w2d, with a spontaneous abruption, praying to feel the baby move.   I had no history of trauma, no cocaine use, no history of bleeding disorders.  My husband (who was, luckily, at home) scooped up our daughter and me and drove at what felt like 100mph to the hospital.   I sobbed in fear the whole way.  Thank god, on arrival to the hospital, our little one had a healthy heart rate.  But I was still bleeding, and contracting, and had some cervical dilation.  What followed:  8 long hours of being NPO in fear that I’d need an emergency C-section.  A long discussion with the NICU fellow about prognosis if my little one needed to be delivered that night.  An admission to the labor & delivery floor “just to watch.”  Then a week in the hospital.  Then 2 months on bedrest.   

No one knew why I had spontaneously abrupted, and therefore no one could say if or when the abruption would recur.  Although no large clot had been visualized on my ultrasound, that didn’t mean that my placenta was okay.  I was a nervous wreck, hoping my little one would gestate until he was big enough to avoid the NICU.

Thank goodness, nothing happened over those long 2 months.  I had occasional contractions, occasional spotting, no bright red bleeding.  And 1 week shy of my due date, my son was born, small but healthy.  And I was healthy.  I realize how incredibly lucky I am, and how much tougher things could be.

Still – it was the scariest two months of my life.  And it has changed my way of doctoring.   I walked away from this experience with 5 major lessons for my own practice of doctoring. 

1. Empathize with patients’ and families’ anxiety.

I now understand why people over-interpret their symptoms.  I get why the patient with a history of CABG comes back to the ED every week for twinges of chest pain.  (“What if?.... Last time… I don’t want to be home alone….”)  Often, my primary role as a doctor in the emergency department is to assuage this anxiety, especially if patients have had a long wait prior to being dispo’ed.

2. Be honest about a lack of knowledge, and explain what we can given the limits of our diagnostic/prognostic ability.

I am a physician, and understand medicine!  But I am not an ob/gyn, and have been out of residency for more than a few years.  The only abruption I saw during my training resulted in a stillbirth, so had no practical experience in this diagnosis.  Scarier yet, even among my ob/gyn’s group, management of moderate abruptions differed.  This was scary.  Luckily my personal physician was stellar at making me feel comfortable both with the lack of an evidence base, and with the recommendations she made.

For my patients who are sent home without a diagnosis or clear prognosis, I now try to acknowledge my frustration with this fact, and give an outline of both what I know they do NOT have (e.g. “I am pretty sure your really bad headache isn’t a bleed, or a tumor, but I’m not really sure what’s causing it”) and an outline of when/why they should come back.  I make sure they feel heard, and reassure them, which is often the whole reason they sought medical care in the first place: just to make sure they were okay.

3. Don’t be offended when patients ask for their personal physician when they present to the ED.

In a moment of fear, you want someone you can trust.  I was lucky that my personal ob/gyn was on call the day of my abruption.  I’m not sure how I would have responded to non-evidence-based recommendations had they come from someone other than her.

Now, when patients’ first words on seeing me are: “Have you called my doctor [X] yet?” – I tell them how lucky they are to have such a great doctor as their PCP/cardiologist/whatever, and reassure them that I will work closely with her/him.

4. Give good, thorough discharge instructions.

I left the hospital not understanding exactly what “bedrest” consisted of, and how much I could/could not do, and what would/would not increase my chances of doing well.  I think this was because no one really knows the right answer!  Still, not knowing was very tough for me at first, as I was scared stiff of re-aggravating the abruption.

I now try to be as clear as possible with my patients about what their instructions mean.  (What is “weight bearing as tolerated”?  When can they stop taking Motrin?  At what point should they return to the ED or their PCP?) … .This often involves rewriting or augmenting our computerized discharge instructions, of course.

5a. Acknowledge, and encourage, the use of social supports.

Being sick is scary.  And I wasn’t even physically sick – I was more worried about my fetus!  I can only imagine how difficult life must be for my patients with limited support systems, no money, and fear of losing their job if they stay out of work.  I know how tough it is for people to ask for help, but I encourage them to do so, for their own sake.

5b. Encourage the exploration of online support groups – Especially for chronic conditions, or diseases with little evidence base, the online community is a godsend.  For me, it was my only “good” source of information (although it was also a source of fear, if I didn’t triage sources well).  Heck, think of how important is for all of us!

 Before my abruption, I was already interested in the use of technology to support patient engagement and behavior change.  After two months of bedrest, I became an evangelist for “mhealth”…

Of course, I don’t think that I was non-empathetic at baseline.  I am, honestly, one of those people who always wants to be liked.  But now I try to listen more.  I try to ask what patients are scared of.  I try to reassure more, and to include patients’ families and social supports.  I try to give clearer indications of “if/then” and “what if” scenarios:  e.g. “I don’t think you’re having a stroke, but here are the things to come back for, and here is what I think is going on”.  I now try to explicitly acknowledge patients’ and families’ fear, and encourage my patients to turn that fear to good service:  to use it to increase their engagement with their families, the online patient community, and their own bodies. 

Most of all, I am now actively researching ways to use technology to facilitate patient engagement with their own health.  I don’t want this message to stop with me.

I welcome thoughts, comments, or partnership in so doing!

Emergencymom is an academic emergency physician and public health researcher on the East Coast.  She is proud mother of 2 (aged 4 & 1), and wife of a small-business-owner.  Her work-home balance is precarious, but generally enjoyable.  She still can't believe that she gets to do research for half her work-week!  She welcomes suggestions on how to get 4-year-olds to stop whining, how to have dinner cook itself, and how to not be perenially 1 hour shy of a good night's sleep.