Perspective

I occasionally have a moment to reflect on my life and wonder if I am missing a message. I wonder if all of the barriers I faced during my PhD were trials meant to make me stronger, or if they were messages telling me that I need to stop being stubborn and take the option offered to me. Over the last month, I've felt as though I am being sent another message by way of coincidences, but I haven't figured out what that message is.

I am uncertain as to what I want to do after my internal medicine residency. I have always planned to specialize in a field, for lots of reasons. No real need to go into it too much today, but specializing would likely help me to enter academic medicine, and it also fits my personality of wanting to know as much as I can about one particular field. Given that my PhD was in cardiac physiology and metabolism, I figured that I would specialize in cardiology. Unfortunately, my clinical experiences with cardiology haven't appealed to me as much as I had hoped (and I've really tried to like it). And as I've mentioned before, it's a tough lifestyle to commit to unless you really, really love what you are doing.

Since cardiology is out (or at least far down on the list) right now, I've been trying to think of other fields that might be a good match. Rheumatology is academic, and I like the autoimmune aspect of it. However, I dislike the musculoskeletal system and joint taps, and the clinical rheumatology I've done so far hasn't been super interesting. I spent one day in the GI endoscopy suite, and that was enough to rule out GI. I've had limited experience with other fields as well, but up until about a month ago, the two areas that seemed to be front runners were hematology/oncology and infectious disease.

ID (infectious disease) was on the list because I enjoyed the month I was on the ID service, and we have very good ID doctors and researchers at my hospital. Ironically, "bugs and drugs" (microbiology and antibiotics) were two of the disciplines I had the most trouble learning in medical school because I felt like it was mostly rote memorization; I like physiology better because it is thinking about how things work.

Heme/onc appealed to me from the academic side. My background in metabolism and chemistry makes chemotherapy a natural direction for my research interests. It doesn't hurt that my hospital just built a freestanding cancer hospital and attracted a bunch of new researchers to the institution. However, after spending a month on the inpatient cancer service, I was doubting whether I had the emotional fortitude to do heme/onc. One of the attendings made me promise to do outpatient heme/onc before I decided to cross the specialty off my list.

A month ago, I took two weeks of my elective time and did outpatient heme/onc. The attendings were very kind and really allowed me time to talk to their patients. I enjoyed the rotation--though in all honesty, I enjoy outpatient ANYTHING over inpatient. I wasn't really sparked to jump into heme/onc, but I wasn't turned off either. It was a blandly pleasant experience.

While I was doing heme/onc, I got some very difficult family news. My uncle, my dad's brother, my godfather, was diagnosed with stage IV pancreatic cancer. It was very sudden--he went in to have his gallbladder removed, and he was discharged without surgery and with a terminal cancer diagnosis. This happened at a hospital not part of my health system, and I am not saying this to badmouth another hospital, but I was absolutely appalled at how he was treated during his stay. The sudden diagnosis was awful enough, but he was sent out with no close followup, no referrals, and no plan for managing his disease. I thought about all of the services (medical, social, spiritual) we provide to patients with a new diagnosis, and I thought about how he was treated, and it made me want to punch his surgeons in the face.

Once I got over my short-term anger, I felt deeply saddened, as did my entire family. We all struggled with the idea that my uncle, who is one of the kindest, most pleasant people you could ever meet, had a disease that no one could fix. And the poor man was miserable from the cancer and had been given no help in treating his symptoms. It was heartbreaking. His kids--my cousins--are in almost the exact age range of my siblings and me. The thought that they would be losing him so soon reflexively made me think about the what ifs--what if that was one of my parents? I've said here before that one of my greatest fears after doing my inpatient cancer rotation was to see someone I love, especially someone in the prime of their life, be diagnosed with cancer. And now, here was that fear. It felt selfish to even think about how upset all of us in the extended family were, knowing that it was infinitely harder for my uncle, aunt, and cousins dealing with this.

I was so deeply saddened by my uncle's diagnosis that I almost couldn't go back to outpatient clinic to see other people dealing with cancer. I made it through, but I was touched so profoundly that I doubted whether I would be able to work in a field where the endpoint was so often mortality. Outpatient heme/onc is far better than inpatient, but I just had a sense that so much of it is watching and waiting, almost with a resignation that ultimately these patients will have to face their cancer again, that no remission is permanent, that there is no such thing as a complete cure.

I could talk about all of the things I've felt since my uncle was diagnosed, but it feels selfish to talk about, as my personal struggle can't touch what his family is dealing with. Fast forward a few weeks, and he has been set up with an oncologist, getting some symptom improvement with palliative chemo, and we as a huge extended family have made it a priority to spend as much time together as we can for as long as we have him. I'm a person of faith (though not as much as I should be), but my medical background has made me realistic about what to expect. My uncle is realistic as well, and for the most part so is my extended family. I'm still sad and upset, but I've advanced a little in my stages of grief. I still think about him nearly constantly. And reflecting on how my family has dealt with his diagnosis has me thinking about writing heme/onc off the list.

Last week, when I was freaking out about not knowing what I am meant to do with my life, I had a thought. And it was so obvious, I wasn't sure why it hadn't struck me before. I wanted a field that would let me do research and teaching. And the research I had done before was on the heart--but it was also about metabolism. And my research involved not just heart failure, but insulin resistance. I could look at it from the angle of the heart as a cardiologist, or I could look at is from the insulin/metabolism perspective--through endocrinology. Duh.

To be truthful, I had considered endocrinology before, but I had ignored it for several reasons. First, after dealing with my old PI, who was an endocrinologist, I didn't have a very good impression of the field. Second, it is one of the few programs in my hospital that I feel is academically weak--really, there is no basic science or translational work being done (though some good clinical research). However, that "other" big medical system in the city has a very good endocrinology program--which just makes our department seem that much worse.

Third, I hadn't seen people who got excited about their work. So many of our patients are diabetic, and most of the doctors I have worked with refer to endocrinology when they become frustrated with dealing with non compliant diabetic patients. I think it is very important to work with non compliant patients--we as doctors can't give up on them--but it can be a very emotionally exhausting group to deal with as your clinic cohort day in and day out. And as residents, these are the patients we generally see in endocrinology clinic. There are more interesting endocrinology patients out there--but they are the group seen by fellows.

When I thought about endocrinology as an option, I almost smacked myself. I had been excluding it based on my biases from my limited interactions with both endocrinology practitioners and patients. It seemed so obvious now. And while it isn't ideal that my hospital has a weak program, there might be a way I could do some work at "that hospital down the street" if I really wanted to pursue metabolism research.

This past weekend, I was fairly certain that I had worked out my life plan. I had even started looking into programs. I got to keep my interest in metabolism but avoid the emotional pain of dealing with cancer.

And then I started my radiology elective/jeopardy call (jeopardy means that if anyone calls off/needs coverage, I get called in). I figured this was a low-stress rotation that would help me in my radiology deficiencies. And on the first day, I started talking to a radiology attending...doing research in chemotherapy. It was right in my line of interest. We were reading CT scans with the radiology resident (who patiently put up with the hijacked conversation). When the attending started talking about his research, he said, "I can tell that you are interested just by the way your eyes lit up." When he heard about my research background and my chemistry major, he excitedly said, "That's it! You have to do heme/onc--I need to get the next generation excited about this work!" And his work was exciting--and interesting--and clinically relevant.

And in about an hour, I was back to considering heme/onc again.

So I am basically back to where I started. The pragmatic part of me says that if I don't want to do cardiology but I want to keep in the same area as my thesis research, endocrinology is the obvious choice. I haven't yet had an endo experience that has gotten me really excited, but there is still time. The emotional part of me leans towards heme/onc. There is so much potential for impactful research--I don't think I would ever use the word "cure," but metabolism is an obvious target for cancer treatment. The issue is my emotional attachment. It's both a blessing and a curse. I got so involved with my patients on the cancer service--each little victory was so uplifting, but ultimately most of the outcomes were heartbreaking. The outpatient heme/onc experience I had was more positive, but now having had cancer touch me so personally, I don't know if I could disengage emotionally enough to see cancer every day.

I want a practice where I develop a relationship with patients. That is why I chose medicine and not just basic science. I want to see my patients every few months, check in with them, see what adjustments need to be made, and make them feel like they are a partner in their care. I also want to stay involved with research. And I want that research to be clinically relevant. I don't know yet whether it will be bench based or a clinical trial. I just want it to be something that has potential to impact treatment and improve the lives of more patients than I could ever see in clinic. I was to be academically stimulated, I'd love to have the opportunity to teach on occasion, and I want to be active in a scientific and clinical community.

I am an emotional person, and I'm not planning to change that. What I am learning is that I need to control my emotions. There are so many other interns that seem cool and collected at all times. That isn't me. I have yet to do an inpatient rotation that hasn't seen me lock myself in a bathroom for a few minutes just to get a good cry. I accept that, I do what needs to be done, and I move on. I want to be emotionally there for my patients too, but I know that for my own long-term sanity I need to find some space. It hasn't even been a year of residency yet. I know that I am headed for huge burnout if I don't find some emotional distance.

It's hard. I feel powerless when I think about how I've done all this training, and all I have to offer my uncle are the same things I had before: love, support, and just showing up when the family needs to be together. I didn't have to go through ten years of medical/science training and a residency to do that. I hope I am more useful to my patients, but their struggles touch me too. I think ultimately my specialty choice will depend on the balance between pragmatism and emotion.

I am sure that being touched by cancer on a personal level will shape my choice as well. There are things that happen to all of us and to those we love, and there is opportunity to grow from everything. I need to find what I am supposed to learn. I'm still not sure I've learned the right life lessons, but I hope I keep looking.

I've really stepped back and looked at life from a new perspective this last month. I've made sacrifices and begged for help from my coworkers so that I could make family more of a priority. Medicine does a good job of forcing you to put your own life on the back burner. You feel that you owe your "80" hours a week to your program, your hospital, and your patients. What I am (slowly) learning is that I need to be a grounded person to be a good doctor. And family is how I stay grounded.

I don't know what the coming weeks and months will hold. I am sure I am in for many more transformative experiences. And in a few years, I may look back at this post and laugh at how much my thinking has changed. For now, I want to step back, re-evaluate my priorities, and think about how I can be what I need to be for all of the people in my life.

Mid year update

(Note: posted on night 7/8 of night float, as it took me a while to get to blogger from the hospital)

I am on night two (of 8 shifts total) of night float. Essentially, that means that two interns cover the majority of the medicine patients in the hospital. Right now, I am carrying the load of 12 interns overnight. That is intimidating and also completely unreal. I am almost exactly halfway through my intern year, and I figure now (at 2 AM, no less) is as good a time as any to reflect. At least until the next nurse pages me :)

Rotations:
Some of these I have reflected on already, but maybe time has given me more perspective. No time for run-throughs now, just a list...
-Infectious disease
-General medicine (VA)
-Primary care (VA)
-MICU (absolutely hated this rotation!)
-Vacation
-Neurology (disliked, thought it was pointless)
-Cancer
-Urgent care/ MICU coverage (VA)
-Night float

Big changes: I was in the MICU when I realized I didn't want to do cardiology anymore. Honestly, I had been slightly unimpressed with it as a medical student. I attributed that to just following people around, as well as having one community physician not quite be the model that I would prefer (think typical cardiologist stereotype). I was on general medicine when I watched a procedure in the cath lab and thought, "well, I could do this if I had to, but I'm not very excited about it." When I was absolutely hating my life in the MICU, I thought about the fact that the cardiology fellows had up to five months in the CICU, as well as several months in the cath lab. And they were constantly on call--which was not going to change much once they were attendings. I thought about my interests, and then I thought about what I want out of life. I think cardiology has very interesting research potential, but clinically, it leaves me a little cold. And a three year fellowship that was equal if not more time consuming than intern year? I knew I would really have to love something to commit to that. And right now, cardiology isn't it.

I have several friends and colleagues considering heme/onc for fellowship. Superficially, this seems to hit the big points for me: patient centered care with continuity, a patient-physician partnership, research potential, fairly decent work/life balance, and a bonus of getting to use some of my undergraduate chemistry background for chemotherapy.  It's still on the list, and I feel that it needs a chance. But after a month on the inpatient cancer service, I don't know if I have the emotional stamina for it. And two nights of night float have me seriously concerned. I had so many end stage patients, many of whom passed away within days to weeks of discharge. Granted, most of the people we admit have widespread disease and are admitted for management of their advancing cancer, so they usually come in with a poor prognosis. What bothered me most were the young patients, many with families, who are at the end of their lives. We had multiple women in their early 40s with children pass away from cancer. And in the MICU as well as on the floor, I have either covered patients or had patients covered by other members of my team with end stage cancer in their early 20s. It absolutely breaks my heart to think about these people, who a matter of months (or sometimes weeks) prior were going about their lives. Most of these patients passed away within months of their initial diagnosis. I am sure it hurts because it is so close to home. I see myself, or Tim, in these patients. I can't even imagine not being there for my kids.

And I think all of my introspection about my mortality has really affected my thinking about what I want to do. I have spent the last ten years of my life busting my butt to do what I am doing now. I realize that intern year is tough for everyone; I am not fixated on how difficult this year has been and continues to be. But I think about the next step: in 2.5 years, I will be moving on. I will either be starting a fellowship or starting a job as a physician. My life has been about delayed gratification; in just a few short years, there is potential to start reaping the rewards of my sacrifices. What do I want to do? And has it all been worth it?

I feel a great deal of guilt that I spend so much time away from my family. While I am on nights, I get to see my kids for about 45 minutes per day. I am so thankful that night float is only two weeks long at a time, but it really makes me think. I've broken my life up into little chunks just to get myself through it. Only 6 more night float shifts; before, it was, "only two more weeks of MICU" or "only three more long calls." I feel like my life, and in turn my family's lives, are just moving by. I know that this schedule is not unique to me. And it also was not a surprise. I wonder though: what will it take to make me feel that all of this sacrifice has been worth it? What is the measuring stick? Money? Really, that has never been important to me (hence why I could give up cardiology so easily). We have made do on a student's stipend, and residency pay is laughable considering the actual hourly wage when you calculate it. So if not money, then what? Prestige? I don't care. Making a difference? There are lots of other ways to do that; I really enjoyed teaching, and that would have been a viable alternative. Academics? Research? I really don't know.

It's difficult being in a place where you are surrounded by sick people all the time. It skews your perception. And being in a tertiary care center, these patients are SICK. When I was in the MICU, outside hospitals would transfer their complicated patients to us because they were too critical to manage at the other facility. And these patients would come in more stable than some of the patients we safely manage on the floor. So, the patient population notwithstanding, working in a hospital affects your perspective. I've seen young and old people who are sick, critically sick, terminally sick, and many of them die--despite our best efforts. It makes you wonder how anyone can be healthy, how anyone lives to a ripe old age. I am 32; I have had patients younger than me die. It doesn't matter if patients have families, or if they were in school, or if they hadn't finished what they set out to do in life. Disease didn't care. And it makes me fearful for the people I know and love.

I know that the statistics tell us that most people will not die young. However, now having seen it and almost having it feel common, it makes me scared. What if? What if I'm the one that gets cancer next? What if someone I love gets the resistant infection? Will I regret how much (or how little) time I have spent with the people I love? Will all of the decades of delayed gratification really be "worth it"?

One of the attendings that worked on the cancer service offered very good perspective on the patients we see in the hospital. He said that heme/onc is 95% of the time an outpatient specialty. Most patients see their physicians outpatient, get chemotherapy or radiation outpatient, and many are cured or improved as outpatients. The people who come into the hospital are the 5%. Even in his practice, which focuses on late stage cancer, most of his patients do not come into the hospital. Our inpatients are so sick that they can no longer be managed outpatient. He was the one that encouraged me to see patients in outpatient settings before I cross heme/onc off the list.

This year has been so full of ups and downs. I believe I have cried (privately, so far not publicly) on every rotation I have been on. I feel overwhelmed on a regular basis, I feel like I will never learn everything that I need to know, and I worry that all of my training will never help me be a good enough doctor for my patients. And then there are times when I cry for other reasons. I have been touched so deeply by some of my patients and their families. I have never expected recognition from my patients. Really, it's unrealistic, and you set yourself up for disappointment if you expect external validation. But on the occasions where patients or families have pulled me aside and said how much my care means to them, it absolutely moves me. It makes those long nights, those tearful huddles in the bathroom, seem like nothing. Pats on the back from colleagues are nice, but warm words from the people I work so hard to care for are like gold.

It is unoriginal and passé, but I want to be a doctor to help people. I have said for many years now that I want to be a doctor to help people on a personal level, and I want to be a scientist to help people I have never met. I know what I want my life to be like in 10 years. I want to be in academic medicine, with a regular outpatient clinic. I want the opportunity to be involved in research, either as a collaborator or a PI, on a project that is relevant to patient care. I want the opportunity to do occasional teaching, whether it be at the medical student, resident, or fellow level (I would do graduate/undergraduate as well, though I realize those opportunities are nearly nonexistent). I think several weeks per year of inpatient service are fine and would challenge me to stay up to date on more critical care than outpatient alone. And I accept that any job will have call/coverage, but I want that to be less than half of the time (and the less, the better).

I don't know what field exactly this dream job will be in. I always saw myself in a specialty, especially since I want to be involved in research, but maybe general medicine needs to stay on the table. I feel like specializing is a safety net for me, and it fits my PhD persona. I like knowing everything I can about a niche. General medicine intimidates me because it is broad; even with all of the technology available now, general medicine requires you to be a walking differential diagnosis machine. That is not a skill with which I feel comfortable yet.

I really don't know where things will go. And I know it is still a few years away, but it affects decisions now. How do I spend my elective time? With whom do I need to develop a professional connection?

I don't really get a choice about how I spend my time intern year. I took the only choice I had; I elected to change my schedule around by joining a pathway in the program that allows for more outpatient clinic. I am hoping that turns out to be the right decision. Even if I don't do general medicine, becoming a better outpatient provider will be a useful skill for any future path.

I don't know yet how I will determine whether all of the sacrifices I have made are "worth it." And I don't know how long I will have on this earth to figure it out. But for now, I just have to keep surviving for my own sanity, and I have to sneak in as much time with the people I care about as I can. Everything else is outside of my control.

Still here!

Hey there, it's been a while!

In an announcement that will come as a shock to no one, I have had little to no free time since starting residency.

Shocker, I know!

I've been through so much in the three months since residency started that this post can't even start to describe it. Here's a brief summary, but I couldn't possibly express how residency has affected me as a person in three very quick months.

My first month was on the infectious disease service. It is one of the busiest in the hospital, with lots of complex infections. And any patient with HIV, no matter how well controlled and with any medical complaint, gets admitted to the service. I had no ID (infectious disease) background, but I learned a ton. I worked insane hours, mostly due to my intern inefficiency. It took me a few hours to admit each patient--mostly because my history & physical for each patient is a novel--and that will get better, I know. But the first time we had to track our weekly hours for duty hour compliance, I worked 98 hours. Yes, that is over 80 hours a week--but those hours are averaged over 4 weeks. And I'm not faulting the program at all. They are great about having things in place to get us out on time, and with only one exception, every senior resident I have had has been outstanding with helping me get done.  It's just that when you have patients crashing and two admissions that come in right at the buzzer, it's difficult as a new intern to get out in time.  That has gotten better, which I am thankful for!

My first month, I saw so much interesting stuff. I saw patients with HIV who have no detectable viral load and a CD4 count that is better than mine. I also saw HIV patients that were not well controlled or newly diagnosed (but had likely had the disease for years). I saw toxoplasma in someone's brain, tuberculosis, cryptosporidia infection, and other complications. Some patients got better and went home. Others unfortunately didn't. It was a very humbling and informative rotation. It was also an emotional rollercoaster. I had good days and bad days--though I think I was only close to tears once, and I kept it together. Sleep deprivation definitely diminishes my ability to keep my emotions in check!

My second month was general medicine at the VA. Again, I learned a ton, and I was insanely busy. I had some bread and butter patients, and I had some rare cases too. I actually saw a lot of infectious disease here--pertussis, west nile, pseudomonas bacteremia, and others. When they say general medicine, they mean it; we had everything. It was another month of very long hours too. I did finally lose it the last call night I had. I had a patient with a very bad infection who was unstable, several other very sick patients, and I got two admissions at the last minute that I really did not think needed to be admitted. I knew I would be there late, likely till 1 AM or later. I was furiously working to transfer my very ill patient and admit my other two patients. This is when I had the only resident I have worked with that wasn't very helpful. His comment was that I needed to be faster, because now he was going to get yelled at for me breaking duty hours.  I was tired and drained emotionally; I was already upset that I didn't get to see my sister leave to go back to California that day, after staying with us all summer.  I held it together long enough to have a nice cry in the bathroom for a few minutes, pulled it together, finished my work (late, but I did the best I could), and I left.

Last month was outpatient primary care. It was exactly what I needed after two extremely busy months on the wards. Mostly 8-5, no weekends, no call...awesome! It had its own challenges--you went to a different clinic every half day, so it was difficult to change gears, figure out what each attending wanted, learn how they like notes written, etc. I did get a chance to catch up on life--and see my kids, who were shocked to see me every day!

This week, I started time in the MICU (medical intensive care unit). As I posted on facebook, changing rotations every 4 weeks means that you have a day every month--the first day on that service--where you feel the most stupid that you've ever felt. That day was Monday in the MICU. I did no ICU during medical school. I could've done it as an elective, but I did more teaching electives so that I could have an extended maternity leave. My first day, there are patients bleeding, stopping breathing, and otherwise crashing everywhere. It seemed like everyone else was totally calm and knew just what to do. I had to actively breathe so as not to freak out. On the wards, when a patient is unstable, you send them to the MICU. I always assumed the people in the MICU knew more than I did. Now I am the MICU! In all fairness though, I probably have less patient influence in the MICU than anywhere else--which is best for everyone. There is always at least one critical care attending, and we have 24 hour MICU fellows. Plus, there are four senior residents and four interns covering 20 beds. And the ICU nurses are absolutely amazing. They do more than any other nursing staff I've worked with--and I think my hospital's floor nurses are outstanding. These ICU nurses know everything, and they are completely in tune with what the patient needs. Having them around helped me get my heart rate under 150 bpm!

The ICU is such an interesting place--there are patients in for a short time, just requiring a tuneup before they go back to the floor. And then there are patients who are SICK. Many patients are unfortunately in the end stages of their diseases and will pass away in the MICU. This is tough for me, especially because many of these patients are young. I have one patient now that had been barely hanging on--I don't know how much I can describe on here, but every morning I came in and half expected her not to be there. I am off today, and I prayed that she'd get a miracle. And today I found out she did--if all goes well, she'll have a new chance at life after today. I had no part in her getting better, but I'm so glad that now she has a chance!

I'm still completely intimidated by the level of illness in the MICU, but it's gotten better in a few days. My senior residents tell me that I'll be comfortable here by the end of my 4 weeks. I don't know that I'd go that far, but we'll see.

I actually haven't done any procedures yet in the MICU--I've been told I'll have patients needing central lines, hemodialysis catheters, arterial lines, and other things that I will learn how to put it. I'm a little intimidated by that, but I look forward to learning. I did do my first lumbar puncture within days of being on the infectious disease service--and I had a champagne tap too (no red blood cells in the cerebrospinal fluid from a traumatic tap). That's given me a little confidence that I can overcome my nerves and do what needs to be done in a pinch. I don't want to do critical care long term; I'm not enough of an adrenaline junkie! I am learning a ton though.

Life has been insanely busy these last three months. There has been some life reflection in the fleeting quiet moments I have that made me think about what I want out of life long term. It has me rethinking medical specialties, but I am still very undecided. More on that another day.

For now, I'm home today (because I work both days this weekend). Time to finish the bills, get my car fixed, and generally tackle the massive to-do list that backs up after months of working 80 hour weeks.

Again, no promises on frequency of posting. I'll do what I can, but my guess is it will be a busy month!  In general though, I am doing well, my kids are hanging in there (thanks mostly to Tim doing the kid care, with help from Amy for a few months and our families in emergencies). I've had low moments to be sure, but overall I am learning a ton. I've got a great group of supportive people in my program--which is absolutely mandatory. So far, so good.

Because Facebook is all I have time for...

Momentous day, as posted on Facebook:

Survived my first day of intern year. Only spent 15 hours in the hospital, ran to one code (which was a false alarm), and had patients that were much more stable than they sounded on signout last night. It was an anxiety-filled day, but much better than I expected. So glad to be in a program with wonderful, helpful, and smart people :)

Last day

Today is my last day at home. Tomorrow I begin orientation for my internal medicine residency program, and I start on the floors on June 24th.

Where has the time gone? I remember thinking that 4.5 months of maternity leave would seem like an eternity, especially after being back at work 6 weeks after Sophie and working weekends 3 weeks after Josh (and back full time at 8 weeks). 4.5 months? That's forever! I had a huge to-do list, and I had big plans about taking trips with the kids.

Well, time's up. Some of the to-do list got done, but most of it did not. We did manage a few trips together (like to the local zoo), but those were usually weekends when we could all be together. I think yesterday was the first day I took the kids somewhere by myself (that wasn't to a family member's house), and that was just a quick trip to the library. I've taken them out in different groups, but one adult to three kids had me scared. Actually, it was mostly just worry about Josh--what if he bolted or wandered off while I had all three by myself? Sophie is a good listener, and Noah doesn't move yet--Josh is the worry.  But, the library went fine, and now I wish I would've taken them out more on my own.

I am pretty nervous about starting back tomorrow. Some of it is due to the fact that I haven't touched a patient since November. I front loaded my fourth year schedule and didn't take any vacation so that I could take electives and maternity leave starting in February. I have a feeling the patient skills will come back--though I have been re-reading some med school material to make myself feel better.

A lot of my anxiety has to do with the kids. I know Sophie and Josh are fine at daycare. Actually, they are better than fine--they really like it, and they've each been upset when I've kept them home (though they usually get over it quickly). Noah is going to be nanny-ed by my sister until August, then he will go to daycare too. We have a mix of family coverage until my sister gets home from California, but I know he'll be fine.

At least he'll be fed...

 

over 300 oz of milk in the deep freezer, and a few more bags upstairs

Though I can't guarantee he'll sleep. He's surprised us twice now with 7 hours stretches of sleep at night, but most of the time we get a 3-4 hour stretch, then a series of 2 hour stretches. Hey, it's progress.

I do have a few regrets about my time home:

-I wish I had made more of an effort to pump. Yes, 300 oz is awesome, but that was just random pumping. If I had tried to pump regularly, at least once a day, we might've done better. I am not going to beat myself up if I can't keep up with him once I go back to work. I'll bring the pump, and I'll do my best, but I had trouble keeping up with Josh once I started third year. I am sure residency will be even harder. More in the freezer would've prolonged the guaranteed breastfed time.

-I wish I would've gone out more. A big problem was that I was so sleep deprived for probably the first three months. I got less than four hours of sleep--and those were in short bursts--most nights, and he wasn't a consistent napper. I think I got two naps in the whole four months I was home. I just didn't feel like I was coherent enough to take him out when I was so tired. And he was still colicky for the first few months--the last thing I wanted was a melt down in public.

-I wish I would've made exercise a routine. I just started watching my diet a few weeks ago, and I've lost a few pounds (and am now down to about 10 pounds under my pre-pregnancy weight, with a lot more to go). Tim signed up for the Warrior Dash in August, and he's been getting up at 5 every morning to train. I wish I had that motivation. I had planned to get up before 5 several mornings a week so that Tim was still home with the kids. With the poor (or no) sleep I was getting, I couldn't justify purposely sacrificing potential sleep to exercise. Noah and I have gone out a few times walking, but the weather has really only started cooperating in the last few weeks. I've always been exercise-averse, and I feel like I just lost a once in a lifetime opportunity to make exercise a habit.

-I wish I would've cooked more. By no means did we starve, but I had planned to try a bunch of new recipes (especially for the crock pot) so that we wouldn't fall into a rut when I went back to work. Didn't happen. I am hoping that when my sister comes home, maybe she can teach me some healthy recipes that aren't too much work.

Things I am happy with:

-Despite having the to-do list, I did a better job this time of just going with the flow. I recognize this is probably the last baby we'll have, and this is definitely the longest time home I will ever get. If Noah just wanted to snuggle all day, that's what we did. Some days were productive, many were not, but I always tried to put Noah's needs first.

-I have so far avoided the mind games that plagued me the last two times I seriously committed to losing weight. This blog actually started while I was doing "crazy talk" and coming to terms with my binge eating disorder. Diets in the past have really messed with me, and ultimately I've ended up worse off than I was when I started. This time, I have been able to detach myself emotionally. When I have a rough day, I move on to the next day. I know why I have good weeks and bad weeks. The diet has been far from easy--if they were easy, no one would be overweight. It is a constant job to make good decisions. And whatever the outcome in terms of weight loss, my number one goal is to avoid the mind games that have plagued me in the past.

-I am looking forward to starting residency. Of course I am nervous, but I feel like I made a good choice in terms of my program and my field of interest. I am looking forward to the interaction with my co-interns and my patients. I've missed that.

Today is bittersweet. I am happy to take the next step--especially not being a student for the first time since I was 5! But I know how much residency will take time away from my family. I know Tim can handle it, and we stayed here so we would be able to call on family if we needed to. But I'll miss all of the time I've had with the kids. Seriously, all I have to do is look at them, and I smile.

I know I will still get time with them, but I also know there are many nights that I'll miss dinner, playtime, and bedtime. I make a point to tell them how much I love them. I tell them that just because I have to go to work doesn't mean work is more important. I love my career, and I love helping patients. That is part of me as a person. But my family takes priority. Once my training is done, I will have the ability to choose what type of career I want to pursue. Until then, it'll be about quality time, even if the quantity isn't what I'd like it to be.

Tomorrow, I'll be someone's doctor. That is frightening and exciting. I respect that responsibility, and I don't want to be just an ok doctor--my patients deserve better. It's time to find the balance in my life in a whole new way.

Time never stops

It's been an introspective few weeks. Tim's grandmother passed away last Tuesday after a long battle with cancer and many other serious health concerns. While her illness allowed enough time for everyone to say their goodbyes, it was tough watching her be in so much pain. She did live to be 90, which seems like such an amazing thing to me. Tim now has no living grandparents. I have my mom's mom, and that is all.

I can remember my dad's grandmother vaguely, but I do have strong memories of all four of my grandparents as well as three of Tim's grandparents. That's truly a gift. It got me thinking about how each of them has passed away on different terms.

My mom's dad passed away when he was 74. It was not an easy few weeks--he had several heart attacks, and there was much contention about whether to let him go or try heroic efforts in ICU to potentially let him live less than a full life. It tore my mom's family apart for many years--my mom came in on the not at all popular "let him go" side--and I still think things are tense sometimes because of the rift that formed. I don't wish to speak ill of the dead, but of the 14 years of memories I have of my grandfather, I honestly can't think of a happy one. Most are neutral; he would sit at the kitchen table by himself, watching his shows, while everyone else congregated in the living room. Some memories are negative; he had a mean temper, and some of my older cousins got on his bad side on more than one occasion. Still, he was my grandpa, and we shared a birthday, so his death was a sad time.

I remember being 14 and thinking that 74 seemed old. My grandmother was a widow at 69. At the time, that didn't seem so strange. It was the first death close to me that I was old enough to remember. I do remember my grandmother being so upset at his funeral, and I remember thinking that I wouldn't be so upset at the loss of a man who had basically been a nasty alcoholic his entire life. Remember, I was 14 then. Things were very black and white for me.

I think back now, and many things strike me. One, love is a strange thing. It's not black and white. Someone can hurt you over and over, and you still love them--you still miss them when they are gone. And now having some experience with alcoholism (and Al-Anon) in my own life, I understand how alcoholism as a disease affects families. My mom's family is textbook for the family of an alcoholic. I can see that now; I couldn't see it then. Each person deals with the struggles of the disease in different ways, and that isn't always obvious to outsiders. As a young teenager, I couldn't see it.

I also think about the ages of my grandmother and grandfather differently now. 74 and 69 are no longer old--they are young. Tim's parents are in their mid-60s. They are thankfully healthy and full of life, but I can't imagine losing them any time soon. And my grandmother--she has had almost 18 years of living as a widow. She initially stayed very involved with her church and her friends, but that waned. And then she was in an accident and could no longer drive. And then her church closed. She's had multiple cancers and serious health issues, and her memory has been declining. But now my aunt lives with her, my mom and her sisters pitch in to keep her company, and the family tries to visit as much as we all can. Still, she has had a tough life. No one knows how much time they have left on earth--I hope it is still years for her--but I'm learning it is what you do with the time that counts.

Tim lost both of his grandfathers while we were dating. His dad's dad, who I only met a few times, was a fiery Irishman. Tim's dad's family isn't close, but his grandfather always seemed very nice on the occasions I saw him. He died suddenly of a heart attack while I was on vacation with my family, so I missed his funeral. What I remember most about his passing is the aftermath--Tim helping to clean out a house that could've been on Hoarders, the contention about whether to include one of Tim's uncles in the will, etc. It seemed very stressful, and it was one of the first times that I thought about making sure I didn't leave a mess behind when I left this earth.

Tim's other grandfather, the husband of his grandmother who passed last week, died in 2001. I was at the NIH for a semester, and when I came home for Thanksgiving, Tim's grandfather was diagnosed with a brain tumor. I never heard what kind--though now I can guess--and he died less than two weeks later. My biggest memory of that time is taking all of my finals at NIH early, packing up my part of the three person apartment into my little Chevy Cavalier, and setting a land speed record to get from Washington, DC to near Cleveland in about 5 hours. I had just enough time to change and switch cars before calling hours. I was 21 then and old enough to be a little more savvy about love and loss than I was at 14. I remember Tim's grandpa as a kind, quiet man. He didn't talk a lot, but he was always smiling and friendly. There was so much sadness at his funeral. Everything had progressed so quickly with the cancer that no one really felt like he was gone. He and Tim's grandma had been inseparable--Tim's grandma didn't even have a driver's license. And Tim's grandma had been the one with health issues for many years. While sadness was the number one emotion at his funeral, worry about his grandmother's future was the number two emotion. She ended up living 10+ years without him, but she eventually moved from their apartment into an assisted living facility in the same complex. That was an absolute godsend for her--it kept her social, kept her memory sharp, and kept her chronic medical diseases in check. And when it was time for hospice, she could stay in her room and get the care she needed.

I lost my father's parents in the span of about a year. My dad's dad--my Pop-Pop--was exactly what you think of when you think of a grandfather. He was warm and loving. He lit up whenever the grandkids came around. He had special habits that were all his--getting us to eat vegetables by calling them "racing beans," telling us crusts of bread are what make hair curly, sharing his butterscotch candies, showing us the moon...there are so many things that I remember. Most of all, I just remember how much my grandparent's house was always filled with love. My grandfather developed Alzheimer's when I was a teenager. I think he was officially diagnosed about 7 years before he died, but the signs were there before his diagnosis. It was heart wrenching to watch him progress in the disease. He could still smile and nod when you talked to him, but he wouldn't be able to tell you your name if you asked. Initially you could tell he still knew who his family was, but as time went on, we all became strangers to him. The last few years of his life were especially difficult on my dad's family. Everyone wanted to keep him at home--no nursing homes--but he was wandering off and could occasionally become aggressive. My dad and his siblings each took one night a week at my grandma's house so she could at least get some rest. It was draining on my grandma, my dad, his siblings, and all of the families, but the unspoken word was that you did what you needed to do because of family.

My grandpa passed away in May 2005. He was in hospice with pneumonia for only a few days before he passed, but it gave everyone a chance to say their final goodbyes. I think we all had mixed feelings. It was such a heartbreaking loss to lose Pop-Pop, but we had lost him years earlier to Alzheimer's. We had been mourning him while he was still alive. It was so hard to watch such a wonderful, dignified man become a child again. Alzheimer's is a horrible disease. We all dug into our faith--which had been modeled for so many years by my grandparents--and realized that if you truly believe in heaven, you have to be happy that he is finally in a place where he was no longer contained within the prison of Alzheimer's. I knew that my grandmother believed that; she had the strongest faith of any person I've ever met. The most heartbreaking thing I have ever seen was when she accepted the US flag at the veteran's cemetery for my grandfather's service in WWII. That strong, vibrant women looked pale and fragile. Just watching her try to be the matriarch in the face of all of her pain made me sob.

Although she would absolutely never say it, we all felt like taking care of my grandfather had to be a burden to my grandmother. She was a vibrant, active women. She had been going next door to my dad's family's church nearly every day before my grandpa got sick. They used to sit on their front porch and say hi to everyone who passed--and she knew just about everyone in their town. I thought that returning to her social life after my grandpa passed away would restore the twinkle in her eye that had dwindled with his illness. Instead, she always seemed a little sad. She would light up whenever she had visitors--and a chance to cook a big meal--but I always felt like there was a little part of her missing.

The last time I saw her was at Easter in April of 2006. We were at my aunt's house, and she seemed so happy to see all the grandkids looking for Easter eggs. I have pictures of her on my aunt's front porch smiling widely at the chaos in the front yard. We talked briefly about her upcoming back surgery. She called it a minor surgery to relieve a pinched nerve. She was looking forward to being able to be active again without dealing with all of the pain.

I was in the lab when my mom called and said she had passed away. She had the back surgery, but then she coded in the recovery room, and they couldn't bring her back. The thought is that she probably had a heart attack. We were all in complete shock--she had no major health problems, and no one expected any problems.

I posted about her here. One year to the day that my grandfather passed away, we buried my grandmother. That was by far the hardest funeral I have ever attended. She was the center of the family. I had thought she'd be around to see my kids. She left about a year and a half too soon for that. She was in her late 70s but seemed so much younger. I still miss her--I think about how much she would've loved to see all of the great-grandkids that have been born. If I can give 1/10th the love that she gave to her family, I would consider my life a success.

When we were at the veteran's cemetery on Friday morning for Tim's grandma, my dad came down to help with Noah. We hadn't brought any of the kids to the calling hours or the memorial service the night before, and the big two went into daycare on Friday morning. Noah was pretty well behaved, but my dad took him just in case so Tim and I could say goodbye to his grandmother. After her service, my dad took us to the place in the cemetery where his parents were laid to rest. I showed Noah their names on the wall and told him how much they loved babies. I wished her a happy mother's day and said goodbye. When the kids are older, we'll take them to see their four great grandparents buried in that cemetery. We'll visit the other great grandparents too. We'll tell them about how much they loved their families. We'll look at pictures and tell stories. I want them to know that these people meant so much to us. Saying "family comes first" means much less than showing them people that lived for their families.

I can't believe how quickly time is moving. I remember events from ten years ago like they were yesterday. Tim and I have been together for 16 years--we started dating in 1996--and I still remember those early years. Now we've been married for almost 10 years. We have three kids--one of whom will be five this year!! Noah will be four months old at the end of the month. He no longer looks like a newborn. He's filled out--he's definitely an infant now. He rolled over multiple times yesterday (tummy to back), so he's officially mobile. Where has the time gone? Even being home with him most of these last few months, I still don't know where time is going.

Every time Noah hits a milestone, I get a little sad. While I would love for him to sleep better, I love the baby stage. I put the 0-3 month clothes away a few weeks ago and got choked up. That is likely the last time we'll use those clothes. This is probably the last time I'll have an infant learning to roll over. I know a few posts back we talked about maybe having another, and that door hasn't completely closed, but each day has us thinking we are done at three kids. There are lots of reasons, which I won't go into today, but I think the little baby days are quickly moving behind us. Being sad about it isn't a good reason to have another one--at some point (unless your last name is Duggar), you have to be done.

I love our little family. I am exhausted, but already I see that Noah at 3 months is easier than newborn Noah. And I look at Sophie and Josh, who (pretty much) sleep through the night, and I know the sleepless phase doesn't last forever. My kids are getting so big--I look at Sophie and am awed by the little person she has become. Josh's speech has exploded in the last few months, and his impish grin makes my heart melt. I know my time is going to be tight in the coming years. I signed up for that willingly, and I do have mommy guilt over it more than occasionally. We may not have the quantity of time together that I want, but I want the quality of that time to show them how much I love them. Both Tim and I came from loving families, and we've had great models of love in our grandparents. I want my kids to be close to their grandparents--I want them to have the same feelings of love, security, and comfort that I had. And I want them to grow up knowing the importance of family. If I can do that, I'll consider my job as a mom a success.

3 months

Where has the time gone? Noah is 3 months old today. Last week, Josh turned 2, and Sophie was 4 and 1/2. I have absolutely no idea where all of the days are going, but life just keeps moving faster and faster!

So, current stats:

Eating: well. About every 3 hours when he is napping well, a little more frequently when he's up. No latching issues with him since day one. Also, I haven't begun a pumping schedule yet to prep to go back to work. I've just been pumping before and after I go out of the house (like all the med school teaching stuff I've been doing). Somehow, I always end up with a lot more pumped that he drank. From that, I've got about 250 ounces of breast milk already in the freezer. Glad we have a chest freezer downstairs--I ran out of room in the main freezer! I'm hoping that the success with feeding continues--I know things will get a lot tougher when I am on the wards.

Sleeping: slowly getting better, but not great. I am not exaggerating when I tell you we have tried EVERYTHING to get him to sleep. If it's on babycenter, an online forum, or been done by anyone I know, we've tried it. Against my better judgment, he is sleeping in the bed, between Tim and I, because the only way he sleeps is to hold onto my face with both of his hands. Even then, he is up every 3-4 hours--which is much improved from the up every 90 minutes we were doing before. By the time I feed and change him, that was giving me only about 45 minutes of sleep in bursts. Now I get 2-3 hours at a time--if he isn't restless. Unfortunately for me, he is a loud, active sleeper, so I often get up to make sure he's ok or replace a binky. It's still a work in progress, but it is getting better. I really want to get him out of the bed ASAP (especially since I rolled out of the bed the other night, due to space issues). We know about pillows, blankets, etc, and have tried to make the bed as safe as possible, but I will feel much better when we can get him into the crib. The bassinet is now too small, because he wakes himself up with all of his activity (that inevitably hits the side of the bassinet). I'm working on the crib thing...

Routine: I'm trying to get him more on a schedule, which seems to have gotten him to the 3-4 hours of nighttime sleep stretches he currently has. Baths just wake him up, so we do those in the morning. I am trying the eat-play-sleep routing during the day. I don't wake him up if he is sleeping, but I'll feed/change him, then play with him for a bit to get him tired, and then get him back to sleep no longer than 2 hours since he got up. He likes to be part of the party, and the overtiredness was making him a bear to deal with at night. I'm working on the daytime nap situation too--so far, he'll only sleep in the swing or if I am holding him, which I am trying to work on too.

Can you tell that we were so desperate for any type of sleep that we tried everything?

Otherwise, things are good. The three amigos get along very well, and Sophie and Josh have both taken extreme interest in helping out with their little brother. The car got small quickly. We realize we will have to scale up to a minivan eventually, but we are trying to hold out as long as possible.

We've already upsized from 0-3 month clothes to 3-6 month clothes a few weeks ago, and Noah has hit a growth spurt that suggests we'll be moving up again in a few weeks.

I'm not getting as much done as I had hoped--this is more than twice as long as I was off with the other two--but I'm ok with it. I'm enjoying our time. I'd be lying if I said I didn't miss just have some alone time, or time with other adult humans sans kids, but I know residency is going to limit my kid time in the near future.

So yeah, time is flying. We've already brought up the exersaucer and the Bumbo seat, which Noah enjoys for brief periods. He is a loud, chatty boy who loves to smile and squeal (no real belly laughs yet). Pretty soon, he'll be rolling over (he's done it once already by accident), jumping in the jumparoo, sitting up, eating cereal, and probably getting teeth. These next few months will fly by too, I am sure.