Showing posts with label Genmedmom. Show all posts
Showing posts with label Genmedmom. Show all posts

Wednesday, July 27, 2016

Talking Politics and Public Health With Patients- Is It OK?

Genmedmom here.

My Friday morning clinic was slow. There were two last-minute cancellations and a no-show. So when Mrs. Smith* came in for her physical, I wasn't in a rush, and we had some time to chat.

We talked about her recent hip replacement, and how thrilled she was to be finally pain-free and physically mobile, so that she could help care for her grandchildren again. Her face was bright with joy as she spoke of the beach and playground and the zoo and how much she loved experiencing the world with her two young grandchildren.

But she hesitated and frowned as she remarked: "I watch the news, and with everything going on today, I worry about them. We're moving in the wrong direction as a society. I mean, look at this presidential election, isn't it ridiculous, to think that a person so flawed could end up as a candidate? I'm frightened for their future."

Then she asked, "Your children are little, what do you think about all this craziness, do you lose sleep over it too? How can we protect them from it all?"

Up to that point, we had been slowly moving through the physical exam, and I had been wordlessly responding to her lighthearted description of her days as Nana the nanny with laughter, positive nods and smiles… When she admitted her fears, I reflected back grim countenance and shook my head, as if to mime What a shame, what a shame, but I didn't say anything. 

I had no idea at this point what her specific views were. Her comments could reflect the opinions of anyone anywhere on the political spectrum. The flawed candidate she was referring to could be either Democrat or Republican. I didn't want to say anything potentially inflammatory, or even mildly awkward.

But she sat there awaiting my opinion.

Her questions hung there, between us, as I shook my head and tried to think of something to say.

Is her idea of crazy the same as my idea of crazy?

Does she want to protect her grandkids from the same things that I want to protect my kids from?

Do I really want to talk about this? And, is it appropriate?

I thought about my morning commute. There's an app on my phone that pulls articles from all the news sources I choose, and I have chosen just about every possible news source, even those representing the far other side of my political leanings. I like to know what's going on, through all the looking glasses. I read it all on the train on the way to work.

For months now, the news has been increasingly disturbing. Mass shootings, terror attacks, senseless violence against minorities and law enforcement alike, war abroad, mass displacement… it's all horrible.

But what's worse in my eyes is that here in the land of equality, in a country founded on sound principles and thoughtful discourse, we are witnessing the ugly rise of a potential dictator. Here is a divisive fascist whose behavior already mirrors that of the worst dictators in history. Historians and scholars continue to make observations and deliver warnings. This kind of a man, this kind of rhetoric, these lies and sick ideas, are what have led to genocide and war in the past. And if that isn't a public health issue, I don't know what is.

So, what do I think about all this craziness? I think about it all the time. It makes me sick to my stomach. But specifically WHAT I think about it may not be appropriate to discuss with patients. I believe that the candidate on the right is a bona fide public health issue, on many levels. But so is gun control, and beyond asking patients if they have a gun in the house and how it is stored as a basic home safety screening question, I don't get into the issue with anyone.

Perhaps we should. Perhaps we, as educated professionals with a sworn oath to promote the health and well-being of our patients- ALL of our patients- should be open about our views on matters that effect patient safety. Maybe that could be a means of educating the public on important issues, like gun control.... and rhetoric that promotes violence.

This all went through my mind...

So, what did I say?

I murmured "I know, it's really scary…", paused and smiled and declared, cheerfully: "Your grandkids are so lucky that they have you. I'm so happy for you that the hip surgery had such a good outcome."

She smiled back, and we went on as if nothing at all was wrong with the world.



*Patient identifiers such as social history and medical issues altered.

Monday, May 9, 2016

What does it really mean to be a mother in medicine?

As in, in real life, day-to-day, down and dirty?

Genmedmom here.

I'm working on a writing project about being a mother in medicine in practice. This is going to be the everyday stuff: the logistics, the scheduling, the practical aspects, the balancing, the conflict. Funny stories, lessons learned, suggestions, and mistakes.

As I was thinking about this project, I realized that my experience in clinical practice is drastically different from women in other specialties. There's no way I can write this without input from moms in every area of medicine!

Things I was wondering about:

When I was pregnant, it never occurred to me not to tell people. I can't keep a secret to save my life. But I have colleagues who kept their bumps hidden for as long as humanly possible, for many different reasons: worries about discrimination; fears of being passed over for promotion; superstition. What did folks out there do? If you felt like you had to hide your pregnancy, how did you, and for how long? Looking back, what do you think, was it necessary?

What about those specialities where there is risky occupational exposure, I'm thinking radiology, surgical subspecialties… How did you manage that in pregnancy? If you needed to step out of the room, how did your colleagues react?

A lot of doctor-moms don't take a full three months of maternity leave. Some take more. Does this vary a lot by specialty? Did folks feel pressured to take less than three months? Did anyone have to fight for three months?

I never pumped at work. (Long story.) For the moms that did, can you share some of the good and the bad? Were offices and hospitals supportive or not? Were facilities acceptable or not? What were your worst pumping experiences? Would you do it again?

As a general internist with no inpatient duties, my call weekends involve, well, phone calls. What is it like for doctor-moms who have to go in? For the surgeons and anesthesiologists out there, is it better to be on call from the hospital or from home?

My office clinic is low-key enough that if I need to, I can step out and answer a phone call from my kids' teachers or the school nurse. But what about for moms working in the operating room or the ICU or on a busy inpatient floor? If you need to step away to take care of your family, are you supported?

My husband travels, and occasionally, I've had to cancel a clinic day to stay home with the kids: blizzard closed the schools, kids throwing up… Have others needed to cancel their workdays for childcare? Did colleagues make you feel bad, or did they step up? For those who haven't or can't, how do you manage those unforeseen events, the school cancellations and nasty illnesses?

I am eternally grateful that I can work part-time. I know that not all physicians approve of that. For those working full-time, how do you make that work? What supports and systems need to be in place for you?

And of course there are more questions, more scenarios… We can all learn from each other!
All specialties should have representation. I would love to hear what you have to say.

Don't feel comfortable commenting here? Email me: mauroratello2@gmail.com


Wednesday, May 4, 2016

Quality Time: What Is It, and How Can I Create More of It?

Genmedmom here.

Typical morning clinic day: I'm up at 4:50 a.m. and out the door before 6 a.m. to catch the train. The commute is prime time to skim the news/ blogs/ email/ social media, or, order groceries for delivery. I arrive at work early to prep charts. My patients are scheduled from 7:40 a.m. to 12 p.m. (and clinic usually runs over). Then, it's patient calls/ prescription refills/ results/ all kinds of paperwork/ maybe some writing until somewhere between 4 and 6 p.m. Then, I run for the train, ride back, run to my car, pick up kids at my mom's. Wrestle kids out the door, stuff them into the car, and herd them into our house. If Hubby is not working or traveling, we make a good effort to sit down to a nice dinner, usually warmed up leftovers from a weekend pot of soup. We tag-team on the evening stuff: get kids to eat if they haven't eaten, feed the cats, unpack schoolbags and yucky lunch boxes, identify any major school communications or homework, make lunches for the next day, wash dishes. The kids start getting super-silly and disobedient around this time, so I cattle-prod them up the stairs, out of their heinously dirty clothes, and into the bath; attempt to wash their hair (which usually has food in it) and yell at them for splashing water all over the place. Get kids out of tub, then chase after them as they actively evade me, giggling and taunting. Pull pajamas on, force them to brush and floss teeth, read books. Read more books. Read JUST ONE MORE BOOK PLEASE MOMMY?

Sigh. By the time the kids are asleep, I'm exhausted, and I realize with great sadness that I've spent most of our precious few hours together yelling, nagging, scolding, threatening, and counting to three about fifty times.

The few minutes we have snuggling in bed reading quietly (well, truthfully, it usually stretches into thirty minutes reading quietly) is the only real "quality time" we've got.

I know there are doctor-moms out there with busier schedules than mine (I only work four days a week).

Busy doctor-moms, how do you create quality time with your kids? What does it look like? When do you fit it in?

Thursday, April 7, 2016

When The Doctor Is Sick, Again

Genmedmom here. Coughing, coughing, coughing. This is the third respiratory thing to catch me in as many months. Damn germs, can't get away from them.


I'm apologizing to everyone: my husband, for waking him up all night with my uncontrollable hacking; my kids, for my medicated and exhausted attentions (or lack thereof); my patients, for spewing my droplets about the tiny exam room; my fellow commuters, for daring to get on the train sick.


I'm following all my own advice. I know I've got cough-variant asthma and I'm on top of the Albuterol. I'm taking Dayquil and Nyquil, and snarfing tea with honey and endless Ricola.


But still coughing, coughing, coughing. No fever, non-toxic, I'm eating and drinking and walking and talking and parenting and working and COUGHING.


Not sick enough to call out; miserable enough to want to.


Docs, what do you do?


Never mind, I know the answer. Suck on my inhaler, take Dayquil and Nyquil, snarf tea with honey and endless Ricola, and suck it up.





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.




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

Monday, December 21, 2015

I Screwed Up and I'm Sorry and Damn It, I'm Going To Say It Out Loud

Genmedmom here.

Anyone who practices medicine knows that sooner or later, we all screw up. Mistakes can be big or small, can result in harm or not. Misdiagnosis, missed diagnosis, delayed diagnosis. Unnecessary tests ordered, necessary tests overlooked. Medication errors, communication errors, clerical errors. Handoffs gone bad, poor signout, lack of discharge followup. Procedural disasters, frank bodily injury.

I've seen examples of all of these; I've been involved in some. I could tell you shocking stories from training. I could tell you shocking stories from last month.

People don't go into medicine planning to screw up, but it's inevitable, and we need to think about what we're going to do when it happens.

When I rotated through surgery as a medical student, I was fascinated by the weekly morbidity and mortality conference (M + M's). It was a highly anticipated event, and the goal was a complete and bloody dissection of a bad outcome. Grizzly semi-retired surgeons, department chiefs, educators, and every trainee sat in a full hall and listened to one poor soul deliver an objective case report, which then was scrutinized, interrogated, discussed. In the end, everyone learned something, and the presenter was, in a way, exonerated. It was a ritual similar to a public confession. 

In internal medicine training, the culture was largely one of finger-pointing. Other people's mistakes were a source of gossip and ridicule; your own mistakes were glossed over, rationalized. Alot of excuses were made. Yes, there were halfhearted attempts at surgical-style M + M's. Mostly, people stewed in their own guilt and shame. It was toxic.

I work in a much healthier environment now, one in which integrity is valued. Error reporting is encouraged, not for blame and punishment purposes, but rather, for learning purposes. The reporting can be done privately, on a systems wide computer application called something like "Patient Safety Reporting". There are occasional medicine rounds M+Ms, and they're run well, but they're just not that common.

It's taken years for me to figure out my own personal M + M's. Writing up a patient safety report is part of it, but, there's more. When there's been a mistake, I try to analyze it, maybe, discuss it with a colleague or two, and then, most importantly, tell the patient.

I had to do this recently... Of course it was a lovely, salt-of-the-earth patient I have known for several years. Someone I've seen many, many times in the office, who I'm very fond of. Such a good person.

When I first realized there had been an error, I started to go in the old, toxic direction. I was just so embarrassed. I imagined the inpatient team on rounds, skewering 'the dumb primary care doc'. I studied the chart to see if there was any possible defensible position, any good excuses I could use.

But that just doesn't feel good. It feels gross. It feels like.. weaselly.

I have a mantra I repeat when I decide to take responsibility, to own the error: I'll take my lumps. It's an old-fashioned saying, but that's how it feels. I'll take my lumps. 

After a long and painful chart analysis, I marched myself up to the patient's room in the hospital and explained to her what had been missed by me in the past, that, if caught back then, may have prevented her medical issue now.

"I really prefer to be straightforward about these things," I stood with my hands folded in front of me. "I'd rather you hear it from me first. And if it turns out that [what I missed] was the cause of [her issue], then I am very sorry."

Then, I waited, waited for any one of a hundred possible responses.

She was quiet for awhile, I think, digesting what I'd said. Her face was serious.

Was she going to kick me out? Fire me? 

Her face softened into a smile. "Oh, don't beat yourself up, doc," she said. "I know no one's perfect. I know you care. If I thought you didn't care so much, well, that's a different story," she laughed. "No, I prefer to move on, go forward. I don't dwell in the past. What's the point?"

We touched base on this again later, and she said the same thing. I've seen her several times since, and she's not mentioned it again. As it turned out, what I missed didn't pan out as the cause of her illness.

Did I get lucky? Maybe. I am aware that one of these days, my M + M approach may end with me getting sued.

But I'd rather be honest and upfront and be sued, than sit in a toxic stew of guilt and shame. No weaselly excuses.

I'll take my lumps.


Friday, November 20, 2015

How It Could Be, How It Is

Genmedmom here.

I was in the grocery store last week, which is rare because at this point in our crazy two-working-parents-with-two-small-children lives, we have everything that can be delivered, delivered, and this includes groceries. It's seriously saved us about three hours a week, ordering our "big shop" right from a cell phone, and having it all magically appear early Saturday mornings.

But, that week, I'd ordered on the fly and, of course, forgotten a few things, plus an item or two had been out of stock. So, in an unexpected free hour on Tuesday afternoon, I found myself wandering our local Big Food Store.

I'm so out of grocery-shopping mode that I got a little disoriented. In the old days, I'd have my list jotted down, roughly organized by aisle, and I'd zoom through the place in relative ease.

But there I was, bouncing from Snack Foods to Produce and back again because I couldn't find the damn Pea Puffs Babygirl likes. Then, way over to Dairy for the cheddar cheese sticks I absolutely have to have with my apple for lunches, and that you can't order online for some reason, and then back over to Crackers because Hubby texted that we're out of the kids' favorite crackers... et cetera.

Then I was lost, searching for the powdered instant breakfast stuff we shake into the kids' morning cup of milk to make us feel better about their nutritional intake. It wasn't with the Cereals... I saw a couple of young employees standing in an aisle, with bar code reader-things.

Oh good, I thought. People I can ask.

But just as I was rolling near, one of them started griping, loudly:

"Man, I am so ready to get off work. Get me the heck outta here!"

His buddy replied:

"Yeah, work sucks. The whole thing sucks."

I veered away, pretending I hadn't been about to ask them something. I wondered how working in a bright, overstocked first-world grocery could possibly be THAT bad. It was kind of a downer.

I never found the stupid instant breakfast, and I was almost out of free time. I aimed for a checkout line.

The man doing checkout was still scanning items for the person ahead of me, but he looked up, smiled, and acknowledged me, calling out cheerfully:

"Hello! Beautiful shopping day, isn't it?"

He turned back to the shopper and took her coupons.

"Smart lady, you're going to save some money today. You should treat yourself to something special, you deserve it!"

The woman and I exchanged smiles and chuckled. In the space of less than a minute, the atmosphere had gone from Ugh, errands to I can't help but smile!.

Now, I've seen this guy before. He's older, has a thick accent, and he's ALWAYS cheerful. Not in a fake, annoying way. I mean, he's just really genuinely cheerful. He always greets people and says nice things, makes a lighthearted joke or two. He's very efficient at checkout. He also bags items with care. He acts like someone who loves their job.

As I stood in line, I studied him. Given his appearance and accent, I guessed that he was an immigrant. I imagined that he had come from a developing country, and had known oppression, hardship and hunger. Maybe it had been difficult for him to get to the U.S., and then to get a job. He might have a family he desperately needed to support, and so, he's amazingly appreciative of the opportunity to work the checkout counter at the Big Grocery Store, and help bag groceries for harried and distracted moms like me.

Whatever Mr. Positive Attitude's story was, he cheered a couple of people up that day. I truly wish everyone was like him. Imagine that!

And whatever the Griping Employees' story was, their complaining brought me down. It's depressing to think how many people sludge through this life like they do.

I've been thinking about this a lot lately. I find that I'm sensitive to negativity, I want to run away from negativity. This regardless of whether it's expressed by my colleagues at my own job, or by friends. Examples at work might include the judging of another provider's care, complaining about some administrative issue, or griping about the electronic medical record. With friends it may be grousing about our school system, grumbling about a spouse, or sharp self-criticism.

I think some venting with a trusted confidant, in private, is okay, and even necessary sometimes. Even better if it's with a mental health provider. Emotions can be validated, and a response discussed. You know, "talking it out". This is head-housecleaning. It's therapeutic.

But pointless negativity (aka "Work sucks") is just toxic. It's just pollution. It serves no good purpose. It should be banned. And there's alot of it.

People who have known me over the years may be surprised to hear me saying this. I was kind of the Queen of Complaining in residency and fellowship. What happened? Well, to sum up: in 2006, the years of sheer physical and emotional exhaustion, unhealthy coping, poisonous relationships, and social isolation brought me to the lowest point in my life.

The struggle upwards involved hundreds of hours of therapy with an excellent provider, liberal antidepressants, formulating meaningful life goals, clean living, and meeting my husband.

Through our very different journeys, we've been touched by the pain and hardships life can offer, and we've been witnesses to some true horrors. A twist of fate, bad luck, the finger of God... bad things can happen to anyone. When they do, some people are consumed, crushed even, and yet, others transcend.

I'm thinking of my patients with devastating diagnoses who choose to stay positive. I'm thinking of our family members who have lost children, and choose to go on living and loving. I'm thinking of the people I've known in Central and South America who suffer true deprivations, but choose to hope. I'm thinking of all victims of random violence who choose to forgive. I'm thinking of the immigrants around the world who are being shunned, but choose to go on in search of better lives.

For everyone who chooses to say:"I'm going to take it day by day, and be grateful for every sunrise", I'm thinking of you.

We are so lucky, so blessed, and we acknowledge that. In our house, we joke that if we ever won the lottery, we wouldn't change much, because we've already won the lottery. We are passionate about our hard-earned careers. We've been blessed with our beautiful kids. We enjoy a place in a wonderful community.

Is everything perfect? Duh. Of course not. Read my blog.

But our eyes have been opened to what could be, and so, we're thankful for what we have. And we are truly happy.







Friday, October 30, 2015

A Doctor-Mom Day Off With The Kids: Halloween Baking Project

Genmedmom here.

I don't know about other doctor-moms, but I have very little "free" time with my kids. Too often, a day off with them gets spent running errands or from scheduled activity to activity. I've found that I treasure unplanned, sort of spontaneous fun stuff, and I think they do, as well.

One recent weekend day, I found myself with both kids and a few free hours. Some groceries and sundries were desperately needed, so we piled into the car and headed to the nearby super-uber-market that sells everything cheap.

Before we entered the store, I laid out our basic ground rules:

No yelling, no fighting, and no running away from me.

If they could do all that, we would do a fun project.

So we did our shop, and I spied some halloween cookie cutters. They were purposefully displayed alongside theme sprinkles, food coloring, and decorator frosting. Hmmm...

I asked the kids what they thought. Two thumbs up! They excitedly helped pick out what they wanted to use.

When we got home, I made the kids wait until all the other stuff was put away, and then, we started. Babyboy only took part until the dough was made, and then he left with the spoon to watch "It's The Great Pumpkin, Charlie Brown". Babygirl owned this project.

Want to try this at home? Below, see our recipe, and photos of all the steps. Enjoy!

(And yes, the kitchen will be an ABSOLUTE MESS, there is no way around it. Flour, sprinkles, colored frosting fingerprints... and, it will have been totally worth it.)


Sugar Cookies Basic Recipe
Let the kids do as much as they can/want!

2 sticks unsalted butter
3/4 cup sugar
1 large egg
2 teaspoons vanilla extract
2 1/4 cups white flour, plus extra for rolling out the dough
1/4 tsp salt

Preheat the oven to 350 degrees. Line 2 baking sheets with parchment paper, or, even better, those nonstick silicone sheets, they are awesome. Soften the butter, but don't melt. Beat the butter and sugar together with an electric mixer until really smooth. Add the egg and vanilla and beat again. Add the flour and salt and just blend slowly until no patches of flour are visible. Squeeze the dough together as best you can and plop it onto a piece of plastic wrap. Wrap it up and place in the fridge. While it is chilling, make the base frosting.

Frosting:
3 cups powdered sugar, plus more if needed
1 stick butter
up to 1/2 cup milk
food coloring

Soften the butter. Add some of the powdered sugar and beat. Add a bit of milk and beat. Keep alternating until the sugar is gone or mostly gone, and the consistency is creamy and very easy to spread. Leave it out until the cookies are ready to frost.

On a flat clean work surface, sprinkle some flour so the dough doesn't stick. Divide the chilled dough into thirds or fourths, and place on work surface. Flour up a rolling pin, and roll away. When about 1/4 inch thick, cut into shapes using cookie cutters.

When first sheet is full, place in oven and bake for around 6-8 minutes, until golden. These burn really easily. Repeat for the rest of the dough.

Cool completely. We decorated like this: We made several base colors from the creamy frosting, orange, gray and white. I spread the base frosting onto the cookies with a plastic knife, and my daughter then decorated the cookies, for the most part.

(FYI: We also had bought one bottle of liquid black decorator frosting, which we used for the black bats. We tried to use it for drawing and writing, but it was too liquidy. In addition, it tasted funky, and made the kids' poop greenish. Will not use again! I'm sure there are better homemade versions out there.)


Rolling out the sugar cookie dough and cutting out shapes

Yes, our kitchen is a disaster.

This girl is FOCUSED
I hope this black frosting isn't toxic.
Ta-da! (and yes, that is our cat's butt on the counter)

Sunday, September 20, 2015

Analyzing My Kid

Genmedmom here.

Our pediatrician had noticed something was up with our son at eighteen months. We were in complete denial until he was two years old. At that point, it just got too ridiculous. He couldn't say a word, only scream and bang his head on the floor... We finally made some phone calls.

Once we got connected with Early Intervention, we started to see and understand. Kudos to the very talented staff who gently- but firmly- suggested a possible diagnosis, and recommended a developmental evaluation.

Months later, we knew for sure. (I wrote about this: So Our Son Is Autistic, And It's Going To Be OK.)

Now, he's five, and he's doing great. Yeah, there's issues, but who's kid doesn't have issues? In his case, he's difficult to understand, but we are so very thankful that he's verbal. Toilet training is an ongoing frustration, but we know he'll get there. He's in a co-taught Kindergarten classroom and he loves his special ed teacher; he's got speech and behavioral therapy and OT, he and his little sister are best friends, and he's a happy kid.

We think he's fascinating, because his mind works so differently from ours. Hubby and I, we're both avid readers and writers. Though he's a sports broadcaster and I'm a doctor, we're both required to be advanced communicators: he describes and dissects sports action for the audience, and I translate medical information for my patients.

But our son is like, a little mechanical engineer. Hubby and I, we struggle with Ikea furniture assembly instructions. Hubby couldn't figure out how to install those little plastic cupboard door locks. I've had a car for three years and I can't remember how to open the hood, I have to look it up in the guide every time. Our son is such a different creature from us, in many cool ways.

He's absorbed by maps: He loves the maps app on our phones, and he studies the weather radar maps and draws out the storm patterns. Below, he's studying a map of Boston. We had to stand there for a long time. I can't even explain how many drawings of maps he'd done... Maps and highways, cars on highways. He talks while he's drawing: "Here's a map of Boston, and here's the cars going out of Boston on the highway, this is Route 93..."

He draws alot of complicated pictures, many moving parts. Below there's a picture he drew during a time of some upheaval in his little life: he was about to start at his new school, with a new teacher. The man in the middle is saying "Help" and "What should I do?" and chaos is erupting around him. He draws what he's feeling, what he's imagining.

He draws, I'd guess, probably between twenty and fifty pictures a day. Many of these, he will assemble into "books": he staples them together and then "reads" them to us. He's able to recite the same storylines over and over, even with his books that he made over six months ago. He seems to have a photographic memory.

He loves to take photos, in that he likes to study a subject by taking a gazillion photos and then examining them. Below, our big fat lazy cat; and then, me cooking. Studies of our home life...

I know that every parent is absolutely taken with their child. Of course. We're in love with this kid, like any parent is in love with their kid.

But, we're also trying to figure him out. We're still learning how his mind works, and just now beginning to truly engage with him. It's really accurate, the autism symbol: the puzzle piece. He's our little puzzle.








Tuesday, September 8, 2015

How I Studied For The Boards...

Genmedmom here.

I saw Mommabee's September 1 post asking for practical advice about how to study for the boards, and I felt compelled to post the link to an article I wrote on this very topic! This was written for the New England Journal of Medicine Knowledge+ blog as a humorous, but essentially accurate personal account: I Studied For The Internal Medicine Boards On The Stairmaster

Wednesday, August 12, 2015

When the Patient Brings Presents… or Punishment

Genmedmom here.

This was an odd week. One patient brought me a beautiful bouquet of flowers as a gesture of thanks… and another totally reamed me out. Both are uncommon occurrences in my practice.

The thing is, I didn't feel like I deserved either.

I told a colleague about it, and we laughed. It's so funny, but so often the case, that we're as surprised by the patient who is grateful as we are by the patient who is angry.

Both cases ended up being professional victories for me:

Usually, when I've received gifts from patients, I have felt some pressure to treat them a bit extra-special, overly gently, with kid gloves. Oh, I won't go there this visit. But in the case of the flowers, I approached a touchy subject anyways, and we were able to address it in a positive way during the visit.

In the case of the reaming, which was really a lengthy declaration of my recent deficiencies as a provider, I was able to hear the patient out. They never raised their voice, used vulgar language, or got personal, so I was able to sit, impassive, and take it. I felt it was therapeutic for this particular patient to get it all out… I apologized for the perceived inadequacies, we reflected together, and then we were able to move on to actual medical issues. Usually, when I get criticized, I get heated up, embarrassed, emotional.

I don't know exactly why, but I was able to stay cucumber-cool. Maintain that professional distance. And, best yet, not bring it home with me.

Of course there have been other cases that have found their way into my head and into my home, intruding on the kids' bedtime routine, making their way into quiet conversation with my husband, delaying desperately-needed dreaming…

In our practice, we have a monthly Balint-style group moderated by a psychologist. We often share cases that get in our heads, and these themes have definitely been explored. Be it gifts or criticism, we have all experienced it. It's been very helpful to hear not only what other providers do in response to these challenging situations, but also to hear what they feel.

We're not made of Teflon, and the water sometimes soaks us. How do other physicians respond in these cases? and, more importantly, how does it make you feel?

I'd love to hear!

Monday, July 20, 2015

A Little Gift To Take To Work

We just returned from a week's family vacation. The kids have been off from school, and Hubby has been off from work, so, we've all been together 24/7.

I have afternoon clinic on Mondays, and we dilly-dallied away the early Monday morning.

Finally, reluctantly, I packed my lunch bag, kissed Hubby and the kids goodbye, and set off on foot for the train.

My three-and-a-half-year-old daughter called out to me from an upstairs window: "Mommy! Mommy! MOMMY!"

I looked up from the driveway and yelled back, "Yes, honey?"

"Will you do me a favor, after work?" She says "favor" like "fay-vow" and "work" like "wowk".

"Of course, Honey! What is it you'd like?"

With adorable preschooler excitement, she stammered out, as loudly as she could: "Will you- will you- will you... I mean, after work, will you... please just come home?"

Oh, so, so adorable. So simple. I melted, I promised I would come home, directly home, and I kissed her on the head.

I kept remembering her sweet little three-year-old voice saying, begging, …will you please just come home?, and it kept me smiling all day long in clinic.

Friday, June 26, 2015

Book Review: Burning The Short White Coat by Eve Shvidler, M.D.

I love reading books written by other doctors. Especially when I actually have time to read them. When I read the P.R. blurb on OB/GYN Eve Shvidler's Burning The Short White Coat: A Story Of Becoming A Woman Doctor, I knew I HAD to make time to read this book:

"What happens when Sex and the City meets Grey's Anatomy?… A medical chick-lit novel, Burning The Short White Coat exposes the personal battles that single women must overcome in balancing a demanding profession and the desire to find a trusting and loving relationship…"

I've been waiting my whole life for the female House of God. I was very excited to know: Could this be it?

Well, not quite. But, this light read is definitely engaging, funny, and fun.

The story follows relatable Elle Gallagher (and BFFs) through four years of medical school, and much romance. The action of the prologue draws in the reader (Overnight call! Crash c-section!). The first chapter, "The Gross Lab", is so gross, it's great. I was having formaldehyde flashbacks, myself. There are such nice touches here: the dissection of the penis by the retired surgeon is worth the price of admission.

But, the issues that plague this book also begin here: spelling and grammatical errors. Lots of them.

Now, I also write for publication, and I hate when some reader expresses extreme annoyance over a couple of typos. But there are ALOT of typos, misspellings, and incomplete sentences throughout this book, so many that even I was extremely annoyed. If I wasn't almost at the end of the book, I would have put it down at "introidus". Which appears twice. These errors make the book read more like a rough draft.

There is also heavy use of clich├ęs, which I can forgive because at the same time, there is also plenty of fresh, unique material.

The chapter titled "Psych" is a fascinating little story-within-a-story featuring one of the creepiest cases I've ever heard. If what is described really happened, that's crazy disturbing. If it didn't, that's crazy good imagination.

One surprise for me is that my favorite character in this book isn't one of the female protagonists at all, it's the slightly immature but lovable surgeon Samy. We all know that attendings who hang out with medical students… well, that's just wrong. But this guy, he's complex, and he has some great lines. His advice to Elle on booty call vs. relationship girls is right on, and I'm not sure I've seen it done so well in a book that wasn't intended for teenagers.

The best part by far, though, was the chapter titled "Good Vibrations". I believe I had a similar hilarious conversation with my medical school BFFs. I would never have dared to write about it, though. I'm impressed!

In the end, I thoroughly enjoyed what was overall a refreshing, real-deal, feminine take on the modern medical school experience. (Yes, people, med students DO party that hard.) I just wish someone had run a spell check and an editor's eye over the text prior to publication.

----------------------------------------------------
Hot off the presses! Addendum! As of 6/27/15 I have just heard from the author that she had already realized there were many errors in the original manuscript, and she put the whole thing through a copyediting process. There will be a new release in about 2 weeks from now, sans errors.

----------------------------------------------------

As an aside, I have to say, the author's blog on Wordpress (https://burningtheshortwhitecoat.wordpress.com) is VERY good reading. Her articles and essays are enormously informative and entertaining. Moms in the audience, do yourselves a favor and read her post Where's My Orgasm from June 8, 2015.

Thursday, May 21, 2015

How Much Do You Share With Your Patients?

Genmedmom here.

In my practice, there are two kinds of doctors. There are those who don't display even one personal photo in their exam rooms, and then, there are those that do. Me? I proudly display a collage of recent kids' photos. Occasionally, a photo will include me and/or Hubby, or our cats.

I've found that the photos can "break the ice", meaning serve as benign fodder for a softer, friendlier discussion in an otherwise sterile, somewhat scary environment.

Let's face it: a bleachy-smelling standard-hospital-grade exam room, where the cold speculum and bristly Pap brushes are laid right out on the chux, is not a fun place to be sitting twiddling your thumbs. No People magazine can change that.

How do I know this? Hey, I have a doctor, too.

What I've personally experienced is that decorations or photos can help to create a warmer, more inviting environment. I'll immediately feel like this provider is confident enough to share of themselves; that they're open to connect with me as a fellow human being.

The exam rooms that don't feature any kind of personal touch may as well be alien spaceship exam rooms: What part of me is going to get probed?

The worst exam rooms I've encountered are at my GYN's office: almost completely tiled without any objects left out in view whatsoever. I feel like a lobster in a pound. They may get high marks from OSHA and The Joint Commission, but I sit there increasingly uneasy, freezing in my flimsy paper gown. Even our dentist does better job with environmental emotional regulation.

Our pediatrician wins the prize for personal adornments. He's got family photos, his kids' artwork, obviously his choice of decorations (all sports-themed), and entertaining items like books and toys strewn all about. Not only am I made to feel more at ease, but my kids are, as well.

Of course, items and photos invite questions and conversation. I think this is good, and I tend to be very open and honest with my patients. Hey, I'm querying them deeply about their relationships, jobs, bad habits, fertility plans, and private parts. These are all topics that are socially prohibited in usual, out-of-the-doctor's-office conversation. I can at least share that my kids are in preschool and my husband works for the Patriots.

Some patients ask more, and I have real conversations with these folks. My general rules of thumb are: no personal chit-chat until the patient's issues and concerns are addressed. No shooting the breeze when I'm running behind. No sharing of my own medical issues. (Well, I'll sometimes share that I used to smoke cigarettes and that it was hard for me to quit, too.)

In seven years of practicing in this style, I haven't had anyone complain that I waste their time or overshare. My colleagues can tell you that I run on time, more or less. (More than most.) At this point, my regular patients excitedly ask for updates as soon as I walk in the door. How are the kids, how old are they now? Still have those huge cats? What does your husband thank about Deflategate?

Obviously, I'm all for sharing. heck, I blog.

What do other docs think?


Saturday, April 4, 2015

A Teaching Moment

Genmedmom here. This was going to be a sweet little post about a teaching experience from my clinic yesterday. A patient presented with a classic clinical finding, and I knew that one of the other providers had a few students with them. So I asked the patient if I could bring in a student or two, and she cheerfully assented. It's been a very long time since I was involved in clinical instruction, and I enjoyed it.

I searched the web for a photo image or clip art to accompany this piece, something that illustrated a female doctor teaching medicine to students. I typed in all sorts of search phrases, but the vast majority of clipart or stock photos clearly depicting a doctor instructing medical students showed male doctors- and often with a lovely nurse standing by.

The best approximation of a female teaching physician that I could find was this (*and, this image is totally copyright of Disney Junior):




I mean, it's a good thing that Doc McStuffins exists, and that this image and the DVD it advertises exist. Not to imply a commercial plug; I must emphasize, I have no financial disclosures here! I just love the example she sets for little girls, all the pink and purple notwithstanding. She's a doctor, and her mom is too. They're African-american. The show is a hit. It's awesome.

So, why was this the only image I can find of a female doctor actively teaching medicine to students? This was mind-boggling to me. I needed to understand. I needed data to interpret; it's just my research fellowship training.

And I found data. According to the Kaiser Foundation, there are 893,851 practicing physicians in the United States, and 32% of those are women. The American Association of Medical Colleges (AAMC) has published a detailed breakdown of U.S. medical faculty, by rank, sex, race/ethnicity and specialty. Per their data for 2014 (which can be found at The AAMC website Reports page):


Of the 155,089 total U.S. medical faculty, 62% are male and 31% are female.

Of those that are at the higher ranks, as in professor or associate professor, 72% are male and 28% are female.

The breakdown by race/ ethnicity is frankly depressing, and I didn't even want to figure it out. For those of you that enjoy crunching numbers, have at it- there's tons of other good data in there as well.

It's clear that we need more women physician role models and teachers of medicine. So, what are the obstacles?

Well, in my case.... When I started by current position at a major academic medical center, I was involved in a medical school course geared towards fostering empathy and communication skills. I think every med school has these now, Patient/Doctor/Society type courses. But then I became pregnant with Babyboy, and realized I would be out on maternity leave for a chunk of the next session, so I never signed back up. Now, with two very young kids and enough to balance as it is, I'm not sure I want to take on the added responsibility of teaching...Not just right now.

I know my kids will get older, and I hope to get involved with teaching again someday. Likewise with medical volunteer work. I'm half Latina, I speak Spanish, and I've lived and worked in Latin America. At some point, I'd like to get re-involved in that work, as well as be a mentor for Latina students...Someday.

Meantime, I very much enjoyed interacting with our students over a case of erythema multiforme this week.

I'm curious what the doctor-moms out there think of these numbers. Do we need more female physicians teaching medicine? How about female minority physicians teaching medicine? And what do others think about Doc McStuffins?

Thursday, March 12, 2015

Up Against The Boards

Genmedmom here.

It's been ten years since I graduated from residency. I was Med/Peds and not quite sure what I was going to do with my life. So, I took both the Pediatrics and Internal Medicine board exams, within two months of each other. I know I studied, but I don't remember feeling overwhelmed by the material or flummoxed by the practice questions. I was a resident and then a research fellow, so I'm sure I didn't have oodles of free time. Both exams were sit-down, pencil-and-paper, highly regulated, proctored, and extremely lengthy affairs. But, somehow, I passed both tests, with minimal pain. (I'm not saying I passed with the highest scores, but hey, all you need to do is pass.)

Fast forward. I've been a Medicine attending for six years, and I'm due to re-take the medicine boards. I've registered and paid and I've got a date: April 15th.

But this time around, I am struggling. Yes, I have two little kids, and may be sleeping even less than I was as a resident. Yes, I'm purely outpatient and far, far removed from acute, inpatient care. There are scads of specialists in my large, teaching hospital- based clinic, and we frequently refer patients for alot of management issues.

But I'm only studying for the Internal Medicine boards, and I've been in practice for six years. You'd think I'd be more comfortable with this material.

Now, I like to study. I'm a dork that way. In my practice, I look stuff up all the time. I earned three hundred CME credits in the course of a year just by looking things up on our favorite medical search engine (yes, you can earn CME credits that way, if you register and then print out the report). So I figured, boards, no problem.

I got the study books and the audio material in November. I read when I can (after the kids have gone to bed, or late on a weekday workday) and listen to the most BORING medicine lectures during my commute.

But, I'm just struggling. I've reviewed a fraction of the total material. I'm getting killed on the practice questions. There are huge gaps in my knowledge, that is clear.

So I'm trying to get my head around this. The re-cert is about 8 hours of testing, now done electronically in testing centers around the country. Looks like a few hundred questions, from these basic areas:

Cardiovascular Medicine
Dermatology
Endocrinology & Metabolism
Gastroenterology & Hepatology
General Internal Medicine
Hematology & Oncology
Infectious Disease
Nephrology
Neurology
Pulmonary & Critical Care Medicine
Rheumatology

There is alot of potential question material under each discipline. At this point, I won't be able to review it all, to ABSORB all the material. I don't have time.

So I'm cramming questions. I'm doing 25-question blocks, and studying the answers, trying to learn patterns, what are they likely to ask about.

The overall pass rate for the October 2014 Internal Medicine board exam was reported as 72%... Ugh. The pass rates have been steadily declining over the past decade. Why? This is, apparently, a matter of much lively debate. In one fun article from the NEJM website, several hypotheses are presented. One conspiracy-theory hypothesis purports that the people that write the exam and charge us to take it have made it harder so that they can charge us to take it more times. Like, it's a money-maker. Other hypotheses include that we're losing the ability to study effectively, because we CAN look everything up on medical search engines... Oh.

So, I hired a sitter to get me 100% protected time on Saturday afternoons; I registered for a boards review course next week; I slashed my clinic hours to two hours per session for the three weeks leading up to the exam; and I limited my time writing blog posts to about thirty minutes a week total (ha!) so I can CRAM.

How does everyone else study for their boards?

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?

-Genmedmom

Wednesday, December 10, 2014

I Don't Know How To Dress Myself

And I know I'm not the only one...

I was thrilled to see a physician-mom address this in the Atlantic: The Clothes Make The Doctor, by Anna Reisman. In this thoughtful and humorous piece, she describes how she met with a potential new primary care doc, and was put off by the sharp-dressed woman's stiletto heels and expensive suit. She then explores how physicians should ideally dress, and thus, present themselves.

She hit on a perennial topic of discussion and debate amongst my colleagues, both male and female. Male colleagues bemoan that they are expected to wear a collared dress shirt and tie, day in and day out. But female colleagues complain that they have no real "dress code", and thus, no guidance, on how to dress for patient care.

In my office, which is an all-female practice, the "work uniform" runs the gamut from: clean and pressed white coat over smart dress suits and heels, to dress suits and sensible shoes without the white coat, to business-casual with or without the white coat, and then, to me.

I'm usually in whatever Bargain Basement Clearance Store pants with less-dirty knit top and scuffed sensible shoes I can match when I get dressed in the dark at 5:30 a.m, with a reasonably clean white coat pulled over it all, like a disguise. I can't remember the last time I ironed anything; I think it stretches back a decade or more. I buy all permanent press or knit clothing. If something needs to be dry-cleaned, it's a once-a-year piece. Sweaters, slacks, scarves- they all must go into the washer and dryer, or be relegated forever to the back of the closet. This all is, I feel, most practical. Who has time to fuss over clothes?

I also LOVE a bargain. And while there are women who can browse Nordstrom Rack or Marshall's or TJ Maxx and put together respectable, even snazzy, professional outfits, I am not one of them.

Still, I can't let go of my old habits. In medical school, we had an informal group of women about the same size who met occasionally to "swap": everyone brought a bag of clothes they didn't want, all higher-quality stuff, and we had a party as we tried on each other's stuff. Everyone left with a "new" item, and the leftovers went to charity. If someone I knew suggested this today, I would so totally be there!

I even found my wedding dress, a 100% silk designer ball gown with an impressive train, for $250.00 at the Filene's Basement Run Of The Brides Traveling Sale, back in 2008. I considered it the find of the century, a total coup, and I told anyone who seemed like they cared how much I had spent.

I still have had no qualms with rooting through school fundraising secondhand clothing sales, and leaving with large bags of the clothes of people who are probably my neighbors.

I think some of my reticence on spending money on clothes stems from the fact that I've gone up and down ten sizes within the last five years. Yes, there were two pregnancies in there, but the ballooning waistline was not due to gravidity. It was due to the fact that I gained an unbelievable amount of weight with each pregnancy, on the order of sixty pounds, EACH TIME. Three months after my second baby, my daughter, was born, I realized that I had even GAINED weight while breastfeeding. My BMI was over 30. I was OBESE.

Then, with a two-year-long concerted effort at a low-carb diet and exercise when I could get it in, I lost fifty pounds. Babygirl is now almost three years old, and I've kept the weight off for almost a year.

Despite being back to my pre-pregnancy weight and size for this long, my closet is still filled with a mishmosh of sizes, and alot of "more comfortable" pieces, like Ponte slacks (read: knit pants). A friend and colleague recently pointed out to me, in a humorous way, that Ponte slacks are in the same category as yoga pants. Meaning, not acceptable work attire.

Unfortunately, in order to dress well, one needs two things: Time, and Style sense.

I know I will never have the time or inclination to study fashion magazines or follow style blogs. And for some reason, when I see someone who I think is dressed really well, meaning, how I'd LIKE to dress, I can't seem to replicate their look (probably because of my clothing care learning disability.)

But, I still want to look like a real, respectable, clean, practical yet SOMEWHAT stylish physician. Someone who is aware that it's almost 2015, but who is also willing to kneel down on the exam room floor to look at a patient's diabetic foot ulcer.

I know, I know. Time to grow up, learn how to iron, make the dry cleaners a regular weekly errand.

I also need a personal shopper. I have seen this mentioned on prior MiM posts (that I cannot locate right now), and people have suggested Macy's, as they offer those services free of charge. Of course, to take advantage of that requires several things: Making an appointment, taking some time, and investing in attire.

Sigh. With two children under age five, a working husband who travels alot, and boards study on the agenda every day, these things are not likely to happen anytime soon.

Tomorrow will dawn, and I will likely be pulling on a wool blend turtleneck, my black slacks with a little elastic in the waist, and Danskos.

But I will be comfy...

-Genmedmom

Friday, November 14, 2014

How Do You Discipline Your Kids- In Public?

Genmedmom here.

Last week, on my usual Thursday off, I was on kids' dropoff and pickup duty, and I had a very difficult time with pickup.

Both kids are in preschool: Babygirl, almost age 3, loves her Bright Horizons daycare/ preschool, and Babyboy, age 4, is becoming more fond of his public Special Ed preschool program, as his teacher has really connected with him. Getting them up/ fed/ dressed/ out the door is always a bit of a challenge, but manageable.

Pickups, however, are getting dangerous. And not just for me, but also for my mother, who is most often on pickup duty.

Given the timing of school dismissal, we need to pick up Babyboy first, and then swing by Babygirl's school. Since you can't leave a four-year-old in a car by themselves, he has to come in with us to retrieve his sister. For the past month or so, once inside, Babyboy finds something he wants to play with in her classroom, and won't leave. He gets obsessed with completing whatever project he's invented, like lining up the construction toys or building something with Legos. I get it, he's autistic, and tends to have these sort of OCD-like moments. If you try to stop him before he's done with whatever it is he's determined to do, he throws himself on the floor in a tantrum. A loud violent tantrum. Even when he doesn't engage in something in the classroom, when it's time to leave, he gets wild, and runs away down the hallways, laughing at me when I call to him.

Babygirl is also now commonly protesting leaving, and has thrown herself on the floor, or also run away, giggling.

All of this is totally disruptive. Not only for the kids in her classroom, but for everyone in the whole school, as my kids scream and shriek and wreak havoc. Heads pop out of doorways, teachers checking on us, kids asking what's going on. If I yell, I'm just contributing to the mayhem.

Last week was the worst for me. It was him running away, and her tantruming. We were in the hallway, me kneeling on the floor trying to dress Babygirl to go outside, as she rolled around screeching, fighting me. I gave up on forcing her into rain gear (it was pouring) and hoisted her up, flailing and screaming. Meanwhile, Babyboy was running up and down the hallways, throwing himself on the carpet and rolling around, laughing defiantly. I had to chase down my son, grab his arm, and struggle out of the building. This was while carrying Babygirl, her lunchbox, raincoat, and backback.

I lost the backpack somewhere (and didn't realize until we got home), probably when I opened the heavy door. I had to let go of Babyboy in order to open it, and as soon as I did, Babyboy bolted out, across the driveway, and into the parking lot. In the rain.

There were no cars coming at that moment, thank God. But I yelled and yelled: Get back here! You hold mommy's hand in the parking lot! It was a safety issue. I had to get him and us out of the driveway and the parking area, and into the car. I yelled, I threatened, but he would not cooperate. Then Babygirl hurled herself down and I had to wrestle her back up, while attempting to run after a defiantly giggling Babyboy. The more I yelled, the worse he got. I caught him, and fairly dragged him to the car.

Finally, I jammed Babygirl into her seat and buckled her in- safe at least! And threatened to do the same for Babyboy. He got in his seat.

I was fairly shaking by the time I got into my seat. My throat hurt from yelling so much. It was so embarassing... What do the teachers think? What do other parents think?

"You both were very bad today," I admonished. I wasn't sure what else to do. They're in the car, so can't do a time-out. I'm not sure a delayed time-out would be helpful. I think spanking solves nothing, and would look awful in public as well!

They've been much the same for my mother all this week. So me, my husband, and mother have talked about this. We're struck with the difference between the kids when they're together, and when they're apart. One-on-one, they're little angels. Barring hunger or naptime, when it's just one by themselves, they're model citizens.

And, occasionally, they're OK together. I've taken both kids to restaurants, just me and them, and they've been wonderful. Random elderly women have complimented us: "Good as gold!" "So nice to see such good behavior!"

We can't figure out why Babygirl's school pickup has become such a trigger for terrible behavior. Sibling rivalry, like, they're competing for attention? Normal toddler/ preschooler defiance, like,as their sense of self forms and they're establishing independence?

We have consulted with a child psychologist in the past, and we will again. But I know there's alot of experience out there. Anyone else sometimes struggle to control their kids in public? What sort of discipline tactics work?

Genmedmom