Monday, February 29, 2016

Because I Hated Every Second of Breastfeeding

Genmedmom here.

There have been many times when I have struggled to empathize with the patient. There are certain healthcare issues, and certain patients, that I have found consistently frustrating over the years.

I've written about this, and been pretty well chastised by readers. I don't mind, because I know that 99% of physicians have their kryptonite issues, and just don't talk about it. I'll take the heat for being honest.

My kryptonite issue has been obesity. I admit, that for many a patient encounter, I've sat there and counseled (for the millionth time) on diet, and exercise, and priorities, and wondered to myself: Why can't you do this? Why can't you just lose weight?

I know that sounds terrible. Heck, it IS terrible. My bias is based on my own experience: I gained sixty pounds in my first pregnancy, and fifty in my second. The weight didn't come off postpartum, and I found myself obese. BMI 30. I dedicated what precious little time I had as a working mom to eating healthy and exercising, and I lost it all. It took two years. It was hard. There were ups and downs. I've written endlessly about it here, and here, and here....

Of course I know that it is totally and utterly unfair to think "Well, if I could do it, why can't you?" but truth is, that's a pretty natural way to think, and many of us think like that.

So I've been making a conscientious effort to do better, to let go of the bias, and the frustration, and meet people where they are, no matter what the medical issue is.

But it was only when I was sitting with a lovely young patient of mine who was upset, grieving, actually, that she had been unable to breastfeed her infant, that I had a real breakthrough.

This poor woman had had a complicated pregnancy and delivery. Nothing had gone the way she had planned. But she held on and held it together, because she knew that if her baby survived, she would do everything right. She would take THE BEST care of this baby. She was determined to breastfeed for a full year. It had never occurred to her that that might not happen.

There were problems with the latch, with the milk supply, with pain, with baby's growth. Still, she was determined. She got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera... for weeks.

But one day when she had spent an hour and a half with the industrial-grade pump and got only about a teaspoon of breastmilk, with her nipples raw and bleeding, with her infant screaming, starving, with the pediatrician's concerns about his growth, with her consultants saying "Just push through! Keep trying!" for the gazillionth time but without any other real suggestions, and without any progress, she broke down.

She gave up.

So the baby got formula. And did fine. And grew. And she thought this burden was lifted from her.

Until the judgments came.

She was part of a social circle that especially valued breastfeeding. Friends and family would comment, say, "Don't you know breast milk is best?" or "Well, if you had only tried X, I bet it would have worked" or "If you had only HUNG ON a little bit longer" or "Those doctors pushed you towards formula, those doctors always push the formula, you shouldn't have listened" et cetera, et cetera.

It got to the point that she hid bottles and formula, or avoided socializing altogether. She felt like a freak, a failure. She worried what awful consequences there might be for her baby. She waited for some severe illness to befell her son, and for someone to blame it on her.

Oh, my heart went out to her.

Flashback. I was pregnant with Babyboy (now five and a half years old). I had a three-page birth plan outlining my natural vaginal delivery. I had a doula. I had Ina May's books on childbirth and Nancy Mohrbacher's books on breastfeeding. I had secured a highly-rated lactation consultant and booked a consult with her BEFORE the baby was born. I bought Medela breastmilk bags and a plastic organizer for the freezer. I arranged a breastfeeding room in my office.

But there were complications. The delivery- that's a story for another day. Emergency C-section for deep transverse arrest. Bradycardia. Meconium. Mayhem. I was discharged with a hematocrit of 22.

Babyboy was fine, but I grieved the loss of my dream birth. I was determined to get breastfeeding right: I wanted to breastfeed for a full year.

But. There were problems with the latch, with the milk supply, with pain, with baby's growth. I was still determined. I got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera.

Miraculously, I was able to breastfeed for a full three months.

But, I hated every single second of it.

When it got close to feeding time, I would inwardly cringe. With his latch, I would outwardly gasp, and clench my teeth in pain. The doula and the lactation consultants gave up on me. It was a nurse practitioner at Babyboy's pediatrician's office who suggested APNO (All-purpose-nipple-ointment), and it was an OB/GYN who prescribed it for me. The APNO cream helped a bit, and it got me through the three months, though nothing really helped.

Inevitably, what would come to mind with EVERY feeding were images:

Of glass-shard covered twine being pulled out of my breasts through my nipples.

Of someone pouring acid over my areolae.

Of my baby with little piranha teeth and malevolent intentions.

Oh, I hated it, and I hated myself for hating it. Wasn't breastfeeding supposed to be this wonderful bonding experience? I would rock and cry, literally cry, while stroking my baby's forehead and begging forgiveness, because I could not WAIT for this to be over.

So when it came time to go back to work, I started on a combined oral contraceptive and took Benadryl, and let that milk supply dry right up. Worked like a charm. I was done. It was such a relief.

When I told my colleagues I would not be needing that breastfeeding room, I got some eyebrow raises, but no one questioned. Many of them had made similar decisions for different reasons.

Most of my friends were understanding (very different social circle from my patient-mom) and for that I was very grateful. As a matter of fact, people came out of the woodwork with their own breastfeeding difficulty stories. I was not only NOT the only person who had struggled, I was not the only person who hadn't enjoyed it, and I was not the only person who had guilt about that.

Yes, there were a few "judgy" moments. People I didn't know well, and luckily didn't give a rat's ass about. A lady at book club gathering, a friend of a friend.

But my patient, my poor patient. Her "support network" was annihilating her. I was outraged on her behalf. I wanted to reassure her.

So I shared my own story with her, and we discussed ways to manage the hurtful comments and avoid the negative people.

For doctors, sharing our own stories and feelings about medical issues with patients is a tricky thing. Sometimes it's appropriate, sometimes it's not, and sometimes it's a mixed bag. In this case, the patient expressed relief and gratitude. She had been initially expecting me to judge her, too, she said. She was so glad to have found validation, reassurance and open discussion instead.

That's when I had my breakthrough: The patient had been expecting me to judge her, and had instead found validation and reassurance.

Wow. THAT is what I need to bring to EVERY patient encounter. Validation, reassurance, open discussion. Because that is what I would want for me, as well. It's what I want to be able to provide for everyone, especially my patients.

Sunday, February 28, 2016

That One Time When You Unknowingly Insulted Me

It was normal Wednesday and I was staring absentmindedly at the surgery white board. I searched its unending list of procedures and "ectomies" that stretched the entire length of the wall, until I was finally able to locate my string of minor surgeries. Lost deep in thought, I wondered if there was any feasible way the labor gods would be kind to me. What were the odds my labor patient would deliver while I was scrubbed in one of my many hysteroscopies? As I came to the conclusion that once again my day was hopelessly overbooked, I sighed only to feel a hand on my back.

Turning around I saw the familiar friendly face of a charge nurse. She looked concerned.

"Dr. RH+, poor thing, were you on call last night?" she asked.

"Actually, no. I slept all night." I chirped.

"Oh....." she said as we stared at each other, slowly realizing that she had just accused me of looking like total crap.

When the awkward silence became too much to bear, I faked a page and make a dash for the locker room, where I stat ordered eye cream from one of the 200 people on my Facebook feed who try to sell me overpriced fancy products endorsed by celebrity dermatologist. Maybe I can be the next before and after picture on their web site.

Asking a doctor if they are post call is like asking a woman if she's pregnant: Just don't do it, unless you already know the answer, then think twice. The "post call" look for me often means no sleep, no shower, puffy eyes and hair style that can only be described as "Beetlejuice"-esque.

Time, stress and life itself have had their naughty way with my appearance. My running addiction is great for my legs, but my crows feet have deepened without the extra layer of fat to cushion them.

While I can't remember the last time a patient asked if I was "really old enough" to be a doctor, I also haven't had anyone question my abilities in an equally long time. At 40, I am enjoying the comfort of my own skin. My patients confidence and my colleagues respect are far more important to me than a few fine lines. I look socially acceptable most of the time (at least I hope so). I wouldn't consider trading the peace and maturity of age for a baby smooth face, but also still it's not nice to tell me I look like a tired old bag either.

Monday, February 22, 2016

The other mothers of medicine...

The greats we learn about.  Often men.  Many of us have heard and read the stories of the "Fathers" of modern medicine.

But let's know and share and never forget the story of these women, Anarcha, Lucy, and Betsey.  We might call them the "mothers" of medicine, of modern gynecology.  Alas, these enslaved women whose bodies were used for physician's research. Without anesthesia.  Consent unknown.

Take a moment to listen to this moving podcast at NPR's Hidden Brain with historian and physician Vanessa Northington Gamble, and artist and author Bettina Judd, telling these stories that need to be told.


Thursday, February 18, 2016

35 pounds

I have lost 35 pounds. 5 pounds at time. Over the last 3 years.

Unfortunately, I have also gained 35 pounds over that same time frame.

3 years ago, when Hubby and I decided to have a second kid, I knew it would be better for my health if I lost 20-35 pounds. I also thought it would take a year to get pregnant because it did the first time around. So I began to exercise and diet. 2 months later and 5 pounds down, I was pregnant. And terrified because I had gained 45 pounds during my first pregnancy.

Then the miserable pregnancy began. Horrible morning sickness for the first trimester. I had expected some because I had it in my first pregnancy but by week 14, it had stopped. I got two blissful weeks in my second pregnancy where I could eat normally at the beginning of my second trimester. Then came feeling lightheaded after eating or abdominal pain that would prevent me from finishing meal. I rarely ate. I wasn't even hungry. At work, I would vomit in empty patient rooms' trash cans. I had to take 4-8 mg of zofran and 1000 mg of acetaminophen before each shift. I never had less than 3+ ketones in my urine. I felt miserable all the time. By week 28, I had gained zero weight, but had not lost any either, and ultrasounds proved Blur2 was growing fine. I passed out week 32 and was diagnosed with gestational diabetes (had passed my 3hr glucose test with flying colors weeks before). On the carb restricted diet, I lost 10 pounds in 9 days. Off the carb restricted diet, my sugars were never higher than 130, even after eating cinnamon rolls and drinking orange juice, and most of the time they were 100-110. Somehow, despite not eating, I gained back the 10 pounds and delivered Blur2 weighing the same as I did when I conceived him.

At my 6 week post-partum checkup, I weighed 15 pounds less. No diet. No exercise. Just baby and placenta and fluids. I was also able to eat normally. I was happy and thought it would be a great jumpstart to my original goal a year prior. Except, I was exhausted with new baby and a toddler and headed back to full-time at 12 weeks of maternity leave. Slowly, I regained the 15 pounds, but not more, as if my body wanted to be this weight.

1 year of adjusting my diet - less carbs, less fluid calories, more protein, used myfitnesspal - and my weight go down 5 pounds with each change and then creep back up.

I intermittently work out. I view exercise as a necessary form of torture. During periods of working out, my diet would get even better and 5 pounds would come off. Of course, I would stop exercising because I hate it and then the 5 pounds came back.

I got diagnosed with arthritis (subtype unknown) and worsening reactive airway disease. Stiffness all the time doesn’t help the working out motivation. Every little cold turns into weeks of inhalers. Steroids (for both), don’t help my weight.

I work evening and nights. I eat on the run or just before shift. I never liked breakfast, still don’t, and often catching up on sleep then. I am the cook for my home and I make healthy foods.

I am sick of the plateaus, the stopping-starting, this weight that my body wants to be, this relative out-of-shapeness. I am also sick of not being able to keep up with my kids and worrying about my future health.

Excuses are easier than losing weight and being healthy.

So I'll restart on Monday. Again.

Maybe this time I'll get to 35 pounds.

Tuesday, February 16, 2016

I Wish I'd Said Thanks

One of my mother's cousins died yesterday.

I hadn't seen in her a long time - there's a fair amount of distance in my family, literally and figuratively. Miriam was married to my mother's first cousin. He's an internist (that runs in my family) and she initially trained as a pediatrician and then did a psych residency so she could practice pediatric psych. Which she did; she was still working part-time when she took ill, just a month or so ago.

According to her obituary, Miriam graduated from medical school in 1971, shortly before I turned 11. I didn't remember the exact dates. I do remember - quite clearly - that she was the first woman physician I'd known. There were lots and lots of doctors in my family. They were all men. At that age, I planned to be a nurse. It had never occurred to me that I could be a doctor. And then I met Miriam.

I made up my mind when I was 14 - I was going to medical school. Miriam started sending me occasional articles from JAMA about women in medicine. It was one of those articles that I learned that there was a first wave of women in medicine in the early 20th century; I asked my grandfather and he told me that his med school class was about 30% women (he graduated in 1927). The Great Depression, the rampant discrimination that made it impossible for women to join hospital staffs and the post-WWII pressure for women to leave the workplace changed all that. My father graduated from the same medical school in 1958 and there were six women in his class. Miriam was part of the second wave, the women who went to med school when the OR changing rooms still said "Doctors" and "Nurses" instead of "Men" and "Women" and when women were still routinely asked why they were taking a spot away from a man, since they were just going to quit and have babies anyway. Miriam had babies - two of them - and never quit. She was the first Mother in Medicine in my life.

I don't know what my life's path would have been if I hadn't watched Miriam walk hers. Even from a distance, she was an inspiration to me, and in many ways my first mentor. I just sent a condolence note to her husband telling him that. I will always regret that I never told her.

When we are touched by death, we often want to hold our loved ones closer, and I will do that. I will also think about the other mentors who have touched my life, and start thanking them today, while I have time.

Monday, February 15, 2016

Guest post: My Valentine

This year both my children have their own Valentines to congratulate. I was eating breakfast at  a hotel when one lady approached and asked to share a Valentine story for her anonymous site. It did not have to be a romantic Valentine. Just anybody who you feel special love for. I immediately thought of one person. My grandmother.

About 40 years ago she was working full time and caring for her elderly parents when she took me in. Initially it was about a better school district and starting me on my first year at school. Then she ended up raising me, giving me the best upbringing ever, guiding me, stressing work habits, taking me to movies, theater, and concerts with her. Her life as a professional and community member will always be what I strive for. She grew up in a village, poor and hungry, in a country where authorities took basic posessions from their citizens for all to share. Her family of 8 children had to give up their only cow to the collective farm.The cow would cry passing their house in the evening on the way from pastures to the collective farm. My grandmother and her siblings would gather at the window to see their beloved cow ("feeder") pass by and would cry silently too. The family was allowed to keep the hens, but they had to give away eggs to the collective farm, so that eggs were a special meal on certain holidays only. My grandmother helped her parents at the farm since age 8. When she complained that she was too small for the labor, her mother would reply, "If you only could pick up one thing from the ground, it would be one less thing for me to pick up." So, grandma kept going. Then World War II came. All the food went to the fighting soldiers. There was so little to eat, many days my grandma's family members had one potato a day per person to eat. Life afte war was desperately poor as well. Nonetheless, my grandmother as a university student exchanged her bread allowance for concert tickets and went hungry to be able to see opera, ballet, and theater performances to educate herself about the higher culture, city life. She ended up running financial affairs of a company employing 16,000 people, exporting goods to 35 different countries. She was always proud of helping people and aiding lowest workers in their hardships and pursuit of better life. Many of her coworkers came to wish her happy 90th birthday last year, it made her so happy they remembered her.

My grandmother was the one who pointed me in medicine direction for a career, advised me on my marriage, came to see my children when they were born, remained my soulmate who I can talk to every day. She tells me her only regret now is she cannot visit her great grandchildren due to age. But she is happy she got to see America, the best country in the world. Turns out visiting America was her dearest dream back then, on the farm. She always wondered why Americans lived better and wanted to see for herself. She did, and she was happy her great grandchildren were growing up here. I will be sure to pass grandma's lessons to them - nothing is impossible if you work hard, help others when you can, what you are is more important than where you are from. I will be forever grateful that I was shaped by such a person as my grandmother. Instead of feeling resentful she embraced life as it was and made the best of it.


Sunday, February 14, 2016

Linea Nigra

I'd learned of it in medical school but never thought I'd have one. I looked for it all throughout my pregnancy, staring down along the midline of my gravid belly. Some telltale signs were there - the nausea, shortness of breath, tender breasts, swollen feet... But I never developed a huge, round, glorious belly that announced the joy of impending birth. Even with the twisting movement of a fetus anxious to emerge, it was hard to believe that this was all real. After years of wanting, of shots and procedures and waiting, it was finally here. But would she come out ok? What would she look like?

Then one day she arrived and they placed her on my belly, now saggy from where she was growing. She was beautiful, and I was immediately in love. Nothing else mattered. The nurse came into the room and announced, "It's time to mash on that uterus, shrink it back down!" It was then that I saw it: a faint, fine, dark line running from my belly button to my pelvis.

It's the tattoo of motherhood, one I never wish to erase, but I know they usually fade after birth. For this year, it's a gift to me from my daughter. A most perfect Valentine.

Wednesday, February 10, 2016

Vomit, Poop, Snow, and Chlorine: A Week In Review*

Genmedmom here, venting.

It's just been one of those weeks. There was no one particular event. We're fine, we're (mostly) healthy, we're happy.

But, it was just one of those weeks.

I was on call for our practice last weekend. Now, our weekend calls are not that bad. We do not round on inpatients at our hospital anymore; the hospitalists care for our patients. There were not that many pages.

But, the pages came at odd hours, and in bunches. Sleep was totally disrupted. There were stressful moments. Then, we have a brand-new, very complex electronic medical record to content with. I struggled with ordering prescriptions and documenting… Again, nothing big, just, annoying.

Then, Sunday afternoon, Hubby started having nausea, and chills, and muscle aches. Ruh-roh!

Yup, we were in for it. One by one, we were felled by the GI bug. Hubby had a mild version Sunday. Minimal active GI symptoms, but, down for the count. Overnight Sunday, Babyboy started spewing. I was on bucket duty. God love him, he never missed the bucket.

Monday, Tuesday, Wednesday, all clear. Long days at work: twelve-plus hour days, mostly immersed in this new computer system. But, no one was sick at home. We all breathed a sigh of relief.

Then. Thursday evening, I started feeling a little queasy. I vasovagaled in the kitchen, caught myself. I went to bed early, wracked with nausea, chills, body aches. I considered calling in sick for Friday. But, I wasn't actively spewing, I just felt like crap.

I debated: There was going to be a snow storm. Going to work in a snowstorm is bad enough, but feeling ill, would be even worse. On the other hand, calling in sick meant I would have to contact the few early morning patients myself, to cancel. But, these patients may be canceling anyways, given the snowstorm... I just couldn't decide, couldn't even deal. It was easier to just suck it up.

Friday morning, 5:30 a.m. I shivered into the shower, bundled up in wool, and headed down. I brewed the coffee, but I couldn't stomach it.

It was just starting to snow. The driving wasn't bad. I drive to the train, and take the train into the city. For the first time since pregnancy, I had to sit down on the train.

Now, I hate when healthy, able-bodied, lazy-ass people take up seats that others may legitimately need. I felt ashamed for sitting, but at the same time, I didn't think anyone would want me passing out onto them, either.

At work, I had plain Earl Grey tea to ward off a caffeine- withdrawal headache. The snow came down. Most patients cancelled. My stomach actually settled. I felt better as the day wore on.

Friday night at home: After I picked up the kids from Nana's house, where they had spent their snow day largely outside, they helped me help shovel out our neighbor. It was after dark, and cold, but they couldn't get enough snow. I was just relieved to be off-call and feeling normal. Whew! I'll get some better sleep tonight, for sure! I thought.

Then Babygirl vomited on the couch.

Babygirl vomited multiple times. Despite strategically placed buckets and towels, we had to change her bed out entirely, twice. She stopped vomiting abruptly at about 11 p.m. and declared that she'd like a glass of water, please. She downed it, and another, and was fine the rest of the night.

Saturday morning, this morning, we were supposed to have a behavior therapy group session with a new family. Babyboy is mildly autistic, and needs help interpreting and managing a lot of social situations. We were supposed to bring Babygirl, too.

We debated. She'd been spewing the night before, but had awoken bright and cheerful. She had wanted warm milk. She drank it, and it stayed down. She was playing, she was smiling.

We decided to take her.

Bad call.

Ten minutes into the session (at another family's house, people we had never met before) she vomited. She managed to warn us, and we managed to get her to their bathroom, but it all ended up on the floor. I cleaned it all up, on my hands and knees, apologizing right and left.

Then, right afterwards, Babyboy had a poop accident. He's five and a half years old. We've been working on toilet training for over two years now. We'd just had a week and a half without a poop accident, our longest stretch ever. We thought maybe, just maybe, he's toilet trained!

Nope. Hubby took care of this mess, in the same bathroom. The family was so kind and understanding, but still. We were so embarrassed. You could smell it for the rest of the session: rancid milk vomitus, foul stool reek.

The kids were supposed to have their first swimming lesson today, as well. It was out of the question for Babygirl. I envisioned her vomiting in the YMCA pool… Good God. No way. Hubby took her home to watch endless Peep and the Big Wide World, all wrapped up in her pink blankie on the couch.

I took Babyboy to the Y. It was his first swimming lesson ever. I was nervous. He was nervous.

It didn't start off well. We walked into the locker room labeled "Family Locker Room". It was packed and bustling with half-dressed men and kids of all ages and moms with babies and SO MUCH NOISE in such a small space… There were changing booths with curtains on them, but I could not remotely imagine getting myself undressed and into my bathing suit, separated from the men and young boys by a flimsy curtain.

But Babyboy made the decision first: "Mommy it's too noisy in here, please let's GO…" He had his hands over his ears like they hurt, overstimulated to a painful degree.

So I took him into the women's locker room with me. We had already changed into our bathing suits when the YMCA police (or whoever she was) came in and informed me that children under eighteen years of age aren't allowed into the women's locker room. At all. Ever. And we had to leave. Now.

The lady was very stern, and Babyboy started to cry. He thought he was being scolded.

"Listen", I pleaded. "I just don't feel comfortable in that Family locker room with all those men and boys around, you know?"

The lady relented. "Well, you can use the Girl's locker room, if you like. Technically, it is for girls, but, he's pretty little…."

And so we did. Apparently, there were no girls of an age that would use the Girl's locker room around, because it was completely empty. We relocated, stuffed our winter gear into a too-small locker and entered the pool area.

Whoa! The pool was super-steamy and the chlorine odor was almost overpowering. I wasn't sure if Babyboy would be able to stand it, but he did. Other than the fact that he slipped and fell on the tiles, requiring a helpful lifeguard to get him an ice pack for his head, Babyboy enjoyed his first swim lesson, such as it was. He wouldn't get in the water without me (I had anticipated this) and there were several other special-needs kids, plus, it's the Y, so of course it was a little scattered and chaotic. But, it was fun, and he was more comfortable in the water at the end then he had been at the beginning.

Back at home, we all laid low the rest of the day. We drew, we read, we watched Peep.

Now, we sleep. I hope…

*This post was written Saturday evening. Sunday morning, our longtime pet cat passed away unexpectedly. The kids were brokenhearted. We were brokenhearted. Obviously, that event overshadowed all of the crap I've complained about here. I decided to let this post stand, however, because it's how I felt at the time. I wrote about our kitty on my own blog: The Biggest Pain In The Ass Cat You Ever Could Love: We'll Miss You, Raffy

Tuesday, February 9, 2016

My Confession

I have a confession to make. It's a secret that I keep for as long as I possibly can from people that I meet, and I feel dread in the pit of my stomach at the thought of a new potential friend discovering my secret. But I trust all of you, so I will share with you my deep dark secret. Here it goes…

I am a doctor.

Try not to all gasp in shock at once. Yes, it's true. Maybe it's just my imagination, but it feels like my occupation is something of a friend repellent. A lot of other mothers that I meet are stay at home parents or work very part time from home, and I feel like they get flustered when I mention that I'm a doctor. One woman weirdly started talking about how much money she made.

Don't get me wrong. Potential friends are not the only people I keep my secret from. When I go to the doctor, either my own doctor or at the pediatricians office, I try not to let it slip that I'm a doctor. That way I can ask stupid questions in peace.

So am I the only weirdo who is embarrassed about my career sometimes?

Monday, February 8, 2016

MiM Mail: A hard pregnancy during residency


I've been a lurker on the Mothers in Medicine blog for awhile, and let me just say, the stories and posts have been so comforting to me, especially on my tough days. I'm a third year resident, currently in my third trimester of my first pregnancy in a two-resident household. I wanted to share my pregnancy experience to see if I could gather some advice from fellow mothers in medicine. I feel quite isolated as the only resident in my male-dominated program to be a new mother/pregnant in a long time, and at a hospital system where few female residents are mothers/get pregnant during residency, in general.

My pregnancy has been hard, to say the least. I envy all of those mothers who have the pregnancy glow, who have boundless nesting energy, and who just "love being pregnant!!!" My pregnancy has not been like that. First, it was unplanned, and happened about a month after my husband and I got married. I found out the day after my 24 hour call; I was so nauseous and I was late. I took the pregnancy test two times before I could truly believe that the two lines were actually there. After I confirmed the positivity and announced the news, it seemed like everyone was happy about it, but me. I had unknowingly performed multiple fluoroscopy procedures, and I was so worried about what the effects would be on the baby. I consulted my OB, a radiation physicist, and multiple radiologists, who assured me that this early, the effects should be all or nothing, and if the baby had made it through to this point, everything should be fine. My husband and I made the decision to proceed with the pregnancy. We felt that women go through pregnancies in worse situations and conditions, and we should be so lucky to get pregnant this easily with a supportive environment there to welcome the baby when he/she arrives.

Anyway, fast forward through first trimester, which was fraught with all- day morning sickness that even lasted through my night shifts and into my second trimester, to third trimester, where I now find myself having failed the 1 hour and 3- hour glucose tolerance tests. Just barely. I'm now diagnosed with gestational diabetes, and I feel like a failure. Prior to being pregnant, I was skinny, fit, and perfectly healthy. The only risk factor I had was being Asian. The news was terrible; I had been feeling like I couldn't excel as a resident, and now, I felt like I couldn't handle my duties to be a healthy pregnant mother. As someone who has been usually been able to balance multiple plates somewhat successfully, these two losses felt like huge blows.

I've been dealing with gestational diabetes the way that I deal with most challenges in my life; through hard work. I've been increasing protein intake, decreasing carbohydrates, logging my food religiously in a diary, pricking my finger 4 times a day, and walking at least 5 miles a day. My post-prandial sugars have been great. They're super tight, and well below the cut-off of 140. In fact, I haven't had an abnormal number. On the other hand, my fasting sugars in the morning are a touch high. The cut-off is 95 at my physician's office, and mine ranges from mid eighties to mid-to-upper 90's. Actually, there have only been 3 values from 95-100. My physician has given me until Monday to get the values down, before I have to go on insulin. I've tried everything to no avail. I still have 2-3 values hovering at 96. I feel like considering these numbers high is like splitting hairs. But I think my physician disagrees.

It's not that I'm against using insulin. I'm all for using insulin... that is, if I'm truly and outrageously hyperglycemic. I've done my research (on primary literature resources) and read that physicians will use cutoffs of less than 90, 95, 100, even 105. My range is in a gray area. There's also been a paper published showing that if the pregnant woman has no risk factors (the baby is not measuring large, there's no polyhydramnios, etc.), then the physician will let the fasting glucose ride to 105 before initiating insulin. The paper showed that aggressively treating lower risk gestational diabetes women (below 105, and with normal to smaller fetuses) with insulin may be associated with restricted fetal growth. I would be considered a "lower risk" mother, as my latest ultrasound this past week showed the baby was measuring below average, and everything else was normal. I also don't want to run the risk of being hypoglycemic, which I think is a valid concern, given that I'm about to enter a much busier rotation in which it will be harder to eat, and in which, if i become hypoglycemic, would be disruptive to patient care.

Do you guys think that my hesitancy about insulin in my situation is unreasonable? How should I approach the conversation with her? Of course, if more of my numbers are abnormal, then I'll definitely initiate insulin. I already superficially brought up this concern to my OB, which is why she has let me wait until Monday. But it seems like she is pretty set on starting me on insulin that day no matter what I tell her. She dropped the cutoff, saying that normal pregnant patients' fasting blood sugars run from 70-90's, and that tight control is necessary to prevent macrosomia and to improve the baby's transition (and to lessen NICU admission). I don't want to be "that patient." But at the same time, even though this is not my field of expertise, I do have health literacy, and I don't want to act too aggressively to make an already stressful situation more stressful. I don't feel like I'm as high risk as she's making this out to be.

I really appreciate your thoughts and opinions.

By the way, I have been and will continue to work 24 hour shifts and nights into my 9 month. But that's another dilemma for another day.

Thank you!

Thursday, February 4, 2016

MiM Mail: Turning Back

Dear MiM,

I was first introduced to MiM 7 years ago when I was on the path to do a clinical psychology PhD and considering changing my career to medicine. A great mentor was trying to encourage me in both my dream to someday have a family (I was single at the time) and to practice medicine. Fast forward and I am sitting in a "How to make a Match rank list" meeting, fighting back tears.

The problem is, I'm not sure I want to Match. Don't get me wrong, I love medicine and I don't feel that anyone led me astray. I can see myself practicing (probably part-time) in the future and being able to love my work. I am not discouraged by the notion of having a family in medicine. I simply do not think I have three more years in me. For months, I've been interviewing and trying to envision how my life would fit into each residency program and I've become increasingly discouraged. I am envious of my friends with their 8-5 jobs that support their lifestyle and am disheartened by the concept of spending a lifetime trying to make my lifestyle fit my career. My partner - who still loves me dearly and who has patiently supported me through a post-baccalaureate program and four difficult years of medical school (and poverty) - has talked about us splitting because he does not believe he can survive three more years of bending to my schedule and being alone so much of the time. (As an aside, I do not blame him for considering this, and I ask that you do not blame him either.) Add to that, there are no programs where we currently live. We have just begun to fall in love with where we live, we have many non-medical friends, my partner has a fantastic job (that is not transferable), and our families are within a reasonable drive. When I started down this path, a partner and a family were merely figments of my imagination. Now, I am the worst half of a relationship, the partner who is never available to be spontaneous and when I am, is exhausted and out of shape. I am the person who is hindering my partner's career and tying him where I need to be. And, perhaps even worse, I owe him everything because I could not have made it thus far without him. Plus, I have some health issues that may impede my fertility, and the clock is quickly winding down to when the risks of pregnancy far outweigh the benefits. Add all that to $400k of debt and I feel terrible while all my classmates around me excitedly making their Match lists.

So do I pack it all in now, graduate with my MD and move on with my life, ashamed but being free of the struggle for balance in medicine? Or do I go through the Match, probably lose my life partner and simply cross my fingers and hope that a) I make it through with my mental health relatively intact and b) I can overcome my resentment and still enjoy medicine? This is such a sensitive topic that I am afraid to reveal my reservations to my mentors and I have valued the fantastic insight of the MiM community thus far. Thank you, in advance, for your support!

Struggling with the Match

Wednesday, February 3, 2016

Happy National Women Physicians Day!!!

Happy National Women Physicians Day to all the wonderful MiM crew!!

Thanks to KC for creating this awesome community of women!  You are our hero!!

#nwpd #iamblackwell

Tuesday, February 2, 2016

Advice on potty training!

Hello fellow MiM,

My little C turned 3 about a month ago. After she adjusted to pre-school at about 2 and a half, her teacher told me she was ready for potty training. In fact, I think the whole process took less than a week! In 1 week, she went from diapers to pull ups to underwear. And a week after, she stopped wearing night time pull ups.

Of course, she wouldn't let me get away with it that easy!

It's been about 6 months since this happened and she still refuses to poop in the toilet. When she needs to go poop, she'll bring me a pull-up and tell me "I need to go poop." I believe a big part of her fear of pooping in the toilet is because she's always pooped standing up as soon as she could pull herself up to stand. Overall, it's not too big a nuisance except when there are times we go out and I don't bring a pull-up and we have to rush home so she can go poop.

Then there have been times that we couldn't go home and she would just hold her poop. I figure in these desperate times that she would just go in the toilet but nope! Doesn't matter how long, she will hold it and eventually go poop at home in her trusty pull-up!

I used to be frustrated but I could sense that I was stressing her out so I stopped (after she pooped in her pull-up, she would ask "are you mad mommy? don't be mad mommy!"), hoping one day that she'll just figure it out. I mean, we all eventually figured out how to poop in the toilet right?

I have tried a lot of different techniques including different types of toilet seats, lots of bribery whether it be with candy or TV time, and even hiding all the pull ups. But she is stubborn, none of these have worked and I always cave because I don't want her to get constipated.

Any advice?

Just let it be? (This has been the approach from the past 3 months but I don't see her changing her mind at all about wanting to go in the toilet!)

Thanks in advance!

X-Ray vision

Monday, February 1, 2016

MiM Mail: Hope it gets better

I hope things get better. At least that is what I tell myself everyday as I leave my house at the crack of dawn to get to work, barely having seen my child the day before. Better I do this now than when she is older are the words of encouragement I get to help me cope with my situation. I knew from an early age that my greatest desire was to become a mom, a working mom that is, until, Miss A arrived. I received the news I was pregnant halfway through my residency interviews. Scared, upset, sad were the emotions going through my head when I found out I was pregnant as this wasn't planned. I just got married and we wanted to wait at least a year. How the heck am I going to manage beginning intern year 9 months pregnant??!!?? I dreaded telling whichever program I matched into that I would have to take maternity leave so early in the start of residency. But, I thought I could do it. I was strong enough. Fast forward almost a year later. Every day I wonder if I made the right decision to not delay starting my residency. I miss so much of her development with my crazy hours. I see all my friends who could afford to be stay at home moms and become extremely envious. How lucky are they that they can be there for their child while I'm stuck working 70+ hours. Why did I become a doctor??!! Right now I am in the midst of reapplying to a more lifestyle friendlier residency but I'm constantly wondering if it gets better. If it is worth it. If I didn't have the massive loans, I would have quit already. I never imagined how something so small could cause you to rethink you life decisions. I fear that whatever little bond we developed during my maternity leave will dissolve. That I will be viewed as a stranger. God, I miss her. I just hope it gets better.