Monday, November 28, 2011

Coming soon

We're actually on our last full day of vacation at the moment (first vacation ever with kids--it's been an experience), and then it's back home tomorrow. I have to study for my boards, but otherwise I am done with clinical training at this point. What this means is that I hope to bring you up to speed on what's been going on the last few months. I've done my medicine acting internship, a psychiatry acting internship, a month of ER/urgent care, and had my first residency interview (with two more in the next 10 days). And I've been teaching on the weekend. And I'm about 10 weeks away from delivering baby #3. So yeah, I've been keeping busy :)

Future updates again soon, I promise.

Wednesday, August 24, 2011

Catch-up, part one

So...hey, how's it going?

It's been a while. Funny thing about blogging--for me, the longer it's been since the last blog, the harder it is for me to get back into it. I feel like I need a good reason to come back. I've started and stopped a bunch of posts over the last year or so, but many of them never make it up. Sometimes it's because I just needed to vent (though many of those posts do end up on the blog). Sometimes it's because I'm not sure what I want to say. And sometimes it's because I never finish.

I have a google reader feed full of people who blog daily or near-daily. I don't think I could ever be one of those people. Truth is, my life is not that interesting on a daily basis. I used to have outside interests, but in all honesty, kids and work take up all of my time. The kids are cute, but even I don't want a record of how many times they pooped every day or who ate what for dinner. I do wish I memorialized some of their milestones better, but I try to at least take pictures on a regular basis. That doesn't mean it I get them off the camera more than every few months, but it's a start.

Really, my life doesn't change much. There are interesting medical and personal moments almost daily, but I'm not sure I have the time to really sit down and reflect each day. Once the basics of my day are done, and the kids are taken care of, there's housework, then work-work, then bed. That's about all I can handle right now.

So if I said that it usually takes a reason for me to start back posting again, perhaps you are wondering what the reasons could be?

There are several, which I will not try to conquer all in one post. But I figured I'd better start with the most obvious first: we are expecting a third baby this February.

Yep, I'm almost 16 weeks. The three F's (family, friends, Facebook) have known for a while, so it's not a secret. I just haven't had much energy to talk about it.

We were trying to squeeze in the famous "fourth year baby." For those not in the medical field, the fourth year of medical school is much more flexible than the third year, and it's really the last break before residency/fellowship/a real job take over your life. So, at least in my program, many women try to have a baby during the winter of their fourth year of medical school so that they get time home with the baby before residency starts. Ideally, a six month old should be sleeping better than a newborn (or so I am told), so not having to wake up every two hours is a perk.

The fourth year baby isn't the last option for everyone, but I honestly felt it was for me. My pregnancies have not been fun (and boy, is this one living up to that--more later), and I knew there was no way I could be pregnant and a functional resident. And to wait until a break in fellowship meant that there might be as much as 7-8 years between Josh and a new baby (and I would be 38). That wasn't realistic either. So, we decided that if we wanted a third, this was the time.

Things definitely didn't happen right away. Without too many gory details, I actually had symptoms that made me think I was pregnant the month before. When the test was negative, I started to worry. Based on our timeline, we had two more months to get pregnant before we had agreed that the time would be too tight for maternity leave before residency. The next month, I was sure I wasn't pregnant, and I was panicked that maybe a third baby wasn't in the plans.

Then the test was positive. No symptoms, nothing. I went from shocked to excited to...oh crap, what did we just sign up for?

Don't get me wrong--we were hoping for this baby. But we had started to self-talk that maybe two wouldn't be so bad, it's a even number, we've got a 1:1 parent:child ratio, we wouldn't have to buy a bigger car, we'd have more money every month, etc. We were looking for a reason to not be disappointed if we couldn't get pregnant.

When the test was positive, all that self-talk reversed: we'll be outnumbered, we can't fit three car seats in the car, etc. We had discussed those issues before, of course, but now that it was real, we had some panic setting in.

The other thing setting in: pregnancy misery. I am not a glowing, vibrant pregnant woman. More power to those people. I am miserable for all but a few months in the middle. The result is worth it, but I dread pregnancy. This one has exceeded all my expectations, and each pregnancy has gotten considerably less fun. One of my OBs commented that it is "the curse of the third pregnancy." He did try to reassure me that the fourth is usually better. I said hell no.

The first trimester, I had horrible nausea, upper and lower GI issues, a constant awful taste in my mouth, and food aversions to everything that wasn't ginger ale or saltine crackers. I also was nearly incapacitated with fatigue. I described it to Tim like this: imagine that you just worked an overnight shift that involved extremely difficult manual labor. Then someone forced you to take a handful of sleeping pills. Imaging feeling woozy, dizzy, extremely exhausted. Imagine that it feels like someone is pulling on you, making it tough to even lift your arms. Now, you have to fight off all of those sensations throughout the entire day in order to get your work done. That's what I felt like for several months.

There's the other typical pregnancy symptoms too (no need to elaborate--google it if you want, but it ain't pretty). Those are just nuisances compared to the GI/fatigue issues.

I saw my OB early on, and I expressed to her my concern that I might become gestationally diabetic this time. I was barely OK with Sophie and borderline with Josh. I haven't gotten my weight where I want it to be, and I have a family history of type II diabetes. I knew I was at risk. She did the 1 hr screen, which I failed (as always), but this time my 3 hr GTT was positive for gestational diabetes (not by much, but it still counts).

And so began testing sugars four times a day, meeting with dietitians and high risk OBs, and cutting carbs (which were the only things I could stomach). Perhaps the most difficult thing was adjusting mentally. I told my OB at my next visit that I was really struggling emotionally with this--I know my chances of developing diabetes after my pregnancy (1/3 to 1/2 will within 10 years). I know that because this was diagnosed early in my pregnancy, my risks are probably higher. I know that while my family history is unchangeable, my weight is. And I feel like I've put all of my kids at higher risk because of this. My OB was very kind--she said that this is like receiving a serious medial diagnosis and can be emotionally draining in that way. She knows my personality, and she told be that we'll take care of the baby now, and I can take care of the weight after the baby.

I've been pretty OCD with my sugars (shocker, I know). My OB actually commented that she should write a book on how educated mothers are much more thorough with their risk management, and she'd use my spreadsheets as an example. What can I say, I love excel...

I've seen two high risk OBs too. I brought in my chart to the first one. My AM fasting sugars averaged in the low-90s, and my 2 hr postprandials average in the 80s for breakfast and lunch and 90s for dinner. The ADA goals are under 95 fasting and under 120 at 2 hrs postprandial. However, this OB said he likes to be aggressive, so he put me on 4 units of NPH insulin at bedtime, which brought my AM fasting sugars into the 80s. Recently, I've been getting a lot of readings (especially after meals) in the low 70s--I was told that in pregnancy, you can go into the 50s and be ok, but I feel pretty crappy in the 70s. But, I do what I am told.

The aggressive high risk OB had said to come back in a week, and he thought that perhaps I'd have to come back weekly during the pregnancy. This was a major bummer--it's hard enough to take time out for monthly appointments, and weekly would be near impossible. The next week, I saw one of his partners, who said I was doing great, he probably wouldn't have started the insulin but would continue it now that it had been started (drat), and there was no need to come back unless my regular OB wanted me to. That made me feel better.

Now, the sticking four times a day for blood sugars isn't fun, and it sure isn't convenient (nothing like walking away from rounds to check a blood sugar). But the insulin shots suck. Really, they hurt. I've tried a few sites (and given myself some nice bruises), and I can cope, but it sucks. The thought of potentially having to do it more than once a day is frightening.

Of course, since carbs were all I could eat, and now I can't eat many of them, I've lost five pounds so far. I am eating a lot of protein--and calorie-wise, I am on target--but I am so sick of eating the same few things that don't make me want to vomit. This should get better in the next few weeks, but I seriously can't look at an egg or cottage cheese for a little while.

My OB is happy with things (though she did tell me not to lose any more weight--first time I've ever heard that), and the ultrasounds have been good. My first check came back looking good, so that's one worry down. We'll have our anatomy ultrasound in a few weeks and see how things look then. I can't say that I'm ok emotionally with things--I'm sure you've realized I have deep-seated guilt issues, and this plays right into that. But I am working on it.

Now that we are a few months in, the panic has worn off. I think we realize it won't be easy with three young kids and me in residency. Tim knows he'll have his hands full. But, he already does the vast majority of dropoff/pickup, and if I am home late, he manages just fine. Having family in town is awesome too--which is why we'll stay in town (at least for residency). For instance, Josh had a nasty bug for a few days, and between the two grandmas, we were able to make it work. That is definitely invaluable.

We will need a car at some point, but we are going to try and stretch my 150k+ mileage Civic until the start of residency, and then we'll probably upgrade to a minivan. I swore I'd never drive a minivan, but you can't beat the convenience...

I'll try to update on med school and the rest of life soon. But now at least you know why I haven't had much energy for blogging recently.

Saturday, May 28, 2011

How time flies

I keep meaning to blog, or at least finish up some of the ones I've started over the last few months, but there just aren't enough hours in the day. While medicine is much improved hours-wise than surgery, my ability to get things done outside the house has not improved. The only reason I am even blogging now is because I am on call this weekend and I haven't gotten an admission yet. If I was home, my to-do list is long enough that I would be busy for weeks!

It's tough to do a general catch-up note on what's been going on, so I'll just give you a brief overview and then fill you in on what's up right now. First, surgery is done, praise the lord. I honestly didn't mind the procedures, but the constant pimping, the scut work, the terrible hierarchy, and the lack of focus on the patient's care really turned me off. Maybe it was the thrill of doing something other than surgery, but within a week of starting medicine, I thought this was what I wanted to do.

I like that the patients are complicated. I like that the focus is on patient care. I like that (generally) you are out when you should be--there are some late non-call days, but if you've got your work done and everything is stable, you sign out at 5. The long calls (till 11 PM) can be stressful, and since med students don't stay overnight, we don't get to be post-call like the interns and residents. So that means I'm in 7A-5P every day, with 7A-11P schedules every four days. For example, this is my "black" weekend. It means I am on call today from 7A-11P, then I come in tomorrow from 6:30A-till everything is done (around 1 P), then I am back on Monday (since Memorial Day is not a holiday in the hospital). So the weekend is "black" because I don't get a day off.

I did have my "golden weekend" (off both Saturday and Sunday) two weeks ago, which worked out perfectly. That Saturday was a family party for my brother's graduation, my graduation, my West Coast sister being home, and Josh's first birthday. Then on Sunday, I walked in my PhD commencement ceremony. That was actually more emotional than I expected. I had originally not planned to walk, both because I thought it was weird to walk 6 months after I defended and because I didn't want to shell out the $900 for regalia. However, between my family and my lab mentor, I was convinced to do. I am actually glad I did. In my institution, they let the family walk across the stage with the graduate, so Tim, Sophie, and Josh walked with me. Then I got to be hooded by my lab mentor. It was a very surreal experience to be called "doctor" for the first time--my family has teasingly called me doctor for years, but when the announcer did it, it was for real.

That golden weekend was a nice break. Although the weekend was crazy busy, it was at least nice not to be spending all my time in the hospital. My schedule since the beginning of March has been almost unbearable--and to think that it is only a taste of what residency will be like! If it wasn't for my mom cooking every few weeks, we'd probably starve. She's put meals in our freezer that have gotten us through many nights of being too tired to cook. We almost never order out, but we do eat more quick fix meals than I'd like.

I just really have no time or mental capacity to do anything outside the hospital. Tim does 99% of the daycare dropoffs/pickups (unless I am magically out early one day). The nights I am on call, he has the kids by himself, unless we've gotten lucky and have family up that night. The laundry manages to get done on the weekends, mostly by Tim (but sometimes I help, really!). Everything else though--cleaning, organizing, cooking--generally doesn't happen.

I sometimes get a few hours here or there and try to catch up. Unfortunately, usually it is just enough time for me to get started but not enough for me to finish. For example, Josh is now in 18 mos clothes. I still have 6-9 month clothing to sort and put away. He has clothes all over the spare bed in his room sorted into piles, but I haven't been able to just commit a few hours and clean it up. It's a similar story for the downstairs, where the wet spring has turned our tile floors into muddy messes and the dining room table is covered in stacks of Sunday newspapers that I haven't had time to read.

And forget about doing the drugstore deals, clipping coupons, and hitting the sales at the grocery store. I am actually out of shampoo and will need to (gasp!) pay for it because I am not up to date on store deals/coupons and don't know where it is free at the moment. We've been buying as few groceries as we can to get us through, and obviously we buy what's on sale vs. what's not, but I don't have time to stockpile good sales. I call it "guerrilla shopping."  We buy milk, bread, eggs, etc when we have to, buying the cheapest brand, but we don't buy anything we don't need right then. It's not my preferred tactic, and it means we are always scrambling to make dinner with what we have, but I don't have the time to plan things out like I used to.

I have a week off at the end of June, once medicine is done. Initially we were talking about going to my in-laws' condo in Florida; then we decided we couldn't afford airfare and didn't want to drive for two days each way. Then we talked about maybe visiting friends in Pittsburgh for a few days, but we weren't sure we could make our schedules work. Then I was just going to keep the kids home and spend time with them. Now the plan is to keep the kids in day care for a day or two just so I can clean the house, and then I'll keep them out so we can have some time together. I love the kids dearly, but there is no way I can deep clean the house the way it needs to be with both of them running around. Seriously, it's disgusting. I feel like one of those reality TV cleaning people should come over and talk about the filth. I mentally will feel better knowing that at least the house is livable and not harboring disease.

Sad, right? This is only the second week off I've had since I had Josh a year ago. I got along without vacations before, but I used to have two day weekends every weekend. Even if I was in lab on the weekends, I somehow still had enough time to keep up with my life. Now, I'm in the hospital at least one day every weekend for long hours, and I feel like the one day a week I do get off should be devoted to my family. That leaves little time for anything else. Honestly, if my bills weren't auto-paid online, I'm sure I'd be behind on my bills--and if you know me, you know that is the absolute last thing I would ever allow.

I just feel so disoriented--I am sure I could not pass a mini-mental exam. When I ask patients what the date is, I usually have to double check and make sure they are right. The time has gone so fast overall, and yet there are so many days (especially on surgery) where it feels like time is frozen.

How is my son already 13 months old? And my daughter is closer to 4 than 3? Tim & I will be married for 9 years this fall. Unreal.

I know that med school (and soon, residency) is really just a means to an end, but the hours are rough. My lab hours were often tough too, but they were flexibly tough. If I had a doctor's appointment, I could set up my experiments so that they wouldn't interfere. Now, I can't take time if my kids or sick, or I am sick. There's no time to schedule things. And I've missed invites to baseball games and other activities because of my call schedule. Luckily, other than my graduation, there hasn't been anything mandatory yet that I've needed to beg to have my schedule adjusted. But what if I had a wedding to go to, or something similar? And forget just taking a long weekend to get away. Tim's parents sold their camp last year, but even if they still had it, there is no way I could get time off to go.

I've been told that fourth year is much more flexible, with electives making life seem worlds different than third yet. I do have acting internships (one in September, one still unscheduled) to do, which will be tough. Otherwise I am looking forward to taking a breather.

And even though I like medicine, it's still caused me to stop and think about what I really want to do. I had my first patient pass away earlier this week, and I have another patient who was just switched to palliative care and will likely pass away before the weekend is out. That isn't an easy thing to deal with.

I also have the worst luck ever and will be on a difficulty team starting on Monday. My last two teams have been ok--the first was intense but educational, and my current team is not interested in teaching and just wants to be done (it is composed of two prelims, a chief resident serving as attending, and a third year resident--all of whom are moving/transitioning to fellowship in July). Starting Monday, I am going to be on service with my former PI, Dr. B, who made my life miserable for 3.5 years. I was initially worried about being on service with him before I even started my rotation. I debated talking to the clerkship director ahead of time but decided that would seem unprofessional. I worked out the chances of being on service with him at about 4% (using number of attendings, # weeks service/year, and # medicine services in the hospital). I thought a 4% chance should keep me in the clear. Unfortunately, that is just my life.

I did try to contact my clerkship director once I found out that Dr. B would be my attending. Unfortunately, I didn't find out until after rounds yesterday, and when I tried to get in touch with the director, he wasn't around.

I think I am just going to deal with it. It will be extremely uncomfortable, and I am sure he won't give me a very good evaluation--which sucks, because I am working really hard so that I can hopefully get honors in medicine. However, it is two weeks, and I dealt with him for years--at least this point has an end in sight. One of the residents also told me that he comes in for rounds, wants to be super quick, and then you don't see him again. So maybe I won't actually have to spend much time with him.  I just think it epitomizes my luck that I had a 96% chance of not working with the one person in the entire system I was trying to avoid, and I ended up working with him. Such is my life.

In general though, I am feeling more and more comfortable with medicine as my choice. I was worried, since I had done everything else and was having a hard time sorting through the choices. I like that medicine is complex (even though I constantly feel stupid). I like that it involves relationships with patients. I like that it allows me many opportunities for different types of practice, depending on what specialty I decide to pursue. I like that (unlike surgery) sometimes people do have lives outside the hospital (and I am hoping I will learn how to do that too).

There are other fields that have pros and cons, but I think medicine is a good match for my personality. I will still specialize in something, though I am unsure what exactly that might be. The other nice perk of medicine is that my home program has a good reputation for it and places people into great fellowships--which means I at least have the option to stay here for medicine if I want to. I will probably apply other places, and if there is a program that jumps out at me, I'd be willing to move. But at least we have the option to stay for residency and then move for fellowship.

Anyway, sorry for the random train of thought. I can't promise I'll be better about updating for the next month, but once medicine is over (and I have my house clean!) I'll try to be a little less sporadic.

Of course, I'll be here late tonight, since it is past 1 PM and I don't have an admission yet. By the time I see the patient, write the note, look up meds/diseases to tweak my assessment/plan, and then staff the patient, it usually takes >6 hours. My team's a bit chaotic, so I am sure that is not the norm, but that's actually a bit optimistic if past patients are any indication. Oh well, such is life. I guess I have all weekend in the hospital to study--that's being optimistic, right?

Thursday, April 07, 2011

Another toddler

Josh officially started walking today--he's been taking 2 steps at a time for a few weeks, but then he would either lunge or sit down. Today, he took multiple steps multiple times, so we're calling it--he's officially walking!

Sophie had an adorable (though preciously out-of-tune) recital tonight for day care, and it really jumped out at me how much the two of them have grown these last few months. I feel bad that I've been missing it with 14 hour days, overnight call, and working one weekend day each week. I keep telling myself it isn't forever--I'll never have a "normal" schedule, but after residency, I'm hoping it will at least be more manageable.

It was another pimptastic day in surgery today--I got singled out by the ICU attending, who pimped me on hyperkalemia for about half an hour. I didn't get all the answers right, but I think I held my own. I can't say the same for the other three hours of pimping I got today, but oh well. Seven more days.

Also, we have a patient on the floor with CRKP. Scary stuff, really, but I am not surprised. These patients get put on vancomycin/linezolid/zosyn/imipenem/etc like it is candy. Antibiotic resistant bugs are a huge problem. Hence, why I was my hands a million times a day (and bugs like C. diff don't come off with the antibiotic foam--you need to actually wash your hands).  Between the superbugs, HIV, Hep C, and TB, I'm sort of amazed our patients have any healing ability left in their bodies.

Wednesday, April 06, 2011

8 days

8 days of surgery left, but who is counting?

I have two weeks of anesthesia beyond that, but I am not counting that in the surgery total. I will have many stories to share once I have the time to blog about them!

On a continuing note re: grades from my last post, I got my summative feedback from OB/gyn. I had only gotten a few evaluations back, and they were generally benign to slightly positive, except for one. I got a not terrible, but not great eval from the preceptor that used to question me for hours, one-on-one, and his comments were generally "little rusty on knowledge due to time away during PhD, but reasoned answers out well."  I'll dig up the exact comments one of these days. Anyway, I figured faint praise is damning, so I wasn't expecting much from my rotation evals. Apparently, more people turned in evals than I saw, because the summative is pretty glowing--the one attending I worked with even suggested I do an OB/gyn AI and consider it as a career choice.

Really? Because I disliked OB/Gyn. I'd say I hated it, but after doing surgery, I'm reserving the term "hate" for neurology and surgery :)

I still didn't do well on my shelf exams, secondary to the zoster, so I'm not expecting honors. Still, I was told I did well on pediatrics, but no one turned in evaluations, so I have mediocre reviews. I feel I did a pretty mediocre job on OB/Gyn, but I have positive reviews (except for that one). Really, who knows how they decide this stuff? Absolute craziness.

Off to read more about things relevant to my patients, but nothing that will help me by giving me info the attendings want to know. For instance, did you know that there is a specific piece of fat near the appendix named for Sir Frederick Treves, who saved Prince Edward from a ruptured appendix days before his coronation? No? Neither did I, but apparently that is what I should be studying, because that is what I was pimped on. Definitely high yield material, don't you think?

Oh surgery, I can't wait to be done with you...

Friday, March 25, 2011

Bummer of a day

It's been a down day--I know, I know, I'm on surgery and it's been a down few weeks. Today has really capped off this last month, though.

I'll start backwards first. We have this online system for evaluation of our clinical rotations. Basically, you log a patient, send it to your preceptor for evaluation, and whatever the sum of your evaluations says, that counts for 75% of your grade. The other 25% is your shelf exam.

I got the results of my shelf exams earlier this week. They aren't as good as I had hoped (I can always blame the raging shingles outbreak, I guess), but they aren't so bad that I'll be able to retake them and improve my score. It's basically at or just above the national mean for the disciplines--I'm assuming that is a passing grade for my medical school, but who knows. I had been in contact with my dean, and the understanding was that if I bombed the shelf exams, maybe we'd work out a plan B. Instead, I probably did enough to pass them, but the grades will prevent me from getting honors. I won't know for sure for a few weeks yet.

The other frustrating thing is that the evaluations/grades don't seem to mirror how hard I worked. I got really positive feedback from my family medicine people, and if my shelf exam had been better, I am pretty sure I would've gotten honors. On the other hand, less than half of my pediatric preceptors filled out evaluations. The ones that did maybe put in one or two general comments--nothing bad, but nothing that stands out. I got my rotation assessment, and it really seems bland to me. I got better feedback from neurology! So, despite the fact that all of my pediatric preceptors told me I did a great job, I was comfortable with kids, I should think about pediatrics, etc, it doesn't count for anything if they never responded to the evaluation form.

I still don't have my OB/gyn comments back, but the response rate on those was about 10%. So, 75% of my grade will be based on 10% of my performance. Not fair, but that is how the system works.

I am really frustrated by this. I worked especially hard in pediatrics and family medicine. Now it seems as though all of that work is for nothing. I could've worked much less hard for the same grade. The whole system seems arbitrary, and it is extremely frustrating.

Today has also been a frustrating day on my current rotation. The other med student on my team is a rock star (S, if you read this, you are totally a rock star!). She's great, and I'm glad she's on my team. It's tough for me to be the less preferred member, though. It didn't help today that the resident and I got our signals crossed. I had asked him three times about what he wanted taken care of--when I did it as we had discussed, it was obvious that I hadn't done it the way he wanted. There was no patient harm or anything--I'd never do anything if I was worried it wasn't in the patient's best interest--but it was frustrating. At least the other med student had heard the same thing I did, so I wasn't totally out of my mind. I could tell that the resident was annoyed with me, so I went and finished my to-do list out of his way for a little while.

I was definitely feeling like I could do no right, no matter how hard I tried. I was helping him change a patient's dressing a little later, and the patient looked at me and said, "You're pretty." I nearly cried. I was tired, my hair was back in a messy ponytail, I had no makeup on, and I was feeling down. (And let's not even touch the body image issues I've been battling lately). I looked at him and said, "Thank you. That's the nicest thing anyone has said to me today." Granted, he was on pain meds and probably said that to every person he saw that day, but it made me smile.

I'm just down because today I felt worse than invisible. Despite my best efforts, I feel like all my team sees are my shortcomings. I try hard to write thorough patient histories--I might've caught a colon cancer in a patient and prevented him from bleeding out during surgery--but that gets no notice. I do blood draws, I run scutwork, I do whatever needs to be done and am always willing to take on more. Instead, my low moments end up being the highlights. Today, for instance, even though the resident was busy and I had confirmed the plan multiple times, I should've asked him to show me what he wanted done. I know that doesn't save him any time, but then it would have been absolutely certain that we were on the same wavelength. I thought I was saving him trouble. I didn't want to seem like a pest. Next time, I'll be a pest.

I am glad my three weeks of vascular surgery are over. I really feel like I didn't learn much more than what I could've learned reading a textbook. The service is so busy that there really isn't time for teaching. My overnight call this week consisted of three (very stressful) emergency surgeries with an attending I had never met before. Thank goodness the helpful resident was also on call, as was another med student from the general surgery team. We had an abscess debridement (where the patient lost all of the skin from his anus to his scrotum), an emergency procedure where the patient was bleeding out into his abdomen (and lost most of his blood volume), and another exploratory procedure because the patient was though to have strangulated bowel. There was also a respiratory code on one of our patients on the floor. Thankfully, everything turned out ok, but we were so busy with emergencies (and then the usual night shift work) that there was no time for teaching.

I got to watch surgeries these last three weeks, but I didn't get to do much beyond retract and cut sutures. I did a few blood gas draws and one intubation with the anesthesiologist, but otherwise everything else I learned was from reading. I've been told there is more OR time on general surgery (I'm not sure that is good or bad). I'm not looking to become a surgeon, but I'd like to learn about how surgeons decide what is an appropriate clinical indication, when surgery is worth the risk in some of these high risk cases, how you manage patients post-operatively, etc. I feel like the clinical rotation is supposed to be seeing how the service works. I really feel like I was more of a minion than a member of the team--and questions about why we were doing something were absolutely not encouraged. I understand not answering a general question that can be researched. However, I sometimes had specific questions about why we were doing X in a patient instead of Y. Sometimes the chief resident would give me a one sentence answer, but generally everyone was so busy and overworked that they didn't have time for more than a few words.

Anyway, it was just a rough day. I felt like a piece of crap, and seeing how much the resident preferred my co-medical student was the nail in the coffin. It is absolutely not the other med student's fault--I am thrilled she is on my team--but favoritism hurts. I guess all I can do is try my best. All the hard work I do may never get noticed, but at least I know I am doing it. It's not like my online evaluations will get filled out anyway. Part of me feels like that if there is no chance to get an honors grade on this rotation, why try so hard? My sanity and sleep would probably benefit from me back things down a bit. Still, I feel like I need to do the best I can so that I know my non-honors grade wasn't from a lack of effort on my part.

Here's hoping medicine is a better fit for me...

Saturday, March 19, 2011

Full circle

It's been a crazy few months. I feel completely behind in my life (as well as constantly exhausted), which many people would say is to be expected from long hours/overnight call/weekends during my surgery rotation. However, back in October or so, I was on neurology (which also had long hours), writing my thesis in the evenings, and teaching a chemistry class every other weekend (and grading whenever I had time). And Josh was only 6 mos old then--while he is still not a champion sleeper, he is doing much better now than he was then.

So why do I feel so overwhelmed right now?

I think a lot of it has to do with decisions. Starting in July, I will be a fourth year medical student. Which means I will start applying for a residency position. Which means I better decide what the heck I want to do so I know where I will apply. Which means I need to schedule rotations that will help me figure out what the heck I want to do.

I have friends who are sure they know what they want. Some have known since they entered medical school, some found a field that goes well with their PhD research, and others found a clinical area during their clerkships that they love but had never considered before.

I envy them.

For them, they know what they are doing, so they know how to structure their time in order to get the best letters, when to schedule their Step 2 licensing exam, and when they will have time for electives. There isn't a time crunch.  That is not the case for me. Since my clerkships run until the end of June, I essentially have July and August to figure out what I want to do. Applications begin on Sept. 1.

I had hoped to do an internal medicine AI in July or August, but they were booked, so I ended up with September. The pediatrics AIs are booked until November I think. I have the option to do electives in July or August, but I am not sure what I want to see. I initially figured that I'd end up in adult cardiology, since that is the closest match to my research interests. I'll probably try to get a cardiology elective in July/August if I can. As for what else might be a good choice--I'm stumped. I have to do a month of emergency medicine and a month of geriatrics per our med school requirements, but I might push those until after interview season. I also have to do another AI, and I might try to do a psych one later (more for fun than anything else).

For licensing purposes, after third year requirements are done, I need 7.5 months of clinical time. Two months are my AIs, two months are ER/geriatrics, and I have one month of credit from my clinical tutorial during my PhD. That leaves me a minimum of 2.5 months of electives. I want to do a cardiology elective, and I think a radiology elective might be helpful for me in general. So, I have to find another 2 weeks of clinical work at a minimum. I'm not too worried about that (and if people have suggestions on helpful rotations, I am game).

The last several months have been extra stressful because all of these decisions about the future have been on my mind. I assumed coming into third year I'd do internal medicine. Unfortunately, medicine is my last rotation of third year. What happens if I don't like it? I'm back to square one. There are a few areas that are definitely out--neurology and OB/gyn for sure. Pediatrics has potential in terms of a specialty, but I couldn't do general peds every day, and I have no exposure to specialty pediatrics, so how would I know if that is a good fit? Psychiatry was very interesting, and I am drawn to "thinking" specialties more than "doing" specialties thus far. However, I have no exposure to outpatient psych, there is a lot of overlap with neuro, and I don't want to solely be doing 15 minute med checks--but a lifetime of inpatient psych seems overwhelming as well. 

So far, I have been drawn to areas in which I've received good mentoring. That's why I thought internal medicine was originally a sure thing--I had a wonderful clinical preceptor for three years, and I looked forward to my one afternoon a week in his clinic. I had a great psych attending for a month. I really enjoyed working with all of the pediatric attendings. I felt like all of these people were human--they cared for their patients, they loved their jobs, but they also had families and a life. They treated me like a human and not like a burden.  My question is this: did I like these rotations because I like the material, or did I like them because I felt that my personality seemed to mesh well with the attendings with whom I was working?

Surgery exemplifies that dichotomy for me. Really, the act of surgery doesn't bother me--I don't wake up every morning excited to cut someone open (as some of my residents do), but I also don't dread it. Vascular surgery is pretty boring, but I don't hate it. I drew a blood gas and intubated a patient within the first few days of the rotation, so I'm not put off by procedures. The actual practice of surgery is ok--I could do it, but I don't dream about it.

The culture, however, makes it seem completely out of the question. It is completely hierarchical, misogynistic, and impersonal. People are rude and angry. No one seems to like their job. No one teaches. I would like to say that is unique to my service, but the other two surgery services at the VA seem worse, if that is possible. I haven't heard good things about any of the other hospital services either. These people are great surgeons, but they are miserable human beings. They have no lives outside the hospital, and if they are married/have kids, they rarely get to spend time with their family.

That is not how I want to live my life.

Who knows, maybe if I had been with a crappy attending in psychiatry, I'd never even think twice about it. Maybe if I had worked with an outstanding OB/gyn I'd be more interested in the field. I'm not even going to pretend neurology was an option--let's be realistic :) But really, I'm looking back at my experiences and trying to understand how much of my interest is related to the practice of that field and how much is related to how well I fit into the culture of each rotation.

That has been my stress--what if I choose a field based on a month of experiences in one specific hospital? What if that was an anomaly? How do I separate liking the practice of a certain type of medicine and liking the culture?

If you haven't seen it already, you need to check out this cartoon from the underwear drawer. I try to be open minded about life experiences--that whole "not judging a book by its cover" thing--but as Tim likes to say, sometimes stereotypes are a great timesaver. Also, if you are in the medical field and haven't seen ortho vs. anesthesia on xtranormal, you need to go here. I laughed so hard I almost fell off my chair. Granted, it was during an overnight call and I was slaphappy, but still...

Anyway, I've found many of the stereotypes about the type of person attracted to each field to be generally true. There are exceptions, as there are to anything, but it definitely seems like each field seems to attract its own kind. I'm not sure where I fit. I am enough of a people person to not want something like radiology or pathology that has little to no contact. However, I don't know that I could do something like family medicine that involves one billion outpatient clinic appointments every week. I'd like to do something that mixes longitudinal care outpatient, maybe some inpatient, and maybe some semi-urgent consulting (not like ER, more like a doc saw a patient and is worried about XYZ and called me...)

That takes me back full circle, something like a medical specialty...like cardiology.

I actually was fairly encouraged on Friday afternoon. I was post-call but didn't get to sleep after call Friday because we had mandatory lectures at the medical school. Instead, I left the hospital after rounds, got home about 8:30 AM, drank half a pot of very strong coffee, got some work done at home, and went back to the med school about 11:30. We had a small group session with one of the cardiologists I had never met before. And I LOVED it. Most of the students were zoning out or not interested. You'd think I'd be so exhausted I'd be falling over. Instead, I drank it up. I learned about new criteria for categorizing patient's cardiac risk and how to best interpret test results in ways clinicians don't normally do. I was so interested that I spoke to the doctor afterward about what it would take to work in his clinic (which unfortunately only runs one day a week). It tied together clinical cardiology, bench research, biochemistry/pharmacology, and translational research.

Granted, it is still not a clinical experience with patients, but it was so nice to remember how it felt to be excited about a field of medicine. There is still the chance that I will loathe medicine or cardiology once I am on the wards, but there's a glimmer of hope that maybe my best specialty match is still out there.

I haven't completely ruled out pediatrics or psych, but I feel much better about medicine.

I've rationalized it in several other ways too. First, if I do medicine in residency, I still have tons of specialty options. I could do something with more procedures, like GI, or I could do something more hands-off like infectious disease. I could do academic medicine, private practice, government healthcare, research, or even industry like working for a pharmaceutical company. There are way more jobs for adult specialists than pediatric specialists, so I have more choices in terms of practice environments and geography. Most of all, I can find a specialty with a good fit in terms of the forms of patient care (inpatient, outpatient, etc) that I like.

It feels a bit like a cop-out to say it, but it buys me some time to figure out exactly what subspecialty I want to do. Maybe I'll love medicine during my clerkship and have no doubts that is what I want to do. Maybe I'll hate it, in which case it is time for plan B. Maybe I'll like it equally with psych and pediatrics, and then I'll need to weigh pros/cons. I can't predict how I'll feel after spending clinical time in medicine. I do feel a lot better after yesterday's lecture in terms of the subject material, though. What can I say--I'm a nerd, and I love evidence-based medicine.

So, over the course of the last year, I've come full circle back to cardiology as a potential specialty. I'm hoping that the stereotype of cardiologists (which puts them in a category similar to surgeons) is not true. If it is, I need to decide if I can get through training dealing with that attitude until I can get into a job post-training that is a better fit for what I want. That is still TBD.

I wouldn't call this an official decision of what I want to do, it's a start.

And we still haven't made any of the other important life decisions yet. Still no idea on if/when we want more kids, where we want to live/work, etc. One thing at a time, I guess.

Tuesday, March 15, 2011

MIA

Sorry to be MIA all of February, and March/April isn't looking much better. I have about 6 half-finished posts saved up, so I'll try to get to them as I can. Here's the brief update:

I finished outpatient pediatrics/obgyn/family medicine about two weeks ago.

I also developed shingles about 2.5 weeks ago, right on my left temple (V1 distribution for you medical peeps). It was painful, and it swelled to cover part of my eye--while I was taking shelf exams. I am sure my scores will be awesome. I talked to my dean about it, so we'll see what happens. It's mostly resolved now, though I do have some residual pain. Here's hoping for no post-herpetic neuralgia!

I started surgery last Monday. I HATE IT. I don't mind the procedures or the patients, but the culture is awful. I had the resident tell me yesterday to stop being nice to patients (I took 10 seconds to put the patient's socks back on after we checked pulses). It's a miserable schedule, a miserable rotation, and it will get worse before it gets better. I'm on vascular surgery now, which at least has limited anatomy to be pimped on. I do general surgery in another 1.5 weeks, and that will be awful.

So, I am up at 4, home at 7 (if I am lucky), on call overnight one night/week, and on one weekend day each week. That schedule has absolutely no time to study, since when we are not in surgery we help run the floor. No time to study or read on patients at the hospital means I have to do it at home. I have about an hour with the kids, then I try to accomplish what I can from 8-10, then bed between 10-11 to get up at 4 again. I was on right after daylight savings on Sunday, so it was like 3:15 AM. And did I mention we don't get to be post-call? Because of our lecture schedule, we can take a nap for a few hours, but we aren't allowed to miss any scheduled AM or PM lectures (or AM rounds). That is awesome too.

I absolutely hate surgery, but I only have to last a total of 8 weeks. However, until the end of April, things will probably be sparse. I'll try to update the half-posts I already have, but I can't promise much more than that.

Ugh. Cross your fingers for me!

Sunday, January 30, 2011

Long time no blog

It's not for lack of having things to talk about...I've had several drafts of blogs that I've saved but have been unable to hit "publish." It's been a very introspective few months, and most of what has been consuming my thoughts isn't stuff I'm quite ready to talk about.

In general, life is good, and I should be skipping around happily every day with a giant smile on my face. Everyone is healthy (minus the usual winter crud), my PhD stuff is totally turned in and done until I walk across the stage in May, our budget hasn't been busted by anything unexpected (knock on wood), and most of the drama in life has settled down. I should be thrilled.

Sure, 3rd year med school is stressful. OB/Gyn was just painful. I'm on a mix of outpatient family medicine/pediatrics/OB-gyn now. It's not fun, and it's made for a few late nights when all heck breaks loose in the clinic, but there is no call. I start surgery in March and medicine in May, which will be a much different story, but I still have a few weeks before then. The weather has been gray (I think we had three days of sun so far in January), and although we've gotten a few big snowstorms, it hasn't kept us from getting to work.

And we've had two weekends in a row where we've either gotten to go out and be social (the winter lab party last weekend) or have people over and be social (my high school friend last night).

So what could possibly be bringing me down?

That's where the personal stuff comes in. Some of it is my own feeling of inferiority based on standards and expectations I put on myself. Sorry for being vague, but that is tied into the personal stuff I am not quite ready to talk about. A lot of it is worry about Tim--he's been working crazy hours (going back into work most evenings after I get home, and going into work every weekend). Add that to the fact that he does most of the daycare drop-off/pick-up, and he's really burnt out. I don't see work letting up any time in the near future, and it's not like my schedule will get easier any time soon.  I keep trying to encourage him to get out, find a hobby, do something fun, but it hasn't worked. I can tell he's exhausted, but nothing I've tried has helped.

That actually ties into the biggest thing that has been on my mind--and it's something that is completely hypothetical at this point. I've debated talking about this too, but honestly, it's been so stressful that I'd rather just have it out there. I think most of my family knows anyway.

Tim and I have been debating what we call "the hypothetical third." Yes, third baby, not third cat or some other possibility--we're trying to decide if we want another one, and if we do, when we should have it. I'm going to be 31 this year, and my family history says that I don't have all of my life to wait. If we want to do this, it needs to be in the next few years.

The two available chunks of time would be 4th year med school or during residency. As I think I've mentioned before, the thought of having a baby during residency is absolutely my last choice--while I didn't need bedrest or have other complications, I am not one of those people who feels good through their pregnancy. I have a few months in the middle that are ok, but the first and third trimester are not fun times. The thought of trying to do that while being a resident sounds like torture. I am unwilling to be pregnant during my intern year, so if we got pregnant my second year of residency and delivered early in my third year, I'd be 34 or 35. That's the absolute latest we could push things. It also means there would be 4.5 to 5 years between Josh and another baby. Honestly, I think that if I had a 7 and 4 year old (or 8 and 5 year old), going back to a newborn would be pretty difficult.

So, that leaves us with 4th year. There are parts of this that would be great: after I finish my clinical time, I've got months of elective time free. Many of these electives can be done at home, or can be vacation time. At the earliest, I could be done in January 2012--although February/March would be more likely. Still, if residency doesn't start until July 2012, I'd have several months free any way my schedule would work out. That would be the longest maternity leave yet--I had 6 weeks with Sophie, and I was back in the lab on the weekends 3 weeks after I had Josh. The thought of having several months at home sounds great.

And my salary goes up in residency, so the bump would cover the jump in daycare costs. We'd need a bigger vehicle than my Civic, but considering I bought that in 2002, and it has about 150k miles on it, it's due to be replaced around that time anyway. We've got an extra bedroom, we have everything we need for a boy or a girl, and the kids would be 4 and almost 2 when the third was born.

Sounds obvious, right?

It's not. As much as I would like a third, and Tim is on board (on his good days), I think it would be too much for him. He's told me as much. Both Sophie and Josh are in tough stages right now developmentally. Josh started walking right after New Year's, and he's standing and getting ready to walk. All of the changes mean he is sleeping like crap, which means we are sleeping like crap. This is much tougher on Tim than it is on me--I'm getting ~5 hours of sleep per night, which is like vacation compared to how it was a few months ago. For Tim, that is misery. And Sophie has been regressing in her potty training the last week for some unknown reason, which also drives us nuts. I can suppress my frustration, but the accidents just drive Tim up a wall.

He's a very good dad, and the kids just love him to pieces--I don't want to paint him in a negative light at all. He handles almost all of the daily kid duties. That on top of his crazy work schedule is exhausting. And when I am in residency, he'll take on even more of the day to day jobs. As much as I really want another child at some point, if he says he doesn't think he can handle three, I have to respect that.  I don't have to like it. And I'd be lying if I said I was at peace with the idea of being done having children. I don't want a herd--three is my max--but I always thought it would be nice for at least one of the kids to have a same sex sibling.

If it stayed just the four of us, I'm sure we'd be happy. I just feel like I am grieving a little for the third baby I always thought we'd have. The last thing I want to do is have a third kid without Tim on board--I don't want him to resent me or the baby if that isn't what he wanted. But he's really the one doing most of the daily child care, and I can't just have a baby and dump it on him. Already, if the kids get sick, he has to leave to get them. If they have an appointment, he has to take time off. I try to have something for dinner for them when they get home, even if it is leftovers, but he has to feed them and take care of them until I get home. And then he goes back to work for a few hours. It's a tough job, and I'm thankful I have someone willing to break out of traditional gender roles and do many of the things that are usually assumed to be the mom's job. He is the one who keeps things running in the house.

If we could afford a nanny, then maybe this would be doable. However, 1) we can't; 2) I think it's important for kids to be socialized, especially after they are 12-18 months old and are starting to understand that other people exist in the world; and 3) it would be silly to have a nanny for one kid and still send the other two to day care.  And it's not like I want to have kids and never see them. That's probably the biggest thing that has been miserable in third year--I hate not seeing my family. I miss them like crazy, and I make sure that the weekends are about them. I hate that my training will keep me from them many nights in the future, but I have promised myself that I will make the most of the time I have with them. And ultimately, I'll have a job that provides us with the ability to go on fun vacations and hopefully lets me be a part of the activities that are important to them. While my medical specialty choice won't solely be based on lifestyle, it'll be a big factor.

Anyway, I'm torn. I can already feel that Tim is stressed and exhausted, and I don't want to add to that. But if we don't have a baby in fourth year, chances are we won't have another one at all. And, umm, gestation takes 9 mos+, so this is a decision we'll have to make in the next six months.

I'd be lying if I said I wasn't terrified of making the wrong choice. I don't know what the right answer is. What is best for the potential third baby? What is best for Sophie and Josh? And Tim? And me? We know that we could provide for another baby--the food/clothing/shelter bit is covered, and daycare would be covered too. It's a personal decision, something I think about every day, and something I am praying about. I'm a rational person who makes decisions by weighing pros and cons. Trouble is, I don't know how to weigh personal feelings and choices.

If having the hypothetical third would only make MY life more difficult, but it wouldn't increase the burden on anyone else, I would do it. I would do anything for my kids, which is why not sleeping/constantly cleaning dirty underwear/reading the same book 37 times doesn't bother me. It's for my kids--so that makes it ok. I have so much fun with them. Watching them grow up has been completely amazing. I feel guilty every day that I don't have more time to spend with them, but they are well taken care of at "school" (what we call daycare) by people trained to take care of kids. And they come home and know we are their family. We try to get them to see extended family as much as we can. Most of all, I think they know they are loved.

My favorite times are when we are all snuggled together, or when Sophie is making Josh laugh hysterically, or when they discover a new skill that they couldn't do before. We have such fun together--there are stressful times too, but I think I do a pretty good job of letting the stressful times pass. Tim holds onto those stresses more than I do, which is why I think life takes more of a toll on him. I'm already worried about how he is coping with the current stresses--I don't think there is any way I could add to that. We've always been a team, and every big decision we've made, we've made together. There's no way I'm going to go solo on a decision as big as having another baby (and, umm, that's not really a solo decision anyway....). We'll keep talking about it. Maybe a way will open. Life has a way of working out. Until then, this will continue to be on my mind.

I always thought that getting through med school would be the most stressful thing I've ever done. In reality, it's not too bad. Yes, the hours can be crappy. But many of my lab years were worse. Yes, it's tough dealing with grouchy attendings. But you are only with them for a set number of weeks. Yes, there is a lot to learn. But it's something that has already been studied and described by someone else--you just have to read and learn it. Yes, I feel stupid on a daily basis. But it's only my ego--better to confirm/ask an attending than put the patient at risk. I'm only a medical student. If I knew everything already, I wouldn't need to be trained.

Maybe that is something positive to come out of my PhD. I take med school so much less personally that I took my PhD. That was MY project, and I felt like it depended solely on me. It didn't, of course, and it should've been my former PI's and committee members' jobs to help me. Hindsight is 20/20 on that one. In med school, it's my job to do the best I can, but the patient is also seen by an attending, and ultimately it is their responsibility to make sure that we haven't missed anything. It won't be this way forever, of course, but it's a comforting safety net at the moment.  I haven't missed anything major yet, but I am sure that day will come.

On the other hand, I am responsible for my family--there is no safety net there. I have to do what is best for them. Every day, there are decisions that need to be made, and I try to make the right ones. I'm lucky that Tim and I think alike. We've been together for 15 years this month, and we know each other pretty well. I read other blogs where the wife comes off as subservient and the inferior partner in the marriage. That is so not us. We work because we keep the other person's needs in mind, and we want to make them happy, but we know that we are equals. It's give and take, based on what is best for the family at the time. We've done a pretty good job of making it work so far. There are decisions we'd like to take back, of course, but nothing really major. Maybe that's why I am feeling so much personal pressure about the "hypothetical third." We're such a good little family now--I'd love to add another little person to the mix, but I'd hate to mess up what we have.

Enough rambling for today. If you've wanted to know what's been on my mind, here's one piece. Like I said, there are also personal issues I'm struggling with (many of which have been a struggle for a long time), but it's not something I want to get into yet. Besides, I think this is plenty personal for one day.

I don't know what will happen yet. We've still got some time to think. But I feel like this is probably one of the biggest decisions we will ever make, and I want to make sure we've thought about everything before we decide. At some point we will have to commit. I'm nervous and terrified that will will choose wrong. But, no matter what happens, we'll make the best of it. And if that means we stay a foursome, I can't say that I won't be sad in my heart, but I will be thankful for what we already have.