Pregnancy in Medical School

"Remember people, well except medical students, typically reproduce before the age of 30."

MD, cardiologist

(via coffeemuggermd)

I’ve had this in my drafts for a while. It still pisses me off a bit. Not that it necessarily should, the cardiologist isn’t saying that no med students have kids before 30 but it’s atypical. 

What pisses me off, is that those who recognize that their life starts NOW, not after residency, or fellowship, or any other magical time, and want to have children are treated as wackos by most of our community. I know I rail on about medical culture and why it is not reflective of reality, but I’m going to do it again. This is another example of thinking that we need to change. 

There is research on just about everything that med students do. You’re the easiest population for medical researchers to bug, so they do.

However, I can’t find much research on being a parent in medical school.  This focuses on mothers (wall free article). It’s the only paper I could find (lots for residents by the way, probably because they are also leading a lot of the research). A lot of the young women I’ve spoken with felt they were treated poorly by the fellow students because they were getting “so many” allowances for time. The new dads in my class felt like they were expected to carry on as if there wasn’t a new sprog at home.  

Back to the paper, “Medical School-Mothers” in the Rhode Island Medical Journal. I’ve never heard of this paper, or this journal and I’m pretty damn excited about all things undergrad medical education and feminism. That’s disappointing. (Have you heard of it and I was just under a rock?)

They don’t tell us how many medical students were interviewed. I want to know what several means - is it 4? Is it 34? Help a sister in research out.

They also don’t discuss fathers. I get that women in medicine is new and all, but I want my colleagues to be good dads. I don’t want any of my colleagues to be fondly remembered by their grandchildren because their own children never saw them. 

“As part of universal precautions, all female medical students who are sexually active with men should be mindful of potential pregnancy.” BARF. Shouldn’t our male medical colleagues also be mindful? This reminds me of the episode in 2014 where a female medical student was at risk of losing her funding to study in Cuba because she “fell pregnant”, while her XY partner was not reprimanded. BARF I say. IUSs, condoms, and access to family doctors for all med students who want them!!

This article is mostly focused on what Student Affairs type people need to know (which is fantastic). 

But. 

What I would like to see is something that talks to many more students to provide curious students with help making decisions, something that gets more into the pros and cons of an educated choice. No one knows when the time is right to have children. Everyone has an opinion on it though. 

I’d also like to see a nation wide mentorship program - to be paired with an attending, hopefully in your chosen field, who also was a parent in med school. Knowing you have someone who has been there and survived. 

I’d like a handbook for parents in med school. Tips tricks and downfalls to avoid. I’d like this to be an open topic of discussion that starts in Year one. I want the parental leave policy to be pointed out to all students during orientation week. 

I want to know how much post partum depression and anxiety are present in the learners having children. We are all pretty crappy at taking care of our mental health, and how many of us have med studentitis? (Pregnant med studentitis is like that on freaking crack - everything that could possibly go wrong, will and you will blame yourself, even though you would tell your patients to think better of themselves. My friend had 10/10 stress through the last 4 months of her pregnancy. Uncool.) 

I want there to be scheduled check ins with Student Affairs during pregnancy and post partum to ensure this isn’t an issue. My suspicion is that the numbers of sufferers in the medical community are high. 

I want to get rid of the shame associated with wanting to be a good parent when you are ready to be one. Seriously. If we don’t stop acting like families in medicine are bizarre while we’re in first year medical school, how can we expect attendings to respect their colleagues and learners’ choices?

One of my colleagues is pregnant. I’m over the moon for her and her MD husband. The amount of stress they underwent preparing to tell the rest of the team about the (wanted, expected) pregnancy was overwhelming to ME. I’m not having a baby. Jeepers. They felt they needed to make it very clear that they do not want to stop practicing for more than 2 months each (like it’s not bad enough that they don’t get parental leave from our governing body). They were shamed into divulging the information much sooner than they wanted due to morning sickness. Our colleagues (all XY but me), have children with stay at home moms and incredibly twisted senses of what parenthood should look like with a physician parent. 

This has got to stop guys. We need to treat each other better and watch each others’ backs. 

What would you add to my list to make it happen?

Information Overload

There is just way too much to assimilate in an orderly fashion. Everything from the marital status of my patients, hip clicking syndrome is a thing, billing codes, anything new in the literature.....

XKCD

No great words of wisdom, no tricks I've found for dealing with this (aside from putting everything patient related into the EMR, no matter how trivial, and everything knowledge related into Evernote with extensive labels). 

I keep being told that I will know my patients in 5 years and that things will seem better then. The patients that I am getting to know do make my days easier to deal with. Instead of having to look up their comorbidities constantly, I have a handle on what may be causing the crisis du jour. That very few of these illnesses are actually controlled yet is a whole other issue. 

My online appearance is more important than my physical appearance

I had a great time today reading posts and comments on Twitter about physicians' appearances.

Things I've learned:
1. Some docs really like this article from 2005 (!!!!) on the importance of dressing well for your patients. Remember it can take up to 3 years to publish an article so this data is from 2003 at the latest. Think track suits and Queer Eye for the Straight Guy.

2. The BBC would really like doctors to generally judge everything about their outward selves. This article looks at "scruffy doctors", overweight doctors, and doctors who smoke. They also acknowledge that many patients are expecting the white coated doctor to be male. 

Which brings me to...

3. A separate discussion has been playing out today on Twitter about how young female physicians are perceived spurred by this blog entry. Female docs are often (VERY often) mistaken for nurses. Even after introducing themselves as Doctor SoandSo. I know I've blogged on this before but I can't find it. We are also assumed to be the assistant, the secretary. As an older than average resident, I was usually mistaken for the social worker or my pediatric patients' mother DESPITE wearing an ID badge and my stethoscope. One intelligent staff member asked me 6 times during my 2 month pediatric rotation to fill out the insurance forms for "my child". She was shocked every time that I was *still* a physician. I was once blocked from a code by the nurse who called me to it because she thought I was a family member (again, with stethoscope and badge). 

While I was on rotations in other hospitals, I would carry a small bag with my "pocket" stuff. Pens, a Drug Pocket, my phone. Most "professional" women's clothing prohibits actually using pockets if they do exist. This teeny satchel was usually the scape goat in my mis-identification. 

This is one of those issues that makes me a bit cranky. Have I told you yet about the preceptor who told me that it was perfectly reasonable to be mistaken for the social worker since "doctors don't have long curly hair, you can't expect to be taken seriously"? It makes me see red. 

If, in real life, I'm mistaken for another profession or not a professional at all, based on my hair and my satchel, what must the medical world think of me based on my online profile? 

Some argue that our online presence allows others to see our "true selves" (it's the basis for many relationships that start online). Social media (SoMe), plays a big part in my life. I'm in a tiny rural town, most of my friends are in different provinces. Without my online presence, I would be entirely isolated. My professional online presence is split between The Imposter and Dr. SoandSo. Maintaining my anonymity on this blog is important to my being able to use it as a sandbox for trying out ideas and ways of dealing with patients in a safe environment. As Dr. SoandSo, I have opinions on family medicine and its role among the specialties. As just me, I am on Facebook with my friends and family so I can watch my family grow up from a distance. 

I'm seeing guidelines and suggestions about how docs (and everyone else) should behave online. It's true, many docs are illiterate in the ways of SoMe, but I think that they are aware of how to behave in a crowded mall. The same rules we learned in kindergarten apply. 

1. Share everything. Post your references so others can also be as smart as you.
2. Play fair. Don't overload your online profile so that your friends aren't also visible. 
3. Don't hit people. Don't call them names. Maybe they have had a really bad day.
4. Clean up your own mess.  Untag any photos that you wouldn't want your mother to put into the family Christmas card. 
5. Don't take things that aren't yours. Credit any source that you use. You wouldn't want someone else prancing around in the sweater you took 3 years to make claiming they knitted it themselves. Our intellectual property is just as important. 
6. Say you're sorry when you hurt somebody. Apologise when you make a mistake and correct those mistakes.
7. Wash your hands before you eat. MRSA y'all. 
8. Live a balanced life - learn some and think some and draw and paint and sing and dance and play and work every day some. Your online friends are interested in the new bottle of wine you found just as much as they are the new journal article that you found so fascinating. Share. But please don't overshare. 

Truthfully, first impressions are just that. The patients who mistook me for a social worker trusted my ability to care for their medical needs. First impressions don't matter nearly as much as who we as health professionals truly are. How many times have you heard from your patients the story about the surgeon in his million dollar suit with no bedside manner? Could you possibly sleep well at night knowing that you had treated your patients in a way that would have put you in the corner during kindergarten? My online presence is as close as it comes to knowing the real Imposter and how she speaks with her patients. 

Dress respectfully for your patients but act respectfully (online and face to face) for yourself as much as them. 

Ask your doc

Chances are he/she will have an opinion.

I recommend you don't get your doc started on Dr. Oz.

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Bias from preceptors

I've experienced so much bias an prejudice during my training. I plan on writing more about this soon, but until then, here's my favourite "constructive criticism".

Of course no one is going to think you're a doctor. People don't take women with long curly hair seriously.


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Residency blues. Again.

I'm lucky enough to not have lost any colleagues to suicide...yet. In the US, physicians are the profession with the highest rate of suicide. Pamela Wible has described three scenarios that I know have at least flitted past my consciousness. The idea that we are supposed to take on as much responsibility as we do and not be allowed to address our own distress is appalling. We shouldn't be afraid to ask for help for fear of losing malpractice insurance.

I know I've blathered on about the stress associated with residency, but honestly feel that I just can't do it enough justice. The words to describe the emotional roller coaster just don't exist. Instead, I'll give you a list of events that I have experienced, usually many in the same day.

Received lab results back that confirm invasive breast cancer in my neighbour.
Been so overwhelmed at work I haven't cleaned my poor kitty's box in well over a week.
Delivered a beautiful baby girl to a mom and dad who couldn't stop kissing each other or the baby to let me congratulate them.
Delivered a beautiful baby boy to a mom who because of her own brain injury will not be allowed to keep him.
Revive a patient during a code blue and have him go on to living a healthy happy life.
Help a young woman suffering from a painful cancer sleep away her last week of life. And then help her parents cope with their daughter's decision.
Lost track of so many emails and Facebook messages from friends I'm surprised they still answer me when I do send a note.
Been told that I'm an incompetent physician who needs to do at least 6 months of remedial training.
Been told I'm a brilliant physician and that my preceptor is excited to have me as a future colleague.
Had patients hug me for telling them about their cancer, their lack of cancer, that I'm leaving a practice, that their mom just died.
Newborn baby exams. Smelling newborn babies.
Helping moms learn to breast feed when they've given up hope.
Missed my nephews special events for work.
Finding my own worrisome lumps.
Had my vacation time continually denied until I just gave up and have weeks of vacation at the end of each residency year left over.

The ups and downs never end. It can be absolutely exhausting. My blog has provided me with some outlet for what I'm doing. I also have a fabulous partner who is extra supportive and a BFF who is going through the same crap. But even with all of the help, residency is incredibly isolating.

This doesn't make sense to me.

Residency is supposed to be preparing us for practice. We should be learning the coping mechanisms now that will keep us from planning a 03:00 dive off a bridge.

Which I suppose leads to the question, what prevents us from becoming hopeless? How do we keep our light shining when we barely have the energy to wash our hair?

Zakari Tatasuggests monthly counselling sessions for residents to address the extra stress that residency incurs. She also says "The idea is not to find a perfect solution but to openly discuss and accept that physicians are vulnerable. The current culture that presents physicians as always being in control of their psychological health should be discarded."

I know an attempt was made in my med school to encourage self care, but it wasn't given as much attention as the importance of knowing how to write a clinical note or avoiding embarrassing the school. Lip service from the chosen few lovey dovey types that isn't also reflected in regular practice is soon lost.

Next week is resident wellness day at my institute. Events will be held in a city I try to visit and will include a speech and yoga. One day a year doing something I could do at home by watching a Ted talk while stretching.

As with most other behaviours, I argue that we need to learn and be taught by example. After breaking bad news, do a debrief and check in on one another. A preceptor who is willing to admit to difficulty dealing with everything on their plate and going through the options of dealing with said overflowing plate teaches a valuable lesson. We are trained to recognize depression and anxiety in our patients but rarely ask our colleagues about it. I've seen a doc whom all his colleagues stated was burned out but none were willing to talk to him or ask how to help him slow down and recharge. The lesson I learned is that my own mental health doesn't matter in my profession.

That can't be right.



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Making patients responsible for their own health

Something we talk about a lot at our hospital is that we expect our patients to take control of their own health.

You're out of breath and coughing like crazy? You should choose to stop smoking.

You've had a headache for three weeks and haven't tried Advil yet? Seriously? I have no words for you.

There are ads everywhere reminding patients that they need to be screened for various cancers. Patients should take responsibility for initiating contact.

Once you make contact, Advil didn't work or want to quit smoking? I'd LOVE to help. But honestly, if I'm pulling you by your nose to take care of yourself, you're not going to like it and I'm going to lose interest. Patients who come in wanting to find out what they can do to prevent constipation or to lower their cholesterol make me glow. I love teaching my patients.

An issue that comes up, as it does with so many patient centred practices, is time.

I try to get around this by building up an idea then giving my patients homework. Next visit, we review what happened. Getting patients to buy in is sometimes tricky but I find it gives us a goal to work towards in our visits, especially those with chronic disease.

I wonder if preparing a journal for patients with a specific disease to work through might work better. This article suggests journaling to improve compliance for exercise in the depressed, and offers suggestions for topics after walks such as "how do the trees around you look?" Maybe having a set list of mini goals to achieve would improve compliance.


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Suicidal Ideation

We are taught to screen for patients who want to kill themselves. Mnemonics such as SAD PERSONS offer us structure for listing risk factors that put us on high alert.


Often I hear things like "what's the point in taking my medication when it's only prolonging the inevitable?", or "I'd rather have hair than live the extra year that chemo will buy me." We call this passive suicidal ideation. People who do not plan to kill themselves but wouldn't mind if they were dead.


Shocking to me today, was the patient who calmly told me his plan for suicide. He has spent months researching a clean, pleasant way to die which he believes will not scar his family. He has even invited his brother to sit with him as he goes. This is a man who may not have long to live and wants to leave the world on his own terms, in the manliest way possible. Being eaten alive by wild animals would be preferable to the slow death his COPD promises.


More shocking to me, was the way I dealt with this news. I didn't miss a beat and continued to ask him to explore the idea.


Now that his plan is in the open, psychiatry needs to be involved to prevent him from preemptively taking his own life. I find myself questioning the futility of that, but will honor my oath and do all I can to keep my patient comfortable and alive as long as I can.


The psychiatrist may lift the Form One because the patient is reasonable.


In the mean time, I'm researching how to get an angry grizzly bear into the Resp unit with no one noticing.
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Another open letter to clinical clerks

If your preceptor asks if you want to stay and see patients, the answer is always yes. Especially if it's not even noon yet.

Checking in

After being so worried about my first block exam (and the gong-show of disasters that surrounded it) I ended up doing OK. I had set the bar low, aiming for a 75% but got a 77%. I can live with that! I had 3 weeks of classes for which I barely picked up a book.

When I'm at home, I feel like I should be available to my partner (who is admittedly, quite needy) rather than studying for school. I've been talking to other people in the class who have partners/spouses at home. The common theme seems to be that they really really don't understand how much work there is to do in med school. It's as though they sincerely believe that we're just having fun all the time. When I'm discussing my day, I try to focus on the positive aspects rather than the negative - why would I ruin his day with my crap? That may seem to put a weird spin on things.

Part of the problem is how much I need to censor myself at home.

Talking about neat specialities I can pursue in the future leads him to be 1) depressed that he hasn't got a dream of his own to pursue or 2) point out that I can't do everything. Surprisingly, I do know that I can't do everything but having the idea that I could pursue a speciality keeps me focused and working on whatever subject I'm currently knee deep in.

Nothing gross. Unfortunately the definition of this changes daily. Last night it was extended to include a cleanly broken bone. Seriously. I get no puss or tumour talk, but a broken bone???

Discussing the MD/PhDs in the class is strictly forbidden as they act as a reminder of his unpursued potential. If he really wanted to use his PhD in Biostatistics, I'm sure he could!!

All this censoring makes regular conversation difficult, especially when it comes to the tough topics like money. Argh with the money!! /end rant

I have finally been brave enough to ask for observerships. I don't know how my classmates have been so quick to find them! I felt like I was asking for a favour and that's hard for me to do. It's really exciting to get an opportunity to see what the "real world" of medicine will be like! My first is set up in geriatrics, the next in child psychiatry. I'm 95% sure I'll be a family doc, but I want to check out the specialities too so that I can be confident in that choice and so that I can be the best family doc ever.