Showing posts with label career topic week. Show all posts
Showing posts with label career topic week. Show all posts

Saturday, December 17, 2011

Welcome to Career Topic Week

Welcome to Career Topic Week on Mothers in Medicine! Posts by our regular contributors and readers on specialty choice will be scheduled to post throughout the week. Thanks for reading.

Scroll down below to see the posts...

Pediatrics is kids and family

How could I have almost passed up the opportunity to post on topic week about a family friendly career? Perhaps because this week I baked for the kids’ school pot luck and bought gifts for their amazing after school counselors and am working on a grand rounds and revising and resubmitting a paper and tweaking the students’ syllabus and conducting meetings with…

All that, and yet pediatrics, the career, is kids and their families. And as such it could not be more supportive of pediatricians raising theirs. Lots of opportunities for part time work, though I have remained full time with enough of “protected” time for non-clinical but otherwise scholarly work, where much of the flexibility is built in.

I aim to be a serious academic and medical educator (albeit still with appropriate levity with my pediatric patients) but at my own pace. After a few “wins” (first grant, first publication, first leadership role) you can pace yourself, pick and choose things (still say yes to almost everything but learn to say an occasional no) in academia. And grow to be a mentor to others.

And all the while my pediatric colleagues have to understand things like pumping, breastfeeding, being called to get your son from daycare, fevers, falls, school performances, and sports events because this is the stuff of outpatient pediatrics. It happens in our lives as mothers (and fathers) in medicine as it happens in the lives of our patients. When I returned from parental leave after 16 weeks the second time around, squeezing in pumping and speeding to daycare pickups, I reassured my boss that that was the last baby for me, and he told me to have as many as I wanted. That was a breath of fresh air (and the legal thing to say), and it was sincere. I continue to have all my patients as “my kids” plus the two of my own, and that is the right number for me in my very full time pediatric parenting career/life.

I think a side benefit of pediatrics as family friendly is it helps in child rearing. You learn the tips, the things we parents struggle with, you read the latest on development, and you can even draw upon your job when you minimize your kids’ screen time, ensure they brush their teeth, buckle up, among other less obvious things. I have nearly said to my children, “If your parents weren’t pediatricians then maybe you could eat that hotdog while playing with matches and then take a ride in the front seat, but….” Furthermore, my children hear me take call by phone some evenings or weekends for our outpatient community-based academic pediatric practice and have nearly become mini-pediatricians themselves. Even though they’ll probably be a rock star (say, Elvis) and an artist (she who draws mostly mermaids).

I didn’t choose pediatrics because I thought it would be family friendly, but much to my joy and satisfaction, in most cases it can be and has been.

Friday, December 16, 2011

OB/GYN: It was the Best of Times. It was the Worst of Times.

How is your specialty family friendly?

While OB/GYN has the reputation for being notoriously NOT family friendly, I have tried to shape my practice to make it at least ‘family manageable’. I know many of our contributors have found balance in academics, for me private practice has made more sense. I own my practice (with 4 other moms); so I can make my schedule somewhat flexible. I work 4 days a week and am on call ¼ of the time. I attempt to plan ahead to take off for my kids plays and special events. Having privileges at just one hospital prevents the added stress of laboring women at two different places. My office which is attached to my hospital is 10 minutes away { make that Seven minutes at 3 am when I am driving the Camero} from my home.

OB/GYN is a field where it is advantageous to be a woman. In general, women prefer to have female OB/GYNs, making it easier to build up your practice. Additionally as a fellow mom, you have an added layer of bonding to your patients. I’ve had morning sickness, stretch marks and sleepless nights with a fussy baby. I think this gives me a level of empathy that most patients appreciate.

Being family friendly goes both ways, though. I have a partner who is due this spring, so I will be working extra to help her while she is out, much as she helped me a couple years ago to take time off when we adopted our son.

The down side to private practice is that it makes it difficult to take an extended leave. We have 20 employees, rent, malpractice, insurance and a variety of other bills that must be paid monthly. So, taking a maternity leave of longer than 6 weeks is financially difficult. Going part time would not be a possibility for me. Also, being a small business owner adds a level of stress to your life: meetings with accountants, minimizing overhead, marketing. This are all concerns that must be added to the ‘to do’ list. We don’t have many business classes in medical school, so it’s mostly learn as you go.

I realize that are there are busy seasons and slower seasons. The fall is crazy. Everyone has babies {curse you snow storms from last winter!}. The surgeries that patients have been putting off all year that are suddenly emergencies now that they have met their deductibles. I know I will have to work more in the fall, but this fourth quarter revenue will help cover my overhead during the lean first quarter months. I plan extra days off with my family during January and February when things are already slower.

At times I miss being in an academic center and teaching medical students. I think that is part of the reason I blog/write is to help fill my desire to teach. At the end of the day I think the autonomy of private practice empowers me to help make my crazy job more family friendly.

What I didn’t realize about OB/GYN until I was in the thick of it:

Being up all night does not get any easier over the years. Yes, it’s part of the job. I accept that and try not to complain, but really it stinks. Leaving your cozy bed at 1 am to drive in the cold to the hospital, then work the entire next day, then come home to tend to the children…. Not easy.

Dealing with loss is emotionally draining. Miscarriage, stillbirth and infertility are truly heartbreaking issues. OB is thought of as a happy healthy specialty, but when things are bad they are often horrific. I recently had a patient that conceived spontaneously, after 10 years of infertility treatments, who then experienced a term stillbirth. There is perhaps, no worse place to be in the entire world, than a baby’s funeral. The emotional toll of this profession can be immense.

Being the bearer of bad news stinks. Probably at least once a week, I tell a nice married lady with a couple of kids that she has a STD. In doing this I am usually telling her that her husband has been unfaithful. This is often completely unexpected and extremely painful. Often I sit with a box of Kleenex, listening to her cry for as long as tears flow. I become more her therapist than gynecologist.

Is it worth it?

I’m in my seventh year of practice and I still absolutely love what I do. It’s never boring. I’ve delivered 8 babies in the last 3 days (that’s why I’m late getting this post done…. Sorry KC); I am bone tired. But even as I write this, I can’t help but smile at the joy that helping bring life into this world gives me. I truly feel like I am making a difference in people’s lives. You can be a workaholic in any field or any specialty and every specialty has its unique challenges. But if you love OB/GYN and are willing to count the costs, then there are ways to make it more manageable for your family.

It's Not Rocket Science...

...but it is brain surgery! Neurosurgery has always seemed to have a certain aura and mystique about it as a specialty. It certainly was glamorous to me when I started out as a medical student. After all, neurosurgeons work in and around the brain, the seat of our very existence. In fact, we work more often on the spine than the brain, but nonetheless, we are "brain surgeons."

I was one of those annoying medical school classmates who started from Day 1 wanting to do neurosurgery, and who continued that path relentlessly, without second thoughts. Having walked the long and difficult road, I will say unequivocally that it is in NO WAY family friendly. It's hard to think of a less family friendly specialty. That's one reason why, even today, only 5% of about 3500 practicing neurosurgeons in the US are women.

There are oodles, scads, of reasons why this is the case.

1. Long and difficult training: Residency is an average of 7 years duration (usually not counting fellowship). Even so, it is hard to learn everything you need to know: patient evaluation, types of pathology, technical skills, reading your own radiographic studies, etc. The days are long and exhausting. I don't know how it is now, since the 80 hour work week, but I suspect it's still very demanding. It's difficult to carve out time and energy for your family. It's also hard to be pregnant during residency, the prime child bearing years.

2. Lots of emergencies: Problems like acute brain hemorrhages and cauda equina syndromes can't wait. In fact, sometimes half an hour makes all the difference. This makes planning your day impossible. As soon as you make plans to go out to the theater with your husband or go to your son's football game, the surgery gods conjure up a subdural. Curse you, surgery gods!

3. Unsympathetic colleagues: This specialty is full of men with stay at home wives who do everything for them. Nothing against SAHM's!! But don't expect your fellow residents or partners to understand taking breaks for breastfeeding. Don't expect them to help you in any way, because they have NO IDEA what your life is like outside work.

4. All or none: There is no such thing as a part time neurosurgeon. Trust me, I've seen it tried.

5. Physically demanding: This specialty demands long hours standing without a break. The sleep deprivation and stress are extremely taxing. Even after residency, there are times when you are so tired that you can't decide whether to eat or sleep first. This is after 24+ hours without a proper meal. Sex? Sleep is better when you haven't slept for 2 days! Add a crying baby to the nights you are home...

6. Culture: In neurosurgery, asking for any help is a sign of weakness. Call me if you need me... but don't call me. This culture is not conducive to supporting things like maternity leave.

7. Help wanted: Out in practice, when most of us are rearing teenagers, it would be great to have lots of partners to share call and PAs to help with the workload. Good luck with that. There is a chronic shortage of neurosurgeons; the ones that exist are difficult to recruit. It took us 4 years to find one to replace a partner who left. PAs are in high demand and would much rather take cushy dermatology jobs than difficult neurosurgical ones. I currently take call every 4th night and consider myself lucky.

8. Social isolation: I didn't expect this to be such a problem. Nonetheless, it has a large effect on our social life as a family. We don't get invited places because friends think I'm too busy. (Or maybe they just secretly don't like me, but this is what they tell me!) At church and school functions, people don't chat with us, they ask me about their aunt's brain tumor treatment. Even neurosurgeons like to talk about the weather and the upcoming football game, y'all!

So having said all that, you may well ask: "Why would anyone ever want to do this awful job?!"

There are oodles of reasons for that, too.

1. It's surgery! How could anyone not love doing surgery? I've said it before... fixing a problem by opening the body and closing it again, and having the patient survive the experience, is nothing short of a miracle to me. It still amazes me after 10 years of practice.

2. Control: As an extreme Type A, I love controlling everything about what I do. I own my practice with my partners, so I am my own boss. What I say in the OR and in the office, goes. My own decisions and actions determine my patients' outcomes, and that's the way I want it.

3. Impact: Every day, I see patients with life-threatening problems. Through my profession, I am able to save lives and keep people out of wheelchairs. Being able to make a real difference in just one person's life makes it all worthwhile. In neurosurgery, that impact on the patient is so often immediate and dramatic. It's high risk, but high reward.

4. Respect: This specialty still commands immense respect, both from patients and colleagues. Not that we deserve more respect than other professions, but there it is.

5. Financial security: It's still a good living, although politics may change that in years to come. Not having to always worry about money is one less strain on a marriage. Further, a neurosurgeon can always provide for herself and her kids should that become necessary.

6. The Challenge: This may be the thing I love most about my job. Every day, every patient, every case brings a new challenge. There are always new things to learn, envelopes to push. I never get bored or complacent, because it's just not possible. Towards the end of residency, I once thought I'd seen it all. Later that day, the nurse at the trauma desk popped her head up to ask, "Hey, are you seeing the guy that got assaulted by the ostrich?!" Never a dull moment!

I love neurosurgery and can't imagine doing anything else. Family friendly? Nooooo. Worth it? Yes! It can be done, although it's not easy. As others here have pointed out, no working mom has an easy time of it. All we can do as MiM's is give it our best and hope that the ones we love understand us and continue to love us back.

Mothers in Medicine

My perspective on being a mother in medicine is a little different than those which have been posted earlier this week. I’ve been at this now for almost two decades, but vividly recall the times when my children were much younger. I have worked 80 hour weeks and been on call 20 weeks out of the year. I have been a pregnant resident. I have been a pregnant attending. This is what I have learned through the years.

All specialties are conducive to raising a family.
No specialty is family friendly.
Wait, what?

Being a mother in medicine is a study in duality. It is the best of times. It is the worst of times.
It is the pride of juggling three, four, five – more – items in a seemingly effortless manner; it is the guilt and defeat when everything crashes around you. It is the memory of your child proudly proclaiming (to anyone who will listen) “This is my mom – she’s a brain doctor!” followed by the innocent (but cutting) comment that “There are lots of moms who stay home with their kids and don't go to work.” It is the sense of relief that you are *finally* home in time for good night stories lined up back to back with the mortification of being shaken awake by your three-year-old shouting “No, Mom! Officer Flossie doesn’t say SNRKK! Read it right!” and recognizing that you’ve fallen asleep mid-sentence. It is ticking off the “to-do” list that you carry in your head at all times and yet – despite the satisfaction of knowing that before 8AM you’ve cleaned two bathrooms, started a load of laundry, fed and dressed three children, got everyone off to school – still feeling the disgrace of arriving at the office 10 minutes late and realizing you’re already behind for the day.

Early in my career, I felt that in order to prove I was a good doctor I had to show my dedication to my job. Putting in long hours I missed more room parties than I attended. I was physically present for my children at the end of most days, but I was exhausted. And I finally recognized that exhausted me wasn’t good for anyone. So I tried to change. It was hard – hard to change the sense that I was somehow shirking if I made it home before 7P on a weekday, hard to change the assumption of my colleagues that I would always be the one who would stay late and pick up the case in the ER. But I found a position that allowed me to grow - as a physician and as a mother. I learned that it was the support of those around me that gave me the opportunity to thrive in my job and at home. I’m not alone in this recognition - it is this support system that is mentioned in almost every essay that has been posted this week. Many have already noted that it’s hard to have everything. Working moms make sacrifices to do what we feel called to do – whether we are in medicine or not. Balancing these sacrifices is the joy and love from (and for) our children, and satisfaction from knowing we have performed a job well done.

Therefore, every residency and specialty has the potential to be the best one for you as you raise a family – or the worst. Look at the support system that comes with the program and then decide. And remember that no matter how good or bad one day is, the next is likely to be the opposite.

It is the best of times. It is the worst of times. Today, I wouldn't trade my experiences for the world. Just don't ask me the same question tomorrow.

Guest post: Thoughts from an Anesthesiologist

I am currently in the midst of a fellowship in pediatric anesthesiology, after completing a rigorous anesthesiology residency at a major academic medical center this past summer.  I had my first child mid-way through my CA-1 (PGY-2) year and my 2nd during fellowship.  I won't lie, completing the residency as a mother in medicine was ROUGH, despite being in a department that honestly was very supportive to me.  There were (many) days/weeks when I thought there was no way I'd make it through, and even if I did make it, it wouldn't be worth it given all I would sacrifice to get there.  Fast forward to present:  even though I'm still in training, fellowship has been significantly better than residency, I can totally see how my life as an attending will be different than these past 4.5 have been, and I REALLY like my job.  I like the people I work with, I love the work I do, and the academic medical center where I work is overall fairly family-friendly (compared to stories I've heard from elsewhere).

When I started residency, I was positive I would not be doing a fellowship and that I'd be headed to a bread-and-butter style private practice job as soon as I could.  As I found out during residency, though, part-time private practice jobs in anesthesiology are incredibly difficult to come by and essentially were not an option at all in the area where we'd like to live (near extended family).  Surprisingly, though, landing a part-time job in academic anesthesiology is much easier, the down-sides being that a fellowship is pretty much required and obviously the pay is lower.  The upsides, though, are better work-life balance, opportunity to teach residents & students, and a daily dose of challenging cases.

Although I love my children dearly, I wish I had known how tough residency would be with a child before embarking down that path as early in residency as I did.  I don't know that I would have been able to tough it out were it not for my awesome husband.  He is not a physician (engineering background/works in business currently) and that has made all the difference in our ability to manage my schedule and our family's needs together.  He totally gets the demands of the schedule of a physician and consequently does all the day care drop-offs (not a single one in our area, including the hospital's daycare, opens early enough for me to do the drop-off and make it to work on time), serves as back-up for daycare pick-ups when I get held up later at work, happily plays "Mr. Mom" when I'm on weekend call, and stays home on the days our kids are too sick to go to daycare.  That's not to say that we've been immune to the challenges of managing it all-he does travel periodically requiring extended stays from my mother to make it work, and has a fair amount of work-related evening commitments, sometimes making it seem like we barely see each other.

Although being a working Mom will never be easy and certainly neither will being a Mother in Medicine, I do feel that anesthesiology has been a great choice of specialty for me.  There are opportunities to work part time, there is minimal work that follows me home, most days I leave the hospital by 4p (sometimes even earlier), giving me a decent amount of time with the kids before bed, and the call schedule is very manageable, at least at my current institution.  While no one is thrilled when one calls in sick, honestly my dept tends to roll with it; as advocates of patient safety working in a life-and-death specialty where a lot of vigilance is required, no one wants you there when you are not healthy enough to adequately perform.  Everyday there is at least one person scheduled as "back-up", to help get all the first-case starts underway, to cover in case of illness, or to provide extra anesthesiologists in the event of a particularly heavy case load that day.  While there will still be days that are rough and make me question my career, today I can honestly say that I'm happy with my choices and as a mother in medicine.

Thursday, December 15, 2011

Ob/Gyn: Helping to expand families at the cost of your own?

At its very worst, that is how it feels. Like two nights ago, while lying in bed with CindyLou, who was bubbling away about her class Christmas party which was happening the next day when she stopped and said earnestly to me, "Mommy, you know, you can come to the party tomorrow if you want!" And, ugh! That familiar little stab of mommy guilt shot through me once again. It is never that I don't *want* to attend her daytime school Christmas parties, sign language presentations, or field trips (scarcely ever announced any earlier than 2 or 3 weeks prior to the actual day they are happening, assuring that my clinic schedule will be full, and if that isn't the case, I am likely on call). Every morning as I am leaving for work, my kids ask if I am on call. If I say "no," it is met with cheers. If I say "yes," it is met with boos, extra hugs, and sometimes tears. So, yeah, my kids are definitely affected by my chosen profession. (And we are in a situation that is *light years* better than the one we were in prior!)

Unfortunately, as many have stated, medicine is not as "family-friendly" as many other careers can be, and to many physicians, we don't stop working when we leave the office/hospital. Our chosen profession is all consuming in general, and Ob/Gyn can be demanding in particular. I feel you have heard the following from me before, I am having a distinct case of writer's deja vu The hours? Horrible. Babies have no concept of time and generally it seems that labor gets good and active sometime between midnight and 4 am. The pace? Grueling. In a medium sized practice, in order just to cover the cost of your staff and overhead, you have to do a set amount of deliveries just to break even. We get very scant education about the whole "running a business" part of medicine in our training, and while it would be great to see one patient an hour, the practice would go under in a year at that pace. As others have astutely pointed out, part-time in medicine is hardly part-time in any other sense of the word, and for Ob/Gyn, with malpractice costs, you just cannot feasibly make it work. If you want to do Ob, you have to be all in. That means call, and most of us work 24 hour calls followed by a full office or surgery day the next day...way more than what residents are doing in their training these days (makes for a rough transition to the "real world," to be certain.) No one is looking over my shoulder and counting how many hours I worked this week (hint, more than 80!!) Malpractice environment? Scary. No really. It is.

I can't say how many times I've bemoaned my career path, pulling myself from my cozy bed at 12, 1, or 4 am to make the mad dash to the hospital. I've thrown too many one person pity parties to count for myself as I work on nights and weekends and holidays while it seems the rest of the world is spending time with their friends and family (before anyone jumps me, I know this is *not* the case, but, pity party, you know, work with me here), but, by the same token, if I really try to sit and think of anything that I would love to do better, I couldn't tell you a thing. Because in the moment, I really do love my job. Once I am in the door of the hospital and with my patient, bringing her baby safely into the world is the focus of my attention. I never cease to be amazed at the miracle.

My family knows that the work that I have the privilege to do is important, and this is the reason that sometimes I can't be with them....even when I really want to be. I hope they grow up understanding that having a job they are passionate about is important, as well. My house isn't spotless, I'm not homeroom mother, I barely know any of the kids in my children's classes, I don't pick them up or drop them off at school, I don't go to Zumba, and am seldom well put-together (read: schlepping about in scrubs). So no, I don't "have it all." I have a good career. I have wonderful friends and a great relationship with my children and my husband. I think that is the best for which I can ask.

On Choosing Pathology and its Compatibility with Motherhood

"What, you are going into pathology? But you actually like to talk to people, you are good with patients. Why would you do that?"

I decided to do pathology at the 11th hour. I already had a rumored slot in ophthalmology - I was looking to stay in my hometown as my ex had recently landed a residency in anesthesia here. At the urgency of my brother-in-law, a first year path resident, I did a month rotation in late fall, before the general residency applications were due but after I had completed my San Francisco match application. Despite enjoying the course and doing well in it I thought "Ha, pathology. That is for complete nerds." At the same time, a voice was nagging in the back of my head about ophthalmology - actually an attending's voice, one I met during a summer rotation in another state. "It's not like it used to be. I see 65, 70 patients a day. Do you think I get to talk to them? No. The techs do. I just look and dictate what goes on the chart and run to the next room. My job satisfaction has plummeted."

Before I get railed on by all the ophthalmologists or ophtho wanna-be's out there, my best friend in med school went into ophthalmology, and she is very happy practicing in a small town, doing lots of surgery, and talking to her patients. I just happened upon a woman in a bad job situation - I realize her opinion was not global. But everything you hear affects what you do, and every one's experience counts for something. I worried over ortho after calling, at the urgency of a male colleague, one of the few older female orthopedics in the state. She said, "If you want a family, don't do it. Do something else." I watched another girl friend start orthopedics, than bail out for radiology.

I admire all of the people that enter primary care, but I was never pulled in that direction. Ironic that I am now somewhat of a generalist in pathology. I do it all at a large metropolitan hospital - lab director, bone marrows, lymph nodes, apheresis, cytology, surgical pathology, frozen sections, traveling to small hospitals and clinics to cover the scope of my practice. So I did become a "primary care pathologist," to use a phrase that someone else coined, but more of a diagnostician than anything else.

Pathology residency was very conducive to starting a family. I had two kids during residency and while in retrospect that was probably more than I and my marriage could handle - when I read about the overnight call and the extent to which my colleagues here have to spend time away from their kids, I feel like I got off lucky. Aside from a few autopsies on weekend call it wasn't so bad. When I entered practice I was awed and fearful of my new responsibility and worked overly hard for the first couple of years, but now I find time to take breaks during the day and do other things. I've gotten into a nice groove. Pathology is feast or famine, and there are days when we get pretty busy, but if there is a school program or class party I can always find someone to cover for me so I can get away for an hour or two, even if it means working late. I imagine this is different from an outpatient practice where you have to show up for clinic if there are patients scheduled, no matter what. Difficult to find coverage unless there is an emergency, and emergency is probably the only reason you would cancel a clinic. My group is 13, including part timers, so it is a rare day that there isn't someone who can function as you, if needed, for a little bit. We all lean on each other so no one feels overburdened. I go to a Christmas program. Another partner needs to help her mom that just broke her hip. Someone needs to get to the bank or post office. Someone needs coverage to get to his son's basketball game. It's certainly not daily, but making the important things that fall short of broken bones in the ED is very do-able.

Most of the time, now that I am four years into practice, I have 8 hour days, even though that often means cramming lunch into 10 minutes. We are all used to that from residency, so not much difference there. I hire someone to get my kids to their after school activities - tennis, dance, etc., and often meet them before the activities are over. My current after school help marveled after she had been carpooling my kids around two weeks. "I tell everyone at my church - she's a doctor and she cooks for her kids! Can you believe it?" I laughed at the stereotype that seems to no longer be universally relevant, especially around here, where we are often begging for recipe ideas. Yes, we have our occasional mac and cheese and fish sticks days, but we sit down at night at the table together and talk about our day. We go over our multiplication tables (They go to 12 these days! I only learned to 10 so I had to brush up) and spelling words. We problem solve daily ethical issues - playground misbehavior they have witnessed, etc. We read every night. Call is usually over the phone and only rarely drags me away from my evenings with them. I fix breakfast and take them to school almost every day - I get help when I am on call and covering frozens for early OR's or have to drive to a small town, but that doesn't happen very often, either.

I know that there are not many readers out there who aspire to do pathology compared to the rest of the medical world - there are certainly a lot sexier specialties out there. But it is fun, it is image based, and although I interact a lot with colleagues, I spend a lot of time by myself and the scope - patients are few and far between. I guess one plus is that I get to save most of my emotional energy for my kids, for which I am very grateful. I have heard that jobs are tough to get these days in this specialty - I can understand why because I see that once you get settled in you are happy and it is tough to leave. I know lots of pathologists that work into their 70's and a few who go into their 80's - it is not a physically strenuous job and I'll bet frozen sections and surgical cases make a good match for Sudoku in staving off Alzheimer's. I watch my dad, a neonatologist in his early 60's, still working all nighters and am thankful that never has been, and never will be me (as a pathologist anyway, I hear with teenagers life gets challenging at night). That being said, most people I know get jobs, even if it is not their first choice of location, and I imagine there are location challenges in lots of specialties.

If you want to work part time, that is another story. Think twice about pathology. Part time path jobs are few and far between, and for those I see that have entered into them they either do too much work without benefits and bonuses and/or are not looked kindly upon by their colleagues even though they are taking a big pay cut for their shorter hours. It seems to have been worked out much better in other specialties - I notice pediatrics where I live, but not pathology. I would love to hear any dissension on this point - my only experience in my field is negative.

I agree with Cutter that being a working parent is a challenge many of us face these days, not just doctors. For women and men out there who aspire to be doctors, and have any interest at all in pathology, the field has my vouch for being a good one to combine with parenting. Our group is half men and half women, and the fathers (they all are - two of us are not mothers) seem to get to participate in parenting a lot more than other specialists I have observed or heard about. But you have to enjoy it - it's not for everyone. I feel lucky that I do.

A Hospitalist in Academics

I fell into hospital medicine rather unexpectedly. I knew I wanted to stay in general internal medicine, but I thought I would be a primary care internist. Then, in residency, I discovered how much I loved the inpatient setting - not for the actual medicine part - but for the educational part: I loved teaching and the ability to do so with scale with the large learner-heavy teams on the wards.

A lot of people equate hospitalists with shift work, and in many cases, this is true. Working within well-defined and pre-scheduled shifts may be very alluring to mothers in medicine: predictable hours, a defined schedule, potentially no call, and the flexibility to easily work part-time.

However, for my particular job as a hospitalist in an academic setting, I don't do shift work. Most of my clinical time is supervising resident-run teams (the other clinical time is spent doing consults or supervising a PA-led "non-teaching" service without residents), which means longer or shorter days depending on team census, the acuity of our patients, whether the resident or interns are in clinic for the afternoon, call-days, and how independent my resident is (new R2 very different supervision time than a seasoned R3). I'm available by phone to my teams when they are on call at night. I work many weekends and holidays. And although I can take compensatory days off in lieu of working the holiday, which is great and something I put into action as chief of the hospitalist section, my kids will be home without me.

Parts of my clinical job are absolutely draining, mentally and emotionally. There's the family meetings to discuss goals of care in dying patients who may or may not have decision-making capacity. There's the bearing witness to tremendous suffering -like those with difficulty coping that they have a chronic disease that brings them in and out of the hospital so frequently. But, these parts are also what give me pause - I have a job where I can make a difference. I can make someone's suffering heard, metabolized, and given meaning. I can lead a difficult family discussion and make sure everyone's needs are identified. Hard but good.

I'm in my 9th year as a full-time hospitalist and in that time, have had three children. I've taken on more administrative duties and my weeks on the wards have accordingly decreased. I have the flexibility to do research, to do committee work, to teach. I'm meeting my personal goals of academic success. I feel like I am compensated fairly for my work and the requirement to work some weekends and holidays. This scaling back of clinical duties has been critical to achieving the balance I need as my family has grown. Granted, I worked my butt off in the beginning doing a much heavier clinical schedule, starting a family, and establishing my ability to take on these non-clinical duties and establishing a research agenda to be able to scale back these last few years.  On admin time, I have major flexibility. Flexibility to linger after school drop-off and chat with the other moms. Flexibility to help out with my daughter's art class. I know I have a really good thing going. And it works. Like others, key to this working for me is: 1) an amazing husband who shares the responsibilities of our home and family equally (minus this last year when he's been deployed to a war zone but that's the topic of another post...); 2) supportive and nearby family; 3) great childcare (which currently is synonymous with number 2); 4) having a flexible enough work environment and an awesome boss; 5) I try hard not to drink the Working Mother in Medicine Guilt Kool-Aid, no matter how tempting it looks some days. (Note operative word is "try.")

Hard but good. I think that about sums it up.

Wednesday, December 14, 2011

Guest Post: Ruminations on Shift Work from a Mother in Pediatric Emergency Medicine

An emergency medicine physician’s schedule is inherently flexible. I can quickly switch a shift with a colleague to accommodate emergencies since there are no patients to reschedule, trade random hours of coverage in order to make it to a school function, pick up my oldest son from school earlier than the other “late day” kids when I have an early shift.

Almost thirty minutes into the resuscitation, the room has gone quiet except for the ding of the monitor alarm. This five year old victim of smoke inhalation from a house fire has a good airway, two good lines, has received several rounds of epi, fluids, even the useless calcium and bicarb and there is no change. His pupils are fixed and dilated. “Time of death 13:52.” my voice breaks the silence. I walk out of the room and wait for someone to find his mother. She was out when the fire broke out.

I finish notes, try to wrap up my shift. His mom arrives and I sit with her and tell her the news as she cries silently. I hold her hand and then the social worker and chaplain take over. I silently leave the room, sign out to my colleague, and leave to pick up my son, also five, from school down the street.

When I arrive, he runs to greet me and the sudden force of his hug knocks my hair into my face. I smell smoke. I have to hold him longer to get control of the tears that are welling up in my eyes.

Overnight shifts are great for the working mom (who is used to sleep deprivation anyway, right?) Now that the baby sleeps better, they hardly know I’m gone. Their dad can get breakfast ready and I can do last minute lunch prep and kid dressing when I come home after my shift. Then I catch some sleep in a quiet house while the oldest is in school and the baby is with our nanny.

Thirty minutes before the end of my shift the radio alert sounds. I hold my breath as the nurse answers - a 6:30 AM radio call is either a radio check or a dead baby. Unfortunately, today it’s the latter. CPR is in progress. We ready the room, draw up meds, check the laryngoscope, and wait. I review drug doses and intubation technique with the resident and all the while I am just grateful that there’s another hospital closer to my house than the one I work in, because it means that this baby is not my daughter.

She arrives and is stiff and cold. Livedo has set in. We make an effort but mostly to dot our i’s and cross our t’s and give the family time to arrive and bear witness to our efforts. We care, we tried, she is important, we are sorry...... but she is the same age as my daughter and later that morning during my protected sleep time I just lay in the bed and cry, holding one of her blankets to my face.

Shift work is one of the features that is supposed to make emergency medicine ideal for the working mom. But shift work in the pediatric emergency department isn’t really shift work after all. I hope that as I accumulate years of experience that I can compartmentalize better and not “take it home with me,” but that’s not looking so promising since I can’t seem to concentrate when I know that my kids are in someone else’s car until I hear they’ve reached their destination safely. I hope that it’s just because my kids are so young and that as they get older I will worry less - but I know that’s not true as I call the pediatric oncology fellow for her opinion on a teenager with pancytopenia and a mediastinal mass. Perhaps all I can do is somehow convince the universe that bearing witness to the suffering of other children and their families is suffering enough, and then maybe the universe will protect my own children.

*patient details changed to protect patient privacy

MiM Mailbag: Baby and OB/GYN internship - HELP!

Hi MiM! First, thank you so much for all of your posts, advice, and stories. I can't tell you how much they have helped me, and I'm sure others.

I'm writing because I have a big decision on my hands and I feel as if the women in MiM might be the only ones who can help me make the decision that is right for me. I am a 4th year med student, in the midst of interviewing for residency. I have long been in love with OB/GYN as a field, but not the atmosphere. So, I decided to dual apply in OB/GYN and family medicine, where the people were more like me, and I could possibly still do OB. My decision to apply in FM was also partially influenced by an intense desire to start a family with my husband, who is a PhD student nearing the end of his degree. We tried to conceive for about 7-8 months as I was in the midst of my surgery clerkship and then my OB sub-Is, and as might be expected my best laid plans to have a baby at the middle/end of 4th year crashed and burned. Even though I was devastated and worried about my own fertility, my husband and I decided to stop worrying about trying to get pregnant until after a few years of residency. Of course, the fertility gods decided to play a little joke on us. As soon as we stopped really "trying" - I wound up pregnant. The baby is due in August of my intern year. I really think I want to do OB/GYN, and I really don't want to lose a year of training, but I'm not sure how I will manage having a baby in intern year. I also don't want to start off on such a bad foot not only with my training but with my fellow residents, who might hate me for 4 years!!

I realize there are a lot of pros and cons to either taking a year off, or starting internship 8 months pregnant and giving birth at the beginning of internship. And, there's also the option of choosing FM over OB, since it is more of a baby-friendly residency, but I'd hate to feel like I didn't choose my preferred specialty because I got pregnant. I guess I'm just hoping to get advice from some of you who are much wiser and more experienced than me in all this. I'm not sure how many people have gone through something like this, but if there are any out there who can give me their words of wisdom, I would be incredibly grateful.

I'm a 4th year med student (I'm 27 and married), born and raised in the northeast, and currently double applying in OB/GYN and family medicine. And I'm 5 weeks pregnant.

Tuesday, December 13, 2011

On My Reality as a Primary Care Doc and a Mom

As a premedical and then medical student, and even as a resident, I was hell-bent to practice International Health in a third world country. I spent every clinical second I could in far-flung forgotten corners of the world, doing crazy medical stuff. I never imagined myself practicing Internal medicine at a well-to-do practice at a major academic medical center in a big city in the U.S. As a matter of fact, I scoffed at that idea.

And yet, a decade later, I made the very deliberate choices that led me to exactly this reality. Here I am; and as shocking as it would be to my 20-something self, I am pretty darned happy.

It’s a long story how I came to be where I am, a story involving first my own naivete/ a hefty dose of reality, and then my own evolving understanding of myself/ the world. And a lot of therapy. That’s a whole other essay. Now, I can comfortably talk about balancing my growing family with a rewarding career in Internal medicine.

Here is my reality:

I’ve been in practice for 3 years. I was lucky enough to be hired into this small, unique practice that sits within a very large medical complex. Every provider here is part-time. No one sees patients more than 5 sessions a week. Almost everyone is heavily involved with some other aspect of medicine- academics, administration, research. We are on call for our practice for 7 solid days every 2 or 3 months. The reimbursement and perks are pretty good, for academics. We enjoy wonderful administrative and nursing support. The environment is positive, supportive, and progressive. (And, it is subsidized by the major medical center we live in, because they need us.)

I started off heavy in academics and research as well as my clinical responsibilities, but have dialed it back to only clinical responsibilities, 5 sessions a week, FOR NOW. I’m no longer working with medical students, and no longer participating in research. The reason is that I’m focusing on my family- getting pregnant, being pregnant, being with my very young kids as much as I can. And this practice “gets” me. They’re all OK with me stepping off that career treadmill, because most of my colleagues did much the same thing. I know I’ll be back, and I am not worried.

And, Primary care is fun! After 3 years here, I can walk into the exam room where my patient Jackie is and say, ‘Jackie, What the hell! Three ER visits for weirdo bizarre accidents- A staple gun to the hand? A tool box on your toes? I don’t even want to know about that buttocks injury. What on earth is going on?’and she laughs and says ‘I know, I’m a clutz, we’re doing the DIY thing and I think me and power tools shouldn’t play together. Even when I’m not using one, I trip over it’.

Or ‘Mary, we’ve been playing this diet-exercise-and-weight-loss approach to your blood pressure for two years now, and it’s not working. Don’t you think it’s time to throw in the towel and take some blood pressure medicine already?’And she says ‘I know, I know- I was wondering when you would call me on it. I wanted to try, though, and I appreciate your letting me.’

It makes such a huge difference in my day that I am beginning to KNOW most of my patients. And, they know me. I’ve got photos of my family up, as well as this great pregnant belly, and people ask me about them, and share their own stories… I insist on 20 minute urgent visits and 40 minute physicals for my patients, and all that extra time gets used, with talking. Really talking. I think it works- not only for me, but for my patients as well.

So, for now, I work my 5 sessions over 4 days a week, and in my spare time I do some blogging. The rest of my time and energy is spent with my Babyboy (17 months old) and currently, being 9 months pregnant with soon-to-be Babygirl; as well as quality time with my husband and parents. We moved back to this city to be close to my parents, and my mom takes care of Babyboy when I’m at work. Hubby is one of those dream husbands who shares the cooking, cleaning, laundry and just about everything else, while managing his career in the media. FYI, I am the main breadwinner. Our life is not extravagant; our life IS very comfortable. We know we will never be able to send our kids to private schools, nor afford fancy vacations etc. and that’s OK. What we have- THIS WORKS.

I think that what makes this setup work so well is 1. my working part-time, 2. working in such a great environment, as well as 3. the family support we have. And all this was no accident. When I actually set about looking for a job, these key things were exactly what we (me and my husband) were looking for. We did have to move to get here. But we are glad.

I freely admit that in the world of medicine, primary care reimbursement is abysmal. I make a decent living- compared to our neighbors. Compared to my med school and residency friends who are now gastroenterologists, endocrinologists, hospitalists, anesthesiologists, and many other specialists, I make a pittance, even taking my hours into account.

I get frustrated that my med school loans are so huge. The interest grew and grew all those years while I was in training. What I earn is barely enough to pay the loans/ interest as well as the mortgage etc. I never thought about that for two seconds when I was pre-med or in med school- I always blithely assumed that it would all get taken care of somehow. We manage- and again, overall, we are very satisfied with life. But there are times when I get mad about it, too.

I get frustrated that so much of primary care work is not recognized, or reimbursed. For example, it’s my day off at home, and I just spent three hours logged into the electronic medical record to check lab and radiology results for patients, and send them their results as well as a plan; also called one young patient to inform her she has Chlamydia and needs treatment, spent 30 minutes with her on the phone; refilled numerous meds (ones the nurses could not refill without collaboration); responded to several emails from specialists regarding mutual patients; answered several emails from patients (we have a system where patients can email us with questions, which is great but TAKES TIME); and reviewed my schedule for tomorrow as prep. This is normal. The workday often spills over into the evening and the weekend. It ends up being a lot more than what is registered on the paycheck.

Having voiced all those frustrations, I know that no matter what speciality you end up in, there are always frustrations. No matter what walk of life, really, there will be frustrations- when you’re in the nitty-gritty, the negatives present themselves. But, in the grand scheme of things, I’ll take my career over anything else.

I think that as a doctor-mom, I have it pretty good. Overall, I am, and my family is, very happy.

Medicine: Not for mothers?

I have to be honest: I'm a little burned out on writing about what PM&R is and why it's so awesome. I've covered it before both on Mothers in Medicine and on my own blog. People email me questions about it frequently, which I'm happy to answer, but... it's just hard to motivate myself to write yet another post about it.

So with the permission of our lovely moderator KC, I'd like to address the topic week a little more generally, and say some things that have been weighing on me lately. Namely:

Medicine is not a great career for a mother.

There, I said it.

Since we were asked to address which aspects are not family friendly, allow me to do so:

1) Unpredictable

When you're dealing with sick people, you can't predict your schedule, whether you're doing inpatient or outpatient. You might think you're going to be done at 5PM, and then your last patient will say, "Oh by the way, I'm having 10 out of 10 chest pain." Imagine it's 6PM, your patient says that, and you know your daycare will close in 15 minutes. It can (and will) happen.

2) Unforgiving of illness

Have I written about this one enough? I think I have. When you've got two children who pass colds back and forth (and then to you), you realize how difficult it is to be in a job where you basically can't call in sick.

3) Must work part time to work "only" full time.

An attending I talked to at a VA (not exactly a rigorous working environment) said that she had to cut back to working 75% time in order to only work 40 hours per week. Between on call time, documentation, phone calls, etc, the hours on your contract don't in any way resemble the hours you work.

4) Will mess with your sleep/wake cycle

It's bad enough worrying that a baby will wake you up. Worrying that a baby OR a pager will wake you up is enough to drive you crazy. I like my sleep, so this is a big one for me. How many times have I wished to be in a job where I could sleep through the night every night... ah, heaven.

5) Residency is killer

Dare I say that no residency is actually friendly to mothers? Yes, I'll say it. I'm sure some of you will come up with exceptions, but I think it's pretty overwhelmingly true.

6) You can't take a break

In a lot of careers, you could probably take a year or two off after your child is born. In medicine, it's much harder. You forget stuff and are rusty when you get back... not a great thing when you're dealing with people's lives. Taking long breaks is also a bit of a dink on your "permanent record." I once tried to apply for hospital privileges through a computer system and the program would not let me submit because I couldn't "account for" the 1.5 months between med school graduation and the start of internship. If I had taken a year off, the computer probably would have exploded.

7) The consequences of a mistake are so horrible

When you're a doctor, you can't mess up. People's lives and livelihood are at stake. You can't be careless for the sake of getting out a little earlier.

Truthfully, I sometimes feel like the entire school system is lagging behind the idea that two parents might be working. I mean, the school day ends at 3PM, which is extremely inconvenient for working parents. Kids get random weeks off from school during the year and the whole summer. And if they get sick, they're supposed to stay home. What on earth are we supposed to do with them if both parents work?

OK, but here's the good news:

I work as a consultant, which allows me to have a lot more flexibility. While I can't just not show up, it's not as big a deal to shift my hours. And the base salary for most physicians is enough that we can work part time (i.e. normal people's full time) and still bring home a good paycheck. (If you want to read more about what makes PM&R a good specialty for mothers, you can click on the link I mentioned above.) And if you enjoy the work you're doing, presumably you're happier in general and therefore a better parent (maybe).

But it's hard not to get a nagging feeling that when you're trying to juggle both motherhood and medicine, you're failing a little at both.

Monday, December 12, 2011

Topic Week: brief thoughts...

I struggled about what to post for topic week. I feel like I should post as a voice of one of the “not family friendly” specialties and a resident, but also I feel like I’m still so much in the middle of training that I don’t have perspective yet. So, all I have to say is this - It can be done. Its hard for all of us - pediatricians, anesthesiologist, OB/GYN’s, surgeons, residents, medical students (I’m just naming some specialties that I know mom-docs). In all honesty, I think its hard just to be a working mom of any type. But, people do it. Children survive and succeed. I love medicine and patients and surgery and I LOVE being a mom. I’m just going to keep doing my best, using my support systems, asking for help and praying that I do this right.

Also, I welcome any specific questions!

Guest post: Med Peds

In medical school, I started off wanting to do Family Practice.  I always knew that I wanted to do primary care.  With Family Practice, I would be able to see the whole spectrum of ages, and care for the whole family across generations.  While I was in the midst of planning my 4th year rotations, a friend suggested that I consider Med Peds.  It was about the same time that I realized how little Peds rotations are required in Family Practice, and how much OB was required.  I knew that I wasn’t going to do OB, so it seemed like a complete waste of time. 

I ended up matching in Med Peds, and realized after the first 3 months of internship when we switched specialties that I was in deep trouble.  (My program, typical of many Med Peds programs, has residents switch from Medicine to Peds every 3 months and so on.)  Throughout my residency, I felt like I was constantly behind all my categorical colleagues.  I was also tired of having to do so many inpatient and ICU rotations.  That’s what happens when you try and cram two 3 year residencies into 4 years. 

When I got pregnant in my 4th year, I was forced to give up my international rotation.  I was very upset, and felt that I was being punished for being a woman and pregnant.  (This harkens to all the blog entries and posts about residency requirements for maternity leave, time off, etc etc.)  There were too many core rotations to do, and so I couldn’t do a “fluff” rotation when I was already going to take time off for maternity leave.  (I took 8 weeks off after having a C-section for a premie, and then in the midst of trying to establish breastfeeding, went back to outpatient clinic 2 half days a week 2 weeks afterwards, and also had to do a rotation that involved reading books and writing papers.  After all that, I had to make up 2 weeks at the end of residency.) 

In retrospect, I would have just forced myself to pick either Medicine or Peds.  It was too stressful trying to do both.  At heart though, I do enjoy being a Med Peds doctor.  I still enjoy taking care of the whole spectrum of ages, and feel that I received excellent training despite feeling behind my categorical colleagues during residency. 

The best part of it is that after practicing for a few years in a more traditional setting with lots of inpatient call, I now have a job that is 100% outpatient.  I see patients Mon to Fri, and have no weekend and no overnight inpatient calls.  Yes, I do have to be available 24-7 to answer telephone calls, but it’s a world of difference from having to go in to the hospital in the middle of the night.  With primary care, it’s entirely possible to find a group that does purely outpatient.  Additionally, you have the option of doing urgent care or being a hospitalist, and these types of options are far better in my mind than traditional outpatient plus inpatient duties.  With the increasing popularity of hospitalists, both adult and peds (though peds is now just starting to catch on), there are now more and more options for practices that allow you to work more regular hours where you can actually see your kids.  It will be not prestigious or lead to awards and recognition if you are looking for a purely outpatient job, but as long as you don’t aspire toward a distinguished academic reputation, then you have options.