Thursday, April 10, 2014

MiM Mail: Banking for the future?

Hi Mothers in Medicine,

I am writing to ask for advice. I am a 28-year-old 2nd year medical student about to take Step 1. I got married last year. I don't want to have children until I am done with residency but I'm not sure how long residency will last because I'm not sure what I want to go into. I recently became aware of an opportunity to participate in a research study of natural IVF that would offer me a free cycle. I love the idea of having my eggs (or maybe an embryo) stored away for future use and not having to worry about my fertility anymore. I hate procedures though and I have a lot of anxiety about pain-inducing procedures (like egg retrieval). Can anybody give me some perspective on this?


Wednesday, April 9, 2014

open notes

Today our electronic charting system was moved to Open Notes, which will allow patients to access their clinic notes online.

This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.

I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.

But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care.  That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.

The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan.  Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.

So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise.  Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.

But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.

The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now.  Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.

And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.

I don’t know. TBD.

Tuesday, April 8, 2014

Guest post: The morning departure

The whole drive to work I relish in the wet spot left on my cheek from the sweet goodbye kiss of my two year old son.  It was tough to leave today.   Never wanting to just disappear on my little one I always say goodbye and explain I'm off to be "Dr. Pohl" for the day. This is a funny concept that my two year old disputed at first, saying "You're not a doctor, you're a mommy!"  Well I'm both.

This particular morning everything about my little guy was endearing and I wanted to capture every cute phrase and silly look. It was a "this is it" morning - ordinary and wonderful. Aiden running around in his footed pj's and his baby sister lounging in the boppy. I'm in the kitchen packing up my breast pump and he yells to me "She smiled a big one at me!"

When it is time to finally depart he clings to me, giving me the cuddle I desperately try to get from him when I have the time to enjoy it. He follows me to the door, and against my better judgement, I lift him up again. He then contorts his little body so I can't put him down.  I plead with my husband to come help me. I say, "My heart is breaking," because it is.  He takes him from me and each kisses me goodbye. Then they wave from the window.  I put on a show of waving wildly back but I'm close to tears.

I carry the feel of that kiss all the way into the hospital, cherishing it-  until I finally wipe it off, crumbs and all, to put on my mask.

Dr. Pohl is an anesthesiologist with a 2 year old and a 4 month old.

Monday, April 7, 2014

Homeschooling options for the busy parent

My husband and I are products of public school education. Don’t get me wrong, we are both extremely motivated and successful but we both believe that our education was lacking in very significant ways. My husband now teaches college students who have only been taught under “No Child Left Behind” and we are both very concerned about the results of this method of learning. As the parents of an extremely bright and energetic 2.5 year old, many of our conversations revolve around preparing him for a future that requires tools that traditional education will not provide him with.

One of my best friends from college who is an innovative teacher and curriculum developer attended Montessori schools for her early education. The methods she used to remain organized during college amazed me. She color-coded and charted and organized in ways that I did not even know existed. Studying for me was always about picking up my book, reading, taking notes in the margins, and more reading. It wasn’t until medical school that I learned how I most effectively studied. I began drawing funny caricatures (nothing close to Netter’s) and charting and mapping things out so that I could better process the material and retain it later. As a second year Resident I still use this method. I can’t even imagine how much stress could have been relieved and how much better I could have learned if I studied better earlier.

Back to Zo, my little genius in the making. He amazes us. He is more than a sponge. Every day he comes home and does and says something new; something that makes us pause, smile, and say "how/when did he learn that?!?" My husband and I are exposing him to as many good things as we can. We listen to music (kiddie things like the Dino V, adult things like soul, jazz, rap, classical) and dance all of the time. He helps us cook (he mixes), plays outside, goes to museums. He attends an amazing Spanish-immersion daycare and knows more Spanish than both of us. We got rid of our TV when he was an infant, though he does watch a few hours of Netflix Dinosaur Train and Turtle Tales on the weekends while we straighten up and prepare breakfast. Every 2 weeks we get a new book kit from the library that contains 15 books on a toddler-friendly subject.

But he’s learning so fast and I know he can learn more, I just don’t know how. I read Amy Chua’s Tiger Mom and I’m not a fan of her parenting philosophy, but I will incorporate some of the things that I agree with and like. I want Zo to learn the best way he can, I want him to learn a martial art, to be fluent in another language (Spanish), and play an instrument (kind of got this from Chua and Fifty Shades of Grey, LOL!). I belonged to an amazing mommy-group in the mid-Atlantic before starting residency where many mothers home-schooled and their children were so inquisitive and learned; it was inspiring. I love being a doctor and homeschooling full-time is just not an option for us. 

I have begun researching “homeschooling” options for working parents and am looking for more resources. If you have done modified homeschooling or know anyone who does, please send them my way. I promise to keep you all updated on our progress. Things will be kept very simple since we only have a toddler, but I’m sure as he ages, I will find other fun, innovative ways to supplement what he learns at school. 

So for this week’s "Homeschooling for the Busy Parent" activity:

- lots of fun time and play, dancing, riding our bikes outside, and time at the playground
- nightly reading of our colors books
- I will make some simple flash cards and we will focus on primary colors and then secondary colors using a concept called “isolation” that I learned on YouTube from a video-blog called “Preschool Homeschool”

Saturday, April 5, 2014

Sentinel Lymph Nodes

Sen.ti.nel: A soldier or guard whose job is to stand and keep watch.

I have a close friend who was standing in the shower one day and noticed a lump under her arm. She is in medicine, and despite trying to blow it off she knew what it might herald, and eventually manned (I mean womanned!) up and made herself an appointment with a breast surgeon. Ten years ago she was diagnosed with metastatic breast cancer. She had a mastectomy with lymph node dissection. She had treatment. She got off her meds, had a child at 47. She has a handsome first grader. She is in her early 50's and she looks like a movie star in her late 30's.

I look at a lot of sentinel lymph nodes. Sure, there are other ones besides those in the breast axilla, but they are by far the most routine. The surgeon injects a radioactive tracer attached to blue dye around the tumor and follows the  path to the nodes that the tumor cells would take to locate them. There are a bunch of nodes in the axilla, but chances are if the cancer is not in the sentinel nodes - the guards - then it won't have traveled any farther. There are exceptions to the rule but like most rules the exceptions they are few and far between.

In the gross room we receive the sentinel nodes and our techs do a gross analysis. Lymph nodes are floppy and brown-grey, much the size and consistency of a kidney bean. Massive metastases are grossly obvious - stellate, white hard infiltrates scream positivity, which is easily confirmed by microscopic examination. But many metastases are insidious - not grossly obvious. We do step examination of multiple levels of sentinel lymph nodes (sometimes there are more than one) which can fill a tray or two of slides (20 slides per tray).

When I get a tray or two of sentinel lymph nodes I often wait until I have a cup of coffee to settle down and look at them - it takes time and major focus. The kidney bean shaped node is full of small round blue cells called lymphocytes with reactive germinal center follicles - white round circles dotting the blue landscape. The border contains the sinus of the node - the most likely place (a small space) for occult isolated tumor cells or clusters of cancer to sneak into. If you blink you might miss some. It takes slow and methodical cruising at high power. I occasionally sub at breast conference for my partner who presents at it regularly, and I am continually amazed at the tiny, almost invisible foci my partners unfold. I know how hard it is to really see that. I have great respect for the amount of time and effort it demands to discover it. I know, I do it too, it's part of the job, but it continually amazes me.

These days we routinely use pancytokeratin immunostains to look for small, isolated tumor cells and clusters. While this is a nice adjunct to help us sleep better at night, it is not a safeguard or panacea to allow us to slack on the job of the routine H&E slide. I have seen cancer cells on H&E that are cut away on the special stains. I have seen cancer cells on the special stains that are not on the H&E (this stands for hematoxylin and eosin - the pink and blue Easter egg colors that we use to stain all tissue for examination). It's enough to keep you up on a bad night, wondering what you might have missed.

You would never guess my friend had metastatic breast cancer - I didn't even know for the first few years I knew her - she was diagnosed before I met her. She has shared struggles with treatment side effects but doesn't touch on what I know I would obsess over - fears of leaving behind my children. She is a perfect picture of poise, elegance, and grace. But she has this underlying Tiger Mom thing, an aggressiveness and intensity that I know must have come with what she has faced in life and dealing with the unknown of the future. Sure, we all have unknowns - I could die in a car crash tomorrow but I haven't dealt with nearly as much adversity as she has in my own personal health arena (yet!).

I love the definition of sentinel. The guard. The lymph node that tries to hold it all in check. I can empathize, as I am sure my friend does too. We women in medicine, and mothers too - we are always on constant watch and hyper-vigilance. For our patient's health, and for that of our children. We can't protect our charges from everything, but that doesn't keep us from trying with all of our power and might. It's the best we can do, and it's good enough.

Thursday, April 3, 2014


I have a few.  One major, a few minor.  I keep reminding myself that I am the kind of person for who the grass is always green on the other side.  So, even had I made other decisions, I would probably have regrets.  Not definitely, but probably.

How do you all deal with your regrets?

Tuesday, April 1, 2014

On the Move

A few months ago I bumped into a pulmonologist in the doctor's lounge I enjoy chatting with. She likes to travel, and I enjoy hearing about her latest trip - I like travel too and would much rather sock new car or house or clothes or jewelry money away and spend it all on traveling. As we were finishing up the conversation she cocked her head, looked at me straight in the eye with a slight smile on her face, and said, "I am so jealous of you pathologists. You get to stay put at your microscope. Do all your work at the same hospital. We are running around all day."

I was so shocked I didn't answer her, but as I walked away I thought "What a false impression she has of us!" We run around from hospital to hospital, covering different ORs and radiology rooms in shifts. Maybe not in one day, but certainly up to a fourth or more of the month. Increasingly, outpatient clinics are putting in histology labs, necessitating more travel to do cases - this can demand travel to two or three different places in one day. Furthermore, we dole out lab directorship amongst ourselves, covering the many different labs we service in our overall domain.  This requires weekly or monthly travel to fulfill clinical pathology duties, which are more and more demanding every year with increasing regulations and education requirements. As our designated lab inspector, I travel to different hospitals around the state and outside of it with teams of expert lab technicians as part of our duty to regulatory agencies that certify us as an "approved" laboratory, meaning we hold up to the scrupulous demands that we require of the labs we inspect in return.

This means that I know how to use many different EMR systems and up to four different sign out programs - some of which are hospital based and some of which are internet based. I can access my home computer remotely to juggle work couriered in from different hospitals in attempt to even out the workload amongst all of us, as it changes daily (I do not envy the math that the gross room has to coordinate daily based on workloads at multiple different hospitals and different clinics!). Yes, I am grateful that I am more of an information-gathering voyeur than an interactive participant in the EMR system, for the most part - we do write notes on fine needle aspirates we perform, as well as apheresis procedures. But I think we make up for this on the back end with our individual dictation and report release software. It's ever evolving and more and more confusing as the years progress.

The days of the hospital-based pathologist sitting (hiding) in the office behind a microscope are over, for better or for worse. We are on the move, my dear travel pulmonologist friend - someday I will explain.  In the meantime, envy me with your wrong impression and I will continue to envy your world travels. I'm starting to catch up. Conference in Hawaii in February and Spring Break ski trip last week to Colorado. I'll break the borders as the kids get older. In the meantime, I'm busy enough traveling for work.

Monday, March 31, 2014

Keeping it moving on an overnight call

5 admissions, 4 discharges, PICU transfer. That sums up my night.

I could dwell on the negatives (exhaustion, cold under-heated hallways with headache-inducing fluorescent lights) or I can focus on the positives.

The positives. We managed the craziness with style and grace. No one died. Though one Nurse did come down with something and ended up in the Emergency Department. We (Interns and I) learned many things about patient care and prioritizing. I learned that even though my eyes are burning and my reaction time has slowed down considerably, I know enough to keep patients alive, manage a variety of conditions pretty darn well, and even alleviate some parental anxiety. I can successfully perform a lumbar puncture even after the Intern is unsuccessful and I have to bust through the big ole’ hematoma he left behind. Bammm how do you like all those red blood cells?!? What lab representative, red blood cells aren’t good?!? Of course I know that but at least I have enough cerebrospinal fluid for a gram stain and culture. Could you run those STAT please?!? I can scrounge up a makeshift meal (cereal, graham crackers, peanut butter, diet Coca Cola) to avoid my own hypoglycemia in spite of the fact that due to budget-cuts the cafeteria now closes at 8pm. I can snuggle sick babies and help position them so that they don’t become hypoxemic at 2:30am. I can make my exhausted Intern laugh at our horrible night. I can make my Nurses feel appreciated and not hate me even though they are ready to label me a “Black Cloud”.

And just to cap the whole night off, after a particularly crazy admission where we were all unknowingly exposed to some infectious respiratory goobers, we exited the room quickly, donned our masks and proceeded to do a modified line-dance down the hallway back into the room where we provided judgement-free exemplary service.

At this point, I just want to curl up in the call room, but there are far too many labs to follow up on and kiddos to check up on.

So to those out there in call-land, keep it moving and keep those patients alive! Cuz’ you know I will :-)

Sunday, March 30, 2014

The Day I was Nearly Arrested on Assault Charges {subtitle: How I'm Finding Time to Train for a Marathon}

Earlier this week I found myself stuck at a “doctor-y” event. As I made small talk with a colleague, I mentioned that I was training for a marathon. Despite that fact that I am currently blogging about running and training consumes most of my thoughts, I promise I don’t talk about it incessantly to random people, but in this instance it did come up in conversation.
After I mentioned my training, her face contorted into what can only be described as a scoff. She then replied, quite condescendingly, “Must be nice to have THAT kind of time.”
My face turned beet red and my blood began to boil. Then without thinking I pulled my hand back and smacked her right across the face, leaving a bright red hand print on her left cheek. She was was stunned at first, but then her instincts took over and she kneed me in the gut. Before I knew it, we were in an all out fist fight in the middle of a cocktail party. My husband broke up the fight, but not before someone called the cops. I am currently writing this from jail. 
Ok. So, nothing in italics ACTUALLY happened (except in mind. repeatedly. for about a week). In reality I smiled and walk away, like a good girl, who didn’t want to have to explain a criminal record.
Obviously in a state of pure boredom, I decided since there was nothing else going on in my life, I would run a marathon. I’m busy and so are my running mates. The expenditure of my time is not something  I take lightly. We all have a lot on our plates, but like all things that are important to us, we are finding the time for this marathon.
How do I find the time for this?
5. Follow a Plan
We are following Hal Hidgon’s Novice 2 training program. The best way to avoid injury and reach my goal is to stick to the plan as close as possible. Each week I check off my boxes as I pound out each mile.
4. Run When I Can
The only time that works for me is mornings. Some mornings have been painfully early and cold, but nevertheless I’m out there. 
3. Accountability
When my alarm goes off at 5:30 and I check the temperature and it’s 13 degrees, knowing that my friends are out in the Arctic air waiting for me is what gets me out of my cozy bed. There are 6 of us training in my neighborhood. Though we can’t do every run together, we are each other’s cheerleaders.
2. Giving Myself some Grace
I have missed a few workouts. If I’ve been at the hospital all night delivering babies and I have to choose between running and sleep, then I choose sleep. I don’t make up my runs in the evening, because that’s my family time. Yes, my Type A personality would like to follow the plan to perfectly, but life happens and that’s OK.
1. Have an Awesome Husband
Obviously, somebody has to get the kiddos ready in the morning while I’m out torturing myself, and that somebody is my super husband. You need your spouse to be supportive (or a least tolerant) of your crazy hobby when you start logging this many hours.
Despite being a runner for the last 17 years, I have never ran a full marathon. In my early 20′s, I did races all the time, but never more than a 15 K (The Tulsa Run, which is still my favorite race). Over the years the responsibilities of life kept my running to 3-4 miles a couple of times a week, barely enough to stay fit. 
As my kids have gotten older, life has gotten a little smoother. I've decided this is my year to check "26.2" of my bucket list. Wish me luck, I'm a month away from my goal and I can't wait to cross that finish line. 
Haters gonna hate. But I'm gonna run.
originally posted at

Friday, March 28, 2014

Jack Of All Trades, Master Of None

(Patient accounts have been altered so as to protect their privacy and identity)

When I walked into my internal medicine practice office yesterday morning at 6:30 a.m., I was surprised to see only three patients on my schedule. Then I remembered there was a major winter storm forecast, and no one was sure how bad we were going to get hit. By the time the early administrative staff was arriving at 7:30 a.m., patients had realized the storm was basically just alot of wind, and they started calling. And booking. The 8 a.m. slot filled, then the 8:20, soon all the rest... I had an almost-full schedule in no time. And it was almost all "urgent care".

I love urgent care. It's so nice to take a break from the "comprehensive annual exam". Or at least, the way I approach those... I tend to obsess over missing something, and so I take the annual exam as an opportunity to comb through the patient's chart, and attempt to make appropriate note of every past, present, and possible future health issue. Plus, this is my big chance to catch up with folks on their Real Lives. So, What do you do when you're not sitting on my exam table in a johnny? Of course, folks come in with their own agendas, the lists of questions jotted down on the backs of envelopes or in the iPhone. Some docs shut all that down, citing "This is your preventive health time only!" which is ridiculous. So, the issues are addressed. Then there's the vaccines review, and lab ordering... These may or may not be straightforward, and more often than not involve additional discussion. My physical exams always run overtime.

So, a day of mostly urgent visits, those single-issue problem visits that can be serious, but at least, straightforward, are a welcome change.

On the other hand, these days highlight what is beautiful, difficult, and terrifying about primary care specialties like internal medicine:

1. You're supposed to know everything about everything.

2. Because we're trained to be always thinking about the Whole Patient- Nothing is ever straightforward.

First patient. The check in sheet states "Cough". Ha, easy. Well, not so much. The cough was undertreated asthma in the setting of a mild cold. But his blood pressure was very elevated. And a quick perusal of the chart showed, this was someone who hadn't been in for a couple of years. Turns out this was someone who had extreme doctor anxiety and alot of issues that needed more fine-tuning. So the visit turned into counseling and negotiations. I set up a followup appointment with the actual primary care and sent my note... Hoping the guy comes back.

Now, running fifteen minutes behind, next patient. "Rash". This is only easy if it's Shingles... and it was. But, the patient is a healthcare provider. And they wanted to know- needed to know- know all the occupational health issues around Shingles. Did they need to notify all the patients they had seen in the past day? How long did they need to be out of work? Did my recommendation around that differ from our hospital's occupational health policy? I wanted to be able to provide a modicum of accurate counseling in all of these areas. I spent some time with her researching the guidelines and then asked her to contact both her supervisor and occupational health for the rest. Then she needed a note. We wrestled over how to phrase it. I hit "print". The printer wouldn't print. Had to run to another computer. Time ticking away.

Then done with that, I had to check my clinical messages (our in-office messaging, where the secretaries and nurses send me anything from patient phone or email queries, VNA concerns, controlled substance medication requests, or abnormal lab or radiology results). I need to quickly scan the list and make sure there is nothing requiring urgent attention. Then deal with those. Someone emailed about their ankle sprain. Nurse: They just want X-rays ordered. Can we do that? Me: Not really, please have them make an appointment. Et cetera.

Then, my email. There's several more emails for me in a now-massive email chain regarding one patient of mine. She has a large team of specialists; her case is complicated; she may need to be admitted, and I would need to arrange that. I read quickly and make sure no one has asked me to do anything yet. I know the specialists probably roll their eyes at my questions. I haven't treated many cases of what she has. I have to read up every time she has labs. But she comes to me, and I'm doing the best I can.

Now hopelessly behind. Next patient: STD screening. Ha, easy! Not. Upon questioning, she tells me one of her partners is a recovering IV drug user. I deliver alot of counseling around this, do a pelvic exam with cultures, send for bloodwork and arrange more followup with bloodwork in two months.

Next: Elderly patient with shortness of breath. She was pretty sick. She told me she had almost passed out in the waiting room. Long and short of it, this person was too sick for my office. But, she resisted my emergency room suggestion. We went into negotiations. I called the emergency room to expedite. We waited for a wheelchair. I typed up my assessment and impression so the emergency docs would have it. Why take the time to chart, when the next patient is waiting? I felt like I needed to present at least a reasonable hypothesis for her condition, as well as defend my decision to send her to the emergency room. I delved more into her chart. Why do her lungs sound like a freight train screeching to a halt? Asthma in someone who's never had asthma? COPD is someone who's never smoked? Pneumonia more likely. Pulmonary edema, maybe.... Type it up. Hit "finalize."

Next: Wrist pain in a guy who does martial arts. I had to do a quick review of the possibilities. Refresh myself on the exam findings in occult scaphoid fracture. Then look up what type of immobilizing brace to prescribe while that is being ruled out. Then the printer didn't work again.

Next: Lovely lady with- finally! A very straightforward issue. Simple. I took care of it and was ready to wrap it up, when, she wanted my opinion on the new blood thinners. She's on Coumadin for atrial fibrillation, for stroke prevention. These new blood thinners are advertised on T.V. The cardiologists are prescribing them right and left. I have never prescribed these. I look it up, with her right there, and review some of the major pros and cons. There's no testing to see if someone is on too low or too high of a dose. That's nice. But, they aren't as readily reversible, so if someone has a car accident or a bleeding ulcer, they may bleed to death more easily than otherwise. Basically, that's what I told her, adding that we can also ask her cardiologist about it. No, she said, I like to know my numbers.

Next, next and next. There was a physical exam in there, and a few more not-so-straightforward urgent care visits. That was it. Nine Patients, and a barrage of clinical messages and emails. I was starving, and I had to pee. I peed, ate something at my desk, and delved into charting, billing, and all the messages/ emails, as well as the arrangements to be made for that very sick patient. I checked in with the emergency room on the lady I had sent in- she was to be admitted. Ha. I knew she was sick.

Mixed in there, I check in with home. I'm thinking about my kids. On my personal email, there are messages back and forth about our autistic son who's had some issues at his special education preschool. School aversion, we don't know why. It's getting better, with a good and patient teacher. But, I worry I'm not doing enough reading and research on autism, that we're not doing enough behavioral work at home. So I got on Amazon and researched, ordered some books.

At the end of the day, I wonder why I'm so fried.

Is it a good, or a bad thing, to be in a job where your mind has to hop, skip and jump and WORK from case to case and even within a case? We see everything and anything, and we're expected to counsel on even more. That, plus the balance with home life, taking care of a family...

Is it a good thing to be a Jack of all trades, Master of none?

-posted by Genmedmom (

Monday, March 24, 2014

Guest post: Tales of a hybrid doctor/stay at home Mum-- Part I

11pm, January, 2009.

I stare at my face in the bathroom mirror with the magical belief that the reflected version of myself might, if I stare at it long enough, offer my real self an answer to the predicament I find myself in.  My bare feet are rooted to the frigid laminate tile, obstinately clinging to that spot and holding my reflective self hostage until she offers up some guidance.

This tumultuous day had started at 2.00 am, that morning, when my 18 month old daughter sat up and, with eyes still heavy in deep sleep, started vomiting. I rushed to her side, watching in dismay as projectile puke, mixed with bits of basil green pesto pasta, erupted all over her bedding and nightclothes, seeping through to her skin and trickling up to matt her brown curls. When her vomiting subsided, I cleaned her up, changed her sheets, took her temperature and gave her the once over: any skin rash? Is she limp or listless? Does she have tummy tenderness or diarrhea? Having ruled out the presence of a more sinister cause for this jarring episode of vomiting the nocturnal drama appeared to be over.  I settled her down back to sleep and then lay down myself and was asleep all of 15 minutes when the puking started all over again. It was a long night filled with five cycles of vomit, clean up, sleep; vomit, clean up, sleep…

At 7am I had forced myself awake and got my son ready for school. I layered him up with sweater, ski jacket, snow pants, scarf and gloves: a mandatory ritual to protect him against the harsh winter morning. I reached for my own coat but was stopped, in my tracks, by the look on his face. He was standing, rooted to the spot, shoulders hunched over when his face became suddenly pale. In a second, undigested milk and cheerios, splayed onto the wooden floor of our hallway and so began another cycle: puke, clean up, wait; puke, clean up and wait…that consumed the whole of the morning.

I had hoped to spend today having quality time with my children, catching up on errands having coffee with my neighbor and, if time permitted, even putting finishing touches on a research paper.  But the day had taken an unscheduled turn and the situation demanded that I submit to the more unpredictable task of caring for my sick children. Patiently, I nursed them and offered them comfort alongside hydrating fluids.  I gave permission for Barney and Blues Clues marathons to take pace whilst I did pile after pile of laundry. As my children sat, huddled together under a blanket, their glassy tired eyes transfixed to the screen projecting their colorful screen heroes, I scrutinized them for signs of more serious illness.  I watched and waited, waited and watched quelling bolts of maternal anxiety with reassurances by the, more objective, physician in me.

Now, in the still of the night, they are both asleep. Our house has been vomit free for the last eight hours and the situation appears to be under control.  Yet, as I stare at my face in the bathroom mirror, I feel surges of anger gathering up from within me. My children being sick had demanded that I be home with them all day, a duty that I fully accepted and was also loathed to delegate to anyone else. Still, hour after hour of not being able to eat, pee, or shower without being interrupted by a child’s need or demand combined with the lack of sleep and extra chores, generated by the sudden vomiting attacks, has all taken its toll.

Most of all, I resent my husband’s absence from today’s circus. Why was he not here to clean up at least one of the 10 vomits?  To comfort our children when my patience was wearing thin? To watch them so I could eat one of the day’s meals seated? Like so many of the husbands that lived on our manicured suburban street, travel had become an integral part of a work life that took place in a global village where competition was omnipresent. One week New York, next week London, a month later a 3 day meet in San Francisco. I had come to dread this time of year for, along with the short days, bare trees and snow storms, his travel schedule became intense and filled with a cycle of conferences, sales meets, deals to close and budgets to spend. Business at the speed of thought, frenetically taking place in four different time zones all whilst he chalked up thousands and thousands of air miles and airline loyalty points.

Years before, shortly after our son’s birth, I had taken on a hybrid identity as both a doctor and a stay at home Mum.  I had returned to work within weeks after birthing both my children, but never to a full schedule. Our profession demanded a doctor be available and on call at all times, so I eagerly offered my services to cover evening, weekend and holiday duties as these were times when my (mostly) male counterparts, who had already put in a long work week, preferred to be home with their families. During the week, my days were filled with diaper changes, making baby food, cooking meals, school drop off and pickups, baking batches of homemade biscotti for the PTA fundraisers and staying on top of the pediatrician appointments, homework, play date and activities schedules. On the days and evenings that I worked my husband took over the child rearing and I headed to the hospital to give expression to that other part of my core identity, that of being a physician.  For the most part, our childcare arrangement worked well and I not only felt centered as I juggled these two joys in my life but had come to feel both these identities, being a mother and physician, were actually complimentary: that becoming a mother had made me a better physician and remaining a practicing physician had made me a better mother.

I did not know many women who had opted for this model of parenting. My friends either stayed home full time and planned to take a long hiatus from their professional careers or, on the other extreme, worked fulltime and had employed a nanny or involved another family member to be the primary caregiver for their children. For the most part I felt I had the best of both worlds but today, amidst the fatigue, anger and the stench of vomit that still lingered in my nostrils, I felt trapped.  My own Mum had never had a professional career and Dad had always begun and ended his day at home. On days like this, our hybrid parenting model along with having a travelling spouse seemed unnatural to me and it made me doubt our parenting plan. I wondered if we were tempting fate by taking on a lifestyle we were not primed to pull off.

In the bathroom mirror, my reflection reminds my dejected self that I have plenty of resources: an education; every possible modern convenience; domestic help; kind neighbors; a tight knit circle of friends and a pediatrician who is only a phone call away.  All of these facts were supposed to ease the anxiety and physical burden inherent to child rearing and I knew, all too well, that such resources were denied to many.  Still, on this particular night, none of this “pull yourself together talk” could keep me from an overwhelming urge to sulk and stew.

My stewing is interrupted by my vibrating cell phone, twirling on the marble countertop, as it heralds my husband’s return.

Landed. Home by midnight. Caught a stomach bug :(  Need TLC.


Dr. S is a married physician and mother of two.

Monday, March 17, 2014

Guest post: Making a career shift to leadership

A few months ago, when I was contemplating a shift in direction in my career, I happened to google 'women leaders in medicine'. Among the websites and blogs that google search generated was 'womenmdresources', and through that, the 'mothersinmedicine' website. Reading through current and old posts was like finding a community of friends I had not known existed. In fact, one of the first blogs I read was from 'anesthesioboist' and the post was about her experience with her child having surgery at Boston children's where she had been a resident. I found myself smiling as I recalled a very similar experience at the very same hospital some years ago with my son needing surgery for a fracture while I was a resident there! It made me feel connected to this entire community out there of women in medicine, especially the unique community of mothers in medicine.

Fast forward a few months, I have made the career shift, which involved going from being a staff anesthesiologist at a small community hospital to being the chief of my department at another small community hospital. It required a lot of thought on my part and discussions with my husband to go after this opportunity especially with one child being almost ready to go off to college in another year and another entering the tween diva stage. Did I want to take on this challenge at this juncture of my career (and challenge I knew it would be) especially with my husband's job needing him to be traveling for most part of the week? It would have been so much easier to stay where I was and go to work and come back home and not have to deal with all the issues involved with taking over the running of a department.

10 years ago, when I was finishing my residency with 2 young kids, if I had had a crystal ball, I would never have seen myself in a leadership position down the road. I thought I would be content with a staff position in a small department, enjoying my work, but leaving it at the hospital when I left in the evening and focusing on my kids and family. And that's what I did. However, few twists and turns in the last few years changed my direction and I feel now, for the better.

I had had some experience with the running of a group without the title of chief in a previous job so I knew the trials and tribulations it would involve.

Ultimately, we decided I could not pass up on this opportunity. That previous experience had whetted my appetite to be in a position to be able to make some changes, to problem solve. I had found it very satisfying when I was able to make some changes to make processes run smoother than they had.

And so here I am, 2 weeks into this new role. It has been a challenging couple of weeks. And I find myself looking forward to more.

-Anesthesia Mom

Friday, March 14, 2014

Guest post: Doubt

Wednesday, March 5, 2014
Queen Elizabeth Theatre

Every seat is taken. The theatre's lights are dimmed over a throng of excited Vancouverites, most dressed in black, some in pearls. After interminable introductions, Hillary Rodham Clinton strides in from stage right, in a navy pantsuit, stilettos and large glasses. She takes the podium and begins her speech on women's issues. She's funny, smart, engaging.

I'm here for the curiosity, not the politics. I was offered a ticket that morning; I didn't even know she was in town. She doesn't disappoint. Her presentation is riveting.

"One of the greatest blocks to the advancement of working women is their own self-doubt and perfectionism," she says.

Yes. That resonates.

She continues, "I've worked with many young people over the years, and almost invariably, when I offer more responsibility to a woman, the response is, 'Let me think about,' or 'Do you really think I could do it?' I have never once offered a promotion to a young man who did not feel more than entitled to it."

I post that to Twitter.

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Friday, March 7, 2014
Residence, Deep Cove

I'm going through pictures of my brother's wedding from the week before when I come across this:

Whoa. How'd that happen? I've got a girl who babysits, attends youth group and just submitted her course selection for high school. If she goes to McGill for university as she intends, I have just over five more years of seeing this face at the breakfast table every morning.

Her childhood has always stretched ahead of me as far as I could see. The chances to do things with her, to become the mother I want to be - I live as if they will continue indefinitely. So how can it be that I can count on one hand the summer vacations remaining until she graduates high school?

Wait! I think, and I suddenly feel scared, sad. I was going to read all of the childhood classics alongside her - A. A. Milne, Roald Dahl, L. M. Montgomery. I collected them from used bookstores, and she's read them, but I never got around to it. I still haven't made her bedroom an idyllic nest; the board is on PInterest but the brown carpet lives on. The plan at the back of my mind was to raise her somewhere with goats and an orchard; we live on a rocky cliff side without even a gerbil.

I was going to become an excellent mom, or even just a really good one, the one she deserves. I could always see just how I'd be one day when I'd conquered all my personal faults. Calm and patient, attentive and selfless. I was going to start going along on field trips and watching her floor hockey tournaments. We would have long conversations lying on her bed in the evenings. I was not going to take her for granted, ever.

I look at the face in the picture above, sweet and spotted, pretty and confident. A flight of conflicting responses pass through me. Pride, panic, affection, sorrow. What to do?

Do I say with satisfaction - Look at that. She knows she is loved, and knows how to love. She's an excellent student, a kind friend. Tucked into the past twelve years are moments I didn't, couldn't have planned. Dissecting a cow heart for her class, sharing anecdotes about her baby sister, playing Clue after dinner for nights on end. I'm irritable and impatient, yes, but I've always been up for adventure. I devote a large part of myself to patients, and she sees the joy that good work can bring.

Or do I say, Hold up a minute! There's still time. Not a lot, and I'm going to have to be very deliberate about this, but there's still time. There are changes to be made, to home and work and heart, and we're turning this ship around, starting tomorrow.

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Saturday night, March 8, 2014
Residence, Deep Cove

"Are you the father you wanted to be?" I ask Pete. I bring these things up in bed, lights out.

"I've never thought about it," he says. I can't believe it. But I do, deeply envious.

"Scale of 1 to 10."

"Ummm. Seven." No trace of guilt or sorrow.

I can't help myself. "Seven's kind of low. Don't you feel bad about that?"

"When you imagine being a parent, you have no idea what it involves. Once you're doing it and you find out what it's really like, you cut yourself some slack. Lots and lots of slack."

-- cross posted to --

Thursday, March 13, 2014

Sick Day

The other night, my daughter Cecelia woke me up at 1 a.m.  The day after her 11th birthday. "I'm sick."

She took me into her bathroom. It looked like an emesis crime scene.  Buckets of puke on the toilet lid, leaking into every crook and cranny, spilling over onto the tile. Spattered walls, spattered glass shower barrier. Spots on the ceiling. I wondered briefly if I could leave it for my house cleaner the next day, and laughed at myself.  After settling her into my bed with water and Pepto pills, which she soon tossed elegantly this time into my toilet, I rolled up my sleeves and cleaned. An hour and two paper towel rolls and a carton of bleach wipes later, it was passable.

The next morning I asked her, "Have you ever heard the phrase 'Tossing your cookies?'"

"No Mom, But I can guess what it means."

She had quite a fill on her birthday - cookie cake at lunch and Baskin Robbins Grasshopper Pie after dinner. It had only a vague resemblance of its original splendor as I was mopping it up, pinching my nose against the odor.

I have been reading Generally Medicine's sad and sorry posts about sick children, congratulating myself about my children's overall good health. I must have jinxed myself. Jack threw up all last weekend. He is being treated for Strep, and has just regained his appetite after two weeks.

The upside - Cecelia came to work with me today. Luckily I found a comfy couch for her to rest on day one after the emesis escapade; my parents were in town and willing to help. I did not have the heart to send her to school when my mom went out of town today - she was puke and fever free but still nauseated and only up to clear liquids. So she came to work with me - an embarrassing first. It was a blast.

Luckily I had made it through the busy post-all-nighter (not a fun college one!) day one - overly busy with a lunch presentation to an audience of around 100. I was uncertain if the queasiness in my own stomach before the meeting was butterflies or bug onset. Butterflies, thank goodness, in retrospect.

This day was slower work-wise.  Not easy, but doable. I did not have a toddler, I had an 11 year old, ultimately savvy with her ipad - busily reading and making silent videos with props in my office while I read slides and made diagnoses. I spaced morning and afternoon visits to the gift shop (she had bday money to spend) around needles in radiology and the ED. We had a long blissful lunch. "Mom, I'm so excited to go to the place you eat work at lunch. I've heard you talking about it for years but have never been." Ugh, really? Am I that far removed? Her eating a turkey sandwich, me munching on a salad - both of us talking about the Divergent premiere I am taking her to next weekend. I'm reading the book so I can help her and her friend get dressed up for it. I wondered tonight what I'm going to wear - I'm that excited.

As I was releasing cases and she was packing up her pillows and gift shop loot she started to do this thing she does when fun things are ending. I used to get really frustrated about it. She focuses on the one negative thing in a day of overwhelming fun and positive. She was trying to leave me a secret fun note under my microscope and was getting angry and upset that I saw. I told her that I worry about leaving my microscope light on and obsessively check it as I'm heading out the door - it would not spoil the surprise because I had no idea what the note said. Last weekend my boyfriend and I took her and two friends to the Lego movie and shopping and she kvetched endlessly over not getting to spend enough time in the mattress store because they spent too much time in the shoe store. I think I'm finally getting it. It's just sadness at ending. It's better to empathize than get angry.

I'm going to miss the hell out of her at work tomorrow - I think she's well enough to return to school. I can't wait to see what that note says. And I am kind of looking forward to more sick days with both her and Jack, now that they are old enough that they don't need my constant attention.

Happy 11th birthday and recovery, sweet and wonderful Cecelia.

MiM Mail: Navigating oral boards (and not going insane)

I am a 31 year old Ob/Gyn in the North East and have two small children, ages 1 and 3, as well as a wonderful husband. I am one and a half years out from residency, am becoming a partner in a small private practice, and am preparing for my oral boards. I have a 90 lb labradoodle that eats all my socks and throws them up in the middle of the night in the corner of my room. I have loans, bills, chores, family responsibility, and the list goes on and on. Basically, I could lose it at any given moment.

Typically I am very relaxed about life. I am calm under pressure and actually enjoy that adrenaline rush during an emergency.  I have rushed a mother to c-section in minutes without breaking a sweat and then came home to quickly throw together a home cooked meal.  All while dealing with my three year old in his second time out and holding the 1 year old who just won't let me put her down.   I honestly felt like I could handle just about anything...Until now.  Preparing my case list for the oral boards has been nothing short of miserable.  After a few days of chest pain and frequent trips to the bathroom from anxiety, I am writing this to ask for help.

I am hopeful I can find a few others out there like myself who had this same experience. I thought that the worst part was going to be in Dallas where I will sit on the "hot seat" for three hours and get baraged with questions. And maybe it will be.  Oh God, what if it is worse then this!!!! Breathe, just breathe.   Let me explain the root of my troubles.  I am currently compiling my case list, which means entering in every delivery and surgery I have done in the last year. Thus I am forced to relive and reanalyze each one.  As I am entering in a case, I remember it all clearly and at first think that yes, I did everything just as I should. Warm fuzzy feelings wash over me as I remember how I helped that woman and improved her life or placed a new life into her arms.  Quickly, feelings of doubt and fear wash over me as I panic. Was that the best way to approach her problem? Did I do the most evidence based treatment? Did she have a readmission for  a postop complication that I am not aware of? Do I actually know what I am doing? How did they ever let me graduate!?!

I tried to explain myself to my husband, and of course he is supportive. Reminding me that most young new graduates undoubtedly feel this way too. But do they? That is where I need your help.  I am certain you have all been in my shoes. Struggling to balance motherhood and medicine. Feeling guilty for not reading all the latest journal artricles and at the same time feeling even more guilty for not reading Goodnight Moon that third time because you just needed your kids to be in bed so you could have a moment to yourself.  Wanting to give your husband attention and wanting to sleep.   My identity is both physician and mother/wife. I am where I am and who I am because of my experiences. I love my job and even more I love my family.  I feel truly blessed to  be where I am, and also slightly terrified.  It seems like just yesterday I was graduating from college with big dreams to become a doctor. Big dreams to one day be married with a family. And all of a sudden here it all is in front of me, and all I can do is panic and want to hide under the covers.

So, I am sending this out into the great internet void to get some clarity and advice. How do I continue to "do it all" and not lose my mind in the process? Is there a secret to navigating the oral boards? I need your help.