Monday, January 26, 2015

That way you talk

I was in the office speaking with a parent and her kids at some point in the past year (how's that for sufficiently anonymized).  The mother was gazing at me for just a little too long.  She could have been pondering my most recent question, or may have been lost in thought, but at that moment I opted to ask her gently if she was okay.  And she simply said, "I'm sorry, I just love the way that you talk with my kids."

Oh how that made me feel that I'm right where I should be and doing what I should be doing.  She saw the way I really ask, really listen, and aim to motivate. It's working, at least in this case. 

You've probably heard similar positive comments from time to time about how you communicate with your patients.  And yet, if I could only do so at home!  I can be ever so calm and motivating, building partnerships, and serving as a measured and informed voice of reason at work.  And while I want to consistently do the same at home, I CAN'T HELP YELLING. AT MY KIDS. SOMETIMES. GOT TO WORK ON THAT.  You?

Sunday, January 25, 2015

moar veggies

My older daughter has always been an amazing eater.  She eats her fruits, her vegetables, her meats, her starches, and of course everything in the baked goods food group. One of her favorite foods? Scallops.  I was a terribly picky eater as a child, so I always wondered what I did to deserve such a great eater.

Well, the second time around, I got what I deserved.

My youngest daughter is a terrible eater. The only thing she wants for dinner every night is chicken nuggets. And even then, I sometimes have to beg her to eat them.  And God forbid they have the wrong shape, like if I gave her the circular ones when she wanted the dinosaur ones, or vice versa. (I'm never going to know which one she wants until it's actually in front of her.)

Recently, she suffered a really pathetic bout of constipation, and my husband asserted that she needs to eat more fruits and vegetables. (He already slipped through some of his fiber cereal in with her Cheerios in the morning.) Well, maybe fruits are possibility, but how do you get a kid who won't even eat the yummy stuff to eat more vegetables?

And furthermore, I have to wonder if it's really worth it. If she has to be coaxed to eat french fries or chicken nuggets, I can't imagine what I'm going to have to do to get vegetables in her mouth. It would probably have to involve a slingshot. So what if she doesn't eat her vegetables? Is it really so awful?

Friday, January 23, 2015

Do Female Physicians Need Female Chaperones?

Genmedmom here.

Our department is considering a policy that would require female chaperones to monitor every pelvic exam. This would include pelvic exams performed by female providers.

As a primary care women's health doc who performs pelvic exams every day, I felt vaguely insulted by this.

But, as both a female physician as well as patient, I understand the reasoning behind this potential policy. In our department's case, it was apparently proposed in response to a complaint involving a female physician; we have no idea what the issue was. Of course, historically there have been cases where there was abuse of the doctor/ patient relationship in this context. Also, cases of perceived abuse. To have an official "observer" present can help to prevent any abuse, or false claims.

My own OB/GYN office uses chaperones. But it always strikes me as odd and impractical. My own OB/GYN is an excellent physician with superior bedside manner who has overseen both of my pregnancies; she even guided me safely through a VBAC. But even she has to leave the exam room and go fetch a medical assistant, who may have never met me and is not involved with my case, so that they can stand there and observe what is basic, routine office care. I've considered requesting that she NOT go fetch the superfluous eyeballs, as I think it's kind of weird, and it would save time, too. But I haven't wanted to rock the boat.

So, as I have myself experienced, having an additional person present for this exam can also in and of itself be uncomfortable, and can make routine medical care feel weird. It may not help many women to feel more comfortable at all.

Are there things we providers can incorporate into practice that can help minimize discomfort and prevent abuse, or perceived abuse?

I really try to help patients through what is generally considered, at the very least, an uncomfortable and awkward examination. For many women, a pelvic exam can even be a traumatic experience, either physically due to atrophy or inflammation, or psychologically due to past rape or sexual abuse.

I think there's some basic things that we can do to help women feel more comfortable and in control when a pelvic exam is necessary. These include explaining why we are doing the exam and what we are looking for before we even start. Does she need a Pap smear, or STD screening, or both? Is she complaining of pain during sex, abnormal discharge, abnormal bleeding? Is there a strong family history of GYN cancers? Is there a family or personal history of melanoma? Then we'll discuss whether the exam will include a speculum exam, or a bimanual exam, or just an external exam, and why. Not everyone always have to do have all of these.

It's important that the patient knows what's going on at all times. I think it's better if the back of the exam table is slightly elevated and the paper drape is pushed down, so that the patient can easily see the provider. I also try to explain everything I'm doing in real time. I don't even touch the patient in that area at all, without saying what I'm doing and why immediately beforehand. I'll hold the plastic speculum up, and explain that it's the same diameter as most regular tampons, that we use plenty of lubrication with this, and it's usually cold. I tend to talk through the entire procedure, Rachel Ray-esque. Often I'll suggest yoga breathing, letting the pelvic muscles and buttocks relax.

In some cases, urinary incontinence is a problem. If Kegel exercises may help, I ask women if they know how to do these. Then, I either test their Kegel, or ask if they want to learn this. What I've seen is that many women who think they're doing a good Kegel squeeze will actually be tightening their buttocks, or simply tilting the pelvis. So I add pelvic floor physical therapy here: a lesson in isolating the pelvic floor muscles, and a test to see if the patient is able to do a decent Kegel. I think if someone walked in as I'm saying "Squeeze!" they'd wonder what was going on. But since Kegel exercises are effective for preventing and treating urinary incontinence, we'd better make sure patients can do them before we recommend them.

Sometimes, a patient is extremely uncomfortable with some part of the pelvic exam. Then, the exam must be halted. I usually pull the drape back down and discuss, ask if they would like to try again, or hold off. I really don't think a provider can proceed in those cases without a time-out and discussion. It's okay, and sometimes absolutely necessary, to just skip the exam. It can be rescheduled; special arrangements can be made as well, as in cases of extreme physical or psychological discomfort, such as exam under anesthesia.

I've had patients tell me that the pelvic exam "really wasn't that bad", or even that they learned something useful. I take this as positive feedback! I'm sure I can do better; we all can. I'd be interested to know what techniques other providers have found to be useful.

If we are required to institute this female-chaperone-for-pelvic-exams policy, it would mean significant logistical hassle. In our office, we work one-on-one with the medical assistants, and several are male. Would the guys need to be let go, transferred to other practices? In addition, our medical assistants perform the phlebotomies on the patients they've checked in. Were this policy to be put in place, we would need to reorganize our whole system, and likely need to adjust the operating budget to include additional staff. And, of course, if we're required to go fetch a chaperone before every pelvic exam, that will add time to all of those patient visits. Either we'll all run even more behind, or we'll have to restructure our scheduling, and likely need to institute longer days for us and our staff, to accommodate. Again, this could mean a budget problem.

In summary, I don't think that requiring a chaperone to stand there and observe every single pelvic exam is a good idea.
But, I'm very curious what women physicians think about this, both as providers and as patients.

What better place to ask, then the physician-mom blog? What's the vote: Yay or nay?

For those docs that perform pelvic exams, what have you incorporated into your practice to help women feel more comfortable and in control?


Wednesday, January 21, 2015

Guest post: Fewer patients, more friends

On the face of it, a day at the clinic seems very social. I see patients, one after the other, from nine until four, with a break for lunch. Most of my patients I've known for a while now. I get caught up on their their lives - school, family, work. "How are your spirits these days?" I ask almost every time, patting my right hand over my heart, using the most effective cross-cultural mood elicitor I know.  It doesn't get much more personal than this. It's just me and the patient, our knees almost touching, in a small exam room with the door closed and an interpreter behind my left shoulder.

I leave work after a day of this, drive the five minutes to pick up my three-year-old from preschool, and begin the commute home to Deep Cove. Suddenly I'm ravenous. I ask Ilia what's left in her lunch box and she hands me some carrot sticks and cubes of cheddar from the back seat. Ten minutes later, around Grandview and Nanaimo, I bottom out, utterly exhausted. The idea of having to shepherd four kids through meal time and bedtime chores after this feels impossible.

If Pete's not away on business, I come home to sous-vide salmon and curried cauliflower, and we divide up the after-dinner work. If he's traveling, we eat the lasagna my thirteen-year-old put in the oven when the big kids came home from school. Then I oversee homework and lunch making, brushing teeth and laying out tomorrow's school uniforms.

I cut corners. I pick the bedtime book with one sentence per page. I move up the bedtimes of the kids too young to notice. I want the noise to stop, even the singing. They're getting shortchanged, I think, but  I'll make it up to them later in the week.

Where I live. And why I live here. © Martina Scholtens. Deep Cove, BC
For years, I've seen patients Monday, Tuesday and Friday. Mid-week I'm home with my youngest, grateful that Deep Cove is off the beaten path. We can't see our neighbours from our place. Looking up from the laptop now, I see a stand of waving cedars, the gunmetal grey winter waters of Indian Arm, and the dark bulk of Belcarra rising from the opposite shore. The solitude is perfect. No play dates, thanks. No community centres or meeting up for lunch, either. I might be up for something on the weekend, but it'll take until Saturday evening to recover from Friday's walk-in clinic.  I need a respite from human contact, and I prefer as much solitary time outside the clinic as four kids will give me.

I forget, though, that seeing patients isn't at all a substitute for catching up with friends over drinks.  At the clinic, the topics of conversation, the confidences, the complaints - they're all one-sided. It often strikes me that family physicians are professional friends: non-judgmental, accessible, reliable, skilled listeners and excellent secret-keepers. There's pleasure in seeing patients, but really, it's business.

If you had told me that I'd have four kids and eight hundred patients, and feel lonely, I'd never have believed you. But my work drains me to the point that all of my spare time is spent trying to recuperate. Pete would love to have people over more, and vacation with other families. I always imagined a noisy, boisterous home with friends and family coming and going, but with my work commitments, I don't have the psychological reserves to make it happen.

Then I had an epiphany. Clinical work exhausts me with the people lineup, and my social life is extremely thin because I need stretches of alone time to recharge from work. I ought to reverse this. I need to implement more solitary time at work, and more people-time in after hours.

I've started on this. In October I gave up my Friday clinic. I've worked Fridays since I finished residency in 2003. Now I finish the week with administrative work and other projects instead, alone in my organization's secret library. Just me, a row of computers with access to our clinic's EMR, shelves of journals on paediatric nutrition, and a yellowing poster on Boolean operators. I can do this very happily for much of the day, and still have the energy to go out with Pete at night. It's been life changing.

I knew from residency that I couldn't see forty patients a day, five days a week. I find it hard to do half that. Maybe it's that my patient demographic, refugees with trauma histories and multiple barriers to care, are particularly challenging. Or maybe it's the demands of four kids. Maybe our clinic needs to use a different model of care. Maybe an office with some natural light and a view of the North Shore Mountains would help. There are probably other changes I could make to bolster my psychological fortitude and soldier on, even thrive, in this setting. But for now, I've reduced my work hours devoted to direct patient care.

Three months in, and no regrets. Before, I felt like I spent everything at the office. Now I've got this feeling of having a bit of pocket money. There's the promising jingle of spare change.

-Martina Scholtens, cross-posted at

Monday, January 19, 2015

Guest post: Loneliness

Cross country move to start a second residency, otherwise known as a long fellowship. Getting pregnant in residency. Health issues in the family. Yearly in-service exams. Patient care. Having a baby. Board certification for the first residency. Learning curve. Conference presentations. And now there is job search. I get by in most of these situations. I must say I have excellent family support, but a physician spouse can also only help so much. I find myself exhausted, sometimes nervous, mostly looking forward to the days going to work and coming home. But I also find myself extremely lonely. There is no time or energy to go meet other mommies. No time to hang out with your single or non-parent colleagues. (They don’t invite you anyway) No time to form new friendships. Hardly some time to hang on to the old ones you have left behind in another city and another country. I love my husband, who is also a hus-friend! But, a girl needs some girl friends.

I find myself making awkward attempts at trying to set up playdates with other moms, who apparently have their baby’s social life all dialed in.

Do any of you other mothers in medicine experience this loneliness? Or is it just me? Should I even allow myself to feel lonely when I have a lovely child and husband. Can you be busy and lonely?

Wednesday, January 14, 2015


I'm sure almost every physician has experienced patients complimenting them, or more likely complaining about, how long young they look. I've been told that I look like I'm in college, in high school, ought to be suckling on my mama's teet, etc.  you know what I'm talking about.

As I get into my mid 30s, these comments are becoming more seldom, which is what I would expect. I've spent my life wearing a sun hat to protect my skin, despite years of ridicule, I don't smoke or drink, but no matter how good care I take of myself, I've never met a 40-year-old who looks like they could be in high school.  So like it or not, these comments are sure to stop in the next few years.

It's not like I feel young. I've been a doctor for nearly a decade, and I am the mother of two children. I certainly don't feel like a high school kid. So I don't know if it's terrible to not look like one.  I would rather be respected for my wisdom.

Before I run out and buy 10 bottles of concealer, share with me what you think the best things about looking older are for a woman.  There's got to be something!

Monday, January 12, 2015

MiM Mail: Starting medical school, need encouragement

Hi MiM,

In six weeks I am supposed to start my first year of medical school. It's been a long time coming. I trained as a nurse, worked as one for a while, and then decided to pursue medicine. I finished off the prerequisites I needed, applied and got in (to a medical school in New Zealand - where I am from originally). My husband and I had a surprise pregnancy right before I was supposed to start medical school so I deferred for a year. I now have a gorgeous six month old and have been enjoying working casually as a RN. However starting medical school beckons, and I find the idea now terrifying. The unknowns of how to manage it all with a baby. I have an extremely supportive husband but he is also studying a PhD so is busy. We have great childcare sorted - our baby will be at the university day care right around the corner from the medical school. I'm not really struggling with the idea of leaving my baby as I'm not the full time stay at home type, but I am afraid I will find school all consuming and miss out on her. Also from a financial perspective having us both studying sucks - my husband gets a small stipend we can survive off but it's hard when our friends are buying houses and taking dream vacations, and we can only afford meat once a week! I suppose I am using this post and community as I imagine many others do - to seek out encouragement and to hear stories from those who have gone on before. How did you do it with a baby? Any ideas on how to manage financially? Is it worth it in the end? Etc. Would love any encouragement, inspiration, advice you can spare.

Thanks so much,

Tuesday, January 6, 2015

Every Bite is a Victory

In the last month or so, it seems that my Doll has absolutely rejected all forms of foods, at all hours.  She will take maybe a bite of something new, then immediately spit it out.  This has led to many hours of distracting her with toys, which hasn't worked.  Her left hand is always up and ready to push away any spoon or fork of food, and she has learned to swing her body from side to side as far as it will go in her high chair just so she does not have to eat.

When my husband is home, together we are able to get a few bites of food in her mouth--eggs, crackers, cheese, fruits, what have you.  Whenever she takes a bite (that she actually chews and swallows), I often feel relieved and frequently say, "Every bite is a victory."

One day, hubby was post-call and tired, but because of nanny drama, had to watch her all day while I was at work.  As a result, he did not fight with her to eat, he just put food in front of her and as a result, she didn't eat anything all day.  By the time I got home, she was hungry and ate an ENTIRE dinner!  I was so ecstatic, I told him he should babysit her more often when he's post-call.

This leads me to think:  am I just overfeeding her, so she doesn't want to eat?  I don't know, doesn't feel like she eats anything ever!  Is she just being a normal toddler who is refusing food?  Don't know, she's my first toddler!

The past week especially, I've been growing so frustrated with all of this, that this past weekend, I vowed to not care if she doesn't eat.  I'll just keep putting food in front of her, and if she doesn't eat, must mean she's not hungry.  (Right? I don't know...)

She started daycare this morning after a few months of nanny-ing... so we will see if this changes her eating habits at all.  I know they won't baby her the way I do at home, so it shall be interesting to see!

Does/has anyone else struggle/d with toddler mealtime?  I know it's not just me!

Friday, January 2, 2015

Princess Service

“Your Princess Service has arrived.” At the end of my holiday shift, those words uttered from the lips of my Dream Guy, were like music to my ears.

I just completed a 6 day holiday shift working what our residency program has deemed WARS (working at reduced staff). You work up to 6 shifts in a row and get either the week of Christmas or New Years off in addition to your 3 weeks of vacation. I gladly got one of my favorite inpatient services with the Division Chief that I most admire. However, after morning 3 of waking at 5am to arrive for sign out by 6am, I was tired, my feet hurt, and I was forgetting what sunlight felt like on my face.

Three years into residency, our family knows to plan for rough stints like this and to have extremely low expectations for how our house will look (though I am so ashamed about how cluttered our bedroom is and bemoan its state daily with apologies). My in laws came into town on day 1 and are staying for 4 days after.

My day of work ends with O calling and making some silly joke about my “Princess Service”. The staff members here call being picked up or dropped off from work “Princess Service” and O has added it to his lexicon. I don’t think he quite knows that it is one of the highlights of my day.

I have arrived home daily to Zo playing on the floor with his grandmother with blocks or making Playdoh cookies, a glass of wine waiting for me, and delicious vegetarian fare cooked by my in laws or my husband. By around 8pm I can be found in my pajamas nodding off on the couch while someone else does the dishes. I somehow make it through story time and have been in bed by 9:30 or so every night. O and I watch our new favorite on-line miniseries, this month it’s American Horror Story, and I pass out.

WARS has ended and I begin the next part of the end of this year, applying for my medical license in the 2 states that we would love to end up in, and preparing for my next interviews.

Here’s to all of the Princess-Mommy-Doctors out there. I hope during this holiday season you feel the joy I feel each time I hear “Your Princess Service has arrived.”