Friday, March 29, 2013

Things Aren't Always As They Seem

I saw a thoracic surgeon in the doctor’s lounge today.  I have read his cases and frozens for a year or so, but never introduced myself.  I still get intimidated in that man’s world of the doctor’s lounge.  It's not just me, my female partner was urged by her male recruiter to eat with him every morning in the lounge when she started seven years ago, and chit chat with the men.  She said although she realized he was trying to be nice, it was excruciating and she bowed out politely after a few weeks.  Walking in there is like walking into an all male club room.  The thoracic surgeon was sitting around the table with a cardiologist, an OB/GYN, a surgeon, and a hospital administrator.  All men I knew individually, but I’m a silent parasite in the lounge, at least during the morning rush.  I breeze in, grab my coffee, smile and wave occasionally, and breeze out.  I wanted to talk to the surgeon about a case, so I waited until he finished regaling an entertaining story about his son’s report on a holiday for school, took a deep breath after grabbing a couple of hard boiled eggs for my lunch in a few hours, and walked over to the table. 

“Hi, I’m Gizabeth Shyder.  I don’t think I’ve met you before.”

A couple of hours earlier I had read a frozen for him.  I called him on the OR bat phone.  Gave him my diagnosis.  “Abnormal lung.”

He countered me sarcastically from the OR.  “Um, abnormal lung?  Is it benign or malignant?  Do you see signs of DAD (Diffuse Alveolar Damage)?”

I took a deep breath.  We use the words Abnormal Lung as a catch all for interstitial lung diseases, which are notoriously difficult to diagnose on frozen section.  Of course I had combed the patient history and knew that cancer wasn't high on his differential.  He wanted more, however.  I gave it to him.

“Well I don’t see any hyaline membranes on frozen section, but they are much easier to see on permanents.  There isn’t much well developed fibrosis in this section.  Or inflammation.  There are a lot of macrophages, I’m wondering about DIP (Desquamative Interstitial Pneumonia).  But that’s not something I would ever diagnose on frozen.  We need to see a lot of tissue to get a good reading on interstitial lung diseases.  I’ll be able to tell you more tomorrow.  I can tell you it is not malignant.  There is no cancer here.”

I think I gained his confidence.  At least his ear.   He replied, “OK, thanks.”  I hung up the phone.

In the lounge, he shook my hand and I struggled briefly to maintain my composure now that I was the center of attention.  I was happy to find that my excitement about the case relaxed my nerves.  “Remember that case we had the other day?  Mediastinal lymph nodes?  The one that was granulomatous inflammation?  All the frozens showed just that, and I reviewed them ad nauseum because you questioned me, thinking there was more, from the OR.  When I got the permanents I found more.  Not on anything you froze, but on your fourth specimen.  D2 to be exact – there were swarms of classic Reed-Sternberg cells.  Not the Owl’s Eye type that's always on the boards, but the mononuclear version.  There were also mummified cells – ones that looked like the nuclei had been squashed by the palm of my hand.  It’s Hodgkin’s.  Hodgkin’s can have granulomas, but I’ve personally never seen them so diffuse and confluent.  They masked the disease entirely in your frozens.  I turfed the case to a lymphoma specialist, and the stains were still pending yesterday, but I’m confident that’s what it is.”

The thoracic surgeon was listening and became energized.  He stood up and walked me to the door – opened it and held it for me.  “I knew there was something more!  Thank goodness it’s lymphoma.  I always tell my patients that’s a much better diagnosis, with a much better prognosis overall, than carcinoma.  Is the report out yet?”

Suddenly I became nervous.  I hadn’t seen the stains, what if my hypothesis hadn’t borne out?  What if it was some sort of rare T-cell lymphoma, with a worse prognosis, that mimics the Hodge (as we affectionately call it)?  I covered up my doubts with confidence.  “I’ll check on it for you.”

Turns out my partner had released the report as Hodgkin’s, just as I suspected, a half hour previous.  Whew.  The surgeon had followed me to the lab and I reported this to him.  We chatted about some other difficult cases he had that week that I had signed out, marveling at the combination of clinical and pathology; patient details he revealed to me matching findings under the scope that I divulged in detail to him.

No matter how far along we get in our careers, it isn’t always easy to handle cases. I’m learning that good communication helps.  Experience and confidence can make a dicey situation more smooth and clear.  But just when you let your confidence allow you to stand up a little too straight, a challenging case will take it down a notch.  This is probably a good thing.  No matter how good we get at diagnosing and treating diseases we will always be reminded that each human is unique and patterns, while helpful, aren't always predictable.  There is a larger design, one that is not in our control, as much as we would like it to be.

The hospital I work at is large.  We no longer have town meetings, we don’t get to know our colleagues easily.  But the extra effort can make a difference.  Now I've got one more person I can speak to informally on the bat phone.  "Hey, this is Giz.  Here's what I see.  Does that fit with what you see?  With the clinical picture?  With what you are thinking?"  The more informal and comfortable we are with our colleagues, the easier and quicker we can diagnose our patients.  There is no room for fear or intimidation in patient care.  Things work best when smart, well-trained people put our heads together to solve the puzzle.  Puzzles aren't single cases necessitating week long work-up, like on TV.  They come hard and fast and in massive daily numbers.  We are all trained intensively over many years to handle it, and we step up to the plate every day.

I got the permanents on the interstitial lung, and was glad I was hedgy on frozen.  With more to look at, without all that nasty frozen artifact, there were loose balls of fibrous tissue filling the alveoli and mild chronic inflammation.  An organizing pneumonia pattern, classically patchy - somewhat nonspecific histology findings that nonetheless direct patient care.  In this case there was a clinical scenario that fit like a glove.  One of the things I love about my specialty is that there is quick satisfaction of closure - 95% of cases are turned around in 24 hours.  99 plus% in 48.  But a first glance, without the clinical and radiographic picture to fill in the gaps, can send you down the tubes if you don't keep an open mind.  Things aren't always as they seem.  A wise clinician holds that thought in the back of his or her mind.

Thursday, March 28, 2013

Guest post: Come back when you are ready

Come back when you are ready.

Those are the words that my boss said to me when I called to tell him I was in labor. And he meant them.

My boss is one of the kindest, most generous and supportive people I know. So after 11 weeks I will return to work, not necessarily because I am ready but because it is time. 

Why 11 weeks if I feel I am not completely ready? I work in a small anesthesiology group and know that my coworkers are covering all of the call I normally take. It allows me to start after Easter and start fresh at the beginning of a month. I also took some of my time off unpaid so I could save some of my vacation weeks for later in the year. If only I didn’t have school loans and bills to pay I could have taken more unpaid time off! So 11 weeks it is.

It got me thinking though, when after the birth of a child would I really feel ready, if ever? Would it be when they learned to sleep through the night? Or would it be when they learned to say mama? Would it be after they weaned from breastfeeding? I thought that since this was my second child, I would not have all of the irrational fears of returning to work that I had with my first. My first child in fact did not prefer the nanny over me and is now 3.5 years old and shows no signs of being scared for life because his mom works. I was able to breastfed for 6 months during residency before my supply tanked and I am worried I won’t be able to even get that far this time. So here I sit, one week left of maternity leave having many of those same irrational fears.

I was in my third year of residency when I had my first child. I was blessed to have supportive attendings and an amazing program director. Yet I struggled for a good 5 months before I learned to let go of some of the guilt of being a working mom. I love my profession but I of course love my children and husband more.

This time, my husband is staying home with our two lovely children. He started staying at home with our first as soon as I finished residency. He is making a sacrifice by leaving a job he really enjoyed to stay home for a few years, and I sacrifice by working full-time. It is what works for our family and my sanity.  Like everyone else, I am searching for that perfect life work balance. Depending on the day or week, I think I might have found it. Yet sometimes the mommy guilt rears its ugly head just when I think I have gotten it under control.

So I pose the question to you. When were you ready to return to work after having a baby?

I would like to thank everyone who contributes to this blog. I have been following for over a year now. It has been really supportive to read these posts and see how we are all just trying to be the best moms we can be.  

- an anesthesiologist in a small private practice group with two children under 4.

Monday, March 25, 2013

MiM Mail: An unhappy Match Day

Dear MiM,

I'm looking for some words of encouragement and/or advice.  Match Day was not a happy one here and I am suddenly struggling with the prospect of long distance motherhood.

As a bit of background, I am a single mom of two adolescents.  We currently live in an area where my kids have a strong social and family network.  The kids' dad is in the picture and while he has a spotty track record, he's good to the kids.

I applied to a moderately competitive specialty and tortured myself enough to apply in another specialty as back up.  Originally, I was going to rank the local programs in my specialty followed by the local back up programs. I realized after interviewing, however, that I really really did not like my back up and it was really not for me. I decided to follow my heart and rank my specialty first all the way. I felt that I had a reasonable chance matching in my area.  Well, of course you never know with the match.

Now reality is here. I'm moving. My kids' dad wants them to stay. The kids want to stay. Both sets of grandparents are here.  This is their community. I am going to be working my butt off and don't have much support where I am going. The place is an hour plane ride away.  My heart is so torn.  I would love to take them with me but if I take a step back, I know that would be selfish - not to mention it would cause a huge custody issue.

I am constantly reliving things - should I have framed my application differently? Should I have ranked programs differently? Should I have just sucked it up and ranked my back up higher? A lot of people around me have been giving me the "I told you so" in various forms. My gut feeling is that my program actually fits me very well.  It makes a lot of sense that I matched there, geography aside.  Still, I can't shake how much I've sacrificed for medicine.

In the end, the match is a contract and I am going - at least for the year, if not the next several years.  I have a lot of figuring out to do.  Anyone else have advice or had experience in how to be a long distance mom?

Thanks very much,

Sunday, March 24, 2013

Need a vacation?

Last year, I took a couple of weeks off in the summer to go visit my parents.

It was miserable. Two of my family members because very sick, one necessitating a 2AM trip to the ER, another resulting in an urgent doctor's visit that I had to pay for out of pocket. I probably got an hour of sleep the whole trip. My husband and I fought on the drive in both directions. And when I got back, the work that had piled up in my absence was overwhelming.

This year, I refuse to go.

I've been thinking about taking two half-weeks off, so I won't return to such an overwhelming load. But at the same time, I wonder if human beings need a longer vacation?

Like, will I get completely burned out if I go over a year without taking a straight week off? And what about my kids? Do they need a week off as well? Are a few days here and there enough?

Saturday, March 23, 2013

Update On Baby Not Sleeping: Baby Is Sleeping!

Alternative title for this post: I Take Back Every Negative Thing I Ever Said Or Felt About The Cry-It-Out Method.

A month or so ago, I had written about our thirteen months of sleep deprivation, as our Babygirl was waking up one, two, three times a night for feedings. It was getting so, so hard for me to get up and get through my clinic. We were perplexed by her behavior, as our two-and-a-half-year-old son has been sleeping through the night since he was about three months old. We were becoming pretty desperate in our quest to get her to sleep through the night.  So, I reached out to all of you!

I had asked for advice, but clearly rejected any remote suggestion to let her cry. I had made a feeble attempt at letting her cry once, and she had not only woken up Babyboy, but also vomited, requiring a two a.m. crib change. Also, I hated letting her cry... It felt awful to me.

I resented my friends who said things like, "Well, when you're desperate enough, you'll try letting her cry again," or, "When you guys are ready to really do it, cry-it-out really works."

I had secret conversations with other moms who were also suffering from frequent baby awakenings, talking about how we couldn't understand those parents who could let their kids cry. "How could they be so callous?" we would wonder, sort of smugly.

Hubby and I soldiered on. We tried stuffing her with food and milk before bedtime, in hope that if she was only full enough, she might sleep. We tried wrapping her really snugly. We tried not wrapping her.

Hubby had a few longer work trips. I was on solo baby duty. And with some of my long afternoon commutes,  I found myself even starting to nod off in traffic.

But what finally changed our minds was the concept that as bad as the disrupted sleep was for us, it was just as bad for Babygirl.

I finally got really serious about the sleep issue and started to read about it. I asked our pediatrician, who was pretty matter-of-fact that Cry-it-out was the only thing that was going to work. I searched online, and did not immediately avoid all advice regarding the Cry-it-out method. I actually read that Weissbluth book, Healthy Sleep Habits Happy Child, which is terribly organized, but actually full of good information.

It finally registered with us that we were not doing our toddler any favors by running to her and feeding her multiple times a night. HER sleep was disrupted, too. SHE was not sleeping through the night. SHE was not learning the skill of soothing herself to sleep, which could lead to endless sleep problems, and even anxiety.

THAT did it. I could suffer endlessly if I thought it was for the benefit of my child. But the idea that we were messing her up? No way.

I decided to man up and extinguish these nighttime awakenings.

And so on a random weeknight two weeks ago, after we got her down to sleep, we simply did not go to her when she cried. This was a few days after she had hurt her finger, and she even had stitches. It didn't seem to bother her, so we went ahead with the sleep training.

It wasn't that bad. I thought of it as the same as when she wants something she can't have because it's bad for her, like toddling out into the road, or trying to pet my mom's mean old cat. She cries when we hold her back from those things, but we don't feel bad about it, because we're keeping her safe from harm.

That's how it was that first night. Sort of, oh well, she's crying, but this is what's good and right for her, and so we can tolerate it.

She only cried for about twenty minutes: hard and angry at first, then sporadically, then just a little occasional yell, and then she was back alseep. She didn't vomit, either. She woke up twice more that night, and cried less and less each time.

The next night hubby was gone, and I was determined to continue the training. Unfortunately, she did vomit on her first awakening, and I had to use great skills to get her out of the bed still sleeping, strap her onto her changing table, change the whole crib, and her, and put her back to bed. That sucked, and she still kind of reeked, but hey, she was asleep. She didn't wake up again, either. Nor the next night. Or the next.

We're solidly into a week of full nights' sleep. TWELVE hours. She's sleeping great! We're so proud, of her and ourselves. I'm on an energy high. I feel like I'm on antidepressants.

Thanks to all the advice you all gave me, and:

I Take Back Every Negative Thing I Ever Said Or Felt About The Cry-It-Out Method.

Next step? We need to clean up the bedtime routine for the both of them. Future post: When Your Kid's Bedtime Routine Takes Two Hours, And You've Got Work To Do. Or something like that... I suspect that it's going to involve more crying-it-out. Any advice welcome....

Thursday, March 21, 2013

Guest post: Cardiologist, interrupted

Combining motherhood and medicine is no small challenge. When attaining motherhood itself became the challenge, I felt lost. It seemed as if I was the first MD ever to find herself in this situation. Nobody I knew personally had gone through infertility. Lots of cardio fellows I knew had had pregnancies during their training, and there were even some who had been seriously ill needing frequent medical treatment. But all that just isn’t the same. The overwhelming feeling of loneliness and having no one to turn to for advice in the difficult decisions that needed taking is why I really wanted to do a guest post here. I hope my story can help someone out there navigate the rough seas of infertility and pregnancy loss.

Our story of trying to conceive started when I was 27. I was in residency then, and had just gotten married. I was looking forward to a year of rather cush rotations. I happily tossed my pill in the trash. The first six months were not so bad. We hardly gave it a second thought that I hadn’t gotten pregnant yet. After all, we were both very fit and in excellent health. My cyles were regular as clockwork. It was bound to happen in the next few months. Except that it didn’t.

After a year, we had some very basic testing done. Gynecological exam and ultrasound for me, sperm analysis for my husband. Everything came back stone cold normal. We were back to the drawing board. By then, our marriage was definitely suffering under the strain of TTC (internet messageboard speak for Trying To Conceive). All the temperature charting, ovulation predicting and sex under duress were taking their toll. I was completely micromanaging it all, and my husband told me in no uncertain terms that I was driving him up the wall.

In the meantime, I had finished residency and moved on to a cardio fellowship in a prestigious, somewhat malignant program. In hindsight it was never a good fit. I was the only woman on the service, and the attendings and other fellows were as macho as they come. When I chose to go there, I was completely blinded by the prestige of the place. When I started work, I was told in no uncertain terms that they wouldn’t appreciate me getting pregnant. I just let the remark slide, thinking that it all wouldn’t be so bad if I just worked hard enough.

A few months in, when I least expected it, I realized I was two days late for my period. That had never happened before. I finally unwrapped one of those pregnancy tests we had optimistically bought 18 months before. And yes: pregnant. We were madly happy and naively optimistic. I didn’t announce, because I was afraid of the repercussions. I just double leaded and kept on cathing. I treated myself regularly to sneaking into the echo lab after hours, looking at the tiny flickering heartbeat and dreaming about the future.

When I was seven weeks along, I was rounding the ICU with the whole team when suddenly I felt the worst pain I’d ever had in my life. I ran to the bathroom and collapsed on the floor of the stall. This could not be good. I went over to L&D, where the OB confirmed my worst fear: the little heart had stopped and I was having a miscarriage.

To say that I was devastated is an understatement. I can’t find the words to describe the grief, depression, emptiness and hopelessness of that period. I couldn’t eat. I had horrible nightmares about having to resuscitate my tiny baby. I contemplated suicide to be with my child. I had such overwhelming guilt about staying in the cath lab, thinking my baby died of irradiation. It’s completely irrational, but it took me over a year to shake off that guilt. Physically, I was crippled by anemia after a serious hemorrhage.

When I returned  to the hospital, I was in for a nasty surprise.  Everyone knew what had happened to me through the hospital grapevine. But no one understood. I was expected to pull as much weight as I had before the miscarriage. It didn’t occur to any of my collegues or bosses that I would need an easier time. And I just couldn’t take it, physically and mentally. Another thing that had changed, was that I no longer gave a flying f*ck about anything at the hospital. I lashed out like a wounded animal at anyone who gave me a hard time. Fellows, nurses, attendings, it didn’t matter anymore. I alienated a lot of people during that period.  I wish I could say that I could have done things differently, but I just didn’t have any strength left for diplomacy. My attendings behaved like jerks, and no-one showed the least bit of compassion during the most difficult time of my life. I was so out of it with grief and depression that I couldn’t have done it differently, even if I had realized the consequences at that time.

Several months after the miscarriage, my husband and I had a long talk about the future. We’d been trying to get pregnant again the whole time. It was clear that if we ever wanted to have biological children, we’d need treatment. We consulted with a fertility specialist. He stressed that that the single most important factor determining the chance of success in infertility treatment is the age of the woman. We had no time to waste.

It was very clear at that point what the priorities were. The hospital I was working in didn’t have a  fertility clinic, and taking any amount of time off work for IVF was out of the question. It was time for an organized retreat.

At the end of the clinical year, I continued my training in another hospital. I had rotated there before and knew a lot of people in the staff. Among them were several women, all with families. The group of cardiology fellows was almost 50% female, the atmosphere was pleasant and collegial. This hospital has a large fertility center, and I became a patient there. For the next 8 months we did back-to back cycles. First stimulated IUI, later IVF. The funny thing is that I hardly missed any work time for all this. The other fellows knew what was going on, and they simply covered for me for the duration of whatever test or procedure I had to undergo. In exchange, I took some late shifts for them so they could pick up their kids from daycare. It was a great deal for both sides. Working in this environment made the contrast with my previous place all the sharper. It’s not about working less hard, it’s about not giving people such a hard time about work.

And then, at the second IVF cycle, we got our lucky shot: I got pregnant. I have to admit that I was completely paranoid about miscarrying again. I put the ultrasound probe on my belly for a quick heartbeat check almost every day. I became uneasy when I was away from the ultrasound machine for an entire weekend. I struggled with traumatic memories of my miscarriage. But I’m out of the first trimester now and things are progressing well. Slowly, the sun is coming out again.

The extent of the career damage from my miscarriage-depression didn’t come out until later. I got a lot of bad rep from my previous hospital, and was passed over as a candidate for a job I really wanted because of it. The people I rubbed the wrong way are quite influential. I’ll have to find a new track in my career, where references from those people don’t matter as much. But I don’t worry about it. It’s never too late to reinvent oneself professionally. I’m an excellent cardiologist, and I will land on my feet no matter what. I just had to do the really important things first.      

Tuesday, March 19, 2013

Women leaders in medicine

Last week, I went straight from the hospital to the Washington DC Convention Center for the AMSA National Convention. I was there to receive the 2013 Women Leaders in Medicine Award, along with 4 other women; part of the award reception was a panel discussion on the significance of women leaders in medicine. We had received some questions to ponder ahead of time that the moderator would ask us, and then it would be open to the floor of mostly women medical students.

The award came as a total surprise. I had no idea who had nominated me (nominations came from medical students across the country), but was excited to hear that we would be each introduced and a brief excerpt shared from the nomination letter. I’ve been really proud of my career so far, but after seeing who my co-award winners were and the list of prior award winners (including Surgeon General Regina Benjamin and former CDC Director Julie Gerberding), I was feeling a tiny bit which-one-of-these-things-is-not-like-the-other.

I was up first, alphabetically, and the excerpt mentioned how well I’m able to balance an academic career with motherhood. My internal response: Well, I’m glad it seems I’m balancing it all! I guess it always feels like a work-in-progress to me. It’s always “trying to balance” and not, “Oh yeah! I’m balanced!” But, if I can send a message to others that doing both – having a successful academic career and family life— is achievable, then I’m glad.

The other award winners were Carolyn Clancy, head of the Agency for Healthcare Research & Quality; Sophie Currier, the woman who took on the NBME to allow time during the exam for nursing mothers to pump (she won!);  Petra Clark-Dufner, Director of the Urban Track at U Conn; Laura Tosi, orthopedic surgeon and director of bone health at Children's National Medical Center.

We represented a spectrum of ages and stages in our career, and I think this made the panel discussion richer since we complemented each other. We talked about leadership – how there’s not just one style but a range, and how you need to find the style that works for you. Sometimes, it’s about standing up for what you believe in, despite the consequences. Sometimes, it’s being the first and paving the way for those behind you. But, it’s also about caring for those you lead. It’s about being generous with your talent and time, and putting the needs of the people you lead ahead of your own: to help them grow.

We talked about mentors, and how you need to look beyond the traditional 1:1 model of mentorship – those traditional models are rarer today –you may have many mentors, people who can offer you pieces that will help you with the whole. And, great mentors may be actually peers, perhaps within a few years of you. Don’t be afraid to approach someone you admire and ask them for their advice or time. The worst they could say is no – and we need thicker skin than that.

We talked about challenges as women in medicine, and what we did to overcome them. For some, it was being the first, being a rarity: a female orthopedic surgeon starting many years ago. I thought having children was the biggest challenge I had faced – from  the guilt of leaving work at a reasonable time to catch my daughter before bedtime, to the mania of pumping.  My solution: I wrote about it. I also started MiM to form the community I wish I had around me (at the time, none of my colleagues had kids and didn’t really understand).

One question from the audience was, "Do you have any regrets?"  None of us did in terms of what field we chose to go into, and I didn't think I had any until I remembered one incident where I assumed people knew I wanted a certain position. I was too modest to directly voice my interest in the position, but many told me I was a shoo-in for it, and I believed it would happen. I wanted it to happen. However, I didn't get it, and when I finally had the nerve to ask why, I was told, "You wanted that? Why didn't you ever tell me? I thought you weren't interested." I was devastated. And I learned to be vocal about what I want. If people, your supervisor, those in positions of power, don't know what you want, you're unlikely going to get it.

One woman asked what would we tell our younger selves? I couldn't think of an answer to this off the top of my head, but did remember we did a topic day on this way back in 2008! (See here and it starts a few posts down: The advice we wish we had in medical school; just re-read mine and agree 100%.)

Another asked, "What's the one piece of advice would you give you women entering medicine today?"
Answer: Do what you love. We can’t predict the twists and turns our career path will take when starting out, but following what you love is the way to having a fulfilling life and keeps you going. There were several themes along this line. The room got quiet and I, who had been silent for this question, said, "Marry well." The room erupted into laughter. But, I explained that my decision to marry my husband (sitting there in the crowd, now getting slapped on the back) was the best one I had ever made for my career and otherwise. Without someone in your corner who supports you, who is an equal partner in life, it's going to be very difficult to succeed in both spheres. (I'm not the only MiM who has said this!)

Our last charge was to leave the audience with one final piece of advice. I said, "Follow your passion," which fulfilled the pithy criteria I was thinking was most important, but now looking back, I wish I had said:
We women need to stick together. We need to support each other. We need to come together and celebrate what makes being a woman in medicine special. We need to lift each other up.

Thank you for being here, lifting each other up.

Monday, March 18, 2013

MiM Mail: Go back to the US?


This is an amazing blog. I have been following for many years, since before I was a mommy in medicine. I am not someone that makes friends easily, or even shares a great deal of myself with the friends I do have. This community has been an enormous support to me, especially since the birth of MK (now 1 year old). I have often wanted to write a post, share my story, but for some reason or another it never happened.

A little background about me; I was raised in the United States from the age of 2 and lived there until I came to England to go to medical school. At the time I thought it was a great way to come out of medical school without too much debt (I was born in England so qualified for greatly reduced tuition), and see another part of the world (US suburban living was boring me into a coma). The plan was as soon as I finished I would come back to where my parents and family was, back to the place I have always considered as home. Fast forward to now, I have finished medical school and married to a born and raised Brit with a baby who came as an utter surprise just before I was due to take Step 1. I have matched to an Obgyn program (like residency) in the UK. Obgyn is definitely my calling, and I would find it very very hard to do anything else. This is a seven year program (all the programs here are MUCH longer), and the hospitals I would be rotating through are less than an hour away from where I live. I have a great MIL who lives minutes away and is happy for me to split childcare between herself and daycare. Because I have a small child, I also have the option of working flexibly (3-4 days a week). This would mean taking longer to finish the program and less pay, but the option is there if I need it. Finally, even if I worked full time my schedule would not be as intense as what some of you have often described (typically 8-5 four days a week, 1 12 hour day a week, four nights in a row every 4-5 weeks, 1 weekend every 4-5 weeks).

I see the benefits of staying here and the positives that are offered by the system here. However I still can’t shake the feeling that I should go back to the US. I miss my parents and I feel like I don’t even know my siblings, I have been away for so long ( I do visit every year for at least 2-3 weeks, but somehow our schedules match up for a very small amount of that time) . I always envisioned our kids growing up together, and if I stay that it unlikely to happen. I miss friendly faces. I miss the sunshine in the summer and the snow in the winter (I miss SEASONS). Finally I miss the American attitude, which you don’t really appreciate until you actually leave and realise the rest of the world does not think the same way. In America, people have a can-do optimism that I would love my son to grow up in. I have seen well established people decide to follow their passion at 45 and drastically change careers, embarking on new challenges. There is a mentality that if you work hard, you will get wherever you want to be. I feel this does not really exist in England. Going back however would mean finding time with a young child and part time work to ace the steps, get into a US residency program and then survive it. And then not look back at what could have been?

I am not sure if my dilemma has any basis. I feel this way maybe because I am homesick and nostalgic at the thought of the next seven years and what that will eventually lead to. For all of you that know the American system better than me,and maybe even some of you who may have had experience in both systems, your thoughts and opinions would be very much appreciated!

-From EnMD

Sunday, March 17, 2013

Guest post: Match day

Friday, March 15, 2013.

Today I watched as one by one, each of my classmates was called to the stage and handed an envelope sealed with their fate.  I watched as each opened their letter and read aloud their assigned location and specialty.  Pediatrics in North Carolina. Anesthesia in Florida. Orthopedic Surgery. General Surgery. Internal Medicine. Family Medicine. Emergency Medicine.

It was a parade of suspense and surprise, triumph and satisfaction. One friend summed up her nerves on her way past me to the stage: “I’m gonna puke.” The elation she showed afterward was bigger than the pit in her stomach beforehand.

Another classmate found out that she did indeed match at a program in the city where her husband already resides for training. They have been living several states apart for the last year. Imagine her excitement and relief!

One of the guys got up, said what he applied to and where he hoped to match. He opened his envelope, and matched somewhere else. I could not decide if his face was one of confusion, surprise, or disappointment.

My name was called, and my husband and I walked on stage. I opened my letter, and rejoiced at what I read. These months of angst and waiting are over. I am going into a surgical specialty and have a residency spot at one of my top programs. We could not be happier!

In two months, I will graduate. In four, I will be a new intern, praying that my patients survive despite my inadequacies. I wonder what I will think six months or a year from now as I look back on this memorable day.

Melanie is a wife, graduating medical student, future resident in a surgical specialty, and hoping to be a mom someday.

Thursday, March 14, 2013


Yesterday I worked with one of our part-time attendings.  She had two cases scheduled.  The first went smoothly.  It was a bit complex and atypical of an operation but it went well and the patient did well. The second case...different story.

Back story: This attending is a part time surgeon, an enigma that you hear about but never see.  She became part time after her second child was born and I've been told I should get to know her ever since my daughter was born.  Now, I've finally gotten the opportunity to work with her.  Mom surgeon mentors are still still nearly impossible to find, especially those that are relatable.  She is a regular person - her husband isn't independently wealthy, she doesn't have 4 live-in nannies and a stay at home dad, she is a regular person, awesome surgeon and a mom.  With a bit of timidity, I've had the occasional opportunity to pick her brain about her career choices when I've taken call with her and she's been an amazing resource.  I also know that she recognizes the career advancement sacrifices that come with her choice to work part time.  She seems a little frustrated by the trade-off but not at all regretful.  

Back to the present: Ok, second case, she decides to try out a different approach she read about to increase exposure.  Unfortunately the change in the approach makes some parts of the operation a lot more difficult.  However, we press on.  Then we hit a key part of the case where a structure needs to be identified to ensure that it isn't injured, and we just couldn't find it!  She called for back-up.  I hear her mutter under her breath: "Can I just get through one case without asking for help!"  One of the senior surgeons came in and helped out.  The remainder of the case proceeded with continual second guessing her every move - "does this look right" "I think I'll go here"  "do you think this looks okay?"  She was reduced to what I like to call 'resident uncertainty.'  We finally finished.  All went well, the patient was fine, the final result actually looked great but I could tell she was defeated. She apologized to me at the end of the case.

Its not uncommon that attendings help each other out and scrub together.  Its one of the things I like about the group of surgeons at this hospital.  I tried to tell her I thought the case was fine that no apologies were needed.  But, I could tell she was disappointed in herself.  I wanted her to know what a great teacher she is, what a great role model she is to her residents and her children.  I wanted to remind her of how her patients gush about how amazing she is.  This attending trained at my institution and I have literally NEVER met a single person - faculty, resident, nurse, administrative staff, who had anything but extremely positive comments about her skill and her judgement.  I wanted her to know that I have operated with senior surgeons who have come to work every day for the past 20 years and still occasionally need to call in back up.  When I think about the two cases we did that day, I think that there are two people that may no longer have cancer because of her.

I read an article recently about how motherhood completely and utterly changes your life.  No matter what you have invested in your career prior to having children, being a mom will profoundly change your career and who you are and every decision you make.  This is so true.  I feel like I'm struggling with it every day.  Fulfillment in two places, work and home, often at odds with each other.

As she walked out of the OR my attending told me that she was on call tomorrow night and that unfortunately I would be stuck with her again.

My response ..."It would be my pleasure"

Tuesday, March 12, 2013

the world's longest adolescence

I've been undergoing more frequent bouts of financial incontinence of late. I bought five sweaters in a recent end-of-season sale and a side table from Serena and Lily that is made of carved wooden swans. My husband describes this purchase as the Most Ridiculous Thing We Own. 

I can feel the end is in sight. I am almost done with my training, after which I will be making several times more money than I ever have before.  

Saturday morning I went to a financial planning seminar for graduating medical residents and fellows. After a brief introduction, the speaker guided us through a program he had developed specifically for medical trainees to calculate exactly what income was required to develop and maintain the life we projected to lead with our future salaries. 

I don't know what my salary is going to be next year. I am looking at positions that vary over $130,000 between them, adjusted for part time vs. full time, and private vs academic. So I entered a figure somewhere in the middle. It's even more difficult to project my husband salary as he owns his own company with a salary that varies month to month. He's gone months without a salary at all, which I've always thought taught us to live beneath our means. 

Beneath our means, but perhaps not beneath our expectations. 

It took about 90 minutes to complete the program.  There were a few numbers I didn't know how to estimate - like the expected rate of inflation and expected rate of return on our investments. There were some shocks along the way - the projected cost of a 4 year state education for my 1 year old son is $360,000 if tuition costs continue to climb. I entered the tuition cost for two kids at the most expensive elementary and high schools in the city, the cost for two weddings, and my medical school debt. I figured in the cost for a standard 3 bed, 3 bath house in our community with a 20% down payment. The program included costs I hadn't thought of before, like the cost of an accountant, orthodontia x 2, and home owners' insurance. It calculated the estimated yearly expenditure of feeding and clothing two kids. I felt pleased to enter the amount we've manage to save in retirement and savings accounts. 

I got to the end.



That's the amount of yearly income we lack in order to meet what I thought were fairly modest goals. 

I've heard medical training as the world's longest adolescence. I've never felt it to be as true as I do now, starting down the last few months of my training and still uncertain of what I am going to do next year. 

After a collective gasp, our speaker smiled and admitted to a slight "glitch" in his program - while the program took into account the rate of inflation, it did not adjust the physician salary for that rate of inflation. In other words, the cost of every itemized expense would go up, but our purchasing power would go down with time. 

That didn't seem right. Of course my salary would go up, perhaps to cover the gap between the estimated salary and the projected cost of our lifestyle. And then he made what I think was the most striking point of the presentation. The partners he left in private practice anesthesia in 1993 are making the same salary now as they were 20 years ago. 

OMG x 2. 

It is unlikely that physician salaries are going to go down, but it is highly likely that, with the restructuring in health care underway, salaries won't go up with inflation. I've heard that said before but didn't think too much of it. Now seeing a dollar amount placed on what had seemed like conjecture has given me pause. And in that pause seeped a now recurring frustration. 

How is it that I started med school a few short weeks of my 22nd birthday, I will graduate when I am 33 and I still can't decide what I want to do next year? What is in the best interest of myself, my family, and the longevity of this career I've been working for since I was 21? 

During my ongoing job hunt, I received the unwelcome advice to "not make any decisions based on money alone", which does seem like sound advice and in keeping with the best interest of my young kids, who would benefit from a mother who is around more, and my career should I decide on an academic path over the more lucrative private route. But in that room I started to re-appraise the relative benefit of the options ahead of me. If I work part time in academics, does that mean my kids don't go to college?

The exercise served to broaden what had been a frustration specific to not knowing myself to include the more generalized frustration that I don't know anything

And it put to rest any lingering consideration I'd had on the idea of a third child. 

Monday, March 11, 2013

MiM Mail: Refusing the bottle!

Returning to work from an 8 week maternity leave has proven more stressful than I thought but for a reason I didn't anticipate!

I'm currently a second year internal medicine resident and welcomed my first child into our hectic world 8 weeks ago. I was all set to return to work (but more time is always be better) ready with my pumping gear and planning out a loose schedule to hopefully make pumping work. I missed the chaos of inpatient medicine but thankfully, I've been eased into my return with an outpatient block but will have to cover a few random overnight calls in the next 2 weeks. As I'm sitting in my office pumping and texting back and forth with my stay-at-home full-time husband, we realize that our LO is refusing her bottle!! We did trial runs prior to this day and she happily took the bottle from her daddy but now she either plays with the bottle (even with her hunger cues) or flat out spits it out and then cries. He has tried many different tactics (different room, walking, holding her different positions, not waiting until too hungry, having something close to remind LO of her mommy or taking it away, etc), and we've discussed our situation with a lactation consultant who offered some additional tips. LO finally took a bottle once while relaxed in her swing after a short nap but struggled with the next feeding. She used to make wet diapers early AM/late night when I was home to breastfeed overnight but this has dropped off during the day. So far (it's only been a couple of days) she's still happy and playful in between her naps. Of course I nurse as often as she wants when I'm home but this makes me nervous as my days can be 14-16 hours long when I'm not on overnight call. This of course brings up the times when I'll be at the hospital 28+ hours. What will happen if she's still refusing the bottle? I know some people will say if she's hungry she'll eat from the bottle, but I don't completely buy that line of thought and she can't make up a whole day's worth of not eating in a couple of feeding sessions. She's not breastfeeding anymore than usual when I return home right now. I'm hoping she'll take to the bottle again, but I wonder if anyone else ran into this challenge.

Thanks for any words of wisdom and support.

Thursday, March 7, 2013

Birthday FAIL

It's my older daughter's birthday tomorrow.

At her daycare, they do a little party for them during snacktime at 3PM. I bring in cake in the morning and everyone sings, and if you're the mom watching, you get little tears in your eyes.

Last year, I happened to have the day off, so I went to the party and then brought Mel home afterwards. This year, it didn't work out that way, but I was still hoping to go to the party. I work pretty close to the daycare, so I could have easily slipped out, gone to the party, and then gone back to work. But I know from prior experience that if I show up at daycare, Mel will not let me leave without her. I don't want to make her cry on her birthday.

After much internal debate, I finally asked my boss if it would be all right if I brought Mel to work with me for a couple of hours, and she'd be totally quiet and good. "Oh God, don't bring her to work," my boss said. "Just go home after the party. It's okay." (My boss is a sweetie.)

So I was all set, or so I thought. But then several things happened, including that my census of patients exploded and I can't reduce my list without begging other people to see my patients, which I really hate to do, especially considering Friday is generally a busy day. I also stupidly scheduled a doctor's appointment for today, which means I can't stay late today either.

And then I got a call from the scheduler for my clinic, asking if I could add on a couple of extra patients for Friday.

I am beginning to feel like I am doing too much to make it to this party. I am calling in favors, inconveniencing other people, canceling appointments, all just to make a 15 minute party. She probably won't care if I'm there anyway and we're having a regular birthday party on the weekend. I should just accept that it isn't going to happen.

But then I think to myself: this is WHY I took a flexible job, so that I wouldn't miss special moments like this. If being there for my daughter's birthday party isn't high priority for me, then I feel like my priorities are screwed up.

It's hard being a working mom.

Wednesday, March 6, 2013

Mental Yoga

My yoga teacher, of 1.5 years, is taking a hiatus.  Jeanie is 60+ years old and she is much more flexible than I.  She looks like a white version of Tina Turner - lithe body and blond spiky hair.  She and her husband are going to Russia for 18 months on a mission trip.  Last Tuesday was her last night teaching my class before she left.  While we were in corpse pose at the end, she told her favorite parable, one about an eagle raised with chickens - who finally learned to fly with the coach of a naturalist.  As her soothing voice and wisdom flowed through my ears, silent tears streamed uncontrollably down the side of my face.  "We are all eagles, constrained in one way or another by our surroundings, but we all have the capacity to fly."  She gave me a big hug as I rushed out the door to pick up my kids from their dad and stepmom's house.  I told her I would miss her, but I'll bet I'm not nearly as sad as her family.  She told us when she leaves she has 22 grandchildren, and when she returns she will have 25 or maybe 26.  Much of her stories and experiences are family centered, she is one of the most grounded and knowledgable individuals I have ever met in my life.  Russia doesn't know how lucky they are.

The other night I was e-mailing my friend.  She was discussing an issue she was having with her daughter - stomachaches.  They seemed to be school related, so she was worried they were stress, but also not wanting to miss something medical - she was researching reflux.  I told her that my daughter was having some big time stomach issues around the time of my separation and divorce.  While the pain was certainly real to her, I could see that it might be an outward manifestation of inward turmoil.  My stress has always gone to my stomach, ever since I was a little girl.

I told my friend that I had taught Cecelia a relaxation technique that I picked up somewhere along the way, in high school I think.  One night at bedtime, I told her to lay down and practice breathing in through her nose and out through her mouth, like a type of yoga breathing.  As you breathe in through your nose, imagine a healing color filling your body, focusing in on the area of pain.  I use bright white light.  As you breathe out through your mouth, imagine you are expelling the pain as a color of your choosing - I use red.  I think the slow breathing is the key, and giving a concrete aspect to it, the color, helps you feel that you are in control of your body and have the power to soothe yourself.  I told Cecelia to take it with her and use it throughout the day if she needed it.  It helped her.  I still use it on occasion - my stress continues to go to my stomach.  If my friend uses it, I hope it helps her eight year old daughter.  If it doesn't, she can continue to problem solve medically.

There are many things I use these days as mental yoga - blogging right now, for instance - this is a busy, stressful week and writing is therapeutic for me.  Yoga and exercise also help.  Listening to music.  Reading.  A glass of red wine.  I pass these onto my daughter and son (except the wine, ha ha), and hope that they can learn to relax and soothe their body and mind in a healthy way.

Last night I went to yoga for the first time to meet the new teacher.  After a three mile run and watching a recent Colbert re-run, I had to fight my inner two year old who was throwing a tantrum telling me to stay home, Jeanie's leaving sucks, no one can replace her.  I quieted the tantrum (Jeanie's voice in my head helping me), grabbed my yoga mat, and met Matt, the new guy.  He is young and is very different, with his masculine energy.  A clipped voice and a different style.  I am going to be sore today in a whole new way, and was more tired than usual after yoga.  I'm still sad that Jeanie is gone, but I'm also excited to explore new heights and stretch new limits on my body and mind with my new teacher.  After all, yoga is a process, not perfection or competition.  Who knows, this guy could teach me a thing or two.  

As I am writing this, I am wondering what other techniques people use to calm their children and themselves, especially along the lines of relaxation.  I would be curious to hear suggestions in the comments if anyone has any.  While Cecelia's stomachaches around school abated a couple of years ago, every new age and stage of life brings frustration and anxiety; we problem solve pressures from school and society on a weekly basis.  Jack is a more laid back fellow, but he has unfulfilled wishes and desires, as we all do, that weigh silently on his mind.  We have lots of fun too - we are not all seriousness here, but we could all use more mental yoga.

Monday, March 4, 2013

MiM Mail: Time to hang up the stethoscope?

I am more and more convinced it is time for me to hang up my stethoscope.  I am a busy family medicine doctor practicing outpatient only family medicine who is increasingly longing for more time at home with my children.   I currently have two young children with one more on the way.

But I am scared, to actually make that plunge.
Scared to leave (what if I want to come back?), scared to leave the income (yes, I know FM doc's do not make anywhere near specialists, but my income allows us a very comfortable lifestyle but we do not depend on it), scared I might get bored being at home full-time, scared what the next step holds for me.  I often dread looking at my schedule, another day of people complaining to me all. day. long. and what seems like endless patient emails and phone calls to answer after listening to all the complaining.  I have always felt it a gift to share in peoples lives, but after doing this for 10 years, it is frankly boring.  I never thought being a family medicine doctor would be boring, but honestly, it is. 
Anyone else experience this?  I am a positive and upbeat person (my glass is always half full no matter what the situation is) and I wish I loved my job more but maybe that is unrealistic.  Maybe a job is just a job, no matter what the profession is?  
I already only work 3 days a week and the "firm" does not allow doctors to decrease any further so that is off the table.  
-Doctor to many, mom to almost three