Thursday, February 27, 2014

Guest post: Can't I just relax?

I am a 30 year old mother of 3 children ages 13, 10 and 8 in addition to being a wife and a second year OB/GYN resident.

It’s the weekend and I’m off, which is a miracle in and of itself.  However, what should be time to relax is never exactly that.  Sometimes because of children’s sports activities, or my husband’s work obligations or maybe because we have scheduled time to go “out” with our friends.  Yet more often than not, despite the extended period of time off , I am incapable of relaxing.  My in-laws jokingly ask my husband on a regular basis what is on my agenda for my time off.  My husband literally can not comprehend why I can’t just sit.  

Here’s the thing from my perspective:

I had my first child at 17, married at 18 and had my second and third children at 20 and 21 respectively.  Throughout all of this I took off only 1 semester of school.  I went straight through college and into med school and now OB residency.  Through all of this I have learned to manage time, multitask and be efficient.  Time is of the essence!  For the past 13 years I have had an agenda.  Clean the house, do laundry, academic reading, pay bills, etc.  So, when given a moment that is not already scheduled for me, I feel the irresistible urge to use that time to it’s fullest potential. I have made it a point recently to get a massage once a month.  However, I will admit that it takes me a full 30 minutes for my mind to clear of the tasks that need done.  But hey, that’s a full 30 minutes that I really am relaxed!  Now, as my children and I are getting older, and I am getting further into my career I can’t help but wonder how to break the cycle in my head and to really enjoy my time off.

Tuesday, February 25, 2014


My soon-to-be five year old will do or say anything to delay bedtime. Recently she's wanted me to tell her about my day – what type of patients I saw, where their cancers were, and who was bald. If the patient was female and not bald, she wants to know if the hair was short or long. If the patient was male, she wants to know if he had a mustache or a beard. Hair, who has it and where it is, seems very important in her understanding of what I do.

Because the nature of the inquiry is flattering, I usually linger a while at her bedside and try to recall the patients I saw in clinic. I am careful to choose the details that are not inherently upsetting, but the longer the talk, the more likely I am to stumble into territory littered with the landmines of subject matter unbefitting the ears of preschoolers, especially in the few minutes before bedtime.

When it comes to the question of how to and under what circumstances do we “shelter” our children, I think I fall somewhere in the middle. Although sex and violence might be part of life, I think it’s appropriate to limit my children’s exposure to those themes while they are young. I'm not sure I feel the same about medical illness and problems faced by people undergoing treatment for cancer. I was ten the first time I went to Guatemala and freaked out when children tapped on our car doors begging for money. Even though I remember that experience as a very negative one, in retrospect it was probably a good introduction to the topic of inequality. I share the story to make the point that exposure to uncomfortable subject matter can be an important part of growing up.

But 5 isn't 10 and death isn't poverty, and I am still unsure of what I should and should not share with my preschooler.

She’s quite interested in the subject of death, even more so than the subject of hair, and I wonder if it's precisely this interest that makes me uncomfortable. She knows that “old” people die, but asks questions that would indicate she suspects there’s something more to the subject. I’m not sure if she knows that anyone can die at any time, and, more to the matter, if she poses the emotional intelligence to deal with the obvious implications of that realization. 

I’ve heard before that the best course of action when children ask potentially age inappropriate questions is to answer only the question posed, in as direct and simple a manner as possible. But she asks a lot of questions, and each answer seems to spurn on a new set of inquiries.  I hate the feeling of lying to my daughter, but I do it occasionally to get myself out of discussion I’d rather not have.

How much “real life” do you bring home?

Monday, February 24, 2014

Stop scaring the "fresh meat"

I volunteered recently at a meeting for Latino high school, college, and medical students as a member of my hospital’s Residency Diversity Initiative. I had gotten the announcement a few months prior and realized I would be on a pretty straight-forward month with weekends off. I checked with the hubby that I could take about 3 hours during his prime studying time to volunteer and he agreed.

The students were engaging. The high school students asked silly yet endearing questions. One absentmindedly asked another resident and myself our specialties three different times because he kept forgetting what we said. He was sweet, but goodness, I hope his focus and attention span increase before starting college.

Several of the medical students asked very educated questions, ones that showed they knew where they were going. One particularly prepared medical student, dressed smartly in an off white blouse, flattering pencil skirt, and pearl necklace asked a series of questions that we answered. She thanked us and left. Then she came back later to chat some more. She began her new string of questions with “I don’t mean to sound, ummmm, superficial or anything, but even though I’m interested in all types of medicine, I am worried that if I go into Family Medicine instead of Internal Medicine that I won’t be able to pay off my loans.” I shared a quick, knowing smile with the Family Medicine resident sitting next to me and we began to talk to her about following ones passion. We also reminded her several times, indirectly and directly that regardless of what type of medicine you practice, each of us will be in the top 1% of US income-makers. The top 1%.

Yes I know $120,000 instead of $200,000 (in a surgical subspecialty) seems like a huge deal, but honestly, every single Family Medicine Attending the other resident knew and every single Pediatric Attending I know is living very well. Yes, they may have a ton of debt they are working to pay back, but every single one has a family that is well taken care of. Everyone I know has a nice house (mostly owned and not rented), a decent if not really really nice car. And none appears outwardly to be struggling to afford their basic needs. I apologize if these are material things, but that’s what she was asking about and we answered because it’s a very real concern.

And that’s the Attendings, not the Residents. Every Resident I know, including myself, lives in a nice apartment. Many Residents in my program own houses, not rinkey-dink jacked up houses, but really nice grown-up houses with nice yards. We can afford to go on vacations and we buy what we want at the grocery store including at Whole Foods (which my father-in-law refers to as Whole Check). My husband and I budget our limited money well and hope to buy a house in the first several years out of residency. And we are already well on our way to having my student loans paid off within 10 years using the income based repayment straight out of medical school. Don’t get me wrong, if we didn’t have my husband’s graduate school scholarships, our family of 3 with a single working adult (me), we would be very close to being eligible for public benefits (Section 8 housing, food stamps, WIC, you name it); some of our neighbors are on assistance now.

So, seriously, I know many of us including myself are in debt. And I know we need to do things to overhaul “the system” so that serving patients and saving lives is compensated in a common sense and equitable way. One that values innovative, smart approaches such as preventative care and comprehensive services. One that doesn’t cause very capable and compassionate students who are interested in our field to go running the other way as they eye the ever-mounting price tag. But even at the lowest-paying end of the spectrum, we all will make more money than the majority of our country. And if we help each other to become more business-savvy, we should never have to struggle to live well.

The medical student left smiling. I left more inspired. Hopefully we encouraged her to pursue what will ultimately make her the happiest so that she can bring her “best self” to work every day; she owes it to herself and to her patients. Yes, it’s a daunting task and the realities of practicing medicine in our country are scaring the crap out of many of us and our future colleagues, but again, we are still positioned in one of the best fields that exists. I am committed to reminding myself, my colleagues, and the “fresh meat” that this is the reality we find ourselves in. A bit daunting, but not too scary.

Thursday, February 20, 2014

Introducing myself...

Hello MiM community!

I am so pleased to  be joining you!  A little bit about me... (as stolen from my bio...)

I am a psychiatry resident.  I am very happily married to Hubby, who is also a resident, and I have a sweet and loving daughter, my little Doll, who made her grand entrance in the summer of 2013.  I like to read, write, and google useless things throughout the day.  Some of my goals include reading more psychiatry and less on google, exercising, eating more vegetables and less chocolate, starting to write a novel, and being the best mother/wife/doctor I can be.

I've been reading MiM for years.  It started when I was googling "lifestyle of an ob/gyn" and along came a list of entries written by various MiMers about a day in the life in their field.  I've been hooked ever since!

Anyways, just wanted to say hello!

Tuesday, February 18, 2014

MiM Mail: From a doctor in physical therapy

Please bear with me through the beginning of this post, but I feel the background is pertinent.  I'm not exactly sure where to start.  I am 33 years old, a wife to a military officer, a mother of a precious 4 month old son, a doctor of physical therapy, and an endurance athlete. 

When I was younger, I spent 4 years in the Air Force as an aerospace physiology instructor.  I completed my A.A.S. in Aerospace Physiology Instruction through the Community College of the Air Force, and my hard work and high performance was recognized numerous times and at various levels through awards, such as the junior enlisted member of the quarter and year.  My flight commander felt that as an enlisted member, I would never reach my full potential, so he encouraged me to separate from the military to complete my degree.  I followed his recommendation, separated from the military in 2005, and took the remaining classes required to complete a B.S. in Biology.  I remember studying for a biochemistry final, looking up at a poster that read "Physical Therapy- We're Hands On," and thinking that might be an interesting profession to look into.  I shadowed with a home health PT who LOVED her job after 20+ years, then worked as a physical therapy technician in an outpatient orthopedic clinic for several months.  I educated myself on the profession, read the APTA's Vision 2020 about how the physical therapy profession was moving towards direct access, autonomy, lifelong learning, and educational programs were now doctorates.  My undergraduate GPA was good, but not stellar, so to demonstrate my ability to succeed academically, I completed a rigorous M.S. in Biology while concentrating my studies in neuroscience, cell and molecular biology, graduating with a 4.0 GPA.  I scored the highest in all of my classes- in fact my pharmacology professor wrote a note on one of my exams thanking me for scoring so well because after grading my classmates, she was beginning to think she was failing at teaching.  My hard work paid off- I was accepted to the University of North Carolina at Chapel Hill Doctorate in Physical Therapy program.

Fall 2008 I started my doctorate.  About a month into the program, I noticed I wasn't as interested in the physical therapy coursework as I was in the pathology or pharmacology classes.  I missed the "science" I had loved so much during my masters...  This trend continued.  I began thinking about medical school, but had committed to physical therapy and thus felt I needed to give it a chance. 2010 I bought an MCAT book, but again talked myself out of it.  Student loans were piling up- did I really want to increase those?  2011 I graduated and began working as a physical therapist.  I spent over $4500 in continuing education that year in an attempt to find something I liked in PT: lymphedema, manual therapy, vestibular therapy, biomechanics of running, treating the multisport athlete (these last two were very interesting, especially since I am a triathlete), etc.  I am a very positive attitude person, yet have found very little in PT that I love besides being a clinician and working with patients.  My masters research involved neuroelectrophysiology on CA3b neurons in the hippocampal formation and very little human contact- although I loved the research, I missed working with people (and my PI never spoke to me).

I thought becoming a doctor of physical therapy would enable me to teach (which I love), but most universities require a "terminal degree" such as a PhD or EdD.  I thought direct access would allow patients to walk into my office with acute injuries and I could treat them before these injuries became chronic- well, not all states are direct access, a lot of insurance companies don't pay without an MD Rx, and in some states I can't even perform Grade V manipulations- something I am well skilled in doing!  Differential diagnosis was heavily emphasized throughout my schooling and clinic work- I am able to recognize flags that warrant a medical examination and referral to a medical doctor.  What is the point of the profession moving to a doctorate when, even as doctors, we are so limited?

Fast forward to today.  I think about applying to medical school everyday.  I read books on perinatal stem cells, biochemistry of obesity, metabolic pathways, pathologies affecting the nervous system and I get EXCITED!.  I want to treat patients- not by teaching them how to walk or improve muscle function- but I want to attack their diseases at the cellular level!  I want to physically excise tumors, shrink them pharmacologically, and get involved in research.  Yet, I hesitate and question if this is practical.  I have read several mothers in medicine posts about burnout, disillusionment- would this happen to me?  If I apply and am accepted, my family will be supportive, but I will be increasing my student debt (I already have $160K), taking time away from spending time with them, and I'm certainly not getting any younger- am I selfish in even wanting to become a medical doctor?  If I become an MD- or even an MD/PhD (I do love research), complete a residency, and fellowship will I have time to spend with my family, continue training and competing as a triathlete, or even just sit back and relax?  Also, my husband plans on spending 8-14 more years in the military before retiring.  I have spoken with PTs that became MDs and are now much happier- but they have all been male.  I have sought guidance from my mentors from PT school- they encouraged me to stay in PT...

I was excited to find this blog!  What thoughts do you all have?  I feel I need to make a decision- this contemplation has been going on since 2008...

Sincerely, Kelly

Tuesday, February 11, 2014

Evidence of things not seen

I usually don't cross-post from my personal blog, but this recent piece seems to have really resonated with fellow residents and physicians in general. People have approached me in the hospital to talk about it, and as a result, I have had a lot of honest, wonderful conversations with my colleagues -- about their love for medicine and for their patients, about the traumas of training, and about the systemic problems that make their jobs less satisfying than they had hoped they would be. These conversations have reconnected me with my own deep motivation to serve patients and have inspired me to fight for a better system. I look forward to hearing from fellow MiMs about your experiences and hopes and ideas for how to better heal our patients and protect ourselves from burnout. 

*         *         *         *         *

I am on retreat with my residency class. We are in an otherwise empty hotel on the Jersey Shore whose just-an-average-hotel-ness is intensified by the lonely quiet of the off season. I can imagine the bustle of summer filling up the space -- trails of sand from little feet tracked in from the beach, brightly colored umbrellas stacked up on the deck, all the various sounds that people can make from within hotel rooms -- but in the emptiness of winter the rooms seem tired. Why are hotels decorated in brown and beige? Are there people who are offended by color? Or is it just to mask wear and dust and dirt? Is the bored eye less likely to see?

There are few opportunities in my life to sleep in but today I could have slept until 8:30am, which as all parents of toddlers can attest, is the new noon. I went to bed early last night, in fact, because I wanted to experience the sensation of restedness this morning, the feeling of waking up out of readiness instead of necessity. But because the universe has both good wisdom and a good sense of humor, my eyes opened at 5:45am -- the very time that my alarm will ring tomorrow morning -- and I couldn't go back to sleep. At first I was filled with a familiar sense of cynical irritation, the "why me" and "well isn't that always the way" that residency has brought to my life despite the comforts and advantages that I enjoy. But then I thought to myself, how often do I get a chance to walk on the beach as the sun rises? According to the sun would be rising at 7:01AM. I put on several layers and slipped out of my shared room, through the muzak in the lobby, and out towards the ocean.

There was no one else in sight. I walked toward the ribbon of pink spreading up from the horizon. The hard, frozen sand up near the beach grasses gave way to the satisfying sink of each step into the wet shore. Several gulls circled and dipped. I looked for shells to bring home to E -- not too small, not too sharp -- and came across some of the odd hints that the ocean delivers up to us about itself. Cracked orange crab shells and dismembered legs half buried in the sand. Plant fronds of various colors and textures and widths. A foot-long brown spear that widened up to what looked like the end of a bone with some white and yellow flesh still attached -- tooth? spine? tail? Breaking the smooth contour of the shoreline, a sudden small pile of sea sponge. I walked for an unknown distance. The sky became lighter and lighter beneath and around the layers of cloud. I wondered to myself when the sun would rise and what would mark the sun's rising. I looked at my watch and it was 7:13, already past the appointed time. The part of my legs between the top of my boots and the bottom of my coat began to tingle and sting with cold and I turned to walk back to the hotel as the daylight continued to bleed into being around the edges of the sky.

*         *          *          *          *

How should I say this? I am worried about the state of health care. I am worried about the state of my own heart. I am worried about the way doctors are trained. I am worried about the way health is defined. I have been in and around hospitals for almost a decade at this point and I feel like I know less and less about how to help people achieve well-being. I feel like I'm getting better and better at keeping people alive and less and less good at helping them live well. I am maybe a little depressed or to use the somewhat more socially acceptable term, burned out.

I went into medicine with a desire to be with people in life's most terrifying and difficult and potentially ecstatic moments. I wanted to understand the body, to understand more about life and illness and death. It's a cliche but a deeply felt one: I wanted to be of service. I also wanted financial stability and the ability to provide for my children. I wanted a job that would be meaningful even on the worst days. But mainly I wanted to form deeply satisfying therapeutic relationships -- it's what I wrote my residency application essay about and it is still what I aspire to accomplish, somehow.

Now, almost ten years later, I spend more than 90% of my day in front of a computer. Sometimes the computer is actually physically located in between me and my patients and I have to crane my neck around its unsleeping eye to see them. I type through the majority of my clinical encounters. During a typical day on the wards, I see my patients for -- at most -- 5-10 minutes per day each. My day is filled with entering and reentering orders on the computer, writing endless admission notes and progress notes which recapitulate information that is already recorded elsewhere in the medical record, waiting on hold to talk to primary care doctors' answering services, calling pharmacies and insurance companies for prior authorization, calling subspecialists to address each of the body's organ systems, and coordinating the complex behemoth of a large tertiary care center to get tests and studies done for my patients. I work up to 28 (actually more like 30 but shhhh don't tell) hours in a row every fourth night which wouldn't bother me except that of those hours I spend at most 2-3 in total with patients. Patients turn over so quickly in the hospital that I might be responsible for the care of over 100 patients during a given week. During clinic hours I am perpetually beset with anxiety at how far behind I am, unable to get through a well child visit meaningfully in the 20 minute time frame allotted for this purpose and because of the fragmentary nature of residency scheduling, I often do not see these patients again. I want to form relationships with my patients, but at times it feels like talking to patients just takes time away from the tasks that need to be done for them. It's crazy, but it's true.

Some of these issues are unique to residency, which is time-limited (though formative), but surveys of post-residency physicians suggest that as a group, we are in trouble. In a much quoted and discussed survey of 24,000 physicians by Medscape in 2013, only 54% reported that they would choose medicine if they had it to do over again. Fourty-nine percent of physicians surveyed reported at least one symptom of burnout and 40% reported that they were burned out.

On the receiving end of medical care both as a patient and as a loved one advocating for sick family members, I know what it's like to receive care from a system of overwhelmed and/or burned out providers. Test results are not communicated. Small details are missed. You wait 7 hours to speak with the doctor, then that person does not know some of the basic details of your case. The care you receive addresses a symptom or a part of the problem, but rarely the whole problem, and rarer still, you as a whole person. I fear being that kind of provider yet I have been that kind of provider despite my fervent desire to avoid it. There are just too many patients, too many data points, too many notes to read and write. There is so little time for relationships to form. There is no magic there.

Doctors are a hard group to sympathize with. Once we finish training (it's long, but let's face it, life is longer) most of us land in the top 10% if not the top 5% or 1%. Training is hard and the hours are long but we choose this life with full knowledge (as much as you can have full knowledge) of what we are getting into. We hold a lot of societal and political power and on an individual level,  in hundreds of thousands of exam rooms across the world, we have the power to examine, to question, to diagnose, to prescribe, to get it right and heal or get it wrong and harm. But if we as a society want to get the kind of health care that not only cures but heals, we are going to have to look at how doctors feel, how they are trained, how their work-life is organized, what we ask of them, and how we support them in their work.

*          *          *          *          *

If you work around sick children long enough, there will be a death that crushes you, that doesn't let go, that you can't let go of. Little O came into my care last month and a few hours later passed away under the most difficult of circumstances. Oddly enough, I don't remember her name -- perhaps because the intensity of our efforts to keep her alive and the adrenaline coursing through my body erased it from my data banks, perhaps because I have been afraid to reopen her chart. I think of her as little O, the little O of her mouth, the round moon of her little face which I saw for weeks every time I closed my eyes. If I will it, I can hear her mother's screams in my mind's ear as vivid as the sounds of my household humming around me as I write: "No es justo! No es justo!"

I want to make contact with her family, to tell them that I feel for them, that I think of her, that even though our lives touched for only a few short hours, I feel the weight of their loss. I have never done such a thing before and I'm not sure if it is even appropriate. Who should I ask? Do I need to get permission from my program director? Do I need to run it by risk management? In the end, the question comes down to one of the nature of my relationship to that baby and her family. Was there one? And if so, what was it? I have been training for many years but have received no apprenticeship in this most important aspect of my profession.

So many hundreds of children pass through my life and I through theirs and we are like ghosts to each other. There are so many layers between me and my patients, layers of bureaucracy, legality, scheduling, vulnerability and power traded back and forth in a complicated dance. Was this always so? Sometimes I fantasize about becoming a small-town doctor, about being part of the community I serve, of knowing my patients and allowing them to know me.

I will likely never send a card or see little O's family again, but this is what I would want to tell them: I will hold your daughter in my heart forever.

*          *          *           *          *

Meanwhile, back at retreat, I am surrounded by the loveliest people. My co-residents are intelligent, accomplished, funny, and kind. To a person they are motivated by the desire to be of service. They are scientists and humanitarians who hold as sacred the trust placed in them by children and their families. They are also spouses and parents and children and friends who struggle to balance the commitments they have made in so many domains in their lives. I feel lucky to know them and I think children are lucky to have them as their doctors.

What I wish for them and for myself as doctors, what I wish for myself as a patient, for my patients, and for my loved ones who are someone else's patients, is a system that allows us to be healers, that helps us to heal. I want a system that allows me to express my compassion, that gives me the space and time to care for people in a meaningful way. Unrealistic? Selfish? Possible? I hope to find out.

Monday, February 10, 2014

Who did what?

As a physician, I remember countless patient's details and stories, and as a medical educator I remember student's sagas, issues, and triumphs.  But I have an EMR, chart-stimulated recall, notes.  

At home I have an imperfect record.  I remember the beautiful moments and the laughter and the tears and the growing older as a family, but I sometimes forget which child's nursemaid’s elbow I reduced (3 times).  Which of my 2 children used to grind teeth at night?  Which one wouldn’t let us take the band-aid off for a month after an influenza vaccine as a toddler?  I know who had the UTI (she did) and I know who had the early --now outgrown-- milk protein allergy (he did).  And I know that she now swims, plays guitar, and reads about as avidly as she eats macaroni and cheese. And that he is now a drummer and a young scientist wise beyond his years.  My two are so distinct from one another in many ways, and yet I've forgotten whether it was my son or was it my daughter who erroneously pressed 9-1-1-send on my cell phone.  Come to think of it, they both did that.  Then again, even at 7 and 9 years of age they sometimes call me "dad." And I’m okay with it.  The memories meld together, and the love is shared.  

Does it always matter who did what?

Wednesday, February 5, 2014

Involved, but not quite a “Lunch Lady”

Today was my first day volunteering at Zo’s daycare. He attends a quaint Spanish-immersion daycare and we love it! My husband and I can’t say enough about the amazing ladies who run the daycare. The children are loved and now Zo knows more Spanish than both of his parents.

I grew up with a stay-at-home mother who volunteered at my school all of the time. Much to my chagrin, for a short while in elementary school she was a “Lunch Lady”. I never really realized just how much it shaped me to have my mother around so much. I may have complained in the moment, but knowing that she was around gave me a sense of stability that has truly shaped who I am.

Flash forward to today, as I sit during a “stay-cation” (not nearly as much fun as Cutter’s "Best Week Ever"), I am working on IRB revisions, completing training modules, a case report, and ordering interview dinner food, all while getting over a fierce upper respiratory infection. In the midst of the many moving parts in my life, I volunteered at Zo’s school today and it was SOO MUCH FUN, here’s how it went:

When I arrived at the agreed-upon 10am, Zo’s eyes lit up and he proudly told every toddler who tried to hug me “this MY mommy”. His teachers began singing a song in Spanish about cleaning up and getting into a circle and 85% of the children obliged. I then pulled out Zo’s favorite dinosaur pop up book “Dino Roar”. The kids, and especially Zo, loved it and we all growled and pointed at interesting pictures. At around 10:35am their amazing music teacher Miss K came in for their weekly music class! She led the toddlers in activities involving drums and little shakers. We danced and clapped our hands and she even reviewed some music composition with them. When she left, I read another of Zo’s favorite books about loving others called “One Love”. When it was time to leave as they prepared for lunch and nap time, Zo cried and I almost shed a tear.

I truly felt like the involved mother I some day hope to be. In a busy day, I incorporated Zo-time, me-time, professional time, and later in the day family dinner time. Far from my mother’s lunch lady days, I hope to maximize my available time and be present in my children’s away-from-home lives as much as possible. It truly was food for my soul.

Monday, February 3, 2014


Lately, I've been trying to get more exercise, which is hard for me because I've never been what you'd call an active person. Unfortunately, there have been several barriers:

1) My lack of stamina, which is just plain embarrassing. When the person next to me on the treadmill runs 5 miles while I can't even run 2, and most of that is spent walking, it just makes me feel bad. I'm sure I'd be humiliated in any class I tried to take.

2) No time. Finding even half an hour to go to the fitness room a couple of times a week is a challenge.

3) After I work out, I'm tired. That was fine when I was 25 and all I had to do after my step class was veg on the couch. But now I have two kids to take care of post-exercise.

But I REALLY want to get in shape.

Well, maybe next year.