Monday, March 30, 2015

MiM Mail: Pressing advice needed for an IMG

Hi MiM,

I need some advice.

I’m a 34yo IMG who graduated and returned back to the USA a few years ago, keeping busy with research and odd biomedical-related jobs, but I’d basically given up hope that residency (and medicine) was in my future years ago. During that post-graduate time I also met and married the love of my life. We’ve been trying to start a family for the last couple of years, but were eventually diagnosed with unexplained infertility. It’s been incredibly frustrating – we’re both perfectly physically/genetically healthy and under 35, but what happens so naturally for others just wasn’t happening for us.

Over three months ago, in December, an opportunity fell in my lap to interview for a one-year preliminary position in Internal Medicine with a large community program that is currently not in the Match. The interview went well, I was immediately offered a position, and signed a letter of intent on the spot. During that time, knowing that we were not getting any younger and you just never know what the future holds, we decided to progress on to IVF. First attempt was a bust, and absolutely emotionally crushing for both of us. Then last month we transferred a couple of frozen embryos into me, and yesterday I got the results from my first beta-hCG blood test – big ol’ positive! In fact, it’s looking like it might well be twins (instant family!). I’m still being incredibly cautious about my optimism, but we’re both certainly happy at the news.

So now I’m left wondering how to handle this upcoming prelim position; they sent me my contract a couple of weeks ago, but I admit I’d been dragging my feet and sitting on it for a while, wondering how this whole IVF thing would play out and how I could/would juggle the two. In an ideal world, I could talk to my program director (who is incredibly nice, so far) about the possibility of starting this one-year gig next year (they’ll still need interns next year, right?). I know this is a job, not some schooling I can defer, but it seems, based on anecdotes here on MiM and elsewhere, that it’s a remote possibility. That being said, I know I’m incredibly replaceable, and I already got the sense that I was offered this position out of pity. My husband and family and friends say to sign the contract (otherwise I lose leverage) and then discuss the pregnancy with the PD and hope for the best. Meanwhile I’m worried that once I sign the contract, I enter into a binding agreement for the year, which makes it difficult to potentially postpone it until next year (if that’s an option). I wish I could discuss it with my PD, but I’m afraid of scaring him away to the point he’ll just decide I’m too much trouble and just walk away.

Maybe I’m just over-reacting, but I’m really not looking forward to the idea of basically spending the last two-thirds of my first pregnancy as an IM intern at a busy community hospital. I know from stories that internship and pregnancy by themselves can be physically and mentally difficult (and frankly, part of me fears them both), so to have to deal with them concurrently – especially as a ‘geriatric’ pregnancy, possibly with multiples – is just NOT something I’m looking forward to dealing with. It’s particularly worrying for me because I know this is an opportunity for me to shine and potentially continue on within the field of medicine, but I have the very real concern that I will simply not be at my best if I’m pregnant during internship and therefore not do my future any service.

I know I put myself in this position, but I'd welcome any advice!



  1. No advice, really. Just want to take issue with one thing. Instant twins = instant family? So having just one child isn't a "real" family?

  2. What's the program's track record with pregnant residents and mat leave? My program was supportive, even back in the '80s, and it's widely variable. That could tell you a lot about how the PD will respond and what your experience might bring.

    (and we were a family before our daughter was born and we're still a family with one kid)

  3. Call them and talk about it. The longer you sit on the contract the more they are going to wonder and feel like you are blowing them off.

  4. Call them and talk about it. The longer you sit on the contract the more they are going to wonder and feel like you are blowing them off.

  5. First of all, congrats on your pregnancy! Second of all, congrats on your "match"! This is such a tough situation. I would try to decide what is more important to you right now, becoming a mom or becoming a doctor (sucks you have to choose). If becoming a mom is more important, and you would be willing to risk your residency spot for it, then go forward however you chose knowing that you could potentially lose your spot. Perhaps you could talk to the PD now, and risk your spot being given to someone else, or best case scenario they are able to defer your spot to next year. Depending on your due date, the timing might work really well for that. Or, go ahead and sign your contract with the intention of doing your residency, but knowing there is a real possibility that you may fail. I was pregnant with twins during medical school and it was very difficult, and that was without any extra risk factors or preterm labor. But if being a mom now is more important to you, then maybe you’d be willing to accept that risk. Best case scenario, you could have an uneventful pregnancy and be able to finish your residency (albeit you may not be at your best during training while pregnant, you will never be at your best again until your twins are grown!) Also, I hate to mention this as an option, but what if your pregnancy doesn’t make it to term, or if twins turn out to be a singleton, in a scenario like that, if you had turned down the residency position, would you regret it? With a history of infertility I’m sure that has crossed your mind, but just make sure to factor that in. Lastly, join a mothers of multiples support group. Good luck!

  6. OP here... First of all, thanks to everyone for their replies.

    Secondly, I'm sorry if my use of the word 'family' offended people, as that was certainly not my intent. My husband & I have only known each other for three years and been married for two, so this all still feels pretty new to me -- certainly right now I feel like more of a part of a 'couple' than as a 'family' with him, but I can understand how that's not how everyone thinks. Of course, certainly having a single child is no less a 'family' than having multiples, but in my situation, if I manage to carry two to term, it would certainly preclude a lot of frustration in the future in trying to have a second child with our fertility problems, and I could have a bigger family more quickly. That’s all I meant. Apologies again.

    A few minutes ago I got the call with the results of my second blood beta-hCG -- it's doubling well, and this time next week I go in for my blood tests and first sono. I read previous advice here on MiM about waiting until at least the 6th week of pregnancy before informing a PD, which sounds like a safe bet to me, so I think I'm going to plan to do that. I guess I’m also lulled into a possibly false sense of security that I have some time to think about things by the fact that the contract doesn’t seem pressing (already signed by the hospital, there was no return-by date, no one has contacted me about it yet, and I’m being included in pre-orientation emails with all the other incoming PGY-1s), but I could be wrong.

    Thanks, DrTwinMom for your kind words and advice. It does sometimes feel like I'm at a place where I might have to make a very tough choice about my future. A huge part of me doesn't even want to put any stock into this pregnancy at all or tell anyone (my husband wonders why I'm not celebrating, even in private) because it feels so precarious, like it might fall apart at any time and I'm steeling myself for future disappointment. Funny enough, even by writing my Mailbag letter and reflecting on things afterward, I came to a similar conclusion to what you said: things COULD go awry with my plans/expectations regarding this pregnancy… and then how would I feel about residency? They always say you regret the things you don’t do more than the things you do. Might be better to sign on for too much, and just let the chips fall where they may.

    Jay: I’m embarrassed to say I don’t know how to find out the program’s track record with pregnant residents and maternity leave. It certainly didn’t come up at the interview, and I don’t know any residents there with whom I could talk. I tried to find out more info about their maternity leave policies over a month ago – it’s not mentioned in the contract, and when I tried to contact the department multiple times to get a copy of the House Staff Manual so I could read the policies, I got blown off each time, told that it’s currently in the process of being rewritten.

    It feels like a gamble, but I think after the (hopefully good) sono next week, I might contact the PD and just lay all my cards out on the table, even mentioning that I haven’t signed the contract quite yet though I want to. I don’t know if his nice-guy persona is real or an act, but based on my previous interactions with him (I know him through a couple of different avenues, including research) he seems reasonable and frank, and genuinely cares about training young doctors. Or is that the embodiment of naïveté? lol. Regardless of how he answers (if I decide to lay it all out to him), it’s not like he can rescind the offer, since the hospital has already signed the contract, right...?

  7. Congratulations on the long-awaited pregnancy and the prelim position!

    There's already been some great advice. I'd mostly like to add a few thoughts from my perspective of a healthy mom who had a complicated pregnancy/delivery during intern year.

    It was hard. It was very, very hard. I sailed along until 3rd trimester complications started to pile up. Thankfully my year was front loaded (ICU, wards, etc). I ended up switching off wards to an elective when I was physically struggling to take care of my work duties and my own medical needs, and delivered a month early for safety's sake. My postpartum course held continued medical struggles, compounded by a busy schedule and not having access to as much food as I needed to support lactation. (White coat pockets hold a finite amount of granola bars and string cheese.)

    My program director handled the situation with grace. They knew I was working hard, that I was struggling physically, and made the offer to switch me off wards. When I went on bedrest and some extra juggling had to happen, they set up a reading elective so I wouldn't lose time. When it became apparent I was struggling with ppd, they were supportive and helped direct me to free, confidential counseling provided through the hospital.

    It was the hardest thing I've ever done. Now, as I consider a second, I still face a decent amount of anxiety and fear. Will I be able to make it through another pregnancy? What impact will it have on finishing out my residency?

    If you think you're up for it, then run with it. Be smart about your schedule and try to work with the program coordinator so you're on lighter rotations by at least 32-34 weeks, as well as when you first come back. Build as much support as you can locally before you start. Make sure you get the basics well before the babies are due: car seat, place to sleep, and a few basic outfits. Most things can be purchased via Amazon Mom after baby arrives, as I learned well.

    If you do broach the idea of waiting a year, make sure you get a contract in writing. Honestly, if your goal is to impress this program in order to obtain a spot there or anywhere else for the remainder of residency, I think it will be difficult with a pregnancy. Hopefully your experience is easier than mine, but I was not at the top of my game for months, and I can't help but think that it would have made it hard to secure additional training.

  8. Thank you *so* much, Ladybug! I really appreciate personal stories like this, and while I'm dismayed to hear about how complicated your pregnancy became before & after delivery (hopefully all is well now), it was certainly nice to hear how much your program supported you. You've given me a lot to think about, including how to handle a lot of logistics both for internship as well as for pregnancy -- like the advice about buying stuff far in advance; smart!! Thanks again!

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  10. I would just say that it isn't really choosing between being a doctor and being a mother. If things go the way you want them to go, you're going to be a mother no matter what (fingers crossed and happy thoughts!). But do you think you can be a mother who is also an intern? That will depend on the support you and your partner have - family, friends, finances, etc. The baby(ies!?!) will be fine one way or the other, you will be tired, one way or the other. Maybe this is a way to just be really tired for a year and get both pathways started at the same time!

  11. P.S. If you do buy carseats early (I'd say wait at least until the 20week mark), make sure you get carseats that can handle as little as 4 pounds just in case you have small babies. We didn't think about that, but ended up very glad to have the seat we picked.


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