Tuesday, February 24, 2015

I Just Want to Dance!

I recently had an idea that I wanted to sign my Doll up for some dance classes.  She is old enough for them, and with a quick google search I found >10 studios in the area! (And many more with a little driving.)  I called all of them.  Each one.  Not one has any classes available on the weekends for children that young.  All of the classes are offered on weekdays, right in mid-day (11AM-2PM).  There is no way I could make that work.  ::Working Mom guilt explosion::

Thought:  My child will just have to be deprived of life's pleasures such as dancing, her life is ruined!!
Feeling:  Guilt and sadness
Restructure to:  My child has many pleasures in life, but dance class will not be one of them at this point.

CBTing myself didn't quite work...I am still writing this blog, feeling deflated.  Oh well, life goes on.

Wednesday, February 18, 2015


I recently recommended my mother read a book called big little lies by Liane Moriarty because I thought that was one of the best books I have read all year, and dealt with a lot of important issues. One of the issues was that the daughter of a woman who had been abandoned by her husband when the daughter was a baby comes back into their lives, and now the daughter suddenly likes the father better.

My parents got divorced when I was a toddler, and my relationship with my father always frustrated my mother. She always told me when that I was older, I would "get it" and suddenly despise my father, yet now I'm older and I apparently still don't "get it." 

This book has gotten her all riled up.  Her latest email to me says that it's better if the father dies than if the parents get divorced, because then there's no bitterness. It's better not to have a father at all than divorced parents.

Right now, I'm older than my mother was when she got divorced. I've been married for over a decade. I've see many of my friends get divorced. I've struggled with my own marital problems. So I really do think that I do "get it." These are my feelings on divorce when you have children, based on my own childhood and everything I have seen:

1) sometimes divorce really is better. If you stay with a person that you hate just for the sake of the children, the children will notice this and they won't think it's better.

2) if you do get divorced, maintain an amicable relationship with your ex. Don't make the children pick sides.

And this is the hardest one of all…

3) if it all possible, don't leave your spouse for another person. If you're having an affair, presumably you're not happy in your marriage. Don't wait for the affair to be the impetus to leave, because it sucks to be left for another person. It's a lot easier not to feel bitter if you don't feel like you were discarded for a younger or better version of yourself. 

My hero is fellow MiM blogger Gizabeth.  She's written about her divorce here, and she's had an exemplary relationship with her ex-husband.  A divorced person should use her as a role model.

Obviously, it's better to have a marriage that is all sunshine and lollipops.  But sometimes (often) that can't be the case.  Sometimes divorce really is what's best for both the children and the whole family. 

Tuesday, February 17, 2015

MiM Mail: Missing life before kids

I am a family doctor in southern Ontario but previously worked in remote northern Canada for 3 years. Up north, I worked in full-scope practice, including OB, ER, home visits, hospitalist, fly-in communities, medivacs and nursing station phone support. When I became pregnant, I could not have my job modified to have a healthy pregnancy. I was concerned about extremely bumpy boat rides to get to and from clinics, helicopter transfers, working in very cold environments, nearly being flooded, stray dog attacks, dust, bugs, and not having safe shower or tap water in certain fly-in communities. I had asked to not work nights but was told this was not an option due to lack of staffing.

Sadly, I left the community I had intended to stay in all my life. I moved near my extended family in southern Ontario. We bought a farm, and my husband stays at home with the baby and farms. We have the wonderful support of 4 grandparents. We now have a very happy toddler and another baby on the way in the summer.

Down here, I run my own clinic four days/week. I am doing walk-in clinics on the weekend. Although I enjoy it and have a very reasonable schedule, I am growing antsy to do more. I find that down here, even the simplest issues are referred to specialists. Compared to the north, people are not very sick when they see me. I enjoy being home with the baby, but only for a few days a week. I am happier working as a physician the rest of the time. I miss the action and adventure of northern medicine. I keep looking at job openings in the north and trying to figure out how this could work. What I always seem to conclude is what is best for me isn't best for my family.

The things that are keeping me from going back up north? Well, for one, I am 16 weeks pregnant. I plan to have two kids, so after this one, pregnancy won't be a limiting factor, but breastfeeding will. My husband doesn' t want to move north, as there are no farming options for him there. He has farm animals that require daily care, so even doing locums and bringing him with the kids isn't possible. I could go alone, but that would be very stressful on a baby and toddler.

Maybe I should just stay put and accept the current situation. I just feel like my skills are being lost for every year I don't use them. I would love to hear some advice or suggestions from others.

Sunday, February 15, 2015

Early Morning Musings of a Snowbound and Homebound Primary Care Physician

Genmedmom here.

Here in Boston, we've been experiencing winter weather conditions never before seen in modern times. I'm not exaggerating. A series of intense winter storms and an unusually prolonged stretch of extremely cold temperatures have combined to create a Pompeii of snow and ice, rather than ashes. The region is near-paralyzed. Frankly, I'm getting bored of writing about it.

But the fact is, weather disasters unite us, forcing us all to realize that we are weak, small, and, well, only human, compared to Mother Nature.

As a primary care doctor, this weather has also forced me to realize some humbling truths.

One: as a 100% outpatient attending, I am not an "essential worker".

Two: I can do alot of my job over the phone, safely, and with greater patient satisfaction.

For the first two of these last four major winter storms, I was home alone with my two children under five years old. It was not physically possible for me to shovel out in time for work, and I had to cancel some clinic days. For the third, my husband was home, but the weather was so bad that between us, it was still not physically possible to shovel out in time for clinic. I cancelled again. Then, as mass transit was also shut down, and most staff had no reasonable way to travel in, our office ended up closing for a day as well. The hospital announced that basically, only employees essential to inpatient services needed to report to work. The Governor of our state announced that only "essential employees" in general needed to be out on the roads.

All of these weather events equaled alot of patients whose appointments had to be bumped. For all of these days, I reached out to most of my folks directly, and offered to handle their medical issues over the phone to the best of my ability. I felt bad, and so I made myself as available as was reasonable using our secure messaging system, email (many of my patients work at the same hospital) and my cell phone.

Everyone I contacted was thrilled that they didn't have to figure out how to get to my office; most were going to cancel anyways. What I found was that most acute issues were handled safely without a visit; physicals, pap smears were rescheduled.

Examples of issues that were managed successfully included UTIs, candida vaginitis, mild asthma, URIs and sinus infections. I've been following some more complex cases, and we were able to determine stability and plan next steps; these are folks undergoing workups for more serious symptoms.

My internal medicine colleagues described similar scenarios, diagnosing and treating everything from shingles to migraine to flu, over the phone. One of these colleagues commented that "it didn't feel good" when she realized that she was "non-essential".

It wasn't always this way. As a resident, and then a fellow with inpatient responsibilities, calling out for bad weather just wasn't done. Later, as an attending with inpatients to round on, ditto. But our practice has since turned to our hospitalist service to care for our inpatients. This was done with the encouragement of the hospital; almost all practices have done the same. Inpatient medicine is now its own animal.

Still, the idea that I'm an M.D. and also "not essential" feels odd. I feel guilty for staying at home with my kids.

A reader then introduced me to a wonderful doctor-mother blog written by surgeons called: Hot Heels, Cool Kicks, and a Scalpel: Trauma Mamas Balance Fashion, Fitness, and Family. One of their trauma surgeons has also been writing about the snow, and I was so glad to read her posts, as they alleviated my guilt, substantially. Two particularly relevant posts:

Rants of a Snow Beleaguered Trauma Surgeon

A Plea For Snow Days and Common Sense

I am learning to make peace with being non-essential. I am also considering offering telemedicine visits to my patients on a regular basis; though reimbursed at a much lower rate, the patient satisfaction would pay dividends. This may also free up visits for more acute illnesses and/ or physical exams.

My thoughts and prayers go out to the essential healthcare providers and hospital support workers who have to get in to work or stay in the hospital through weather like this, and I would be interested to read more about the experiences from "the other side"....

Wednesday, February 4, 2015

Guest post: Trust me, I am a mother

I never went into medicine to become a better mother. I never became a mother to become a better doctor. But, the two journeys merged in 2013 when I knew something was seriously wrong with my almost six year-old son. My son is like any other boy his age, other than occasional mild irritability that is slightly over the average and incredible creativity. He usually springs out of bed ready to tackle the day, excited about all the projects he is going to do. For about ten days, I noticed that not only was he not interested in any activities, but he was incredibly irritable at even the most minor setbacks. He has always had a high pain threshold, yet we started noticing an increase in his frequency of "got hurt" episodes. There were no focal deficits on physical exam. I sent an email to his teacher asking if she noticed any limitations at school. She said no. I didn't know if I should go to a pediatrician or a psychologist. Then, he developed a minor unprovoked pain in the shin. I jumped on it as now I had a reason to take him to the pediatrician. I reasoned with the pediatrician that given the irritability and mild low grade temps at night time for two days, his shin pain may have been an indicator of something systemic. After an exam, she ordered some blood work and X-rays which came back normal, other than a slightly elevated WBC and platelet count. She told me to trend the fevers and to come back if there was no improvement.

The same night, I noticed a slight temperature and called the on-call doctor. I explained that I was concerned about the low grade temperatures without an obvious source, and that the shin pain might point to a musculoskeletal or neurological issue. She also told us to "trend" the fevers and call her back in the morning. Completed unreassured, we took him to the emergency room. A full day waiting in the emergency room led us again to blood tests that were mildly abnormal but not convincing for any diagnosis. An MRI of the leg was done which was read as normal. I pulled the pediatric ER physician aside and told her my concerns: was there something systemic? As an adult critical care physician, I was not the kind of parent to seek attention unless I was truly concerned. I alerted her that I was concerned regarding the elevated white count and thrombocytosis without an obvious source and even more concerned that the MRI was normal. We were told to "trend" the fever, and if it became more than 101.5, to seek attention. We were also to give scheduled ibuprofen to suppress any synovial inflammation that may be happening in the hip from a viral infection two weeks before. After a dose of ibuprofen, they tested his walking, and said that it was noticeably better, so it must be Transient Synovitis, a diagnosis of exclusion. One caveat to this "give the drug, and see if this gets better, if then, it must be this" argument is that it is absolutely flawed. If the participant knows that "he or she is supposed to get better" then the free will overcomes any pain and of course, he is going to walk better. It may or may not have anything to do with the drug. We walked out of the Emergency Room still concerned.

I continued to give him ibuprofen over the next day. He continued to limp. The ibuprofen suppressed the fever, so now we had an afebrile child who couldn't walk. After no significant improvement, we took him back to the pediatrician office the next day and asked for a neurological exam and, bingo, over the course of a few hours my child developed cerebellar ataxia, clonus, and inability to stand. All of this happened within the time we saw the pediatrician, got him back to the emergency room, and a MRI was scheduled. That night as I sat at the edge of the MRI machine holding his leg, I had never been more frustrated with the fragility of the human body. I loathed hospitals. I never wanted to step foot in the hospital again. The doctor inside of me put the differential diagnosis of "epidural abscess, brain tumor, meningitis, encephalitis" on the list, while the mother inside of me put "something really bad" at the top. While the initial scout films started coming up, my husband, who is a body radiologist subspecialized in MRI, stood by the MRI technician with a solemn look in his eyes  -- one that I had never seen before. As he drew his finger in a vertical line across the computer monitor, the heart of the mother inside of me sank, while the doctor inside of me said, "Wait, that could mean it is not a focal tumor or an epidural abscess, but could it be a diffuse tumor? Maybe, it is meningitis."  With one hand on my child's leg amid the deafening noise from the machine, I kept waving to my husband to see if he could tell me something. He asked me to come outside and knowing my child was already asleep in the machine, I stepped out and could immediately notice the flair abnormality that swept across the spinal cord. As the axial cuts were pouring in, we could see the flair signal lit up like two snake eyes pointing to the diagnosis of Transverse Myelitis, which we knew only held very good prognosis one third of the time. There was no Brain MRI ordered as the ER staff wanted to "focus on one thing at a time," and it  seemed that the spine was the problem. Thankfully, the neuroradiologist who was examining the scout images, and who was about to leave in thirty minutes for the night, noticed the transverse myelitis throughout the spinal cord and asked the technician to add a brain MRI. Within minutes we found her and discussed with her and confirmed the diagnosis of Acute Disseminated Myeloencephalitis with Transverse Myelitis, a disease that occurs in my child's age group, typically after a viral infection or a vaccine.

During the hours in the emergency room, my son went from being able to walk with a limp to being unable to move both legs and becoming tachypneic. Prior to returning to the emergency room from the MRI, I told my husband that knowing the diagnosis, they will for sure want to do a lumbar puncture to rule out active bacterial/viral meningitis and this will of course delay steroid treatment if the lumbar puncture was not done in an expedited manner. We were already in the emergency room for twelve hours by the end of the MRI and given the progressive course of his symptoms, further delay could have caused him to progress into a coma and the risk of hemorrhagic encephalitis existed. Upon return, we asked the team to be present at his bedside, and we made our concerns open to them. The on-call ER physicians were skillful and quickly performed the lumbar puncture. We soon knew that there were no alterations in protein/glucose/gram stain and that we had the right diagnosis. The ER team hung the bag of 600mg of IV solumedrol before we were transferred up to the ICU and every successive day resulted in more return of neurological function. Within five days, we were at home recuperating after this nightmare of an illness. The neurologists repeatedly told us that they have never seen a child with such degree of MRI severity not have the physical signs to reflect the changes; it is likely because we sought attention right in time. The mother inside of me was strong during the five days, and the doctor inside of me was quick to decline any unnecessary blood draws and made sure that he got out that hospital as quickly as possible. For if anyone knows how deadly hospitals can be, it was the doctor inside of me. We were welcomed at home by a supportive community and his return to school and activities was a breeze because of the love and support from family and friends. When I bought my son a couple of youth basketballs to help his recuperation phase, he jumped out of the sofa, ran to me, gave me a big hug and said, "Mommy, how do you know me so well?"

I said, "Trust me, I am a mother."

Monday, February 2, 2015

"You're full of it"

I have read countless articles about how medical trainees have been berated and belittled, yelled at or pushed. I have never in my years of training felt that way or been treated that way. Yes, I’ve been questioned strongly. Yes, with lines of questioning sometimes called “pimping.” I have felt like I needed to study for 40 more hours and have gone into the bathroom afterward to cry, but I’ve never been berated. I’ve never been pushed. I never even thought of what I would say or do in those situations. I have heard my share of racist and sexist remarks and have found ways of addressing it directly and highlighting to the team why it’s unacceptable. But what would I do if someone directly belittled or disrespected me? Would I cry? Would my knees buckle? Would I yell?

Well, that all ended when a Pediatric Surgery Attending told me, “You’re full of it” in front of my staff while I was working in the Pediatric Intensive Care Unit. This particular Surgeon has a history of yelling at Resident Physicians that I learned of after the incident. That night, I was caring for a postoperative patient who had just left the operating room. During interdisciplinary sign out I asked for clarification of a medication dose as I was preparing to enter routine orders such as for PCA-administered pain medicine. The Surgeon turned and said, “No, we will enter the orders” meaning the Surgery Residents. I told him that in my experience PICU Residents enter the orders and manage the PICU patients. He said, “No, who trained you, this is my patient?”  I looked around and of course, everyone was staring at their feet. I was in my second month of PICU service and had heard countless times how our unit was a “closed unit” and that we managed our own patients, but this gruff, aggressively self-confident, tall male Attending with salt and pepper hair and a fresh tan was staring me down. I said, “You will need to speak with my Attending because this is not what I have been trained to do.” He turned, stomped away, and snuck in a low, yet completely audible, “You’re full of it.”

I stopped in my tracks and said more audibly, “Excuse me, but you just said ‘You’re full of it.’”I paused, collected myself and continued: “I feel very uncomfortable, and that was disrespectful. It is not appropriate to speak to trainees that way. I only want to provide excellent patient care.” He froze. When he turned around he had a look of utter contempt and disbelief; it was like no one had ever told him he cannot speak to people that way. His eyebrows furrowed and he spit out, “Well, I’m sorry,” and turned around. At that moment, my Attending arrived and my Fellow said, “Well, I’m glad you said it because I was about to.” I quickly excused myself as my hands began to shake and the pounding in my ears began to dull everything else out. I exited the unit, and sank onto the bathroom floor and cried. Big crocodile tears as my grandmother would say. I was anxious and nervous, but I was damned proud of sticking up for myself.

My PICU Attending found me later and asked me what had happened. I explained the facts and he shrugged and said, “I’ve heard worse,” and told me something about how that Peds Surgeon had cursed at him during his Residency. I told him that I hadn’t heard worse and had never experienced that type of behavior but that I thought it was unacceptable to speak to any member of the team that way. He shrugged and said he would address it with the Surgeon later. As I entered the Unit, the Nurses individually applauded me for speaking up the way that I had. I asked a trusted Nurse mentor if she thought I handled it well and she said I nailed it, and my Fellow echoed the sentiment. I didn’t get emotional, I said what I needed to say, and kept it focused on the patient. One of the Peds Surgery Chiefs came up to me later and had heard about it and gave me a quiet nod of support. She agreed that Surgery Residents who did not spend the night in the hospital should be consulted but they shouldn’t be the ones putting in orders since the PICU Residents are the ones who stay in house overnight. It’s a patient safety issue.

Many thanks to a different fabulous PICU Attending who a week earlier coached us on working in uncomfortable situations. She told us to use words such as “uncomfortable” and “unsafe” and keep things focused on the patient. Without her words, I probably would have shut down, my knees buckled and I wouldn’t have been able to say things in a way that would have gotten any response from that Peds Surgery Attending. I still believe, “You’re full of it” has no place when we are caring for patients.

I spoke on a panel earlier this year sponsored by the Student National Medical Association. They asked a group of underrepresented minority Attendings and Residents to discuss discrimination in medicine. I shuddered as I listened to the horror stories the Black and Latino Attending Physicians recounted. I think I would have quit if I had to endure the downright hostile environments they practiced in in their early careers. I don’t discount the real experiences highlighted by other trainees around the country and applaud them for their candor in sharing. I hope that we all are continuing to work so that abuse and disrespect are not allowed, and when they do occur can be apologized for and learned from.