Monday, December 30, 2013

MiM Mail: To be a stay-at-home mom or not?

Dear MiM,

I am an OB/GYN in East Texas and mother of 2 boys 9y/o and 3months.  I recently discovered your blog and am delighted to find a place where real women are having real discussions about the challenges of this balancing act. 

My question is have other MiM taken a break while their children where small 2-3 years and then jumped back in?  What challenges did they face?  Any regrets?  In my specialty I fear the "re-entry" - being given a chance by employer and gaining patient trust.  I have worked hard to be where I am and love what I do but given an option to stay home with my children for a few years and I find my heart screaming yes.  Am I over thinking this?


Saturday, December 28, 2013

How motherhood changed my medicine

Better late than never.  Here is my post from topic week on how medicine has changed me...

I've been trying to think of what to write about for this topic week.  How has medicine changed me? I found myself at a loss.  I have been on this journey for SO LONG.  Medicine has grown with me more than changed me.  Then I thought to the one singular occurrence in my life that has changed me the most ... hands down motherhood has palpably and incomprehensibly changed me more than I could have ever imagined.  As a result, after reflecting on how medicine has changed me I really felt compelled to write about how motherhood has changed my medicine.

Here are my thoughts:

- Motherhood has given me an honest compassion that is different than the compassion I had before.  I find it hard to explain, but it is simpler and more organic.

- Motherhood has given me a more zen-like patience with which to approach the craziness and chaos of medicine and residency.

- NICU nurses like moms more than surgery residents ;)  I used this to my advantage and as a result, loved taking care of my NICU babies.

- My priorities have shifted.  My goals are similar, but now they must fit into a different version of me.

- I can't do it all and I know it.  However I will still try.

- I prioritize my time at home and at work with crazy efficiency.  I definitely think the constant balancing act has helped me in being a chief.

- I love sharing my life with my daughter, therefore while at work I am even more motivated to make it count for something, to "help people" as she tells me, to heal, to learn, to affect change.  She has inspired my medicine in ways that make every struggle of motherhood well worth the gain in every aspect of who I am.

Happy New Year.  Here's to motherhood and medicine.

Thursday, December 26, 2013

MiM Mail: Deciding between residency programs

Dear Mothers in Medicine,

I've been an avid follower since the beginning of medical school, and am amazed by the amount of wisdom and advice that passes through. I'm currently a 4th year who is struggling with deciding between residency programs, and was hoping for some much needed advice.

I'm applying for PM&R programs, but applied to a limited area since my husband is a graduate student, and has a few more years of training left in the city where we live now. We met in high school, and had a long distance relationship in college, which was very difficult for both of us. We decided that we would never do that again, and made staying together a priority. We both compromised for medical and graduate school, and went to a city where we could stay together, even though the programs weren't otherwise our top choice. For residency programs, I decided to apply to the surrounding area, because I couldn't stand the idea of being separated.

I'm lucky in that there are a couple of PM&R programs in the city where we live, and a few in a city that's about 2 hours away by car, and an hour away by train. I'm currently struggling with my rank list - I love the programs that are further away, but it would require us moving in between the two cities, and each commuting an hour to 1.5 hours each way, or me taking public transportation, which can take up to 2.5 hours, taking into consideration waiting time for the train and delays. Fortunately I have a friend in the city that I can stay with on the rougher days. Since PM&R has pretty reasonable hours, and I would theoretically study on the train, I'm trying to convince myself that it wouldn't be so bad, but I'm having my doubts.

None of the programs that I've applied to are considered the very top residency programs for PM&R. However, the programs that are further away are better known, and I feel like I would get broader exposure and better teaching from the attendings. My main  question is - how much does the reputation/quality of the program matter in the long run for jobs and fellowships? Obviously there are requirements that have to be met for every residency program, and I've heard from many people that what you put into a program is what you get out. Could I get the same out of a higher quality program as I would out of a lesser known and weaker program, where I put in a lot more effort to self study and seek extra exposures?

Of course it would be easier to stay in the same city, where we have a house and are already settled. But I can't help thinking about the programs that are further away, since they seem like a better fit. I'm afraid that if I decide to commute for the programs that I like better now, the commute might take its toll on both of us, and I would end up regretting it in the end.

I've been agonizing over my rank list for a few weeks now, and still have no idea what to do. Any help would be much appreciated!

Thank you,

Stuck Between Two Cities

Monday, December 23, 2013

Guest post: I do not want to be a vacation parent.

I will preface this blog by saying that I feel very lucky to work at the academic medical centre where I landed right after residency.  I love my clinical work and my education leadership roles. Mostly, I have good support and reasonable bosses. I try to keep all these happy thoughts in mind as we go through the painful process of developing an accountability framework in my large department. Generally, I succeed. I am 100% in support of the major requirements, which boil down to: please do the work you’re paid to do, and provide the people who pay you with some evidence that you’ve been doing that. Sounds good.

At a recent meeting, though, a seemingly minor comment about a seemingly minor clause made me quite upset. In this agreement, a small amount of income will be “at risk” if a departmental member is not deemed to have participated in sufficient departmental activities. Fair enough. However, this requirement includes a certain percentage of rounds held early-ish in the morning (not surgeon-early, but early). The comment made was: “We tried to be sensitive to family needs when planning the timing of these rounds ….  But there are also __ weeks of vacation, of course.”

There was no discussion about this. Introvert that I am, I needed to process this. Weathered faculty member that I am, I knew to shut up while reacting emotionally, until I had time to process my thoughts. They’ve been processed. They’re still emotional. They follow.

I do not want to be a vacation parent.

My husband spends many more awake hours with our 5.5 year old son than I do. As a full-time student, his hours lend themselves to this - he picks the boy up from school and actively parents the kid for a few hours before supper.  I work hard to get home for 6:30 p.m. so we can eat together. I enjoy the 1.5 hours before bedtime where I’m in charge of glockenspiel practice, speaking French (a.k.a “homework”), and then we share bath/bedtime duties. In the morning, I am in charge of the Mandatory Morning Cuddle (there are far worse jobs), and then we have a typical “get everyone out of the door” scramble together. In there, I head off to work just as the boy leaves for the bus.

If you do the math, on weekdays I see my child awake for a grand total of about 2.5 hours daily, at most. When I’m on weekend call, I am at work for about another 4 hours both days, which is minor compared to many, but does mean I miss my share of skating and swimming lessons. Most weekends I work at home for at least a few hours, though I try to do these while he is asleep, but this isn’t always possible. I do not complain about these hours. Compared to many physicians, they’re light. They are what I signed up for, and I believe they are fair.

However, if I add in more morning rounds, I’m incrementally cutting into the time I parent the boy on a daily basis. On days where there are mandatory morning meetings, my son may not see me at all until 6:30 p.m., as I usually need to leave around the time he gets up. These are mostly ad hoc meetings, so I don’t complain (much). Twice weekly rounds start to add up quickly – two days a week of no Mom in the morning.

I do not want to be a vacation parent.

This is really the crux of what bothered me. How is it acceptable to declare “you get lots of vacation time” (for which I am grateful) as a rationale for “parents should have no excuse not to attend these rounds”? At what point is it appropriate to expect parents to not be present in the day-to-day lives of their children, for the sake of non-patient-care activities? I realize that there are many other very valid non-parenting reasons why this might be problematic, but this was a direct comment about parents not wanting to attend rounds at the hours chosen by the Department.

I do not want to be a vacation parent. I want to be present in the day-to-day mundane activities of my son’s life. Believe it or not, I want to be part of the mornings where he is grumpier than a bear, and he has a meltdown because his socks don’t match his jeans. I want to be there to help with the snowsuit battles. I want my mandatory morning cuddle, dammit. I want my son to go to bed at night and know that I will be there in the morning. We worked hard to achieve this balance, and it works for us - well, it works more often than not – what more can we ask for?

It is (almost) irrelevant that I don’t learn well in lecture-based rounds, and that I have to travel more to get to and from these rounds than most in that they are not held at my home hospital. It’s (almost) irrelevant that I participate in teaching activities significantly more than most of my colleagues, so my departmental contributions are considered to be quite high overall.

Clichéd as this might sound – it’s the principle of the thing. Going on vacations with my child is not the same as being there daily. I’m quite sure my kid would forfeit our family vacations in exchange for both his parents being present daily. I would. My bosses may have the right to require me to work different hours, but let’s not pretend that it’s not a problem for families because “there is vacation time”.

So, a portion of my income may well be at risk. Currently, I’ve decided they can keep that if they like. I will cope with the consequences of my dereliction, because I cannot put a price on my Mandatory Morning Cuddle.

I do not want to be a vacation parent.

Thursday, December 19, 2013

On having an au pair

After doing daycare/preschool exclusively for a time (when we only had my daughter), a live-out nanny, and a live-in nanny at various times, we went the au pair route 1 1/2 years ago and couldn't be happier. It's just what our family needs right now. I wish I had known more about it earlier on, since it may have made life easier and richer back then. People may have had different experiences, but here's ours.

We've had two au pairs so far, and both turned out to be great matches for our family. The matching process reminds me a little of residency matching, but without the rank list. You search through au pair profiles, filtering by what's important to your particular family (maybe a strong driver or experience with taking care of multiple children or a particular religion), can read a "personal statement," watch a video they made to tell you more about themselves, scan their letters of recommendation, and their childcare experience. You can select  au pairs to interview (via Skype generally) and have a certain amount of time to render a decision whether you want to match with the au pair. The au pair must accept the match as well, and you agree on an arrival date.  It was a bit unnerving to select our au pairs, not knowing exactly how it would turn out in the end - would she like living with us? Would we like living with her? How would she be with the kids? Like residency matching, you go a lot by feel of a program and projected fit.

What we didn't anticipate was how much our au pairs would be like family to us. They have launched out on their own, excited to see the US - everything is new. You are their host mom and dad, and it does feel a little like that - parental and guiding, showing them the ropes and helping them have a good experience in a new country. Our au pairs have been from Mexico and Brazil; we've learned about their countries. Last year, I made a Mexican Christmas dinner with our au pair at the time N; this year Brazilian.

N was with us for only 6 months. This is not typical. The contract is for a year. However, N's family needed her back home; a family member was ill so she had to break her end of the contract and our au pair company arranged for us to match with someone new. M, from Brazil, has been with us for almost a year. We love her. The kids love her. She loves being here. She's extended her contract for an additional year (the maximum possible) which is great news. There's a ramp up period of about a month when they first arrive for driving lessons, figuring out routines, roles, etc, so having her want to stay longer is a huge plus. Meanwhile, we keep in touch with N who writes me occasionally and updates me on her career and relationships. She's getting married next year and has invited our family to Mexico for it. It's kind of like a mentor/mentee relationship.

In November, M's mom and her mom's friend came to visit, stay with us and travel. They were here for an entire month. This included a trip for the "Brazilians" as my husband and I nicknamed the trio, to Europe for 9 days and a weekend trip to NYC, but otherwise our house was full of warmth and Portuguese  for the remainder. It seems kind of crazy that we had all of these people in our house, but to tell you the truth, it was really nice to have them here. They are such sweet, wonderful people who were the perfect house guests. They made dinner for us all a few nights. We miss them.

An au pair's hours have certain restrictions; they can provide a maximum of 45 hours per week. With our youngest in half-day preschool, this gives us a chance to have a date night each week or coverage on the occasional weekend day I have to work. She picks up the kids from school, drives them to their swim lessons, gets them bathed. We juggle the days and hours when there is an unexpected snow day or sick day. That flexibility has been key. You have to have space for an au pair to have his/her own room and be okay with someone living with you.

I remember one day, during M's first months, she was Skyping with her family in our living room. Her family - her mom, dad, brother, and brother's girlfriend were all there on the screen saying hi to our kids. I looked over at the screen to find all of her family members on the computer screen with their two hands forming the shape of a heart on their chests, and my children mirroring them on our side. I thought:  this is such a good thing.

I drove M's mom and her mom's friend to the airport when they left; I hadn't realized the impression we left on them. They vowed that they would start some traditions back home since they enjoyed them so much while they were here: having wine with dinner each night and listening to classical music. And even though they said their thanks solely in Portuguese, I saw in their eyes what they meant.

We started a tradition last year of including N in our Christmas card photo with the family. This year's card has us all sitting on our local high school bleachers, each of the three kids on our laps - me, my husband and M. This will help us remember the years when our family was a little bit bigger. M cried when she saw the card for the first time, to be included. We couldn't imagine it differently.

Tuesday, December 17, 2013

MiM Mail: Babies and money

Dear MiM,
I have been following this blog since before starting medical school.  It's been so great to be able to draw from your experiences, and to know that it is possible to make family and medicine work (even if it's a little rough).  I am a second year medical student getting married in June. My fiancé is a wonderfully kind, caring person who is more than supportive of my career goals in every way. I'm trying to figure out the whole first kid during training thing and I'm wondering if any of you have advice on how to make it work financially.
My fiancé (F) and I have been under a lot of financial pressure since I went back to medical school, largely due to the loss of my income and the fact that I am currently in repayment for several private loans from undergrad (I could be the poster child for the student loan bubble, and no, they won't let me defer… even though I'm in school).  The thought of having a kid in medical school didn't even occur to me because we can barely afford our dog's vet bills, much less a baby.  Well, lucky us, F got a pretty significant raise, and now we are looking at having a pretty livable income, and the first thing that popped into my head was, "Awesome!  Now we can try to have a baby during M4!"
My concern is this: We are only just getting to the point where we don't hit 0 in the account every month.  F works in fashion production/photography, so while I know he will most likely be able to work from home some of the time, there are days and weeks where his schedule looks worse than an intern's and is probably more unpredictable.  This, of course, means we'll need to work out child care.  Unfortunately we live in Westchester, just outside NYC, so everything is more expensive: rent, car insurance, food, and (I'm assuming) daycare.  We do have family support (his entire family lives near by, including his sister who is a stay at home mom and great with kids) which is great for emergencies, but I feel like we would need to have something in place for the regular day to day. 
For those of you that had kids in med-school/residency, how did you budget?  I know if I wait until residency, childcare will be a lot easier to pay for because we'll have a second income, but I also like the idea of having a little more time with my first born, and being pregnant during what will probably be a comparatively docile year  (especially since I'm thinking I want to do OB GYN).  While all of that sounds great, I don't want to get myself into a situation where I'm not able to do what's best for my child because I didn't adequately plan ahead.

Monday, December 16, 2013

Healthy, nutritious, and delicious to a 2 year old?!?

It is pretty darn hard making food that is healthy and nutritious when you are working 80 hours a week in the Neonatal Intensive Care Unit (NICU) or 50 hours plus commuting in clinic. Add to that the eating preferences of a 2 year old and you have very stressful situations at least several times a week.

Before, I get into what has worked for us, I raise a question to my fellow MiMs and readers: what has worked for you? Please share recipes, links, prayers, spells, themes or anything else you have found useful. 
With the ever rising obesity and dental caries epidemics, O and I are always trying to provide Zo with healthy options. When I have patients in clinic with body mass indexes (BMIs) consistently over the 70th percentiles and disturbing rates of weight gain, and the parents report the child’s favorite foods as “pizza and chicken nuggets,” I cringe. I know it’s hard to get your kid to eat what they need, but it’s worth it, their lives depend on it. And as a doctor, and especially as a Pediatrician, I make it my job to practice what I preach.

Here are a few of our favorites here at the Beehive:
- we prepare what we want to eat (tuna salad, stir fry, slow cooker beans and rice, chicken noodle soup, etc) and then we chop it up, add a bit of cheese, pan fry it on a tortilla and make a toddler-friendly quesadilla that Zo can dip into his favorite Trader-Joe’s garlic-chipotle salsa
- breakfast: greek yogurt with raisins and honey, oatmeal with raisins and molasses, handfuls of raisins (theme = Zo loves raisins)
- lunch: turkey sandwiches with baby spinach, hummus with crackers and grapes
- anytime: hummus by the spoonfuls, oatmeal, Greek yogurt
- when all else fails: his favorite smoothies (said by Zo as a “I want smoo-deeeeee”) option 1 with ripened frozen bananas, a few apple/pear slices, a heaping handful of spinach, milk/ice, and a drizzle of honey or option 2 with ripened frozen bananas, 2 heaping tablespoons of organic peanut butter, milk/ice, ½ cup of raw old-fashioned oatmeal, ½ teaspoon of cinnamon, a splash of vanilla

Hope you enjoy some of our favorites and I look forward to hearing what works for you.

Friday, December 13, 2013

Topic week: How has medicine changed you?

Welcome to MiM Topic Week on our reflections on how our chosen profession has changed us (or not). Throughout the week, we'll feature posts by some of our regular writers and readers on this topic. In the past, we've had topic weeks on everything from work life balance to metablogging (blogging about blogging) to a day in the life. See the sidebar for others.

Scroll down to see the posts. Thanks for reading!

For the better and for the worse but mostly for the better

How has medicine changed me? The honest answer is: for the better and for the worse. Let's start with the latter.

Before medicine, I inhabited time slowly.  I spent a lot of time writing, a lot of time reading, and a lot of time engaged in no task in particular. I would make a salad with a friend and then eat it with her and then linger over the empty bowl talking about love and then seven hours later get up to make dinner and start over again. Before medicine, stories were as much about the how of the telling as the content. I loved words. I loved spending time with friends. I walked and sometimes even ran. I meditated. My memories from before medicine are of a particular way the light used to fall on the floor in the afternoon, of sitting at the kitchen table in the middle of the night reading a novel and crying at its beauty, of falling in love. Whatever work I was doing at a particular time was not what defined my life. It was never a day off or a day on, it was just a day.

Now I can never seem to have enough time. I am always behind on charts. There are always at least two more patients on the board waiting to see the doctor, both literally and figuratively. I am always aware of time. If I am off, I am aware of the need to take full advantage of that. Am I using my vacation time efficiently enough, I wonder? Am I relaxing enough? When I am on, there is the pressure to see patients faster, discharge them faster, order their antibiotics faster, think faster and talk faster and faster faster faster. When my formal work day is over, then there is the research work, the studying and reading, the charts to finish. I am no longer able to be at peace with time. There are too many people who need too many things! When I listen to a patient tell a story, I am waiting for the details to click into place that will allow me to identify their disease. Though I wish it were otherwise, I am not always really listening as they describe the dinner they were eating the night before the symptoms started. I am typing the things they have already said and waiting for the salient details to arrive: When did the pain start and where? How many times did the child vomit? Oh, a few days of cold symptoms and then barky cough and noisy breathing? Croup! Done! The story can be reduced to a sentence. I used to be a poet, enamored of the space between things, now I am a master of pattern recognition. I used to appreciate good novels, now I appreciate good historians, patients who can recall a sequence of events in roughly chronological order, people who have an innate sense of what is important and what is not.

Now for the better: Before medicine, I was anxious a lot of the time. Scared of public speaking. Scared of illness and death. Scared, ironically enough, of hospitals. I remember as a child seeing an elderly person in a wheelchair at the park vomiting into the bushes and feeling weak with a kind of existential nervousness about what life might bring. I took a long time to make decisions, worrying over the potential consequences of a wrong choice. I didn't like novelty. I didn't like surprises.

Now I can walk into a room with a child who is gasping for breath and it is still very scary, but my adrenaline translates into action. For me, it turns out that the drive to help a person who is suffering is stronger than fear. Medicine has organized me around a purpose, and even when that purpose feels daunting, exhausting, or completely impossible, I just do it. After presenting on rounds hundreds of times and being asked hundreds of questions publicly to which I didn't know the answer, I am able to accept that I am a work in progress. I used to worry what people would think of me if I made a mistake. Now I worry what will happen to patients if I make a mistake, and that change has been profound. I still worry a lot, mostly over the things I did or failed to do for patients, but this kind of worry makes me better at what I do. I am still afraid of illness and death, but I understand in a way I could never have understood before that these things are the way of life. When they find out I am a pediatrician, people often say, "I could never be around sick children. It would make me too sad." And I think to myself, "Someone has to be with those children." Children get sick, children die, and creating distance between ourselves and that reality does not change that reality. Medicine has taught me how to be strong for other people.

Sometimes it is hard to remember, or re-enter, the world of everything else, by which I mean the world in which things are happening that are not related to how the heart and lungs and kidneys are functioning. When I go to a performance or concert now, sometimes I have an intrusive thought about what I would do if the performer collapsed, if they were pulseless and needed compressions, if they had a seizure. In the midst of watching a person accomplish an incredible act of beauty or physical agility or creativity, I find myself mentally reviewing the ACLS guidelines for cardiac arrest or wondering if the venue has an automatic defibrillator and if so, where. I have trouble relaxing out of the life of the body and into the life of the mind. For me, beauty used to be the highest calling. Now I just want to make sure that everyone makes it through the night. I have to fight the impulse to turn to whoever is sitting next to me at the show and whisper something along the lines of, "Don't you realize our bodies could fail at any time?!" Then I have to remind myself that there is more to living than maintaining physiologic homeostasis, even if nothing would be possible without it.

To summarize: I feel less and do more. I spend less time contemplating and more time problem solving. I am both farther away from and closer to life. I miss the person I once was and am proud of the person I am now. Maybe one day, when my own journey in a body is nearing its end, I'll return to the light on the floor in the afternoon and the spaces between things and the lunches that turn into dinners. In the meantime, I am going to work on getting better at taking care of sick children and will probably always be behind on charts and will spend my vacations trying to get as much done as possible with only minimal success. 

The ways we grow

A patient recently eyed me right before a bedside procedure (I was supervising my residents) and asked with one eyebrow raised, “How long have you been a doctor?”

I thought about it for a couple of seconds, doing the math. “13 years.”

His face registered a small shock. Then, he relaxed a little. “Do you have children?”

“I have three.” His eyes widened, and he smiled.

Thirteen years is a long time; many things have happened to me that undoubtedly have shaped who I’ve become since I graduated medical school. I’ve certainly changed in many ways. Which ways were due to medicine and which were due to plain old maturation? My marriage? Having children? Other life experiences?

Upon reflection, I think medicine is responsible for this: more compassion.

There is a belief that medical training may result in the opposite. That because we see so much death and suffering, we have to harden a little to get through it all and come out emotionally unscathed. I certainly don’t think that’s universal and likely some of those observations arise from the development of burnout, the dampening of resilience.

As a hospitalist, I witness suffering from illness regularly. I am, not too rarely, the bearer of bad news – the cancer we found, the poor prognosis, the decline in function that is unlikely to be gained. I see people at angry, vulnerable, hurting points in their lives.  I’ve seen illness stem from poor choices. But just as often, I’ve seen illness strike with absolutely no provocation, turning someone’s life into a nightmare overnight.

Being a doctor has not made me numb to the suffering of others, despite sometimes feeling surrounded by it. On the contrary, it has made me more acutely away of what makes us human and connected. I think this has altered my approach to the universe. Probably, choosing to work in the veterans health system has something to do with that. I’m driven more by service now than when I was younger. I did community service in college, more because I felt I had to rather than because I wanted to. I do it now because it fills a need to serve and sustain.

The man who cleans my office is my favorite person at work. He is a wonderful soul, kind, generous and thoughtful. One day, after reading a column I wrote about emergency research done without consent, he said to me, “KC, I have observed that you have a deep, abiding compassion for those without a voice.”

I didn't know what to say.

Is that me? That wasn’t me before medical school, but if it is me now then I am grateful that becoming a doctor has made me so.

Thursday, December 12, 2013

Guest post: How Medicine’s Changed Me – the Good and the Bad

After 11 years of training and going on five years of practice, there is no question that medicine has changed me in numerous ways. Some definitely for the good. Some for the not-so-good. On good days, I’m more optimistic and have a deeper faith in humanity as a result of my practice.  As a pediatrician, I see patients who are often funny, are so incredibly resilient and have lives full of possibility ahead of them. I have seen and participated in miracles. I have witnessed deep compassion and graciousness, in both my coworkers and the families we serve. I have seen others make sacrifices to do their best for our patients and their families. My practice is frequently deeply rewarding.

But my practice can also be incredibly difficult. As a pediatric emergency medicine physician, I bear frequent witness to the senselessness of tragedy. I have struggled to save a life and failed. More than once. I deliver news of devastating new diagnoses - the brain tumor, leukemia, intracranial bleeds. I have been yelled at, cursed at. It is a rare shift that I don’t see a child for suspected or known abuse. I care for families who are at the end of their rope, trapped in generational cycles of poverty and violence.  I see children whose physical symptoms are the result of anxiety, fear and toxic stress. At times, I feel my patients are trapped, that their lives are not filled with possibility. Currently, it is the changes brought about by this aspect of my practice that I struggle with.

I know that I’m not the same person now that I was when I slipped into my first white coat. I’m not even the same person I was when I finished my fellowship not quite five years ago. There are days when I struggle to be compassionate and gracious to my patients, their families, my coworkers and myself.  Days when I feel unable to tolerate complexity. Days when I don’t tolerate the chaos of my home as well, when I feel unable to be fully present with my husband and children. There are cases that haunt me, that I feel will always haunt me. This problem goes by many names - compassion fatigue, vicarious trauma, secondary traumatic stress.  Some say it is burnout; some say it contributes to burnout. Define it how you will, it is real and it is common.

There is a growing movement in the medical community to combat this dark side of our vocation. The hospital at which I work recently started a program for staff well-being that includes mindfulness seminars and meditation sessions. Even though I am in the beginning stages of a practice of mindfulness, it’s already helping me deal with this dark side of medicine. This new awareness, this mindfulness, is another way that medicine is changing me.  Out of necessity, yes, to enable me to deal with some not-so-good ways that I have been changed by carrying out this calling to bear witness and to enable healing. But ultimately, learning ways in which to combat these not-so-good changes that often accompany a life in medicine will result in another good change - the ability to be more present at work and home, to live more fully and to care more compassionately. And to retain my sense of gratefulness for this vocation that I am, when it comes down to it, oh-so-thankful to be pursuing.


5 Ways Medicine Changed Me

I like lists so let's go for it:

1. I'm more outgoing

Except in certain fields (rads, path), you just can't be as good a doctor if you're not at least somewhat outgoing. I think introverted doctors come off as cold or aloof.

2. Sleeping with a pager wrecked my sleep

I used to be able to sleep through my husband snoring. Now I can't.

3. I'm a much bigger hypochondriac

I really wish I didn't know the worst possible case scenario for every illness.

4. I'm more humble

Because I know that there's no way I can know it all.

5. I've gone from being incredibly squeamish to feeling like there's nothing so bloody or disgusting that I have to look away

Well, except maybe in the movies.

Wednesday, December 11, 2013

A Different Perspective

The title for this topic week is change; specifically how becoming a doctor alters one's life.  There is no question of change, only how.  For me, the most profound change is the perspective I have gained from training and experience, which has been both comforting and distressing.  The ultimate goal is to find a balance in the enjoyment of what you do despite the inside look at inherent system and personal flaws that are revealed on that long journey.

As a pathologist in a large group practice, I work intimately with my co-workers sharing tough cases.  As a fresh trainee I had a lot more defenses built up about showing a "stupid" consult.  Over time, as I have become more comfortable and developed relationships with my partners, it has become easier.  Some cases are diagnostically challenging, and just as a clinician doesn't always nail the patient's disease with the first test they order, a first glance at the tissue doesn't always provide clarity into the disease process.  Even though we are all trained to render similar services, we each have our strengths and weaknesses based on training level and personality types, and I am thankful that I do not practice solo because we are so much better as a team.  And I don't mean just us pathologists - I am also thankful that I can open the EMR and get input from radiology, pulmonology, oncology, and all the clinicians or just pick up the phone.  Communication often makes a difficult case crystal clear.

Numerous recent articles are highlighting the drawbacks of our medical system, and having inside perspective makes a lot of it ring true.  "You're Getting Too Much Healthcare" by Jamie Santa Cruz was published in The Atlantic this week and Elizabeth Rosenthal is doing an illuminating series in the New York Times I have been following called "Paying Till It Hurts."  Sure, every system has its positives and negatives, but it's easy to become disillusioned when you get first hand experience navigating the real world and jumping through all the hoops that seem distant from your idealistic image of yourself as a pure patient advocate.  One of the most challenging things I work on is finding value and purpose in the many things I do that help the patient, and not getting too frustrated over the more mundane and nonsensical aspects of medicine that I witness - many of which appear business driven.  Having a rich life outside of work with children, family, relationship, friends, exercise, etc. - all of that helps round out the negatives.  An alternative would be to bail on the system - something I have witnessed a handful or so of my classmates do over the last ten plus years since I have graduated.  They have found happy and fulfilling lives outside of medicine.  I don't think there is a wrong choice; everyone has their own path to follow.  Mine is certainly in constant evolution.

Up to this point in my journey, I have shed a lot of the insecurities of youth but gained insecurities of experience; the latter being much more tolerable and rationally tackled through knowledge and resources.  I have been elated by success and ravaged by missteps.  I have been buoyed by support from this community of women and also retreated from it to nurture myself and my kids.  Change is inevitable when you choose this road.  Although some of it feels reactionary, which can yield cynicism and doubt, the most important changes are those gained from knowledge and experience - lifelong processes - the kind of glacial change that affects your core being.  This kind of change brings a sense of control, purpose, maturity, and peace into your daily challenges and decision making, both inside and outside of the hospital.

as an extrovert without good answers

Though I am loath to admit it, I am, by nature, an introvert. And despite the recent torrent of articles espousing the benefits of being an introvert (also see herehere, and here with funny retort here), it's the part of my personality I like the least. I wish I was better at small talk, better at making friends, more relaxed in a crowd, not so ready to leave a party, and not so frequently told to "smile".

Medicine made me into an extrovert. Or maybe an introvert who can affect the persona of an extrovert with an enthusiasm that actually is genuine. I do smile, a lot actually, and frequently when I don't feel like it. In my white coat I am animated and chatty and quick to introduce myself. Perhaps not surprisingly, I like myself as the extrovert - it's like pretending to be the cool kid I never was. And, again painful to admit, I think patients also prefer Extrovert Me.

On a less frivolous note, I was very much looking forward to this Topic Week, and so am now surprised by how difficult I've found writing on the subject matter. It's hard to collect all the ways medicine, with its messy contacts and daily pressures, changes its practitioners, then analyze and distill that change into a theme confinable to a blog post. I think, after many hours staring at my computer screen, that I can't be complete in the assessment. I will have to focus my thoughts more than I'd planned. 

Please excuse the generalization, but I think oncology, perhaps more than primary care and medicine subspecialties, treats patients whose disease cannot be clearly linked to poor lifestyle choices. Yes there are associations between obesity and breast cancer, smoking and (amongst others) cancers of the head and neck, lung, and bladder, and the various HPV-associated malignancies, but the majority of patients had no reason to think they were at risk for cancer. In plain terms, they never saw it coming. These patients, and particularly the young ones, will spend a significant portion of our initial visit asking and re-asking the question "how did this happen?", for which an abbreviated synopsis of cancer genomics is often emotionally unsatisfactory and scientifically insufficient.

I am just beginning to understand how frequently life lacks good answers to some very good questions. Terrible things happen to people undeserving of an early death or a near lifetime without their spouse. We do not all get what's coming to us. 

I used the fumble the question "Do you like what you do?" because, although the answer is yes, there are times when it's truly horrible.  I can't cure a substantial number of people who walk through the door and my job can involve making people understand something they don't want to understand. But there is meaning to what I do, there is meaning to palliation and prolongation of life, even when the situation itself seems meaningless. Medicine has taught me to find meaning where it isn't apparent and, in doing so, helped me to enjoy this short life that happens to us all. 

Tuesday, December 10, 2013

How medicine changed me during the snow and ice

I am in medicine, where I must get out of bed and leave home on a “snow day” after arranging care for my own kids, to de-ice my car, commute through snow, sleet, and freezing rain, so that I can be available in person for my patients.  Before medicine, I would have probably lounged around, woken up late, and perhaps taken a walk just to enjoy the snow.

As a medical professional, I have responsibilities rain or shine. Just like a post officer, "neither snow, nor rain, nor heat, nor gloom of night stays these couriers [read: medical professionals] from the swift [read: caring and comprehensive] completion of their appointed rounds." The mother portion of me as a mother in medicine feels particularly bad leaving my family on a snow day. The medicine portion of me as a mother in medicine feels good, to be in a service profession, indeed.

(And maybe we'll get out early, in time for some twilight sledding.)

Medicine Made Me the Person I Am

As someone who went directly from college to medical school, I have spent most of my life in medicine. Medical training morphed all the areas of my life. I have no idea what I would be like if I wasn't a doctor, but I know medicine has made me a stronger, more appreciative person.

Medicine made me stronger. Its 3 a.m. and the baby's heart beat drops into the 60's. It's my patient's third baby. I check her cervix and she's a good 8 cm. The nurses and I give her oxygen and change her position but nothing helps. As the bradycardia approaches 5 minutes the tension in the room begins to rise. I am the doctor. Likely the only one at the hospital, at this hour. It's a tough decision, but this is my call. My pulse starts to rise, but I take a deep breath to calm myself down. I'm bone tired, but that really doesn't matter because I've done this so many times; I know I am strong enough to push through the fatigue, the stress and pressure. I have to be. This team needs be to be a calm, confident leader. As the bradycardia passes 10 minutes, I communicate the seriousness of the situation to the patient but not try not to scare her. We must proceed with an emergency C-section. A chaotic symphony of orders, instruments and bed pushing ensues. A healthy baby is born moments later.

Moments like these have given me some wrinkles and grey hair over the years, but  have also given me nerves of steel.

After surviving residency, two kids and private OB practice not too much scares me. I know that I can tackle most any challenge whether emergency surgery, bodily fluids or board meetings. I am afraid at times, but neither fatigue nor feces make me flinch.

Medicine taught me to appreciate the little things. Life contains so much sadness; too much cancer, drugs abuse and loss. Beauty and miracles abound, but around the next corner you find stupidly ridiculous tragedies. Life in medicine becomes a daily decision not to become jaded. I'm stronger and little rougher around the edges but I refuse to be jaded.

One small way I do this is to purposefully enjoy the happy moments of my day. When I deliver a baby, assuming mom and baby are happy and healthy, I take a moment to soak in the moment. I simply observe the mother's face light up as I place her baby in her arms for the first time. I watch the expressions of astonished love and the happy tears rolling down dad's face. I remind myself that THIS IS WHY I do it. All the late nights,emergency c-section and all the sadness ARE worth it. I get to make a difference in this family's life. I get to play a small but integral part in helping make their family.

This goes to my home as well. I appreciate my own children's health. The little moments of hugs, giggles and homemade cookies are stored away in my memory for safe keeping. Many bedtime stories are missed but the ones I'm there for are cherished.

Medicine made me a scientist. Medicine teaches you to reason. I look to randomized controlled studies to help make decisions for my patients. I follow the standard of care for my specialty. I know my strengths and limitations. I find these principles spilling over into other areas of my life as well. I have consumer reports and google ratings to help decide on appliances or any other purchase. I rarely make a decision without research to back it up. If only there was a published standard of care for parenting toddlers.

As a premed college student, I was nearly bursting with enthusiasm over my chosen profession. I could rarely wait for the point in an introduction when I would get to declare my plans to "be a doctor." But medicine is more than a profession, it's really become a large part of who I am. Medicine has made me a stronger, smarter, better person and I'm thankful for the privilege of being a physician.

Guest post: How has medicine changed me

Since the age of 22 I have been entrenched in medicine-went right from college to medical school and residency. The formative years of my 20s have been busy dissecting bodies, studying dense medical textbooks, giving case presentations, rounding, taking call, eating bad cafeteria food, searching Up To Date, and learning how to adapt to different classes/teams/attendings/colleagues every month. I also took A LOT of tests. Looking back now 4 years post-residency, I am simply not sure how I did it!

Medicine has changed me in ways that could be viewed as “good” and “bad.” Medicine has given me more empathy; it has showed me the importance of compassion and hope; it has made me a better listener; it has given me confidence and the strength to be vocal; it has given me a career to be proud of. Medicine has also given me my husband! (We met, married, and couples matched in medical school.) It has shown me the value of wonderful friends and family, which many people do not have. It is a privilege to help people in their times of need and share intimate details of their lives. I trained in emergency medicine and have a valuable breadth of medical knowledge from excellent training. The knowledge helps me daily both on the job and off.

On the flip side, medicine has changed me in some negative ways. I am more judgmental-there is a need for quick (instantaneous) decisions when talking to a patient in the ER. I am cynical-while practicing medicine is considered a privilege, it is also a burden, and we usually see people at their worst. I take frustration out on my family because I know they will always be there (I hope). Medicine has been consuming and I have missed out on a lot of experiences….like family birthdays, funerals, weddings, parties, leisure, travel, holidays, and such. These missed experiences have caused me to be resentful and bitter at times.

I am not sure about you, but I feel like one of the most important things medicine has done is make me a better mom! I have 2 young kids and am grateful everyday for my medical knowledge. I know how to observe, study and treat my kids. I also know where to look for the answers I need for them. This medical knowledge helped immeasurably with my son’s near-death from kidney failure when he was 2 weeks old and all the subsequent care he has needed. Some mommy physicians complain that they “just know too much”....but I would never trade in that knowledge for ignorance.

No field or career can only have positive impacts on a person, and overall, I am proud and grateful to be a physician. Being a ‘mommy’ physician is an even bigger badge of honor in my mind. There have been a lot of challenges/walls/ceilings to break through….and a huge inner struggle to conquer the mommy guilt and “just keep swimming….” (Thanks, Dory.) Time out of training has brought more clarity with this issue and the compromises needed to make work and life, work. I wish all of you luck with making medicine work, as well.


Monday, December 9, 2013

How Has Medicine Changed Me?

KC suggested this topic, and I have had to think and think about it. How HAS medicine changed me? 

As an uber-idealistic practically socialist gunner med student, I had a vision of myself in the future as a doctor completely devoted to the poor and disenfranchised of the world. I was going to work for Doctors Without Borders or something like that. I was going to deliver skilled medical care with aplomb, to the suffering and forgotten. My vision was pretty vague, but definitely included basic field hospitals, palm trees and grateful patients.

I held onto this vision well into residency, shrugging off questions about how I would finance my dream, seeing as I paid for med school with loans, and would end up about $120,000 in the hole, before interest.I shrugged off those questions, figuring where there was a will, there was a way. I did every international elective I could. I ended up in crazy places (and I have many crazy stories) from Guatemala, Nicaragua, Peru, Ecuador, Sri Lanka...

As the end of residency approached, along with those ever-increasing loan statements, I started looking for a job in my dream field, which was, in my head, basically "International Health". Of course most medical jobs in this area don't pay much; and though many allow loan payback deferment, the interest still mounts... I considered going for an infectious diseases fellowship, but I had signed on for Primary Care loans, and would take a penalty if I broke my commitment to primary care.

I tried some things; I did work in HIV research and thought about pushing that work into something more... international. I struggled. I got kind of depressed, trying to reconcile my vision with the reality of life, and finances.

But then, something else was happening. I was in my mid-thirties, and I was starting to have other visions... Visions of family. Of settling down, raising kids, of community, of stability.

There was a transition, a positive one, and I ended up here, in a very nice suburban home, with my wonderful rock-stable husband and two healthy kids, working in a small practice at a respected academic institution, providing primary care to decidedly American patients. I'm really very happy.

A lovely patient of mine, someone who has faced many medical adversities, told me once that "it's the kindness of caregivers that gives a person courage." I do try to remember that, even when faced with an angry patient... Be kind. It matters, whether it's with first-world or third-world patients.

So, I try to be kind. And it's all good. What's so funny is that I feel like I'm a nicer person now than I was when I was supposedly devoted to saving the world...I seriously think that's how medicine has changed me. It's made me a nicer person, though not in the way I anticipated it would.

Thursday, December 5, 2013

Guest post: The Things We Carry

Tim O’Brien’s “The Things They Carried” begins with a list of items carried by a platoon of soldiers during the Vietnam War:

First Lieutenant Jimmy Cross carried letters from a girl named Martha, a junior at Mount Sebastian College in New Jersey….  Henry Dobbins, who was a big man, carried extra rations; he was especially fond of canned peaches in heavy syrup over pound cake.  Dave Jensen, who practiced field hygiene, carried a toothbrush, dental floss, and several hotel-sized bars of soap he’d stolen on R&R in Sydney, Australia. Ted Lavender, who was scared, carried tranquilizers until he was shot in the head outside the village of Than Khe in mid-April.  

In a writing class, you might learn about O’Brien’s use of repetition, about how he uses the list to reveal something about each man’s character.  But I’ve been wondering lately, what do the things that we carry through life reveal about each of us?

My husband and I have too many possessions, this I know; more than we need or can even use.  I am also aware that this is a developed-world, middle-to-upper-class problem, and that such complaints are at best insensitive and petty.  This is not a war zone and our possessions are not strapped to our backs; instead these are the clothing and household items that pad our comfortable lives.  Acknowledging these facts, I still believe that things deserve some examination.

There are the hand-painted margarita glasses that we purchased in Mexico and that have followed us, cloaked in too much bubble wrap, from apartment to apartment.  Each time they settle onto a new shelf where they sit undisturbed until the next move.  There are the clothes that get passed over each time we dress for work or a special occasion, but that remain in our closet because they might be perfect for an event that just hasn’t happened yet.  There is the chair reminiscent of the one that sat in my parents’ vacation home when I was a child, the one that brings back memories of hours spent reading novel after novel.  Except neither my husband nor I has sat in the current chair since at least two apartments ago.  Instead it holds stacks of books, clothing, and anything else temporarily without a home or that we are too tired at the end of the day to put away. 

Why do we keep all of these things?  Is it emotional attachment, fear of loss, just plain inertia (of the staying-at-rest variety)?  And how might our lives be affected if we were able to detach from our possessions, declutter, simplify?

I recently came across an article written by a woman who, along with her husband, had decided that it was time to do exactly that.  They sold or donated many of their possessions, making it a point to buy only what they truly need and will use.  In the process, they paid off a large chunk of debt, but the benefit that interested me most is somewhat surprising, something that I crave more than anything: “We're finding more time for the things we gave a lot of lip service to but didn't always make time for: health, fitness, reading and each other.”

Over time I’ve started to realize that, at least in my own life, carrying around a lot of physical stuff can feel just as burdensome as carrying a lot of emotional or psychological baggage.  All of that stuff demands management – cleaning, storing, organizing, or at least sifting through as you search for something else – and thus time, energy, attention.  If I had less stuff, if I limited my possessions to those that were really important to me, would I use them more?  And would I discover more time to devote to the things that I really want to do in life?

It certainly seems possible.  My husband and I have decided to give it a try.  We are not emptying out our home by any means, but we are parting with a lot of the extras, the things that we had previously kept around on the basis of “what if” or “someday.”  Already in our lives it feels a bit easier to move and to breathe.
Except there is one complication.  A large part of the impetus for our decluttering is the fact that we are expecting our first baby in February and we desperately want to maximize the time that we are able to spend together as a family, as well as to grow even more fiscally responsible in order to provide for the baby’s future.   But with a baby comes stuff.  A lot of stuff.  And how easily the line between the things we need and the things we need becomes blurred.
When we made the obligatory trip to Babies “R” Us to set up a registry, my husband paused before scanning our first item and warned, “Let’s just stick to the basics.  Let’s not go overboard like we did for our wedding.”  I paused and recalled the hours we had spent perusing china, crystal, and every isn’t-that-neat-looking kitchen gadget that caught our eye, ultimately adding several of each to our wish list.  With this approach in mind, we braved the first overstuffed aisle.
This, I suppose, will be our first test.  It is one thing to purge one’s home of a few belongings; it is another to retain the patience and thoughtfulness to avoid reflexively refilling it just because there is space available.  And while we have no desire to raise a child or children with rooms overstuffed with rarely-used and under-appreciated toys, neither do we wish to impose on them a stringently spartan lifestyle.   The answer for us, it seems, lies somewhere in the balance.  And for the first time, we feel ready to set out in search of it.

Becky MacDonell-Yilmaz is a pediatrics resident at Brown University/Hasbro Children’s Hospital in Providence, RI.  Her work has been published in the Annals of Internal Medicine, The Writer's Circle, and The New Physician. She blogs about her experiences in training at The Growth Curve: ruminations of a pediatrician in training.

Monday, December 2, 2013

Guest post: Fidelity

I achingly relate to other doctor mamas each time I read this blog. It is not an easy path that we have chosen. There are a myriad of challenges and rewards on this journey. Some challenges and rewards will be generally the same between us, such as becoming mothers, graduating medical school, and starting practice. Yet even those general similarities will be experienced differently by each mother, each doctor, each wife, each partner, each daughter, each sister, each aunt, and each of us women, under the many hats that we wear.

Lately there has been something on my mind. Not the usual things, like medicine and professional development and children's needs and schedules, though those are all still there. My career as a military physician has taken me away from home a lot this year. The time away from home has presented many challenges (which I would love to discuss with other military doctor mamas), but there was one that I did not anticipate: what do you do when you are attracted to someone else?

We have all had chemistry with someone as soon as we meet them. An instant attraction. Some people are just destined to get along. This chemistry might be with someone of the same or opposite sex, and is probably a prerequisite for those great friendships that sustain us all. I have many friends of both sexes with whom I enjoy a lovely chemistry. Have I found other men attractive since I got married? Of course I have. But I have always considered the question of fidelity (and consequently the topic of unfaithfulness), to be an issue of uncontained sexual desire, and therefore, not applicable to me, since I can "control" myself.

However, now, as a human being and wife and mother, I find myself struggling with thoughts and questions that never occurred to me before. My marriage is actually quite wonderful. I love my husband. Yet, we are separated by so much time and distance lately, that sometimes my life at home takes on that same wispy feel as a dream lost on waking. I miss it and I want it so badly, but it is frustratingly inaccessible. I'm certain that many women in medical training or practice can relate to this feeling. I remember longing for my husband and family even when I was home, because I felt like I was never there. However, I also have always felt that my connection to my home life is more real and tangible than any other connections I have.

Realistically, many of us in medicine will see our colleagues, on an hour-for-hour basis, more than our own families. We can and should expect to form strong bonds with those people at work whom we genuinely connect with. But what happens when one day, you find that the bond is something deeper and stronger than you anticipated – and you don't know what to do?

I know that I am committed to my marriage and I do not ever, ever want it to end. I know that I want to share my life with the wonderful man that I married. I do not foresee that changing. How then, can I struggle to realistically and honestly address the question of fidelity?

Given the sensitive nature of this topic, I hesitate to divulge too much, but I would like to explain this: the person I am attracted to is also married. He is not a patient. He is not in the military. He has a family. He loves his wife and kids. Our attraction is mutual. We genuinely like each other and respect each other, but we are not in love. We have discussed it. We have vowed to not "act" on it. It seems so simple on paper, but I never could have imagined how hard it would be. Even as a write and re-write this post in hopes of "getting it right," I see that nothing I write can convey the frustration, loneliness, doubt, guilt, and confusion that I feel.

I have no doubt that some people will judge me for confessing to these feelings. I recognize that this post might make some people uncomfortable. It makes me very uncomfortable. I write in order to open the door to genuine discussion on a very taboo and (I believe) common topic. I don't know if anyone will post on this other than in a safe, generic way, since many of you have an online presence which may preclude you from writing honestly as yourself. I understand that. I want to be anonymous, too. Yet my own sense of shame bothers me. What exactly do I have to be ashamed of?

I hope that some of you will reply. I sincerely want to ask – what do you do when you are attracted to someone else? How do you cope? Especially when you are away from your home and family? How do you answer those haunting questions that you never, ever thought would be in your head, such as: Is it wrong to be attracted to someone else? If so, why? Is it only wrong if you "act on it" by crossing some sort of physical or sexual line? If so, why? Is it therefore less wrong to "only" have an emotional connection with someone? Why?

Perhaps KC would be willing to post comments for those who are not comfortable doing so.