Friday, July 29, 2011

Guest post: Get your boots on

Last week, I was pleasantly surprised to see Sheryl Sandberg, Facebook’s COO, featured in The New Yorker. Considering her TEDWomen talk in December, and her recent commencement speech at Barnard College, she has been front and center in the effort to support women’s success at the very tops of their fields.

For those who can’t access the links, Sandberg’s main points from her TED talk are these:

1. Sit at the table; own your own accomplishments. Studies have shown that for men, success and likability are positively correlated, whereas for women, success and likability are negatively correlated. Women need to attribute their own success to themselves, even though there is a risk of not being liked. In her Barnard speech, she says, “[But] I know that the truth comes out in the end, and I know how to keep my head down and just keep working.”

2. Make your partner a real partner. Women still do twice the housework and three times the childcare as men, even though they also are working outside the home. In homes where responsibility is equally shared, the divorce rate is halved. “It’s a bit counterintuitive, but the most important career decision you’re going to make is whether or not you have a life partner, and who that partner is. If you pick someone who’s willing to share the burdens and the joys of your personal life, you’re going to go further.” (Side note: a recent article in Time magazine notes that women and men work about the same hours in the day, although women work more unpaid hours, i.e. in housekeeping and childcare. This is usually accomplished by the woman scaling back her paid hours.)

3. Don’t leave before you leave. It is so common for women, from the moment they even start thinking about having children, to start leaning back from their careers, sometimes without realizing it. “Keep your foot on the gas pedal until the very day you need to leave…and then make your decision,” says Sandberg.

I watch these videos of Ms. Sandberg, and wish she could have teleported herself through the last decade and shaken some sense back into the old college me. You see, I made the wrong career decision ten years ago, and the only reason was because I didn’t believe in myself. I became a nurse when I really wanted to become a physician. Even ten years ago, there was no question in my mind that I would have made a good physician, and no question in my mind that I would love, adore and provide for my future family. But I still feared becoming a mother in medicine.

So why didn’t I go for it? For years, my pat answer was that I wasn’t sure medicine was for me until I was well into my nursing career. Now that I can finally admit this to myself, I think the real reason went deeper than that. I chose nursing because I was afraid that if I chose medicine, my boyfriend might get cold feet, and I might emotionally damage my future children. I was afraid that medical school rejection could be the ultimate social suicide. I worried that my friends and family might judge me for “choosing career at the expense of my family” and turn their backs when I most needed their village around me. As Sandberg might say, I was simply afraid of not being liked—in the most extreme way.

But ten years later, I do have something else to say, and that is that I did go to medical school, I did marry my college sweetheart, and I do have two happy, well-adjusted children. I am surrounded by friends and family, and I have done well in school. The sky, in fact, has not fallen.

While I am so proud of the above accomplishments, I still find at times I still revert to my old ways. I apologize for everything—for taking 20 minutes to pump breastmilk on clerkships, for passing off daycare duty to my husband, for not knowing when I will get home. But here’s the kicker: I don’t actually feel bad about any of the above, and I don’t think anyone in my family even expects me to feel bad. They know it comes with the job. What I feel bad about is that I should feel bad and I don’t. It’s as if I’ve been conditioned to believe that worry is synonymous with love, and that constantly shortchanging myself is penance for wanting children.

This, to me, is the fundamental problem of women today. It seems like we have no faith in our social or professional supports to help us get done what we need to get done. We’d rather hide behind the fa├žade of martyrdom than find a way to get what we need—and then we tell the next generation “I gave up my career because you can’t be a good doctor and a good mother” or “I had to work 100 hours per week, and that is the only way you can deserve this job.” And so we saddle the next generation of mothers in medicine with the baggage of choosing either success or likability. Again.

What if we women did something radical instead? What if we thought long and hard about what we really want and actually asked for it proudly? Maybe that means finally having “the talk” with your significant other. Maybe it means keeping the kids in daycare one more hour to get something important done. Maybe it means daring to ask for part time—or partner. Maybe it means saving your apologies for when you have actually done something wrong (and, ahem, it is not wrong to have a career and a family).

When I think of the two most radical things I have done in my life—applying early decision to medical school with a marginal MCAT score and asking the cute guy in my dorm to come swing dancing with me, I realize that they are two accomplishments of which I am most proud, because those risks have given me a thousand-fold return. What if, when it came to big decisions, we honored our id as much as we do our superegos? What if we not only made radical decisions but celebrated other women who dared to do the same?

I was a child in the 1980s, and the message to little girls was “you can be anything you want to be.” I still believe that. But I think our daughters need a stronger message: “You can be anything you want to be, on your own terms, and you deserve to be happy.” And when we live out this message, it won’t be in an aggressive, cold-hearted way, but rather our way—with kindness, creativity and collaboration.

I just got back from a U2 concert, and my ears are still ringing. The turning point in the concert for me was watching four men singing at the tops of their lungs:

“You don’t know
you don’t get it, do you?
You don’t know how beautiful you are!”

So ladies, strap on your boots. We are a new generation of mothers, and we are proud to have it all, and share with each other in our successes.

mamascrub @ gmail-dot-com
So now it’s your turn, anonymous or otherwise: Tell me one way in which you have shortchanged yourself. Now tell me one way you might do something radical. What would you do if you knew you could not fail?

Monday, July 25, 2011

MiM Mailbag: Considering a medical career later in life

Mothers in Medicine:

I just stumbled upon your blog in my quest for information about later careers in medicine.  I have been considering a transition to nursing.  I am 32 years old, have never been married and haven't been a mother at this point.  However, I was wondering if you might have any information or resource suggestions regarding preparing and applying to medical school later in life.  While I am interested in nursing, I did not realize medical school could potentially be an option, that older candidates could be considered, and I would love to find more information about how women are doing this.

Thank you for any guidance you might provide - this blog is great!


Friday, July 22, 2011

Boards. Tomorrow. Ack.

Sorry I have been incommunicado, but I am taking my Step II CK tomorrow.

Wish me luck.

Tuesday, July 19, 2011

Practical advice for nursing mothers

When you announce on the internet that you're nursing your baby and need advice, women are only too happy to give it to you. However, I've noticed that the women most likely to give advice, the ones who frequent the breastfeeding communities, are the so called "boob nazis." They feel so strongly that breast is best, that even an ounce of formula is criminal. For example, a new mother I know was just "dropped" by her online breastfeeding mentor because she confessed that she started giving her newborn one small bottle of formula at night (for the sake of her sanity).

To me, this seems crazy! If you believe so strongly in breastfeeding, isn't it better to encourage women to at least do it part of the time, rather than reprimanding them for taking measures to make it more doable? I've gotten some ridiculously useless advice from women who refused to compromise their breastfeeding ideals. (i.e. When I started giving my daughter solids, I was advised to have her reverse her sleep cycle to spend most of the night awake so she could nurse during this time. Seriously??)

With that in mind, I'd like to offer some practical tips and advice for breastfeeding and pumping, coming from a working mother who believes strongly in breastfeeding but is not a "boob nazi." You can take this advice with a grain of salt, because this is just based on my own personal experiences:

1) Breastfeeding is actually not that easy. I was amazed how challenging it was the first week. Your nipples hurt, the nursing itself hurts, you get dehydrated, and you never seem to have enough milk. Don't give up after just one week. It gets way easier. Promise.

2) One (or even more than one) bottle of formula will probably not result in terminal nipple confusion or a sharp decrease in supply. Due to an ABO mismatch between me and my husband, we produce very jaundiced babies. They got bottles in the hospital. No evil resulted.

3) You are not a horrible person if you allow your partner to give the baby a bottle at night so that you can get a few consecutive hours of sleep and feel human. I resisted this for as long as I could with my older daughter and finally gave in when my health started suffering. It actually ended up being wonderful because it made my husband feel closer to the baby and more comfortable taking care of her.

4) You don't need to have five gallons of frozen milk stored up when you go back to work. If you do: awesome. But if you don't, it's not the end of the universe. Due to a variety of reasons, I had absolutely no stored breast milk when I returned to residency. Despite this lack of foresight and my daughter's monstrous appetite, she didn't get any formula at all for the first three months I was back at work. Obviously it would have been better if I had planned ahead, but I'm just saying that you can make it work.

5) Expect to hate pumping. I have yet to meet a woman who didn't find pumping really depressing.

6) If you're having a hard time pumping during your maternity leave, try pumping first thing in the morning every morning. Your supply will be highest then and the pumping will be most successful. Nurse one breast, pump the other. One 5 ounce bag of milk every morning for 11 weeks will give you about 400 ounces of milk, even if you don't pump any other time.

7) If you work standard hours at your job (Monday through Friday with most weekends off), your supply will probably decrease as the week goes on and be highest on Monday. Take advantage of this by pumping like crazy on Mondays and over the weekend. I used to nurse on Monday morning AND pump out 10 ounces.

8) Keep well hydrated.

9) If you feel you can't breastfeed and your baby gets formula, your baby will still be healthy and absolutely nobody will judge you except for a few nut jobs on the internet. When I was an intern, a graduating resident told me she couldn't make breastfeeding work because of her hem/onc fellowship. That woman was an awesome resident, a wonderful person, and I bet anything she is a great mother. If nursing is going to make you tired, cranky, and unhappy, and you hate it and are only doing it out of guilt... well, I just don't think it's something worth feeling guilty about.

Anyway, that's all I've got for now, but feel free to add your own practical advice. Hopefully, this will help some new moms or mothers-to-be.

Monday, July 18, 2011

Guest post:: Trying to conceive

Twice a day, during my typical 5am - 7pm style day, I sneak away to the bathroom with a little sealed packet.  In that little packet is a small white test strip.  I have a small plastic cup in my hand.  You can buy these little packets online -- 50 of them for about $10.  I  pee in the little cup and dip the stick, waiting to see what lines develop.  One dark line and one lighter line; nope, no LH surge.  Still not ovulating.  Then I wonder, for the hundredth time: is it my irregular schedule?  Is it the q3 call, even though it's home call, still tends to extend my work hours to the 80/week boundary?  Is it the stress of running an Orthopaedic Surgery trauma service?  Is it my complete lack of sleep?  I bury the little stick in the trash, hoping nobody notices it, and I rinse out the cup, dry it off and palm it, heading back to clinic.

I'm disappointed again today.  I do this twice a day -- looking for my LH surge, looking for a sign that I'm ovulating.  On my OR days, it's harder to test in that daytime window.  I usually manage at least one pee-in-a-cup time a day, though.  My cycles aren't regular enough for me to just count calendar days.  My basal body temperature pattern isn't consistent enough just to test around "expected ovulation" time.

When the two lines are the same color, I'll get home at around 7 or 8pm and try to coax some energy into my body in order to get some lovin' from my husband and work on this conception business.  Small windows in time where gettin' busy really matters.  Small windows of time in my life where I want to catch up on sleep.  In the 6 months we've been trying, there have only been one or two cycles where I was pretty sure I had an LH surge and I ovulated.  After those cycles, it was hard not to get hopes up.  Each time, blood in the underwear heralding menstruation left me disappointed.

Each morning, around 5am, I take my basal body temperature before getting out of bed.  All the temperature/charting folks say 3 hours minimum of uninterrupted, good sleep are necessary for a reliable basal body temperature measurement.  HA!  Have they ever met a surgery resident before?  My chart looks like a saw blade ... up down up down up down ... it's no wonder I can't figure out whether or not I've ovulated.  My OB/Gyn doesn't really know what to make of my temperature charts.  He tells me: "Sure, I'd love to say 'get more regular sleep,' or 'try for a more normal schedule,' or 'work on your stress levels,' but I was a resident once, too, and I know how ridiculous that sounds to you.  He's right - if I had a "normal" job, or a "normal" life, those would be reasonable suggestions.  I do what I can with the life I've chosen.

All of this is difficult, even though I've been off hormonal birth control and we've only been officially "trying" for about six months.  What compounds the difficulty, though, is that all this has to be kept under wraps.  Most women who start down the path of trying to conceive are, understandably, quiet about their journey, unless they have a kindred soul (who may also be trying) with whom to share their experiences.  Being a surgical resident just adds another level to the need for secrecy.

In my program right now, there are several male residents whose wives are pregnant.  All of those announcements were met with a lot of "way to go, man!"  "Congratulations!  When's she due?"  "Not much longer until she'll want #2, eh?  Too bad we've got residents' salaries!"  In my program, we average one woman for every 5 or 6 men -- and that's actually a good number, for an Ortho program.  There have been two women before me who had children during residency, and one woman in the class below me.  When they got pregnant, there were significantly fewer "YEAH!  Way to go!  Congrats"-type responses.  Instead, it was a whole helluva lot of "how much time are you taking off?"  "Wait, you're due during a rotation where you're q3 call -- who is going to cover your call?"  "We're going to have to book down that clinic for a month, aren't we?"  And while they were away on maternity leave - most of them took 4-6 weeks - there was definitely a fair amount of grumbling.  I found myself defensive for them: "If this were YOUR WIFE, I'll bet you'd be fighting for every single day of her leave," I'd tell the complainers.  The double standard still gets me.

And so I continue to sneak away to pee in my cup and look for signs that I might be ovulating, despite this ridiculous schedule and stress I put on my body, my mind and my spirit.  I'll deal with the double standard when I get to that point; right now, I'd just like to see two lines of the same color, and my husband and I will keep hoping.

-I'm an orthopaedic surgery resident on the west coast. No children yet.

Friday, July 15, 2011

Safe Landings

A couple of weeks ago, the kids and I went to Florida with some friends. It was an amazing trip. I didn't get to do a vacation with the kids last year - was so busy with divorce and house selling that it didn't happen. I realized, after this trip, how much we all really needed the break from life.

We flew into Destin/Ft. Walton Beach late on a Saturday night. While standing in line for a rental car to drive 2.5 hours to our final destination, the kids were running around the baggage claim area burning off energy. There was a big display of brochures advertising various activities next to the rental car desk. Cecelia (8), oops I mean Ce-silly - she asked me to change her blog name to a pet name her second grade teacher called her - picked up one on parasailing.

"Mom! I've always wanted to do this! Please can we parasail?"

Me, yawning. "Um, OK maybe? Let me look into it tomorrow." I still had the drive in front of me - unknown territory in the dark - and was a little anxious. I was thinking parasailing? Really? How had she even heard of this? I did it once back when I was 15 or so, but hadn't thought about it much since then.

We arrived safely around 2:30 in the morning and had a magical week with friends and lots of kids. Ce-silly was relentless about the parasailing thing throughout the week. On Wednesday I finally picked up the brochure. It advertised that kids 6 and up could participate, which put Jack (6) into play, if he was willing. More enticingly, we could all ride together. I called the place in Destin and they said they would reserve us a spot at 9:45 on Saturday morning, leaving us plenty of time to parasail and catch lunch before our return flight to Little Rock. Everyone else drove, so it would just be us three. Catch was to convince Jack.

"No way, Mom. I'm not doing that."

I explained the process to him, told him I had done it and he would love it.

"What if the rope breaks?"

"I'm pretty sure the rope won't break. Haven't really heard of that happening. I think you will be fine, but it is up to you. You can stay on the boat if you want, and I will sit with you."

Ce-silly has amazing lawyer-like powers of convincing and negotiation, and by Saturday, Jack was game. We boarded the speed boat and headed out of the bay to the open ocean. We listened to the instructions of the guides and got to watch a couple of people go before us and return safely, so Jack was excited when it was finally our turn. We harnessed up and sat on the front of the boat.

As the boat sped up, the rope loosened and carried us 800 feet up into the air. It was surprisingly quiet up there - I was in the middle of Jack and Ce-silly. Much quieter than on the boat where the motor competed with the 1980's music. Seagulls and pelicans flew by. We watched a plane carrying a bank advertisement in the distance. Jack turned to me in amazement.

"Mom, this is my dream! My flying dream. You made it come true. Thank you so much. I love you."

My heart melted all over my thorax, despite the fact that I worried I had peaked him out at age 6, and it would be all downhill from here. I noticed that his hands were clenched on the ropes.

"Jack, you can relax your hands, if you want. Sit back into the seat. You will be fine. Did you notice down below, how the sun is shining all sparkly on the water? It looks like diamonds, doesn't it?"

He nodded in assent. Ce-silly said, "Mom, I have to pee. I wonder what it would be like to pee 800 feet in the air?"

I laughed and told her - "Well if you have to, I understand. But hold it if you can - we'll find a bathroom as soon as we get off the boat."

"OK, I think I can hold it. Mom, you know what? This is the best 10 minutes of my life. Only I wish it was a little faster - might be more exciting."

Just then the boat slowed us down and dipped our toes into the water before taking off and carrying us back into the air. Ce-silly got her thrill.

We landed safely on the boat and snuggled up happily to watch the last two rides. Both kids and I were sitting serenely, dazzled by the experience. Maybe we'll go again next year. I had to pay $20 bucks for photo service, but for once, I was on the other side of the camera.

Here's to safe landings for everyone.

Tuesday, July 12, 2011

Is 12 weeks long enough?

I was recently on the phone with a friend of mine who is 40 weeks pregnant. (My husband has dubbed 2011 "The Year of the Baby" because pretty much every couple we know is having a baby.) She was having very painful contractions that were coming at regular intervals.

"I think you should go to the hospital," I told her.

"No, I can't," she said. "I still have to go to work tomorrow so it won't count as a day off."

I can't throw stones. I spent most of the day I went into labor having contractions at work that were increasingly painful, and ignored the charge nurse yelling at me that she was NOT going to be delivering my baby. I had to get my work done for the day so that it would "count." (In my defense, the contractions were still 15 minutes apart when I finally went home.)

Honestly, I liked it that when people asked me when I was due, I could reply, "Tomorrow." I was proud of myself for working till the day I went into labor for two pregnancies. But that was pretty much all I liked. The last two weeks of pregnancy were an uncomfortable blur of swollen and achy feet, exhaustion, having to pause dictations multiple times to catch my breath, and Braxton-Hicks contractions that liked to come when I was driving. If staying home during that time wouldn't have cost me any money or time with my baby, I wouldn't have hesitated to do so.

FMLA guarantees 12 weeks off. That seems like a long time in some ways, probably the longest I've gone without work or school since I was three years old, but it also means you're going back to work and leaving a two and a half month old baby behind. It means that you don't want to sacrifice any of that time to stay home without a baby in your arms.

And a lot of residents and other professionals take far less than 12 weeks off. I know many women who took only 6 weeks off. I know a few who only took 4 weeks off.

This is not unique to medicine. Most of the women I know in other fields also worked until the bitter end. I don't know any who were happy to be still working at 40 weeks, but it's a necessity when the law only gives us a maximum of 12 weeks, and often that time is unpaid. Canada gives women a whole year to spend with their babies.

I'm not sure I'd enjoy taking a whole year off or if I'd really do it. But it would certainly be nice to live in a country where it was an easy option.

Monday, July 11, 2011

Feelings of loss post-partum

by FreshMD | Martina Scholtens

When Ilia was a few weeks old, Pete asked, and said it so casually from the couch where he was reading after dinner, "Do you miss our old life?" The relief to hear it said. I did. I missed the old routine, driving in to Vancouver in the mornings with four-year-old Ariana in the back seat, CBC on the radio and a day at the clinic ahead of me. Yes, there will be a similar routine in a few months, with an infant in the car and a graduated return to work, but those other days, the particular way they were, are done.

"I guess you'll never have another son-baby, hey, Mom?" asked my six-year-old son cheerfully as he ate his after school snack the next week. I could have cried. I saved all my kids' clothes in anticipation of this possible fourth, and now that she's here I have boxes of corduroy pants, sneakers, little ball caps to set afloat. Somehow my daughters' infancies seem preserved through Ilia wearing their hand-me-downs, but I can't kid myself: my son's baby days are over.

And then I overheard Ariana greeting her little sister. "Good morning, Ilia," she said seriously. "It's your medium-sized sister." Saskia's still the oldest, and Leif's still the only boy, but the crown of youngest child has been passed from Ariana to Ilia, by my choice. Then, after church an elderly woman tugged on my arm, admired the baby and confided, "Mothers have a very special relationship with their youngest daughter." At that moment Ariana came into view, long dark pigtails, thin legs in purple boots making their way across the room to the gardens outside. There she was, the daughter with whom I would have had that extra special relationship - except I'd taken that from us and given it to this newest baby.

Those first two months, I missed my bodies. The one before this last pregnancy. The one before I had ever been pregnant at all. The pregnant one, even, that at least looked purposeful. A week post-partum, sitting at the breakfast table, Leif gestured at my paunch with his spoon and asked, "You know why that looks like that? Because all the equipment is still in there."

Most of all, I've struggled with the (temporary) loss of my identity as physician. At the little good-bye party over cake in the chart room in February, I asked the clinic to please just stagnate until I returned. Of course they will forge ahead and do all sorts of interesting things while I'm away, and I hate to not be a part of it. Some of my patients requested six-month supplies of medications to tide them over until my return. I didn't comply, but I understood. I'm grateful for my locum, but I'm jealous of her, too. I miss the collegiality of the clinic, the focus on others' lives, the escape from my own head, the sense of contributing to the community, the academic stimulation. I'm back to work in the fall, but in the meantime, I feel a little unmoored.

This is my daughter:


How I love this little face. I marvel that someone I couldn't have imagined months ago could feel so inevitable, could have an entire family happily orbiting around her.

Don't mistake this for ingratitude. It's simply an acknowledgment that for this new mother, mixed in with the bliss of those first six to eight weeks, were feelings of loss and grief. Surely I'm not the only one.

Monday, July 4, 2011

Must the doctor ALWAYS be in?

First of all, for any of you who decided to read this post because you thought it might be a follow-on to the discussions about whether it's ok to work part-time in medicine, nope, that's not what this is about. Rather, it's about the tendency to wear our doctor hats even when we're off-duty, when it comes to our own health.

It was a Facebook status update, or rather a string of them, that first got me thinking about this issue: the epidemic of medical hypochondriasis among doctors and other folks in medicine. (For my friends in psychiatry, let me apologize for using hypochondriasis in the lay sense, not with any DSM criteria attached, and for my friends in epi, I know it's not really an epidemic.) A friend of mine, who is a mom of three and a critical care nurse practitioner in the PICU of a large academic center, often posts on FB about her anxiety related to her kids' health. One of them has a fever, and she wonders aloud whether she is the only mom checking for petechiae. Another says she's too tired to bike (in the 98 degree weather) and wants to come in and watch TV in the air conditioned living room instead, and she frets about whether she is severely anemic--it could be acute leukemia! It is easy to witness someone else do this and see the absurdity in it, but when it's YOUR lymph node that you think you might feel in your neck or YOUR lumpy breasts or YOUR bone pain, etc, it becomes a lot easier to let your mind spiral off into the crazysphere.

Most of the mothers in medicine with whom I have discussed this freely admit, "Oh yeah, my thing is cancer" or whatever. Everyone seems to have something she is convinced she is going to get, and it's often what she's surrounded by, not what she actually might be at increased risk for due to lifestyle or family history, that seems to drive the fears. My good friend from medical school who is now a pulmonologist in a tertiary care center became convinced that she had pulmonary fibrosis when she found herself out of breath in kickboxing (after taking off 2 mos from it). Another friend who is a high-risk OB attending just about drove herself insane with fear that she would have fetal death in utero. I have seen her on multiple occasions in all of her (3 healthy) pregnancies sitting in the hospital cafeteria with a sugary drink in one hand and the other hand on her gravid belly, brow furrowed, checking for fetal movement. Another who is a rheumatologist is obsessed with developing lupus, and given that lupus can cause any number of symptoms/signs, she gets a near-weekly dose of affirmation that THIS TIME, she really does have lupus. Kind of ridiculous, right? Except when you're in it rather than on the outside looking in.

I find myself worrying about cancer mostly, which I guess isn't shocking since I'm an oncologist. Every patient I see--well, except for a fortunate few who have been misdiagnosed--has cancer, 100% of them. And I see mostly second opinions, so they are usually pretty sick and often complicated patients. Though they all come with a big, thick chart, I always take my own history, and even in patients with several years of metastatic cancer, I always start with how the cancer first presented. I am struck again and again by how subtle the first signs were--that little twinge of pain in the chest that only lasted for a few minutes or noticing that she was slightly winded, just slightly, after dashing up a couple flights of stairs. Or whatever. I don't see the zillions of people who also had little twinges of pain in their chest or mild dyspnea who turned out to have costochondritis or an albuterol deficiency or absolutely nothing at all. I don't see ANY of those people. In other words, I have no denominator to provide me with perspective. Of course, these histories I'm taking are all retrospective, and maybe the "first signs of cancer" patients report were in fact utterly unrelated to their diagnosis, but have taken on significance in the wake of being diagnosed and repeatedly asked these questions by oncologists. All of this, I know, but I can't seem to remember any of it when it really matters.

So, I wonder: does this worry simply come with the territory when one works in a field where life-threatening diseases are the price of admission? Would I still worry if I were a primary care pediatrician, where the majority of my patients are so healthy they are actually labeled "well child"?

Do you find yourself worrying more than you feel is reasonable about your own health or that of your family/friends? Do you worry about the diseases you see in your own practice, or do you have "a thing" like cancer that you worry about, even if it's outside of your usual practice? And if so, how can we do a better job of being a voice of reason to each other? Because we are doctors. And we are mothers. Which means we have more than enough REAL things to worry about!

Sunday, July 3, 2011

My Grams, Her Battle Was My Battle

There are some wonderful people that will pass through your life and when they leave it is very difficult to go on at times. Holidays, special events, and birthdays become painful reminders of their absence. I wrote this article a few years ago when my Grams was still alive and I read it at her funeral two weeks before I deployed overseas to the Middle East with the Air Force. 2007 was a tough year for my family but my Grams was a beautiful person who blessed my life.

"When my grandmother, Grams, came to live with us in 1997 she was depressed and a shell of person that I had known in my childhood. She came to us because she was leaving a violent marriage of 20 years. The Grams of my youth was vibrant and energetic, spending many summers with my younger sister and I shopping or playing miniature golf. But that cold day in April of 1997 I saw a sad hunched over figure in a wheelchair being wheeled off the airplane. I almost did not recognize her.

Grams settled into our home, spending many hours with my young daughter, Emily, looking at the stars and discussing what to wish for. Over the course of the next 7 months her divorce was finalized and we moved from Ohio to Texas closer to my mother. By this point I was beginning to see shimmers of happiness and energy from Grams, but on occasion she would fall back into the depths of depression. She struggled with being dependent on us for everything and pushed away opportunities of socializing with others outside the family.

By 2001 I had begun my third year of medical school and my grandmother watched the youngest of my 3 children, Gabriel. In October she called to tell me that her mammogram had showed an irregularity and she was told by her doctor that it would need further evaluation. My heart sank as I had a gut feeling that it was going to be bad news. I spoke to many physicians asking which surgeon they would take their mother to and Dr. Ronaghan's name came up more than once. We had her referred and Dr. Ronaghan gave us the grave news. She indeed had what looked like breast cancer and biopsy would be the only positive answer. Grams took the news as if you told her that she had a simple cold. My assumption was either she was in denial, had completely lost her mind, or extremely stoic. I, on the other hand, was falling to pieces inside. The thought of losing my grandmother made me nauseous, but I knew she was counting on me to be there for her. Little did I know that I was going to be leaning more on my grandmother during this process than she on me.
A few days later she had a lumpectomy which revealed lobular carcinoma and would need further surgery. Grams remained enthusiastic and positive about her outcome, she almost seemed happier than I had seen her in 4 years. I didn't know what to make of it, but then again things flew by so fast that I didn't have time to process it.

She went on to have a bilateral mastectomy with positive lymph nodes on the right side. So, we weren't out of the woods yet, she would require chemotherapy and radiation. Chemo would begin in December, 2-3 times per week for several weeks. By the tenth day her hair began to fall out in clumps and we began looking for wigs. One night she asked me to shave her head so she would not have to deal with her hair falling out anymore. I had cut hair many times, even Grams', but this request made me anxious and hesitant, almost to the verge of tears. It made me feel as though the cancer was winning, she was losing herself to the enemy. It was taking her beautiful thick white mane that made her my Grams. Well, we went to the kitchen and I plugged in the electric razor. I stared at her for a long time until she prodded me saying, "Laurie, it will be alright, don't worry. Anyway, I am hoping that it will come back curly!" At that moment I began to realize that the cancer was not going to win, because my Grams was strong and positive in heart and mind. I was looking at the Grams of many years ago, vivacious and alive! Yes, alive...she hadn't died yet. Wake up Laurie and join the fight! I went on to shave her head of course after we entertained the idea of a mohawk.

She continued with the chemotherapy and had good and bad days of vomiting and fatigue but her optimistic attitude never wavered. The children had adjusted to having a Grams without hair, the boys, Jonathan and Gabriel, loved to run around in her wigs. In preschool Jonathan was asked to draw a picture of his family. He drew his mom, dad, brother, sister, and Grams. We all had hair except one figure had no hair and was holding something in her hand. When asked who this was and what were they were holding, Jonathan promptly replied, "That is Grams holding her wig." As the story was relayed to her, Grams eyes twinkled as she replied, "Well, it's too hot to wear a wig all the time."
Grams went on to have six weeks of radiation therapy that resulted in severe burns across her chest. She was in pain most of the time and we did what we could to make her comfortable. She never cried or felt sorry for herself. She always asked me how my day went, always worrying that I wasn't eating right, getting enough sleep, or working too many hours. All the meanwhile she was in the middle of a life and death battle with an ever imposing enemy. She prayed and read her Bible daily, always reassuring the rest of us that she would make it.

Indeed, 5 years later my Grams is still here without any signs of recurrence of the cancer. She taught me the power of positive thinking, humility, love of family and faith in God. I can only hope and pray to be a fraction of the woman that is my Grams. And yes, her hair came back curly."

I hope you enjoyed this and share it with others. Remember each day is a blessing and there is only a finite number of these! Create an impact on someone's life, and it can only improve yours.

Thursday, June 30, 2011

Guest post: No more second guesses

I walked in and out of his room repeatedly during my 30 hour shift, he was the one I was worried about.  It was the same room where, on my first ICU shift, my patient had died in an early morning code.  I feared that the same would happen to this patient, however I did not hope to avoid death of this patient, just delay it enough so that his family could arrive.   The patient was a young man dying of metastatic cancer.  I knew that I had to get him through to the early morning so that his family could be there by his side.  So armed with my lasix and morphine and one of the best nurses I have worked with, we both made it through the night.  I was as happy as I could be in the face of death, to see his family walk through the door.  We finished rounds,  I finished my notes,  and headed home.  I knew it wouldn’t be long.  I later found out that the patient died about half an hour after I left, with his mother and father holding his hands, just about the same time I was arriving home to eager hugs from my own two boys.

I hadn’t allowed myself to think about my kids all night, I had forced them out of my consciousness, so that I could do my job.  I did this to protect myself from imagining what I would do if it were one of my sons in that bed.   I drew the line between hospital and home, and I stuck to it, for better or worse.   At the start of internship I thought I would call home each night I was on call to tell my kids goodnight.  I never did this, in fact, most nights I didn’t have time to sit for dinner, aside from bites while writing notes into the wee hours of the morning.  What bothered me most, perhaps, was that I didn’t even think about doing it most nights.  I can’t count the number of bedtimes I missed or the number of daycare pickups my husband had to do this year.  It is acceptable to me to have to miss a soccer game or a play, it is not acceptable to me to miss most soccer games or most plays.  I can deal with missing a bedtime or a daycare pickup, but I do not want this to be the norm and I certainly never want to reach the point where I feel that it is acceptable. 

I wrote just over a year ago about my mixed emotions on my match and my future career in dermatology.  I felt logically, at the time, that this was the correct choice for me and my family, I just wasn’t sure emotionally.  Now, days from finishing my internship, I am thankful that I made the logical, not the emotional decision.  What a year it has been.  In my professional life, I have performed my first deliveries and pronounced my first deaths, I have treated infants and I have treated senior citizens, I have stayed awake for a 30 hour shift and returned home to stay awake with my children for several more hours, I have made tough decisions and I have made mistakes.   In my personal life, I have uprooted my family and exposed my husband to more call nights than I can count.  I have come to appreciate his patience and commitment to our family in a way I never knew that I could.  And, I have found clarity in my decision to pursue dermatology.  I think it truly hit me that dermatology, had in fact, been the right choice on my ER rotation this year.  I was never as happy as when I was able to fill my day with patients with chief complaints of rash and lac repair.  Or perhaps it was when I reported skin findings while on the cardiology service on a patient admitted for a STEMI.  Or when I noticed all I was teaching my medical students were skin findings and that I actually liked to look at the  NEJM photo quizzes of skin findings for amusement.  Perhaps some of my doubts from a year ago were unfounded.  I am now to the point where, had I to make the choice again today, I could do it with much less angst, knowing that I will enjoy my work and that I will have a tolerable lifestyle.

After this year, I know that I could have been successful in either ob/gyn or peds and I would have been satisfied with my work life.   In fact, in both of these rotations, attendings approached me about why I hadn’t gone into that field.  I give the one liner to these attendings and anyone else who asks, which goes a little something like this: “I love that in dermatology I will get to do both medicine and small surgeries, that I can follow patients across the lifespan, that I can cure cancer in 20 minutes, and that I can be home with my kids at night.”  But the longer answer is that I know myself enough to know that I do not do things half heartedly.  I am there when I need to be, until everything is finished and when I am at work, my mind is completely there. 

I need a career where I don’t have to feel guilty about how much I work or that I enjoy my work so much that I am not thinking about my kids and husband throughout most of the day.  And I need a career where I don’t go home and feel strange that I can be so emotionally distant from the things I have seen that day.  In dermatology I can have all of these things.  I love so many aspects of medicine and I feel privileged to have been a part of births and deaths and to have had patients share with me the most intimate details of their lives on a daily basis.  I will have patients who are as thankful to me for enabling them to control their acne or psoriasis as they would have been had I been there for the delivery of their children.  I will not have to tell another woman that she is miscarrying or tell another wife that her husband has died on my watch.   I am frightened as I move forward, for the sheer mass of information I will have to master, but relieved that I will be able to study at home at night, after putting the kids to sleep, where I cannot forget or ignore my life beyond the walls of the hospital.

Monday, June 27, 2011

Friday the 13th

May 13, 2011 started out like most of my Fridays, with a 5 am jaunt to the YMCA for masters swim class. As I was nearing the end of my workout, the day quickly took an unexpected turn as the receptionist ran into the pool area.

“The hospital needs you to call immediately,” she said. I was instantly in the locker room, digging through my giant bag for my phone. I wasn’t on call, so for the nurses to track me down at the gym, something seriously bad had to be occurring. I assumed that one of my partners must need help with a hemorrhage or some other emergency. Never in my wildest dreams did I expect to get the news I received.

“JB just suffered a cardiac arrest. She was transferred to the ICU. We are not sure if she is going to make it...” My partner’s voice was shaking on the other end of the line.

At this point, I just went numb and everything began to happen in slow motion. This could NOT be happening. JB was my friend. I had delivered her baby just a few days before. She was most likely going to die. I had failed her. She was my patient, my responsibility. I had obviously missed something.

The four mile drive to the hospital seemed to take two hours. My mind raced through all the possibilities: stroke, seizure, heart attack, pulmonary embolus. None of the options were acceptable. I tried to think of what I might have missed. I analyzed every detail of our last conversation. She had called me from home the night before with symtoms of a headache and high blood pressure. I had told her to go to the ER. Being the clever nurse practioner that she was, she tried to talk me out of it, but I had insisted. Later my partner had admitted her, in order to watch her overnight. I had delivered her third baby 10 days earlier, boy number three for her. At the end of her pregnancy she had developed preeclampsia, a fairly common complication that usually resolves with delivery. I kept thinking of what I could have done differently, but as I went back through the case in my head, everything seemed to have been done appropriately.

This can’t be happening. I’ve never lost a mom. Healthy 35 year old women’s hearts don’t just stop. My prayers were brief and desperate. Lord, let her live.

With my hair still wet from the pool and my eyes still puffy from my swim goggles and crying, I arrived in the ICU a few minutes later. She was stable, but still in a coma. I began to have hope that she might make it, but could dare to hope that she would really be OK, to not have a brain injury?

I reviewed the history with my partner and the other physicians. Her husband had stayed with her in the hospital overnight, and heard her gasp and stop breathing. He quickly called for a nurse. She found no pulse. A code was called. After 12 minutes of resuscitation the team brought her back. She was essentially dead for 12 minutes. All the while her husband stood by, holding their newborn son.

I tried desperately to focus on the medical facts and numbers, while pushing the emotions to the side. This became impossible as I walked into her room. My beautiful, intelligent friend lay intubated in the ICU. Her normally tan skin was grey and dusky. Her blonde hair disheveled, while tubes and monitors encapsulated her small frame. The girl who never stopped moving or talking now lay before me unresponsive, with restraints on her hands.

When I saw her husband’s swollen, tear stained face; mt own tears once again began to roll. We hugged.

“Doc, Is she going to be OK?” He asked fearfully.

“Yes, I hope so.” I said, more as a statement of faith, than medical fact.

The morning was a blur of activity. A stream of specialists were consulted to help us search for a cause. More tests were ordered, but no answers were found. We ruled out some dreaded possibilities: brain hemorrhage, heart attack and tumor. I tried to remember if I've ever had a patient fully recover from a cardiac arrest. The only patients who had coded in my care were elderly. The ones who made it, had severe brain damage. The thought of her surviving but in a severely disabled state was almost as frightening as the thought of her funeral.

As all the tests began to come back negative, I began to let go of the guilt over what had happened. None of the things I knew to check for had occurred, so maybe it wasn’t my fault after all. Still the questions lingered.
Being a typical Friday, my office schedule was fully booked. All patients who could be were rescheduled. The rest I saw in short bursts, as I ran back and forth between the office and the ICU. In the office, I attempted to feign interest in the mundane yeast infections and round ligament pain. I tried my best not to be distracted, but it was nearly impossible.

As the morning stretched forward, we got our first bit of amazing news: the neurologist finished the EEG and it showed normal brain activity. He was hopeful for a full recovery. When I told the good news to our office staff they literally cheered. I assumed the recovery would be long and painful, but there was hope.

The afternoon led to even more good news as her oxygen requirements began to decrease. Yes, she was still on a breathing machine, but needing less and less help to breathe. She was beginning to wake up and fight the restraints. The specialist in charge of ICU decided to keep her sedated and let her heal, and then take her off the breathing machine in the morning.

I left that evening guardedly hopeful, praying for a full miracle.

When I finally made it home, I embraced my husband and kids like I hadn’t seen them for weeks. My heart was so thankful. Never would I take my life or family for granted. The usual dinner routine seemed surreal. Then as I was finishing my hamburger helper, my cell phone rang.

“Call from JB,” it said on the display.

My hand was shaking as I picked it up and hit the accept button.

“Hey it’s JB Husband, just letting you know that they took the tube out and she’s awake… and talking!”

“I’ll be right there.”

Within minutes, I was walking back on to the unit. The neurologist had warned us that she would have short term memory loss, likely for a week or two. He felt that she would most likely not remember the cardiac arrest. Still, I wasn’t sure what to expect.

As I walked into her room, she was sitting up in bed, looking absolutely fine.

“Hey, what are you doing here?” JB asked.

“How are you?” I said.

“A little sore…. Why are you crying?” JB responded.

“I was worried I would never hear your voice again.” I replied. Weeping. Again. For what felt like the millionth time, during this roller coaster of a day.

“Really? I don’t understand, I just had a c-section?” JB replied

The room, which now included several members of her family, laughed with relief. She remembered nothing that had occurred since she had her son 10 days before. She just woke up, assuming she was waking up from her c-section.

During the first few days, talking with her was akin to having a conversation with your elderly aunt who is suffering from dementia. It was definitely ‘her’ in there. All distant memories were intact, but during a conversation she would begin to repeat herself every few minutes. This also created the challenge of having to tell her, over and over, what had happened. Each time she would react emotionally as she ‘heard’ the dramatic news for the first time. After about 4 days her memory began to improve and she could remember things that had occurred the day before. Currently, she reports occasional forgetfulness, but has had a full recovery. She required no rehab and has had only minimal discomfort.

With all tests essentially coming back normal, the heart specialist determined that she had an underlying arrthymia. This abnormal heart rhythm was then exacerbated by the stress of preeclampsia on her body, causing her heart to go into cardiac arrest. This extremely rare event just happened to occur at the right time and the right place. He felt she could be at risk for cardiac arrest in the future, so a permanent device was implanted in her heart before she left the hospital. The device will automatically shock her heart back into a normal rhythm should she ever go into arrest in the future.

Since that day, I have thought many times of the ‘what ifs.’ What if she hadn’t called me? What if I hadn’t sent her to the hospital? What if her husband hadn’t stayed with her? What if the code team hadn't responded so quickly? If any one of these elements had not occurred, she would not be with us today. I am so thankful for the prayer chains that were activated, the attentive nursing staff and the many specialists who were involved in her care. I am most thankful to God for allowing her to have a second chance on life.

-The previous story is true and told with the patient's permission. It is cross posted at The Pregnancy Companion

Friday, June 24, 2011

The MiM curriculum

One morning last week, I was standing at the mirror in the gym locker room getting ready for the day. In the corner of my eye I saw a person scurry past. I recognized her immediately. I was excited to see a familiar face, yet she disappeared before I could say hello. When I peered around the corner and she was nowhere to be found, I realized that she was likely avoiding me. Not really a good practice to stalk someone in a locker room, so I turned away. Then as I blow dried my hair the conversation that did not happen played out in my head.

She is a cardiology fellow. Mother of two. I know this because her children are the same age as mine. She breast fed both babies. I know this because her co-fellows teased her about it at the end of the year roast one year ago.

She was hiding from me because I am an Attending. She did not want to be seen at the gym at 8AM on a work day. She fears that she would seem lazy, less dedicated or selfish.

What she needs to know is that I am so proud of her. One tough mama taking all of her call, doubling up while gravid to trade days to allow a maternity leave. Finding a way to be an equal to the guys without being one of the guys.

I would like to tell her that making time to exercise squeezed between early morning mommy duties and full time fellow work is an enviable feat. That what you have done, is perhaps one of the most important tasks you can do to ultimately ensure your success. Yes, I know it is not in the cardiology fellowship curriculum. This lesson really should be Chapter One of the MiM curriculum. Stepping out of the role of mother and physician to see yourself is crucial. By recognizing your need and fulfilling it. Because it means more than just finding time in a busy schedule. It means making time, trading off that early morning conference or sneaking in a little late to read echos. Whatever. Over ruling what is expected of you, to recognize what is actually best for you. A brave move that will make you stronger at the core.

And of course, I would never utter to another soul that I spotted her at the gym. Dear, your secret is safe with me.

Thursday, June 23, 2011

Maternity Leave and Psychiatry Residency

I'm not a psychiatry resident, but I have two female friends/acquaintences in psychiatry residency at two different programs who are both going through some issues with their maternity leave and I was wondering if anyone has any thoughts to help them out:

Apparently, one year of psychiatry residency involves an outpatient continuity clinic. Due to the rules of residency, you cannot miss more than six weeks of this year at risk of repeating the entire year.

So despite the FMLA guaranteeing 12 weeks of leave, a woman having a baby that year can only take a maximum of 6 weeks off, or else repeat the entire year. Even if you have a C-section.

I just got off the phone with my friend, who is in tears over this. She was ready to make up any time she missed, but not repeat an entire year. She's gone over the situation with her chief resident and he claims there's no way around it.

Has anyone had any experience with this and has any advice? (Beyond "suck it up"?)

MiM Mailbag: Pumping during fellowship

Hi, I’m so glad to find this group! I’m starting GI fellowship in 10 days and trying to figure out a pumping plan. My husband (a surgeon) and I have a 12 week old son and we’ve just moved across country for fellowship. I have the Medela freestyle, which I love. However, I stored up enough expressed milk to only last us maybe a couple weeks. My program is supportive of my need for pumping, but given the amount of conferences and rounding on a daily basis, my only time to pump is essentially in two 2-hour blocks when I need to see consults and perform endoscopy (unless I’m in clinic). I’m trying to decide whether I should try and pump during the day or just switch to pumping bid (morning and night). I feel like formula supplementation is inevitable. I’ve already noticed my supply go down with changing to pumping 4x/day in anticipation of fellowship starting. Any advice?