Call Hierarchy of Needs

Now that I am not on call, all day, every day, I have found there is a certain behavioral pattern emerging on my call days. Something similar to Maslow's "Hierarchy of Needs," if you will.

First Goal - Be able to leave the hospital. You may laugh, but some days it is d*mn near impossible to do. I am always figuring and re-figuring in my head if I am going to be able to go home that night, or if I will wind up being stuck until after office hours the next day.

*First goal bonus if I am able to leave the hospital before my children's bedtime, so much the better to actually *see* them.

Second Goal - Shower at home. This seems like an odd one, I know, but I *hate* to shower in the hospital call room bathroom. It just is not the same, and it also slightly squicks me out. So if I achieve the first goal, I proceed immediately to goal number 2 as soon as I step foot in the door.

Third Goal - Eat. This rule has stayed the same since residency, "eat when you can."

*Third goal bonus if I actually getting to eat with my family or if I am not eating something like Ramen noodles.

Fourth Goal - Spend (somewhat) quality time with family (while obsessively keeping one eye on the computer L&D and ER census for potential roadblocks to goal number five).

*Fourth goal bonus if I am able to tuck my children in for bedtime and maintain a normal evening routine before getting called back to the hospital.

Fifth Goal - Sleep in my own bed. This one is a bit more elusive, as you can imagine.

*Fifth goal bonus if I get to sleep in my own bed *all night long.* (HA HA! Almost never happens.)

**Extra bonus if I get no pages while I am sleeping in said own bed, and wake up the next day frantically checking my pager to be certain the battery hasn't expired. (Again, elusive.)

Let's face it 5/5 goals happens once in a blue (full) moon. If I am able to achieve 4/5 goals, I feel pretty good about my call night. Satisfaction with the night decreases exponentially with each goal not met, naturally. Before I am derided, of course my ultimate and overriding goal is to provide quality care to my patients...and to sleep in my own bed. :)

**Cross -posted at Mothers In Medicine

Ob/gyns are terrible people who deserve to die, and other misconceptions

Tempeh writes: Still, I hate to generalize, but I've met far more "toxic" docs in OB/GYN than in other specialties. I always find it odd. The majority of OB/GYNs with whom I have interacted (as a med student and through 3 full-term pregnancies) have been women, who are supposed to have better communication skills, higher pt satisfaction, etc. And they work in a field where most pts are healthy and, in the case of OB, happy to be in the office/hospital because they are pregnant or delivering. Why are they so bitter as a group? It mystifies me. Maybe some of the very pleasant OB/GYNs amongst our MiM writers can shed some light on the specialty.


I'm not really certain if I fall into the category of one of the "pleasant" Ob/Gyns or not, but I will give this question a shot. Bitterness and Ob/Gyn, alas, does seem to go hand-in-hand. I believe that, first and foremost, it is an incredibly important, busy, special, and stressful job. True, most of our patients are healthy, but when they get sick, they can get sick quickly, and when healthy young women or babies get sick, injured, or die on our watch? That's especially devastating. I can't think of a single person that went into Ob/Gyn as a bitter person who hated women, but at the end 4 years of constant sleep deprivation, sometimes another pregnant woman in labor is no longer a miracle, it just means more time spent away from fulfilling basic human needs like using the bathroom, or eating, or, most elusive of all, sleep! It is also seeing women, not only at their best but at their very worst, hours of staring at monitor strips, worrying about when to pull the trigger on a cesarean delivery, wondering, if it is too early that we will be blamed for "unnecessary surgery" and trying to get to our golf game or (god forbid) home for dinner, or, if too late, we will, much worse, have a sick or damaged baby (and possibly be sued for everything we have). Women can be very difficult patients, who require a lot of communication, not a problem for patients who are willing to return to discuss issues, more of a problem for people who wish to stuff a year's worth of problems into a 10 minute annual exam. It's persistent 36 hour shifts, often skipping breakfast and/or lunch, and 72 hour weekends (remember how much you hate call Fizzy? Would you be bitter if you did it all the time?) It's adrenaline burn-out, hours of nothing followed by a harrowing roller coaster. It's constantly being second-guessed, by our partners, other physicians, the L&D nurses, the patients, the internet, ourselves, even when we *know* we are practicing to the *standard of care* for our profession.

It's the malpractice, multi-million dollar coverage premiums to pay yearly, the threat of lawsuits for up to 18 years after the fact, shrinking reimbursement (universal for all physicians), trying to pay our staff and our overhead, having to fit more patients into the same hours in the day, trying to be a good doctor for them, trying to at least support our family since we can seldom be there to see them. It's medicine, surgery, primary care, and caring for two patients all rolled into one, and sometimes it eats at your humanity. Sometimes, you come home at the end of the day so emotionally exhausted that you have little to give to the rest of your family. Sometimes the sadness of discussing a cancer diagnosis, or miscarriage, or fetal death lasts for weeks or days. Sometimes it is impossible to *not* take your work home with you. Sometimes we care *too* much, causing us to start separating ourselves from our patients, building a wall, becoming callous, so the better to protect ourselves.

Sometimes we deal with the stress in inappropriate ways: too much wine, snarky humor, or snappish answers. Likely, many of us are clinically depressed. Many of us have little time to exercise (Rh+ and her most excellent example notwithstanding). Because women Ob/Gyns are women too, and usually mothers and wives, who feel guilty when we are at work and guilty when we are at home, just like other working mothers. Because, despite how much it sucks, we still really love our jobs, think pregnancy and birth is amazing, and wouldn't do anything else (even if we wish we could); because we care about mothers, women, and babies. Hope this answers the question in a non-bitchy way, please excuse the sentence fragments and horrendous grammar. I had a terrible, horrible, no-good, very bad day today, and seeing some of the commentary on Mothers in Medicine regarding my profession, usually a refuge, stung quite a bit, I must say.

Little Wonders

I sat with my patient, a new mother, in the examination room. She was there for her first post-partum visit and we were discussing the events of the last few weeks. We chatted about breast feeding, birth control, lack of sleep, how annoying it is that men can sleep through *anything*, and then, I asked, as I always do, about how she was handling things emotionally. I always make it a point to screen for post-partum depression, many times, if you don't ask, they will not tell you how they are really feeling. This time, though she passed the screening for depression, she gave a laugh and said, "For the first time, I know why my mother is the way that she is." She went on to elaborate how she always made fun of how emotional her mother is, and now how she couldn't watch Kleenex commercials any more without bawling like a baby. It is so true. When we become parents we are forever changed, not only do we understand our parents better, but the way that we look at the whole world is different.

For me, it was the same. Before I became a mother, I loved to watch scary movies. The scarier the better. Imagine my surprise when, not long after Cindy Lou was born, and Mr. Whoo and I settled in to watch a horror flick when I realized that I had changed. I could not watch it, couldn't even get past the first 30 minutes. Why? Because there was a little girl child in it who was missing, and I couldn't handle thinking of a child (my child) being lost, scared, and alone. I never realized how many horror films use disturbing images of children before having a child of my own. It changed how I watch movies even now, far removed from the emotional lability of the immediate post-partum days. The same holds true for news stories involving children, footage of the 2004 tsunami devastated me, same for Katrina the summer after. The tears flow more freely now, happy, sad, and wistful. Most of all, music speaks to me, and often moves me to tears. There are certain songs I associate with different stages of my children's lives, and find myself tearing up just thinking of the lyrics. For Cindy Lou, it is "Baby Mine" and "Return to Pooh Corner." For Bean it is "Sweet Baby James" and "Little Wonders." Especially these lyrics:

"Our lives are made, in these small hours, these little wonders, these twists and turns of fate.
Time falls away, but these small hours, these small hours still remain."

So now I know how my mother felt when I was younger, when Cindy Lou turns to find me wiping away a happy tear or two and says, "Mommy, if you are happy, then why are you crying?" Perhaps it is because the transformative joy and wonder of having a part in creating these precious lives fills up our hearts until they break, just a little, from the magic of it all. How have your children changed the way you see the world?


***Cross Posted at Mothers in Medicine***

Things I Say Almost Every Day**

One thing that I love about my job is that it is ever-changing, and there are no two days that are exactly the same. That being said, I have my own daily script that I find myself reciting as I move through the more routine parts of my days in the office and on labor and delivery. My nurse could probably come up with a million more things (since she gets to listen to my spiel 30+ times a day), but these were the first off of the top of my head:

1. That's normal.

2. You're going to feel a little pressure.

3. Are you feeling any pressure?

4. Do you have any questions?

5. In a normal cycle, you have a rise of estrogen, then ovulation, then a rise of progesterone. If you don't become pregnant, then your progesterone level will fall and *then* you will have a period.

6. That's normal.

7. Take a deep breath.

8. Now, wiggle your toes.

9. No one will know your breasts better than you.

10. Tell me about what has been bothering you.

11. Is that interfering in your daily life? How?

12. The definition of menopause is no periods for one year.

13. It takes two 16 oz packages of cottage cheese to equal the Calcium in one 8 oz glass of milk.

14. You can do this.

15. Congratulations!

16. There are risks, benefits, side effects, and alternatives...

17. I'm sorry for your loss.

18. That can be normal.

19. I know it is counter intuitive to "relax" but try to make your muscles as loose as possible.

20. Do you understand?

21. Tell me what you know about birth control, then tell me what you would like to know.

22. That is a normal physiologic change of pregnancy.

23. I promise that you won't be pregnant forever (usually after discussing our elective induction policy of no earlier than 41 weeks gestation.)

24. How can I help you today?

25. I know this is scary, but I am going to talk you through it.

**Cross Posted at Mothers in Medicine**

Why I Do This

Lately, for me, all you have been hearing is bitch, bitch, bitch about how this or that sucks big hairy balls (can't wait to get the misguided google searches on that one). So why, you collectively ask me, either outright or in your minds, do you put up with all that you do? Why not quit and become a garbage collector or something? This list, my friends and frenemies, is why:

~ Bringing babies into the world is, quite simply, awe-inspiring. I love it. It is so special and intimate, that moment when a family is born (and re-born), and I feel privileged to be a part of it.

~ I love helping women. Women are way too busy taking care of every one else to worry about taking care of themselves. It is good to have 15-20 minutes to sit and listen to women, and make suggestions on how they can better care for their own needs.

~ I like to *fix* things. I am, at heart, a fixer. I want to change things for the better, and being an Ob/Gyn allows me to do this more often than not. I find this infinitely satisfying when I can make things better through surgery or medical treatment.

~ I enjoy the continuity of care that being an Ob/Gyn affords. I love being able to deliver multiple babies for the same patient, and then be able to take care of their Gyn needs once childbearing is over. I like the lasting relationships the field can foster.

~ I like to do Gyn surgery. General surgery, to me, was overwhelming, but Gyn surgery affords me the ability to do a variety of cases in a limited area of the anatomy. The perfectionist in me enjoys the focus on one organ system, but there is always good enough variety to keep it interesting.

~ Procedures are fun. Not just surgeries, but colposcopies, LEEPs, IUD insertions, polyp removals, and endometrial biopsies are all very enjoyable, and the results are often immediately evident. Highly satisfactory.

~ There is a limited amount of pharmacology. For me, it is pretty much antibiotics, hormone replacement or suppression, birth control, anti-inflammatory meds, the occasional hypertension or diabetes med, and some anti-depressants. I loathe polypharmacy, so I enjoy the clean and simple pharmaceutical profiles that Ob/Gyn provides.

~ The patients. That's right, for all that they do to drive me crazy, it's the patients that keep me coming back for more. Be it the infertile woman that I helped to conceive, or the anemic, miserable woman whose ills were cured by a simple procedure or surgery, or even the chronic pain patient who got the correct diagnosis, treatment, and subsequent improved quality of life. I do this for the patients, plain and simple.

~ At the end of an exhausting day, I feel that I am making a difference and an impact for good in people's lives. That fact makes the unbearable actually bearable.

So, look, I love my job. I love it. For all of my whining, I wouldn't do anything else. I hope this answers the questions out there. Thank you for listening.

**cross posted at Mothers In Medicine

Don't You Forget About Me

Although, I wouldn't blame you if you did. I know it has been over a month. I have a lot of great excuses that you probably don't want to hear right now. The long and the short of it is that I've been studying for oral boards, a lot, and working, a lot. When I'm not doing either of those things, I am lying upon my couch like a slug, it is my only defense (name that classic movie). In the meantime, I will post a link to my most recent post at Mothers in Medicine, and promise to be more present in the blogosphere in the coming weeks. Hope everyone is having a wonderful fall weekend!

I'm Baaaaack

Ack! Long time, no blog, I know. I'm sorry. I suck. I missed you guys, too. A few bullet points to catch up, and a longer post later this week if the L&D gods are kind to me.

~ First and most important, my baby Bean turned 1 year old on July 19th. My *baby*! *sniff*

~ We celebrated with a cookout and cake. Bean ate and smashed his cake to pieces, had a bath, and then slept for 14 hours straight (sugar coma).

~ I had my second blogiversary. Whoa. (How do you spell that? It is a made-up word... makes it difficult!)

~ I delivered 20 babies in the first 23 days of July.

~ I then lapsed into a deep coma, er, "went on vacation."

~ My lovely office staff booked 22 patients (in 3 hours) for my "half day" prior to leaving for vacation.

~ This made me so happy that I started my trip with a "to go" cup of vod.ka and Sprite, just to get the party started right.

~ Driving for 8 hours in the car with a 4 year old and 1 year old (who is not yet big enough to sit facing forward) is a bitch. Even with the aid of vod.ka and Sprite.

~ Even so, my kids are awesome, and were quite well behaved 95% of the time.

~ I visited with my husband's family for 10, boring, I mean, fun filled days in which I subsisted primarily on hot dogs, turkey sandwiches, chips, and spaghetti. Oh, and vodka. So much for low carb.

~ I am fat. I love food. I am screwed.

~ I finished my oral board case list. Woot! Let the angsting over that on which they are going to grill me on commence.

~ I scheduled 4 more interviews. (I know, I said I was done...I wasn't, apparently.)

~ I went to not one, but two of my husband's family reunions. I deserve a medal for that.

~ I also deserve an honorable mention for spending 10 days without any form of air conditioning.

~ I wrote a post for Mothers in Medicine for the "birth story" topic day. Check it out if you want a long-winded account of CindyLou's delivery.

~ My grandfather had a heart attack, a couple of heart caths, and fortunately has made it back home ok. I worry about how much longer he will be with us.

~ Last but not least! Thanks to anonymous for the tip...I got linked in an article by Melissa Healy in the LA Times, y'all! (The LA. Freaking. Times.) I was linked along with some real giants of the blogging world like Kevin, MD, GruntDoc, and Dr. RW. Of course, the rant that was selected to quote I sounded the most unintelligent and angry out of all of them. In fact, I was called "ribald" which means of lowly status or base {boo} or lewdly funny {that's more like it}. I own that, and hey, it's the LA times.

So, I'm certain that lots and lots more than this happened, but these are some of the highlights. Now I have to go clean the house and do laundry so the cleaning lady can find the floors and counter tops tomorrow! It's good to be back!

P.S. Holy crap, it's August. Where did July go?

Is there life out there?

Wow, has it really been a month already? June was a veritable whirlwind. I finished out that last call and then embarked on a 3 week "tour of duty," visiting friends that we hadn't the opportunity to see for 2 years (eek) and also doing some interviewing. I wish that I could say that I've found the perfect job and everything is going to be happily ever after, but so far that hasn't happened. All of the interviews that I have had have gone wonderfully well, but it seems that I just can't find the dream combination. For example, I interviewed at a rather prestigious "big city hospital" and loved all of the aspects of the job. The facility, the physicians, the work schedule and call schedule were all great. The compensation was good, and, as cities go, the city was really nice. But....it is still a city. The housing prices, property taxes, and available homes are a little less than desirable, and while there are good schools there, I worry about raising my children in a larger city. At least there, I would have better chance of participating in their lives. I am moving forward with the next steps to see if this position is the right fit for us.

I also interviewed at another practice, in an area of the country where Mr. Whoo and I have always wanted to live. The practice was nice, hospital was beautiful, and, of course, the area was everything we wanted, but I sensed an underlying air of malignancy amongst the physicians working there. I could sense that they really were not friendly outside of work, there were several family member with controlling shares of the practice, and there were a few warning flags raised when discussing the financial aspects of the practice. So, while the area was perfect, the job was not. If anything, the visit cemented in our minds our desire to one day live in this area. We are continuing to look for other practices there, but so far, nothing has panned out.

I do know, as I've gone through this process, that there *is* life out there. Every day that I spend in this particular position, I am missing out on a better lifestyle. It gives me a lot of hope to see that I can still do the job that I love while simultaneously enjoying my life and family. It is just a matter now of finding the best fit.

In other news, it is crunch time for finishing my case list (due August 1!), and I find myself once again in the midst of 18 days straight of call (boo). My little baby Bean will be one year old on the 19th of this month (impossible). I am also very honored join a new blogging group of physician-mothers, Mothers in Medicine. This is an amazing group of women (regular posters and guest posters alike), and what they write hits home with me so much, I find it difficult not to comment on every post..."Me too!" "Oh, that's exactly how I feel!" etc. Check them out! I hope everyone is having a great weekend, and for my readers here in the US, I hope you are having a great time celebrating our country's birthday!