Saturday, December 19, 2009
Monday, December 7, 2009
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.
Tuesday, November 24, 2009
Tuesday, November 17, 2009
As luck would have it, I readmitted this delightful patient to the hospital on Sunday night.
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.
Monday, November 9, 2009
Tuesday, October 27, 2009
Saturday, October 17, 2009
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.
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.
Saturday, September 19, 2009
Monday, September 7, 2009
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.
Sunday, August 30, 2009
Saturday, August 29, 2009
Thursday, August 27, 2009
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.
Monday, August 3, 2009
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.
Wednesday, July 22, 2009
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?
Friday, July 17, 2009
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.
Saturday, July 11, 2009
Saturday, July 4, 2009
"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."
Saturday, June 27, 2009
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.
Tuesday, June 23, 2009
Thursday, June 18, 2009
Wednesday, June 17, 2009
Thursday, June 11, 2009
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?