Friday, December 11, 2009

A Medical Student Mother's Day in the Life

I am a medical student in Grenada with my husband and 2 boys, 6 yo and 4 yo.

1:30 am.  Finished studying pathology for the evening.  Read through my favorite blogs to clear my mind before attempting to sleep.  The house is quiet except for the plethora of creepy crawlies outside singing for companionship.  When I first arrived on the island, I thought I would never sleep with that noise.  Now, I can't sleep without it. 

4:30 am.  My oldest taps my leg.  He had a bad dream about a Tsunami coming to the island.  He asked if the water could come in through the windows and if it did, would it carry him away?  After a quick discussion on geographic phenomenon, I tuck him back in with his soccer ball pillow.  He is asleep in less than a minute.  I wonder how he does that.

6:30 am.  My youngest is up with the sun.  He burrows into our covers and snuggles in between Mommy and Daddy.  Unfortunately, that also means that sleep is over as we know it.  He chatters away as we slowly wake up.

7:00 am.  Time to actually get out of bed.  My brain is still foggy with visions of pancreatitis while I make toast.  My hubby dresses the kids so I can get ready for class.  Hot tea.  My savior.

8:00-10:00 am.  Microbiology lecture.  Diarrhea, how do I cause thee?  Let me count the ways.

10:00-12:00 am.  Pathology lecture.  Renal glomerular diseases.  I am amazed at the intricacies of the kidney and diligently take notes in the margins of my Robbins.  Our professor is actually quite excited this morning, gesticulating, and even showing us his own personal artistic rendition of a glomerulus.  The class oohs and aahs.

12:00 pm Break for lunch.  Ok, well, more like eat my granola bar while I walk to a meeting for hospital coordinators.  Looking forward to clinical training.

1:00 -3:00 pm  Physical diagnosis rounds with standardized patients.  I interview a "patient" who has been physically abused by her husband.  After a series of denials, she slowly opens up to me and we discuss her situation.  While I realize she is only acting, I feel a visceral reaction when she describes her abuse.  I wonder what to do with those feelings if I am with an actual patient? 

Our group discusses and another student tells our preceptor that he felt I shouldn't have prodded the patient into revealing her abuse.  The patient states otherwise, that she didn't feel like telling him about it and that she felt comfortable enough to tell me.  She also says she didn't feel safe telling a male about her abuse. 

We discuss the different options we would have back in the states for referrals and also how to handle child abuse.  I tear up just thinking about it.  I leave the class in a pensive mood.

3:00 -5:00 pm  Pathology laboratory, working group.  I present my case on urine casts and the diagnostic capabilities of everyday old pee.  Our facilitator grills me on rapidly progressing glomerularnephritis.  I hold my own.  The kidney is my friend.

5:00 pm  The hubby and kids pick me up after lab.  They chat about the huge rat that ran through their open air school today.   Luckily, there was a large man nearby with a machete.  Ah, the joys of island living.

7:00 pm Story time with the kids.  My oldest reads us his Big Book of Everything.  I see the page on Tsunami's.  Ah, right.  He skips ahead to the volcano eruptions.  Mass destruction and carnage right before bed...awesome...

7:30 pm Have a nice talk with the hubby about our days.  Wish I could just relax with him and watch a movie...

8:00 pm  Chat with my study group on Skype and Facebook.  Distribute our topics for the next week of pathology cases and discuss the day's lectures.  Everyone is feeling the stress as we gear up for finals. 

8:30 pm  Make tea.  Arrange my notes and prepare for another long date with Robbins.


Thursday, December 10, 2009

A Day in the life of an O&G Registrar mom

(Australian equivalent of OB/GYN resident)

Well it’s really a night in the life as I do one week of on site night duty each 5 weeks-

7:30pm leave to drive to work
8pm start 12 hour shift- handover from day registrar, go and introduce myself to women in labour ward.

Manage labour ward- all labouring women plus unscheduled antenatal attendances, complications.
Manage complicated postnates e.g. preeclampsia, FDIU
Manage complicated post operative gynaecology patients
Handle all ED calls
Run first trimester complications service including performing ultrasounds and counselling re: miscarriages and options for treatment
Perform D&Cs booked from previous day if not yet had OT time
Teach residents/medical students/midwives (if any are around).
Try and fit in some study if able (time and energy wise)

8:00am Handover to day registrar (if I’m lucky, and not in OT performing caesarean section or instrumental delivery)

Drive home. Try not to crash

9am Home, hello to husband and son, crash into bed

330pm Wake up- generally too hot to go back to sleep (I always seem to get nights on the 40 degree days). If I am lucky, son hasn’t worked his way into bed and woken me before now (Husband is good at keeping him away but 4 year olds are wily!)

Play with family

5pm eat dinner together
7 pm get ready for work- do it all over again

We do 7 in a row- the cumulative fatigue is a killer

Well that is what it was like before- now when I return from maternity leave after baby number 2 (the princess, 5 months old) in January there will be an extra breastfed body to figure into the equation- so you can add pumping time and woken for day feeds in there too. Still not sure how it’s all going to work….

About me:
34, halfway through my specialty training program in Obstetrics and Gynaecology
Wife to a wonderful Stay at Home Dad and Mum to Master 4 and Miss 5 months.


Key: Registrar = Vocational trainee (equivalent to Resident in the US)
Resident = Pre-vocational trainee (equivalent to Intern in the US)

A Typical Call Day, Ob/Gyn Style

5:30 am - Alarm goes off.

5:35 am - Alarm goes off again. Unconsciously turn the alarm all the way off, turn over, and snuggle the sweet 2 year old boy who winds his way to our bed sometime between 12:30 and 4:30 am almost every night.

5:45 am - Second alarm goes off.

5:47 am - Finally roll out of bed into the shower.

5:50 am - Stand in shower, mentally plan the day, pray a bit to the call gods.

5:50-6:25 am - Get dressed and ready, pack overnight call bag, double check that CindyLou's Kindergarten homework is done.

6:25-6:30 am - DIET. COKE.

6:30 am - Leave the house before anyone else is awake, drive to work, eat Zon.e bar for breakfast, let air conditioner "blow dry" my hair.

6:45 am - Run the L&D board - check vitals/labs on all post-partum patients, write notes, tuck in (write H&Ps on, examine, check, and discuss the plan for the day) inductions/C-sections/Pgels. Feel a little happy about having two multip inductions, one of whom is already 5-6 cm dilated, and allow myself a little hope about getting home before the kiddos are in bed for the evening.

7:30 am - Scheduled C-section

8:30 am - 9:30 am - Office patients, OB checks, problem visits.

9:31 am - Call from L & D, Induction #1 is pushing

9: 35 am - Back on L &D waiting for delivery

9:40 - 10:15 am Delivery, repair, charting, pictures with new baby and family.

10:20 am - Resume office schedule, 6 patients waiting to be seen.

10:21 - 11:07 am - Frantically catch up.

11:10 am - 11:30 am Check on 10:30 NST for post-dates, notice irregular contractions, patient states she has been leaking fluid since 9 am, confirm ruptured membranes by speculum examination, write H&P, call L & D charge nurse, give verbal orders. Hopes of getting home for the evening? Unfortunately dashed.

11:31-11:47 am - Catch up charting, sign off labs, return patient calls, correspond with the nurses on 18 patient messages new since the beginning of the day.

11:50 am - Grab a stale raisin bagel from the Doctor's Lounge on the way back to L&D, check on labor patients, greet noon C-section, sit down and write H&P for noon C-section, gnaw on bagel.

12:00 - Scheduled C-section

1:00 pm - Back to the office, more labs to sign, more messages to return, eat frozen diet meal in 3 bites. More Diet Coke. Pull up L&D monitor strips on the computer, watch laboring patients from afar.

1:15 - 4 pm - Complete the scheduled patients in the office without interruption (yay!) Peek periodically on laboring patients via computer. All is well

4:01 - 4:25 pm - Call patient with CT results, large pelvic mass, likely malignancy. Discuss differential diagnosis, surgery options, answer questions.

4:26 pm 4:30 pm- Call GYN ONC colleague, discuss patient's CT findings, arrange consultation.

4:31 pm - 4:45 pm - Finish all charting, remaining labs, and straggling patient messages.

4:50 pm - Back on L&D, check on 2 remaining labor patients, accept with a bit of defeat that both deliveries are likely going to be later in the evening, chat with the nurses.

5:00 - 6:00pm - Evening rounds on my partners' post-operative patients for the day, "Wal-Mar.t orders" for the floor nurses, write notes.

6:01 pm - Go to car to pick up overnight call bag, left in the car in hopes that it would not be needed. Boo.

6:06 pm - 6:30 pm - Grab a call room, microwave some canned soup and steal crackers from L&D for dinner, keep one eye on monitor strips, one eye on the ER census via computer.

6:31 pm- 6:45 pm - Call Mr. Whoo, CindyLou, and Bean. Chat on the phone, say good night to the kiddos, sniff a bit about not getting to see them today.

6:46 pm - 7:15 pm - Lie on the call room bed, watch mindless entertainment news, wait for the nurses to change shift.

7:16 pm - Greet evening shift nurses, discuss patients and plan of care.

7:35 pm - ER consultation, admission for PID.

7:37 - 8:03 pm - In the ER, examining PID patient. Confirm ER physician's diagnosis, write admission orders and H&P, have lengthy discussion with tearful patient about her diagnosis.

8:04 pm - Stat page from L & D, patient (Induction #2) that was 5 cm @ 5pm is now complete and on the perineum.

8:06 pm - Arrive on L&D after running up the stairs, pant excessively.

8:07 pm - Gown, glove, prepare for delivery.

8:08 pm - Quick, easy, and laceration-free delivery of a healthy, "surprise" baby boy. I love it when patients wait to find out!

8:10 - 8:27 pm - Charting and chatting with L&D nurses.

8:30 pm - Check on post-dates patient, no cervical change since 5 pm, place IUPC and discuss pitocin augmentation.

8:35 - 10:30 pm - Back in the call room, pull up monitor strip on the computer, lie on call bed, flip channels, drift in and out of consciousness.

10:31 pm - Re-check post-dates patient, good cervical change since 8:30 pm, reassurance given to the patient.

10:35 pm - Find newly admitted PID patient on the floor, change pain medicine regimen, discuss admission orders with her nurse.

10:45 pm - Back in the call room, lights out, try for some rest.

11:45 pm - Call room phone rings, triage patient, 22 weeks with a UTI, who has had dysuria for 3 days, but confusingly (but unsurprisingly) picks the middle of the night to come in for it. Antibiotic prescription written, back to sleep.

12:48 am - Call room phone rings, another triage patient, possible term labor, irregular contractions, dilated 2 cm, have patient walk for an hour and re-check cervix, back to sleep.

2:00 am - Call room phone rings, walking patient with no cervical change, reassuring fetal strip, orders for Ambien and discharge home. Check on laboring patient's monitor strip and notice some early and variable decelerations.

2:05 am - Check post-dates patient, she is completely dilated, but feeling nothing due to super-epidural, decide to allow passive descent.

2:06 - 3:02 am - Chat with the nurses and laugh.

3:03 am - Post-dates patient calls out, "Feeling pressure."

3:04 am - Post-dates patient starts pushing with her nurse. Nurse reports back to me "this is going to take a while." Back to the call room, rest fitfully, peeking at the monitor strip approximately every 5 minutes.

4:17 am - 4:45 am - Called for delivery. Gown, glove, help deliver a 9 pound baby girl, get misty when Daddy starts crying. Collect cord blood for banking, repair perineal lacerations, leave the room to start charting.

4:46 am - Informed of triage patient's arrival, 30 weeks pregnant with possible premature rupture of membranes. Head to triage.

4:47 am - 5:07 am- Talk with patient, speculum examination reveals gross rupture of membranes, bedside ultrasound confirms AFI of 2 cm. Discuss implications with tearful patient and her husband, plan transfer to nearby hospital with Level 1 NICU and Children's Hospital. Orders for steroids, fluids, and antibiotics given.

5:09 am - Call on-call physician for nearby hospital, discuss the patient, transfer of care accepted.

5:15 am - Quickly write H&P on PROM patient, return to triage, discuss plans with patient's family which has quadrupled in size in the last 8 minutes.

5:25 am - Finish charting from previous delivery. Start rounding on post-partum patients, pray for 7 am to arrive, shake fist angrily at the call gods.

6:00 am - Watch PROM leave the unit with the ambulance squad.

6:05 am - Round on PID patient. She is feeling better, no fevers since admission.

6:22 am - Back to the call room. Shower. Clean scrubs. DIET. COKE. Pack up call bag.

6:45 am - Check out with the next call victim, finish post-partum rounds.

7:00 am - Officially off call! Ready for another full office day.

A day in the life of a part-time medical oncologist

Note: I am a medical oncologist who works part-time, two full days and one half-day at work and the rest of the week at home with my kids (almost 2, 4, and almost 6). We have a part-time nanny who comes on my 3 workdays. This is my half-day, which probably captures a little bit of both of my worlds.

5:10am Wake up to sound of husband opening drawers as he gets dressed. Open eyes briefly to see gorgeous man a few feet away. Too tired to appreciate him aloud, I smile blissfully and fall back to sleep. I'm married to that guy!!!

5:55am "Mama, milk please. Milk, Mama!" on the monitor. Go get my youngest from her crib who greets me with a toothy grin and nurse her in my bed. Wonder if I am still nursing her (usually once a day, either morning or bedtime, but occasionally both) because I am tired and this gives me a few minutes of snooze or because she likes the bonding or because I like the bonding or all of the above. Fall asleep wondering how I will wean her--she will be 2 in a couple months.

6:15am Wake up to youngest saying "Shhhh! Listen...mourning dove!" She's right. How does she know what a mourning dove cry sounds like? Aren't they supposed to fly south for winter? "Read Tick-Tock, Ears Hear a Clock!" Hop up, make the bed, change diaper, get her dressed for the day, and read her about 15 board books in her glider under a pile of blankets.

7:10am My 4 yr old wanders in with bedhead and slides under the blankets with us. We reread half of the stack of books, as well as two Fancy Nancy books she brought with her. Kids finally tire of reading and start to play together. I pee and brush teeth.

7:50am My 6 yr old wakes up to the sound of his sisters playing together very loudly. He is grumpy because he's still tired. He needs 12 hours of sleep per night or more and seldom gets it because he is such a night owl. Vow to do better at coaxing him to bed early. Start his Pulmicort neb.

8:00am Big kids use the potty and get dressed while I supervise. Dispense kids' Calcium chewables and son's asthma medicines and ask them to identify the pattern (my son's latest kindergarten task): "pink, purple, purple, orange...A, B, B, C" the older two shout in unison. Brush 3 sets of teeth. Start washing machine, loaded up and forgotten at bedtime last night.

8:15am Cook oatmeal while big kids decorate Christmas cards for friends and classmates at kitchen table and baby drives her doll and Curious George around downstairs in shopping cart. Empty dishwasher and finish packing lunches for preschool and school. Think it would be better if I emptied dishwasher and packed lunches the evening before.

8:30am Breakfast with kids. Baby insists on sitting at table, not in high chair.

8:40am Baby dumps bowl of oatmeal and raspberries everywhere. Clean up floor and notice that there's also a LOT of dried-up dinner remnants from last night and random fuzz down there, too.

8:45am Load dishwasher up, then chase kids around downstairs with the Swiffer Vacuum (incidentally, they love this and don't realize that I'm actually doing housework since I run with it like a maniac...try it.)

8:55am Walk 6 yr old son to bus stop for kindergarten. Kiss goodbye. Nanny arrives and drives 4 yr old daughter to preschool with my 22 mo old daughter along for the ride.

9:00am Grab charts, work papers, laptop, gym bag, lunch, cell phone, and wallet. Check email. Move clothes from washer to dryer. Get into car to head for the gym.

9:05am Back at home. Forgot my glasses. On the way to gym again.

9:15am Pilates.

10:20am Surprise preschooler by joining her preschool class in the pool for last half of their rec swimming time (preschool and our gym are adjacent and share a pool). Asked nanny to bring the 22 mo old up to the pool, too, so we all swim around together.

10:45am Shower, dress, dry hair quickly, no makeup (which is the rule rather than the exception lately, though I try on workdays...). Drive a mile to my son's elementary school.

11:15am Help my 5 yr old son and 22 of his classmates stamp snowman shapes onto t-shirts using glitter paint and potatoes.

11:45am Eat a sandwich in the car while driving to clinic. Conference into a meeting about clinical trial design issues, listening through the car's speakers via Bluetooth. Feel glad that we did not trade in our Prius for a second giant family truckster when we had our third child.

12:05am Sign clinic notes, bill outstanding visits, discuss patients with fellows, review two abstracts on which I am a co-author, read and respond to work email. Overhear fellows talking about the new breast cancer screening guidelines. They ask what I think about them. I explain that I can see both sides. Note that all of the female fellows are somewhat sympathetic to the pro-screening side of the argument; none of the men are. Interesting. Wonder how that impacts our counseling of patients. Note that inbox is now over 2000. Wonder what would happen if I just emptied it. Nurse asks if I had exfoliation or something. Thinks I look younger today. I tell her thanks but no. Remember that I'm not wearing any makeup. Look at my reflection in the exam room mirror--maybe she's onto something. I do look younger without makeup.

1:00pm-5:00pm New patient consultations, all breast cancer, often alone, occasionally with fellows. A representative sample:

32 yr old woman with high-risk early stage breast cancer. Recommend a clinical trial. She will need to travel to participate. Could also do aggressive chemotherapy outside of a trial, but not my first choice. Offer tissues to her as she cries periodically and entire tissue box, flashlight, reflex hammer, tape measure, and rolls of gauze to her 13 month old son who is toddling around the room and holding it together remarkably well for the lengthy visit. Mother, also in attendance, expresses outrage over the new breast cancer screening guidelines, which could have killed her daughter. I explain that her daughter is only 32 and wouldn't have been affected by these guidelines, which refer to women age 40 or older. That her tumor was palpated and not visible on the diagnostic mammogram even after the mass was felt. That these very aggressive tumors, such as her daughter's, tend to develop over months, not years, and often appear between annual screenings anyway. Cases like her daughter's are part of the case AGAINST mammograms in young, premenopausal women. She reiterates that no one seems to care that the guidelines could have killed her daughter. I decide I am not being a very effective communicator.

43 yr old woman with a smallish focus of ductal carcinoma in situ. Has had genetic counseling and isn't a BRCA mutation carrier. I recommend lumpectomy with radiation and tamoxifen for 5 yrs, which will reduce her risk of recurrence or a new breast cancer by nearly half. She wants bilateral mastectomies to save her life. Tell her that her prognosis is excellent, that there is no data to suggest mastectomy will improve her survival, and that bilateral mastectomy is absolutely overkill. She has two small kids and doesn't care. She wants them off. Wonder if I might not make the same irrational decision if I were in her place. Print out a patient education sheet from one paper showing no survival benefit for mastectomy. She shrugs and I give her the name of a good reconstructive surgeon. She declines the tamoxifen.

78 yr old woman with a recently resected very large, node-positive neglected breast cancer. Really, really, really don't want to have to give her chemotherapy. Wonder why she ignored this thing for so long. So I ask her. I was hoping I'd die before anyone ever told me I had cancer. Does she want to die? No, of course not. Does she want treatment for cancer? Of course. Recommend chemo in addition to hormonal therapy. Hold breath and hope chemo will do more good than harm. Think it will but never know how old a 78 yr old really is until she gets chemo.

35 yr old woman with stage 1 breast cancer, no family history, diagnosed by screening mammogram. Recommend chemo and hormonal therapy. Talk about fertility preservation and the chances of having a successful pregnancy in her 40s after chemo and 5 years of tamoxifen. She is angry about the new breast cancer screening recommendations. Her life has likely been saved by a screening mammogram, at age 35 no less, that her GYN recommended based upon several years out-of-date guidelines. She asks what I think about the new guidelines. I can't tell if it's a challenge or not from the tone. I spend 15 minutes explaining how there are valid points to both sides of the debate. Again. She seems unsatisfied. I think she was hoping I would agree with her or disagree with her but not both.

42 yr old woman with locally advanced breast cancer that was diagnosed by a screening mammogram, but must have been palpable months before. Wants a second opinion about the choice of preoperative chemo. Also asks what I think about the new breast cancer screening guidelines for women in their 40s. Think maybe I should put what I think on a shirt and wear it to clinic. I tell her that it's kind of like playing the lottery. You'll probably buy a ticket every week (i.e. get a mammo every year) and nothing will come of it. It will definitely cost you, but probably not that much. If your number gets picked and you win, you will think you clearly made the right choice to play. If you don't, maybe you'll regret all those tickets you bought and maybe you won't--that's kind of a personality and values thing. It's the shortest and least meaningful commentary I have made on the breast cancer screening guidelines (which I have discussed about a dozen times a day at work and socially) since they were released. I am tired. "That's the clearest, most thoughtful way of summing it up that I've ever heard," she tells me. Sigh.

5pm Grab charts and rush out to Tumor Board. Run into (literally) an out-of-town patient in her early 40s I had seen almost two years ago with a very high-risk, inoperable triple negative breast cancer. She had flown down to see plastic surgery about reconstruction and decided to stop in to surprise me. When I saw her in 2007, I had recommended that she go on a clinical trial that involved traveling hundreds of miles from home frequently. It would take her away from her school-aged kids. I had agonized about whether it was the right choice--it was a long shot--given all the time away from her family and her potentially short survival if it didn't work. She had been lost to follow-up at our institution. She had done the trial, had the preoperative chemotherapy, had an amazing response. At the time of mastectomy, she had a pathologic complete response (no tumor left in the breast or lymph nodes). PET scans every few months had all been clear. It is likely that she is cured. YES!!!! She hugs me and cries, cries, cries. Tells me that's the first time she's cried since the original call from the surgeon telling her she had breast cancer. I think I might cry too--a combination of joy, exhaustion, and hypoglycemia.

5:10-5:45pm Slide into Tumor Board 10 minutes late. Eat a disgusting pastry left over from some conference earlier in the day. Regret it. Think I should really plan better and bring a healthy snack. I am always famished after clnic. We have plenty of food in our fridge. Why is that so hard to pull off? Discuss my and my colleagues' challenging cases. Surgeons are running the show and have little patience for the medical oncologists yapping on and on, so we end 15 minutes early.

5:50pm-6:10pm Commute home. Listen to NPR for a few minutes and then call my best friend, who also commutes home at this time, via Bluetooth stereo speaker. Love the Prius again!!

6:10pm Enjoy the hero's welcome at the front door by all the kids and hubby. (Incidentally, no hero's welcome for me from the kids on the days I stay home with them!)

6:10-6:30pm Make black-bean pumpkin soup with 5 minutes of prep and quick-steam string beans in the microwave. (Love Aviva Goldfarb's Six O'Clock Scramble website for fast, healthy meals that everyone in our household will actually eat--check it out!) Mix up banana bread from scratch (6 yr old has food allergies, so no mixes for us) and put it in the oven. While dinner cooks, sit down at our kitchen table with a family-sized bowl of strawberries. Help 6 yr old with his phonics homework, congratulate 4 yr old on being selected "Top Dog of the Week" at preschool, and collect a few dozen random items on my lap, brought to me by my 22 mo old.

6:30pm Dinner with the whole family.

6:45pm Chase kids with Swiffer Vacuum again (they could do this all day) while husband loads up and starts dishwaser.

6:55pm Bath time!

7:10pm Everyone in PJ's. Back downstairs to have a bedtime snack of banana bread and apple cider. Love the fall treats!

7:20pm Help son with a Lego dragon he is building. Girls come into the room wearing dress-up clothes and costume jewelry (pajamas off). Make up a story that incorporates princesses AND dragons. Agree to tell the exact same story a second time, by popular demand, if girls will get back in pajamas. Make this request about 10 times. It eventually works.

7:45pm Everyone BACK in pajamas. Teeth brushed. Play Tickle Monster, also by popular demand. The baby old slips in her footie PJ's and falls. Big tears, overtired tears. Boo-boo buddy and special blankie. Evening saved.

7:55pm Husband starts reading bedtime books to all 3 while I fold the laundry on the floor in the room with them. As I finish up, little one comes over to sit in my lap with her thumb in her mouth and a longing look.

8:05pm Nurse 22 mo old in her room. Wonder if I am nursing her because it gives me a chance to sit down and unwind in a dark room or because she likes the bonding or because I like the bonding and decide it's all of the above. Wonder how I will wean her--she'll be 2 in a couple months. Fall asleep wondering. Jostled into the land of the living by my son, who wants me to read the last book.

8:15pm Put little one in crib and tiptoe out. Read the last book. Put my 4 yr old in bed and sit in her chair, her nightly request, for 10 minutes to talk about her day. Kiss her good night.

8:25pm Flop on my son's bed and beg him to join me. He draws portraits, dinosaurs, robots, all the items he would like at his next birthday party (including details of the party favors, pinata, cupcakes, and juice boxes), and does math problems standing at his dresser. I get snapshots of his day with answers to every third question.

9:00pm I tell him I will give him math and spelling problems if he will get in bed. We lie there together in the dark. Ok, how about CHICKEN? Um, C-H-I-C-K (it's CK, right, Mommy?)-I-N. Close, it's E-N. What about THICKET? T-H-I-C-K (it's CK, right, Mommy?)-I-T. Close, it's E-T. Ok, try CRICKET. C-R-I-C-K-I-T, no wait C-R-I-C-K-E-T!! Hey, is this a pattern, Mommy!! Let's do more patterns. Ok, try 2,4,6, blank, 10? He yells out 8. How about 10, 30, 50...? He says 70, 90, 110, 130, 150...I fall asleep while he's still counting. Apparently counting sheep works even when there aren't sheep and even when you count by 20s. At some point, I notice that he has gotten back up and turned the light on to draw again. When he sees me wince, he dims the light but keeps drawing, standing at his dresser. We should get a desk for his room, maybe for Christmas, I think. On second thought, maybe not--he'll never go to bed again. I fall back to sleep.

9:50pm Wake up in my son's bed to my son, now back in bed, asking me to scratch his back. I do and he falls asleep. Vow to get him to bed earlier tomorrow.

10:00pm Find my husband flipping between sports channels and playing Scrabble on computer during commercials. Sit down to watch 30 minutes of stand-up comedy (Brian Regan, totally hilarious). Laugh really hard, but fall asleep at the end of it.

10:25pm Husband shakes me awake, and I get in pajamas, brush and floss my teeth and wash my face. This wakes me up. I decide to go downstairs to pack lunches for the next day, notice that we need their thermoses which are in the clean dishwasher which I then unload, notice that we are out of yogurt and napkins so start a list for the store, sift through the day's mail and notice two bills that I need to pay. Too busy to let them wait, we might forget. Get online to pay the bills and realize that I also need to do our bi-monthly nanny payroll, which I do. Notice on our office desk a receipt for Motrin and Benadryl and fax it into our FSA. Look on travelocity at plane tickets for Christmas, which are now too expensive for the 5 of us...guess we'll be driving. Speaking of Christmas, I still haven't written our Christmas letter or done almost any of my shopping. Get on and order gifts for the nieces and nephews since they all have to be mailed, as well as a few things for the kids. Try to figure out what to get my husband (don't know) or what I want (keep getting that question from my family, don't know). Send my sister pictures for a calendar she is making for my dad for Christmas. Spend 20 minutes on Facebook reading about who is still eating their kids' Halloween candy and who says The Gentleman from Connecticut had better not filibuster, buster and who has found a lonely cow on their farm.

12:05am Join sleeping husband in bed.

12:06am Realize it's cold in the house. Go cover up the girls and put my 6 yr old, who falls out of bed every single night, including tonight, back in bed.

12:08 am Join sleeping husband in bed. Look at the window and realize the Christmas lights are still on. Go down and turn them off. Feel pretty awake again. See New England Journal and Real Simple on the chair by the door. Decide to read Real Simple for just 10 minutes. Read for 15 minutes. Feel guilty. Start reading "Case Records..."

12:30am Wake up when my head jerks forward. Re-join my husband in bed and fall asleep.

A Day in the Life of a Neurosurgeon – SERIOUSLY?

6:00 am – Out of bed, to the shower
6:35 am – Wake up 11 yo son, remind him to take ADD medicine this morning
6:40 am – Feed 3 hungry cats, out the door to work
7:00 am – Sign and update day’s surgical H&P’s, type an overdue office note into EMR so procedure can be precert’d for Friday
7:10 am – Breakfast, grits and poppyseed muffin, with premed student who’s shadowing this month
7:30 am – See first surgical patient in preop, sign chart, dress in scrubs
7:45 am – Call medical records to assure them I did the overdue discharge summaries last night and I’m back on staff
8:00 am – Do first case, small outpatient procedure
8:40 am – Talk with first pt’s family, see next patient in preop holding, write postop orders, handwrite prescriptions since EMR printer not working AGAIN
9:00 am – Start next case, 2-hour outpatient procedure.  Get page about emergency cerebellar stroke pt en route to ICU from sister hospital, need to consult
9:30 am – Review films of stroke pt during short pause in surgery, obviously needs emergent craniectomy.  Book case, give anesthesia instructions while operating.
10:30 am – Still operating on pt #2; get paged about another consult, not emergent but needs to be seen today.
11:10 am – Finish case, stroke pt not here yet.  Speak with family, write postop orders, decide to proceed with next case (1 hour inpt surgery) while waiting for stroke pt
11:40 am – Start case #3 after difficult awake fiberoptic intubation.  Play Christmas music to improve mood.  Get paged about consult #3 – brain mass.  Start getting irritable, since this was supposed to be a short day (get home at 6:30, actually see family and get dinner made, start decorating tree we brought home on Saturday).  There goes any chance of getting home before 9:30 AGAIN, on a day I’m not on night call.
12:45 pm – Finish case #3, talk to pt family, write postop orders.  Run upstairs to see stroke pt.  Awake but with ominous “pressure” headache.  Discover the internist started him on blood thinners 2 days ago (including Plavix), and he had a dose this am.  Delay emergency OR so platelets can be transfused. 
1:15 pm - Cancel last 2 scheduled elective cases to accommodate emergency.  There goes Dec 18th’s light schedule.  Soothe angry patients who have to be fixed before their deductible starts over Jan 1.
1:30 pm – Field call from our other hospital’s trauma committee chief, chewing me out for taking too long to see a trauma patient in their ER two weekends ago on call.  Explain that when I got their call, I was operating on the day’s second emergency case in the other town and couldn’t leave that patient on the table.  Called partner for help, who wouldn’t come in.  After finishing case, drove straight to ER 30 min away at 11:30 pm after operating since 8:00 am. Got stopped by police for speeding. Took pt straight to OR, operated until 4:00 am.  Pt survived and had great outcome.  “Oh, okay, I guess the circumstances were understandable.”
1:45 pm – Drop by doctor’s lounge for a cup of soup while platelets are being prepared.  Watch news about health care reform.  Wonder how many hospitals will have to close with Medicare cuts, and how many physicians will be able to stay out of hospital employment situations.  Realize there’s nothing I can do about it.
2:30 pm – Pt rolls into OR.
3:00 pm – Begin emergency surgery.  More Christmas music, reminding me I haven’t done any shopping or even thought about what to get for which people.
4:58 pm – Still operating.  Get paged about consult #4.  On call partner takes over at 5:00 pm.  Hospital called him first, but he told them to call me.
6:00 pm – Finish emergency.  Speak with family, write postop orders.  Review films on postop pt in rehab with new leg pain.  Can’t tell if his graft has migrated.  Order CT scan.
6:15 pm – Change out of scrubs, see patient with brain mass.  Order additional testing, type consult note.
7:00 pm – Answer text from husband to tell him I won’t be home for dinner AGAIN.  Attach sad emoticon.  Advise him to use olive oil to make couscous for the vegetarian exchange student who lives with us during the week.  Remind him to make sure son takes anxiety meds tonight.  Husband texts back that son only got sent out of one class today for disruptive behavior.  Progress.
7:05 pm – See consult #3, pt with back pain.  MRI films aren’t here, instruct pt’s family to bring tomorrow so we can make decisions.  Type consult note.
7:45 pm – Field question from floor nurses about a postop patient, preventing the need to disturb the on call partner.
7:50 pm – See consult #4, pt with back pain.  Explain to family why I didn’t get here earlier.  Discuss treatment plan, not surgical.  Enter orders and type consult note.
8:30 pm – Check on craniectomy pt in ICU.  BP is 210/130.  Start Cardene drip.  Otherwise doing well.  Hug family member.
8:50 pm – Stop by office to check messages.  Ignore inbox on my desk (known to my staff as “ Mount Surgeon .”)  Review To Do list, realize I can’t mark off a single item.  (There are 18.)
8:55 pm – Glance at call schedule accidentally, reminding myself that I’m on call Christmas (Thurs-Mon) and on backup for New Year’s.
9:00 pm – Rest for 5 minutes to read this blog, am inspired to write this guest post.
9:20 pm – Start wiping away tears as I think about what I’ve just written.  I used to love my career, but I am realizing how sick and tired I am of this workload - of not seeing my family, not being ready for holidays, using weekends to catch up on charts… of being dumped on by partners and pushed around by insurance companies.  I can’t remember what I used to do for fun, and I can’t figure out why I’m still getting out of bed for this, day after day.  Why would anybody want to have a day like this, or worse, 5+ days a week?   I know, it’s supposed to be hard, and the culture of neurosurgery is to suck it up and avoid asking for help, because that’s a sign of weakness.  Maybe my fellow residents were right after all, and I’m just lazy.  Maybe I just need to finally reconsider my options and decide whether this has devoured enough of my life.

Wednesday, December 9, 2009

Day in the life of a physiatrist

Note: I am a PM&R clinical and research fellow.

5AM: Melly crawls into our bed and the kicking commences. If her head is on our pillow, how is she still able to kick me in the ear?

7AM: Alarm goes off.
Me: "I have to shower."
Husband: "No, I have to shower."
Me: "Goddammit."

Me: "Melly, would you like to sit on the potty?"
Melly: "No."
Me: "If you make on the potty, you'll get a treat."
Melly: "No, I'm doing something."
(She's a very busy girl.)

Me: "Melly, it's time to get off the potty."
Melly: "No."

8:10AM: Day care drop-off.
Melly: "Mommy, I don't like day care. I want to go home."
Me: "You can come home later."
Melly: "No, NOW." [tries to slip out the door]

8:20AM: I arrive at my bus stop. Bus is just pulling away from stop. I am waving my arms and yelling, but it doesn't stop. I am certain everyone on the bus sees me and is laughing to themselves. If I am feeling particularly limber, I chase the bus down at the next stop.

8:45AM: Arrive at work, pretending I've already been there for the last fifteen minutes.

Patient: "My back hurts."
Me: "I think you might benefit from a course of physical therapy and/or injections."
Patient: "Can I have Percocet?"
Repeat x infinity

11AM: EMG time
Me: "Please relax your arm while I stick this giant needle into it and move it around."
Patient: "Gaaahhhhhhh!!!!!!"
Me: "OK, you're not relaxing."

1PM: Work on IRB application during lunch, while fantasizing about a long ago, simpler time, before I knew what the hell an IRB application was.

2PM: Research meeting
Colleague #1: "Research is frustrating."
Colleague #2: "There are many barriers to doing research. Let's discuss these."

4:30PM: Head home.

5PM: Arrive at daycare. When I get there, all the remaining kids crowd around the door, crying out, "Mama!"
Me: "Time to go home!"
Melly: "I don't want to go home. I want to stay here."

Day care worker: "You know, Melly really loves babies. You should have a little baby brother or sister for her to play with."
Me: "If she agrees to take care of the nighttime feedings, then no problem."

6:30PM: Dinner. For years, we used to eat in front of the TV, but now my husband wants to eat at our dining table and have "family time." Loser.

"Melly, would you like to use the potty?" vs. "Don't worry, we'll clean up the pee on the floor."

8:30PM: Melly's bedtime. I lie next to her in bed and generally fall asleep myself, waking up 1-2 hours later, completely disoriented.

11PM: Watch one of a selection of TIVO'd programs, including The Office, 30 Rock, Parks and Recreation, Top Chef, South Park, or Glee. In the meantime, I prepare lunch for the next day for me and Melly.

11:30PM: Bed time for real. I drift off to the sound of my husband's CPAP machine.

A Day in the Life of a Part-Time Pediatrician

I am a pediatrician working part-time and mother to a 4 month-old and a 6 year-old.  I work 3 days a week.  My husband is a physician working full time.  Below is a typical work day.
5:15 AM Wake up, try to sneak out of bed without waking co-sleeping baby, shower, get dressed
5:45 AM Eat breakfast, take a pill of lecithin to prevent plugged ducts (I must hold some sort of record for having the most number of plugged ducts by 4 months post-partum)
6:00AM Call hospital to find out how many newborns to round on then call other docs to come in if reinforcement is needed
6:30 AM Get to hospital and round
7:50 AM Pump in NICU pump room while reading Us Magazine
8:20 AM Drive to clinic and start seeing clinic patients
12:30 PM Done with AM clinic, answer Mommy calls, Pump, drive home to kiss baby a million times and have lunch
1:30 PM  Start seeing clinic patients
4:00 PM Pump
5:30 PM Done with seeing patients, answer Mommy calls
5:45 PM Pick up 5 year-old at After-School program
6:00 PM Make dinner (I have help with making dinner on work days), play with baby, help 6 year-old with homework, wonder why first-grade homework is so demanding, try to keep baby awake until hubby comes home
7:30 PM Baby is now irritable and wants to sleep NOW, hubby comes home and spends a bit of time with baby, I put baby to bed
7:45 PM Eat dinner
8:45 PM Hubby and I help 6 year-old floss, brush, pick out clothes for next day
9:00 PM Pump then time to relax!!!  TV, internet, read for fun
11:00 PM    Bedtime
1 or 2 AM     Baby up to nurse, change diaper
3 and maybe even 4 AM     Baby up, sometimes I nurse, sometimes I don't and just let him settle down on his own, depending on how tired I am
Yes, I am exhausted but feel so privileged to be able to work part-time.  On my non-work days, I get to play with my kids all day long.  It is truly having the best of both worlds.     

An Average FD Weekend

December 5 and 6, 2009

I am an assistant professor in the family medicine/osteopathic manipulative medicine department at a medical school. My job includes teaching on campus and two days of clinic per week. I do not work with residents or do hospital work at this time.

0530: Hit the snooze.

0600: Get up, shower, dress, meet Husband in the great room where he is feeding Daughter breakfast. Have fifteen minutes "share time," a luxury in our marriage.

0730: Pull into parking garage of local hotel which is hosting the winter cme program sponsored by the medical school for whom I work. This is the final day of the program. I am both presenting and moderating today and must stay through the last lecture.

0745: Have a frightening conversation with an elderly family practice doc, retired, who "never believed in mammograms. " Wow.

0755: Cardiologist thought he was to speak at 0800, my speaking time, and he has to get his son to a soccer thing. I trade spots with him because I'll be here all day anyway.

0845: I give my lecture on EMR (history, political stuff, choosing and implementation). To my surprise, it went very well and was well-received. Spend rest of the day basking in the glow of good feedback.

1200: Had to cut the financial planner's discussion short as it was clear he was overtime and wouldn't be stopping anytime soon. I don't feel too bad as it was basically a sales pitch. I apologized profusely to him and the audience and he kindly left the room. I'm pretty sure I see his tail tucked between his legs.

1300: Final lecturer finishes and I realize his area of interest is mine, too. We briefly collaborate and agree to start a project together, trade contact info. I realize my self-imposed deadline to identify an area for my academic research by the New Year has been met. I give myself an internal high-five, which may or may not feel like a Kegel exercise.

1340: Fill up gas tank, decide to go to WalMart, closer to my house, rather than Target, closer to the gas station, for my quick errand of getting pantyhose.

1400: Leave WalMart SEETHING that they no longer carry Just My Size. Queen size is the biggest they carry now and for my height that means no heavier than 185. Am I the only obese WalMart shopper? Hmmmph! Go through Taco Bell drive-thru as I'm sure a taco will ease the psychic pain.

1415: Back at Target, telling Sister via iPhone about the WalMart incident. She asks me to pick up panty hose for her, too, while I'm there. She too has her work party tonight.

1500: Now at Catherines all the way across town because Target also doesn't carry Just My Size. Picked out a festive party blouse for my work holiday party tonight. Threw in some cheap costume jewelry for safe measure. Retail therapy. I feel calm and somewhat refreshed.

1530: Deliver Sister's pantyhose to her house. She leans in to take them from me and notes my nasty chin hairs reflecting the sunlight. I produce a pair of tweezers from my purse and she plucks them as I sit in my car in her driveway.

1600: Home. Son is playing Noggin games on the computer. Daughter is grumpy, so I give her a bottle and put her down for a nap. Husband jumps in the shower. We need to leave for the party at 1745 and his mom should be here to watch kids by 1730. My mom, apparently, also will be here at 1730 to pick up library books she checked out for Son. After an all out search, we find only two of the three books.

1630: Update my Facebook status and start this post.

1700: Gettin' purty - makeup, sparkly top, jewelry and perfume. Mom-in-law arrives to watch the kids.

1830: Husband and I arrive at the most expensive and exuberant employee party EVER. The Las Vegas theme was complete with showgirls, elvis impersonators, a great band, aerial artists a la Cirque du Soleil, food, booze and gambling (fake money). Many of my colleagues are in costume. We'd planned to stay 30 minutes then ditch out but stayed for the duration. On the way home, Husband notes that the atmosphere was different than he had ever experienced because it was clear everyone, from the president of the university to the maintenance people and cafeteria workers, was part of the same group. "You all seem to really like each other," he said. I agreed. Best Job Ever.

0000-0530 Sleep!

0530: Wake up and straighten house for cleaning lady. Mom-in-law spent the night and agrees to watch the children, for whom a long church day is exhausting because nap time is missed. Husband makes our turkey sandwiches for breakfast so we can eat in the car on the hour trip to church.

0730-1300: Travel, choir practice, School, worship then travel home.

1300-1600: Skip lunch in favor of a nap. I wake when Daughter is crying on the monitor placed by her crib and note that at some point, Husband has taken Son for their weekly parent-child bowling league.

1600-1730: While Daughter plays, I finish up just a few outstanding EMR reports so I can start with a clean slate in clinic tomorrow. I then check the upcoming week's, practical exams for the students, serial committee meetings and Husband will be out of town Tuesday through Thursday.

1730-1830: Dinner with the fam. Turkey casserole that Husband made yesterday while I was at the conference. I note that Daughter shares my love for all foods and I feel a pang in my heart. It will important for me to try to model some healthy habits for her, but first I must adopt them.

1830-1900: Bathtime and bedtime for kidlets.

1900: Finish the medical records catch-up and this post.

2100 (anticipated): Fill my weekly medication dispenser then Go. To. Bed.