Thursday, December 23, 2010

Peds recap

Late, as usual, but here is a quick recap of my one month pediatric rotation (done in November). I'm a little behind partly because I have been crazy busy, but I've also been trying to think about what to say that might be helpful when 4th year "me" is debating about residency applications.

Peds (pronounced PEEDS in the biz) started out not so great, as I noted in an earlier post. It did get better, though as I will mention in a minute, many of the undertones of concern from that first week lingered throughout the rotation. Overall, it was pretty benign--any of the really sick kids get sent from the hospital I was at to main campus. Basically, my team's job was to recognize when kids were really sick and needed to be sent out ASAP (there were a few of these), when we could treat them in-house, and when they could go home. Part of the issue was that outside pediatricians could admit their own patients, but as the house team, we did their admission history and physical (H&P). There were many times where we checked the patient out and really didn't think they needed to be admitted, but the outside pediatrician was in charge of their care, so we went along with it.

Most of the kids fell into: bili babies (high bilirubin in newborn babies--they just spent some time under phototherapy lights), gastroenteritis, RSV/bronchiolitis, asthma, or MRSA cellulitis. There were a few other kids that didn't fit into this category, but I'd say 90% of the kids were one of the above. There was one case that was pretty tough emotionally (in addition to the one I talked about before): we had a 5 week old boy come in for failure to thrive, and he ended up having pyloric stenosis. He got his pyloromyotomy, stayed in the hospital a few days, gained some weight, and went home. There were concerns in the hospital about the mom--she wasn't all there, and she visited for about 15 minutes a day while the baby was in the hospital. There were no outward signs of abuse, and social work checked her out, so the baby went home on a Sunday.

On Tuesday, the baby was back in--he had lost significant weight even in the two days since he went home. When he was admitted, mom was told she needed to stay with him 24/7 and do all of his feedings so that she could be observed. She had been given a rigid, every 2 hour feeding schedule, and it came out the first night he was in that she hadn't been waking him at night (or if he was sleeping during the day) to feed him. There was a lot of drama with her, and the baby was still vomiting most feeds/not gaining weight, so it was a tense few days. Two or three days into the baby's admission, the mom admitted that the baby was too much for her (she had a 4 year old at home too), and she was willing to give the baby up for adoption. It came out that she didn't even know she was pregnant until her third trimester, the baby's father was a short term relationship, she hadn't told him about the baby, and he had cerebral palsy and would be unable to care for the baby even if he had known.

It was an obvious relief to her when she heard that she could give the baby to a family who could love and care for him. It turned out that an extended family member (along the lines of a second cousin) wanted the baby, and adoption proceedings started the next day. As soon as the mom said the word "adoption," she left the hospital shortly thereafter (visibly relieved), and the baby was put into temporary care with the future adoptive family (the mom gave them temporary guardianship) while social work figured out the details.

It had to be tough, but at the end, it really worked out for the best for the mom and baby. I wish them both the best.

So, there's a mostly happy ending. Overall, most parents came in, obviously concerned about their kids, and they were cooperative and pleasant to work with. I loved working with the kids--they were sick enough to be in the hospital, but they weren't chronically sick, so they felt better pretty quickly and were social/playful while on the ward.  I am sure it is much different with chronically sick kids.

The likes:

-The attendings. Personality-wise, I am probably a perfect fit for peds. All of the attendings were awesome--great teachers, interested in the kids, social and helpful with the team/each other, and they all had lives outside of the hospital. I had a lot in common with them, so there was always a lot to talk about on call/during downtime. I missed them as soon as I started OB!

-The kids. I just like kids. This was a good group of patients, because we helped them from being really sick to being nearly 100% recovered within a short hospital stay. Again, this is totally different from chronically ill kids.

-The lifestyle. This group is a hospitalist group, so they rotate weeks on service and overnight call. Many of them are hospitalists at several local hospitals. Your service week is 8-5, and call is 5PM-8AM (with 24 hr weekend call). It works out to a week of service every 5-6 weeks and call a few times a month when you are not on service. It's great.

-I'm not going to put salary as a plus or minus. It's not as much as adult, but once again, anything is a step up from where I am now.

The potential dislikes:

-The parents. This is a potential dislike, because there were only two cases in the month I was there that parents were a big issue. Most were compliant and pleasant. However, I can see how, long-term, parents could be a stress. If they aren't interested in helping their kid get better, that would infuriate me. I'm an overprotective person, and it wouldn't be very professional to go all mama-bear on them.

-The routine. The way I see it,there are a couple of types of pediatrician lifestyles. There is outpatient, which really doesn't interest me (though I have yet to do this part of my rotation). That is full of well-child checks, colds/flus/strep/ear infections, and other non-intellectually-stimulating activities. There is always the chance you will see a really sick kid who needs to be admitted ASAP, and a pediatrician needs to remain vigilant for that reason. The other end of the spectrum is something like peds heme/onc, where you deal with chronically sick kids (cancer patients, in this case). From what I've been told by attendings, kids that have to stay inpatient for their cancer usually die, and I think working with dying kids would be exceedingly tough. My attendings said that most kids can get their treatment on an outpatient basis (after an initial inpatient admission), and those are the kids that can do ok. My one attending said that every kid she followed during her inpatient heme/onc time died within six months of her seeing them. I don't think I could handle that. The general inpatient I was on this month would be ok, but even I had the protocol for the usual diseases memorized in a month. I don't know if I could do that long term--I might be bored to tears.

The happy medium is probably a pediatric specialty. We had a few cases at the very end that involved a pediatric cardiologist, and that could be a good overlap between my cardiac research and peds. I'd need to do an elective to see what it is really like, but it's a possibility.

-The unknown. I really like kids, but I don't know how it would be to have my own kids and see other people's sick kids all day. Would it make me a hypochondriac about my kids? Would it burn me out? I don't know.

So, the overall is: maybe. I'm curious to see how I like medicine. I think peds stays on the list, unless I find out that I absolutely love something else. If it does stay on the list, I need some more exposure, both more serious illness (like a peds ICU, which someone suggested) and some specialty exposure. I am just worried that I may not have enough time in 4th year to sort all of this out.

I have one more week of OB/Gyn after the holidays, and then I can give that recap. Overall, I have to say that I am very unimpressed so far (to put it mildly).

Thursday, December 16, 2010

Nearing a break

I am so over OB/Gyn--I have one more week of it left after the holidays, but starting tomorrow afternoon, I get two weeks off for Christmas! This time will be filled by a huge catch-up list, which includes some blog time. I need to catch up on sleep first--I averaged 4-5 hours a night before going back to third year, 1-2 hours/night while I was writing my thesis/doing 3rd year (and several sleepless stretches of 2-3 days at a time), and I'm up to 3-4 hours per night right now. I'm functional, but I'm not fun. There is some serious sleep debt to fill (I know you can't actually make up a sleep debt/bank sleep, but it isn't going to keep me from trying!)

I just have to get through tomorrow, and then I only have my giant to-do list left!

Sunday, November 28, 2010

Neuro rundown

It's been over a month, and I am still not sure enough time has passed for me to give an objective overview of my time in neurology. Therefore, this will be a shortened recap, because there is no chance I will do neurology as a career.

The neuro rotation is one month long, and I did mine at the VA hospital (though a different VA than the one at which I did psych). The attendings switch every two weeks. My first two weeks, my attending was pleasant but demanding. I mercifully did not have to localize any lesions for him (though the other med student did, poor thing), but his MO was to pimp you until you couldn't answer any more questions. There were two junior residents and a senior on the team, in addition to the two med students. The juniors saw the admissions, and the senior saw the consults, but when there were med students, we saw the consults. Most were old strokes, Parkinson's, rule out NPH (a constant and perennial favorite), etc. There was also an MS clinic Tuesday mornings and a general neurology clinic Monday afternoons. Those first two weeks, we had around 4-8 admissions and another 5-10 consults we were following, with a few new ones every day (and about an equal number signed off/discharged every day). It was busy, but the attending was very efficient. We started about 8 (and we pre-rounded before that), and we were done by 5-6 PM most nights.

There was some teaching built in--we had a teaching session with Dr. Daroff every Wednesday morning. I don't usually mention doctor's names, but Dr. Daroff (I have been told) is probably the leading living general neurologist. He's my kind of guy--he's been around for decades and loves telling stories. We learned about the different types of reflex hammers (he knew Babinski well!), locked-in syndrome via his own experience with perhaps the most famous locked-in patient, etc. I can listen to people like that talk for hours. He was a great diagnostician too, and we had him look at some of the trickier patients on the floor.

We also had grand rounds every Friday AM, followed by case studies the rest of the morning and regular small groups back at the med school every afternoon. It was different than psych, which had didactics spaced throughout the week instead of all crammed into Friday, but it worked. Because so much of psych occurred in AM rounds, losing Friday morning would've been much more detrimental than it was on neuro, where we were busy all day. And I was thrilled to have one whole day away from the neuro team.

So, the first two weeks were very busy but manageable. I saw some interesting cases, like progressive supranuclear palsy, ALS, fluent aphasia secondary to glioblastoma multiforme resection, and others. I also saw a lot of bread and butter neuro too: Parkinson's, old stroke, dementia, multiple sclerosis, coma, seizure, and syncope. I did not see a single new onset stroke--the other med student saw one, but most of those patients went to a different hospital system (which has a specific stroke service).

Overall, I was struck by how little we could really do for these patients. Even if the second half of my neurology rotation (which I will get to) never happened, I don't think there is any way I'd want to do neuro in the future. There is some treatment for Parkinson's, seizure, and MS, with varying degrees of success, but most of the patients I saw had no available treatment options or had exhausted all available therapy. And, I hated neuro in second year med school, and my feelings on the nervous system in general haven't changed. No offense to budding neurologists, but neural tracts and localization are the stuff of my nightmares.

As I mentioned, the neuro attendings change every two weeks. My first attending was demanding but fine. The second one was hell on earth.

He had a weird affect and poor social skills--I wondered if he was Asperger's or some other autism spectrum--and his mood varied from generally annoyed to hating life. He was super anal retentive; we timed vibrations at multiple joints with specific frequency tuning forks, he made his own reflex hammer because every available hammer was sub-par, and we measured muscle bulk on patients with a tape measure to compare symmetry. And, even if the patient was a consult, you were expected to have looked through every note in the chart (some of these patients have almost one thousand notes). It took hours to do a history and physical, and several more hours to look over the chart.

Thank goodness the service slowed down--we had 0-2 admitted patients and 2-4 consults at a time. Even then, we stayed till 8 PM or later (sometimes 10 PM to midnight) just to see a low volume of patients. These were non-call nights; medical students were supposed to take home call once a week until 9 PM. Obviously, when you are staying in the hospital as late as we were, every day is basically a call night.

The resident team also switched, and while the juniors were fine, the senior was much less efficient and involved. He hated working with the attending, and rather than helping everyone else get done, he just left people alone and let the attending get into it with them.

There are tons of examples about how tough it was to work with the attending--he was a grouchy man usually, and he loved to pimp (and was happy to call people stupid on a regular basis--he was equal opportunity with that). He was rude to everyone--he actually got into a screaming match with another attending during clinic, right in front of a patient's room. He was unprofessional and nasty. And then, he'd suddenly change and try to be social. He'd talk about his kids, movies, music, etc.

I've got to share this one story--we were in the work room, and somehow the topic of kids came up. I was the only one with them, and he asked me how many I had and how old they were. When I told him, he asked me if I had ever seen the movie "Idiocracy." I said I hadn't. He said that I had to have at least one more kid, because right now I was only replacing Tim and I in the tax base--I wasn't adding to it. He said that people who did not contribute to the tax base (but drained it instead) were having many more children than were taxpayers, and it was my job to produce offspring that could continue to support generational welfare. Otherwise, the political system would collapse, and there would no longer be a tax base to support the government. Basically, the idiots would take over.

Umm, ok...

Even after brief moments of what appeared to be interest in people's personal lives, he could then switch gears entirely. The day that broke me was Sophie's birthday. It was a Monday, and I had told him on Sunday (you had to round at least one day on the weekend) that my daughter's birthday was Monday. I reminded him again on Monday morning. The service was slow--we had one admission and a few consults that we had been following at a distance for a while. Of course, rounds still took forever. By the end, we had two new consults, one in the ER and one admitted to another service. I took the admitted patient and a resident took the ER patient. Neither was life threatening--mine was a rule out NPH (turned out to be a 93 year old with moderate dementia), and the other was a Parkinson's patient who was out of medication.  We each had our H&P's done by 2 PM, but the attending couldn't come back to round right away. He didn't say when he'd be back--he just told the team to wait until he got there.

We waited for four hours--he finally showed up at 6 PM. I was already upset that I was late for Sophie's birthday. The senior tried to tell the attending that my patient could wait until the next day's rounds, but he wasn't having it. He wanted to see the ER patient first, and he was shocked when we got to the ER and the patient was gone. The ER doc said the patient got tired of waiting and went home. Instead of letting that go, we had to go through all the records, talk to every nurse/doc in the ER to see what they knew, try to contact the patient at home to have him come back in, etc. At this point, it is after 8. The senior again says that my patient is admitted on another service and can wait until the morning.

Instead, the attending sends everyone else home except for me and the on-call resident. He sent the senior (who saw the patient with me after I did the H&P), the other junior resident, and the other med student home. Worse, he singled me out, saying that I hadn't been on call that week (it was Monday) and I was supposed to be on call every week (it was actually supposed to be every other week). I can't express to you the nasty tone he took with me. He was one of those people that you couldn't reason with. The senior again said that this patient could wait, that the senior had already signed my note, and that it was my daughter's birthday. The attending said he didn't care. So, he and I went to see this very basic patient, spent forever doing another H&P, ended up just signing the note I had already written, and then said to me, "You make me tired. I need to go home." It was after 10 PM.

The on-call resident had to go to her car to get something, and she and I walked out together. I didn't even get to the parking garage before I burst into tears. I composed myself pretty quickly, but she again said that everyone knows this attending is terrible, people dread working with him, he's nasty to everyone, and I shouldn't take it personally.  I heard this from so many people--including the clerkship director, who apologized profusely for making me work with him. It didn't stop me from crying the entire drive home that night. Sophie was in bed when I got home, and she had been asleep when I left in the morning. I didn't see her awake at all on her birthday. We did celebrate it as a family the night before, so I didn't miss the party, but I didn't get to spend time with her as a family at all that night.

That was a Monday. I had to go back Tuesday, but then we had didactic sessions all day Wednesday (which unfortunately, this attending had a one hour block of teaching scheduled), the psych shelf exam Thursday, and the neuro shelf exam Friday. I steeled myself and spent Tuesday doing what needed to be done, but had I needed to spend one more day with that man, I don't think I could've taken it.

There are so many other things that made me hate my neurology rotation, but dealing with that skunk of a man for two weeks sealed it for me. I know not everyone is like that, there are bad attendings in the world, etc, but the fact that his behavior was well-known and yet still tolerated by the neurology department confirmed that this was not a group of people with which I wanted to work any further.

Anyway, it's done, I survived, and I don't have to do any more neurology until maybe residency. And now, I will probably try to erase it from my mind. Interestingly, I got my written evaluation for my neuro rotation, and it is actually positive and complementary. I don't know my final grade yet, but I was shocked by the clinical eval--I was sure this guy would just rip me a new one. Maybe he was having a good day...

A pediatric rotation recap to follow soon--at least that was much more pleasant. I start OB/gyn tomorrow, so wish me luck!

Tuesday, November 09, 2010

Done!

I defended my PhD today, and I passed. So, I guess that makes me a doctor! Well, kind of :) Half of the MD/PhD down, half to go! Now off to celebrate :)

Thursday, November 04, 2010

Peds, week one

Neuro redux coming soon...lots to say on that one, but let's just say it is off the list of possible career choices!

I started pediatrics on Monday...really Tuesday, since Monday was just orientation. My medical school class gets divided into three health systems for each clerkship, and then each of the health systems subdivides into main campus, community hospitals, etc. I am the only student in my health system that is at a community hospital--it is a new program, and there is only room for one student at a time. It's been a much different experience from what I have heard about people doing pediatrics at one of the main hospitals.

First, it is a hospitalist service. There is a practice of pediatric hospitalists who only see inpatient kids. They also cover newborn babies. Basically, community pediatricians have the option of managing their patients when they get admitted (or are born), or they can choose to have the hospitalist service manage their patients. That means that, currently, there are three patients being covered by my service on the peds floor, and there are 15-20 babies/day that need to be seen either for admission (after birth) or before discharge.

The pediatricians can also be called to deliveries if the OB has a concern that there might be trouble with the baby. I got to see my first delivery today (that wasn't for my own child)--the concern was for an IUGR baby, but she turned out just fine. I did get teary watching the baby being born--it's such an unreal event! I still have no interest in OB/Gyn though :) That's next month...stay tuned...

On this service, we get signout from the overnight physician on call from 8-8:30. The resident and I then head to the peds floor and see whoever is on our service. The attending is usually in the nursery seeing the newborns at that time. Then the attending comes to the peds floor, we go over the patients, and we are usually done around noon. Then it's lunch, and so far this week, then it is dead time (though this would be the time for admissions if they come in). It's good in some ways: after crazy neuro, it rocks being able to eat and pee during the day, it gives me time to look up med information, and we've also gotten to do some teaching/learning about important peds topics (jaundice and asthma so far).  The down side is that it is SLOW, and I am worried I may not get to see everything I need to see.

For instance, we had the ER call the other day with a kid who was vomiting. However, the kid was a newly diagnosed diabetic. This peds unit doesn't take diabetic kids (unless the community physician is willing to come in and manage them, which they generally are not) because they can be so sick so quickly. So this kid got sent to main campus. We had another call yesterday for a dental abscess, but there is no dental/oral surgery here, so he got sent to another hospital. Basically, we get jaundice, asthma, acute infection (pneumonia, GI, etc), MRSA abscesses, etc. That's not quite what I was hoping to see. It does make it feel manageable--anything touchy never really gets to us--but it's not what my peers are seeing in some of the tertiary care units in the big-name hospitals.

I did see one case yesterday that I wish I hadn't. Again, no details due to HIPAA, but we had a child come in that had evidence of (and self reported) child abuse. This child had "only" belt welt marks on the leg, but there was a history of abuse by the older sibling that required stitches and a general history of hitting/verbal/emotional abuse by both parents. The child was very pleasant and social--a bit energetic, but nothing off the charts for the age. Talking to this patient was tough--the patient talked about how the parents didn't want them anymore, that the parents gave them medication (focalin and risperidone) "because I am crazy," how the older sibling threatened to kill them at night, etc. The parents were arrested and put in jail briefly after bringing the patient to the ER (initially for "behavior problems"), and reading the note was so sad. Apparently, no one was willing to take the patient--the grandparents agreed to take the older sibling, but no one wanted the patient.

We of course got social work and the county involved, but the county wouldn't take the patient. So, despite a restraining order, the parents got to choose who took the patient. There was much drama last night while I was on call about who was actually coming to pick the patient up (and whether one of the people was actually the mother posing as someone else). We did all we could to try and get county/temporary foster care to take the patient, but they wouldn't. When the person picking up the patient arrived (with security, of course), it was obvious that this person was annoyed and wanted nothing to do with the patient. We all stood helplessly at the nurse's station as the patient left, knowing that more than likely, the mom/dad was waiting in a parking lot nearby, and the person who picked up the patient was going to ignore the restraining order and give the patient to the parents.

We all had fears that this patient would get beaten, and the parents wouldn't come back to the ER, since they got arrested last time. This patient was returning to a terrible home life. We protested, we called social work/the county continuously all day long, and there was nothing we could do to keep the patient from it. I'm praying that I don't recognize any news stories in the next few days. The attendings were frustrated too, and they had other stories about abuse kids--how long it took to finally get kids removed from homes, how sometimes what you fear ends up happening, and just generally about how some parents can do such terrible things to their kids. The attendings tried to reassure me that cases of abuse like this are rare, but it didn't make me feel better about this patient.

I am a fixer, and if I could have, I would've personally taken this patient away from the family. I wanted to protect them from what they were facing.  It was so sad--the patient said that they feared the mom, dad, and sibling, yet they wanted to go home. While the patient was here, all they wanted was approval. They tried to please the nurses and doctors. The patient was happy and social here--I know no one can live at the hospital, but the fact that life in a little room was better than what waited at home was so sad. The entire time the patient was in, no one called about them, no one came to visit, and no one wanted to take them out of the hospital. It was absolutely heartbreaking.

It also exemplified the biggest concern I have about peds. Let's start with what I like first: the people are great, I enjoy working with kids, and so far, the hours are fantastic. The downside: depersonalization (or lack thereof). I am so protective of these kids. The first day, there was a patient the exact age of my son. The patient's parents were teenagers, and they really wanted nothing to do with the kid. The child couldn't roll over, couldn't sit up, and actually had a flat head because of always being laid down. The parents were never holding the baby when we came in--they were sleeping at all hours of the day, and the patient was in the crib, alone, all day. The patient was so excited to see other people come in! I wanted to smack the parents around. If you don't want the kid, give them to someone who does!

Other patients have been fine--there are plenty of parents who are very worried about their kids and want them to get better. But I think I would have a hard time in peds dealing with parents who obviously could care less about the kids--or worse, parents who are negligent/abusive. I am way too involved with that emotionally. I don't expect parents to be perfect--I am FAR from perfect, and I think a good chunk of parenting involves making mistakes. However, if you learn from the mistakes, and you try to be a better parent, that's the right thing to do. I just don't know if I can see parents that are uninterested or mean to their kids.

The attendings have said that you get desensitized to the parents, but I am not sure if that is good or bad. I think children need advocates. I'm naive in the sense that I think I can make a difference. I don't think I can fix every bad parent out there, but I want to help the kids that I do come into contact with. I just don't know if I can do peds.

And, if I did peds, I couldn't do general pediatrics. I know nothing as a med student, and already some of general peds is mind-numbing. It's the same issue I have with adult medicine--my personality is such that I like knowing a lot about one small specialty, and I like when things are challenging. It's a balance though--I don't want every case I see to be life or death, but I want to have to think about diagnosis/treatment challenges regularly. I like being a detective. Specialty pediatrics could be a lot like specialty adult medicine, which could be fun. But I'd still have to deal with the parents. At least adults are responsible for their own bad decisions. Kids don't have responsibility for what their parents do.

I'm curious to see how I feel at the end of this month. Maybe I will learn to depersonalize and find a way to channel my need to smack parents upside the head. I really enjoy the medical people so far, and they seem very understanding of work/life balance. Those are definite advantages. However, I don't want to come home and feel demoralized and dejected because I couldn't help kids the way they needed to be helped because their parents got in the way. 

I may have to do a rotation in one of the busier tertiary care pediatrics wards to see what that is like. Other med students have said that their pediatric rotations were intense and very busy. While I am thrilled that this is low key (I need a little of that in my life right now), it may also not be representative of real life.

Plus, there's always the issue of what to do with my PhD if I do peds. I'm still not convinced that I want to do bench research again, but I also don't want that six years of my life to be a total waste, career-wise.

I guess this pediatrics thing is still TBD. I like the medical people, I like the lifestyle, and I like kids. We'll see if that is enough to put pediatrics on the list!

Friday, October 01, 2010

Psych redux

Today was my last day of psych, and I was sorry to see it go. I'm going to try and figure out why (mini-psychoanalysis, I guess) so that, in a year from now, I can remember the pros and cons about each of my rotations.

I think part of me liked it because it wasn't the lab. That makes any rotation look good! There were a few low points (one in a minute), but overall, I looked forward to going into work every day. I learned a lot, I thought my team was great, and I feel like I came out of the rotation one baby step closer to being a doctor. Of course, I also liked being an armchair analyst; I listened to lectures and thought, "Oh, family member X must be borderline! Friend Y is totally bipolar!" (relationships changed to protect the innocent!). I didn't mean this in a judgmental way--it was more in line with, "wow, if they were actually treated for this, I wonder how much better their life would be!"

Here's the story on the worst day I had. On Tuesday, I really thought I was going to end up sitting in my car, crying, by the end of the day. The psych ward was extremely busy. I had a new patient whose note needed to be in the computer by 2:45. Rounds went till 12:30, then the ROS/mini mental/physical exam went till 1. We had case conference that was scheduled from 1-2, but it actually went till 2:30. I appreciate that the psychiatrist was letting a manic patient be tangential, but all I could do was sit there and fixate on how in the world I was going to write a huge admission note by 2:45. It was 2:40 by the time I got back to my desk, and when I called my attending to tell her the note wouldn't be done on time, she wasn't there. I checked my email to see if she had tried to catch me that way; she hadn't, but I had a bunch of emails from my lab PI about thesis stuff, and I had emails from Tim that day care had called about Josh.

I just felt very overwhelmed. I called Tim quickly, and apparently day care noticed a rash on Josh and wanted him to go home. He didn't have a fever, he was eating, he was sleeping, and he was otherwise acting normal. It sounded like the rash was just where his sleeper had been touching his skin. Tim, Sophie, and I all have sensitive skin; I told Tim to tell them to put him in another outfit and call if things got worse. I felt terrible, like I was abandoning my baby. Tim had meetings all afternoon, and I was crazy busy. So, we agreed that as long as Josh seemed ok, we'd let it go.

I couldn't even respond to the lab emails. My blood pressure goes up every time I get something from my old PI. It's not personal--it's just that everything is made to sound like a total emergency. I keep telling myself that I don't have to have my thesis to the committee until the end of October. That doesn't give me a pass on finishing it,  but it doesn't have to happen this instant. I can't seem to impress that upon my boss, so I have stopped trying.

It did take me a long time to write the admission note. I was so anxious about it being late that I gave myself a headache. Of course, it could have also been that I had not eaten or peed all day (which is normal--I didn't get a chance to eat lunch on the vast majority of the days I was there). When I finally heard back from my attending, she said it wasn't a big deal that the note wasn't in. The goal is to have the psych note in within 24 hrs of admission onto the ward. Since we only see patients on morning rounds, that meant that if someone gets admitted after about 11 AM, we don't see them till the next day. The nurses see them, obviously, but the official note doesn't go in. But, my attending wasn't worried about it, so I calmed myself down about it. By the time that note, all my other notes and orders, and patient family calls were done, I had just enough time to review them with my attending before she left. I got in my car, took a deep breath, and prayed that I wouldn't have another day like that for a while.

That was really my personal low on this rotation, but looking back, most of the anxiety was self-produced or outside the rotation. I didn't want to let my team and the patient down by not having my note done on time. That led to me staring at the clock (and unable to focus) during case conference. That should have been my only stress of the day. Once I was sure Josh was fine (and Tim agreed to be backup in case he did have to be rescued), I should've let that go. And the lab stuff--good God, the lab stuff. The emails on Wednesday were even worse than Tuesday--we got the galley proofs back, and although there were only two sentences they wanted clarification on, it somehow turned into this giant email back-and-forth with a ton of people. I was stressed about it, and then yesterday, I just let it go. My boss can sort everything out with the other author (who suddenly had a bunch of changes that he hadn't mentioned before). I just let it go.

Today, after letting go of the lab stuff, having no kid health concerns, and knowing I wasn't going to have an admission on team today, I was able to relax and enjoy my last day on the wards. I spoke to the team psychologist, social worker, resident, nurse specialist, and nurse practitioner, and they all encouraged me to think about psychiatry. I know this is fairly common, but they all talked to me individually and said they thought I was a great fit for it. The nurse practitioner said to consider the VA as an employer too--she was a single mom of two kids, and she said the VA is great about flexibility. She also said the health care and retirement packages more than made up for the lower pay versus private practice. She thought VA psych would be a great fit for me, if I wanted to consider it.

I met with my attending later, and she said many of the same things. She thought that since I was a bit older, and a mom, I had more insight into personal dynamics. She thought I had a knack for dealing with the psych patients. She didn't push me to commit to anything--she just suggested that, in general, I do some introspective searching and figure out what makes me happy. We talked for quite a bit of time. I agreed with her on a lot of points--like the fact that the goal isn't to make the most money or get into the most prestigious residency/fellowship, just to prove that you can. The goal is to find a job that you enjoy going to every day. If that's psych, great. If not, find something I like. We talked about knowing yourself and what is a good fit.

So that's what I am thinking about now. Honestly, I had not considered psych as an option before this rotation. I enjoyed the committee (they called it the "mind" committee) in medical school. I enjoyed the general psychology class I took in college. But I was not thrilled about the inpatient psych ward. I've experienced being a visitor on these wards, and I was always intimidated. I'm not going to say that I think living in a psych ward would be fun--please! let's be realistic. It sucks to be a patient on a psych ward (although most of these residents have asked at one point if they could live here--beats the streets). But, most of these patients make progress while they are here. Many, if not most, of them will come back. But you help them, you see them improve, and when they are ready, you send them out. If they come back, it's because of their disease. People with chronic medical diseases can have multiple hospitalizations. Psych patients shouldn't be stigmatized because their diseases bring them back to the hospital. Many patients go years between hospitalizations. There are a few who boomerang, but not all. These people get better slowly--but most of them can manage their disease on an outpatient basis.

Things that I liked:
  • the patient contact. I really enjoyed the time we are given to talk to patients. I'd like to spend some time in the afternoons with new patients, to maybe get a developmental history instead of just a general past psych history. But this part is fun.
  • the team concept. Not every psych ward works like this, but I loved that there are so many people with different backgrounds working collaboratively to help the patient.
  • the underlying psychology. I love thinking about the mind. We had a great lecture on psychodynamics of depressions (id/ego/superego stuff). I don't necessarily agree with all of it, but I do think the mind has its own ways of processing information that differs from person to person.
  • the nature vs. nurture debate. This is one of the few areas of medicine in which we still know precious little about the actual biology of the diseases. For instance, it is known that there is a genetic component to psychiatric diseases, but why do some people develop the disease and others don't? I think there is such potential for research and understanding--which would also increase treatment options (and maybe even prevention.)
  • the ability to watch a patient improve. So many of these people--especially the schizophrenics--can improve when they are on the right medications. Most of the admissions were about a week long, and in that time, some of the patients were drastically better.
  • the lifestyle. Let's be clear: I worked ~8 to ~5 every day. Some days were longer, not many were shorter. But for third year medical school, this is AWESOME. This will be the easiest rotation, schedule-wise, that I will probably have. As I said, you are very busy during that period. But being able to be home by dinner? That's awesome
  • it's fun. It's like playing detective. What's their diagnosis? What is the best plan for treatment? If X didn't work, what should we try next?
  • training is 4 years after graduation, versus 6 (3 medicine + 3 fellowship) for most specialties.
Neutral
  • Pay. Again, anything is more than what I make as a student. And the fact is, psychiatrists make less than internists and about what pediatricians make. The amount varied, but the info I found was that the average is about $175,000. That's less than a cardiologist makes (which averages about $300,000, but can go higher). But come one now. That's almost ten times what I am making now, and it is freaking six figures. Basically, anything that is above the student stipend I am making now is a CRAPLOAD of money.  Really can't complain.
Negative
  • This is a negative for most of medicine as a whole, but there is very little "curing" of people. Many of these patients have their lives improved dramatically. And I've been told that on the outpatient side, many people return to normal lives with medication + therapy. But for this inpatient crowd, most of these people will be back in the hospital, mostly due to...
  • noncompliance. This is noncompliance in general--mostly with medications, but also with substance abuse. Some of the patients don't understand the disease and therefore don't understand the medication. Some are paranoid. Some don't like the side effects. Some can't afford the meds. And for substance abuse, most can't keep with it (alcohol dependence has an 80% failure rate for treatment). This is sad, but a big part of treatment is getting people to own their role in the treatment of their disease.
  • There is no diagnostic test, procedure, or lab for most of these diseases. When you diagnose something, it's all you. You can ask a colleague for another opinion. But basically, you have what the patient is telling you, what you can gather from other people's collateral histories of the patient, and that's it. You have to be confident enough in your estimation to discharge someone who threatened suicide--are you sure they are better? Is this person really just looking for attention, or are they dangerous? Those are big responsibilities.
For me, I think psych stays on the list. I enjoyed my time in outpatient medicine when I was still in the lab, so medicine (and a specialty) may still be the frontrunners. But to my surprise, I think psych is running a strong #2 at this point. We'll have to see how I feel in the future.

Neurology is my next rotation, and I think I can safely say that it is not on the short list in terms of a career. I hated neuro in med school. This is one month that I am just going to try and get through...

On another note, I came across this post when I was googling psych stuff the other day. Very interesting:

The ten biggest mistakes psychiatrists make

Saturday, September 18, 2010

As posted on Facebook

It's 11 PM on a beautiful Saturday night. The kids are both asleep. What are we doing? I'm working at home, writing my thesis, and Tim went back to the office to do work. We'll both be up way past our bedtimes, and not even for very fun reasons. When did we get so old?

Thursday, September 16, 2010

Sweet dreams?

My late night reading has consisted of schizophrenia diagnosis, subtypes, and treatment, substance abuse and mood disorders, and a bit on delusions and hallucinations. I'm sure that will make for some sweet dreams, if and when I ever get to bed.

These two weeks on the inpatient psych ward have been good and bad, for many reasons. First off, it means I am progressing in training, which is a huge relief. Second, it's gotten me back in touch with the patient experience, which I enjoy. Unfortunately, it's much more time consuming than I thought it would be. And I'm trying to finish a thesis and teach a class on top of doing my rotation. Today though, what's affecting me most is this: it makes me sad.

My biggest fear starting this rotation is that there would be a situation between me and a patient that would be uncomfortable or dangerous. This is taken care of in the unit I am on: the psych teams (usually consisting of some combination of an attending psychiatrist, nurse specialist, social worker, psychologist, pharmacy resident, medical student, and nurse) meet together in the conference rooms to see patients as a group. The patients are brought to the conference room--there isn't a one on one exam in their individual rooms. I really appreciate this, not just for the safety perspective, but because it is more efficient to have everyone hearing the same thing and divvying up the to-do list together.

So, my preparedness for threatening situations is not needed. While I overestimated on that account, I underestimated how much my personal feelings would really affect me. I'll give you two specific examples, though there are many more.

The first was a patient admitted last week. Due to HIPAA, I'm not going to give out specific information. I'll try to give you what we are given in case studies, to keep things legal. So, this patient was admitted for a suicide attempt. He has a long, tumultuous history with his wife, and he attempted suicide, which he later claimed he didn't take seriously but was doing just for attention. The underlying issue was that he was an alcoholic, in complete denial about how serious of an issue his drinking was, and he had no interest to work on his issues. He had been out of work for some time, he had anger issues (and a domestic violence charge in the past), and he fully believed that the anger/violence was due to his wife's provocation and not the alcohol that he drank every night. It was textbook alcoholic dysfunctional family--everything was swept under the rug, things were fine, it was a one time issue, and no, the preteen son had no idea what was going on.

My attending's response: yeah right. Of course the kid knows what is going on. Of course nothing is going to change. Even the way that the husband emotionally controlled the wife was apparent when she came in for a visit. The patient was pretty angry when the team said that his chance of being successful in therapy was slim to none unless he quit drinking. My attending was very up front about the fact that antidepressants don't work for alcoholics, and neither do sleeping pills. The alcohol has to clear the system, the brain has to reset, and that takes time. She (my attending) refuses to baby people through the process. She'll get them the recovery help they need, either inpatient or out, but she tells the patient it's their choice and their responsibility to take charge of the illness.

This alcoholic patient was assigned to another member of the team (though I saw the patient every day on rounds). I was relieved by that. I saw such a reflection of what my mom has gone through in the past--from the hospital ER he was seen in to the intensive outpatient program that he was looking into attending after discharge. It was almost an out of body experience to see that entire dynamic play out with people I had never met before. There have been other alcoholics staying on the ward, and the dynamic is so similar in each case. I really appreciate the opportunity to hear my attending's take on things--I really respect her. She's got a no-nonsense attitude, but she is also very empathic with her patients. It's a good life lesson. But it's still sad to see all of these patients and families battling the same demons--especially when it is a demon I know well.

The second example happened today. We have case conferences every week with a long-time, well-respected staff psychiatrist. Today, we went to see one of the other student's patients. He's diagnosed as a schizophrenic, but he has had an atypical progression. What drew us to the case was the extent of his bizarre delusions. I don't want to tell you all about them here, but even the psychiatrists with decades of experience have said that this man has some of the most bizarre and persistent delusions they have ever seen.

While it was a great learning tool to hear how this man described his illness (which he completely denies having), what came over me was this immense feeling of sadness. Here was this man, beyond middle age, describing a lonely life in which he had never had friends, never had a romantic relationship, and had lived as a loner his entire life. I just found myself feeling so bad for him. The medication isn't helping his delusions, and even when he's been "healthy" in the past, his OCD rituals for keeping his life feeling less chaotic completely consume him. He mentioned several times how his "brain was lonely." It just broke my heart. This man will probably never get better, never have those close personal relationships he longs for, and even if he could find someone willing to take on his illness, his delusions would likely prevent him from engaging in any sort of personal relationship. There's nothing we can do to cure him, and even managing him hasn't given him a "normal" life.

That is the toughest part of medicine for me. There are lots of specialties where we can't "fix" the patient. I accept that, and I understand that a lot of medicine is chronic disease. I also understand that we are all terminal--at some point, people die. I know I am going to need to toughen up and depersonalize better in order to make it through medicine.  But psychiatry seems tougher for me than the limited experience I've had in medicine. For the most part, medical patients can understand their diagnosis and what it takes to manage it. Not everyone chooses to be compliant, but at least they have the choice. Inpatient psychiatry is full of people with limited to no capacity to understand what their disease is, and noncompliance is rampant because the patient's can't understand what the medication is from. PS, having a stranger in a white coat feeding you pills and giving you shots is great fodder for paranoid delusions and hallucinations--not helpful!

It was also pointed out on the first day that this service really carries the psychiatric patients with the worst prognosis. It's a process: the veterans on the ward are here because they have no private insurance, usually because they couldn't work after being discharged, usually because they had a severe psychiatric problem that prevented them from working. Many are homeless, most have a concurrent drug abuse problem, and they have nowhere else to go. I've seen ex-convicts, homeless, an elderly man who lived in his son's crack house for years, suicidal patients, homicidal patients, and patients with severe delusions and hallucinations. And I'm only in week two.

There's a part of me that sees such potential for helping people in a field like this. But there's a bigger part of me that knows I would break down. So many of these people boomerang after being discharged. Meds are only good if you take them, and they aren't always that good even if you are compliant. Most of the people that come on the ward have been here before, and they will be back. The one patient I am seeing right now is on his/her fifth admission this year. That's a story for another day.

I feel very stupid on a daily basis, but I also feel like I'm learning a lot about how to be a doctor. Psychiatric issues are a huge comorbidity in the population. It's going to have to be something with which I am familiar. On a personal level, I have a big family history of psychiatric disease, and so does Tim, so it's also in my best interest to know what to watch for and how to deal with it (not prescribing meds to family members, don't worry!).

I'm just worried about how well I am going to deal with my clerkships. I started with psych because it is supposed to have the best schedule and be one of the "easier" rotations. I'm working like crazy. If this is what psych is like, God help me for surgery or OB/gyn....

The psych ward waits for no woman, so off to bed, with all of my reading material percolating in my subconscious. This should be an interesting night--assuming all of the kids/pets let me sleep long enough to actually hit a dream cycle.

Monday, September 06, 2010

New Beginnings

I'm sitting here, feeling nervous for my first day of school. And this is the second time I've felt this way in just over a week--I had similar jitters before I taught my first weekend college class of the semester. Those jitters went away as soon as I started teaching. I'm doubting my current jitters will evaporate when I slip on my white coat. If anything, I expect them to get worse.

I'm excited, nervous, anxious, worried, and feeling inferior. I had grand ambitions of reviewing all of my psych notes from med school (from back in 2003) before heading to the clinics tomorrow. Unfortunately, life didn't feel like cooperating today. Therefore, none of the things on my to-do list for the day (thesis, thank you notes, notes/assignments/lecture for Saturday's class, and reviewing for med school) got done today. I am hoping tomorrow will be mostly paperwork, and I'll have one more night to prepare.

In the course of getting things ready for tomorrow, I came across my clinical tutorial evaluation from my preceptor. He filled it out on 3-31-10; I just found it in my clinic bag. I gave him an envelope to seal it up. He told me that he wanted me to read it before I turned it in. I hadn't read it yet--I'm not sure why. I don't know what I was afraid of, but I read it tonight. It was extremely kind and thoughtful, and while I am not sure that I believe all of the praise that is in it, it has helped me remember that just being a good person and a hard worker are big parts of having a successful clinical experience. I will need to remember/learn the material at some point. But I'm telling myself it's ok to go back--it's been more than six years since I finished the second year of medical school and took my boards. And it's been five months since I last saw a patient. It's natural that I have some rust--I just have to shake it off and do my best. I hope that'll be enough to get me started.

It's been crazy that my first class was last Saturday, Josh started daycare last Monday, I'm starting clinics tomorrow, and Sophie is also starting Montessori tomorrow. That last one was a bit of a shock. Tim and I carpooled on Friday (my car was in the shop again--that's another story). We both dropped the kids off in the morning, and Sophie's AM teacher asked if the PM teacher had asked us about moving her up to the next classroom. We said no, and the teacher said that since the fall "classes" had just started in Montessori, Sophie would be better off starting ASAP. We were both a little surprised at this. We knew it would be coming--her infant room is for kids 18 mos-3 years, and she'll be three in October. But they transitioned her over a period of weeks when she moved from infants to toddlers. We were expecting the same with the move to Montessori.

When we picked Sophie up Friday evening, her PM teacher reaffirmed that starting Montessori could happen ASAP. Sophie's teacher said that it might help the behavior issues she's been having--her teacher seemed to think Sophie was bored, and that's why she misbehaved (and spent so much time in time-out). I was concerned that she might not be ready--as far as potty training goes, she's nowhere close--but Ms. Sue thought she'd be fine. We asked Sophie if she was ready for Montessori, and she said yes.

A few points of clarification. First, Sophie has spent a little time in Montessori--if Tim drops her off, she spends some time with the older kids for 15-20 minutes max until they can open up the toddler room for breakfast. She's liked the time she gets to color or play.  Second, I didn't even know what Montessori was when we first started her in day care. It was the only opening of the many places I called, and I figured we'd have time to decide if we liked the Montessori classroom. The infant/toddler rooms were pretty standard.

Guess what? Time's up. And while I've read about Montessori online (basically, mixed age groups and self-directed learning), I'm still not totally positive why it is better/worse than other things. And honestly, as long as it isn't totally traumatic, it'll be fine. Sophie is comfortable with the routine, comfortable with the teachers, and Josh is going there now. I think we've missed the window to move her. And barring disaster, she'll stay there until it's time to start school.

I just can't believe how many "firsts" we've had in the last week or so. It's been a crazy time. It will continue to be crazy for a long time, I am sure, but I am hoping we'll get some time to enjoy life soon. I really haven't had a weekend to just chill with my little family, and there are a lot of people that I've been meaning to catch up with and haven't had the opportunity yet. Maybe this fall, I can start to feel organized again! I'll try not to feel like a total failure on that front if it takes a bit longer than I'd like :)

Off to find the white coat and the other goodies I'll need. I'm not sure what I need to pack for tomorrow, but I guess I'll figure it out--just like how I am still figuring out the rest of my life on a daily basis.

Friday, September 03, 2010

Transitions

Today is my last day in the lab. Honestly, with everything I have been through, I really wasn't sure this day would ever come. I also didn't expect to feel sad.

Every job has their issues and quirks. My current lab is no different. But, compared to the hellhole I was in for three years in Dr. B's lab, this has been heaven. The recent scientific meeting I went to was a great note on which to end. I've always enjoyed meetings, because it reignites my scientific passion. I love hearing about what other people are doing, what new questions are being answered, and how people have decided to approach their questions. The time I've spent in M's lab has helped lessen the disdain I had for bench work and reminded me that science isn't what I loathe--it's the bureaucracy and politics involved in academic science. And PIs from hell--I loathe that too :) If only he wasn't still on my committee, life would be perfect!

I'm still not willing to say that I'd jump back to bench research as a career. That's a bit TBD, and I have a lot of clinical training ahead of me before I make any sort of career decision. But, if my time in Dr. B's lab had never happened, I definitely think I'd be considering bench research. I still don't love how much of the day to day work of a PI involved stupid politics, but maybe if I was in a different environment, that would be better.

I do love teaching--I had my first weekend college class for this semester, and I think it is going to be a good class. I'd love to find something that was a mix of clinical work and teaching, so I'll have to see what is around when I am finally done.

It's been a busy summer. I've fallen way behind on lots of things--and sorry, but blogging gets cut when time gets short--but it's been a good summer overall. The marathon last week was being at the meeting in Canada, getting home really late Thursday night, prepping like a madman Friday to clean the house/get ready for the party, teaching Saturday morning, having family dinner Saturday night, and then having Josh's baptism on Sunday. We had fewer people than we expected Sunday (only about 50 came), which caused a little bit of hard feelings (the no-shows were mostly on Tim's side, and he had seen them the day before at another cousin's party, but then they didn't come to ours...drama). But, we're over it, and everything went fine.

This week has been Josh's first week in daycare, which seems to be going well. It's at least been making him tired--he slept through the night for the first time last night! The monthly check is now more than the mortgage on our house (even with the buy-one-get-one-half-off deal they are giving us), but we've been preparing for it since we found out we were pregnant, so we are making it work. If my car would stop breaking down, things would be fine :) I just have to limp the car until I start residency in 2012--then we'll have enough extra to afford another car payment. Come on, car!

Really, we're planners, and we've been saving for emergencies for all 8 years of our marriage. A car repair is an emergency, as was the tree down/broken fence episode from the summer. I'd rather be putting into the emergency accounts instead of taking out, but I keep telling myself that's why we saved for the five years before we had kids. That planning is definitely paying off. We don't have anything extra at the end of the month, but we've budgeted, and we live within our means. My own personal mini-challenge for September is to see how little we can spend on groceries. With the stockpile of dry goods in the pantry, and the meat in the deep freezer, I am going to try to buy only the perishables (milk, eggs, produce, etc) we need to make meals. Tim's already spent a little on pop, which I guess can be his necessity for the month, but I'm going to try my best to not get tempted by the sale papers and only buy what I need. This will take more planning than I've been investing recently, but it'll be a good habit to start with me returning to med school.

I really haven't invested much mental energy into returning to med school. I have always thought that it was so far off. It's the practical things--things like the fact that Sophie ruined my last pair of dress pants, so unless I go shopping, I will have no pants for the first day in the clinics. I think I am going to go thrift shopping this weekend and see what I can find--I like to spend about $5 per pair of pants, so we'll see what I can do. I rocked Target clearance the last time I needed dress clothes, so I may try that too. So, there's the practical (clothes) that I have to plan for, and I should also revisit some of my med school notes to remember how to think. I'm starting with psychiatry, so I'm trying to ease into my rotations.

I still have to give my dissertation, which won't happen for a little while, but otherwise, I won't be in the lab again until probably fellowship. It's a really strange feeling. We'll see how much I miss it when I am gone!

Friday, August 20, 2010

Oh crap

Things to do in the next 48 hours:
-finish revisions to the paper
-work on my thesis
-prep for the start of my fall course, including a full semester syllabus and four hours of lecture for the first class
-pack/prep for a week-long international business trip next week
-go shopping for food for the baptism party
-clean the house
-prep meals for Tim next week...

Doesn't help that I spent two hours on the phone with United, Continental, and CATSA (Canadian TSA) trying to figure out how to get the pumped breastmilk home. I was even looking into shipping it home. After all that, it turns out I can pack an empty cooler and freezer packs on the way out, and then I can put the milk in the cooler with the freezer packs and put it inside my checked bag for the way home, and we are good to go. Seriously, that's all it takes? I could've carried it on if I was only traveling in the US, but not so much in Canada.

And, Josh is refusing to nap, and Tim has plans tonight. So, hard to do anything today, and once Sophie gets home, I'm on my own with the two kids.

Basically, that means that I'll have late nights once the kids go to bed the next two nights, and I'll have to get most of the classwork/thesis stuff done on the plane rides.

Tim will be getting help next week from his mom (for two days) and my mom (for two days), and he's going to be home with the munchkins the rest of the time. I've got next Friday to clean/cook, then I teach Saturday AM, Tim's going to a party with Sophie Saturday PM while Josh and I host the fam for dinner (Amy's back!) Saturday night (and I am roping the fam into helping with baptism setup after dinner), and then the baptism/Amy's final going-away party is on Sunday.

I am looking forward to this conference next week, but talk about worst possible timing! I've only got one full week when I get back to finish my thesis, and then I start back to med school the day after labor day.

I've always said that I work best under pressure. I guess this counts!

If the posts are sporadic the next few weeks, you'll know why!

Wednesday, August 18, 2010

As posted on Facebook:

PAPER IS IN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
It needs minor revisions, but they (hopefully) won't be a problem.
I get to go back to med school!!!
HOLY CRAP, I'M FINALLY GOING TO FINISH MY PHD!!!!!!!!!!!!!!!!!!!

Saturday, August 14, 2010

Making money

Still nothing about the paper--it's been 5 weeks, and we were told we would hear yesterday, and we haven't. So, I am thinking this is not good news. Instead of stewing about it, I've decided to avoid talking about the general anxiety it is causing me.

In the spirit of changing things up, I have talked to multiple people in the last week or so about earning money through the interwebs. While I would consider the money I earn through the drug store savings to be somewhat internet-related (since I find a lot of deals/coupons there), I'm going to focus on things that don't involve you leaving your house at all. Although, I really only do Rite Aid deals at the moment, and I've made a few hundred dollars (plus getting all the free personal products I need) by combining sales with coupons. If you want more info on that, I can fill you in.

So, in order of how good of a deal it is, here's my list:

1) Communispace from Anthem: this was invite only, but I make $10/mo in Amazon.com gift cards for doing about 5 minutes worth of work every week, and there are lots of bonus activities that can bring in $10-$20 Amazon.com money at a time. I've made close to $200 I think (maybe more) doing this since joining less than a year ago. If you get an invite, do it!!

2). Valued Opinions: a general survey site. This site is pretty good at quickly screening you out of surveys you don't qualify for (a big pet peeve of mine), and when you do qualify, the rewards are good. I just finished a panel that made me $25 for minimal work. And, sometimes you'll qualify to try out full sized products in exchange for giving your opinion about them later. In a year, I've made about $160, which I've redeemed in Amazon.com money, but there are a few other redemption offers as well. And, if you join InboxDollars first, you can get another $2 for joining Valued Opinions through your Inbox Dollars account (more on that later).

3). Mypoints: I've been doing this program for many years, maybe going on 10. It's very simple: you get a few points (around 5) for reading emails, 10 points if you don't qualify for a survey/~50 if you do, and then some points for offers, shopping through the site, etc. I don't do much of my shopping through here (I earn more through ebates or fatwallet usually), but just clicking emails/doing surveys earns me between $50/$100 a year. If you want to be kind and link up through me, I'll earn a small percentage back from your referral. Not necessary, but if you feel like sharing the love, send me an email with your email address and I'll send you a personalized link :)

4). Zoompanel: This is a middle of the road survey place for me. On one hand, the surveys are (usually) pretty straightforward, and you get 5 points if you don't qualify. On the other, you only redeem for merchandise, and I've had trouble in the past getting credited the points that I've earned (though after I've contacted customer service, I usually get credit). It seemed like one style of survey never wanted to credit for me, but I've started saving the emails with survey links in a "completed surveys" folder in my email, and then I can double check to make sure I get the points. In about a year's time, I got enough to redeem for a 10-cup food processor, which runs about $60. There are other rewards that are cheaper on the site. I prefer cash/gift cards, but this isn't bad. I've also gotten full size trial items to try through this site, which is fun.

5). Inbox Dollars: This one took me a while to get enough money to cash out, but after that, it's going a little faster. Basically, you get 2 cents for every email you read. You can get money by doing free offers (like the Valued Opinions signup I mentioned before), or more money for trial offers (which I don't do, because I forget to cancel). After you get $30, you can cash out. They'll tell you that it "costs" $3 to cash out, or if you agree to wait a while and earn more money, they'll cash you out for "free". Whatever--I cashed out, and I instantly got a $3 "cash-out survey" that made up for the "fee" they charged. It's slow earnings, but money is money, right?

6) Surveyhead: I've earned decent money on this, but it's more of a time-waster. I do NOT end up qualifying for the vast majority of the surveys they send, and you get nothing if you don't qualify. So, it takes about 2-5 minutes to find out I don't qualify (or that it is full), which drives me crazy. And, it takes 6-8 weeks to get your reward once you cash out (even though the reward is online usually). But, you can get your money transferred to PayPal, which you can then put into your bank account, so it is the closest thing to cash that I've found. I usually only choose to do the surveys that seem like a good fit from the title/description and try to save time that way. I've earned about $80 in 1.5 years, so at least it's decent money. And you may be able to sign up through another program (like Inbox Dollars or Mypoints), so that would earn you more money too.

7) Swagbucks: I just joined this on Thursday, and I've already got 342 swagbucks (a $5 gift card to Amazon.com is 450). There is a swagcode out now that gives you a total of 70 swagbucks at signup (I can direct you to the code, but it expires tomorrow, 8-15-10, at midnight). You usually get either 30 or 40 for a regular signup. They had a code hunt on Thursday that gave me a bunch of codes, and then I won some big codes from searching the internet yesterday. I'm still figuring this out, but basically, you do your regular internet searches through their site (or toolbar, which I installed and find much easier to use), and periodically you "win" swagbucks that you can then redeem for prizes or gift codes. We'll see how well this earns me money over the next few months, but after I figured out the learning curve, it seems pretty intuitive. One note: if you find swagcodes, you can't just post them online. You can give clues to people to help find them, but if the site finds out you just posted the codes, they'll deactivate your account. Just an FYI--my impression from reading other sites is that they take this pretty seriously.

8) Other sites: I just signed up for Global Test Market (through Inbox Dollars) and Opinion Outpost (through Inbox Dollars) less than a month ago, so I can't vouch for those yet. They don't seem as fruitful as some of the other survey sites, so once I reach a cash-out level, I may bail on them.

9) Bzzagent: I've been doing Bzzagent for several years. You get invited to campaigns, they usually send a full size free item plus some coupons/trial size items, you tell people about them and write reviews, and then you get rewarded in Mypoints. The freebies vary from awesome (Starbucks, scrubbing bubbles, and covergirl) to kind of lame (Michelin--just a tire gauge, no easy way to Bzz). I've gotten over 20 campaigns in the last 2.5 years,  and it's pretty low key and easy to do. Sometimes I'll be in 4-5 campaigns at a time, sometimes none, so it just varies. And until you earn "honeycombs" to increase your status, the campaigns are usually a little slim. But it's a great way to get new products to try before they are on the market, and spreading your real opinion about them can be fun.

10) ExpoTV: I just joined this recently, but it's basically a video review site. They post items for which they want reviews, you upload a short (~2 minute) video giving your honest opinion, and they reward you with points. They also have a tryology section where they send you a product to review, and you upload a video--you don't get points, but you get to keep the product. I've gotten about 5000 points from this in a few months, and a $50 Amazon.com gift card is 6000 points. Plus, I've gotten 3 tryology campaigns, 2 of which had great goodies. I don't love seeing myself on the computer screen (a personal hangup) but the points reward to time ratio is good.

11) Earning money through online shopping: both mypoints and inboxdollars will reward you for shopping through their links, but I usually find a better deal through ebates or fatwallet. Plus, those usually have a $5 bonus for signing up (or more if you take it in a gift card). The trick is you have to start on their site, you cannot already have anything in your shopping cart at the site you are purchasing, and you can't use a coupon code that is not listed on the ebates/fatwallet page. I usually find what I want at the shopping site, write down the catalog number, then go to ebates/fatwallet to link to the site, then search for the item and add it to my cart.  I check both sites to see what the discount is at my desired shopping site (either ebates/fatwallet is better for each particular site), and I also search retailmenot.com to see if a discount code will save me more than the percentage I might earn from ebates/fatwallet. It sounds like a hassle, but it doesn't usually take me more than a minute or two to figure out the best deal. I don't earn a ton from this (most of my online shopping is at amazon.com to spend the gift certificates that I've earned, and there is no shopping reward there), but a few dollars here or there isn't bad.

One note: if you are unsure about a site, google it first. I signed up for a panel last week, and then I thought to research it, and an almost instantaneous google search showed it was a scam.  I also recommend using an email account that you check regularly, but isn't your primary personal email. I don't use my school email for anything other than personal/work email, and I have a yahoo account that I use for personal/legit sites (those listed here), and then I have a yahoo account that I use for questionable sites and freebies that I only check maybe once a week. That way, if I get spam, it's not clogging up my regular email.

Overall, I earn a few hundred dollars a year through about an hour or two's worth of work every week. It funds most of our "fun" purchases, like CDs and video games, and we also redeem for gift cards that we can give as gifts or spend (it is financing a good part of our deck).  It's a bit of a learning curve at first to figure out what is the best use of your time, but once you figure it out, enjoy!

Wednesday, August 04, 2010

Quick break

Sorry for the gap--I've been waiting to hear back on my paper, and I still haven't heard, so I'm being a bit superstitious and not talking about it much--but I found this article today and thought it was very interesting. Hopefully more of an update soon :)

Economic odds stacked against mothers

Tuesday, June 29, 2010

Omen?

Yesterday was my first day back at work. I had planned to spend Sunday night getting organized. Unfortunately, we had a strong thunderstorm come through about 5 o'clock. It only lasted a few minutes, but when it was done, our yard looked like this:
Yep, that is our fence under that tree. And it also took down the power lines behind our house. Our power doesn't run off of those lines (the people behind us likely won't have power for days--there were at least 5 different trees down over the stretch of power line behind our neighborhood). But, we had to be careful--with wet ground and a wet tree touching both a power line and the fence, it's possible that the fence was electrocuted. So we didn't get too close.

Our power went off at about 5:30. We had another storm roll through about 9 PM, and although there was a lot of lightning and rain, the wind wasn't too bad. It was enough to knock another big branch down, but that likely would've fallen anyway.

The power stayed off until the next morning. It had been 91 degrees on Sunday--that, plus rain, equaled hot and sticky. I wasn't too worried about comfort--I was worried about the 150+ ounces of frozen breast milk that might thaw. Had the power not come back on, I was going to take the milk to work with me and freeze it there.

Ahh, work. I was trying not to take the crazy storm and falling trees as an omen. I got up Monday morning and actually had Josh fed and Sophie ready to go ahead of schedule. We got to day care--and found out day care had no power and likely wouldn't for 3-4 days. So, it was back home with Sophie, and my sister had a two-for-one baby day on her first full day of watching Josh. Luckily, she was an ace and wasn't in her car driving back to California by the time I got home.

It was a crazy day, and today is another one. Our power went out again, I had to take Tim to work since we dropped my car off at the dealership last night, daycare was still out so Sophie was home again, Josh had his 2 month visit and vaccinations, Tim's dad came over with the earthwork contractor to plan the deck, and then I had to go to work--all by about 9:30.

And I won't go into my feelings at work. The sense of abandonment is less now than with Sophie--probably because I've been through this once before, and also because I've been into the lab quite a bit during my "leave". I am very frustrated that the first time I got revisions back from my boss was 4:56 PM on Thursday--as in, one business day before I was supposed to come back into lab anyway. But, I am trying not to focus on that. I just want this stupid thing out already.

I'm just glad I'm not superstitious, because falling trees and power outages might otherwise be enough to convince me I shouldn't go back into work just yet.

Wednesday, June 23, 2010

Family history

It's funny--there are so many things in life that I take for granted or ignore completely. For instance, take my family medical history. I took histories on every patient I ever saw at my VA clinic, and yet I know only bare bones basics about my own.

My GI system has a long standing history of not cooperating. Things have been acting up again recently, and it wasn't until I was talking to my mom that I realized how much of a history I have. I don't want to put all the gory details out on the internet, but one of my immediate family members had their first precancerous lesion found by colonoscopy at age 35. By the CDC/American Cancer Society guidelines, I should have been screened ten years before the age at which the first precancerous polyp was found, or age 25. I'm now 30.

It was suggested that I get a colonoscopy in 2002 after I spent three days in the hospital with GI issues. However, with the insurance we had at the time, it would have been extremely expensive. So I didn't get one.

The GI issues I have seem to come and go, and I know the scary symptoms (melena, hematochezia, etc), but I also know things can happen quietly. I do not think the current issues I have are at all related to cancer (and I've had the same issues for decades), but maybe it's time to get checked.

I don't know why I am so hesitant to see the doctor, and when I do go, why I'm not more proactive. I ask when I have questions, but I am not a fan of medication or procedures on myself if I can help it.

I guess part of me is happier not thinking about my own chance for disease. I know there are some things I need to watch for. Breast cancer is one: my great grandmother died of it, and my grandmother had it as well. Thyroid disease is another: it is very prevalent on my mom's side of the family. And I know things like heart disease, high blood pressure, high cholesterol, diabetes, and obesity are also fairly common on both sides of my family.

Knowing all this, why am I not more concerned with preventable factors like losing weight and getting more active? I guess the answer is that I am concerned, but I am also overwhelmed. I have so much mental and emotional baggage tied up with my weight and body image that it isn't as easy as just going on a diet and starting a serious exercise program. I start making steps in the right direction, but in a very short period of time, I start sabotaging myself without even realizing it.

I need to make progress in that area. I need to make it more about my health than a number on the scale. And I think I need to find out if I'd be covered by insurance for a colonoscopy. It's probably something I need to do sooner rather than later.

First, I need to sit down with both of my parents and do an extensive family history. It's time to find out what other surprises are out there. And I'm the oldest--if I do this now, when the time comes for my sibs to start getting screened, they'll have all the information they need to be informed.

Tuesday, June 22, 2010

Change of pace

I decided it was time to spruce things up a bit. More posts to come soon, but let me know if you have strong feelings on the design one way or the other (easier to read? harder to read?). I can change things accordingly. I read my blogs through Google reader, and I don't think this changeup affects that at all, but I want to make the actual page as easy to read as possible. Plus, it's a little more upbeat :)

Monday, June 21, 2010

Worth the read

I like to pass around articles of use every now and again, and this one really struck me. I think the title says it all:

Why American Workers Need to Toughen Up

Really, I don't think my generation (or the ones on either side of it) have had a lot of adversity. The feeling of entitlement is one of the main things I want to avoid passing on to my kids. Even in my own personal experience, people who were given things don't appreciate them as much as people who have to earn them. This was extremely obvious in college (I worked seven jobs and paid every cent of my college education, and the few subsidized loans I took out are in my name). I knew that my scholarships depended on my GPA, and I worked my butt off. There were plenty of people who had college paid for them by their parents, and in most (but of course, not all) cases, they were much more likely to worry more about the social experience of college than the academic one.

This is also true in my graduate education. There are some people who have been handed their PhDs, either by virtue of a lax set of requirements in their chosen departments, or by joining labs where the projects have already been worked out and they are nothing but a glorified technician. They get their degree (much faster than I have gotten mine), but I have seen first hand how they then flounder in either a postdoc or a position.

I have been blessed with much in my life, but I try never to feel like I am entitled to anything. Even with this stupid PhD, I remind myself that I'm not entitled to it just because I've been around so long or suffered so much. As much as I wish some days (ok, most days) that they would waive the requirements and just let me graduate already, I understand that I have to pass the standards like everyone else.

I want to provide for Sophie and Josh, but I don't want them to feel entitled. I read an article here about how to raise them without entitlement, and we'll see if I can do it. I don't want to manufacture false adversity for them. But I also don't think it's too much to ask them to work for some of the things they want. I'm talking more about things like a car when they turn 16--we had to have a job and have six months of car insurance saved up before we could take our driver's test. But I think even school age kids can pitch in.

I hope that I figure out a way to accomplish this before Josh and Sophie are too old to learn the lesson. Some days it is so tempting to just give in to get some peace and quiet, but I know that boundaries will help them in the long run. Josh is too small for boundaries now, of course, but Sophie isn't. We're trying, but we are definitely not successful every time. I guess we are learning how to be parents--no amount of studying can prepare us for every test.

Tuesday, June 15, 2010

Routine

I could talk about the ongoing lab drama (nothing new), or how behind I am in general life stuff (very), but instead, I want to talk about something a little lighter. And probably genetic. That is routine.

Josh apparently has started a routine. Last Monday, here was his routine. He got a bath, and then he was chill and happy:

Then he ate, took a nap in the swing, and had a poop. And I mean, a poop:
That is an out-both-sides, up-the-back, leaking-on-the-changing-pad poop. So, it was into a new outfit for him.

This Monday, he got up, I gave him a bath, and then he was chill and happy. (No pics this time, but you get the idea). He ate, took a nap in the swing, and then:
Yep, another blowout. And he hadn't had one since the previous Monday.

So, my child is also a routine-loving person, like myself. However, this is one routine that I think needs changing.

He did change it up today by peeing all over me, the changing pad, himself, etc. I hadn't had one of those since just after he was born.

Seriously though (or maybe not so), this lab stuff is a huge stressor and consumes a lot of my daily energy, but life is good otherwise. Josh is colicky, and he is still crying several hours a day, but it is getting better. And, he slept for five hours last night, which was just awesome.

And, my cousin had her very adorable baby boy on Monday, so he and Josh will be exactly seven weeks apart. My cousin and I were three months apart, and it was always nice having someone close in age to play with at family gatherings.

And my sister came home from California today--hooray! She has graciously agreed to live with us and the colicky baby for the summer. We'll see if the toddler or baby makes her change her mind, but for now, it'll be nice to have someone else (besides Josh) to hang around with during the day. I really liked the days my other sister and/or my mom came up to hang with me, so having my west coast sis around is sure to be fun.

The whole fam, minus my youngest brother (who is filling the role of California sibling at the moment), got together for dinner, bubbles, and sidewalk chalk tonight, and it was a good time.

(my pic of my brother and sister-in-law was blurry, but they were there too!)
It's the good times like this that I plan to remember, and not the terrible, stressful times that the past six years in my PhD have brought me. I can't say I'd redo the last six years, because then we wouldn't have Sophie and Josh, but there are definitely choices that I want back (say, deciding to stay in my PhD after Frank, my first boss, left in 2005). Oh well, I can't have them back, and I can only take things from today.

I don't like being negative, and I don't want to keep putting negativity out into the universe. I need to get through the paper and my thesis, and then I can get back to my life. Finishing med school won't be easy, but at least it is a defined period of time. After all, I do love my routine.

Wednesday, June 09, 2010

Once again

I'm back in lab tonight, and I will be back Friday and Saturday as well. After getting home late last night, I decided that I was more mad about this lab situation than anything. I will have come into work five days this week, in addition to all of the work I've been doing at home. And this is while I am supposed to be on maternity leave. I am supposed to be off for another two weeks. And yet, I think why I am really mad is because, although my boss is putting a lot of pressure on me, I have yet to receive any feedback whatsoever on what I've already sent her.

If I felt like my time was making progress towards me graduating, I think I'd be less bitter about it. Instead, I've been working on my paper during my entire maternity leave. And it sucks, because most of the time I am in work is time I could be spending with Sophie. She came home today, and the first thing she said was, "Mommy, you leaving for work?"

Already I feel like she needs extra attention, since we just had a baby, and instead I'm spending less time with her. It's like I have two full time jobs: I am home all day taking care of Josh, and then I work the minute I can.

And I don't mind the infant caretaking. It's a lot of work, but I'm much more comfortable with it this time. I just wish I wasn't splitting my time.

And since Sophie is third fiddle behind Josh and work, that puts Tim fourth, and me fifth. Not a good thing. Tim and I are coping ok (besides the occasional argument over whose turn it is to wash the dishes), but I've had three hours of free time (one to buy plants, one to plant them, and one to go out looking for planters with my sister). Ok, if you count a visit to the dentist (which I don't), I've had four hours. That's fine for now--I'd much rather have more time to spend with my family.

Sophie was home all last week, and other than a 2.5 hour trip to the zoo, we didn't do anything special with her. I feel bad about that. We were supposed to have family time, and instead my time was consumed with work.

I want to graduate--I am soooooo ready for this phase of my life to be over. But if my time over the last few weeks isn't actually progressing my paper, then why I am here? If this paper doesn't go out until I am back in the lab (which at this point, seems like a safe bet), I could've done this all when I got back.

Oh PhD, how I loathe you...

Tuesday, June 08, 2010

Not where I want to be

So, I'm in lab. At 7 PM on a Tuesday night. And I will be here until at least 10, probably later. Why? Because every time I think I am done with experiments, I am not. Let me rewind.

I've been working on lab stuff since mere days after I delivered. I came into lab to run experiments about three weeks after I delivered. And on Saturday night, I was up all night long re-doing figures so that I could meet with my boss at 9 AM on a Sunday. I worked for eleven hours straight, no sleep, during a tornado watch/warning (the same one that killed 5 people in northwest Ohio). And this was a night that Josh was cooperative and actually slept well (Sophie did not--I think she was up 8 times that night). I pulled an all nighter, got into work before 9 AM Sunday morning, and didn't get home until close to 3 PM. And really, it was nothing we couldn't have done over email.

Part of the Sunday pow-wow led to this week's experiments. I have to re-run gels in a different layout so that we can get a pretty picture for the paper. The data collection is done--this is just for an image. So, running today, blotting/stripping/reprobing tomorrow, blotting/stripping/reprobing again (probably Friday), then blotting on Saturday.

Where is this so-called "leave" that I am supposed to be on? This is really getting out of hand. Ok, it's been out of hand. I want to graduate, but I'm burning myself out. Taking care of a newborn is hard enough. Last week, we had Sophie at home for "vacation." Luckily either my mom or Tim was home to help with both of them. But really, the entire point of maternity leave is to heal, rest up, and take care of a newborn. Josh turned six weeks old on Monday, and I have yet to take one nap while he was sleeping.

I am supposed to get eight weeks of leave. I was thinking this would be better than the six I got with Sophie. Not so much!! I have absolutely no energy whatsoever. I'm still flabbergasted that my boss thinks I should have all this time to be working. She has two kids--granted, she had them before she started her PhD (she didn't get her PhD until she was in her 40s). But still--it's a lot of work. I knew I'd have to be splitting time when I went back to work. I really think it is unfair that I'm splitting so much of my time now.

Unfortunately, there is no on to complain to that has any power to change things. The requirements for graduation are clear, and unless I get this paper out soon, there's no way I'll be on the schedule I set for myself. So, that's why I am here.

This sucks. I think my final verdict is in: the PhD was so not worth the time, energy, or emotional angst I put into it. I wish I had a do-over. But I'm too stubborn, and I've put too much time into it, to quit at this point. So, it's back to experiments and the paper for the rest of the evening.