Sunday, February 27, 2011

I Got Your Lobotomy Right Here...

Thank goodness, we have made it to the end of this youth hockey season!

My 12 year old son loves sports, especially hockey. I'm still trying to adjust to being the mom of a jock (sorry, *young athlete*). It often seems that life is made up of only two things: neurosurgery and watching youth sports.

He plays football in addition to hockey; he's also now the goalie for his school's JV soccer team. I suppose spring will vacillate between operating and cheering for excellent saves.

Hopefully it won't involve any hooliganism...

Hockey parenting has worn me out recently. I get that hockey is a physical and sometimes violent sport. What I don't get is the vitriol spouted by players - and their parents. We're talking about 11 and 12 year olds here. For instance:

Last year, our team was in the semifinals of the league tournament. Admittedly, one of our kids was very big for his age. He therefore drew a lot of attention from everyone, including referees. You might imagine that a kid so big could execute a pretty effective check. Thankfully, he never seriously hurt anyone.

Well, the game is ticking along, and several kids (including him) go down in a pile in the corner of the ice while chasing the puck. As they disentangle themselves, an opposing player grabs our big kid's leg while he's trying to get up. Probably their kid was trying to clamber up himself. Regardless, it evidently appeared to the opposing team's parents that our kid was deliberately stepping on their kid with his skate.

At this point, a mom from the other team standing close by started hopping up and down, screaming abuse at our kid at the top of her lungs. "Did you see that?! He stepped on our kid! Throw him out! ##@*^^&! I can't believe this! $$@#**..." She went on and on in the same vein.

After about 5 minutes of this ranting, I had enough. I turned to her and politely said, "Do you think it's possible that our kid might just have been trying to stand up, and that he might not have been trying to step on anybody deliberately?"

Fuel to the fire! Instantly, her vehemence redirected itself at me. "OOOOhhhhh, no! Look here, I got it all on video! Do you want to see it?! He did.... etc. etc..." waving her video camera ecstatically around her head. I stared, fascinated, as her face turned redder and redder. Finally, she shrieked, "Stop looking at me! You're STILL looking at me!!" Of course I was, sort of like rubbernecking at a car accident... I'm sure my eyes were as big as saucers at that point. What, really, did she expect?

I must admit, I have no experience with this sort of thing. Being a classic nerd, I was never involved in any fisticuffs or hair-pulling in the halls of my high school (although I have witnessed such events). But, surgeon-like, I do have a temper, as I have admitted elsewhere. By now, I was angry at her hooliganesque attitude and the things she screamed at our 11 and 12 year olds. Hence, a few low-level comments did fly back and forth as the game progressed. (I know, I shouldn't have needled her.)

Unfortunately, the offending mom became further inflamed by our team's obvious impending victory. Finally, she appeared beside me, literally dancing with rage. "I'm a dentist, and I can fix your teeth; how about THAT?!" she seethed.

As I mentioned, I am a novice to this sort of thing. Now I was thinking, "OK, if she wants to wage the war of the degrees, she's not going to win..." So I replied, quite seriously, "Well, I can fix your brain..."

This was not received in the spirit in which it was intended!

After I declined her subsequent invitation to come outside to the parking lot, rolled my eyes, and redirected my attention, my less naive husband started snickering. He had been standing behind me, knowing what I was thinking. He told me later that he was muttering under his breath, "Don't say it... don't say it.."

Well, so my knuckles (and my teeth) remain intact to this day. But I continue to be horrified by some of things hockey parents yell at kids on a regular basis. Some rinks, unfortunately, actually sell beer for adults to drink at youth hockey events. You might imagine this doesn't make things any more civil. It's not limited to just hockey, either, from the stories I hear about other youth sports. My son tells me about the profane trash talking he's heard from kids (and their coaches!) on the ice; wonder where they get that? I just can't wait to see what things are like when he's in high school.

I Wrote a Book. Really.

Two years ago my friend Jessica, who is also my patient, invited me lunch. Jessica and I met in a small group at our church. We were merely acquaintances when she first became my patient, but our friendship had deepened over the years.

After the lunch date pleasantries had past, there was a long pause in conversation. “I have an idea,” she said, “Remember when I was pregnant and I would pull out all my pregnancy books every time I felt any twinge of pain? The books would scare me to death, so I would call you freaking out that my baby was going to die from eating deli meat. Then you would explain it to me and calm me down?”

Me, “Yeah”

Jessica replied, “Well not everyone is friends with their OB and can do that. Let’s write a book together! You write the medical information and I’ll write from a patient perspective. We can write from a Christian slant as well, to help women lean into their faith to give them a greater amount of peace as they walk through their pregnancy.”

Me, “Sure, sounds like a great idea, though I have never done anything like this before.” I will now admit, I didn’t really think anything would come of it at the time.

We wrote a proposal and the first chapter. A few months later we got an agent. Then we waited.

On November 11, 2009 my husband and I brought home our son from the hospital. On November 14, 2009, Jessica and I got a book deal. The manuscript was due in four months. So when I wrote this post about my maternity leave, I left out a few stressful details: like getting up every morning at 5 am to frantically write for 2 hours before work each day.

We finished the book mostly on time. Then there were a zillion rounds of edits. I learned to enjoy the process, but it was stressful because there were so many unknowns for me.

Jessica was attempting to have another baby as we were writing the book, so we decided to start a blog to journal her process and promote the book. Sadly her journey was a little more exciting than we had planned, but after a ruptured ectopic and 4 rounds of clomid, she is now expecting a baby boy.

I was very torn as to whether to ‘out’ myself and mention my book on this blog. My publisher does not know I that I write for this site. Yes, I recognize the irony that most bloggers are eager to get a book deal, while I have failed to mention to my editor that I am a ‘blogger.’ After much thought, I decided to mention my book on this site for a three reasons:

I am so amazingly proud of the book and all the hard work that went into it. I think it’s an awesome resource for women and I want as many people as possible to know about it.

I can cross post at both my book blog and this blog and save TIME! Sadly this is probably the key reason.

I wanted to say thank you to our readers and my fellow MIM writers for their support and encouragement over the last few years. I know that my experience here helped give me the confidence I needed to attack this project.

Yesterday was our first book signing (That's me on the right). It was surreal. So, many people came out to support us and our book, that we sold out the store. It was amazingly gratifying to see all our hard work pay off.

So here's my book: buy it, link to it, contact our website if you are interested in reviewing it or simply ignore it.

When we were done with the writing, and we entered the marketing stage, I was asked to come up with "just a few lines to describe the book." Really? Describing a years worth of work in a few lines is more challenging than you would think, but here's my blurb:

"My prayer is that this book will enable women to enjoy as much of their pregnancy as possible, relishing the hope that is growing inside them, and not be deprived of their peace by unnecessary fears.”

Tuesday, February 22, 2011

OMG, I've got to get out of here!

In the division of labor between myself and my husband, I have been given the task of daycare drop off and pick up. It makes sense for a variety of reasons, one of which is that my husband often gets home after the daycare closes.

As a result, at the end of the day, I am sometimes FREAKING OUT that I've got to get out of the hospital before the daycare closes.

Our daycare has pretty long hours, so 90% of the time I arrive very comfortably before the deadline. 5% of the time, my daughter is one of the last kids there, but it's still no problem. Then another 5% of the time, I'm racing furiously through traffic to get to the daycare before closing time.

I've always made it there in time, sometimes with a safety margin of only a minute or two. I guess it wouldn't be the end of the world if I were late. Basically, I would be charged like $20 per minute after the deadline and I'd have to find my child sitting there all alone with a forlorn, abandoned expression on her face. That's still better than the hospital-based daycare a friend of mine was using, where they would call child protective services if you were more than five minutes late.

Most of the physicians I work with don't seem to have this issue. All their kids are older or they have a spouse or relative to help out. They say they were at the hospital till 8 o'clock the night before and just shrug like this is no big deal. In medicine, things come up. If you've got one foot out the door and a patient says he has 10 out of 10 chest pain, what are you supposed to do? There's no excuse not to stay. You can always put off dictations a little bit longer, but there's no excuse for not caring for a seriously ill patient.

It's yet another thing to consider when entering medicine. You do lose a degree of flexibility and control in your life, which can be rough when you have small kids.

Friday, February 18, 2011

Thinking Outside of the Box

I know the electronic medical records get a lot of flack. Some of it is well-deserved. But as a pathologist who started training in a void, the EMR has been an invaluable addition to my practice. Traditionally, we pathologists work inside a black box. We rarely venture out of our lab closet caves - god forbid going to the floor to wade around in the muck of the paper chart. We all have computers next to our scopes, and gaining access to our patients in this manner - radiology, clinic notes, etc., makes the glass slide with a two dimensional slice of Easter egg dyed tissue spring to life.

Some clinicians are better than others. Surgeons and radiologists are notoriously brief, with rare exceptions. There is a certain infectious disease specialist at my hospital that writes so voluminously and well that I feel like I am sitting at the bedside of the patient I am puzzling over. There is a big difference in the large hospital I am primarily based at versus the small town hospital I rotate at once a month. In the smaller town, clinic notes are piped into the hospital medical records (must be easier there to do this I guess - less clinics, less complication) so I can access outpatient records - the clinician's thoughts can illuminate a tough GI biopsy and make it so much easier. It saves me lots of headaches and phone calls.

Performing wet reads on CT-guided needle biopsies in radiology is a particular sore spot. I know the radiologists are busy - drain an abscess here, do a paracentesis there, squeeze in another needle between a couple of radiofrequency ablations. But I still get irked when called to a lung biopsy and the radiologist doesn't know the history. I know, I know, I don't have to worry about causing a pneumothorax and putting in an emergent chest tube or dealing with a pulmonary hemorrhage - and they do. We all have our places in the cog of the medicine wheel. Thankfully, with EMR, I don't have to worry about what the clinician did or did not communicate to the radiologist - I can just open up the computer and get all the information I need to know. Information aids diagnostic accuracy, and ability to triage the specimen appropriately.

Take for instance the other day. I was sitting in my new (beautiful - yes still a closet in a lab, but with brand new coppery Formica and linoleum hardwoods that render me the envy of all the other pathologists) office and grabbed a CSF (cerebrospinal fluid) case. The cytotech screened it and called it negative. 90-95% of the time they are right. I picked up the cytospin, threw it on the stage, and looked in the scope. Low cellularity -appropriate for a CSF - a few lymphocytes and monocytes. But wait, what was that? A plasma cell? Plasma cells are never normal in the CSF. Often they herald chronic inflammatory issues or viral illnesses. I opened the EMR on the patient.

This patient had a diagnosis of plasma cell myeloma with recent acute mental status changes. So the lone plasma cell or two I was seeing, among the lymphs and monos, could indicate leptomeningeal spread of the patient's disease process. I reversed the tech diagnosis to atypical and added a lengthy comment - unfortunately there weren't enough cells to attempt flow cytometry to assess for clonality of the plasma cells to cinch the diagnosis. But with the information in the EMR I was able to get a more holistic picture on a couple of cells and provide better care for the patient. I cringe to wonder if I might have blown them off as lymphs without my crutch.

I open the EMR every day, all day, on almost every patient. In the rare instance that I see cancer in a specimen where there is no clinical or radiographic suspicion, I can take extra measures to ensure that I have the correct specimen and gain additional consults to firm up my suspicions. I am a pathologist, but with EMR, I no longer live in a black box. And for that, I am thankful. I really don't know how my predecessors got along without it.

Thursday, February 17, 2011

MiM Mailbag: Become a surgeon and have a family?

Hello All,
I just found this blog and was excited to see women discussing topics that I am interested in.
I have recently decided that I want to go to med school and become a doctor (as I near the end of my graduate education). My husband is supportive and willing to sacrifice as I start the process of preparing to apply to medical schools. I am currently 28, working full time (in the energy industry) and attending graduate school part time.
After that I will need to take pre reqs and then mcat before I will be able to apply to med school. This means that I will be going to school during my 30's. I want to become a neurosurgeon, but I also want to have a family. I am not sure how to do this. Since I don't know anyone else who is trying to do something like this I have no examples and would like some advice.
I have thought long and hard about what it would mean for me to become a surgeon and have decided that it is worth the effort and sacrifice. But I don't want to forgo family and motherhood. Is there any one of you who have experienced this same dilemma. If so, please give some practicle advice. I would like to be as prepared as I can be.
Thanks so much!

Tuesday, February 15, 2011

This one's for the girls

At the risk of exposing my musical tastes (and innate sappiness), I have a confession to make. Whenever I hear Martina McBride's This One's For the Girls, I tear up. I'm so not kidding. I'm not even a country girl--I prefer The Killers to Carrie Underwood --and I couldn't tell you another song that Martina McBride sings. But, this song has always made me want to link arms with women everywhere, celebrating how much we share in common: the broken hearts, the high dreams: reality ratio period, our struggles to find ourselves. You're beautiful the way you are. See. There I go again. (NB: for all of you who have never heard this song, I suggest playing the YouTube video linked above but just listening; the video kind of weirds me out. Who directed that thing?)

It's with this background that I write this post, a post I've had in mind for awhile now and directed to all of you in your 20's.

What I wish I knew in my 20's: it gets so. much. better.

When I was in my 20's, I remember thinking that this must be my peak age. Bone mass and fertility must all go downhill from here. I had no reason to believe it shouldn't. I steadied myself for a future of decline in all respects.

Now, comfortably past the mid-way mark of my 30s, I would never trade being in my 20s again for now. Now is awesome. With time, the insecurities, the not knowing myself, have gradually slipped away. I feel more powerful, confident, and, yes, comfortable in my skin than ever before. With time, I know me, accept me, in ways that the younger, more stronger-boned and fertile me could never have imagined. Plus, now there is a growing family - and the joy and richness that brings, a more mature (and ever stronger) relationship with my husband, and a satisfying career on a path that I'm setting, not anyone else. The 30s rock.

And, I have a suspicion, and a hope, that it just keeps getting better. Perhaps "all you girls about forty-two" could chime in...
There's no need to fear growing older, MiMs. Look forward to it. The best is yet to come.

Monday, February 14, 2011

Battles: health vs not health

The battles begin, continue, and at times seem to never end. And while I'm defining "battles" quite loosely, such is parenting. For at least one of my two children, (glass half full, that's 50% of my kids where parenting goes smoothly!) we battle over things we humans needs to do. In a pseudo-valiant attempt on my part to limit battles to those things that would impact one's health, I've let lots of things go, but not when it comes to her health... so what really constitutes health for this MiM? Might depend on the day and my patience.
  • Brushing teeth? Health. Must happen twice daily. Worth the battle
  • Brushing hair? Jury's out on that one. Might be health. Battle not worth it, but still occurs
  • Washing hair? See above
  • Wearing coat? Survey says: Not health. No battle.
  • Eating vegetables, or even one vegetable, even one time? Health. Worth the battle, but losing it.
  • Eating fruit? Health. Mission accomplished.
  • Refrain from antagonizing brother? His health. Battle would ensue, but tenets of role modeling would say to avoid battle and let them work it out.
  • Going to bed at a reasonable hour? Health-related. Battle prolongs time awake. Fail.
  • Letting this MiM sleep a few more minutes in the morning? My health-related. Battle sets bad tone for the day and promotes wakefulness anyway. Resolve not to battle.
  • Hugging and making up? Ahhh, that's what it all comes down to, what are we battling for???

Monday, February 7, 2011

One clinic day, three responses to my pregnancy

I dislike that pregnancy forces me to bring my personal life into the office. I don't have pictures of my kids on my desk, I am vague when curious patients ask where I live and on Monday mornings I never volunteer my weekend activities to the staff.

But this pregnant belly, no matter how discreetly swathed in muted professional clothes, begs comment from everybody.

* * *

A patient comes to see me for follow-up after a miscarriage. I am acutely aware of how difficult it might be for her to see her doctor pregnant.

As I call her from the waiting room I feel that I am flaunting my fertility. I will my belly to shrink down a little, to look less jaunty, but her gaze is fixed on it as she approaches. She grabs my arm, looks at me earnestly, and says, "I'm happy for you. I really am." And I can tell - she really is - and I am moved by her graciousness.

* * *

I'm signing off results, standing in the reception area with my Sharpie fineliner in hand and a stack of cream-coloured files in front of me. One of the secretaries swivels around in her chair. "Hi, Mama!" she exclaims. I look up briefly, say hello, and slide the next chart towards me.

She looks me up and down and beams. "When I was pregnant with my first . . . " she begins, and I only half-listen as I methodically sign off hemoglobin levels and ultrasound reports.

I snap to attention, though, when I hear, "You've even got a bit of a booty now, eh?" I turn to look at her, and my expression must have some level of fierceness to it because she quickly amends, "Only a very small one, though," and turns hastily back to her keyboard.

* * *

I have lunch with a colleague in town for a conference, a forty-something man with no children, and he asks what benefits I receive as a member of our provincial medical association. I list them: CME funds, malpractice insurance, an RRSP program, maternity leave benefits --

He interrupts me. "Why should others pay for your lifestyle choice?" he asks bitterly. He gives a short diatribe on the injustices borne by childless men. I try to interject but give up when he complains about having to pay taxes for neighbourhood schools which don't benefit him directly.

"If you get a leave to have a baby, I should get paid leave to take a water-colour painting course," he concludes.

A few days later he swings by my office. He sets a steaming coffee on my desk and offers, "You can have as many children as you want, Martina."

Sunday, February 6, 2011

My Favorite Patient of the Week

My last patient of the day was in quite a foul mood.

She had just come from the orthopedist office. He had told her that due to her recent roller blading injury she could no longer snow ski.

"He's a bastard," she said "I'll show him, I'll do my physical therapy and be back on the slopes next year!"

She is 76.

She is awesome.

*details changed to protect patient privacy

Thursday, February 3, 2011

When a patient is not a board question

I am really enjoying my Geriatrics rotation. Although my attending preceptor is primarily a geriatrician, he also sees some patients who are younger. I took a history on a patient who was younger than me today, in her early thirties.

She started off complaining about insomnia and headaches, and then said she had some sort of an "attack" earlier this week. She quickly added that her husband died suddenly three weeks ago, and her therapist recommended that she come to see her doctor. I immediately offered her my condolences.

My mind quickly flipped to a frequent practice board question as I gently asked her about other symptoms. A 40 year old man presents to an outpatient clinic complaining of insomnia, poor appetite, and feeling helpless and lonely. He frequently thinks of dying to join his wife. He lost his wife of 18 years five weeks before. Was she suffering from loss of appetite? Was she able to return to work? Had she thought about hurting herself? What did she mean by an "attack"?

Telling the difference between Bereavement-Related Depression (BRD) and Major Depressive Disorder (MDD) is a frequent sample board question that I have come across in various forms as I have been doing patchwork board review. Bereavement is an exemption from a MDD diagnosis for two months after the death of a loved one, while the duration of depressive symptoms only needs to be for two weeks otherwise. Board review questions often dance around this time period. This BRD exemption (and the duration of symptoms for MDD diagnosis in general) is also the subject of some controversy as experts are constructing the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-V), which is the guide to diagnosing mental illness.

I snapped out of my board review musings and continued to question and console the new widow. When I got up to leave the room, I strongly considered asking the patient if I could hug her. Since it was only my third day on the rotation and I was in the room with the physician's assistant, I decided against it. I think if this would be my own patient in my own practice in the future, I would not hesitate to ask. When I left the room and told the other student about it, I teared up.

I guess my empathy toggle switch is still operating just fine.

Cross posted at Mom's Tinfoil Hat

Tuesday, February 1, 2011

Anger Issues

When I was in my intern year, one of my attendings named Dr. Pasture informed me that I had anger issues.

Dr. Pasture was leading a small group exercise where another intern was playing the doctor and I was playing a difficult patient. I had fun with it and tried to be a difficult patient to the best of my acting ability, laying it on as thick as I could. I was later presented with an Academy Award for Best Supporting Actress. (Just kidding, I only got a Golden Globe.)

I noticed that during the role-playing, the other intern started getting flustered to the point where I felt a little guilty. So after we were done, I laughingly apologized.

Later that day, I had a clinic with Dr. Pasture. While I was in his office, he said to me, "I want to talk to you about something, Fizzy."

That didn't sound good. I immediately started to panic. "What is it?"

"You know," he said, "it's okay to get angry. If you felt a need to apologize for yelling during that role playing, I suspect you never show any anger. I just wanted you to know that it's okay to get angry at people."

That was the last thing I had expected him to say. At first, I was just baffled. But the more I thought about it, the more I realized he was kind of right.

I do get angry, of course, but I never, ever yell. Or even snap at people. I don't even do it in my own home, because both my husband and daughter are exceedingly sensitive. As an example, a few nights ago, my daughter spilled a big cup of water everywhere after I warned her to be careful... all I did was say her name sharply, and she ran crying to the closet and hid in a suitcase. So I've kind of trained myself never to yell.

But what's so bad about that?

My husband showed me some study (I'm too lazy to find the reference) where women who didn't vent their anger at their husbands had a shorter life expectancy. I'm not entirely sure why he'd show me a study that would encourage me to yell at him more, but I guess he felt concerned that I was angry at him sometimes and just not expressing it. I'd argue that while I may not yell, I do other great wifely things, like whine, complain, and nag. I certainly don't walk around constantly feeling angry at my husband. And I vent a lot of my frustrations through writing.

Then again, I do sometimes find it hard to let go of things. Every now and then, I compose rants in my head directed at people who I feel wronged me years ago, thinking about what I wish I'd said to them. ("The jerk store called and they're running out of YOU!") Am I the only one who does that? It doesn't feel particularly healthy.

I'm not sure what to think. I don't particularly like people who yell a lot. I tend to think they have poor control over their emotions. But who's more likely to have the early coronary, me or them?

Thursday, January 27, 2011

The month I almost switched specialties

I am finishing up a really great month on outpatient pediatrics. I thought I wouldn't love it. I was scared in the beginning how much I really love it. I had a moment in the first week or two that made me waver, ever so briefly, from wanting to do obstetrics.

I love the babies, even when they are screaming. I especially love the girl ones, since I don't have one of those at home. I love the variety. Sure, there is an awful lot cough, runny nose and fever X 2 days on top of the chart. But, I have been pleasantly surprised by the variety.

I have done everything from a one month well baby visit to STD counseling on a young man. I have seen children living with autism, a child with Fragile X syndrome, one with mosaic Klinefelter syndrome, and a few with insulin pumps. I have seen congenital and developmental variations.

My main fear was becoming too upset by seeing a serious ill child. I cried more than once during my preclinical years during films and lectures about terminal developmental disorders and abuse. I still have to do a month in Peds ER, but my rotation site doesn't do pediatric trauma. I hope I don't end up too emotionally overwhelmed by anything I see. I don't have to do PICU or NICU. I think I would have been fine if I wasn't a mother. Now, I identify with every parent and associate all the kids with my kids.

I think one way we end up picking a specialty is by what we can't handle. Some people can't handle the idea of treating someone who is pregnant. I have an internal attending that always jokes that treating someone under eighteen makes him diaphoretic. I know another who can't face pus. There's a student who dreads the ER.

I still haven't done my ob/gyn rotation yet. I am pretty sure I'll love it, since I trained as a midwife. If not, I suppose I can switch everything over to pediatrics. I really doubt I'll be doing it, though.

Wednesday, January 26, 2011

Bitter? Well, a little....

For those of you who read my posts, such as my rant about how much it sucks to work weekends and how the bright light at the end of the tunnel is a big fat lie, probably think I'm incredibly bitter and unhappy. That I'm some kind of cranky old doctor who sits on my porch confiscating the wayward baseballs of little children. Some of you have suggested that I switch fields.

Well, really, you don't need to worry so much about Fizzy. The truth is, I kind of like my job. It's not perfect. You're not going to catch me and my job alone in a closet doing unspeakable things (I worry about some of you, really), but I'm quite satisfied. For starters, I don't work weekends. I sometimes really help people. I have a lot of flexibility. I can eat lunch or go to the bathroom any time I want. (I'm not joking. This is huge.) There's a lot of room for career growth and research. If someone told me I'd still be working at the same place 20 years from now, I'd be pretty happy. Like they say in Office Space, it would be nice to have that kind of job security.

So your next question is undoubtedly, "But Fizzy, you're always whining and moaning. If you're happy, why don't you just shut the hell up already?"

Well, that's a good question, although quite rudely phrased. It's sort of like this: say you spent the whole day cleaning your giant house. It sucks but then when it's done, maybe you can finally relax. Except you can't relax because you pulled a muscle in your back and have excruciating pain for the next several weeks. It's sort of like that.

I wish I could say that my training sucked and now it's over, thank god. Except it's not so simple.

All right, my pre-clinical years were not great. My school had a failure rate of something like 10%, which meant that 10% of the class actually had to repeat an entire year. That puts a lot of pressure on you, especially when you're in the midst of a bad break-up and some family medical issues. But I was used to studying hard, so while it was bad, it wasn't that bad. The clinical years were when I started to fall apart. Some people simply don't like waking up at 4AM and working 27 days of the month. Some people start to physically deteriorate. I was in the latter category. I've always had a pretty low energy level (which would explain my impending obesity) and I really struggled with the physical demands of clinical work (e.g. sleep deprivation, standing in place for eight hours, etc.). It was pretty bad, but I got through it.

It was intern year that really got me though. It changed my conception of myself, and not in a particularly positive way.

For starters, my first resident as an intern was a cruel bitch who tore me down on my first day and continued to bat me down every time I tried to recover. (You can read more about her cruelty here.) People like her over the course of my training really brought down my confidence in myself. But it wasn't just that.

I'm a typical oldest child in that I always feel this compulsive need to be responsible. I'm not Type A, but when you ask me to get something done, you can bet it will get done and at least a day early. In school during group projects, I was always the one who quietly did everyone else's work while they slacked off. I am extremely reliable and organized and always have been. Except I discovered during my intern year that after 2AM on a call night, I wasn't particularly reliable. I'm not going to elaborate further, except to say that I'm not proud of my behavior on some of my call nights. (I will at least say that absolutely no harm whatsoever came to any patients.)

That was part of why I switched residencies, in order to have a more regular schedule. Leaving my residency was the most drastic thing I'd ever done in my life, very unlike me, but I was horrified that I couldn't trust myself during call-heavy ward months. I don't think of myself as prone to depression, but I became desperately miserable that year. I was recently reading a journal I kept during intern year, and I wrote one very serious-sounding entry where I said that I wished a car would run me down on my walk to work the next day.

So that's my story. Years later, I still have negative thoughts about myself due to those early years of training. I have trouble thinking of myself as the old reliable person I always was, despite three extremely successful subsequent years of residency. And some of the physical ailments I developed under the extreme stress of my early training still haunt me. But I guess in some ways, I got off easy. One of my colleagues attempted suicide during intern year.

Some of you have applauded me for my honesty and this about as honest as I can get. I don't know how common my experience was, but I've learned it's more common than I thought. I was, after all, a very average intern, as my shocked program director told me when I informed him I couldn't take anymore. I suspect there are people reading this now who feel the same way I did, have in the past, or will in the future.

Tuesday, January 25, 2011

Guest Post: When it snows, it pours

*All names and potentially identifying information (including some physical descriptions and case details) have been altered to comply with HIPAA regulations, as well as to be nice and ethical.

It was snowing one recent morning when I got up to drive to work. It was supposed to rain. I’m a primary care doctor in Boston, and my commute can be 12 minutes or 60 minutes, depending on the traffic. I was lucky I left early, because the unexpected snow on frozen asphalt created a slippery mess, many accidents, and much traffic. It was pretty bad. I wouldn’t say half my morning session cancelled; rather, I was surprised that half was still on the schedule. Tough New Englanders! I took off my soaking wet boots and pulled on my white coat and waited to see who would show up in the snowstorm.

Part of me was hoping that I’d have the rest of the day off, and I could go home to cuddle with my 6-month-old. Of course, then I would have to make up the day later on… I was here and decided to make the best of it. With oodles of extra time to lavish on my patients, I looked at the schedule. My first patient, Brenda Z., was a 22-year old for a physical. Usually, I only have 20 minutes for these, but today, we would have a whole 45 minutes!

Brenda is only 5 feet tall, but she weighs 244 pounds, putting her Body Mass Index (BMI)(1) at 48. Unfortunately, she is not only one of the 34% of Americans who are obese, but one of the 5.7% who are extremely (morbidly) obese.(2,3) Predictably, she has many obesity-associated problems: asthma, sleep apnea, polycystic ovarian syndrome, and almost-high blood pressure. For the past year, I’ve had her come in every 3 months for weight and blood pressure checks. She comes from a middle-class home, works at a supermarket checkout, and goes to school part-time. She’s a hard worker and a good kid. But best of all, she had lost 11 pounds, by eating mostly fruits and vegetables and Slimfast shakes. I wasn’t at all sure this would stick, but hey, it’s a start.

As Brenda left, I noticed that the medical assistant and one of the nurse practitioners were steering a fairly off-balance woman into my other exam room.

“Um, if you don’t want to see her, I guess we can ask one of the other docs to see her, but this was the closest room…” said the NP.

The M.A. was more blunt: “This one’s drunk. Falling-over drunk.”

It’s not at all common for patients to show up at our office drunk, but this lady, Alexa J., had just wandered in looking for her usual primary care physician, who was out. She was in a bad state, so the staff had taken it upon themselves to make her safe. They checked her in and took vitals, as she promptly passed out face-down on my exam table.

“Hello? Hello, can you hear me?” I rubbed her shoulder, more than a little alarmed. She was dressed well, but absolutely reeked of Vodka. Fumes. I felt dizzy just standing over her.

“I need help, I need to stop,” she garbled.

“Stop what? Are you alright, are you hurt?”

“Alright… I want to stop this, stop drinking.” That much was clearer.

I stood and thought for a moment and then just picked up the phone and called our ER. The triage nurse took the information with aplomb, simply adding “Passed out, eh? Good luck getting her down here.” But the M.A. and I wrestled her into a wheelchair, and with two escorts, off she went to be evaluated and possibly admitted for detox.

I then got a call from a psychiatric hospital. A patient of mine, a middle-aged mom named Jane L., had been admitted with suicidal thoughts, in a background of Bipolar Disorder. I was surprised and pleased to get a callback from the treating psychiatrist, who filled me in: that she was stable, but would need residential placement after acute treatment. I offered some of my take on the situation, but the psychiatrist did not seem all that interested… That’s OK, I’m in over my head with someone who is a danger to herself; she’s in the right place. But I remembered that just a few months ago, after she had come in to see me and had expressed that she wanted to overdose on her pills or crash her car, I had walked her down to the emergency room myself. Just a few years ago, she was working and supporting herself and doing well. Now, she was on disability, in and out of the hospital, her finances in ruins. I so wanted to see her better.

My next patient was new to me, a healthy mom with a cold and a cough, and some mild wheezing. She asked me about Boston Med, the 8-hour ABC-TV documentary series that aired last summer.(4) I was on maternity leave when it aired, but my husband and I watched every episode. It was touching, yet also stereotypical: lots of trauma drama.

She asked, “Are they going to film another series like that? I hope so!”

I didn’t know. But I pointed out that the fact that only surgeons and ER staff were profiled, and that very disappointing to us primary care docs! “Primary care is exciting too,” I said.

She had some mild bronchospasm, so I gave had given her an inhaler. She seemed so reluctant to accept the inhaler, that I had to ask her why. She told me about her son who had been a micro-premie and survived, but with bad lungs. He was 9 years old now and doing well except for asthma. He had been in and out of the hospital with many infections, pneumonias, and was better now but didn’t react well to the Albuterol and they had to keep trying new meds- Pirbuterol, Levalbuterol.

“Will this happen to me?” she asked, really worried. She had equated his long battle, the sequelae of premature lungs, with her new diagnosis of reactive airways, which means mildly “twitchy” lungs that respond well to occasional puff of Albuterol. I couldn’t dismiss her fear, borne of a painful experience… and I couldn’t alleviate her fear with any quick explanation. And so we had a long discussion about it.

“Thanks for spending so much time with me today,” she said.

My next patient probably had the flu. Then I said Hi to my diabetic patient whose sugars are all over the place, and I’m following her along with our diabetes nurse.  Thank God for our diabetes nurse, who can take a good diet history and offer good solid recommendations on eating.

My last patient was Nanette M., a 32-year old African-American woman with a new breast lump. She had no breast cancer risk factors at all, and the lump was round, but it was deep and immobile. We decided to do an ultrasound and a mammogram.  Statistically speaking it’s probably a benign breast cyst. Still, breast cancer is the most common cancer in women (besides skin cancers). Also, breast cancer rates are higher in African-American women than white women before age 45. (5) I wanted to be careful. Though I have seen many women with breast changes that turned out to be benign, one time I examined a patient with breast thickening, and it was breast cancer, invasive but not metastatic. Surgeries and chemotherapy took a whole year from her. Her treatments left her a changed woman. Thankful to be alive, but changed, older. So any breast changes, basically, scare me.

And that was that. I ate a snack, tried to do some paperwork, but then I called home. I spoke to my mom (our nanny) and heard my baby squawking in the background. Then I spoke to my Hubby, who urged me to get home soon before rush hour. Baby just sounded so cute, and Hubby was worried, so I packed it up and made for home, leaving behind some paperwork and a snowy morning at the primary care office.


1. Centers for Disease Control and prevention: Vital Signs: Obesity. accessed 1/18/11

2. Statistics related to overweight and obesity. National Institute of Diabetes and Digestive ad Kidney Diseases. US Dept of Health and Human Services. accessed 1/18/11

3. National Heart Lung and Blood Institute BMI Calculator

4. Boston Med, ABC medical documentary Summer 2010:

5. Breast Cancer Facts and Figures 2009-2010, American Cancer Society

Monday, January 24, 2011

Amnesty Hour

Last Friday I was working at a satellite hospital in a smaller town. The work was light, which was a relief after all of the snow craziness the day before - getting babysitters for kids, arranging for possible overnight lodging which I thankfully did not have to use. I sat down for lunch with some of the lab techs.

I'm not sure how the conversation ended up on kids and discipline, but one of the techs said that even though her kids are almost out of high school, for years they had an amnesty hour every day, usually at mealtimes, where they could talk about anything and not get in trouble. Her kids would talk about things that happened at school, discuss words they overheard but didn't know the meaning to, etc. She started when they were in elementary school. The tech discussed some of the more interesting revelations that came out in teenage years. Then she said that once, when her daughter was eight, she asked her what a "blow job" was - she had heard a kid say it at school. After the mom almost fell out of her chair, she said, "well, that is something for adults and you will learn more about it in a few years." That seemed to satisfy her daughter for the time being, and I think it was a nice, age appropriate response to close the door for a little while.

The idea got me thinking, and on Sunday morning when the kids and I were snuggling in late, I explained it to them. My kids are only 5 and 7 - we certainly don't need a whole hour, maybe not even once a day. When it was Cecelia's (7) turn, after expressing incredulity about being able to say anything and not get in trouble, she talked about a boy at her school and how he was mean to other kids, and what he did. Jack's conversation turned to a couple of the more intense fights he had with his sister over the last year - both I remembered well, when her teasing and torments pushed him to physical retaliation. This was a little awkward considering Cecelia was in the room, but it was nice to hear his side, what stuck with him and his feelings. I think it was good for Cecelia to hear, too - her opinions and words tend to overbear his unless there is someone around to check her and force her to listen. Her teacher tells me that most kids her age need to learn to listen more and talk less, and she is no exception. Most importantly I was there to mediate and comment on their reflections of scary subjects.

Later on that day, we were playing a new card game in front of the fireplace my mom bought us called Spot It! I can't wait until Jack can read - our repertoire of family board games will branch out tremendously. This one is fun because you have to look at both cards, each with about 10 pictures on it, and the first person to spot the match wins the hand. They teamed up against me, and after they narrowly won three games (I know I shouldn't admit this, cause I would never want them to know but I do let them win at this age - I have an unfair advantage of highly developed visual recognition skills - hell I'm a pathologist - and it makes them so happy to beat me - but it shocks me how close I actually come to losing for real as they are getting older), I told them I was determined to win one game before dinner. As I started winning Cecelia completely lost her cool, focus, and her game. She forced me to continue but by the end she melted down in tears of frustration and post losing accusations of cheating - she was a little worn out all weekend from a sleepover Friday night - and when I told her we weren't going to play again since she wasn't having fun, she dissolved in sadness and anger. I sent her to her room to calm down, eventually telling her she'd better go before I lost my cool.

When I wandered back into her room about ten minutes later, we were lying on the bed hashing it all out. She was in a better place, and listened. I was less frustrated, and listened. We talked about the meaning of "sore loser," - she has such a competitive streak we have to do this talk over and over (like mother like daughter). Suddenly, when we were in a good place, I leaned over to her. "Amnesty hour without Jack. Come on. Lay it on me." She talked about how sometimes she hated Jack so much. Then she struggled with something, and I encouraged her, even though she worried aloud about saying it. Finally she said, "Remember just now when you told me you were going to lose your cool? And sent me to my room? I was thinking how you didn't really have any in the first place. You know, cool." I had seen the sway in her backside and the swish of her hair as she marched down the hall and it fit her thought perfectly. I laughed inside, and told her, "Cecelia, you want to know the truth? I'm glad you didn't say that to me when we were both really mad and upset, but if we were kind of joking around? About me losing my cool? The cool I never really had? That would have been a really funny thing to say."

How about readers? Any thoughts, suggestions, remembrances, or ideas about how to get your kids to open up on hard subjects? I can see that as they are navigating rougher waters in school, it will be really important to stay in touch without being too overbearing.