I haven’t been here in a long time! But I’ve been drafting posts in my head throughout my day for the last week so I figured I’d start putting some of them down in print. I amy not finish a thought as completely as I’d like but at least I will have some of it down.
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One of the things that bothers me about my job is how gendered conversations are. When we are talking about the babies, gendered pronouns are hard to stay away from. Lately I’ve been trying to use “baby” as if it is a pronoun.
One of the ways I am showing my age and probably my radical-ish feminist roots, is my disdain for the “gender reveal” parties. It isn’t a gender reveal, it’s a genitalia reveal, which sounds as creepy to everyone else as the popular term sounds to me.
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It’s July again, and that means a new year of medicine, a new crop of interns. My relationship to new interns is different this year, I have more opportunities to teach because I feel more comfortable with my job and I’m starting to transition to the end of 2nd year role, training for and looking toward the role a 3rd year has on L&D. This last week, I delivered babies with a med student and with a family medicine intern. Being the “knowledgeable one” in the scenario (with my chief or attending watching most of it from the corner of the room) was a new place to be. It was fun, especially because said student & intern are very competent & enthusiastic about learning OB stuff.
The juxtaposition of learner and teacher requires a nimble sense of self. One night I did an extensive perineal repair under the direct guidance of my chief - it was an excellent opportunity to discuss & learn and improve. The next night I directed the intern in completing another repair, albeit a simpler one.
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My kids are having an important summer in their growing up - they are both engaging with their feelings and navigating the world in response to those feelings in a new, stronger, more resilient way. It makes me so proud to see them growing up into self-possessed, well attached people. Some things have been hard about the summer for them, but I’ve come to peace with the fact that growing up is a messy process and my job in their lives is not to shield them from the splashback but to help them learn to manage it. There’s a lot less pressure on me if I accept how little control I have over the whole thing!
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Daily, I am grateful for the leave of absence I took from residency. I cannot express how much of a difference the time off has made. “Time off” is a really poor choice of idiom in this case. It was not time off. I was working very hard the whole time I was not in residency. I was working on my physical health, my mental health, my children’s health, my family system. I was processing the end of a long marriage that was mostly good but for a few years was in fact pretty toxic and had turned me into something that I didn’t want to be. I started the long, slow process of actually dealing with an eating disorder that, for over 30 years, I have been controlled by or desperately tried to ignore.
The investment in all these parts of myself has resulted (this will probably not surprise anyone) in making me a better resident, a better team member and a better doctor. Frankly, as capable and responsible as I like to consider myself, I was not as capable and responsible as I could or should have been. Now that I do not have a back burner filled with stress and pain, I have more bandwidth to perform at work.
(Bandwidth is one of my favorite phrases. I often describe my choices in terms of my bandwidth - I would love to date more often, to volunteer, to putter around the house, to be crafty. But I don’t have the bandwidth to do everything. It isn’t a question of “want” or “willing” so much as an issue of how much will fit into any given day.)
And I am absolutely LOVING my job. The hours and responsibilities are absolutely insane but the work, the Work, is an absolute joy. Even when I’m taking care of very sick people, even when tragedy is striking or trauma is making a patient’s course frustrating, I love my job.
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Two more sleeps until my son comes home! He’s had something of an unexpected and disappointing summer but also he has done an excellent job of tuning into his feelings, tapping into resources and making lemonade. Amongst other things, he realized he has some roots in Asheville that he missed - his dog, his girlfriend, even me (I was way flattered when he said that he missed hanging out with me!). He’s coming home 2 weeks before his sister. It’s a nice easing back into parenting for me as well. I’m going to work to keep my level of focus at work and not be distracted by unfounded worries or preoccupations with my kids, who are actually doing quite well and don’t need me as much as they did before. It’s okay for me to focus on my own priorities now.
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One rotation that we don’t have as a 2nd year is Gyn Oncology. We are very focused on L&D in 2nd year, spending half our time there. In the other years, we spend 2 6 week blocks on Gyn Onc. The patients are very different from L&D, generally sicker and older. And it’s a complicated dynamic to navigate - there is a Gyn Onc group we work for, we assist with their surgeries and round on their patients daily, we are in-house on nights and weekends to manage most needs. It is a busy service with complicated patients, very involved attendings (rightly so, just to be clear, I’m not complaining about that - but there are 4 of them and every week there is a different style, it takes some nimbleness). I’m a little nervous going back into the Gyn Onc world - it is a different kind of stress than I’m used to on L&D.
One of the differences between our program and the private docs in the community is that we are always in the hospital. There is one group that has a nocturnist, another that has a midwife that works with them but usually they are not here all night every night. Sometimes they have a patient who is sick enough that they really need someone actively looking out for her all the time. We have sometimes taken over care of these patients - their doctor explains to them the level of care they now need, we introduce ourselves and we become their primary doctors.
Something I’ve heard from recent graduates of residency is that the volume of private practice is much lower/slower than residency. One may only do a few hysterectomies a year, not see a patient with preeclampsia for months, or rarely see an ectopic pregnancy. In this community, we help out the private docs however we can. Sometimes they review standards of care with us (our chiefs & attendings) or they ask us to assume care of someone who is really sick or we help them with surgery to save them from having to call in a colleague from their practice to operate with them in the middle of the night. If they have a patient in Triage and she needs a quick set of eyes on her before going home, we will often meet the patient and make sure everything is on the up and up for them, saving them a trip into the hospital in the wee hours. In addition to the patients we serve, we are serving the broader community. It makes me think about how I will manage these sorts of cases in my own eventual practice. Knowing what referrals are available in a community will be an important data point.
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Today was my first grumpy moments back to work. It was 100% because of a misunderstanding on my part that led to some other crap that is no big deal but pushes all my buttons. Also our team has been tumultuous this week, one of the downsides of days is that there is some fluidity in the schedule. This is the time of year that our new 4th years are doing things like job searches and fellowship interviews, so there are days that one or two of them might be gone and we have to patch holes in the schedule. Now I am not in ANY position to complain about that, and I’m genuinely not complaining. BUT having to do that shuffle of people is stressful for many of us - the new person covering for a colleague doesn’t know the patients, has their own communication style and way they like to run a team. We all work together and we can all work well together, but when you have four chiefs in 3 days, it makes for a little bit of nuttiness.
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Here’s another important thing I realize now that I have internalized about doctoring: taking care of patients is in no way like substitute teaching.
Lemme ‘splain…
When you have a doctor, they investigate, examine, diagnose and treat you for a given condition. In many cases, there are multiple ways to manage said condition. There may be a difference in the order of treatment options, different medications, counseling, weighing of certain factors in making decisions. Any individual clinician will have their own concerns, plans and ideas.
When one doctor takes over for another, there is next to no sense of loyalty to a plan just because it was implemented by a previous clinician. I may take over the treatment of a patient with a complication that *could* be treated with meds but wasn’t. I will look at that decision making process, try to get sign out from the other clinician and realize that in this case, I would have done something different.
Often the doctor taking over will try to find a way to bend the plan more to their comfort level. In this specific circumstance, I may document a change in management by prescribing medications that had previously been held. This makes things confusion for patients - they think the left hand doesn’t know what the right is doing. As someone with high health literacy and experience with health care, I didn’t understand this aspect of medicine before I was in the decision-making position myself.
