Wednesday, March 24, 2010

Matching to a Different Drummer

 Hi and thanks for the blog, I love reading it when I get a chance to sit at my computer and procrastinate!

My question is this- I'm a caribbean med student from the midwest, and due to odd scheduling, I'll be done with my 4th year electives in July, taking step 2 at the end of that month.
This means I will miss this years' match, of course.
What should I do for the 10 months that I have off before residency starts in July 2011?

Get a job in research at the hospital that I'd like to get a spot with?
Get a job as an EMT?
Get a job with nothing to do with medicine and study like mad to take step 3 before residency starts?
Is it possible to start residency in September?? ( I want to do Peds)

I'm single and childless- but I have joked that those 10 months off would be the perfect time to be pregnant! :) Current BF grins while looking green... lol. I'm not looking to have a kiddo yet, just seems from reading your stories that this is the last time I'll have 10 months off in a row!

Thanks for any replies!! I appreciate you all.

Being out of step with the match can work to your advantage in several ways. Some positions do open up in the middle of the year, when people drop out, switch specialties and so on. I am not quite sure where such positions are advertised, but the dean of your school may know, or you can check in a specialty newsletter. If you have graduated before you apply, you are not obligated to go through the match at all. This frees up a program director to take a position out of the match and sign you up at any time before submitting a match list. If you are applying to a residency that has trouble filling slots some years, this can work to everyone’s advantage. Programs hate to have positions unfilled on Match Day, and it also frees you up to do whatever you want, knowing your position will be there in July.

If you are looking for interesting things to do, there are many opportunities in international relief related medicine, including disaster relief, maternal child health clinics, HIV clinics and so on. The internet is full of requests for people who want volunteer in Haiti, and the need is going to be there for years (try Partners in Health as a sponsor, in particular). You can also use your time to get far along with another degree—for example, if you take a full semester of courses toward an MPH, you will likely be able to finish it during residency, and that is a great credential to have later on. You could also take courses in humanities, again with the idea of cultivating medical humanities in residency and teaching in this new field in the future.

Another or additional activity is to learn to be a standardized patient—the work pays something, is very flexible, and teaches valuable patient relationship skills that may be helpful during residency. Other medically related, paying jobs that a medical student is qualified to do include phlebotomy, being on an IV team, and being a “sitter.”

Finally, there are some educational experiences that you could pursue if still enrolled, for example, the neurology elective at the Queen’s Square hospital in London or the advanced psychopharmacology clerkship at the National Institutes of Mental Health. Students also can go to some professional meetings for free as recorders—the Child Psychiatry meetings for example—and that could really enrich the time between school and residency.

How To (and not) Breast Pump at Work

A friend of mine (anesthesiologist) is expecting her first baby any day now. She had a lot of questions about breast pumps, ie how difficult was it to pump at work? How did you deal with call? What were your colleagues' attitudes towards pumping? What breast pumps would you recommend? How much time does it take to pump (on average)? How long did you breastfeed for, and was your decision to stop influenced by work issues?
I did read Fizzy's post a while ago (formula vs breast milk) but my friend and I want to know the details. If you don't feel this would be too repetitive, it would be great to hear what the other mothers in medicine think.

My daughter, Sicily, was a dream baby as far as the pumping goes. I'm paying for it now, in elementary school, but that is the topic of another blog. Pumping was tough to learn, but once my friend Mel showed me the ropes, it was smooth sailing. I had a top of the line Medela - I'm sure there's a newer model out now. It was worth it to me to shell out the bucks for efficiency. All of the books recommend that you pump as often as you would nurse, but when you have a hungry, demanding baby this seems unreasonable. I usually tried to pump twice a day at work. I was on clinical pathology rotations my second year of residency - had adequate time to manage my goals. I studied during the process.

I tried to pump in the pumping station at the hospital near OB, but it was so far away and all of the dried milk spots on the chairs, walls, and floors in the cubicles behind sheeted doors freaked me out. So I used Mel as a mentor again and pumped in an empty apheresis room - nice and clean. And I'm nice and clean so it worked out for the apheresis attending. I usually pumped at 10:00 and 2:00 - it took about thirty minutes start to finish, including rinsing out the parts and storing the milk. Toward the end I was able to back off to once a day when my production started waning. There was one unfortunate incident of a male nurse walking in on me while I was pumping - it was embarrassing at the time but funny in retrospect - he couldn't look me in the eye for weeks. I think he was more embarrassed than I was.

I was a cow as far as production goes - I remember once falling to pieces when the power went out on a weekend when I was alone at home. I called the poor Entergy company assistant in tears.
"When is the power coming back on? I have all of my milk in the freezer! If it thaws, I will have to throw it away. Are you sure they are fixing it? Can you please tell me again the exact time you expect it to come back on?"

When you work that hard, a tiny bag of frozen milk is like liquid gold.

I pumped/nursed for eleven months with Sicily. It was just time to quit - we both seemed to know it. It was a very smooth transition to frozen milk, and she was on formula by a year.

When I had my son two years and four months later, I thought I was living my dream. Perfect marriage, doctor husband, girl and boy, and well on my way to (in my opinion, and many others, some will beg to differ - there are a lot of great jobs in this state) the best job in the state. I was going to work at the hospital my dad and husband worked at. Plans don't always work out the way you want them to, but this isn't always a bad thing.

At the time, things were going according to my plan. But with my son John, things degenerated. He didn't sleep all night at three months like my daughter - he wanted to nurse three times a night. Hard to blame him - he didn't get much of me during the day - but it was killing me. I was also on some tougher rotations, so I reduced pumping to once a day. I would nurse in the wee hours of the morning, pump again after getting ready before I went to work, and suck it up until around noon, when my breasts were like lead balloons. Well, not really lead - they were a little more lumpy. Think a million tiny shrubs under your skin, full to bursting point. I had to get a third storage bottle - I was going way over 12 ounces. I didn't have time to go down to the apheresis unit on the first floor. I just ate a quick stash of processed food for lunch, and made fast friends with the residency coordinator/mom, who let me pump in her office. I could squeeze it in (or out!) in twenty minutes, now. I was a little more rushed overall, at that time in my life.

I sat on the residency coordinator's floor with my face to the wall. Sometimes she left. Sometimes she stayed, and we chatted about kids, life, and family. I really enjoyed that - it was one of the highlights of my day. Female bonding.

This style of pumping was OK for John, but not for me. I had a lot more problems with dehydration and blocked ducts. I've got a pretty high pain tolerance, but blocked ducts have to be one of the most painful experiences on the planet. Worse than childbirth (well, I did have epidurals, so that is not a fair comparison). When he was around seven or eight months, in early winter, I let him cry it out at night, and stopped nursing. This was a much more painful emotional experience because A) We weren't ready B) I was exhausted and had to start studying for my Anatomic Pathology/Clinical Pathology boards in June and C) I was beyond sad and depressed and strung out and D) I knew this would probably be my last time to nurse. It was an amazing experience overall, and I couldn't see myself ever doing it again. I was going to miss it. Luckily, I have nursing dreams to remember the rush of relaxing hormones that accompanied contraction and let-down. I am not talking about pumping here, I'm talking about the real thing.

I wish I could speak to the call, but we pathologists get a break, on the call. So hopefully someone will comment on that in the comment thread. Colleagues attitudes - I am sure I occasionally annoyed, but this was usually temporary, situational, and not always my fault. It is tough to control other people's moods, and sometimes they will project their frustrations onto anything. I did have to get coverage some days, especially with John, when I was responsible for junior residents or covering frozens. People ask to be covered for a lot of reasons, and this was one of the few I asked, so I tried not feel too guilty when others worked for me and made sure to do extra favors when I was around. I like to think that overall I was admired tremendously by residents and attendings. I'll bet if I took a survey the results would back up my hunches.

I am proud of all of my efforts and work, even though it got a little crazy, single-minded, and self-sacrificing at the end. I beat myself up way too much for giving Sicily that extra few months - I felt like John needed it more, since he was six weeks premature. But he is a happy, healthy, well-adjusted four and a half year old, so I think I did all right by them both, in hindsight.

Tell your friend good luck, Liana! Thanks for the question.

Tuesday, March 23, 2010

Day Care Drop

How do you manage day care or school pick-ups, drop-offs, holidays and sick days for your children? My husband is a surgery resident so he can't drop my daughter off (he leaves the house at 5am), and most days even if he *thinks* he may be able to leave early, something inevitably comes up and he can't leave as planned. He sometimes can get a day off to care for our sick daughter, but he certainly can't do it every time she's sick. I know there shouldn't be a difference between MiMs and FiMs (Fathers in Medicine) but hey, I think the reality is there is a difference. Just curious.


Bea is married to a PGY-2 surgery resident and writes a blog about medical marriages and her experience thus far.

Thank you for the question Bea.

When I headed back to work after my maternity leave I was surprised to find how pre-occupied I was (constantly) with this very issue. Working mom's may seem busy with the task at hand, but a small part of their attention is always dedicated to the child(ren). During my day there is a second schedule (not included in my outlook). It includes a series of toddler activities: reading time, art projects, music, lunch and nap. As I move through my day I am thinking about my son and what he is up to. As the day winds down this turns into an obsession watching the clock. A real MiM fear, getting caught up with a sick patient and not able to be there for your child.

The day care is a wonderful place, overall. A little less wonderful is the yellow highlighter they use on the classroom sign-in sheet. Ten hours per day, maximum. That seems like a long day for a one-year old. It is a blink of an eye for a Cardiologist. Drop off at 7:30 AM, pick up at 5:35 PM..... violation! Marked in fluorescent yellow for all of the parents in the class to see. Oh the judgement and guilt served by that mark!

My husband is not a Father in Medicine, but he is a Corporate Executive where the majority of his colleagues are married to women who do not work. We try to stagger the drop-off and pick-up so that we can each work a full day. The game plan however, is altered more often than not leading to a frequent race against the clock.

I hope others will chime in and add their creative solutions, depending on your specific situation there may be a novel idea that could be applied. In our house, salvation recently came in the form of Miss Kim. She is a teacher in my son's classroom, and he LOVES her. She is single, and lives between the school and our house. She now "picks up" for us, bringing my son home from school. Sometimes they stop at the park, other times they rush home to take the dog for a walk. She feeds him dinner. Now my husband and I arrive by 6:30 with a happy and fed little one. We then spend the next two hours relaxed, fully engaged in the bedtime routine.

Another strategy for me, our University has Major and Minor Holidays. The Minor holidays being those where school is out but most work places are open. If we work the minor holidays we receive an extra vacation day. I have my admin block all Minor Holidays- Out of Office. It is my Mommy prerogative. That way it is set up in advance, and I am not scrambling the week before to cancel clinic or find child care.

Then for those rare days, when my day is a short one and I can greet the little man mid afternoon. The best is making it for "buggy time" at 430, when the kids are strapped into the multi-kid stroller. Carrying my son around the block while the others ride, taking in part of his day- I am on top of the world.

Feeling the Love

(*Leah lucked out and had 2 MiM writing in response to her question!)

Leah recently earned a PhD in Immunology and is married to a 4th year medical student/ soon-to-be orthopedic surgery intern. She has a newborn and a 2 year-old.

What are some special things that your spouse has done to make you feel loved/supported during your residency?

There are too many things that my husband did (and still does) to make residency a little less miserable for me. Those listed below are just a few of the highlights....

~ Put his career and plans on hold to move with me and follow me from medical school to residency to my jobs thereafter.

~ Wrote me love notes left on the kitchen counter on the days we could not see one another.

~ Listened to me whine, cry, and gnash my teeth, and provided a broad shoulder upon which to cry.

~ Did his best not to vomit when I chose to share certain details about my day (he tends to be a bit squeamish).

~ Went to the grocery store, folded laundry, got a cleaning lady for our house.

~ Put me to bed when I would come home post-call and pass out on the couch with an un-touched open bottle of beer in my hand.

~ Surprised me with the china hutch I had been coveting one weekend when I was on call, and set it up with all of our china displayed so that it was the first thing I saw when I walked in the door.

~ Took care of me when I was having pregnancy complications, and stood up for me when I was being mistreated by the residents that I thought were my friends.

~ Arranged a surprise 30th birthday party for me with good friends at a time when I was feeling lowly and friend-less.

~ Always, always, always made home a safe, warm place to fall. Thank you, Mr. Whoo....I would have never survived residency without you!

Helpful Spouses

What are some special things that your spouse has done to make you feel loved/supported during your residency?


(recently earned a PhD in Immunology and is married to a 4th year medical student/ soon-to-be orthopedic surgery intern. She has a newborn and a 2 year-old.)

My spouse was amazingly supportive during residency. He listened to me when I needed to rant about my crazy day, understood when I needed to work late and would make special visits to bring me dinner when I was on call. He had always been helpful around the house, but that also went to a new level in residency.

Residency is about survival, so one thing we found helpful was to dream. We had regular date nights, and early on it was hard not to spend the entire time at dinner just complaining about work. So we began to talk about our future life or plan the next vacation. Having something to look forward too was always helpful.

We had our son during my third year, so that obviously changed the dynamic. At that point he became a stay at home dad and truly embraced that position.

So, I think the answer is to do everything you can to meet his needs. Which will be different for a man than a woman. It will obviously be challenging since you have needs too, a job and 2 small children going into this process. He may not care about the house being clean, so figure out what is most important to him, focus on those things and let the other crap go. I am going to venture out on a guess that his 2 biggest needs are respect and sex. This is based completely on my observation of men and specifically orthopedic surgeons.

Obviously he should try to meet your needs as well, but the question was how to be supportive of your spouse during residency.

Monday, March 22, 2010

How Do Duals Do It?

I am wondering how the women of dual physician couples have shaped their careers to manage their children and families. My husband and I are MD/PhD students nearing the end of the end of the programs and trying to decide what we should do for residency. We have a daughter who is about 1.5 and may have another child before I graduate. I knew exactly what I wanted to do until I had my daughter and now I am feeling very confused about my career. First, I haven't found any examples of dual physician couples with children who both work full time jobs at academic centers and do research etc. Second, even if I could, I am not sure I want to be away from my children so much. Here is what I have observed. 1) The mother doctor works part time. She therefore doesn't do research and usually works in a more private type practice. 2) The mother doctor works full time and her husband has a job that is more flexible and not in medicine. 3) Both people work 3/4 of a job - share a practice. 4) Both people are trying to do everything in a field they like but it isn't working and they have to choose easier/more flexible options in their field or do a bad job (ie fail to get a grant). 5) Both people choose specialties that demand the fewest hours possible. 6) One person does only research. I would like to know how dual physician couples have shaped their lives in order to accommodate their families and careers. Specifically, did your children influence what field you went into, or the center where you practice, or the amount of research vs patient care you do? What is the best strategy as a student deciding on a career after med school and what are the options?

- 7th year MD/PhD student

At times I find myself still wondering as well! But nonetheless I will attempt to answer as an academically inclined MIM married to an academically inclined physician who is also mostly in medicine, primarily doing health-related research for the government. You (yes you, 7th yr MD/PHD student and reader of our MIM blog!) have the answer, many various answers, included right there in the question you so thoroughly posed. Starting with "I knew exactly what I wanted to do until I had my daughter." That’s it precisely, we have certain ambitions and interests which we tackle full force, and then we are moved to incorporate the new people (little people, big people) into our lives as new, sometimes unanticipated (sometimes unintended) passions of ours.

The other set of answers to your questions are all there too…. in your proposed answers #1 though #6 or some combo (choose all of the above), over the course of your careers. All the while having a heightened awareness to recognize that doing a bad job (or a bad parenting job) means something has got to change quickly. You might sometimes work part time, and that might mean part clinical and part research so you have (or make) the flexibility to alter/design your schedule. Or, your partner sometimes does so. You or your husband might take a more flexible job, even within your field of medicine/research. And you might change what you do over time, or your partner might. And so on.

In my situation, I'm in pediatrics, some would say a "less demanding" field, and my husband, also a pediatrician, is primarily a health services research for the government. He does have flexibility, yet he does both research and a small amount of clinical time. I do a quite a mix of clinical, medical education, and research. The mixture keeps it interesting and allows for some tweaking or major alterations throughout the course of one’s career. We had children a few years after my residency and while his residency was coming to a close. So I guess that makes us a little older (though I didn’t have any gray hair until just recently). We found the mix that worked for our family, and we work hard; that is we work hard to get home for a family dinner every night. By dinner I don't mean spectacular meal, but rather time together mostly around the table, chewing and talking and listening to each other (vying for each other's attention, mostly!). And we work hard by day (for the most part) to get home to pick up our kids and be fully present for them, until after they go to sleep, when I tend to do a little more work (husband opts not to).

Back to your primary question: For us, having children didn't influence our choice of field (we were already pediatrician and graduating pediatric resident) but it did influence the ways in which we fulfill our academic goals. At times we do so more slowly, for example, I used to work weekends and evenings (even if not clinical, I mean work on various academic projects) and go to many academic conferences (pre-kids), and nowadays weekends and evenings are family time (when the kids are awake at least), and I now go to fewer (no?) out of town meetings or evening/weekend events. One tip, always plan to present at the national meetings that happen to be held locally in your region! Collaborate, and pace yourself.

I will mention that pediatrics does tend to be family friendly, because while we take care of others' kids all day, our colleagues understand when one's own children's issues have to take precedence. Work among people who support each other. Keep the discussion open with your partner/husband so that you can serve as a support to one another and also as a reality check as to whether the work-family arrangement is working for all of you. And remember, your kids (and we hope your husband/partner) are with you for the duration, in sickness and in health, and all that… but you or your husband/partner can tweak or even overhaul your career choices over time.

PM&R: The Holy Grail?

Hi, kids! I'll be tackling two questions today:

My name is Brittany, and I am a third year medical student obsessing daily about what kind of doctor I should be. I struggle daily because I have loved mostly all of my clinical experiences thus far and could truly see myself in a variety of different fields. All around me my classmates are making decisions about career choices, and it just does not seem like an easy choice to me! Considering family life and how it will factor into whatever choice I make makes the decision even more difficult.

So, my question is how did you choose the specialty you went into? Was there a moment or a series of choices or did it just make sense? How much did family factor into this decision?

I realize that everyone says, "do what you love and you'll be alright." However, I love medicine as a whole and different specialties for various reasons, sometimes completely unrelated--there are other factors that influence this decision, and I am curious how others dealt with them.

And more specifically:

My name is Alli and I'm an MS 3 who is in search of the holy grail in medicine-- a profession that provides both financial stability and flexibility. Here's my story: I live with my boyfriend, and future fiance, on Long Island and as I get deeper into looking into residency I am petrified. I love my boyfriend, and want nothing more to have a family (why didn't I want to be a math teacher again??) but I'm really concerned, not only about juggling being a mother and wife with being a doctor, but about finances. I am SO in debt and my boyfriend is a firefighter and doesn't make much money, meaning I would be the primary breadwinner (shudder). Is there a medical field that exists that would allow me to provide for my family while also being a dedicated wife/mother? Don't get me wrong, I'm not trying to get out of working hard and I honestly love what I do. I'm just afraid that years later I will burn out and realize that I wasn't there for my family and that I could have made just as much money doing something else. I have already ruled out certain specialties that I have an interest in because I'm afraid they demand too much (i.e. surgery, ob/gyn) and others because while they might be low key they don't have enough financial stability (i.e peds). I honestly love pediatrics, and was considering it up until I discovered physiatry. Physiatry is a great field, and certainly a strong second choice. I was just wondering your thoughts on my situation, if you have any input about physiatry programs in NY and physiatry salaries in general for a future Mother in Medicine.

OK, since I just blew a bunch of space posting those questions, I'm going to cut right to the chase and be brutally frank here:

For many graduating med students, lifestyle matters. A lot. When we applied to med school, we all had a convincing story about how we want to help people, blah blah blah. And maybe at the time, we meant it. Or at least, some of us did. But when it comes time to decide what specialty we want to do for the rest of our lives, other things become more important than just "helping people" and generally doing good. We've all got loans, rent, children or potential children, future alimony payments, etc., so money is important. And many of us have gone through waking up at 4AM for surgery rotations (on Saturday! horrors!) and decided that's not so much for us.

I'm going to continue to be brutally frank. Get ready:

I don't like to work that hard. I don't particularly like to wake up at 4AM. In fact, even 7AM is a bit early for me. And that whole going to work on weekends thing? Not a fan. Or staying up the entire night on call? Also, not my favorite thing. When I was entrenched in my third year of med school, I realized that I desperately wanted a 9 to 5 type of job. Lots of people have 9 to 5 jobs. Why not me? Why?? Why did I have to suffer through 3+ years of a horrible lifestyle in residency just to possibly have an equally busy practice after residency? I had already worked SO HARD in med school. It wasn't fair. IT WASN'T FAIR DAMMIT!

There were specialties out there that could have catered to the lifestyle I wanted. Dermatology residents have it pretty good. But my grades weren't good enough for that. My grades were good enough for radiology perhaps, if I was willing to go anywhere. But I wasn't. I was following my husband where he wanted to go for his career. (Yes, I was one of THOSE women.)

The brutal frankness continues below...

If you want an eas(ier) lifestyle during residency and your options are limited by your grades and/or geography, there are two options: psychiatry and PM&R.

Psychiatry: Everyone knows what a psychiatrist is. I know this, because people accidentally call me a psychiatrist about five times a day. In any case, psychiatry wasn't for me. I won't get into the reasons, but I was pretty sure about that.

So that left PM&R, which stands for either Physical Medicine & Rehabilitation or Plenty of Money & Relaxation, depending on who you talk to. I did a rotation as a med student, expected to be bored, but actually really liked it. I did my residency in PM&R and it was.... easy. It was rare that I had to wake up before 7AM. I got home most days around 5PM. I spent maybe one or two nights in the hospital during my entire residency. I had a life like a normal human being. Amazing.

The field itself is a hodgepodge of different things. One day you're directing the care of a 24 year old with a new spinal cord injury, the next day you're treating a 60 year old stroke patient. I injected a lot of knees, shoulders, and spines. I performed hundreds of electromyography studies. I got to see young patients who couldn't run two marathons next week because of knee pain. I did acupuncture as part of my residency. I worked races. I had fun.

Even though I was a mother for most of my residency, I was still able to be a great resident. I knew my shit, I was responsible, I was enthusiastic (and I was also modest). I was able to fulfill all my work responsibilities and beyond, had free time to study, time to spend with my daughter, and even *gasp* time for myself. In most other residencies, I would have had to sacrifice something.

On graduation, there were definitely job opportunities, although you may have to be a little flexible about geography. Also, for people interested in research, PM&R is wide open, especially compared with older fields. Now for the salary: according to the Medical Group Management Association's Physician Compensation and Production Survey in 2007, the median salary for physiatrists after 1-2 years in practice is $213,701. A lot of my class ended up doing one year fellowship to specialize in Pain, which commands a much higher salary.

The worst thing about the field is that nobody knows what I do. Even my parents don't know. I mean, nobody here is writing a post called "What is a Pediatrician?" It gets tired to keep explaining to patients what a physiatrist is, especially since the answer requires a few paragraphs.

Let me be totally clear though:

Do NOT do PM&R just because it's easy. We hate it when med students say that and it's always a big mistake to go that route. PM&R is a really fun field with lots of procedures and a chance to really develop relationships with your patients. It's got a good lifestyle, which is something I love about it, but is only one of many things I love about the field. If you work in a field you love, you'll never work a day in your life. (I never really could have been a dermatologist.)

Also, please check out my FAQ on PM&R.

Tips for Surviving Call during Pregnancy

Great timing for Q&A week! I just found out last week that I'll be a new mom in November, making me an official mother in medicine! I've been reading the blog for a while, because I love hearing what all of you have to say about your lives. Here's my question: What tips would you give for surviving residency while pregnant, especially 30-hour calls (without caffeine)?

From a future mom and Family Medicine resident in the midwest

Congratulations on your pregnancy! I know that being pregnant during such a difficult time as residency seems daunting, but you can (and will) survive! Overnight call is never fun, but with a few small changes, you can get through a 24-30 hour call with relatively minimal discomfort.

Survival Tip #1 - Bring lots of snacks to work with you. As a resident, especially on call, you often have an erratic schedule, and sometimes it is difficult to eat at regular intervals. If you are fortunate enough to avoid severe nausea in the morning, then try to eat before you leave the house. Pack your pockets with snacks that are portable, like protein bars ( bars are really good, more crunchy than chewy, and covered with chocolate. Yum!), hulled sunflower seeds mixed with dried cranberries or raisins, or even the standard peanut butter crackers. Having something on your stomach at all times will help stave off nausea and fatigue.

Survival Tip #2- Some caffeine is still ok! No, really! I am not sure how much caffeine you have been consuming prior to pregnancy, but a small amount (150 mg-300 mg) of daily caffeine has been shown to be safe in pregnancy. The official March of Dimes recommendation, I believe, is 200 mg or less. One (regular) cup of coffee or 2 caffeinated sodas per day should definitely fall well within the safe range, not to mention the occasional chocolate fix (so needed on certain call days).

Survival Tip #3 - Learn how to prioritize your duties while on call. It is likely that you already do this to a certain degree. Do the most physically strenuous tasks (procedures, lines, rounding) as early as you can in the call day, when you have the most energy. Try to chunk as many things as you can on a single floor, and "gravity round" (start at the top of the hospital and go down floor by floor). Don't be ashamed to use the elevator, but by going down steps, you can get a little physical activity without straining yourself. Do your best to anticipate any additional orders (nausea medications, sleep aids, pain medicine, diet orders, etc.) that may be needed throughout the day and write them while you are on the floor, saving yourself middle of the night phone calls for Tylenol during the 2 hours that you may have been resting! Another thing you can try is to do quick PM rounds. Alternatively, call and talk to the nursing staff, floor by floor, asking about any issues that may need to be addressed prior to trying to lie down, thus avoiding the "sit on bed, pager goes off" phenomenon to the best of your ability.

Survival Tip #4 - Stay hydrated. I know it is hard to do, and even more annoying when you have to stop working and actually *use the bathroom* on occasion, but trust me, adequate hydration can stave off multiple discomforts of pregnancy and decrease the development of more serious complications like pre-term contractions. Have a bottle of water accessible throughout the day, and refill it often.

Survival Tip #5 - Don't stand when you can sit, don't sit when you can lie down. Rest as much as humanly possible, even if it is just the short time between one clinic patient and the next. Go to the call room and lie down on the call bed instead of sitting around and chatting at the nurses' station, even if you don't sleep, you will be much better rested and prepared for that inevitable page from the ER at 3 am.

Survival Tip #6 - Bring your meds with you. If you are one of the less fortunate ones (like me) who happens to be plagued with persistent nausea/vomiting throughout the pregnancy, Zof.ran will likely be your very best friend. Bring it to work with you, along with Tyle.nol, Sud.afed, Zan.tac, Tum.s, and your pre-natal vitamins. It will help you to avoid having to get IM shots of Zof.ran from the nursing staff or walking around with an IV (both happened to yours truly) for fluids.

Survival Tip #7 - Utilize any support that you have. I'm not sure if in your program you take solo call, or if you have a junior person and a senior person on call at the same time. If the latter is the case, then utilize your support person to their fullest potential (if they are amenable, that is). Try to "divide and conquer" tasks instead of tackling them together. If you are the senior, then trust your junior to do good work without you hanging over their shoulder. If you are the junior resident, don't be afraid to ask the senior for help if you feel you are in over your head.

Survival Tip #8 - It's ok to whine....but don't whine about your pregnancy discomforts to your co-residents or to the nursing staff. Call your husband or your best friend, or compose a long, whiny email and then delete it if you must. It is normal to feel whiny when you are pregnant, but it may ultimately foster unwanted and unpleasant feelings in your co-workers if you vocalize these feelings. It saddens me to have to write this tip, but this is a mistake that I made in my pregnancy that came back to bite me. Sympathy is not always rampant in the medical community, so try not to seek it there, and you will not be disappointed.

Survival Tip #9 - Be aware of your limits. As you progress in your pregnancy, you should not be lifting more than 20-25 pounds, nor should you be feeling more than 4 contractions in an hour. Don't push your body's limits in order to be a "super resident." It is ok to ask for help if you need it, and don't ignore the warning signs that something may be wrong. Often, we as physicians will push aside our own physical discomforts and keep on working. Don't ignore serious signs like contractions, shortness of breath, headaches, excessive swelling, or increasing abdominal pain.

Survival Tip #10 - When you go home, do nothing else but take care of yourself and your needs. If you need to go home and sleep for 10 hours, then do it, dishes and housework be damned. Celebrate the fact that, in spite of being up all night, you have this time catch up on sleep. When the baby arrives, your call shift will never truly be over. Luckily, in many ways, motherhood is infinitely more rewarding! I wish you all of the best as you enter this exciting new time in your life, you can do this.

Wednesday, March 17, 2010

Playing doctor

This week, I got to have one of my best experiences ever as a physician: I got to teach the kids about being a doctor at Melly's daycare!

I have literally been waiting for this moment for 25 years, since my own father came to my school and taught my classmates about being a doctor. And it was every bit as fun as I hoped it would be. I dressed the kids up in masks and caps with rubber gloves, let them use my stethoscope to listen to each other's chests, let them pump up my sphygmomanometer, and checked knee jerk reflexes on every one of them.

It was a hit. The kids were shooting their hands up to volunteer. I kept a dozen kids ages two through four captivated for 45 minutes, and when the teacher broke it up for snack time, the kids were crowding around me for more. I loved hearing the other kids saying to my daughter, "I didn't know your mommy was a doctor!"

It made me happy that I have a career that seems so fun to little kids. If I were, say, an investment banker, I'm not sure what I could have done. I wonder if I converted any of the kids to wannabe doctors.

And today they made me a card to say thank you.

P.S. Good luck to everyone on Match Day! Apparently, there's a very scientific method to assure everything works out OK.

Saturday, March 13, 2010

Stat Pap

This week, I was rotating on EV cytology. EV means "extra-vaginal." I always wondered why my group doesn't call it NG (non-gyn) like the rest of the world, so I don't have the word "vagina" in my rotating service. EV cytology is anything other than pap smears. Fluids, fine needle aspirates, ultrasound-guided thyroid biopsies, and CT-guided biopsies.

The only exception is when there is a "stat" pap smear. Stat pap smears don't come up very often - they are usually done in the OR when the surgeon sees a fungating mass on the cervix or something, and wants to confirm cancer prior to his or her surgical removal.

Earlier in the week, the head of cytology came into my office.

"I've got a stat pap. I think I need to explain it to you, it's kind of confusing."

She told me that a patient received a diagnosis of High Grade Squamous Intraepithelial Lesion (HGSIL) a week earlier. All paps these days also get molecular HPV (Human Papillomavirus - that is the virus that causes cervical cancer) testing - the wave of the present and future. The molecular testing for high risk HPV types came back negative. I've been in practice for almost three years now, and that is a first for me. The molecular always backs up our diagnoses. She's got a lot more experience than me, so I asked her, "Has this ever happened before?" She shook her head like she couldn't remember a time, and said, "Not often."

I said, "Do you have the pap there? Why is it stat?"

"The OB referred it to someone else, and the new clinician wants to know why the results don't match up. We, of course, would check this ourselves, but they are already aware of the mismatch and want it resolved quickly."

My first question was, "Who reviewed the original pap?" I didn't want to step on any toes. If it was me who reviewed it, I would want to be in on the problem, and I would want to be part of the solution. I saw the pathologist's name, and looked up at the schedule. He was off this week. Darn it. Oh well, I could fix this without him.

I looked at the pap smear while she was standing there. All of the techs had already reviewed it, and all were on the fence between HGSIL and ASC-H (atypical squamous cells of undetermined significance-cannot rule out a high grade lesion). As I moved the slide up and down on the stage, I immediately saw the problem.

Usually, when we see high grade lesions, it is pretty easy because there is a lot of low grade, raisinoid nuclear change in the background, and there are clumps of ugly, hyperchromatic cells with irregular nuclear borders - classic high grade lesions. Here, I saw a few single cells that I learned in fellowship were called "litigation cells." Easy to miss (and subsequently get slammed with a lawsuit because you've got to pay attention to every cell) - because there is no low grade change in the background, no clumps, just rare single cells with really ugly nuclei.

"OK, I see why he called it high grade. In retrospect, in light of the molecular, we could go back and change it to ASC-H, if the OB wants us to do that to triage the patient for proper treatment and follow-up. But first, let's call the molecular company (we currently send these out) and ask them to repeat the hybridization studies. When you call them, find out how often this happens and if there is an explanation - I know there are some rare strains of high grade HPV that aren't covered in their assay. Let's find out what they are, and if we can test for them."

She agreed, and called me later in the day. "The company is going to repeat the qualitative hybridization assay and also run concurrent quantitative PCR studies, which should be more sensitive. They'll call us with the results."

I worried over calling the clinician. I worried over having to change a colleague's diagnosis. I showed the pap to another cytopathologist, didn't give her any of the history so she wouldn't be biased, and she basically agreed with me and the techs. "I'm on the fence. Could go either way." It was easier for us all to be hedge-y in light of the molecular. Those few cells were darn scary.

The cytotech called me the next day. "PCR came back positive. They think it is a rare high risk strain. The diagnosis stands fine, and we will just release the report to the clinician."

Whew. It feels good to make the right call, so the patient can get the right treatment.

Thursday, March 11, 2010

Bradley Method for Life *

At 3 am this morning I stood by my laboring patient's bed. I know her very well. Her heart's desire was to have a natural childbirth. She was 6 cm and progressing well. She looked at me after her contraction.... "Doctor, How much LONGER will this Take.... I can't do this for hours!"

I encouraged her, you don't have to make it for hours. Just make it through the next contraction. Then will think about the one after that. Relax in between. Breathe.

Two hours later she delivered a beautiful baby girl naturally. Tears of joy rolled down her face.

Tonight as I finally drove home, after a full day at the office, my mind raced. I miss my kids, deadlines and responsibilities are looming everywhere. How on earth am I going to make it through the stress of the next few weeks. I am currently back in survival mode. I haven't been here in a while and its not pleasant.

I will make it, though. One day at a time. One patient at a time. I'll try to find moments in between to go to my happy place. Perhaps when it gets really bad, I'll get in the 'knee chest position' and moan or perhaps soak in the tub..... but I will make it.

*I am not an expert on the Bradley Method, though I am a fan.

Wednesday, March 10, 2010

Announcing Next Topic Week March 22-26: Q & A

Our next topic week is going to be in a couple of weeks, with a theme of Questions & Answers. We invite all readers to submit questions - either specifically for one our our regular MiM contributors, general questions that one of us will try to answer, or questions directed at the greater MiM community.

What do you want to know?

We hope this will a fun Topic Week to get to know our contributors better, involve you, the readers, more, and answer any burning (or not so burning) questions you may have for mothers in medicine.

Please feel free to submit your questions starting now at You can also submit questions via our Facebook page or on Twitter (@motherinmed).

Hope you will join in and submit something! Include a short one-line bio (anonymously, if you prefer), for example: Izzy is a surgical resident in the Pacific Northwest.

If you are new to the blog, check out our prior Topic Weeks and Topic Days in the sidebar, under Labels.
For all those students about to find out where they are matching: check out Match Day Topic Day from last year.

Thanks for reading and making this such a wonderful online community.

Sunday, March 7, 2010

The brutal nanny hunt

Tomorrow morning my nanny starts and this is not something I take for granted.

I had a nanny for almost five years, she now wants to only work part-time so three months ago, I went about looking for a replacement. Yes, amazingly, it has taken me three months to find a nanny.

There are so many things about this search that were painful. Amazingly, despite the slump in the economy, experienced and affordable nannies are hard to come by.

In our area, the cost is crazy - most nannies value themselves on their hourly rate, feeling that they are entitled to at least $15/hour. Well, that's fine except that they also want all the benefits of being on salary - like vacation, sick leave, personal days, health benefits etc...for my husband who runs his own company, this drives him crazy because because we are paying more per hour than his (more formally educated) office manager and this 'hourly' rate that nannies use doesn't include the 'true' cost to us - the real baseline is $17/hour since we have to pay social security and unemployment on top....(painful since these are all AFTER tax dollars).

The second most painful thing was finding the right person. I hired one lady who I thought was perfect, and she didn't show up for work the first day because of something 'personal'.

Then I hired another lady who was cheaper, a little less experience but willing to work longer days and she just had no instincts about caring for a baby (mine is now 10 months). Plus, she was missing her own two kids while working long days so that didn't last but a week.

Third, I hired a 25year old student who was taking classes on the weekend. I was really excited about her because she was young, energetic and would live with us so we would have the flexibility of having her babysit in the evening. So we moved all 3 of our kids into one room to accommodate her (yes, I really thought I could manage with all 3 in one room...). The second day she was watching TV, on email while my baby was sitting under the table. The next day my Mom came to check in on them and she was barefoot in the garage, trying to adjust the stroller while she had the baby PROPPED UP on a box...ultimately she confessed that she had no time to babysit and we both agreed it was not a good fit.

The fourth lady seemed amazing on the phone but it turned out she had NO filter. When she came over for the first time, she expressed many opinions including inappropriate commentary about my kids in front of them. She also only provided references from five years prior and didn't show up to her second day on trial because she thought it would be ok....when I called her to tell her she didn't get the job she really let her words sneak out of her mind and I was reassured that I made the right decision.

Finally, we found our current nanny who has been with one family for the last 8 years- she's wonderful. We found her from a teacher at the preschool.

I must have interviewed over 30 ladies on the phone and brought 20 ladies home over the last few months. I bought subscriptions to all the nanny websites and as good as their services are, the nanny I loved came from a personal reference...which in the final analysis is really the best way to find a caregiver.

For anyone who's interested, Here are the sites I used: - good listings, good sample documents to use - utlimately the best site I found, I got a lot of responses from this site and found the spectrum of young and mature
- found most of them to be quite young and a lot of people who just want part time work - the indian classified ads, people willing to work for good rates, good hours but most want cash

Others include:;

I would be happy to share many more pearls from the nanny hunt for anyone who's interested. For now, I'm just enjoying all the free time I have!

Saturday, March 6, 2010

MiM Mailbag: Self-entitled?

Editorial note: We received an anonymous comment this past week to a post that was published about a year ago on this blog (Fizzy's I hate boys). I debated whether or not to publish this as a MiM Mailbag since it has the potential to become an inflammatory discussion that would ultimately not be constructive. However, the comment presents challenging views that many women face when having children during training (and sometimes beyond); a thoughtful and respectful discussion about the issues raised could further understanding by all. So, feel free to join in, but please keep comments constructive and respectful so we can have an intelligent discussion. Thanks.

I am not really sure why all of you self-entitled people in medical school and residency, think that it is actually an acceptable time to be having children at all.

Your absence put a huge burden on the remainder of your class, and your constant need to leave early to "be with the kids", "take care of sick kids", etc. just highlights the fact that maybe you should have chosen a career more inline with what you percieve to be an ideal life - like being a PA, nurse, etc.

The ultimate problem lies in the people who seems to "want it all", but feel they are "special" and don't need to sacrifice anything. Because some of us don't want children doesn't mean that we should supercompensate for those that do. Not everyone was meant to be a doctor, and if other people started using similar excuses in would certainly raise eyebrows - eg: I NEED to go on frequent climbing trips because it is consistent with my world view of life and you OWE it to me.

Basically just entitlement by another name, but not overly surprising in this society.

Wednesday, March 3, 2010


When I was pregnant with my son (now 15 months) I sat down with Dr. Sears' book. I probably did not fully grasp the true philosophy of attachment parenting. What I do remember is one statement in an early chapter that disturbed me at the time and haunted me since.

I remember reading that mothers who work full time and take time off for maternity leave have a high risk of attaching poorly to their babies. That instead of completely focusing on the role of mother they instead are preparing for the day they will leave the child. Preoccupied with their career they are unable to be fully responsive to the needs of the child.

I am sure many reader's blood is boiling right now. Now if I have mis-quoted Dr. Sears I apologize, but even if I did my real point is this: I think about this all of the time. When my son was a newborn and would not nurse, my sleep deprived hormone toxicated brain determined it must be because I planned to pump when returning to work. When he did beautifully with the transition to day care, I figured he didn't really miss me. When he runs to daddy when tired, I take it as further evidence of my shortcoming.

This is working mommy guilt and as a Mother in Medicine I did not invent it. Upon reflection I think overcoming this thinking is a unique challenge for the following reasons. First, I sacrificed a remarkable amount of sleep, happiness and personal well being to become a cardiologist. The idea that I could continue to sacrifice in a way that I would later regret is a true possibility. Second, in reality if I had to choose either my career OR motherhood it is not 100% that I would have chosen motherhood. This is perhaps difficult to explain but I feel like my work is a calling that I was born to do and is my mission in life. Finally, I am a master organizer/ planner. Indeed I was pre-occupied during maternity leave planning my return to work. But only because of my deep respect for how challenging it was going to be- and my desire to arrange help so that I could enjoy my son (an hopefully not kill anyone in my mommy-head state).

So I put this out there to share how my consideration of attachment parenting led to a judgment that is difficult to shake. The challenge to be a mother, as a full time physician, as a perfectionist, as a woman committed to caring when it seems no philosophy can be easily applied to my reality.