Perils of Partnership

Before I begin, is anyone else flashing back to Data from "The Goonies?" "Pinchers of Peril! I've been saved by my Pinchers of Peril!" Anyone? Just me? Ah, well.

So, hi! I guess working full time, having a 4 year old and an almost 8 (!) year old in multiple activities, actually having a bit of a social life from time to time, and experiencing a intense sense of perfectionism if I do have the chance to write = no blogging for me.

We've been keeping very busy in the practice, and I have been navigating the waters of working with a large group of physicians, who may or may not treat patients in the exact way that I would treat them. Sometimes, with the really complicated patients, it almost feels like a game of "hot potato," with each physician hoping that they are not the one left "holding the bag," so to speak. I've never experienced this to such a degree, and there is one culprit who rises to mind beyond the others. It really ruffles my feathers, because I was always trained to do the best thing for the patient at the time, even if it was inconvenient for you, as the physician. I don't know if this is something that comes with being older in practice, more burnt out, perhaps? Being one of the junior partners, I can't help but feel, at times, that I am expected to "prove myself" to the more senior physicians in the group, by working just a little harder, complaining a little less, and dealing with getting the less than desirable cases. Kind of like being a glorified resident in many respects, and, let me tell you, that is d*mn tough to swallow. I also feel like I have to fight to bring up to date practice standards into the group managed patients, in this, I am having some success. This makes me happy because I think it benefits all of our patients. I am really hoping to adjust the way that we see patients while on-call, and have been hashing out some ideas to discuss in some upcoming meetings. I am happy to say my schedule is always full, but this is also daunting, because sometimes it is over-full (am I forever doomed to struggle with scheduling issues??), and I have had patients tell me it is difficult to get an appointment with me. I suppose all of these issues are swirling around my brain because in a few short months I will have the opportunity to become a full partner in the business, and I don't know what I don't know.

I'm excited and nervous to make the next big step in my career. Any wise words from those who have gone before me? Any questions to ask? Things I need to know before signing the dotted line?

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.

Into the Fray

So, I admit it, I've missed you. A lot. I've been trying and trying to stay away, but, blog, I just can't quit you! So, hello to all of those of you who know my name, I hope you'll see that even though I'm human, I am still a d*mn good physician who cares about her patients, even when the day to day grind predisposes to bitterness and sarcasm. I desperately owe my good, bloggy friend Dr. Rupe a book review, and, being just a bit OCD, I didn't feel like I could properly do it until I had the chance to read the entire book (not easy in this crazy life). Good news! I've read it (and loved it) and will post a glowing review worthy of it ASAP. I still have no idea how in the world that she was able to co-write the book, when I've barely had time to read it! Many apologies, Dr. Rupe, I wanted to do your work justice!

You won't be surprised that not much has changed around here. Work is crazy, my children are sweet, lovable, and growing up too fast, my husband is a saint, and OMFG it is blazing hot! I'm working a lot, but just came off what may have been my best weekend call of my whole entire life (got to sleep in my bed all three nights, that will never happen again)! I also dropped 20 lbs since April ( I'm thinking, mostly water weight from sweating my *ss off all day long). Most of all I have missed writing, want this outlet back, and thank you for still being out there to listen to my ramblings. Please know that everything posted about clinical situations on this blog is altered to protect every patient's privacy. More soon...

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...

Office Dos and Don'ts

When I am not on call and juggling office visits and catching babies, I am still working in the office seeing both OB and GYN patients every single day of the week. I realize that most of you spend only a fraction of that time in any physician's office, and frankly, we can tell. Here are some helpful hints to make your day at the GYN go a bit more smoothly:

Ob/Gyn Office *Dos*
1. Do make an early appointment. Whenever possible, make your appointment the first appointment of the morning or the first appointment after lunch. Trust me on this one and see below.
2. Do arrive for your appointment at least 10-15 minutes early. I know, I know, why would you want to show up early when you just *know* you are going to be in the office for *hours* on end. Here's why: The Snowball Effect. Invariably, as is required by the office, your insurance, or pencil pushers from various state and local agencies, you will be asked to fill out some kind of form upon your arrival. These are usually not mind-shatteringly difficult, but they can take time. Then the receptionist has to verify your information, make sure your insurance is still good, find your chart, and send it down the line to the MA/RN who will be bringing you into the office. The MA then fills in any new information, takes your vitals, asks the reason for your visit, and takes you to the room. Imagine what happens when you are "just 15 minutes" late for your appointment, everything that has to be done gets done further and further away from your appointment time. Before you know it, you are in the exam room 30 minutes after your appointment time, and if you think your schedule is thrown off, multiply that by 12-15 patients in a half-day. If all of them are even 5 minutes late for their appointment time, it creates a significant backlog for the physician to overcome. We're good, but we can't reverse time. It's just not feasible.
3. Do know your personal and medical history. Be sure that you have approximate dates of any surgeries or hospitalizations that have occurred in the last few years. Know what body parts you do and do not have. Know what medications (and their doses) you are taking, for the love of all that is holy! I have no idea what birth control pills are in the pink rectangular package, and will not be able to divine it easily. Have a tentative idea of when your last period happened. I also have no idea what is in your medical history unless you bring your records to me to look at or have them sent to the office *before* your appointment, so please don't wave a dismissive hand and mumble something about how "it's all in there somewhere."
4. Do bathe. Applying soap and water to your body sometime in the 24 hours before the appointment is considered common courtesy. I really don't care if your legs or any other areas are shaved, hair maintenance really doesn't concern or bother me in the least, but the courtesy of bathing is much appreciated.
5. Do know what you want to accomplish. Write down the questions that you have or issues that you want to address at your appointment. In the hustle of the office routine, you will probably forget something. Keep a little list on a piece of paper or on your phone to review...and I stress *little.*

Ob/Gyn Office *Don'ts*
1. Don't make a routine appointment for an out of the ordinary problem. This, of all things, is my number one pet peeve when it comes to office visits. If you are feeling depressed, your libido is in the toilet, your uterus is falling out, or you feel like you are bleeding to death every month, even if it *is* just about time for your pap smear, please, please, PLEASE don't call the office to make an "annual exam" appointment. Believe it or not, GYN physicians do more than just pap smears. If you want to see the doctor for a problem, make an appointment for such. Here is something you may not realize: You do *not* have to disclose to the scheduler *what kind* of problem you are having! Simply stating you have a problem you would like to discuss with the physician is totally adequate and spares you any embarrassment you may feel. Annual exam appointments are usually given about 10 minutes, but problem appointments can be scheduled for 15 minutes-30 minutes. This means you get more time with your physician to discuss treatment options and formulate a plan to get you feeling better. In the same vein, don't save up all of your problems for your annual exam; there is only so much we can do in an annual exam. Change your birth control? Yes. Change your birth control, cure your depression, diagnose your infection, and evaluate abnormal bleeding? Not so much. Scheduling the appropriate kind of appointment sets up a "win/win" situation for all involved.
2. Don't expect to get an immediate answer/treatment/cure after one visit. Some problems (like infections) are easy to solve, but some problems are more complex and require data gathering and imaging studies. Your initial appointment may need to be followed by a secondary appointment in order to assimilate information and assess treatment efficacy. You may not have all the answers after seeing your physician one time, but I can assure, you will be headed in a definitive direction for treatment.
3. Don't be rude to the office staff. They are there to do a job, and when you get seen, how you get seen, and certain office policies (like late policies) are totally out of their control. We all work together as a team, and you can bet that if you are a raging b*tch to my MA, I am going to hear about it before I step foot in the room. I can't guarantee a warmed speculum in those cases, either (I KID, NO HATE MAIL, PLEASE!!) On the flip side, if our staff is rude to you we want to know about it, so please share your experience with us.
4. Don't expect your physician to (do even more) work for free. Trust me when I say that much of the "behind the scenes" work that we do goes uncompensated. It is common courtesy to inform you of your lab results over the phone (usually our nurses or clinical staff will do this), however, if you want to discuss the interpretation of your labs or formulate treatment plans based on the lab results? Make an appointment. Physicians' clinical opinions are based upon what we spent years learning; this is our professional service, and we deserve to be compensated for services rendered.
5. Don't attempt to dictate your own treatment. Dr. Google is great for answers in the middle of the night, but printing sheaves of paper dictating how you *think* you should be evaluated/treated is incredibly off-putting. I value an educated patient, and appreciate when my patients "do their homework." This is not the same thing as demanding of a physician a specific test or treatment that you happen to think you may need. We want to collaborate with you about your care, and have spent years of training learning how to do this. Our knowledge is not so easily replaced by We.b.M.D. or W.ik.ipe.d.ia.

And two more months slipped away...

Happy Belated New Year, blog and blog friends! I will spare you the "busy, busy" rigmarole because you've heard it all before. Needless to say, it hardly seems real that the last time I logged on to post anything on the blog was back in October! Life and time have continued to move forward at the speed of light. Over the holidays we (or, more precisely, our builder) finished building the house, we closed (i.e. hemorrhaged money), and then, for extra fun, we moved in...the week before Christmas. Why (you ask incredulously)? Because I'm insane (in the membrane...er, sorry), apparently, and, more accurately, because I already had requested that week off in order to (HA, HA!) relax the week before Christmas. To add to the fun (and this torture was completely self-inflicted, by the way), we just didn't feel *right* about depriving poor little CindyLou and Bean of a Christmas tree and decorations until the week before Christmas (think of the *children!), so we bought a tree for the rental, decorated it and the rental house (including the outside, of course!), undecorated, bought a new tree for the new house, and the decorated the new house once again. I cannot vouch for my mental stability, that bit of madness was unbelievably ill-advised. Regardless, despite several snags, we arrived safely and soundly in the new house before Christmas. Santa even found us and everything! Whew!

So now, I am digging out of boxes, cursing the paper clutter and all of the things that can't be thrown away, but do not yet have a "home." Paper clutter is my true nemesis. We all love the new house. It is so nice to be in a home that is truly "ours" from the very start. Cindy Lou's bedroom is bedecked in lavenders, pinks, and fairies. Bean's is bathed in blues, "Cars" characters, and, let's not forget, monster trucks. We are very happy here, which is good, because (hear this internets) I AM NEVER MOVING AGAIN! (I hope.)

Work is going well, getting back into full swing since the holidays. I find I have so much less to complain about these days. Likely because I am not much on the front lines any more (no more midnight phone calls about cough syrup selection), I am getting more sleep, and more weekends off to play and love on my sweet little family. I still have the occasional fist-clenching moments, like the two sisters, due a week apart. The younger went into labor first, even though the older was *due* first, and the older got so p*ssed off she *refused* to come to the hospital bedside to support her sister. I mean, *dammit* she *always* gets *her* way. (These are grown ass women we are talking about here, you wouldn't believe the adolescent machinations, mostly on the part of the older sister.) Younger sister's baby ended up having an unknown health problem after delivery, which would have made me feel like a criminal that I wasn't there for *my* sister during that time. Older sister's baby was born about a week later and was *perfect,* and I got the vague impression she was feeling quite smug and justified about that. Sad, sad, sad.

There was also the patient whose MIL jumped all over me when, after going to have a "for fun" ultrasound where the US tech said the cord *might* be around or near the baby's neck, I tried to explain that, if indeed the cord was around the neck, there was not a thing in the world I could do about it! I spent 30 minutes with the patient and her MIL, even obtained a (completely normal and beautifully reactive) NST. At the MIL's visit to my partner the next week (for her own medical care) she expressed to them how I just "rushed" them right through the appointment, and how her DIL needed "more TLC" from our practice. GAH! The unmitigated *gall* of that woman! I give up. Haven't seen her or DIL since, and I'm not crying about that one little bit.

So anyway, time marches on...double numbers are luck for me, so I think 2011 is going to be a good one. Maybe, just maybe, I can lose the rest of that weight, organize my life, de-clutter, become a great cook, run a marathon, found a charity organization, and still find the time to be the world's best wife, mother, and doctor. Hmmmmm, probably not! Good to be back, and I hope to write more in the coming year. Hope you are still out there and listening!

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 is my OB always running so *late*?"

Recently one of my friends posed the question as to why her Ob/Gyn physician would routinely run at least 45 minutes late, with the caveat that she would be fired for doing the same to one of her clients. In typical fashion, I posted a long, rambly, and overly detailed answer in her comments section, after (thankfully) seeing a lot of other friends chime in on their personal experiences with their particular physicians. I realized that this is most likely a very universal wonder/complaint, so I am re-posting my response for you, my dear readers. I am sure you have pondered this at least once whilst sitting on an exam table, shivering in a paper gown.

Allow me to describe my day, in order to better explain why we may routinely run late. Today I am on call, and so, while I am responsible for all that happens on labor and delivery, in the office, I do have patients scheduled. The majority of patients are OB visits, most of which rarely take more than 5-10 minutes tops for routine appointments. We also will see check problem patients (early pregnancy bleeding, labor checks, blood pressure issues, hangnail, etc.) So, our scheduling staff (none of whom are medically inclined or have any clue what we do on a day-to-day basis) has most "on call" schedules looking something like this:

8:30 OB patient 1:15 OB patient
8:45 OB patient 1:30 OB patient
8:45 OB patient 1:45 OB patient
9:00 OB patient 1:45 OB patient
9:15 OB patient 2:00 OB patient
9:15 Problem 2:15 OB patient
9:30 OB patient 2:30 Problem
9:45 OB patient 2:45 OB patient
9:45 OB patient 2:45 OB patient
10:00 OB patient 3:00 Problem
10:15 OB patient 3:15 OB patient
10:30 Problem 3:15 OB patient
10:45 OB patient 3:30 OB patient
10:45 OB patient 3:45 OB patient
11:00 Problem 4:00 Problem

So, we have anywhere from 5 to 7 patients scheduled in an hour, and if everything is hunky-dory, there are no issues, long litanies of questions, no problems, or complications, I can generally run on time for these appointments (and by, "on time" I mean that once the patient checks in (usually running at least 5 minutes late, themselves) the nurse talks to them, does any necessary screening labs, checks their weight, urine and BP, listens to fetal heart tones, brings me the chart, which I then review, I am seeing them at *best* 15 to 20 minutes past their original appointment time).

Then, add in the inability to predict labors (I had a couple of laboring patients today) and scheduled procedures (I had 2 cervical ripenings and a C-section scheduled-not by me-at 7:30 am and then another scheduled C-section at noon. Unfortunately, one of my laboring patients delivered at 12:15, smack in the middle of when I was supposed to do my noon C-section, so the section was put on hold until after the delivery. So, by the time I finished the (complicated) scheduled C-section, did all the necessary charting and orders for both deliveries (mind you, not having any time for lunch) I was able to get back into the office by 3 pm. If I am lucky (today I was), my colleagues will have mercy on both the patients and me and pick up a few charts to see patient or two in between their already over-packed schedules. If I am not, then all of the patients scheduled from 1:15 are still waiting to be seen at 3 pm.

So, (whew) does this make it a little more clear why we are not running on the spot of time? It is completely different than making one appointment (that you probably schedule yourself, when it is convenient for you, allowing for travel time, and keeping in mind how long you expect most meetings to go) with one client for the span of 30 minutes or an hour, so the two are really just not comparable...at all. Hope that this helps the next time you are waiting for your physician. P.S. If you grow to expect the long waits, start bringing entertainment (iPo.d, magazines, books, cell phone bejeweled or solitaire) or little projects you can do (bills, checkbook, cleaning out your purse), and know, it really could be worse. Back in Whoo-ville, OtherDoc's patients would wait for him for upwards of 3 hours...now *that* is ridiculous. ;)

Answers for A

I recently received a comment on the blog posing the following questions. At first, I was going to just correspond via email, but I thought perhaps my readership could also jump in on answering these questions from "A," a 3rd year medical student considering Ob/Gyn. So, thank you in advance for your help!

Hi Dr. Whoo,

I have thoroughly enjoyed reading your blog and appreciate the time and effort you put into your posts to provide us readers with a glimpse of your life. I am currently an MS III with only 6 months left to decide on what to do with my medical career. My top 3 choices are OBGYN, Anesthesiology and Psychiatry. I loved my OB rotation and feel that the field is a perfect blend of medicine, surgery, procedures and primary care.

Hello, A! Thank you for the nice words about the blog, I am glad to be able to provide a glimpse of life in the world of Ob/Gyn. I agree that Ob/Gyn is a perfect blend of medicine, surgery, procedures, and primary care. It is a really great field, but it does have its limitations.

However, I am afraid to commit to the field for the following reasons:

-Work hours. I cannot get a straight answer from the academic faculty on what to expect after residency. Most of them have flat out discouraged me from choosing OB, telling me that I should just do one of my other 2 choices. Is it possible to find a job working 60-65 hours/week and still come out with a salary of $250-$300k in smaller cities in midwest or the south? I just want to be well-informed of what to expect before I take the plunge to ensure that I don't end up hating my career .

HAHAHAHAHAHAHA! Ahem, I mean, ah, not likely right off the bat, at any rate. I think you can get the salary you want with more work hours, or the work hours you want for a lower salary, but it would be rare to find the above combination just out of residency. My average work week (5 person group practice) is right about 60 hours with weekday call, 110 hours for weeks where I have weekend call. As an employed physician, I make less than $200,000. My pay will increase with each employed year until I am able to "buy-in" to the practice. After that, my income will increase (but a large portion of it will go back into buying into the practice). After about 5 years of "paying my dues," I will be able to set my ticket for income. It just takes some time.

At my previous job, I made over $250,000, worked in a rural, under served area with high Med.icaid, and only had 4 days off per month, so 168 hours the weeks that I worked weekends, 120 hour weeks the weeks when I had the weekend off. Trust me, it is far better to make less money and work less hours, especially now when O.b.ama.care looms on the horizon. (Plus, think of the taxes you will be paying on a higher salary, you may get to keep more of your money working for a lower income.) So, while I am sure you can find some places where low work hours and higher income combines, that would certainly not be the norm until you establish a practice.

-Liability. How stressful is this aspect of OB if I choose to move to a state with Tort Reform or low liability?

Liability, Tort Reform or not, is always stressful in OB. It will loom over your shoulder with every decision you make, especially with respect to managing labor and delivery. Even when you uphold the standard of care, you can still be sued for bad outcomes, and all it takes is one case to destroy you financially, personally, and professionally. Malpractice premiums are fairly exorbitant in the field, as well. You may not be able to cover your malpractice costs if you have a poor payer mix, meaning more volume, which leads to more chances of things going wrong. Vicious cycle. Most of the time, it is just like static noise in the background, other times you hear the alarm bells clanging. You get used to it, but it is always there.

-I am a male (a minority in the pool of OB applicants). I have been told that being a male would make it difficult for me to find a decent job because practices tend to prefer women OB's (hence males have to settle for worse locations, work hours and call schedules). How true is this?

Well, to be honest, I am not sure, since I am not a male. (Any male Ob/Gyns out there want to field this question?) I know that in many of the positions for which I interviewed, they were very interested in procuring a female physician. One field that you may consider, if you are so inclined, is the field of Urogynecology. I think it is a 3 year specialty after residency. It is a more surgery-heavy specialty, and, in my experience, still fairly male-dominated. You still get some procedures, good primary care and a lot of good surgeries, no babies, so less liability, and likely better hours and compensation overall. I hope that these answers helped somewhat, and I hope my readers are able to clarify further some points I am not able to elaborate upon. I truly wish you the best of luck with the rest of your training, and in whichever specialty you choose to pursue.

Dropping In and Frustration

Since my move from Whooville to Newville, I've had to make some adjustments to the new patient population. Perhaps the most frustrating of all, however, are the "drop-in" patients on Labor and Delivery. My previous hospital was a rural, community hospital. It was certainly off the beaten track, and the building? Was old. Really old. The L & D suites were certainly sufficient and functional, but luxurious? Not so much. You had to know where you were going to find the hospital, and it was quite the rare occasion to have patients just "drop-in" for care.


Not so for the new digs. This hospital is new. Pretty much Brand Spanking New, and posh, and beautiful, and, oh yes, right off of a major highway, visible for all the world to see. Which makes for the fascinating phenomenon that is the OB "drop-in" patient. "Drop-in" patients come to this hospital "because it is close," or "because it is nice," or "because it was on the way." So, what is so bad about working in a hospital in which everyone wants to deliver? Well, what is so frustrating is the women who *know* that they want to deliver at our hospital, but do not seek pre-natal care from physicians that cover our hospital. Therefore, any pre-natal labs or records, or history of complications are virtually inaccessible at the time that they come in for delivery. Often patients from the large, downtown academic center (who don't have insurance or have insurance not accepted by our practice) receive all of their pre-natal care "for free" at the downtown center clinics and the purposefully come to our hospital to deliver. The patients are often not troubled by this, and often seem mildly surprised that we "aren't all the same" and have no way to access their records. After all, they are getting exactly what they want. It is much harder for us, as physicians, however, to help these patients. Especially when it comes to their expectations for delivery. It is difficult to develop a proper rapport in the few hours that we have with them. I think that trust is so important in the delivery room.

Even more difficult are the transient patients who stop in on their way through town, like one patient who had absolutely no pre-natal care, and was on her way to deliver her baby somewhere "non-medical" when her water broke, and she decided to stop-in at our hospital. She had, indeed, broken her water, but she refused an ultrasound to assist with proper fetal dating because she was concerned that the "x-ray waves" would damage the baby. She then proceeded to refuse any medical assistance from the hospital at all for over 24 hours, tying the medical staff's hands, and putting them at risk for liability at the same time. Eventually, she agreed to augmentation of labor, and even requested epidural analgesia after a prolonged labor. With medical assistance, she eventually was able to deliver, but the baby boy had definite signs of septicemia (likely due to prolonged rupture of membranes) and ended up in the NICU for over a week. When all was said and done, the mother, upon release from the hospital, said that she and her infant would never step foot in another hospital again, despite the fact that it was with the hospital's help that her child was born and made well when he was sick. To this day I will never understand why she "stepped foot" in the hospital from the start, if she did not want any intervention that the hospital could offer. This case brought a lot of issues that plague the medical profession in this day and age to the forefront.

Thankfully, her baby, despite some health issues at birth (that likely could have been avoided with faster intervention) did well...but what if he did not do well? What if the infant did not survive? Then who is at fault? The hospital? The physician? The mother? These are the questions the haunt physicians' sleep at night. Obstetrical interventions are not only done to avoid lawsuits, they are done to protect the safety and health of both the mother and her baby. However, one bad outcome, one wrong decision, can result in catastrophic professional, financial, and personal losses for the physician. Is it any wonder that we are hyper-vigilant? Is it any wonder that we would jump at any opportunity to prevent a bad fetal outcome, even it it means surgical intervention risks for the mother? It is thanks to Jon Edwards and others like him that the cesarean rates are rising, VBACs are being refused, that patients are being over-monitored, and that interventions are becoming the exception rather than the rule. Without tort reform, without the ability of the physician to operate from another position than that of fear of a poor outcome, then I am afraid that obstetrical care will remain the same in this country for years to come. Please consider that your rage just may be misdirected.

Ob/Gyns are *not* evil

Just because I'm an OB/GYN physician...

~ don't assume that I don't care about you as an individual.

~ don't assume that I'm out to cut your baby out of your womb in favor of getting home for dinner.

~ don't assume that I go home and roll around naked in piles of money.

~ don't assume that I view pregnancy or birth as an "illness."

~ don't assume that I don't know anything about "natural " (unmedicated) labor, transition, or alternate pushing positions.

~ don't assume that any inductions of labor that I schedule are done for *my* convenience.

~ don't assume that I will roll my eyes at your birth plan.

~ don't assume that my attempts to educate you about your pregnancy are "scare tactics."

~ don't assume that I am "what is wrong" with the way women give birth.

~ don't assume that the only way I know how to facilitate labor and delivery is through "unnecessary interventions."

~ don't assume that I am an unfeeling automaton who wants to "put you on the assembly line."

~ don't assume that I am "too busy" to take proper care of you.

~ don't blindly believe everything you see and read about my profession.

I've been doing some browsing through different labor/nursing/birth blogs, and, as it is wont to do, it depresses the living hell out of me. Partially because I know that I am not close to 90% of the descriptions I see from women out there, and partially because I'm starting to worry that maybe I am an exception and not the rule. In my current practice, I can see a definite split between the younger generation of physicians and the older generation. I certainly believe that through medical school and residency that I was taught a much more "collaborative" model of care than earlier generations. However, no one in my practice comes close to the urban legends out there perpetuated by the anti-medical world. I know I've ranted about this before, but it bothers me! So many physicians with whom I work have sacrificed *so much* for their training, for their ability to help people, just to be mistrusted and maligned by the population at large. Perhaps the most disheartening thing, is that there can be no real dialogue between the two philosophies, so jaded are our particular perspectives. Nothing I can say on this blog can convince you that I'm not a knife-wielding harpy, but if you were my patient, you would know.

P.S. I have been playing around, trying to start a facebook page for this blog. Any tips on how to make it better? I am poor at social networking!

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!

Workin' on the Weekend

Ah, weekend call. When I was in residency, the nurses would refer to it as the "3-day hostage crisis." I find this hilarious. And, in many aspects, true. In my former job, weekend call just seemed like a continuation of a long parade of call days that flowed seamlessly, one into another. I resented being held from my life on the weekends just as much as I resented the weekdays. Now, weekend call is a distinct, and separate being.

Weekend call for me consists of Friday, Saturday, and Sunday, starting at 7 am on Friday morning and ending at 7 am on Monday morning. Definitely a long, lonely stretch. Blissfully, the Monday after weekend call is mine, all mine. So there is always a break on the horizon, which, sometimes, is the only thing that keeps me going! Hospitals have a different overall feeling on the weekends. The pace is slower (usually) and generally, not a lot gets done. This even extends to Labor and Delivery. While it is true, babies have no concept of weekends or evenings and tend to come whenever they damn well please, but there are no elective inductions, no scheduled C-sections, and most patients are eager to leave the hospital.

The best thing about weekend call, for me, is the ability to spend as much time as I need to on Labor and Delivery, without feeling rushed. Weekdays usually will have scheduled C-sections at 7 am or 12 noon (sometimes both) and inductions can range from 1 to 3 for our group, there are circumcisions to be done, patients to be rounded on, not to mention a full slate of office patients for the day. Getting it all done can feel impossible, even when there are other partners there to divide the work. Splitting work can also be stressful, wondering if all the patients were seen, or if someone got missed in the shuffle. On the weekends, there is something peaceful (or is it merely resignation?) about knowing that, come what may, *you* are the one responsible. Sometimes it makes me wonder if I would prefer being a "laborist," because I really love the ability to stay on L & D, close to the action.

Some mornings there are just a few patients to see, and I can sleep a little later, and spend a lot of time with each person. Other mornings, there are many patients to see, but the pace doesn't necessarily have to change. Following the cardinal rules of deference to the call gods, I never make a single plan for my call weekends. If it happens to be slow, we spend some lazy time as a family together at the house. If it is busy, then I can take up residence in one of the (really, way too nice) call rooms where I can read, flip channels, and watch laboring patients simultaneously, or I can hang out at the nurses' station, chatting and getting to know my co-workers (and usually get access to some really great food, the staff definitely eats well on the weekends!)

So, while I still get a little wistful when I hear of others' fun weekend plans on the weekend that I have to work, I am bolstered by the knowledge that my "day off" lies just on the other side of the weekend. I am further heartened to know that weekend call is only once a month, leaving 3 other weekends wide open for fun plans of my very own, without fear of the dreaded page from L&D. WTF is wrong with me? I never thought I'd see the day when I appreciated weekend call; I must be getting mellow in my old age! Working or not, I hope you all have a wonderful weekend.

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.

The Almighty Call Gods

Any one in medicine, or with a loved one in medicine already knows that we tend to be a superstitious bunch. Funny, since you would think that people, who are, in general, so scientifically minded, would scoff at silly ritual and the whims of fate. *Everybody* knows that you should never, ever say that you are having a "quiet" day or an "easy" case. And, what ever you do, you should not piss off the forces that are better known as the "call gods." When you are on call, especially in L&D, you never know what kind of call you are going to have. Some days and nights are smooth and easy, and some are absolute hell on earth. You can be certain, if you you are having the latter kind of call, that you have transgressioned against the call gods, and they are exacting their wrath upon you.

How exactly do you anger the call gods? I'm not entirely certain of all the ways one can anger them. One way is to plan to do something, anything at all, on the day/night/weekend on which you are on call. If you make plans other than sitting at the hospital on your call day, it tends to blow up in your face. Another way is to get too comfortable, especially at home. Woe betide the on-call physician who dares to try to change out of scrubs into pajamas, take a long bath, or, heaven forbid, take a nap, for the call gods will smite thee mightily. I think another thing that rouses the wrath of the call gods is becoming anything less than vigilant about scouting potential customers coming in through labor and delivery or the emergency room. Your radar must always be roving for potential impending disaster.

For whatever the reason, or, perhaps because they felt bad for destroying me over my last holiday call, a Labor Day weekend 13 delivery-palooza, the call gods were incredibly kind to me this past weekend. I started with a full census, delivered one baby at 3 pm on Friday, discharged every single patient from the census by Sunday, did one consult on Sunday, and delivered another baby at 2 am this morning. I slept in my own bed for 2.5 out of 3 total nights on call. It was the strangest, most unsettling feeling. I kept checking my pager and the computer. I kept waiting for the other shoe to drop, but truly, it never did. That is, of course, until this morning, feeling safe from the call gods' collective hearing, I happened to post to fac.eboo.k that I had an eerily slow call weekend. Oh how my hubris was heard and met with a swift and mighty justice. Not 30 minutes later, I received a call from a sick colleague, requesting that I cover call tomorrow night in exchange for them covering my week-day call next week. Of course, I agreed. I am not looking forward to the kind of payback that the call gods have in mind for me.

Cool....and not so cool.

Every day in the office is a day to hear something new. In OB/Gyn, the work is pretty much the same, wherever you go (at least in the US). Annual exams are annual exams. Prenatal visits are pretty standard. Common problems are approached in much the same way in one office as another. The patients are the ones that make it different, interesting, and even, sometimes, really fun.

I am still getting acclimated to the new group setting. It is a little strange to work within a group dynamic when you are used to essentially a solo practice. You have to give up some control (difficult for a control freak). It is much harder to know the patients well and remember every detail about their history, and it is also challenging to work within the boundaries of other physicians' comfort levels. Before, any call that I made...testing, induction, observation, only had direct bearing on the patient and on me. Now, I have to consider group gestalt. I am getting there, and the time off is well worth the trade-offs thus far.

I am seeing quite a different patient population in Newville, a bit more urban and sophisticated. Ways in which this is cool...

~The patients are well educated, they are aware of their bodies and have done a lot of research into pregnancy and what is happening in each trimester. I rarely am telling them things they did not already know. Makes my job a bit easier.

~The happiness! I got to see a woman, coming in for a regular annual exam with an incidental finding of a positive pregnancy test. She was ecstatic. Her husband feigned needing a glass of water and hyperventilating. The cuteness was killing me. (I am used to tears and hysterics over an unplanned pregnancy!)

~The responsibility. These patients are amazingly compliant, and hold their and their baby's health in high regard. There are very few smokers, and I have yet to see Mountain Dew in a toddler's bottle. Unbelievable.

Ways in which this is not cool...

~The, um, "sophistication." I have met several young women for their first exams (17-21 years old), who qualify their number of partners as "really low." However, when pressed further for ballpark numbers, they toss out a number like, oh, 10-12. (!!!) Whoa.

~The bossiness. Never have I been instructed on how to treat a patient for a certain condition so often. Sheaves of information printed from the internet. "Drive-through" attempts at obtaining treatment. Sorry, honey, this isn't Bur.ger K.ing and you cannot "have it your way!" Yikes.

~The nonchalance. I kid you not, I had a woman that texted on her phone throughout her entire annual exam. Breast exam, pap, and pelvic. Holy cow! I wanted to know what she was texting..."now my breasts are being checked. Now the speculum is going in?" "Pap smears suck?" WTF?

All in all, I am settling in nicely here in Newville, and I am so happy to be back to loving my job once again. That being said, I am gearing up for my first full weekend of call (and a full moon to boot). Since I've not had a weekend call since July, we'll see how sunny I am come Monday. I wish you all the happiest of Labor Day weekends! Thanks for not giving up on this blog!

Stuck, stuck....STUCK!

As my time in Whooville was drawing to a close, I found myself in a very harrowing situation. As per usual, I was extremely busy delivering all of OtherDoc's patients, as well as my own patients during his vacation. (I never understood why he wouldn't limit the number of OB patients he would take when he knew he would be gone for half the month...oh, right, all about the dolla bills, y'all.)

There was a young patient (YP) that I had seen in the office earlier that day, she had been contracting, and while she was not yet dilated, she was beginning to soften and efface. I wasn't too surprised to see her later that evening at L&D. She was extremely uncomfortable, contracting every 2-3 minutes, and had dilated to 2 cm/90% effaced. It had been a long day, so I assumed that we would get her comfortable (she was requesting an epidural) and then she could labor through the night. The day shift left and the night shift came, and sometime in the middle of her bolus for her epidural, YP began to get a little out of control....like "I'm in transition" out of control. If you've never seen it, it is kind of like that seen from the Exorcist, minus the rotating head. I checked her, and surely enough, she was 8 cm. She had gone from 2 cm to 8 cm in the space of about an hour and a half. So much for the game plan.

The patient progressed quickly from 8 cm to complete, and that, dear friends, is when the fun began. As the patient began to push, the baby began to get unhappy. The more she pushed, the more unhappy the baby became. There were persistent and prolonged, deep variable and late decelerations. After tolerating the strip as long as I could, I talked to the patient and talked to the OR. preparing for a C-section. One problem, the anesthesiologist was not in house. Just at that moment, the baby decided to express her extreme displeasure with the proceedings by dropping her heart rate. To the 60s...one minute, two minutes, reposition, oxygen, scalp stim...no response. Three minutes, four minutes, more maneuvers, still no response. The patient was pushing with all of her might, her family was a step a way from hysterical, the baby was in trouble, and there was no anesthesiologist. The vertex was just barely at +2 station, so I attempted an emergency vacuum delivery. I pulled once...no descent...I pulled twice...small descent...I cut an episiotomy and pulled one final time to no avail. We had to go to the OR, and we had to go right then, anesthesiologist or not. At that point the baby had been in the 60s for about 10 minutes. "Please don't let my baby die." were the last words I heard before we left the floor.

We ran to the OR, and I told the CRNA to put the patient to sleep, anesthesiologist or no. I remember that the staff was moving as slow as molasses, even though I had relayed the urgency of the situation. We splashed the belly with betadine, draped her, the CRNA put the patient to sleep, and I went from skin to baby in under a minute. The nurse had to push up from below, and it was difficult to elevate the head out of the incision, but, thankfully we finally got her unstuck. All 9 pounds 8 ounces of her. She was a little pale and a little floppy, but pinked up almost immediately to get Apgars of 6 and 9. She was ok. Mom was ok. The nurses and I were puddles of goo. The adrenaline surge was so strong I was shaking.

I think the anesthesiologist finally got there as I was replacing the uterus. Thank God we didn't wait for him. After the C-section was over, I repaired her episiotomy. It didn't seem quite fair to be sore both places, but she had a happy, healthy baby. I kept turning the situation over and over in my mind. How could I have changed it? What could I have done to avoid the outcome? I felt like I had failed her in so many ways. It seemed incongruous when the nurses told me how "awesome" I was, and how the family cried and hugged me after the surgery. Afterwards, both mom and baby did wonderfully well. It was better than I could have ever hoped for, and an experience that I never, ever want to repeat.

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.

More Advice you Never Wanted to Hear: Residency

Holy shit, new residents are starting on Wednesday! Residency, for me, was such a far cry from medical school. When I started residency, it was back in the "dark ages" of medicine. Read: prior to the (oh so benevolent) 80 hour work week. That's right. I worked 120 hour weeks in my first 2 years. Uh huh. I'm the monsta. But seriously...I did have weeks when I was on call Monday, Wednesday, Friday, and Sunday. 36-48 hours on, 6-8 hours off. It was unbelievable. Surreal. I often fell asleep in my bed after a (much needed) shower with a Smirno.ff Ice or Be.er in my hand. I remember holding a retractor for a vag hyst, in an oncology case, at 9 pm, when I was post-call. I had tears streaming silently under my surgical mask. I thought I was going to die. But, guess what? I did not die. Not physically, anyway.

Residency isn't as hard as it used to be, but the principles remain the same. Work. Your. Ass. Off. I mean that. In order to be a good intern/resident, you'd better work (now turn it to the left). Pay attention in morning rounds. Make check boxes and lists. Make sure the labor and post-partum floors are taken care of when you are the OB resident. Be sure that all Gyn cases are covered, pre-opped, and post-opped when you are the Gyn resident. Be everywhere at every time. Seriously. I mean this.

A good resident knows his/her patients. Labs are checked often. Notes are written. Labor progress is always recorded. Gyn patients are rounded on 4 hours post op, AM, and PM. Know your patients better than the attendings know them. Be able to regurgitate labs, post-op blood loss, and diet orders. Help your fellow residents and interns. Don't throw people under the bus. Work as the team. If someone isn't sleeping, then *no one* is sleeping. Divide and conquer. Be nice to the nurses. Round on the floors and give universal "Wal-Mart orders" to the floors before you try to lay down (IE. if they can buy it at Wal-Mart ~heating pad, Tylenol, Tums, fan~ they can have it!)

Help your junior residents, and teach them how to run the board. There is no such thing as a "little" case. Scrub in on as many surgeries as humanly possible. I don't care if you have seen a million c-sections, scrub in on the next one....it may be a C-hyst. You need as much surgical exposure as humanly possible. Especially now in the restricted 80 hour work week.

If you have to do research for your residency graduation...do it NOW. Do not wait until your Senior year when you are trying to interview for jobs, study for written boards, and get licensed. Do the research early. Just suck it up and do it. Be good to your nurses, and they will be good to you. Don't whine. Don't ever let them see you cry. Stick up for yourself. Enjoy your time off. If you are considering a family, residency is a decent time to have a kiddo. Just be ready for the way your fellow residents will treat you. Especially if you are in a small program. No one wants to work more than they have to work, but you may never have so many people to cover your absence again. Don't delay your personal and family life for residency. Take care of yourself. Don't eat those fries with a grilled cheese at 2 am because you "deserve it." Exercise. Leave your job at work. Stay in touch with family and friends.

Learn as much as you can. When you go out into the "real world" you will wish that you did more surgery and paid more attention in clinic. Even when it sucks, you can do it. Even when you think you won't make it, you will. One day you will look back and 4 years of residency will be over...seemingly instantaneously. You can do it. One foot in front of the other. Life on the other side is good. Keep moving.