Family wedding

Last weekend my brother Andrew got married. The wedding was really gorgeous and I'm so thrilled to have a new sister. In other news, it was Sam's second wedding, but his first as a dancer and he wowed us all with his moves.

Part-time residency

Now that I'm out of the Q5 frying pan and into the Q4 fire, it seems like the right time to write about part-time residency.

One or two years ago, part-time residency wasn't even a glimmer in my imagination. Never occurred to me that it might be possible. Then I received my UCSF residency interview invitation and discovered !they offer part-time residency! I interviewed there -- and was so impressed with the program -- but ultimately decided that adding an hour long commute to my life was the opposite of family-friendly. But the seed was planted and I matched at Stanford with the expectation, misguided maybe, that part-time residency was going to work for me. Hey, if they can do it at UCSF, why not at Stanford?

As it turns out, they *can* do it at Stanford. At least, I can. After some careful negotiating, I am the proud owner of a shiny new part-time residency, starting next year. I'll spread my remaining two years over three years total, doing two months on, followed by one month off for 36 months. Even better, the call schedule quiets down considerably starting next year. As an R2, I anticipate five or six call months; I'll have four or five call months as an R3. In other words, stanting in July, my life will go like this: call month, followed by elective month, followed by month off. Rinse, repeat.

To say that I am overjoyed about this development is a severe understatement.

There are some downsides here. For one, I won't be paid during my months off and neither will I be eligible for benefits. Happily, Brian earns a salary and receives benefits, so this isn't a crisis. Also, I'll have to keep up my continuity clinic during the off months, at least for the first 24 months. On the one hand, drag. On the other, it's probably for the best that I'll keep the clinical side of my brain engaged during those months off.

While the major motivation here is simple -- more time to mother my small son -- I do anticipate doing some research during my off months and I've begun to talk with my research advisor about possible projects. Even so, he's encouraged me to enjoy these months off for what they are: pulses of diastole amid the systole of residency.

Oh, I am happy about this.

Postcard from internship

So the other night, I'm interviewing this vet with no legs. At some point, it seemed reasonable to ask about it.

Me: Sir, I notice that both your legs have been amputated above the knees. What happened to your legs?

Him: <flinging the sheet aside, inspecting his well-healed stumps with some surprise> I don't know, Doc. Couldn't really tell you. I don't remember.

You can't make this stuff up.

Excuses

Last month, one of my ICU patients called the police from his hospital bed and told them I was trying to kill him. The police showed up at 2 AM -- I suppose they have to -- to take the patient's story and to question me. As it happened, that night was one of the busiest nights in the ICU that entire month; we admitted four or five patients over the course of as many hours, several of them desperately sick. I stopped briefly to talk with the officers as I moved from disaster to catastrophe. Of course I'm not trying to kill my patient, I told the cops. Although now that you mention it, the idea does have merit. I'm not sure what's happened since then with the investigation; I certainly haven't heard anything more from the police. And the incident did yield a dash of surreal humor to what would have otherwise been an entirely humorless night.

As luck would have it, I readmitted this delightful patient to the hospital on Sunday night.

Un-freaking-believable.

So far, he hasn't called the police again to report me (so far as I know), but every encounter with him is intensely unpleasant. This man may be the most miserable human being I have ever met. He is nasty and hostile. He is racist and sexist. I can't so much as greet him without being subject to a stream of profanity and disdain, sarcasm, rage, hate. Because he's been sick more or less continuously since July, he has been cared for, at one time or another, by many of my resident colleagues. So far as I can tell, he is universally despised. Post-call yesterday, I was briefing the dayfloat resident (DFR) who covered for me in the afternoon. As it turned out, DFR also had cared for my patient, a couple of months before, and he knew more about this man's history. Apparently, a few years ago, my patient's college-aged daughter was raped and murdered. And that's why he's so miserable and mean, DFR said.

Wait a minute, there. I certainly don't diminish the tragedy my patient has experienced. But does a tragedy -- even a horrific one -- entitle him to be hateful to strangers? Maybe I'm heartless, but I don't think it does.

California Academy of Sciences

Yesterday we took Sam to the California Academy of Sciences. He pretty much made this face all afternoon:

Great Pumpkin 2

Great Pumpkin

Last weekend, we took Sam to a local pumpkin patch.

There was a little petting zoo at the patch:

We had a wonderful time!

The more things change

I have a day off from the ICU today and I’m sitting in Starbucks, putting together a poster for the annual ASN meeting next week in San Diego. I finagled another day off for the conference and will fly to San Diego and back all in one day to present my poster and hopefully meet some of my future colleagues in academic nephrology. Catching a 6 AM flight only to fly home 15 hours later doesn’t sound like much of a day off, but that’s probably just the crazy-tired talking.

The crazy-tired does a lot of talking these days. Truthfully, the ICU has been harder than I expected. Part of the problem comes from that fact that our VA ICU is an MS-ICU, which means that both medical and surgical patients are cared for by the same ICU team. In some ways, this is a good thing. For one, my residents this month come from general surgery and anesthesia, as well as medicine, and I’ve enjoyed meeting and learning from this diverse group. For another, managing a post-CABG patient, the bread and butter at our VA, is good learning for medicine interns. Where else do you consistently encounter concomitant distributive and cardiogenic shock? On the other hand, some of the differences in approach between the two services (medicine and surgery) are -- how to put this delicately? -- frustrating.

Right now in our ICU there is a patient with severe congestive heart failure, in cardiogenic shock. Essentially, the pump function of his heart is failing and he is unable to pump sufficient blood forward to supply oxygen to his organs and tissues. One consequence of this problem is that the patient’s lungs slowly fill with fluid as it backs up behind the failing pump. The medical approach to such a patient is to temporarily give medicine to augment the strength of each heart contraction (inotropy), as well as medicines to reduce the extra fluid in the lungs (diuresis) and to lower the pressure against which the weak heart is pumping (afterload reduction). The surgical approach, apparently, is to insert a chest tube to drain the fluid around the lungs. The surgeons are also refusing to allow the ICU team to provide afterload reduction. Meanwhile, the patient is requiring ever-increasing doses of inotropic support, in the form of intravenous dobutamine, which increases his risk of a dangerous arrhythmia. Our various consulting teams are wondering, first politely, and now with escalating boldness, why -- why, exactly? -- the ICU team is mismanaging this patient so spectacularly. It’s an irritating situation and brings to mind that old joke about the various specialties: Internists know everything and do nothing. Surgeons know nothing and do everything. Psychiatrists know nothing and do nothing.

But despite the irritation and the crazy-tired, I’m doing OK. Brian is home from Japan, finally and blessedly. And Sam is Sam. And that right there is enough for today.

Puzzles and tricks

Last week Alex promised Allie more Sam videos, so here ya go! Replete with our standard gold-plated production values, to say nothing of the editing botch job. Eh. Good thing the kid's pretty cute.

Blogging fail

I can’t help thinking that when I read back over these posts next year, it will seem like my intern year was composed entirely of days off spent at the spa. I’m off today, sitting with my post-pedicure toes under a dryer, wondering how many minutes are required before I can safely slip my sandals back on.

It’s early in the afternoon, but already, it’s been a productive day. Since Sam went to bed last night, I’ve performed the final post-mortem on our Thursday night dinner party (read: two hours of scrubbing dishes, the stove, the kitchen floor), done three loads of laundry, finished up a few nagging research details and sent them to my advisor, planned our family menu for the upcoming week, gone to three grocery stores and dropped off a donation at Goodwill. Now Sam is napping, and I’m blogging. I’m hoping my toes dry in time for me to get in a short nap myself before he wakes up.

I love not being at the hospital. Oh, how I love it.

But that’s not what I wanted this blog to be about. I wanted this blog to be about my life at the hospital and about my patients. It’s not that there’s a scarcity of stories to tell. Just in the last couple of weeks I’ve dealt with addiction and psychosis, sepsis, flash pulmonary edema. I’ve called strangers in the middle of the night to tell them a loved one is unexpectedly dying. Alcohol withdrawal. Heart attacks. But I’m finding it very hard to find the space and the energy to tell those stories.

On a lighter note, Sam loves to watch Brian in the kitchen lately, which Brian facilitates by letting Sam stand on a dining room chair so he can see up on the counter. Downside here, obviously, is that Sam tends to fall off the chair. I've been thinking about buying this:

... but the $200 pricetag has dissuaded me. So tonight while I was napping on the couch, Brian fashioned a solution out of a dining room chair, an old bike tube, two C clamps and some zip ties:

Aaaaaand now I'm thinking $200 sounds like kind of a bargain, now that you mention it.

In order of awesomeness

Things that are awesome:

1. Chicken schwarma for dinner
2. Pictures of Sam on the Golden Gate Bridge
3. Three tickets to Tuscany for my vacation in April
4. A day off from night float

In no particular order

Things that suck:

1. Night float
2. Night float
3. Night float

Night float

It's almost 2 AM and I'm camped out in what passes for a "hotel room" in our hospital. It looks more like a drab dorm room: narrow twin bed, non-functional lamp, cramped desk. Even the alarm clock is broken. Tonight's my second of fourteen nights on night float and my pager has been relatively quiet but I can't sleep because a) ever the pessimist, I drank an enormous quantity of coffee four hours ago and b) I'm waiting for a repeat hematocrit on a bleeding patient, anxiously refreshing and refreshing my computer screen.


Night float is a necessary evil in medical training. In years past, before new limits on duty hours for residents were adopted, the on-call resident handled cross-cover and admissions, but this genius system resulted in marathon shifts lasting far longer than the supposedly enlighted 30 hour maximum that's the current standard. So now we have night float and for the next two weeks, I'm it. My shift starts around 8 PM and lasts until the primary interns and residents return to the hospital in the morning to resume care of their patients. I cover patients for 12 doctors overnight -- typically about 80 -- but I'm not responsible for admitting new patients. All night long, I answer pages about Ambien and hypotension, I follow-up on recommendations made by subspecialty consultants, and I see and evaluate patients for whatever comes up overnight: pain, agitation, abnormal vital signs.


Night float is generally considered to be a pretty miserable time, and so far, I'd say that's right. It's lonely, it's boring, it's annoying, it's frightening. The good stuff about residency -- the honor of a patient's trust, the commaradie among residents, the satisfaction in mastering a new skill -- is essentially absent. What's left is the chaff of residency: paperwork, a never-ending succession of pages, uncertainty and inadequacy. For instance, I just took a break from writing this post to see a patient downstairs who's nauseated and vomiting. I have no idea why he's vomiting. A quick review of his chart reveals that the vomiting is a new problem for him, so the doctors who know him well haven't left me any clues. He could have an infection, or the vomiting could be the result of his kidney disease, or maybe it's from the medicines we're giving him. I suppose he could have an entirely new problem: heart attacks and pancreatitis can cause vomiting. So can a million other conditions, like migraine headaches, toxic exposures, small bowel obstructions. But my patient doesn't have a fever or an elevated white blood count. He's getting regular dialysis that appears to be adequate. He has no additional symptoms like chest pain, abdominal pain, headache. So here I am. Other than medication to treat his nausea and a couple of simple blood tests that I don't expect to be spectacularly revealing, I'm not sure what to do. It's now 3 AM and frankly 7 can't come soon enough.

Day off

Yesterday morning, post-call and semi-delirious, I was rushing around the hospital to examine each of my patients before our early rounds in the CCU. One of my patients this week is a lovely woman in her mid-50s with radiation-induced pulmonary fibrosis and severe damage to her heart from chemotherapy many years ago. The radiation and chemotherapy cured her cancer, but that's small comfort now that her heart and lungs are failing. She's been virtually confined to bed for years, but lately she's taken a turn for the worse. Her left lung is full of fluid and she can't so much as roll over in bed without becoming severely short of breath. Making matters worse, several times each day, her heart goes in and out of a very fast rhythm that exceeds the upper limit of her pacemaker. After listening to her breathing (crackly in some regions and eerily silent in others) and her heart (fast with a loud whoosing murmur), I started to leave her room, already ruminating on my next task. Once I was halfway to the door, I thought to turn around to ask my patient if there was anything I could do for her before the day got underway. "Just enjoy your life," she said sadly.

Whew.

So today, my first day off in ten days, I am determined to do just that. I started the day with an early morning hot tub soak and massage, then biked home to play with Sam and feed him lunch. This afternoon, my sister and I will pick our youngest brother up at the airport and I'm hopeful that we'll have time to take Sam to the park before the gang of us go out for dinner. Maybe after Sam's in bed, we five can sit in the backyard and share a bottle of wine. There's laundry to do and dirty dishes in the sink, but they can wait. Today I'm enjoying my life.

Insomnia

It's 3 AM and I can't sleep. This almost never happens. There was one night in college when I rolled around in bed for most of the night and for years afterward, I refered to the experience as "that time I had insomnia". Generally, I fall asleep as my head is hitting the pillow, if not before. Tonight, though, I woke up a couple of hours ago to the sound of Sam having a nightmare, and although he fell asleep again almost immediately, I haven't been so fortunate.

Here's what's bothering me: what if I'm making a terrible mistake?

I start Saturday in the CCU, which means for all intents and purposes, I start internship on Saturday. And suddenly, I feel sick to my stomach. I am reasonably sure -- as sure as you can be, I suppose -- that Sam will make it through the year unscathed. But will I? Earlier today, Brian and I talked (calmly, rationally) about how he and Sam will likely go to Oregon for Thanksgiving and Christmas, leaving me here in California alone. (Thanksgiving = VA wards; Christmas = University hospital wards.) So I will miss my baby's second Thanksgiving and his second Christmas.

Oh, nuts. Now I'm crying.

More than the holidays, though, I'm going to miss a thousand ephemeral moments with my tiny son over the next year: swinging at the park, snuggling on the couch with a library book, hanging out laundry in the backyard. And I just wish there was some way to know for sure that it will be worth it. I wish there was some way to look forward to the future, to the time when I envision meaningful work matched with ample time to mother and ask my future-self: was it worth it?

I've thought this issue through from every side, talked about it with friends and family until there's nothing left unsaid. I'm desperate to make the choice that will most bless my son, my husband and myself, over the long term. Caitlin Flanagan famously wrote that "when a mother works, something is lost." What she failed to mention is that something is lost either way. If I don't complete an internship, I'll leave behind a career I've worked years to build. Doctoring offers me the opportunity to set an example for my impressionable son, flourish in the public sphere, nurture my peer marriage, maintain my economic independence. A second income will give my family security in uncertain times. More important, I'm good at it. More important still, it needs doing. But at what cost?

Beach baby

Last weekend, while Brian lived it up in Gold Beach, some friends rescued me and Sam, and spirited us off to Pescadero for an afternoon at the beach. We had a wonderful time and I took this little movie of Sam digging in the sand.

Warning: this movie contains no content. It's just Sam, digging. If you aren't crazy about this kid, the movie may actually bore you to death.

By request

My mother asked for a new video of Sam. He isn't exactly John Barrymore, is all I have to say.

Chest pain

Being on call for our university-affiliated nursing home this week has been an interesting introduction to doctoring. On Thursday morning, I was paged for the following question:

"Mr. W. is having some new left-sided chest pain. He thinks he's having a heart attack and he'd like to take an aspirin. Can we give him aspirin?" There's a pause while I reflect momentarily on the insane conversation I'm having.

"Okay," I say to the nurse on the phone. "Aspirin is fine." And I'm thinking, she can't be serious.

"Well, what dose of aspirin would you like us to give him?"

WAIT, she IS serious.

"Do YOU think Mr. W. is having a heart attack?" I ask her.

"I don't know," she says, sounding disinterested. And I'm thinking, aren't you CURIOUS? I sure as hell am.

"Let's get an EKG," I suggest.

"I don't know," she says, dubious. "We'd have to send him to [our university hospital] for that."

WHAAA?

Off to a slow start

Well, I've been a resident for four days now, and so far, it's been a breeze. I started on geriatrics, which is a soft landing to say the least. All outpatient, no real call, Fridays and weekends off. On my very first day as a doctor, I saw a total of two patients, both in erectile dysfunction clinic. (Oh, the jokes. So many jokes.) In an odd example of life imitating my nightmares, both patients asked me how long I've been a doctor. I figured, they had already opened up to me about much more intimate matters. Plus, they weren't wearing pants. So, I came clean: "Today's my first day!" Juuuuust what they wanted to hear.

On the upside, I never have to say that again.

I was also "on call" over the weekend for the skilled nursing facility associated with our university hospital. I got called exactly once, for a very trivial matter which I knew how to resolve. Weirdness. And the nurse on the phone kept calling me doctor. More weirdness.

To round out this useless post, here's a video of Sam eating a popsicle. I love summer.

Apologies to Mae West

Too much of a good thing is wonderful!

Twins

Wherever we go, people tell me my son looks exactly like my husband. Frankly, I just don't see it. When I look at Sam, I see Sam. But we were looking through some old family pictures recently and even I have to admit that baby Brian looks an awful lot like baby Sam.

Scheduling

So I have a tentative schedule for next year. There's clearly something wrong with my schedule because it includes five -- count them, people, FIVE -- weeks of vacation. That won't last. My other beef with the schedule as it stands is that my first rotation is geriatrics, which is BY FAR the cushest intern month at Stanford. And I have it first! DRAG. It would be lovely beyond words to have a geri-vacation sometime in the middle of the winter when it's really needed. Instead, I get it in July. I'm already all rested up! And it's too early in the year to use the geri month as Step 3 study time. Other lowlights of the schedule: Thanksgiving and Christmas on call. And I get to finish off the year with back-to-back wards months. Honestly, it's hard to find much to like about this schedule. Other than the five weeks of vacation. Which, like I said, won't last. In any event, here's the run-down:

1. Geriatrics: 1 week

2. Vacation: 2 weeks

3. Coronary care unit: 4 weeks

4. Rheumatology: 2 weeks

5. Endocrinology: 2 weeks

6. VA ICU: 4 weeks

7. VA wards: 4 weeks

8. University wards: 4 weeks

9: Nephrology: 3 weeks

10: Vacation: 1 week

11. Oncology: 4 weeks

12: University wards: 4 weeks

13. Vacation: 2 weeks

14. Infectious disease: 2 weeks

15: County hospital wards: 4 weeks

16. VA wards: 4 weeks

On the upside, there's no neurology. And no night float. And no emergency medicine. And as it stands, I never have more than three call months in a row. So I suppose it could be worse. But really not that much worse.

This residency thing is seeming less and less like a good idea.

In other news, our program director -- widely regarded as a Force for Good in the universe -- is resigning come September.

Pffffft.

Graduation

We did it!

Lady of leisure

So lately I've been thinking about leisure. Mostly, my thinking goes like this: Mmmm, this couch is so absurdly comfortable. I freaking LOVE sitting on the couch. Next year -- and by "next year" I mean two weeks from now -- I won't be able to sit on the couch like I do now. Which is a serious drag, because this past year, I have turned couch-sitting into high art. I've had more leisure time this year than any other year in recent memory. It has been absolutely luscious. I have luxuriated in my endless afternoons. I have reveled in my free evenings. Golden weekends, every weekend.

I've always thought I prefer to be busy. Productive! But this year I've been more or less a part-time researcher because I wanted to seize the opportunity to spend significant time with my son before residency. I expected to love the time with Sam: taking walks around our neighborhood, playing at the park, lingering at the library. But what I didn't expect, exactly, was how exqusitely I love doing ... not much at all. Turns out free time is habit-forming and I'm hooked. Today, for instance, I woke up with Sam, around 7 AM. We took our sweet time getting dressed and eating our oatmeal. We listened to the news on the radio and made the beds together. During the late morning, we ran a few errands. At Target, we browsed the aisles, just waiting for something to catch our fancy. I bought a new dress, jeweled sandals. An orange rash guard for Sam. We dallied at the grocery store, then back home for lunch. I intended to work on my abstract submission for ASN during Sam's midday nap, but instead, I curled up on the couch and read a novel. In the afternoon, Sam and I walked to midtown for a few more groceries and an iced coffee. After dinner, Brian and I ate ice cream and watched Benjamin Button. It was a perfectly delicious day.

Recently I asked some friends, both academics, what's the optimal number of leisure hours per week? One of them counted the bulk of his working day as leisure, because he loves his job so much. Lucky him! I like my work well enough, but I definitely don't consider running around the hospital "leisure"! The other friend came up with a number: 30. That sounds reasonable to me.

Maybe a better way to pose the question is this: how many hours each week do I want to work? Based on how happy I've been this year, how balanced I've felt, I'd say the ideal number for me is somewhere between 30 and 40. I'd love to work 30 hours a week forever, but I'd be willing to work more like 40-50 under the following conditions: 1. One full weekday per week free, 2. Home for dinner most nights, 3. Off most weekends. I think a schedule that adhered to those requirements would result in an adequate amount of couch-sitting.

This kind of analysis is relevant for me because in the near future I need to begin to make professional choices that will result in more or less leisure, and I want to think the decision through carefully. So I'm interested to know how other people think about this question: what's your dream schedule? How much couch time do you need? How much do you want?