Sunday, September 18, 2011

My personal statement

I just filled out my residency application. Ugh. Here is my personal statement:

At the last postpartum appointment following the birth of my second child, I wasn't worried for his future. I was worried for my own. I had just gotten my MCAT score and started the medical school application process when I became pregnant. I couldn’t decide if I was more elated or upset. I desperately wanted a second child, but my body and circumstances conspired against that desire for years. My seemingly perfect plan of having two children during premed, then entering medical school with them potty trained and ready for elementary school turned into a dream of having an only child and going to medical school.

Now I was holding a new baby, and my medical school application hung in the balance. Although I was happy my family was now complete, I came to medicine as a second career, and I was already an older applicant. I couldn’t imagine putting off school and residency any longer, and I wasn’t sure if I wanted to face the demands of rotations and residency with a toddler at home.

When I told the midwife of my fears, she said, “Why don’t you come to the midwifery school here?” I laughed and immediately refused. I had no interest in obstetrics. I wanted to be an endocrinologist. I thought it would fit my interest in having long term relationships with patients, with lots of opportunities for education during clinical visits.

But, over the next few months, her invitation kept resonating with me. I had loved my prenatal appointments. I read voraciously during my pregnancies, and found the material very interesting. I started the midwifery school when my son was three months old. Two years later, I thought it was the best and worst decision I had ever made.

I found out that I loved everything about medical care of women, especially during pregnancy and birth. I had the continuity and clinic experience I craved. I loved it even when I had been up for a day and a half. I loved it even when there were fluids and meconium and discharge. Yes, I even loved it when the women were screaming. Yet, I was unsatisfied.

The midwives knew it. I would discuss research and evidence. I would read about pregnancy complications that were outside the scope of a midwife’s practice. Although I loved the training, especially the extensive hands on clinical experience, I felt that I meant to be a doctor, not a midwife. I was the first to volunteer to go whenever there was a transfer to a cesarean section. I wanted to be able to do surgeries and advanced procedures. I finally had what I refer to as my “midwife crisis” and left the program to apply to medical school.

Despite being an older student, a working mother, and former midwife student, I was happy to learn I fit in and even excelled at medical school, preclinically and clinically. I was president of the obstetrics and gynecology interest group, and went to every ACOG Annual Clinical Meeting. I had dedication, a work ethic and time management skills earned from my diverse life. I won a research fellowship with a full tuition scholarship, and studied labor and delivery interventions for a year. The fellowship allowed me to work with CDC funded researchers, practitioners around the globe, maternal health care stakeholders, and academics. I also reviewed and contributed to the anniversary edition of Our Bodies, Ourselves, and various medical websites such as KevinMD and Mothers in Medicine, along with getting published in peer-reviewed journals. My hundreds of hours of clinical experience during midwifery training put me way ahead when I started rotations.

I am sure my clinical skills, intellectual capacity and endurance are up to the challenge and that I would be an asset to any obstetrics and gynecology program. I am eagerly awaiting the opportunity to shine. My last baby is now almost seven. My dream did come true - my kids are independent, proud of their mom, and can’t wait for me to be a doctor.

Friday, September 16, 2011

Guest Post: VIMP

When I was a resident on ICU, the staff physician mentioned that his mother needed an ultrasound. He asked the radiologist what the waiting list was like. This was in Montreal, so the answer was something along the lines of "Bad. Who's it for?"

"My mother."

"Oh, your mother! I'll squeeze her in."

"No, that's all right. We can wait our turn like everyone else."

I felt ambivalent, hearing this story. On one hand, I support a one-tier, publicly funded medical system, which is not the majority view among my more verbal friends. On the other hand, I think that if I can assist one of my colleagues in any way, I will do it. Our health care system is so tight and this is one of the last ways we can make it more pleasant for someone ill.

This comes up in the emergency room all the time, of course. I will see a nurse's relative, for example, ahead of the waiting throng, and usually, at my hospitals, this is not such a big deal. We don't have the 14 hour waits. But one day I saw several people ahead of time and I felt uncomfortable about it.

Meanwhile, I kept trucking along until, at 19 weeks of pregnancy, I passed some blood clots.
I woke my husband up and said, "I think I'll go use the bedside ultrasound in emerg. If the baby's okay, I can still make my appointment Montreal." Bedside ultrasound takes approximately zero skill after ten weeks of pregnancy, just to check on the baby.

I felt the baby roll—or was that the beginning of a cramp? After a minute, I felt a kick. And then two more. But then I remembered more about second trimester bleeding.

I woke Matt up again. "I have to get a real ultrasound. In first trimester bleeding, you want to know if the baby is alive. But in second trimester, you have to start looking at the placenta. If it's a placenta previa or an abruptio placenta..." My bleeding was painless. Therefore more likely a previa. Ultrasound was not always diagnostic, but it would definitely help. Me sticking an ultrasound wand on top of my belly was not going to help. I couldn't tell you whether there was a bleed or not.

"You may end up on six months of bedrest," said Matt.

I waited the marginally civilized hour of 6 a.m. to call one of my hospitals. The emergency doctor, who is also my friend, said she could arrange the scan.

I walked in just over an hour later and the nurse looked at my belly and asked, "Are you still bleeding?" So the word had gotten out.

That made it easier for me. I didn't have to explain, just let her take my vitals and breathe in relief when another nurse successfully found the baby's heartbeat with the Doppler. I ended up writing my own ultrasound requisition and paging the tech, who was already with the first patient, but the next slot was free.
The emergency doctor talked to the radiologist, who agreed to call me on my cell phone with the results. And pretty much immediately afterward, the ultrasound tech was ready for me.

And the baby looked good! The placenta was less than 2 cm from the cervical os, so that probably explained the bleeding.

Before lunch, the radiologist called me and said, "The baby looks fine." He wasn't convinced that the placenta was marginal, based on the views he'd seen, but he concluded, "Good news."

This is Very Important Medical Person treatment. Scanned two hours after I called, results another two hours after that.

Is this right? Should I just meekly line up at the ER and wait my turn with the doctor? By then, it would be too late for the 7:45 a.m. open ultrasound slot, so I'd have to wait and see if a spot opened up later that day. Then I'd wait for the radiologist to read the films in order. Then I'd wait for the ER doc to get the results. I'd wait for him to tell me said results, either before or after he called the ob for an interpretation.

I know that's the "right" thing to do, in some people's books. But I don't see the medical system like that. I see it as a resource that I understand and need to maximize. So yes, I could have hung around. But then I'd be one more patient clogging up the system. In and out and we're all happier.

I'm not a star. I don't get the red carpet rolled out for me. Paparazzi don't follow me around and sell my photo for thousands of dollars. But when I need medical treatment, I have doctors and nurses who will help me get it as quickly and pleasantly as possible.

Is that wrong?

-From an e-book by Melissa Yuan-Innes "The Most Unfeeling Doctor in the World and Other True Tales From the Emergency Room."

Wednesday, September 14, 2011

We will all go down (and then up again) together.

Seeing and hiking the Grand Canyon through the eyes and feet of a 5 and a 7 year old. With husband. Which family member thought which thing?
  • There is no railing.
  • There are lots of large mules with large body parts and large piles of poop.
  • I'm thirsty.
  • There is vast beauty, and vastness in general.
He who notes there is no railing (husband-pediatric-researcher) also notes that there are many death defying curves and rocks and edges and did I mention there is no railing? On the very top rim there may be a railing, but what about on the hike down into the canyon? Nope. No railing on our trail. Mules? Check. Mule poop? Check. Spectacular views? Check. Opportunities to fall to one's death? Check.

What, me worried? And yet for some reason I was not. Probably because pediatrician-researcher husband did enough worrying for more than both of us.

It was truly awesome, not in the like totally 80's way, but in the I am just a speck in this immensely astounding planetary way.

Yes, they could fall over the edge, get heatstroke, dehydrate, burn in the sun, fall over the edge.

Holding hands. We will all go down (and then up again) together.

Monday, September 12, 2011

Pick your battles

The other day, I was on a hay ride and overheard the following conversation between a mother and her four or five year old child:

Mother: "Are you enjoying the hay ride?"

Little Boy: "Yeah."

Mother: "No, don't say 'yeah.' It's 'yeS.' Say 'yes.'"

Little Boy: "Yes."

Of course, because all parents secretly judge other parents who make parenting decisions that are different from theirs, I thought this woman was being totally ridiculous and wasting her time. If you're going to pick a battle to fight with your kid, I think the yeah vs. yes battle really isn't worth it.

To me, there are a few battles worth fighting. We've fought with Mel to get her to wipe herself after pooping (recently won), clean her room (still in progress), and hold hands when walking down the street. There's also one other battle we've been fighting with her and I'm not entirely sure it's worth it....


After Mel's multiple cavities, we decided to enforce nightly toothbrushing. Apparently, we've also decided to subject ourselves to nightly screaming and fighting from a kid who really does not want to brush her teeth. Some of the excuses I've heard:

"I'm too sleepy."

"I'm too scared." (???)

"I'm so tired of doing things."

"I'll do it in the morning." (Yeah, right. I mean... yes, right.)

And really, I'm not convinced that her putting the toothbrush in her mouth and half-heartedly chewing on it has any cavity-fighting effects. OK, it builds a good habit, I guess. But when I was four years old, not only did my parents not force me to brush my teeth, I'm fairly sure they never even bought me a toothbrush... yet now I brush my teeth religiously twice a day. (I know three times a day is recommended, but only psychopaths brush their teeth three times a day.)

So I'm just not sure that with all the other stress in my life, if the toothbrushing battle is worth it. Is this really how I want to spend the few hours I have with Mel between daycare and sleep? Maybe I should just give up. They're just baby teeth, after all.

Thursday, September 8, 2011

Guest post: My Story

I'm a 27 year old, married mother of one 3.5 year old son and live in Toronto, Canada. I'm not a doctor - I'm not even in medical school. But I want to be. Here is my story and the journey I’ve started on.

I've spent the past 5 years of my career feeling trapped and lost. I was doing well in the traditional sense. I got promoted, I passed the required exams for my CA designation (CPA equivalent in the US). I got good performance reviews.

But from the moment I accepted my job offer with a Big 4 accounting firm, I have been nagged with a sense of doubt. Am I making a difference? Am I adding value? Is it normal to have a constant feeling of dread when thinking about work? Am I proud of what I do?

At first I just ignored these feeling (and yet, even shortly after graduating and accepting my job offer I’d be browsing the medical school pages of various universities, already jealous of all those unknown people who would be starting medical school the same time I’d be starting my job as an audit associate). I reasoned that how can I know that this isn’t what I want to do before I start? Wondered if I was just infatuated with the thought of being a doctor, the way some people wish they could be a Hollywood star? In any case, I was never a quitter and thought I just need to give it time, until I understand more about my profession, until I got to deal with the interesting issues. This is the bed I made; now I should lay in it (and make the best of it).

But the years passed and the feeling of dread grew. I started to resent my job for keeping me away from my family (yet never once did I wish I could just be a stay-at-home mom). I wonder why I can't enjoy this job more, the way so many of my collegues did. I’d be incredibly envious of friends I’d meet who seemed to not only enjoy their jobs but feel a sense of purpose from them. And I dreamt the “what if I could go to medical school” dream all the time

Then one day I was having a chat with a friend of mine who mentioned how her sister-in-law had a similar feeling – she had just graduated from law school and was offered a position with a top law firm, where she had spent her past 3 summers articling. Days before she was due to start, she gave notice and said she was applying to medical school. Fascinated by her story, I thought, hm, maybe I could do this too! I reached out to her to ask her point blanc, if she thought I was crazy. I’m 27, I have child and a mortgage – not to mention nothing in my educational or extracurricular background to indicate any knowledge of medicine. She told me to go for it – that she had people in her medical school class who were older than me, and if this is something that I felt passionate about, I’d make it work.

After doing a bit more research, I also realized that I can actually apply to most medical schools in Canada without a science degree. Many require 1 or 2 university level science credits, but many consider the overall applicant and state that people of all educational and professional backgrounds are welcome to apply. Luckily I had very good grades both in high school and university. I’ve also lived in different parts of the world, am fluent in 3 languages and have managed to obtain my CA designation while juggling motherhood and wifedom.

So I decided to bite the bullet and try and I’ve officially embarked on this journey. I’ve signed up for a Biology course through an online university to help me get a couple pre-requisite courses that are required by some of the universities. I’ve perused books and blogs that focus on what a career in medicine means. I bought (and started to review) and MCAT study guide. I'm also hoping to negotiate going down to a part-time work schedule so that I can make room for volunteer work and to study.

However, as hopeful as I sound, I’m very aware of how hard this will be. How I will undoubtedly question my decision and how I will want to give up. But I also know that I may fail. Even if I do everything I can (take perquisite courses, do some meaningful volunteer work, do well on the MCATs) I may not get selected. I know how incredibly competitive this field is and I may not be the best candidate.

But I’m fine with that. This is my dream and I want to try. If I fail, I fail – but at least I won’t have to live with the regret of not trying.

-Kasia Smith

Wednesday, September 7, 2011

The best career for a mother

I recently read a blog post about whether medicine is a good career for a woman, since you can work part-time to be with your kids and many specialties are very family-friendly. I wasn't thinking about kids when I was 21 and applying to med school, but I was told medicine was a good career for a woman because it is a field where a woman can earn a good living and face less discrimination than in some of the math-oriented fields I was considering.

As for being a mother in medicine.... if you had asked me five years ago, I would have said that being in medicine is a horrible idea if you want to be a mother. Now I revise my opinion and say that it's only a horrible idea if you want to be a mother before you turn thirty. But it's still not ideal in that you can't easily reschedule a roster of patients because your kid has a fever, and squeezing in a pumping session can be difficult during a doctor's typically busy day.

It got me wondering though: what is the best career for a mother? Because lately, I've met an awful lot of women who have become mothers and given up their jobs.

Traditionally, I think teaching has been considered a good job for a woman and therefore mother. But a friend of mine who had a baby and is now quitting her teaching position says otherwise. The pay is low, there is grading and planning work even once you finish teaching, the hours are surprisingly long due to clubs and phone calls to parents and etc, you maybe get one break the whole day, and you can't easily sneak out early for an appointment or a sick kid.

Nursing is another "traditionally female" job. But I've heard nurses complain about how it's hard to find time to pump during their shifts and that the hours are too irregular, making daycare or school harder to manage. Like with teaching, if your kid gets sick, they have to scramble to find a replacement so it's not so easy to just stay home.

I'm convinced that the best job for a mother is something like actuary or engineer, where you work on projects that don't rely on you showing up at exactly 7 AM every day, and work can usually be put off for a day if something urgent comes up. But strangely enough, these fields don't seem to attract women.

Friday, September 2, 2011

The MiM Risk Score (MRS)

In honor of the Labor Day Holiday...

This evidenced-based risk score was developed to help predict overextending of Mothers in Medicine. The goal is to prevent burnout, stress, and associated unpleasant psychological states by monitoring weekly risk, and following guidelines for treatment accordingly.

To calculate risk:

MRS =          age/2 * number of dependents + k [C + Lu + Na]
                             Number of spouses/life partners * + 1


Age = Age of MiM in years

Number of dependents = number of children, care-requiring parents, exceptionally ineffective spouses/life partners, very large and needy household pets. For pregnancy,  multiply total by factor of 1.5.

k= work constant. For full-time work, k=1. For part-time work, k= 1.5 * % of full-time worked (e.g. ½ time = 0.75 since hours worked is always more and uncompensated)

C = number of times you have to call your cell phone to find out where you put it in the past week.

Lu = number of times you are too busy to eat lunch, forget to eat lunch, or accidentally bring a Tupperware with a half ear of corn and half of a large white onion by mistake instead of the lunch you packed the night before. Hypothetically speaking.

Na= number of times you have called your children the wrong name in the past week.

*for polygamists, add only 0.5 for every successive spouse after primary spouse; for work spouses, add 0.25 each; only spouses/life partners currently living with you for the majority of the week count in full.

**** Risk score interpretation ****

MRS > 50 = High risk for overextending. Schedule child-free vacation, delegate projects, get a babysitter for a night out, add another spouse/life partner (or increase efficiency of current one), for the love of God say no to new commitments. Wine.

MRS 41-50 = Moderate-high risk of overextending. Schedule spa date. Say no to new commitments. Delegate projects. Possibly add another spouse/life partner (or increase efficiency of current one). Adjunct retail therapy.

MRS 30-40 = Moderate risk of overextending. Schedule coffee with girlfriend(s). Say no to new commitments. Delegate projects.

MRS < 30 = Low risk of overextending. Good job! Offer help to your MiM friends in higher risk categories.

n.b. Risk score prognostication has not been scientifically validated.

Wednesday, August 31, 2011

Please help me!

Eventually all good things come to an end and very soon I'm going back to being a working mom, but now a working mom with two kids.

Scared? Yes. Overwhelmed? Yes.

In need of advice and reassurance?


Tuesday, August 30, 2011

Just Another Manic Monday

No one has written about a typical day in their field in a while. I thought today would be a good example to remind, most importantly the surgeons who think we are sitting back drinking coffee while they are waiting for their frozens to be read, but also everyone that pathologists do not just sit around admiring each other's ear hair grow.

I was in the carpool line at 7:30 this morning when my pager went off. I was happy sitting in the carpool line, since last Thursday and Friday I had to drop the kids off at 7:00 so I could make it to the Conway hospital to cover the OR. I watched the kids bound out of the car and then called transcription. "You are on standby for CT3 for a needle."

Standby can mean either five minutes or thirty minutes, depending on whether or not a tech remembered to call and give us a heads up, and also how long it takes the radiologist to guide the needle to the mass of interest in whatever organ is under investigation. I told her I would be there as soon as possible, and hastily trucked it down the interstate. Luckily I made it to the transcription area in about 10 minutes, right when they called to say they were ready for me. Unfortunately I simultaneously remembered that I had a record seven pending cases from Conway sitting on my dining room table. One was a medical liver that needed to be sent out for consult. Three were diagnostic cancer cases. Oh shit, I whined to a colleague. Headed to CT.

As I walked into CT3 I noticed that the tech, a sub, was placing the slide into alcohol for a modified Pap stain. I sighed and glanced at the radiologist. "You forgot I am a diff-quik girl." We all have our stain preferences, and they hadn't screwed mine up in a couple of years. He looked at me and said, "You want me to get you some more? I can get more. You haven't been around here in a while." It had been about six weeks since I covered EV cytology. I glanced at the CT monitor and saw that the needle was in a large mass in the lung. I told him I would give it a shot and see. Peered into the microscope and luckily it was a no brainer. I wandered back over to the radiologist. "Despite the fact that I feel like I am Alice in Wonderland, I think I can call this one. Positive for malignancy." I got the schedule from the tech and saw that there were many needles today - liver, lung, mediastinal mass, a couple of inpatients that needed to be worked in, but nothing for an hour.

I got coffee, got coverage, and booked it home to get Conway cases and bring them back to work. I was busy with cases and needles until noon. I got a call around 10:00 from one of the transcriptionists asking if I would do an outpatient referral FNA from an ENT in fast-track ED at 1:00. "Sure, I'm not going anywhere, thanks for asking." At noon I was hungry, but got paged for standby. I normally don't like to eat when I might get called out, but hell, I thought, I've got this lunch thing down to a ten minute fine art. Heat Morning Star spicy black bean burger in microwave 45 seconds. Prepare nuts and carbs of my choice. Add liberal honey and small amount of spicy mustard to heated burger. Eat quickly and chase with bottled water. Finish off with Take 5 for dessert. I managed to squeeze it in before I had to go to CT again.

At 1:00 the cytotech preparing the outpatient came into my office. "The patient is here but they can't get us a room for another hour in fast-track ED." I asked him how in the world did this happen, didn't the transcriptionists call ahead to reserve the room? We are supposed to call ahead if it is scheduled for after 11:00, ED gets busy in the afternoon. I was a little mad, we had been over all this months ago - it was supposed to be working smoothly by now. I went out and apologized to the luckily good natured gentleman with a facial mass. He had another appointment at 2:30, but said he would stick around until then in case a room opened up. It didn't. He said he would come back at 4:00.

I called the head transcriptionist into my office. "Can you please gently remind all the people that schedule needles that we have to call ahead to reserve a room after 11:00?" She told me the problem was that some of the people in ED told them they didn't have to call ahead, and it had become confusing. I told her, "Tell them to ignore those people, from now on. This is compromising the patient's time, and that is not fair." She agreed, and I decided that was enough for right now.

The week filled up all afternoon - fat pad aspirate on Thursday, special request from a breast radiologist for us to do and immediate on-site evaluation of a breast mass at the breast center at the end of the week, etc., etc., all requiring phone time and logistics. Cases got finished, needles got evaluated, and I even found time to fill out picture order forms for kids school pics and print out their menus for the next couple of weeks. The kind gentleman came back at 4:00. We chatted in between me sticking a needle in the side of his face. "That thing is pretty scary," he said. "Oh, you mean our gun?" He laughed. "You call that thing a gun?" I said, "Yes, isn't that funny - it is really only there to create negative pressure. I thought about using the French technique here, meaning I wouldn't use this gun to hold the needle and syringe, but the texture of the lesion requires this contraption, sorry."

I made it out the door in time to problem solve some phone issues at Verizon before heading home to relieve my after school help and start dinner for the kids. Cecelia had been to the orthodontist, her mouth was sore, so I suggested pasta for dinner and prepared elbow noodles, cheese tortellini, Parmesan, hard Romano, basil pesto, and spaghetti sauce - we had a sort of a pasta bar going on and everyone was happy. After 15 minutes of itouch time and 15 minutes of me demonstrating yoga poses (I started back last week after a 9 year hiatus) to the kids for copying, much to my son's amusement and my daughter's amazement, we started bedtime.

I hope tomorrow is a little bit lighter. Based on the last two weeks, I'm doubting it. Something about school starting and everyone, doctors and patients included, returning from vacation has made our lives much busier lately. Hard to complain about work, I guess. But there is something ominous about the pager going off in the carpool line. It sets a frenetic pace for the rest of the day.

Monday, August 29, 2011

Depression and the Working Mom

I can't possibly be the only working mom who sometimes contemplates life as a stay at home mom (SAHM).

I've had periods where I got to briefly experience life as a SAHM, such as during maternity leave or the month between residency and fellowship. I love it in theory. It's nice to be there for your kids all the time, make nice hot dinners on the stove, and keep the house tidy.

And as we all know, juggling full time work and kids can be a huge challenge. I get jealous of women who don't have to resort to bribery to get out the door before their first patient each morning, and get to spend the whole day enjoying their kids. I feel sad sometimes, thinking about how I'm missing out or that my life is too stressful. My kids are only going to be so cute and little once and I'm missing it.

However, my father (obviously reading my mind), recently forwarded me an article about how SAHMs have a higher rate of depression than working moms. (He's always forwarding me helpful and relevant mental health related articles. After I got married, he forwarded me an article about how women who got married and divorced had a lower rate of depression than women who never married. Thanks for the confidence, Dad.)

And actually, reading this article made me feel better. It was a reminder that even when I don't love every aspect of my job, I like feeling productive, interacting with people, and of course, bringing home a paycheck. It makes me appreciate my kids more when I'm with them, and it makes me feel less like taking a bat to the TV whenever I see Spongebob on the screen. And it fills me with pride when my daughter says she wants to be "a doctor like Mommy."

Saturday, August 27, 2011

Running, Running…and More Running

Have you noticed that as time marches on we are always running, often literally. We are rushing to work, to an appointment, answering a page, picking up the kids, making dinner, paying bills, planning vacations, reading CME and just trying to keep our heads above the water. No wonder we are stressed and anxious. Did we just replace our ancestors’ worries of finding food with time consuming errands?

Our lives are so filled with little worries that together they take one big toll on our peace of mind. And then you add economic worries, job loss, news of wars and droughts and is becomes overwhelming! When did life become so busy or was it always like this? When I was a kid we did not have money, computers, vacations or the internet. We had TV but when dad came home he took it over and if you were within hollering distance you became the remote control. Oh, how I hated that. Solution…go to your room and turn on the radio, read or go outside to play with your friends.

So, how did I get from there to here? Here I am in the middle of life and truly believe all the information coming at me has caused me to have issues. I want to participate in many things, travel to foreign lands with my kids, see my children participate in sports and music and excel in school, learn Spanish and the guitar (oh if I could only sing!), train for a marathon, write another book, hike and spend more time taking pictures. Seriously, does anyone else have this problem? Is it a personality disorder yet to be discovered?

I really want to simplify life and slow down to smell the roses but my fear is missing out on an amazing experience. Can you imagine going one week without any TV, radio, internet and cell phone? I know I panic when I realize I can’t find my phone or when the internet is down. How about you? Are you addicted to technology and has it affected you or have you seen it affect your patients?

Tuesday, August 23, 2011


Last year, I was at a Costco, waiting on a very long line. There was a family ahead of me with two small kids. The parents weren't really paying attention to the kids and I happened to notice that the little girl had peed her pants. There was urine all over her pants and a little puddle underneath her.

I must have stared at that girl for several minutes, trying to decide if I should alert her parents. On one hand, I think I'd like to know if my child was standing in a puddle of her own urine. Then again, I didn't want to be a busybody. Finally, when the parents still weren't noticing, I decided to say something:

Me: "Um, sir... your daughter...."

Father: "Oh, it's okay. I've got my eye on her."

Me: "No, she, um... peed...."

Father: [looks at girl] "Ava! Oh no!"

I guess I did the right thing by telling him, but I immediately felt kind of guilty for making a comment about someone else's kid. Believe me, this is not something I ever do. I was recently at the zoo and stared in agony at this woman who had a one-month old baby with no head control front-facing in a baby carrier, with his head sagging down like it was about to fall off.... but I never would have said anything in a million years. It's none of my damn business.

While I think it's despicable when someone goes up to a complete stranger and tells them not to give their baby a bottle or something like that, I wonder if there are situations where it's appropriate to intervene. For example, would you say something if you saw a woman hitting her child? Or worse?

Tuesday, August 16, 2011

Ob/Gyns are terrible people who need to die, and other common misconceptions

Tempeh writes: Still, I hate to generalize, but I've met far more "toxic" docs in OB/GYN than in other specialties. I always find it odd. The majority of OB/GYNs with whom I have interacted (as a med student and through 3 full-term pregnancies) have been women, who are supposed to have better communication skills, higher pt satisfaction, etc. And they work in a field where most pts are healthy and, in the case of OB, happy to be in the office/hospital because they are pregnant or delivering. Why are they so bitter as a group? It mystifies me. Maybe some of the very pleasant OB/GYNs amongst our MiM writers can shed some light on the specialty.

I'm not really certain if I fall into the category of one of the "pleasant" Ob/Gyns or not, but I will give this question a shot. Bitterness and Ob/Gyn, alas, does seem to go hand-in-hand. I believe that, first and foremost, it is an incredibly important, busy, special, and stressful job. True, most of our patients are healthy, but when they get sick, they can get sick quickly, and when healthy young women or babies get sick, injured, or die on our watch? That's especially devastating. I can't think of a single person that went into Ob/Gyn as a bitter person who hated women, but at the end 4 years of constant sleep deprivation, sometimes another pregnant woman in labor is no longer a miracle, it just means more time spent away from fulfilling basic human needs like using the bathroom, or eating, or, most elusive of all, sleep! It is also seeing women, not only at their best but at their very worst, hours of staring at monitor strips, worrying about when to pull the trigger on a cesarean delivery, wondering, if it is too early that we will be blamed for "unnecessary surgery" and trying to get to our golf game or (God forbid) home for dinner, or, if too late, we will, much worse, have a sick or damaged baby (and possibly be sued for everything we have). Women can be very difficult patients, who require a lot of communication, not a problem for patients who are willing to return to discuss issues, more of a problem for people who wish to stuff a year's worth of problems into a 10 minute annual exam. It's persistent 36 hour shifts, often skipping breakfast and/or lunch, and 72 hour weekends (remember how much you hate call Fizzy? Would you be bitter if you did it all the time?) It's adrenaline burn-out, hours of nothing followed by a harrowing roller coaster. It's constantly being second-guessed, by our partners, other physicians, the L&D nurses, the patients, the internet, the media, ourselves, even when we *know* we are practicing to the *standard of care* for our profession.

It's the malpractice, multi-million dollar coverage premiums to pay yearly, the threat of lawsuits for up to 18 years after the fact, shrinking reimbursement (universal for all physicians), trying to pay our staff and our overhead, having to fit more patients into the same hours in the day, trying to be a good doctor for them, trying to at least support our family since we can seldom be there to see them. It's medicine, surgery, primary care, and caring for two patients all rolled into one, and sometimes it eats at your humanity. Sometimes, you come home at the end of the day so emotionally exhausted that you have little to give to the rest of your family. Sometimes the sadness of discussing a cancer diagnosis, or miscarriage, or fetal death lasts for weeks or days. Sometimes it is impossible to *not* take your work home with you. Sometimes we care *too* much, causing us to start separating ourselves from our patients, building a wall, becoming callous, so the better to protect ourselves.

Sometimes we deal with the stress in inappropriate ways: too much wine, snarky humor, or snappish answers. Likely, many of us are clinically depressed. Many of us have little time to exercise (Rh+ and her most excellent example notwithstanding). Because women Ob/Gyns are women too, and usually mothers and wives, who feel guilty when we are at work and guilty when we are at home, just like other working mothers. Because, despite how much it sucks, we still really love our jobs, think pregnancy and birth is amazing, and wouldn't do anything else (even if we wish we could); because we care about mothers, women, and babies. Hope this answers the question in a non-bitchy way, please excuse the sentence fragments and horrendous grammar. I had a terrible, horrible, no-good, very bad day today, and seeing some of the commentary on Mothers in Medicine regarding my profession, usually a refuge, stung quite a bit, I must say.

***cross-posted at Ob/Gyn Kenobi

Gestational Diabetes

(Note: I'm posting this story because someone requested it in the comments of my last post. I apologize if it gets long.)

I failed my gestational diabetes screen by two points.

For those of you not familiar with the screen, it’s a test during pregnancy where you drink this horrible, sugar drink and then come in an hour later to get your blood glucose tested. Considering I was seven months pregnant, not showing, and weighed only 116 pounds, I didn’t think there was any chance of my failing the test. I was so overconfident that I had some crackers right before I had the drink, to make it go down easier. (This was allowed, but probably stupid and likely pushed me over the cutoff.)

The cutoff my practice used was 135 and I had a blood sugar of 137. In some practices, a cutoff of 140 is used. And when I looked this up in research studies, in a woman of my age, race, and BMI, it is appropriate to use a cutoff of 140. Or actually, some say the screen isn’t even necessary in the first place in someone like me.

Now if you fail the screen, the next step is a three hour glucose tolerance test. You come in for a fingerstick and if that’s normal, they give you a huge amount of sugar, do a venous draw for blood glucose, then repeat that every hour for three hours. I did not want to do this test.

You are probably thinking to yourself, “Why is she being such a baby? It’s just four blood draws.” That’s exactly what I’d be thinking if someone told me that story, believe me. I’ve had like a billion blood draws in my life and I’ve always thought of it as no big deal… needles don’t bother me.

Except for some unknown reason, my ob/gyn practice gave the most painful blood draws known to man. Now I can deal with short-term pain, no problem, but on two separate occasions of having my blood drawn at this practice, my arm was basically incapacitated. The pain in my biceps was so bad that I was actually awakened during the night due to pain. I could barely move my arm to drive and I had bruises going all the way up to my deltoids. And the pain persisted for over a week. Both times! Their phlebotomist was obviously not the greatest.

So I wasn’t thrilled by the idea of having four of these blood draws in a row at that practice. (The only other place they’d do them was at a hospital a million miles from my office.) My job involves a lot of writing and I was terrified by the idea of my arm being taken out of commission. I was literally in tears at the thought of being unable to function or sleep due to these blood draws--blood draws that I felt were basically unwarranted given the fact that it was so unlikely that I had GD. If I felt the baby were in danger, I’d have done anything, but it seemed more like this test was being done so they could cover their ass.

Anyway, I did try to keep a somewhat open mind. I felt if they had a convincing argument, I’d do the test. I went to my appointment for the 3 hour test at 8:30AM. I did the fasting fingerstick, which was 90. I asked if it would be possible to briefly speak to any OB at the practice about the test before doing it. Immediately the phlebotomy tech looked really put out, and acted like this was a ridiculous request that would take hours to fulfill.

About five minutes later, they miraculously located an OB that was between patients and she came over to talk to me. Except before I even opened my mouth, the doctor’s arms were crossed and she looked really angry at me for taking up 2 minutes of her precious time.

I explained that I was a doctor, that I researched the test myself and that I knew I was extremely low risk. I explained that research showed that with someone my age, race, and weight, testing wasn't indicated at all, or at the very least, a cut-off of 140 was warranted.

Doctor: [snippily] "OUR cut-off is 135."

I then tried to explain to her about how painful the blood draw had been at that office. They clearly went through the vein both times due to the pattern of bruising. I had been awake all night in pain. And then continued to have pain for a week after both times.

Doctor: [snippily] "That's impossible."

So I guess I was lying?

At this point, all I wanted to do was run home crying. Finally, I said I would do the test in fingersticks on my left hand.

Doctor: [snippily] "Fine, so I'm documenting your refusal to do venous draws!"

The phlebotomist was kind of cold to me after that too, possibly since she was the one who gave me the two painful draws. She started ranting about how she didn't know how to document my results. I felt like I had to apologize with every single hourly fingerstick.

I don’t know exactly what the doctor could have done differently. I would have preferred if she gave me an actual explanation of why it was so important for me to have the test, aside from just reiterating the cutoff. Or if she did agree with me the test was unnecessary, she could have nicely explained to me that she had to document a refusal, but admitted that I was very unlikely to get a positive result.

Anyway, three of the four fingersticks weren't even close to the cut-off. The fourth was below the cut-off, but only slightly. I was terrified the entire night that the mean doctor would call me and try to bully me into repeating the test and threaten to kick me out of the practice.

What did end up happening was that I had to call the next day (originally, they promised they’d call me, but apparently they wrote me off) and they got a different OB to speak to me. It wasn't my usual doctor, but it was one I had seen before and liked. He told me that the test was definitively negative. He didn't know what to make of the one borderline number, but said their glucometer tends to run high, and one abnormal value wasn't enough to diagnose GD anyway. He said to me, “I kind of remember from seeing you and from looking at your weight here… you’re pretty tiny, aren’t you? I really don’t think you could have diabetes. That test was probably overkill. Just, you know, eat healthy.”

(I then proceeded to not gain any weight for the next month because I was so nervous about eating carbs, and meat made me ill.)

Even though I guess it worked out in the end, the whole thing left me with a negative feeling about the practice. I felt uncomfortable coming to my visits and I imagined everyone was angry at me. Moreover, guess which OB in the practice was on call the night I went into labor?

So now that it’s all over and I’ve given birth to an average sized baby, you can go ahead and feel free to judge me and tell me that I sacrificed my baby’s health for the sake of avoiding discomfort.

Monday, August 15, 2011

Being a difficult patient

Especially since I'm a doctor myself, I hate being a difficult patient. I want to be the sort of patient who does everything the doctor tells me to do and never complains and is always healthy.

In some sense I've succeeded. As a mother, I don't call the pediatrician's office after hours more than once or twice a year. Aside from making appointments, I only called my OB's office once: while in labor. But I also feel like I should advocate for myself a little bit as a patient, and I worry that sometimes might cause me to be perceived as annoying.

For example:

At my last visit to the OB/GYN, it was noted that I had my last pap smear six months ago. As such, the doctor told me I'd need to come back in six months for my next annual pap.

Now don't get me wrong, I love getting paps. I love having to pay for them out of pocket due to my deductible, I love waiting an hour to get in to see the doctor, and the exam itself is pure enjoyment. I wish I could get them every week. But in actuality, the guidelines from the ACOG say:

Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years

And actually, the last doctor I saw before I moved a couple of years ago was a primary care physician who confirmed that I only needed to get this delightful test every three years.

So now I have two choices: I can either get an inconvenient and expensive test I don't need, or I can be that patient who shows up with the ACOG guidelines in my hand and explains why I'm refusing the exam.