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

She's Complicated

A commenter from the post below states that I'll not likely elicit sympathy by stating that women can be difficult patients, who require significant amounts of communication. The question is also raised why I would "generalize" 100% of my patient population, as surely, if there were no women to treat, I could no longer be an Ob/Gyn (sic). I find it overall amusing that anyone would believe the post below was written, in any way, to garner sympathy, and I also find it a bit irksome to be told that I "shouldn't generalize." I'm not. I am speaking from my own personal experience. Perhaps I should expound upon this point.

I went into Obstetrics and Gynecology precisely because I enjoy caring for the(complicated, difficult) female patient. I would not do anything else, but I would be absolutely lying if I said it wasn't without its difficulties. For the record, I happen to find male patients, no offense guys, infinitely more simple in many ways, but less likely to follow any directed care of a physician unless there is fear of loss of life or, ahem, other *important* functions. In my interactions with male patients, there was little extraneous conversation, merely exam, diagnosis, suggestion for treatment (which they may or may not decide to take, but they certainly weren't going to ask you any questions about it). Women patients, quite simply, are different. They do require a lot more communication; not just about the reason for certain symptoms that they may be feeling, but also for the rationale behind the treatments to alleviate the symptoms.

Usually, this is not a problem for me, being a woman myself, particularly verbose ("talks too much" was a very popular comment on my report cards sent home from school), and, not to mention, I happen to like explaining physiologic changes in a way that women can understand and to which they can relate. However, sometimes something as relatively facile as communication can cross the line. At times, it can be repetitive and monotonous (likely not so different from other jobs). At other times, I feel as though I am speaking a script, word for word. Sometimes, it can be frustrating (for both the patient and myself), because no matter how I frame the explanation, I cannot communicate my point. Most of all, it can become emotionally draining. Women routinely tell me things that would feasibly make most people's ears burn, make me worried for them, and sometimes bring me to the brink of tears. I have an impeccable poker face, but over time the walls get chipped away and I find myself unable to stop bringing my work home with me.

I suppose it is a good thing to be human, but in medicine it is important to remain detached in order to stay objective and to provide good care. It is a difficult balance between being connecting with the patient without becoming emotionally *involved* with the patient. This is difficult and soul-grinding, especially for those of us who have a tendency to try to "fix" people. It is a burden I more than willingly shoulder every. single. day, but honestly connecting with patients can be good for them and harder for me. I'm not willing to stop doing it, but to say that it shouldn't affect me emotionally is far more presumption than I would have the wherewithal to make from the outside looking in. In summation, saying that women are "difficult and complicated" patients is not meant as an insult or to "generalize" women, it is simply a statement that I find to be true, not only of my patients, but of myself, as well.

Like a Hurricane

So, yeah. That, apparently, is my new nickname on Labor and Delivery. Hurricane Whoo. Because it is more than just a "black cloud." Because just about every time that I happen to be on call, it's bound to be a sh*t storm. It has gotten to the point, so I am told, that the entire nursing staff offers up a collective groan when they hear that I am the physician on call. Yikes. They hasten to add that they still love me, though. HA! Apparently babies and pregnant ladies love me, too. A lot. The last weekend that I was on call, I delivered 12 babies admitted 2 more in labor before I was finished. It makes the time fly by too quickly, and I hate to find myself wishing my life away. To say that work has been busy would be an understatement, add to that increasing children activities (soccer! Daisies! tumbling!), the arrival of warmer weather, and the presence of a pool at our ready disposal, and my blogging has languished in the corner for more than two months with hardly a glance in its direction! Sorry about that. It's not you, it's me.

If you have been reading for a while, then you may know that my blog started as a primarily anonymous outlet (and boy, have I used it to vent!), save for a few people (Mr. Whoo and one friend who also happened to have an anonymous blog). Well, it so happens that those few people told a few more people, then I told a couple of people, and made a couple of bloggy friends, who were then my face.book friends and boom! Not so super-anonymous any more. This was not a big deal, as it was still mostly amongst my circle of friends, from whom I lived far, far away, and trusted to know me as the person behind the words. Then I moved, and I was closer to some friends, and those friends knew friends, and friends of friends, who also went to the practice where I am working. This is where I keep running into an ethical dilemma. Some people reading this blog know who I am, where I live, and where I work, but are not my close personal friends (friends of friends of friends). Given the atmosphere surrounding the Internet, face.book, and social media with respect to physicians in general, this makes me a bit edgy. Let's face it, I'm not the type to mince a lot of words on this blog, and this is who I am when I am being me. (Because this is my blog, dammit!) My professional persona is not nearly as raw. In fact, if you asked most of my patients, I do believe the word "sweet" would come up more than once. (STOP LAUGHING!! It's totally true!)

At any rate, now I am unsure of my reading audience, and I find myself trending more and more toward self-censorship, which I hate. I just keep wondering if the patient sitting across from me is wondering if I am filing her experience for a blog post for another day. I don't want this to interfere with my relationships with my patients. It was never meant to be a blog that my patients, who knew me as a professional, would read. Maybe that is narcissistic. For all I know, my patients could care less about my ramblings in cyberspace. Patient confidentiality has always been, and will always be protected. Any clinical scenarios that I post are altered from actual occurrences, I imagine I will be posting less of these in the future, as well. So, this blog will be evolving as I try to navigate this slippery slope. Bear with me, readers, and thanks for sticking with me this far...

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***

Aw, yeah!

Hi! Don't you love how I swear that I'm back to blogging and then don't post for two weeks? Time keeps slip-sliding away, but the main reason is that I was on *vacation.* Woo hoo, right? There were good, bad, and ugly parts, just like any old fashioned family vacation. The good: time with family, spending time in, near, and on the water, reading books (for fun!), eating good food, and having absolutely no responsibilities, pagers, emails, or Internet access. The bad: family overkill, NO AC in our rental (and 90 degree temps, if you know me, you know how disastrous this was), mosquitoes the size of my pinky finger (and a blue million mosquito bites), not really having anything to *do*, eating way too much good food, and no Internet access. The ugly: 23 hours in the car (each way!), with a 6 and almost 3 year-old. Yes, you read correctly, a total of 4 of my vacation days were spent driving in the car, with my whiny, don't- know-how-great-they-have-it children, slowly going insane. I believe that the first "Are we there yet?" came about 17 minutes into the trip, so yeah. Fun times.

The hilarious thing is, Mr. Whoo and I were crazy enough to make this trip about 5 years ago, with our just over one year old, and swore we would never do it again. HAHAHA! See how time dulls the sense of abject horror? Well, time, and over $400 per person for plane tickets. The first time around, CindyLou was just a little over one year old, and, while we had a DVD player (the makeshift kind that would hang in between the front seats and plugged into the cigarette lighter), CindyLou had the attention span of a gnat, and would only watch *one* of the many DVDs we had brought for her pacification, er, viewing pleasure. Any other of the videos made her bored, or scream, so we lucky people in the front seat got to listen to Ses.ame Stre.et "Sing Along" approximately 4872 times. The first couple of times, it was cute. We sang along with the songs and giggled at CindyLou's response. The next few times, we grinned and bore it. The next 100 times after that we started making up rude lyrics to the songs and commenting the actors "Mystery Science Theater 3000"-style. Any time after that, we just became hysterical and delirious. Seriously, this 30 minute video was the funniest sh*t we had ever heard. To this day we have quotations from that show (both real and altered) that we use in every day life, including a very enthusiastic "Aw, Yeah!" which came from an owl-type character in one of the songs. At the end of that trip, we (for some reason) kept the DVD, but did not watch it again for 5 whole years (mostly because we could recite it by rote)....until this trip.

We were a good 6 hours into the first day of traveling in the car, the novelty had worn off, and the kids were no longer interested in the snacks, our conversations, or the scenery. We were each "taking turns" choosing movies or music, when CindyLou and Bean just could not agree on a form of entertainment. The situation was devolving, and no amount of Capr.i S.un or Gold.fish could keep our offspring from complaining about one another when Mr. Whoo suddenly got this evil smile on his face, looked at me, and mouthed "Sing Along." My response? "Aw, YEAH!" So we played it. Bean was enthralled, CindyLou was still enthralled, and Mr. Whoo and I were laughing so hard we cried. The rest of the trip, we tried to engage the kids in the old standards such as the "Billboard Alphabet" game, the "License Plate" game, and "I Spy." We tried to give them a little taste of what it was like to travel back in the dark ages before DVD players, iPods, and Ninten.do DS. I'm not sure how much they appreciate it now, but hopefully, in time, they will. It is funny how the things that drive you the most insane are sometimes the best memories that you have. So family vacations, gotta love them. Now I am back in the fray, and just waiting for the next extraordinary happening in an ordinary day. Aw, yeah!

Far from Fine

I am blessed. I have a great family, healthy children, a loving marriage, a career that I (mostly) love, and many good friends. But I still have things that I worry about, there are still things that are far from fine with me. Despite a 22 pound weight loss on my previously mentioned program (woo!), I am still obese and now that I am "graduated" from the program, I find the bad habits slipping back in and pounds creeping slowly back on. I eat when I am stressed. I am stressed a lot. Therefore (logic 101) I eat a lot. I wish I ate a lot of vegetables, or even a lot of fruit, but mostly I eat a lot of pasta. It must release some kind of serotonin, because it calms me like nothing else can (except wine, and I *really* don't want to go down that slippery slope, you know?)

I'm worried about our country's path, our future, my children's future. What the hell is going on with our politicians...all of them? Our government is so perverted from what our founding fathers originally envisioned. It is almost laughable, but worse, it is scary. I am scared to death about freedoms and rights that are being stolen from us right beneath our noses in the interest of some kind of unrealistic, Utopian "greater good." Many of my friends "get it," but there are also many that don't understand what I am saying or seeing, and it drives a wedge in these friendships.

I am worried about the future of my profession. I can see what is coming down the pike in the coming years. It is ugly and is going to get uglier, and I'm pretty sure that physicians had a hand in sealing the demise of our profession as we know it by being the types of people that physicians are...altruistic to a fault. While I'm doing what I can on a local level, I feel helpless to change the runaway freight train that is the bureaucracy surrounding what should be built on a case by case (patient to physician) basis.

So, I fret, and rage against the machine, and beat my head against the wall trying to get people to understand what they refuse to try to understand in both my personal and professional life, and I eat. I recognize that I am self-medicating...but what? Frustration? I'm not clinically depressed. I do have some anxiety and OCD tendencies, but nothing that has been interfering with my daily life. I am just using food as a crutch, instead of healthy sublimation like exercise, I am raising fork to mouth to push down my feelings, my fears. It isn't working for me. So today, after having pasta for breakfast after a particularly harrowing weekend call, I got off of my arse and went for a walk. The hardest step is the first step out the door. Right?

Things I Say Every Day (Home Edition)**

1. Good morning, sunshines!

2. I love you.

3. No.

4. What do you say?

5. Hmmmmm?

6. Put your clothes in the hamper.

7. Stop teasing your brother.

8. Stop torturing your sister.

9. Sorry, you cannot have mac and cheese for breakfast.

10. Sooooo, whatcha want to do for dinner tonight?

11. Thank you for (doing laundry, the dishes, going shopping) honey!

12. Are you ready for a bath time? A bath time party? This is old CindyLou (and Bean) ready to get that bath time started....

13. So, tell me about what you learned today...

14. I need some snuggles (or, the abbreviated, "snugs")!

15. I missed you today.

16. Did you set the DVR?

17. No, no, it is (CindyLou's/Bean's) turn to sit in the front of the tub.

18. Pick out the book you want to read tonight.

19. What was your very favorite part of today?

20. Good night, sleep tight, sweet dreams...see you in the morning.

21. Ahhhh, adult time!

22. We need to go to bed earlier.

23. I am going to bed early tomorrow.

24. I love this show!

25. Maybe we can work out....tomorrow.

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**

New Sensation

In my previous job, I essentially functioned as a solo practitioner, so I could be fairly certain that (like it or not) I would deliver nearly all of my OB patients. Not that I didn't wish sometimes that a few of them would happen to deliver on one of the 4 days that I was freed from the hospital. In many ways, knowing all my patients from beginning to end was really wonderful. I knew who was stoic and who was, er, well....not stoic. I knew who was a worry-wart, who never had a single complaint, who had a birth plan, and who wanted an epidural when they hit the front door. I knew who was having complications, how far along (ball park) they were, and sometimes could even remember how dilated they were at their previous checks (should they arrive in triage thinking they were in labor).

The very best part, however, was the relationships I developed with the patients during the span of their pregnancies. We got to know one another, build trust, and when the time finally came for delivery, the rapport was usually strong enough for us to communicate well during the process, and to celebrate together when the delivery was complete. Sometimes this could actually be somewhat detrimental, as getting "emotionally attached" to patients can be a hindrance to good medical care, but mostly, while I cared for women on a personal level, I was still able to objectively direct their care. Of course, I didn't "click" with every single patient (that is impossible) but I did feel like a level of trust and mutual respect was able to be fostered with many.

Now, in a much larger practice where there can be anywhere from 60-80 patients due in a single month, it is much harder to develop the same rapport. There are times when I haven't even had a chance to *meet* a patient before attending her delivery. We try to have the patients see every physician at least once, but sometimes it just doesn't happen. This makes it much harder to develop trust in one another, during a very crucial time. So far I have overcome this by taking some time when admitting the patient to review all the records (sometimes helpful, sometimes not, depending on who was doing the documentation) and to discuss the plan of care with the patient and their family members. It is strange to deliver someone that you don't know well, and though I did experience this with some of OtherDoc's patients back in Whooville, it was not on the same scale.

Another adjustment I have had to make, and I think I may have mentioned this before, is adjusting to the "way of the group." Before, the medical decisions I made about patient care were mine alone, now I have 4 other physicians that have to be somewhat on board with a plan of care. Not to mention the way that they handle gestational diabetics and inductions is very different than to what I had become accustomed in the prior four years. Plus, when I order certain tests, sometimes another physician is the one that gets the results and then makes the decision on how to proceed. Scheduling inductions is also tricky, sometimes I can't schedule them for myself, and worry that I may tick someone off by scheduling someone on their call day.

Through all of this, I have noticed a strange new phenomenon. It isn't consistent, but I am starting to be able to "feel" who I am going to deliver. I know, it sounds completely bat shit crazy, but it is the strangest sensation. I just get this little gut feeling with certain patients that I am going to be the one that does their delivery. It matters not if I happen to personally like the patient or if the patient is one with whom there is not a strong connection. There is no basis in anything concrete, and it sounds so new-agey and non-scientific when I write it out like that, but, so far, each time I have "gotten that feeling" it has been correct. Verrrrry interesting. I will continue to observe as time goes on. Has anyone else, patient or physician, experienced anything like that before?

The really nice thing about getting my bearings and settling in to the new job is how well I am clicking overall with the patients and the nursing staff at the hospital. It is so great to hear the nurses tell me that they like the way I manage patients, or to have a patient tell me "You were my favorite, I hoped it would be you delivering my baby!" Very satisfying, indeed. Happy weekend, all!

New Year, New Me

Year after year, I have seen resolution after resolution fall by the wayside. We always start the new year with the best of intentions, but, more often than not, our perfectionism gets the best of us. We inevitably fall off the wagon, then, once off, tend to wallow in the mud. I will say that I have not been perfect, but instead of wallowing, I have picked myself up and tried to be better. Since starting my new regimen, I have lost 15 pounds, 6 inches from my waist, and 4 inches from my hips. I also ran in my very first 5K (boy, is my body pissed off about that one!) So my resolution for 2010, is much the same as every other year. To be a better mother, doctor, friend, and person. But this time, when I inevitably fail, I won't give up on myself as a lost cause. I will dust off and persevere. I know I can do this, and so can you. 2010 is going to be a great year, and I hope to be able to share more stories with all of you.

I am six months into my new position, and I cannot believe the difference. I am still working very hard when I am at work, but when I come home, I am home! I see my kids, we do normal family-type things. We have *plans* each weekend! The days that I am on call, I expect to stay in the hospital, but luckily, those days only come one week day per week and one weekend per month. The past four years are becoming more of a dim and distant memory. I have no idea how I did it, besides sheer adrenaline. I remembered that when I thought that I might die in the last mile of the 5K that Mr. Whoo and I ran together. If I can survive those 4 years of stress, I can survive a measly 3.1 miles.

Recently, I discovered that a woman that I know from college is a patient of our Ob/Gyn practice. This is a bit of a sticky-wicket for me ethically. We weren't the closest of friends in college, but we knew one another well, she is my face.boo.k friend, etc. I find myself worried to death that something will go wrong with her pregnancy, and that she will feel like it is my fault. So far all is going well, and she is excited that I am part of the group taking care of her. I, however, am petrified. The closest thing I have come to before was being a physician for the nurses with whom I worked in the hospital. At least they knew me as a professional *before* becoming my patient! Anyone else out there with advice on how to handle being a physician for someone who knew you before you became a doctor?

P.S. Whoever keeps commenting with Asian characters/links/advertisments, would you please CUT IT OUT? I will not publish these comments, and they are cluttering up my message feed. Ugh.

I guess that's why they call it "The Blues."

So here I sit...alone, in a very empty, lonely house. Mr. Whoo, CindyLou, and the Bean are moved out and already in our new home city, while I sit here on my air mattress, waiting for my sentence to end. As a part of the agreement I reached with my current employer, I am being forced to serve one more term as indentured servant while OtherDoc takes his annual 2 week vacation. It has been a very rough week. The day that the house was finally packed, and Mr. Whoo and the kids had left for new city, my old, fat, girl kitty died. I have half a mind to think that she realized that we were moving again, and was going to be damned certain that she didn't have to go through it again, but it doesn't make it any easier. I found her curled up in her bed, as though she were sleeping, but when I touched her back, she was cold and stiff. She was old, and fat, but I just wasn't prepared to lose her just yet. The fact that I found her dead the same day that the rest of my family had left me alone in the house did not help matters one little bit. Poor Kitty. Poor me.

True to form, I have been inordinately busy, so I haven't much time to contemplate staying in our house all alone. I can't help but wandering through the empty rooms when I finally do get home, remembering all of the times when the rooms were full of us, our stuff, and our memories. Now, all that remains are those memories and faint impressions of furniture upon the carpet. I am alone, with my sole surviving kitty, an air mattress, a laptop, and a new set of books (The Sookie Stackhouse series). I thank God for the interwebs, facebook, and hulu. I have been watching reruns of "Dead Like Me" on hulu. If you haven't seen the series, I highly recommend it. It is a very cute show (despite the fact that it is about Grim Reapers and Death and the like.) I miss my babies, and tear up every time I hear their sweet baby voices on the phone. I miss my family so much that it hurts, and I can't wait to start the next chapter.

I have some hair-raising work stories percolating at the moment, and will post them within the next few days. It appears as though I will be going out of this job with a bang rather than a whimper. I have but a week left in my current position, a new horizon looms ever more brightly in front of me. I can't wait to share my newest adventures with all of you.

Ass-vice: The Med School Years

Oh yes, so where were we? Medical School. Everyone finds their path to medical school a bit differently, but once you are there? It is a completely new "ball game." Once upon a time, you were the best of the best. You worked the hardest. You got the best grades. You were the smartest person that your friends knew. Guess what? Once you get to medical school...everyone is the same as you. You are all the smartest, the most rigorous, the most dedicated, and, no, you cannot all be the best in the class. Perhaps, for the first time in your young life, you will be an "average student." Please don't let that kill your self esteem. You know what they call the person to graduate last in his/her medical school class? That's right...Doctor.

For me, I felt like once I got to medical school I could actually *breathe.* I had, for all intents and purposes, made it to the "end game." I did not go into med school with a super clear idea of the field in which I wanted to specialize. (Aside: I thought Dermatology would be way cool with awesome hours/lifestyle, but, much to my dismay, I came home disgusted every day from Derm clinic (and also with a case of ringworm before the rotation was over).

However, first things first. The first two years of medical school? They suck. Hardcore suck. It is massive amounts of information, crammed into your brain in ways you never thought possible. You thought you studied hard in undergrad? Freaking forget it. I remember that I would sit....cross legged on my futon in my apartment, hunched over my books and notes for 8-10 hours (after going to class all day), pausing only for bathroom breaks and meals. I would do this, and then I would make a B or a C, because I was in the middle of the (incredibly intelligent) class. So. Frustrating. Studying in medical school surpassed anything that I ever dreamed of in undergrad, but so did the parties after the tests. Crayzee. I made my first D in medical school. I failed my first class (Endocrinology) in med school. I felt lower than I ever had felt....until 3rd year. Once we got into the wards, it all changed. I was taking care of patients. I liked it!!! All of the angst of the first 2 years felt redeemed.

For those of you going into medical school knowing that you want to specialize in Ob/Gyn...you have a leg up. I had no idea who I wanted to be when I "grew up." I blindly stumbled through the blocks until I found something that I really loved to do. For me, it was Women's Health. I loved reading about it. I enjoyed the clinics. I was intrigued with the GYN surgeries, and, of course, delivering babies was the biggest rush in the world. I remember vehemently wishing that I didn't love it. I looked at the lifestyle and was scared to death. But, I knew, just knew, that being an Ob/Gyn was what I was meant to do. I wished it was different, but I couldn't fight how I felt.

If you do know that you are passionate about Ob/Gyn in medical school, get involved early. Look for research (ugh) projects with residents. Bust your butt on your rotations, make yourself invaluable to your team, and impress your attendings. You will need good letters of recommendation from at least a couple attending physicians, so do as many rotations and electives as you can do. Be highly visible. Scrub every surgery that you can manage to do, get your hands in on as many deliveries as you can, and offer (often) to run scut for your interns. Learn the lifestyle before you take the final plunge.

The good news for you is that Ob/Gyn, because of the lifestyle, isn't super-competitive like Radiology or Dermatology. You don't need AOA to get into a good program. If you are a good student, with good references, you will likely go where you want to go. I graduated in the top 25% of my class, and I got my first pick from the Match. So, again with the bullet points:

~ If you know what you want to do, get involved early.
~ Don't despair, the first two years suck for everyone.
~ Go above and beyond on your Ob/Gyn (and, really, every) rotation. Make yourself invaluable to your team (without being a PITA).
~ Find research opportunities through the residents and interns. Everyone needs someone who can research charts and compile data.
~ Be thinking about your letters of recommendation early.
~ Work hard, and the rest will follow.
~ DO NOT be a know-it-all, or do anything listed here.

Up next, how to survive your residency...with your sanity somewhat intact! :)

"I give myself very good advice..."

"...but I very seldom follow it." I've been getting a few requests in comments and emails about advice for people in various stages of pre-medical and medical life. I think I have spilled a few kernels of (snicker) wisdom here and there within the blog, but I'm feeling froggy enough to try to organize my thoughts for your collective benefit. Since there are a million ways from point A to point B, what I will do is to describe what worked for me, and, if you are in a hurry, will bullet point the highlights at the end of the paragraph.

Elementary School

Joking! Joking! Ok? You people are way too serious.

High School

I wish that I could say that I was consciously preparing for a medical career even in high school, but in truth, I really wasn't. I liked science, hated math, and loved to read and write. For a brief time, I thought I wanted to be a lawyer...that lasted until I took a class in Law. I did make good grades, participated in a lot of activities, and took as many Advance Placement courses as my high school offered, so the better not to have to take them in college. Let me clarify that my parents had already prepaid for a state school, so I had no lofty aspirations of Ivy League schools. My fascination with my Anatomy and Physiology class led me to choose to be a Biology major in college.

~Make good grades
~Take as many AP courses as you can handle
~Have FUN (it may be the last time you are able...Hahahaha. Just Kidding)
~Get involved (volunteer, sports, music, student council, doesn't matter what, just do something else besides study!)


College

So, once I went to college, and chose to be a Biology major. I had to seriously consider my options for a career. I could be a research scientist, go for the PhD track, maybe teaching, or I could pursue the medical field. Once I had an inkling that I wanted to declare myself for "pre-med," I began to actively seek opportunities to volunteer. I worked at a hospital rehab center a few evenings a week, shadowed an (family friend) anesthesiologist during the summer months during surgeries. I also sought out other "extracurricular" activities, many of which involved leadership positions in my junior and senior years. When I was applying for medical school (back in the dark ages, though I imagine it is much the same now), the main goal for many schools was to find the "well-rounded" student. (read, *not* the person buried up to their eyeballs in books day and night).


Don't get me wrong, I did *plenty* of studying. I studied harder than I ever had before, and was fortunate enough to make Phi Beta Kappa, Golden Key, and Mortar Board. These things look good on a CV. Bio majors' classes were always Monday, Wednesday, and Fridays (so no four-day weekends) and usually started at 8 am. Oh, how my college self suffered, only being able to go out 3 nights a week instead of 5. I still managed to make great memories and go to football games, even if I didn't get to go out on as many Thursday nights as I would have liked.


I also did not take a class for the MCAT prep, and I totally wished that I had. I did my own prep, and did just fine (obviously), but I hate to think of how much better I could have been. I didn't even automatically release my scores until I saw them, I thought they were that bad. Luckily, it all worked out.


One thing that I always loved was being able to take some "non-major" coursework in the subjects which interested me, like Astronomy and Philosophy. My Biology major afforded me the flexibility to take a few classes "just for fun." I know that you can still go to medical school without a science undergraduate major, but it is more difficult to do. I couldn't imagine trying to get in all the pre-requisites for a completely different college *and* fulfill medical school requirements. I know people who did it, but I was far too lazy for that!


~Choose a science major (unless you are not lazy).
~Volunteer and expose yourself (not like *that*) to the medical profession in any capacity possible.
~Again, get involved! Leadership positions are a plus, as well, and you are going to need good people skills. (Trust me on this one.)
~Don't be a martyr. Yes, you are working hard, and no, your final exam isn't going to be as easy as making a giant cardboard Apple poster (no shit), but you ain't seen nothing yet.
~Study harder than you did in high school.
~Take non-major classes that interest you. This is your last opportunity to learn about something "for fun."
~Take an MCAT prep course.
~Again....HAVE FUN! I had a great time in college, and it was because my studies and social life were fairly well balanced.


Ok, I think I will stop here for tonight. Up in the next installment....ass-vice, I mean, advice for Medical School, Residency, and beyond!

To Get to the Other Side

There are times in life when everything seems to fall right in to place, and then, there are times like now. I can see the shimmering oasis of a new life, just on the horizon. A better call schedule, closer to family and friends, a chance to work in a collegial (not competitive) environment, more time with my precious kids and husband, and a chance to grow as a physician. Between the oasis and where I stand, however, is a treacherous, rock-filled, rapid river, swirling and threatening my ability to ever reach the opposite shore.

Obstacle #1 - Our house is on the market, and we have shown it at least a dozen times. Yet, despite positive overall feedback, not a single offer. I don't mean to boast, but our house is a beautiful house. I love it. I was ready to buy it the second I walked through the front door, and I can't believe that everyone else that sees it doesn't feel the same way. We never thought we would have to sell this house. Maybe we should have thought about selling it before we bought it. If we don't sell before we move, we'll have a hefty house payment, along with any rent payment we need to pay in Newville. This alone will be a financial strain.

Obstacle #2 - Mr. Whoo has yet to find a job, nor procure an interview in Newville. Granted, he has only starting looking in earnest recently. However, he is looking for work in the finance world, which isn't the best place to be seeking employment given the current state of our economy. We have been fortunate that he was able to quit his job last fall when our family really needed it, but now we worry that the employment gap may cause an impetus with new employers. Plus, without an additional income after the move, there will be more financial strain on our family. (See Obstacle #1)

Obstacle #3 - My current place of employment is not letting me go without a fight. There have been veiled and outright threats of lawsuits and damages and liabilities for me leaving earlier than my contract had mandated. There is also the matter of giving back a portion of student loans paid by the hospital. The fact that we would have to pay back was not unexpected, however, the amount that we calculated is about half of what the hospital estimates. We are procuring the services of a contract negotiator and a lawyer, who seem to believe we have a case for inducement, but I'm having angina just thinking of it. Not to mention the fact that, if the hospital's calculations are correct, they want us to pay up in less than 2 months. Add more financial liability to the swirly, cold, and fast water.

Obstacle #4 - Emotionally, I am wrung out. I am completely exhausted, and barely hanging on by my fingernails to make it to the date I indicated I was leaving. Being on call, continuously, with only 4 days off per month (plus vacation time), has left me completely burnt out. I find it hard to drag myself to work and muster compassion for my patients. They deserve better than the doctor I am right now. My health, mental and physical, is suffering. The remainder of my contract is a mere six months, and by finishing it out, I can alleviate much of the financial burden of the above obstacles...for the price of my very sanity. I want to cry just thinking of it.

So, I sit here on the bank, pining for the oasis, and unsure how to navigate the obstacles that lie before me. Oddly, I am reminded of the "old school" computer game, "The Oregon Trail." When faced with a river, you can try to ford the river, float the river, or hire someone else to help you across. Right now, I am pining desperately for someone to throw me a life line, or at the very least, a strategy for surviving these treacherous waters. The best advice I can relate to our readers is to know what you are getting in to before you sign a contract. There is no such thing as a perfect job, and if it seems too good to be true, it, in all likelihood, *is* too good to be true. Caveat emptor...and pass the caulk.

*cross posted at Mothers in Medicine

Cleanin' Out My Closet

With all due respect to Em.in.em (who I strangely love), it is not as interesting as he makes it sound. We are T-minus 3.5 months and counting from the big move from Whooville to NewCity. Mr. Whoo has been a packing machine (watch him get down), and we are getting ready to pack the first of our P.O.D.S. in anticipation of the move. Unfortunately, the closet has been begging and pleading for our mutual attention. We have been fortunate enough to be blessed with a home with a large master closet. Well, I guess I mean blessed and cursed, because every damn thing that does not have a home ends up in our spacious closet. Oh, shit! Company coming? Shove it in the closet. Stacks of paper with no where to put it? The closet sounds like a good idea! No time to deal with it now? Put it in the closet. And so on, and so forth for 3+ years and counting. Except now? We need to show the house, awesome closet and all. Not to mention the fact that we need to pack, and, my lord! Do we really need all of this *stuff*?

So, for the last few days, we have been working on the closet. I have been forced to go through all of my clothing, hanging on hangers in the closet since 1991. I am not kidding. There were clothes in my closet that I wore in high school, and I have the yearbook pictures to prove it. To me, this begs the question...why in the *hell* am I holding on to these clothes? For one, there is no hope in hell of me fitting into my old high school clothes...ever. And, even if I managed to get back down to 110 pounds soaking wet, would I really be wearing a flowered shirt from The Limited? Really? (Does that store even exist anymore?) I took the plunge, made some hard (ahem) choices, and managed to purge more than half of my closet in favor of donations to Good.will. Going through the clothes was kind of therapeutic and fun, in a way. I finally parted with the cute gray skirt I would wear out on chilly nights in college with tights, and the sundry "dressy" skirts I would wear to my sorority chapter meetings. There were a lot of good memories in that closet, and, hopefully, the clothes that I donated will go on to a new owner (someone that can actually fit into them) and be a part of their memories. I feel a bit anthropomorphic, thinking of my clothes this way, but hey, I am the girl who cried about packing away stuffed animals because I thought they would miss me (damn you Veleveteen Rabbit book!)

I am finding that the more of the clutter that we pack away, the clearer my mind becomes. I have loved visiting the past by sorting through old clothes and sundry items stashed in the closet, but I have also felt comfortable leaving them behind and moving on to better things. I feel good about moving forward, and I am happy to be getting closer to a new life...one closet at a time. I hope you all are well...Happy Friday the 13th!

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

"Blah"ging

Wow, I just went fifteen days without even thinking about blogging! Maybe that is because I have delivered 12 babies in the last 2 weeks, including my second set of twins for the month. I am very happy to have attended 2 twin births this month, both vaginal deliveries, one without an epidural (go mom, woo!). February has been filled with post-dates patients and big babies (though none coming close to my recent 11 pounder!) It has also been filled with more C-sections than I would like to have, but I guess my good run of vaginal deliveries had to end somewhere.

The word is out that I am leaving the hospital. The feedback that I have gotten overall has been really positive. By that I mean, people seem sad to be seeing me go, but they aren't being jerky about it. Most people are very understanding of my family and call situation, as well as the reason why I am leaving. It's nice to know that I will be missed by the staff and the patients, for I will surely miss (most of) them. We have been showing the house sporadically. Let me tell you, getting the house "show ready" with two messy kids and (let's face it) two fairly messy adults is a serious challenge. After every showing I get this huge surge of hope that we will finally sell the house. And then? Nothing. I know it is a bum market right now, but the thought of carrying this house payment with us after we leave is daunting. So much hinges on whether or not we sell the house. Will we buy or rent in NewCity? Are we looking for temporary or more permanent? CindyLou will be starting Kindergarten (!!!) in the fall, so we are trying to find the area in which we want to settle in the "right" school district. So much uncertainty is fairly uncomfortable.

The licensing process is dragging on and on, but I think I have it all pulled together. Now I just have to get it all submitted. I don't know how anyone could fake being a physician and get a medical license. I can barely get all the bases covered, and I am totally legit! I just can't believe how much I am being nickeled and dimed to death on all of the various and sundry fees. I've decided that New State will be our final destination for the duration of my medical practice. I cannot fathom going through the licensure process yet again.

Mr. Whoo, CindyLou, and the Bean are all doing great. The Bean is 18 months old. (Can you believe it?) He is such a little sweetheart. His language has really taken off since he got his tubes put in last summer. He loves books, and will sit in your lap, snuggle, and read books for hours! He idolizes his big sister, and while he cannot say her name yet, he calls her "sissy" in the most adorable way. CindyLou is a stellar big sister, and, at times, is very much a little mommy to the Bean. She is so smart and curious. She drives crazy with her constant jabber sometimes, but I suppose this comes naturally. Both Mr. Whoo and I often got the admonishment of "Talks too much!" on our progress reports and report cards! Mr. Whoo continues to be the best husband on earth. I don't know where our family would be without him. I feel so lucky to have such a wonderful partner.

As for me? I'm getting through one day at a time. I am still 2 steps forward and 2 steps back (Paula Abdul reference completely unintended, sorry!) with respect to weight loss. I still find myself turning to food for comfort at the end of a long, hard day. I keep seeing everyone with whom I went to high school and college (via facebook, mostly) all looking so fit and well rested, I veritably seethe with envy at times. I look ten years older than I actually am, not to mention 50 lbs heavier than I should be. I know better times are on the horizon; I just need to quit making excuses. Any way, I just wanted to check in and let you know that I am still alive and kicking! Now I just have to figure out 2 snazzy posts for MIM before next Friday. Hmmm....

Is Mercury in Retrograde or Something?

Hello all, what a crappy week it has been. Is anyone else having "issues" this week? My week actually started out on a pretty good note. One of my patients, pregnant with twins, began to develop preeclampsia. We made the decision to augment labor (she was already contracting and 3 cm), and late in the evening I got to do my first vaginal twin delivery since residency. I was nervous because I am used to doing twin deliveries in the OR as a "double set up," just in case there is a need to emergently deliver the second twin by C-section. In Whoo Hospital, there are no ORs on the L&D floor, so the deliveries are done in the room, and, should an emergency arise, you have to go down several stories to the OR. In a situation where minutes and seconds are precious, this is a daunting thing, especially as the night wore on and I realized that she would deliver in the dead middle of the night (aka skeleton crew time). Luckily, it was the smoothest twin delivery I'd had or seen in a long time. The first baby had no complications on delivery, the second baby stayed vertex, we broke the second bag of water, and baby number two was born about 5 contractions and 2 pushes later. Both babies and mom did wonderfully well. It was truly an amazing experience, and I was happy to be a part of that.

After that, though, it all went downhill fast. Of course, due to the middle of the night delivery, I got very little sleep. Therefore I overslept, and was later than I wanted to be getting to the hospital. Waiting for me there was a consult for the ever dreaded "pelvic pain." Before I get roasted about pelvic pain, let me emphasize that yes, it exists. Yes, there are gynecologic causes. Yes, it is not always supratentorial (all in the patient's head). But this patient definitely had supratentorial pelvic pain. She was already on a cocktail of narcotics and benzodiazepenes, and she spoke of severe excruciating pain in the calmest of voices, her pulse at 60, blood pressure at 90/60. Her exam was completely normal, as were her labs and imaging studies. She blithely asked me to "go ahead and do a hysterectomy while she was "here" (IE admitted to the hospital for pneumonia)." I blithely declined, set a follow up appointment in the office, offered medical suppression for her cycles (got denied), and asked her to sign a medical record release to obtain information from her prior ("out of state") physician.

Already in a *fantastic* mood by this point, I proceeded to the office. Where my right hand woman, SuperNurse, had slipped on the ice in the parking lot and (unknown at the time)broken her leg. For a while she tried to walk on it, but we all finally convinced her to go get xrays. So then, I was stuck with NotSoSuper medical assistant, who may well be the laziest person on the face of the earth. Any one who has worked in an office knows that the nurse who assists you can make or break the flow of your day. This day was definitely broken. The afternoon dragged on with the most draining kinds of patients around including such hits as "every organ system bothers me, can't you just wave a wand and fix it?" and, after a "routine" annual, a 20 minute nervous breakdown over the (unfounded) perception that her female anatomy was somehow horribly disfigured, and she wanted vaginal reconstructive surgery, not one but two Op.rah inspired "natural hormones" consults, and, last, but certainly not least, a patient with known cancer, sent to me by her radiation oncologist for a "skin tag" removal, that I am almost 100% certain is a vulvar carcinoma. Good times, good times.

Then, after a long, hard day already at 5pm, I log on to the internet to learn that one of my friends that I knew from middle school, high school, and college had taken their own life, and leaves behind a small child. I was shocked, then dismayed, and am still very sad over the whole thing. Just terrible news. Mr. Whoo had his community service club meeting, so I kid wrangled alone for bedtime and bath time. Exhausting. To top all of the rest of the day off, after being unnecessarily snarky when I had meant to be funny, I had a misunderstanding with one of my friends, feelings were hurt (I believe on both sides), and now I am getting the technologic freeze out which isn't very pleasant, either.

I am still struggling with the license application for obtaining my medical license in New State. So far I am out almost $1000 in various fees and I haven't even submitted the application proper (which will be $5000 +). We haven't sold our house yet, we haven't begun packing, I'm still over weight and not losing, despite my best efforts, and for extra fun, I have decided to cut all alcohol consumption for the month of February. Oh yes, and I am on call this week and all weekend long. So yeah, my week has pretty much sucked! How about you all? Am I the only one?

Commentary

There were a couple of comments from sarai on my last post that were rather lengthy, so rather than leave them in the comment section, I am posting them both here, in their entirety, along with my response. Italics are sarai's words, and the regular text words are mine

It can be very hard for the patient however, after having the doctor be wrong numerous times over the years with drastic consequences to your life. I don't watch Oprah, and the articles you mentioned irritate me, but yes, I do look for reputable internet sites, and before the internet was available, I researched.

sarai, I realize that your postings are coming from a place where you have been burned by the medical profession, but I certainly do not believe that physicians are anything more than fallible human beings who will make mistakes. That was not the point of the post.

That doesn't mean that I approach the doctor like I know more, and like I expect them to act as my puppet. But if I go to an OB appointment and say my baby isn't moving as much, and I am concerned about placental insufficiency, for example, I DONT want to hear "you're baby is moving just as much, it just doesn't feel the same because he has less room". Excuse me, doctor, YOU are not the one that's actually pregnant here, DON'T tell me how much my baby is or is not moving. YOU are not the one that will have to live with a dead child if there is a stillbirth (which the medical world is completely unable to understand how to prevent) I and MY HUSBAND ARE.

I think you are misunderstanding me. I *do* appreciate an informed patient. As I stated before, I practice collaborative medicine, not paternalistic care. I take my appointment time with patient to educate them and talk about treatment options. I even have a list of reputable internet sites on which to research information. That is completely different than someone coming in (or better yet, just calling the nurse line) and telling me that they have already diagnosed themselves, and now would like me to prescribe this medicine or order this test for them.

Again, I know that you've been hurt, but I am not the doctor that didn't listen well enough to you when you knew something was wrong, so please don't cyber yell at me. Just because I may vent my spleen on anonymous blog about things that irritate me about patients does not mean that I quickly dismiss them or am rude to them, quite the opposite actually. I take my patient's complaints seriously and act quickly on alarming symptoms. The dismissive attitude you are attributing to me does not apply in real life. You only see the seedy underbelly of my brain here.

You doctors don't always know how many times in person's life a previous doctor missed something important and the patient paid a heavy price. The doctor may have done nothing wrong, they may have met the standard of care, but to the person living with the consequences, it just doesn't matter, and they will do anything they can (watch Oprah, read really stupid Reader's Digest, surf the net) to try to make sure they get more observant care next time around.

Yes, as I said, "we doctors" are not omniscient. I did already know the patient about whom I posted, and have been doing her GYN care for 3 years now ( and each time I did her pap, her small speculum was warmed and lubed). She is not new to me or my practice. My care of her has been as observant as can be. Doctors are human, we do our best, and sometimes, despite our best efforts, it just isn't good enough. It sucks, and we try hard so it won't happen, and it bothers us perhaps more than you will ever know.

As a nurse, I've seen term babies stillborn, (decreased fetal movement, doctor ignored, or minimized), diarrhea was actually Ecoli, which turned into HUS, by the time treated (after being sent home 3 times) kid had stroke and ended up needing kidney transplant, a "viral upper resp infection" was actually a bacterial pneumonia, doc wouldnt believe patient couldn't breathe well 'cause sat was OK, vomiting and increasingly decreased LOC was actually juvenile onset diabetes (also sent home a few time before ER doc figured it out -- kid almost died.) This may be why some people are reading articles and trying to advocated more vigorously for their own care. I know I am. Even as I feel sincere empathy for you as I see the look on your face when you see my internet sheets........

See above, and there are even term stillborn babies where there were *no* warning signs. No decreased movement, no pain, no bleeding, sometimes babies just die. We do everything we can to prevent it, but despite our best efforts, babies still die. Yes, there are physicians that dismiss patient concerns, or miss pertinent signs, but we are not all the same person. Advocating for your own care (what you are talking about) and telling the doctor what to do and how to do it (what my post was about) are two different things entirely.

And here's something that just kind of bothers me about your blog, which, BTW, I otherwise enjoy reading.........it's judgement both from you and commenters, about women's birth choices.

Well, I can't speak for my commenters, but part of my job is to regard "women's birth choices" with my own clinical judgement. That's my job. If women come to me for care, they are, in fact, asking me to use my clinical judgement in their care.

If I'm reading your blog right (and correct me if I'm not), the "ideal" expectant mother in your practice wants to go into labor naturally, not mind being past due date, and not object if you feel at the last minute she needs a crash c-section. Moms who want to be induced (God forbid a week or two early) prefer a c-section straight off, or "insist" on a "happy vaginal midwife birth" even if things don't go according to plan are subjected to the eye roll.... Kind of a tall order, Dr. Whoo.....

I don't know if there is a "right" way to read my blog, so who am I to say who is "reading it right" or "reading it wrong?" I do think that you may perceive my words in a more malicious way than they are intended, and this is probably only highlighted by your bad experiences. I vent on this blog when things get tough to take, a safety valve, if you will, so that I do not blow up in the presence of an actual patient. There is no actual eye rolling going on in the presence of my patients. No matter their circumstances, personality quirks, or clinical needs, they are treated fairly and equally.

Loosely speaking, my "ideal" patient (as you put it) doesn't exist. My guidelines for delivery, elective or otherwise, are dictated both by the standard of obstetrical care, my clinical judgement, and the individual aspects of each patient. What I expect of my patient is a relationship of mutual respect and trust. Those are things that must be earned...by both parties. There is no "laying down the law." There is a give and take that is natural in these kinds of professional relationships, and quite honestly it doesn't merit many blogging entries because it is so routine. I don't think that you understand, you only see so much of me here.

One thing I did NOT NOT want with my first child was a crash c section. Either a vaginal birth, or a planned section, didn't care which. Of course, doc wouldn't do a c-section just because I wanted one, so we had a crash vag delivery with vacuum, (baby crashed too late to get c-section) where I got to experience watching my firstborn be revived, separated for her for hours after birth while she stabilized, and was so sore and torn up that I didn't want to have sex for months and months, and still deal with stress incontinence since that delivery well over a decade ago.....but because I didn't go to med school I didn't get to decide what would be better for me. I would like to argue, both as a nurse and as a mom which was physically better for me -- ugly vag birth or planned c-section. Yep, I'd choose c-section. Sorry.

I'm sorry that you had such a traumatic experience, and that it still haunts you. There is no way to predict when something like that is going to happen. Crash deliveries of any kind are heart stopping, but it *is* the physician's decision, in that moment, what will lead to the best outcome for mother *and* baby. If there is a terminal deceleration, and the baby is on the perineum, it is much more likely you will get a better fetal (and maternal) outcome with an assisted vaginal delivery.

I'm sorry that your bottom got torn up, and you had to undergo the trauma of seeing your daughter (successfully?) resuscitated. But, if I'm reading correctly, your baby survived. If your physician did what you wanted them to do, what you *perceived* to be "physically" better for you, and did a c-section, your baby's brain could have been deprived of several additional minutes of oxygen, with possible disastrous consequences. Whose fault would it be then? Yours? No, it wouldn't, it would be the physician's fault, who let the clouded judgement of an overly involved party (read, you) make the call. Instead of a torn up bottom, you could have hemorrhaged and required an emergent hysterectomy, precluding any future deliveries. Would you take the responsibility of zero future fertility, just because you *wanted* a surgery? Or is that the physician's responsibility? So yes, when you put your medical care into the hands of your physician...in that critical moment...you may not get to make that final call on what you *think* may be best for you. That is what a physician is there to do.

The recovery from next delivery was even worse, crash section, nobody's fault, but if I had it to do over again, possibility of crash section or planned section, well, I'd choose planned every single time. The crash carries psychological scars --- many of them. If you are lucky, you get to go to sleep and miss your baby being born. If you are unlucky, you have to stay awake, with no one talking to you, while your baby gets CPR. and your husband is God knows where. Physically, its a lot harder, too, and wound healing is not nearly as good than it is when the surgeon has time to take his time.

Agreed, but the point is the same, you cannot always predict these things. You said yourself, nobody's fault. Precisely. Planned surgeries are often more controlled than emergent surgeries...but not always. There are exceptions to every single "rule." Again, I sympathize that you have had such traumatic experiences, but the neither medical profession at large (in general) nor I (in particular) are to blame for this. I didn't have the perfect, ideal, rainbows and orgasms births that I would have loved to have, either, but I was fortunate and had 2 viable, healthy babies. I wouldn't trade that for any "experience."

The reason that patients want to run the show is because THEY have to live with the outcome!!!!!!! Tell yourself over and over and over again, its not about me, its not about me, its not about me!!!! especially in your profession where the stakes are so so high.......

But in order to be safe, objective, and effective the patients cannot feasibly run the show! They can (and should) be involved in the decision making process and development of a treatment plan, and they can consent or not consent, but they *cannot* "run the show." That is what a physician is supposed to do. Run the health care show.

This blog *is* about me! How I feel about the things that I do and that I see. Here, in this little corner of the internet, it *is* all about me. That doesn't mean that I disregard what my patients want. It also doesn't mean that I haven't had to make a decision that a patient was not capable of making on their own.

Maybe they really want to be induced when they know YOU, whom I'm sure they all really like, will be there. Maybe they are tired. Maybe afraid of late 3rd trimester stillbirth. Maybe they are struggling financially and need tax break. Maybe already not able to work anymore and trying to maximize maternity leave. Wanting to be induced at 38 1/2 weeks is not a sin.

Perhaps it isn't a "sin," per se, but it isn't valid medically. There is a lot of research to read about elective inductions, especially prior to 39 weeks. Often the outcomes are less than stellar, both maternal and fetal. Wanting your own physician, or "being tired," or "being afraid," or "needing a *tax* break (!)" are not viable indications for medical procedures that can have lasting impact on fetal and maternal health and well being. Elective induction of labor is associated with higher rates of cesarean deliveries, fetal distress (and dreaded "crash deliveries"), and fetal hospitalization for various immaturity issues.

Take a page from your midwives book. Listen to your patient. Ask questions. Try to figure out what the patient is afraid of. What she values. Try "why is this so important to you?" instead thinking "I can't believe she wants to have her baby by Christmas!" Find out what other experiences she has had with other health care providers. Maybe the last doc that did a pelvic jammed a large cold speculum where the sun does not shine, and she thinks you respect Oprah more than her. And remember, if she wanted a midwife, she'd probably be seeing one, so try to tactfully ask what she wants from your expertise, if you feel like she is treating you like her puppet.

Not to beat a dead horse, because I'm already feeling nuts for defending myself for talking about the way I feel on my own freaking blog, but how do you know that I *don't* listen? You don't know. You don't know me. You don't know how I treat my patients. The last doc that patient had for a pelvic exam was *me*, and I did not jam a cold, extra large speculum into her.

I've found that being a patient and having really horrible medical experiences makes me a lot less offended by my patients. Because if a patient asks me "will the doctor use a small, warmed speculum like it says to in Oprah's magizine?" my first thought is not to roll my eyes, it is to ask, "what has your past experiences with pelvic exams been like...."

Unfortunately, having really horrible medical experiences makes you a lot *more* offended by the things that I say, anonymously, on this blog, and causes you to extrapolate and frame my commentary in a less than favorable light. I hope my response has given you some insight. And truly, for all the snarking on the blog, I never forget that my patients are just people, just like me, with a different frame of reference. Even if it doesn't translate in text, I'm certain it translates well in person. I wish you healing as you attempt to move forward from your painful past experiences.

Done, done, on to the next one...

Oh, my poor little neglected blog, how I have missed you. I am finally done with the oral boards...at least for this year. All I can think about is of what I should have said that I didn't (and what I did say that I shouldn't!) The exam was over quickly, mercifully, but the more I think, the more morose I become. No matter now, if I fail or if I pass, I shall not speak of it again on the blog. Suffice it to say that I am done and trying to get over it, and now must focus my attention to the holiday that is a mere 14 days (FOURTEEN DAYS!!!) away. I have cards, cookies, and call on tap for the weekend, along with a Christmas and a birthday party. Oh, and online shopping, the working woman's savior.

Our house is properly Christmas-ed, thanks to Mr. Whoo. We have made the the obligatory mall Santa visit, complete with non-screaming children in the picture, a coup! CindyLou is *beside* herself with excitement. It is so wonderful. To see her joy and wonder about Santa and the season does my poor, 3-sizes-too-small, grinchy heart so much good. Bean is fascinated by the tree and the lights, and while he doesn't quite "get" it all, he is loving the experience. Of course, my favorite moment of the season thus far comes from Mr. Whoo, explaining our nativity to CindyLou.

Mr. Whoo: "...and this is Mary."
CindyLou: "Oh! Like 'Mary Had a Little Lamb'?"
Mr. Whoo: "No, more like Mary had a little Jesus."

It was priceless...maybe you had to be there. Anyway, I'm back, and, if the pregnant ladies cooperate (ha), I will try to get back to more reliable posting. Promises, promises. :)