Friday, September 3, 2010

Little Wonders

I sat with my patient, a new mother, in the examination room. She was there for her first post-partum visit and we were discussing the events of the last few weeks. We chatted about breast feeding, birth control, lack of sleep, how annoying it is that men can sleep through *anything*, and then, I asked, as I always do, about how she was handling things emotionally. I always make it a point to screen for post-partum depression, many times, if you don't ask, they will not tell you how they are really feeling. This time, though she passed the screening for depression, she gave a laugh and said, "For the first time, I know why my mother is the way that she is." She went on to elaborate how she always made fun of how emotional her mother is, and now how she couldn't watch Kleenex commercials any more without bawling like a baby. It is so true. When we become parents we are forever changed, not only do we understand our parents better, but the way that we look at the whole world is different.

For me, it was the same. Before I became a mother, I loved to watch scary movies. The scarier the better. Imagine my surprise when, not long after Cindy Lou was born, and Mr. Whoo and I settled in to watch a horror flick when I realized that I had changed. I could not watch it, couldn't even get past the first 30 minutes. Why? Because there was a little girl child in it who was missing, and I couldn't handle thinking of a child (my child) being lost, scared, and alone. I never realized how many horror films use disturbing images of children before having a child of my own. It changed how I watch movies even now, far removed from the emotional lability of the immediate post-partum days. The same holds true for news stories involving children, footage of the 2004 tsunami devastated me, same for Katrina the summer after. The tears flow more freely now, happy, sad, and wistful. Most of all, music speaks to me, and often moves me to tears. There are certain songs I associate with different stages of my children's lives, and find myself tearing up just thinking of the lyrics. For Cindy Lou, it is "Baby Mine" and "Return to Pooh Corner." For Bean it is "Sweet Baby James" and "Little Wonders." Especially these lyrics:

"Our lives are made, in these small hours, these little wonders, these twists and turns of fate.
Time falls away, but these small hours, these small hours still remain."

So now I know how my mother felt when I was younger, when Cindy Lou turns to find me wiping away a happy tear or two and says, "Mommy, if you are happy, then why are you crying?" Perhaps it is because the transformative joy and wonder of having a part in creating these precious lives fills up our hearts until they break, just a little, from the magic of it all. How have your children changed the way you see the world?

***Cross Posted at Ob/Gyn Kenobi***

Wednesday, September 1, 2010

To all who have gone that way before

I am staring down the barrel of the residency match. Yes, I still have a year and a half until my match day, but there is a lot of planning that goes into the process ahead of time. I know it was a topic day here once. (Covered beautifully, I might add!) But, I have a specific concern, and a specific question.

The concern: I already have kids. I am a single mom.

The question: What is more important, what is inside the walls of the hospital, or outside?

Before I got separated, I was looking at programs based on certain factors: geographical location - was it a cool city where I've always wanted to live? (Like Portland, Oregon). Was the program a progressive program that seemed woman centered? (Like OHSU in Portland, Oregon.) Was it an academic program? (Like OHSU in Portland, Oregon...see where I am going with this?) Was it a program that had a reputation for being a happy place to work with reasonable attention paid to resident work/life balance? (OHSU again).

But, Portland is across the country from my family and my support base. About as far as you can get and still be in the continental US. Yes, I have friends there. A lot, actually. Some of them are mothers. But, my kids' dads and grandmas and friends and schools are all here.

I was OK with moving the kids out of the area when my younger son's dad was going to be moving with us. Now that we're separated, I am having serious second thoughts. Not only would there be legal wrangling and custody issues, but I would be starting a residency in a new city as a single mom. It was hard enough arranging child care and new schools for both of them here in Miami. I can't imagine trying to do it in a new, unfamiliar city without two grandmas helping me out. I also don't know if I can justify moving to a new place and then disappearing, for up to 80 hours a week.

Peers in medical school have told me to go for the residency of my dreams, and if mama's happy, the kids will be happy, and it will all fall into place. I am not so sure that is the case. My kids are happy and well adjusted, but there is only so much even happy and well adjusted kids can take.

Throw in the uncertainty of whether I can even get into the local program, the recent uber-competitiveness of ob/gyn and whether I can get into any program at all...sigh. And, if a closer program that I do get into is malignant, and I am stuck there for four years, am I really better off?

Any thoughts?

Monday, August 30, 2010

MiM Mailbag: Give up the dream?


I just love your blog, from the touching to the funny, all of it real.

I have a question I'd love posed to your readers (feel free to edit it down if I'm so lucky as to have it used, I tend to get wordy):

I have wanted to be a doctor since I was a young teenager. I entered undergrad taking courses that would prepare me for the MCAT and med school, I met with advisers. Then I either got scared or realized I was too immature (the answer depends on how you look at it) and switched to a major in the liberal arts school. Graduated, then looked into taking the MCAT again, but then my boyfriend (now husband) and I moved, married and had kids and I put my dream on indefinite hold.

Every six months or so I spend time looking up medical school prerequisites and local post-bacc programs and read message boards and blogs of moms who have done medical school with children. Crazily enough, I am not entirely daunted by the tales of long hours, pressure and scant family time.

However, I am in my early 30s and I have four kids. Four kids under the age of 8.

Every bit of sense I have tells me, "Don't even dream it, give up before you start, you can't possibly make it work and keep your family intact." And yet I keep reading stories of people who've done just that.

So I want to ask some questions of those who went to medical school after they had kids. Do your kids resent the time your training takes? How did they take it if you had to move? Would you do it again at the same stage in life? Will you have enough time to pay off your student loans if you don't start practicing until you're 40 (or older!)? Is it worth it??

I am so torn. I really, really want to do this and think I could do it, but I worry about the kids.

Thank you!


Anonymous, so my friends don't think I'm crazy before I've even jumped into the crazy pool

Sunday, August 29, 2010

The empathy toggle switch

In our clinical years, our medical school has instituted a program in which we do learning modules along with our in hospital experience and didactics. I was happy to see a module on empathy for my second month of surgery. The last question to be answered in this module was: "Although the studies on empathy are very consistent other authors have indicated that medical students are really not losing cognitive empathy, rather they are learning to engage in a “toggle switch” approach to patients where one side of the switch is “associated with the patient” and the other is “disassociated from the patient” which is necessary in order to perform medical procedures. Please discuss this and use example which you have seen or in which you have been involved."

Here is my answer:

I am not sure if I agree with this. Yes, there is a certain amount of disassociation that may have to happen in order to get through the day, and I guess I felt a “toggle switch” moment when I was first in the OR, and the patient was not a patient but more of a sterile field surrounded by drapes. But, I think there are complex layers of desensitization, not just an on/off switch situation that happens.

I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it. I knew I would have plenty of opportunities to do pelvic exams on awake and aware patients whose humanity I would face directly and whose informed consent I would be able to directly assess, and I was willing to wait for that opportunity.

I did promptly forget about the patient and what she was going through when I was observing the procedure with the physician. I was more fascinated by the tools I had seen used in other applications and in workshops, but never used in a real D & C. I was eager to listen to the physician and thrilled that he was a willing and excellent instructor, and wanted to explain everything he was doing in great detail. I suppose there must have been some sort of toggle-switch moment where the patient was no longer a patient, and I was only cognitively aware of dilators and an os, and the integrity of a previously scarred uterine wall that was attached to a nameless, faceless body.

After the procedure, I happened to come across the patient in the holding room immediately post op. She was not doing well. She was feeling incredibly nauseous, and felt like the room was spinning. I was saddened that she was alone. I summoned the nurse, and the nurse tended to her needs medically by getting some anti-emetics on board. Still, I stayed with her and talked to her about how she felt, emotionally, about what she was going through. It is hard enough to feel nauseous and dizzy, but it has to be even harder when one just definitively ended a much desired pregnancy. Also, her family was not with her in this recovery area, and I felt bad for her for being so alone. I guess if I was ever switched off, I was definitely empathetically switched back on at this point.

I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.

Cross posted at Mom's Tinfoil Hat

Saturday, August 28, 2010

Get confident, stupid!

I've now been an attending for less than two months and I've received all of the following comments*:

The latest was yesterday, when I asked one of my patients if she recognized me and she said, "Of course. You're that little one that everyone thinks looks like a student."


My usual response is, "I'm older than I look." Inevitably, the patient will then ask me how old I am because when you're either older than 80 or younger than 10, you can ask whatever the hell you want. My reply is, "I'm in my thirties and I have a child." That usually satisfies them.

Now don't get me wrong. I like being told that I look young. What woman doesn't? I mean, if it really bothered me, I'd stop yanking out those gray hairs, right? Sure, we sit around and complain about how "annoying" it is when patients tell us we look young, each trying to top one another with our stories. One of us will complain that a patient thought she was in college, another will complain a nurse thought she was a high school student, and another will say that at her last delivery, nobody could tell her apart from the newborn. We're all secretly flattered though, trust me.

I've also noticed that men don't complain nearly as much about being told they look young, possibly because the Doogie Howser comments actually bother them, not just fake bother them like us.

So in summary, I don't mind being told that I look young. (Or thin. That's okay too. Thanks, Woman With Hip Replacement.) But I am bothered by the lack of respect that seems to accompany some of these comments. When an inpatient I've been seeing for weeks calls me "kiddo," that makes me think I'm not being particularly respected.

I suspect it's a matter of confidence. Confidence makes you seem older. As a brand spankin' new attending at an unfamiliar hospital, my confidence is not super high and I'm not good at faking it.

I'm not sure what I can do to build my confidence. I see other physicians (usually men) who have less experience than me under their belts saunter into the room and act like they know it all. Do they truly think they know it all? Do they know more than I do?

And then I see other physicians, older ones, who are so effortlessly confident. They know the answer to every question I ask... or if they don't know the answer, they can tell me why there is no answer. I wonder if I'll ever be like those attendings and have that level of confidence and knowledge. Is it just a matter of time and experience? When does it happen?

*Cartoon cross-posted to my blog, A Cartoon Guide to Becoming a Doctor

Tuesday, August 24, 2010

Grand Rounds at my place!

This week, I'm hosting the infamous medical blogger Grand Rounds over at my blog, A Cartoon Guide to Becoming a Doctor. Please check it out. It's supposed to be funny or something.

Monday, August 23, 2010

MiM Mailbag: Is it worth it?


I am 21 (just about 22 years old) and in the process of applying to MD schools. I have worked very hard throughout my undergrad experience and (at least according to my advisors) will likely be admitted into medical school. I have been following the blog for a really long time, and I can't think of any other place to pose this question.

Is it worth it?

I am going through this journey without the financial aid of my parents, and having done some research, I have read that malpractice insurance/taxes take about 60-70% of a physician's salary. Knowing that I am going to have over 200,000.00 in loans, it almost seems like following this path means committing myself to a life of financial agony. I have dreams of Doctors Without Borders and inner city clinics, but my dreams do not even seem feasible in light of this. I know my personal financial issues are of little relevance to any of you or the blog, but my question is this. Is it worth it to pursue this dream? Or if given the chance would you have pursued a Physician's Assistant position or something similar?

Thanks :)

Love the blog!

Thursday, August 19, 2010

First Day of School

On the first day of school eve, Sicily lost a tooth. Her sixth. I say sixth, she says seventh. She is convinced that there was a third in her top two front that just isn't growing in a new one because there is no room. I can see her confusion - the little snaggletooth.

I got up early to run and dress nicely in a skirt and blouse - I wanted to look good for them both. Wandered into Sicily's room at 6:45 to wake her.

I sang a good morning song, one that my Mom sang to me when I was little. Peppy and light.

Sicily (7) rolled out of bed, sleepy-eyed and disheveled. She reached under her pillow and seemed unimpressed by her tooth fairy money - an amount that would have staggered me when I was little. She announced her breakfast choice at my urging, got moving, and I went into her little brother Jack's (5) room.

Another round of the good morning song. Jack squinted his eyes, looked up at me, and announced that he wasn't going to school. "Jack H. won't be there." His best friend from last year transferred to a new school, and he was sad. He injected the emotion into the morning. He refused to eat breakfast, announced he would not get dressed, and retired to his closet cross-legged on the floor in his underwear. I sighed, still trying to be cheery, and went to find Sicily.

Sicily was lying supine on the couch in the kitchen, rumpled in malaise. I chided her to get up, brush her teeth, brush her hair, and get her shoes on. While I was juggling breakfast and Jack's foul mood, I heard a wail from Sicily's room. It seemed that the shoes she had bought with my Mom less than two weeks earlier didn't fit, and there was no other option. I discussed with her the fact that new shoes sometimes need to be worn in, but even without the shoelaces she decided she couldn't even take two steps. So I wrote a note to her teacher promising to address the problem in a timely fashion and put her in forbidden crocs.

I asked her, "Sicily, would you please try to cheer Jack up while I am fixing breakfast? Help him get excited about his first day of school?" I had checked - he was still sulking in his underwear.

"How can I get Jack excited when I'm not? My best friend is in another class (she had seen it on the roster). I'm miserable."

Whew. This was not the way the first day of school was supposed to go. I marched into Jack's room and got tough. He was whining and begging me to put his clothes on. "Jack. You are five years old. You can get dressed yourself, or go back to the pre-school class and take naps. If you can't get ready, I will take away tickets and you might not get to pick out of treasure chest on Friday."

They finally made it to the breakfast table and we had a short reprieve of happiness and interested guesswork about their new year as they both ate a hearty breakfast. Then, as I was trying to find my pager and get the camera for pics, they dissolved into picking at each other and fighting. Sicily refused to be in a picture with Jack, and he howled and banged on the piano. I finally convinced her to let him be in the picture, and here is what I got:

Not perfect (why is the font suddenly blue? Oh well) but I love it. That's us. Not perfect, but we do our best.

As I pulled into the carpool line both kids screamed excitedly as they recognized teachers and students from the year before. They tumbled out of the car at their respective drop-off points happy and smiling. I was glad to hear tonight that they had a great day.

Wednesday, August 18, 2010

The Start of Something New

In a less than a week, I will be a full time university student for the first time ever. I'm 27, I've been married for over 9 years, and I have an 8 year old son and 5 year old daughter, but somehow this milestone still feels enormous.

My husband and I are both transferring to the university after many years of on and off attendance at our local community college, interrupted by marriage and child birth and sudden medical issues with our youngest child. He is a criminal justice major and I am biological and physical sciences major, working steadily to complete my premed requirements. Last semester he and I alternated nights in evening classes during the week, and on Saturday I spent the day in Biology II. Add in his full time job and my volunteering at the hospital, and we were like two ships that passed occasionally to hand off the children and their information and we generally managed collapsed into the same bed at night, except when KayTar (my youngest) was sick and demanded his place in the bed.

This semester is promising. He is able to complete the remainder of his degree online, and I am finally able to take day classes. We may have some semblance of a normal family life for a few months! KayTar will be starting Kindergarten, which means both of our kids will be in school for full days. KayTar has a slew of special medical needs (that are mostly well-controlled at this point) and gets sick frequently, but my mother has agreed to keep her when she is home sick from school. She knows how to tube feed her, check her urine for ketones, test her glucose levels, and administer her medications. She knows her favorite books and television shows. She is one of KayTar's favorite people and I know they will be fine. And yet? I'm nervous and I feel a little bit guilty. I've been KayTar's primary care giver, in sickness and in health, ever since we realized things were not quite right with her. Stepping away from that, even in a small way, is going to be a bit of an emotional adjustment for me. KayTar is already excited about spending her sick days with my mother!

Our schedule is still a little bit wild; shared drop off and pick up from the kids' school, driving to and from downtown to get to my school, volunteering at the Children's Hospital, volunteering at the local free clinic, volunteering at the kids' school, shadowing physicians, baseball and cub scouts for BubTar, dance and twice weekly therapies for KayTar, along with interspersed appointments with her various doctors...hopefully we don't have any ER visits or urgent surgeries this semester like we did last semester! It is going to take a lot of teamwork to make this work, but I think it will be worth it. Wish us luck!

Tuesday, August 17, 2010

Peptic ulcers notwithstanding

Much like I feel like I deserve an award for bringing my two young children to IKEA and returning home with the same two children, so do I for finishing my 15th letter of recommendation for fourth-year medical students each Fall.  Sure, some letters are easy:  those whom I know well and can share insightful anecdotes about basically write themselves.  But, then there are the students who I know less well, or worse, have reservations about, where the objective is to write the most positive letter I can without lying. After writing fifteen letters, it’s hard to sound fresh and engaging. I’m just hoping to use the correct pronouns consistently.(1) Then, after I send that last letter off to the Dean’s office, I’m left looking around for the man with the medal who is supposed to say, “Thank you for your service, Ma’am. Here’s that medal I promised you.”

Like being a mother, being a clinician-educator is full of thankless tasks.  There are no trophies for remembering to buy enough diapers so your child doesn’t have to wear swim diapers (again). There are no engraved plaques for having a one-hour feedback session with a student who is not performing at an acceptable level, but doesn’t agree with that assessment. There’s not even a blue ribbon for winning first prize in “Guess what this abstract finger painting is of (Hint: not your first instinct),” or “Pin down the last evasive attending that needs to give their input before the final grade computation.”

Yet, I’ve also found that, like mothering, being an educator means you do these thankless tasks out of love. Because your job and who you are is why you do what you do. You know that they will grow up and, at some point, hopefully, appreciate the time, the patience, and the energy you put into everyday. And, even if they don’t ever say “Thank you for ruining your body forever by having me,” or “Your investment in me made me a better doctor,” deep down inside you know you made a difference.

The labor of love that is parenting and educating is one and the same: at times painful, occasionally the cause of a peptic ulcer, but, in the end, unbelievably rewarding.

Still, more awards (or medals) for both jobs would be nice. A girl can dream.

(1) NB: some to all parts of this post are written tongue-in-cheek. Please do not send hate mail or actual medals.

Monday, August 16, 2010

MiM Mailbag: First intro to medicine

first of all i want to say i love all of your stories. they inspire me to go through school and achieve what each and every one of you have achieved.

i have connections to a hospital and was told that i could shadow a doctor. i was given pretty much free reign as far as my choice and i'm supposed to tell them what i'm interested in and they will arrange who i shadow by what i tell them.

well, i'm interested in obstetrics...but i have a feeling that might be kind of awkward to shadow. other than that i have no real preference.

so my question to all of you lovely ladies is this: what area of medicine do you think would give me the best experience? this would be my first intro to medicine and i want to pick something that would be a positive experience and that would be able to show me a basic "day in the life of".

thank you!

Thursday, August 12, 2010

Why I loved having a nanny

I've made no secret of the fact that Melly was a nanny-baby, and it's a decision that I'm very grateful that we made. We loved our nanny.

For those of you struggling with the nanny vs. daycare question, as I was, I wanted to share a post I wrote on High Heeled Mom about the pros and cons of having a nanny.

Wednesday, August 11, 2010

Seeking inspiration for inspiration

We have a new first year class staring in two weeks. A colleague asked me to suggest something they might read about a physician to provide inspiration. We agreed that books about heroic doctors going to dangerous places were not suitable, but I couldn’t come up with anything else. I also realized that most doctor-heroes—at least the ones who inspire others to write about them—are men, often men motivated by religious faith or medical missionary zeal. The women doctors who have fascinated and inspired me all come from the pioneer period, when just going to medical school was itself an act of heroism. For this class, in which women are the majority, those kinds of accounts would likely seem quaint at best. Who inspired you? And who do you think might foster the spark in the class of 2014?

Monday, August 9, 2010

MiM Mailbag: Having kids during med school

Hi Mothers in Medicine,

I love, love, love the blog and use it as a nice way to procrastinate from studying when I need a break. It's medically related, so that makes it okay, right?

I thought I would submit a question with something I am struggling with in hopes that I can get some advice from all the mommy-doctors out there.

I'm currently a rising 2nd year and I would like to have my first child while still in school. However, I am battling with the timing of it all. I realize that the entire process of parenting doesn't necessarily work out as planned, and that we may not conceive immediately, but ideally I would like to conceive in November so that the baby would be due in August since I would like to take off a year to stay home with the baby and the natural break in the summer would be perfect for that.

So, my options are either have the baby between second and third year, or between third and fourth year. I found my passion this summer while shadowing, so I know without a doubt I want to be an emergency medicine doc.

Here is my assessment of the two options for 'baby having'.

Between Second and Third year-

Pros: natural break in curriculum between class and clinic medicine, when I do start back in 3rd year I will be still be sharp in 4th year during my ER rotation for a rec. good letter, starting family sooner (28 instead of 29 if we wait a year)

Cons: Being preg. during 2nd year when the courses are tough, being pregnant while trying to study for the boards (I've heard 'pregnancy brain' can really affect your memory), and being very pregnant (7~8mos) while actually taking the boards (bathroom breaks?), having a 1 year old during 3rd year rotations when time is limited and not your own

Between Third and Fourth year-

Pros: Not worrying about how pregnancy may have effected my board scores, having 4th year coming up which is considerably lighter than the first 3 years of medical school

Cons: Since I would be off an entire year between 3rd and 4th year, I'm worried that I may be rusty on my clinical skills and I really need to impress during the ER rotation which is during 4th year, Being pregs during 3rd year and how this may effect those grades which are more important than preclinical grades.

I realize there is no "right" time to have a baby during this training process, however, I was wondering if I could have some insight from women out there who have been through it and have children now. Obviously, I have no idea the amount of energy and time a child needs, so from women who have been through this arduous process of medical training and know what it entails to be pregnant and to be a mother, what would you do if you were me?

Many thanks in advance.

Wednesday, August 4, 2010

MiM Mailbag: CRNA or MD?

Hi, I'm looking for advice from mothers in medicine. I am a biology major, in my senior year with a 3.9 gpa. I also have a 2 and 3 year old. I'm debating whether to pursue medical school or CRNA. Even though these paths are separated only by 2-3 years, I am leaning towards choosing CRNA because of having a family. I fear that the medical school and residency experience will be too great of a sacrifice of family and time. Can you offer any advice? I am worried that I will regret my decision, regardless of which one I choose. If I choose CRNA, I will regret not achieving my own personal best or ultimate fulfillment. If I choose M.D., I may regret losing countless hours with my family along the way. This of course rides on the assumption that the CRNA route, although comparable in measurement of years, will be much easier in terms of time invested (hours of study, etc.) I would really appreciate some insight from those who have chosen the M.D. route and may be familiar with that of CRNA and could make a comparison or at least shed some light on how manageable medical school and residency are with young children, and if you believe that you would do it again if you had the chance to turn back time.
Thanks you so much!