The Stupid List

Do you know what a Stupid List is? I don't mean that thing you needlessly create everyday in your iPhone, planner, or head. I mean a list of things that routinely get neglected until something goes wrong and then you say "I can't believe I was so stupid!". That list. It's almost the end of 2010 and now is a good time to attend to your Stupid List. Want a practical example of what should be on said list?

1. Update dog's microchip when you move or else when she runs away and gets picked up by a policeman and taken to the Humane Society they will have no idea how she got from Chicago to Madison. Or how in the world to get ahold of you, her stupid owner who didn't update her microchip info.

See how easy that is? Here's another one,

2. Clean out email contact list so that when your account gets hacked you don't send emails selling *cheapest* electronics to your previous employer and your stylist who moved to Atlanta years ago and that guy you met on a cross country flight before you ever laid eyes on your husband.

On a practical note, how about checking when your passport expires? Wouldn't it be a shame to plan a big beer drinking trip to Belgium and discover that your passport expired the month before? And how about your Facebook privacy settings? Better check on that before you post those NYE pics, huh? Do you have any old email accounts that you don't use anymore? What if a long lost acquaintance sent you a holiday message? You might want to peruse your inbox. If only to remind yourself of who you used to be. My old email address is girlyhood@.... Why? I don't remember, but I like it. Oh and while you're checking old email addresses, google yourself in the advanced search option. It's important to see how you are being portrayed to the world, intentionally or not. Any random credit cards you don't use anymore? How do you know someone else isn't using them? Check your credit report. Like Wilford Brimley says about your blood sugar, "check it often".

Whew, don't you feel productive and organized? Just in time for the new year. You're welcome.

How To Live A More Interesting Life

I have this friend whom I love dearly and is nothing like me. I tend to gravitate toward people who are living lives that I would love to be living, at least a little bit. She is one of those people who has a new adventure planned every weekend and has changed careers mid-life. She always seems to 'fall into' random experiences and has the most awesome stories. She embraces life daily and does not apologize for it. She is successful at making her life interesting. So, as I struggle with building a suburban life in the Midwest and holding down a very 'adult' job, I'm conscious of holding onto that small part of myself who still craves a little 'randomness'.

I came across this blog called "The Friendly Anarchist" and I want to share with you what he says about living a more interesting life.

The mistake when trying to find out about interestingness is to look at what interesting people are actually doing. Because this only leads to even more passivity on the side of the spectator:

• “Oh, Tyler Tervooren can jump out of an airplane, but I couldn’t possibly do that because I don’t fly. Climate change is more important than having fun.”
• “Oh, Sean Ogle is traveling to South East Asia and checking off the points on his bucket list, but I couldn’t possibly do that because I love my home and wouldn’t want to leave.”
• “Oh, Karol Gadja is building a business around his Ridiculously Extraordinary blog, but I couldn’t possibly do that because I haven’t got any idea of internet marketing and writing.”

One thing is for sure: You will always find reasons not to do something interesting, even if other people are doing it. Often enough, these reasons will be pretty good. Sometimes, they won’t. But you’ll definitely find some!

I believe we have to look at what these people are not doing. And then we have to stop doing that, too. For example:

• Stop worrying 18% of your life.
• Stop overthinking everything.
• Stop remaining seated comfortably.
• Stop accepting things as they are, even if they suck.
• Stop taking the path of least resistance.
• Stop living the life other people planned for you.
• Stop worrying 18% of your life. (This comes twice, as it’s really the basics.) The good thing is that interestingness doesn’t always have to be confronting pickpockets or jumping from airplanes. It may be small things:

• 
  

• Buy unknown food at your supermarket (or an Asian / African / Latino shop) and try to cook something tasty with it.
• Go to a new bar / restaurant instead of always going to your old favorites.
• Watch a recommended movie from a genre you normally ignore.
• Engage in a street fight.

It may be big things:

• Quit your boring job.
• Write and publish that novel you’ve got inside.
• Sell everything you own and travel the world.
• Have and raise five children.

And it’s really your personal choice. Each of us is different, each of us has different ideas of how to live an interesting life.

There’s one thing interesting things have in common, though: They make us feel at least a tiny bit uncomfortable. Anxiety is the perfect indicator. Instead of worrying about or trying to ignore it, maybe we should let it be our guidance. This is not about becoming an adrenaline junkie, though. It’s not about extreme sports, about permanent travel, or about becoming an entrepreneur. It’s about taking the direction that you want to take in order to make your life more interesting.

Just wanted to share something in the blog-o-sphere that brought a little bit of clarity to my day. Hopefully you get something out of this and make a small change today!

Another Awesome Word I Didn't Create

Intrapreneurship. Know what it is? I didn't think so. It's another awesome word I didn't come up with myself. Like 'bromance', 'bootylicious', and 'staycation'. It is defined as follows:

While an entrepreneur ventures out on their own to pursue an idea, an intrapreneur does this within the organization in which they already work. It could be creating a new product, coming up with an innovative idea, or improving a service.

I'm an intrapreneur right now and I didn't even realize it! Here's what i'm up to. As part of an academic hospitalist division, I felt that we needed to do more...academic things. So, I am in the midst of trying to drum up enthusiasm for starting a divisional journal club. That's important right? We are responsible for teaching and modeling for medical students and residents so we should attempt to uphold the academic standards on which our profession was built. Here's my issue, albeit a minor one. I'm not sure that everyone is quite as passionate about reading journal articles as I am. So let's say that only half of our division wants to participate and the other half aren't that interested. Should I make it totally voluntary? I foresee that becoming pushed by the wayside when other 'mandatory' things come up. Soon enough it might be a club of 2 members. And that's sort of sad. But, if I make a schedule with everyone assigned to a month in which they are responsible for journal club, I'm afraid I will make some enemies. And they will whisper "who the hell does she think she is?!", preferably to my back and not to my face. Yes, I worry about these things.

So, the concept I am "intrapreneuring" is a division journal club. But really maybe I should be inventing a way to make learning a passionate endeavor for all.

I'm Ridiculous: Part 2

I just finished up a weekend of call and I'm exhausted. Yes, I slept in my own bed. No, I did not have any "middle of the night" admits. So why the heck am I so tired??!! If you read the first year of my blog you will understand how ridiculous this is. I spent 2 years working nights and weekends in the NICU and would've been overjoyed to have a job where I could sleep in my own bed at night and not be up for over 24 hours multiple times a week. Our call from home currently requires us to personally see every admission within 2 hours regardless of acuity or time of day/night. But herein lies the rub.....I like to be prepared for whatever situation may befall me. "Plan" is my middle name. So what do I do when i'm on call from Friday night to Monday morning and I don't have any nighttime admits? I anticipate them. I lie in bed and anticipate the beeping of my pager. I anticipate dragging myself out of bed at 2 am. I anticipate getting into the car and driving to the hospital in the 10 degree weather. And I anticipate getting home with just enough time to get comfortable before my alarm goes off signaling a new day of rounding on patients. I think subconsciously my body does not want to relax because it is so much harder to get out of bed during a dead sleep than not. So I lie awake waiting for the inevitable admission that never comes.

This is problematic on so many levels. There is no way I can justify being tired after a night of call when I don't even get called. I have to carefully conceal the bags under my eyes and tell my coworkers what an easy weekend of call I had. I can't blame my less-than-enthusiastic teaching and blunted affect the next day on the rough call night I just had. Sometimes, and I can't believe i'm saying this, I think I would sleep better if I just stayed at the hospital. The mere anticipation of leaving my bed and driving to the hospital in the wee hours of the morning clearly throws off my tenuous grip on stability and sends me into a spiral of anxiety the likes of which prevents my brain from shutting down. Any advice? Meditation? Hot tea? Peanut butter chocolate chip cookies? My battle against sleep deprivation continues...

A Gentle, Hairy, Non-English-speaking Co-pilot

Have I ever told you about our dog Swayze? Well, she's crazy. She's part Boxer and part Lab and part Wookiee and super excitable, especially around other dogs. And squirrels. And fast moving children. When we lived in Chicago, our back deck was surrounded by a high fence and whenever she would hear people or dogs she would go crazy whining and clawing at the fence to get out. So, when we moved to Madison we bought a house with a big yard and no fence. Solved that problem didn't it?

Under the influence of our realtors and the fact that we could not imagine the ridiculousness of putting Swayze on a leash to walk her in our front yard, we had an invisible fence installed. The way this works is that she wears a special collar when she goes outside that delivers 'an uncomfortable sensation' when she gets too close to the perimeter of our yard. The discomfort level is really variable dog to dog and since our dog has bloodied her own paws while playing we honestly had pretty low expectations that this would work for Swayze.

It took a couple of weeks for her to 'get it' and make a definite association between straying to the edge of the yard and getting 'shocked' but alas....it happened. Now when children ride by on their bikes and couples walk their dogs by our yard and a squirrel darts across the road, sometimes all at the same time, Swayze automatically sits and wags her tail and stares. Sometimes she trembles with the effort, but she makes herself stay far from the edge of the yard. She knows that the 'uncomfortable sensation' is a powerful motivator for avoiding that situation.

A coworker was in an unfortunate situation last week where she felt she had not managed a patient in a manner in which she felt proud. The patient was ultimately transferred to the ICU and there were rumblings about her 'sitting on the patient' for too long. She was in my office beating herself up about this and she asked me "How do I get over this? How do I move on?" And I responded that the only way I have gotten over this same awful feeling is to remember it and the situation that gave birth to it. Not trusting your gut and deferring to someone else just because they have a few years on you = this same awful feeling. So, next time I encounter that situation, I remember and I make a different choice. A choice that will hopefully allow me to avoid the 'uncomfortable sensation' of feeling like I failed a patient.

Learn from your mistakes and move on. Take comfort in that. If Swayze can do it, so can you. Trust me on this one.

Feedback Sandwich With A Side O' Chips

I went to a faculty development session the other night about feedback. Who knew there is so much to learn about feedback? I know when I was a medical student and resident, I craved feedback from my attendings. But only if it was positive. Then when I was a fellow and pseudo-attending I just wanted to be told if I was doing something wrong. Now that I am faculty, I just want to be told how I can be successful.

I raised my hand and admitted at this session that I was uncomfortable giving feedback because I don't like to hurt anyone's feelings and I want everyone to like me. Do you know what the speaker said to me? He said "The people who are most worried about hurting another's feelings are the least likely to ever do so." Wow. I don't think I could have felt better if he had said "Have you lost weight? Because you look thinner." Well, maybe a little better, but you get the point. In that instant I lost so much of my hesitation to give the students and residents with whom I work 'constructive criticism'. I now see it as a chance for me to help them to be successful...without having to wait until they are faculty.

When I started on the wards this week with my new team I warned them in advance that I would be giving them feedback immediately after their presentations in front of the rest of the team. I've done it in a way that is matter-of-fact and nonjudgmental, all the while thinking of how I want them to be better doctors because of their experience on my team. I'm not perfect at it, but I think they are learning....and I think they still like me.

When You Play This Record Backwards, It Says "Get Over It"

Have you ever held your tongue when you really wanted to speak up but didn't think it was your place? I know everyone has. Being a quiet person by nature, this happened to me often growing up. I would stew and vent and replay all the things I should have said but the same thing would inevitably happen to me in another situation. My mom used to tell me "Angela, when you get older and more confident you won't care so much what people think and you won't be so afraid to speak up for yourself." Weeeeelllll, I'm definitely older, and maybe a tad more confident, but I'm still not speaking up. When is that magical age when I won't defer to someone older and more experienced to make a decision that I should feel confident making?

I was in a situation (again!) last week where I didn't listen to my gut. I allowed the opinion of another physician to comfort me and didn't think independently enough to make my own decision. Everything ultimately turned out fine, but in a much more circuitous and unattractive way than I would have liked. I have been beating myself up about this for 6 days now...I've replayed all the things I should have said and done numerous times and you know what? It feels different. I can't explain why but for some reason I feel like a switch has been flipped and this won't happen to me again. At least not like this. I am done with this feeling of insecurity about my lack of experience. I may not know all the answers but I know that I can trust my gut to lead me to someone who can. I think if I say this mantra to myself enough times, I just might believe it by the time I'm another year older.

Pick A Little, Take A Little

You know what's been on my mind lately? Baked goods. Lots of them. I think it's the weather. Nothing sounds better to me than cakey, doughy sweet goodness for breakfast, lunch and dinner. To get my mind off of said baked goods, I've also been thinking about mentors: being a mentor, finding mentors, having secret mentors, having no mentors but wishing you did. Yes, all of these things. Let me tell you about my experience and you can think about yours.

I recently volunteered to be a faculty mentor to one of the pediatric interns. We met for lunch and were given a list of 'helpful topics' to discuss. Talk about awkward! It felt more like a job interview at first with me looking down at my paper and saying "Let's see. How are you handling stress and what makes up your support system?". Let's just say I recognized the awkwardness and nimbly manuevered away from its impending destruction of our mentor-mentee relationship. Once we put down the 'helpful topics' and starting really talking with each other I realized that there was so much about her that I recognized in myself and it was comforting. I felt like I really had some worthwhile experiences to share with her. And the best part? She has done some things that I totally admire and I felt like I learned from her. That, my friends, is what makes the best mentoring relationships...learning from each other.

As a young faculty member I am charged with creating a mentorship committee for myself made up of senior pediatric faculty who have experiences and goals that align with my own and who will guide me down the road to promotion. I have spent hours researching who would be good people to have on my committee. I'm at the point where I've narrowed it down but have to actually ask them. The problem is that I don't know one of them yet. I've read her CV and she has been recommended to me by multiple coworkers but we have not had occasion to meet each other yet. So then it becomes like a blind date...I'll email her and tell her a little about me and suggest we go for coffee and then she can decide whether or not she likes me enough to spend the next 7 years answering my panicked phone calls for advice and pleading my case to the administration to promote me to the next level. Ugh. Yes, I know. Time to grow up and just do it.

I have a secret mentor too. Although I'm not sure I can call this a true mentor relationship because she doesn't know I exist. I don't provide any benefit to her whatsoever. She happens to be a peds hospitalist who is active in the Section on Hospital Medicine and posts frequently on the listserv to which I subscribe. She is brilliant and funny and thoughtful and has the same educational values that I do and sees through all the smokescreens to really get at the heart of what pediatric patients need. I save her posts to the listserv and read them multiple times. On second thought, maybe I am less of a mentee and more of a creepy stalker chick. Either way, she is an excellent role model for me.

Lastly, I have been in a place where I could not for the life of me find a mentor. I was surrounded by people who did not share the same values and style and vision that I did. I did not feel valued as a person or as a peer. More importantly, I did not feel known. Now, I recognize that I played my own role in this failure of mentorship but the bottom line is that I was not meant to be there and it was not the right arena for me to advance and achieve my goals. So I left that place and it was the hardest thing I've ever done but I am so much happier for it.

As professionals, we can't underestimate the power of having mentors. Take stock of your surroundings and find people who support the different pieces of who you are. You have to invest time in a lot of different people in order to find the ones who will change your life. Sort of like dating isn't it?

Chocolate Chips Do Everything But Get You Promoted

Today I read an article titled "10 Most Common Excuses for NOT Making Ideas Happen" and I just had to jot down my thoughts. I've recently been coming from a place where I second-guess myself. A lot. There are all sorts of ideas I have about what I want to achieve and areas I want to explore because they get me excited to come to work in the morning. But when someone asks me the dreaded "So, what are you interested in?", I feel like what comes out of my mouth completely pales in comparison to what I envision in my head. Then I feel like a lame. A lame who should go home and make pumpkin chocolate chip cookies to make herself feel better. But I digress.

Number 2 on the list is "I'm afraid of the competition." How many times have you read a published study and thought "I totally could have done that" or "I thought of doing that a long time ago"? I do it all the time! Now when I think of something I want to study, I convince myself that someone has already thought of that idea and is putting their infinite supply of resources and time to that very project. The author makes a point that "competition validates your idea by creating a category". Hmmm, point well taken.

Number 5 is "I have to plan it out properly first." I think this would be the title of my memoir! Truly, "spend more time doing, and less time planning." Thanks for the reminder.

Lastly, I love "I can't overcome the inertia". According to the article, setting "lofty goals from a resting start" is a recipe for failure and discouragement. Setting smaller, more manageable goals allows momentum to build and powers you through to the big picture. I use this all the time when I clean the house (I'm just going to start with the dishes, then we'll see how it goes from there) and I never thought about utilizing this idea more often with my career.

Here's the link to the full article. Check it out.

http://www.openforum.com/idea-hub/topics/managing/article/10-most-common-excuses-for-not-making-ideas-happen-behance-team

How the Other Half Live

Here's what I've been up to.....holding the cutest damn baby for hours on end and loving it! That baby happens to be my new niece. People who know me well are surprised that I am so head over heels about this baby because, despite being a pediatrician, I've never been a "kid person". I dislike chaos and sticky hands and saliva. It's no secret. But I can stare at that little face for hours (and I did!) and be endlessly entertained.

As luck would have it, she developed hyperbilirubinemia on day 3 of life and was admitted to the hospital for phototherapy. I went with them to the hospital and for once was not in control of the admission because I was on the other side of the process. It was a weird feeling to just sit in the room and not recite her history and physical for the residents and let them know what the plan was. I am not a laid back person and believe me when I say it took a lot of effort to stay in the background so as not to embarrass my sister and be that obnoxious family member we physicians are all so familiar with. You know, the one who makes us whisper "A little bit of knowledge is a bad thing" and roll our eyes when we find out one of our patient's parents is a physician.

However, I did learn some things that I will take with me back to the wards.

1. When a large group of 'medical people' walk into the room of anxious, sleep deprived parents it can seem a little like being in front of a jury arguing for your life while trying to do your taxes at the same time. Not at all fun and slightly terrifying.

2. Dividing and conquering, ie one person is examining the baby while another is asking the questions while another is entering orders while another is watching the cardiac monitor makes parents jumpy and unfocused. Don't try to distract them with detailed questions while handling the most precious vulnerable little responsibility they will ever have and love more than they could have imagined. It's just not nice.

3. Consider how every little decision you make will affect your patient AND their family. Putting a baby on a cardiac monitor for hours with no compelling reason to do so while the parents have to constantly hear the alarms (called alarms because they are alarming to those not used to them) and freak out that something is wrong when really the pulse ox isn't 'picking up' is unacceptable.

4. If the family is going to be stuck in the room waiting for something, anything, to happen and there is a delay, someone should come and update them AND apologize. I realize things move slowly in an academic center but when you are the one waiting it is very frustrating to be lost in the "waiting for the doctors to enter the orders" wasteland of time. Come on people, start the phototherapy already so we can be done with this and go home. Remember these are new, sleep deprived, anxious parents.

Do you know how often I've thought about these things when I've been the person on the other side of the curtain? I am ashamed to admit...almost never. That experience with my niece will make me a better doctor, I guarantee it. Just one of the many things she will teach me, i'm sure.

A First For Everything

For the very first time I felt, at the end of this week, that I was tired of treating sick children. Don't get me wrong, I love my job. I love being a pediatrician and I love hospital medicine. But not this past week. That love was on hiatus.

Never before have I felt so "drug out", as the father of one of my patients kept saying to describe his previously healthy son who was unable to speak after a viral encephalitis. The kids I took care of this week took my previously in check emotions and took them for a joy ride down Depressing Road. I came home every night thinking about what lay around the next corner and how impossibly lucky I've been thus far in my life. When we wake up each morning we can't possibly know how our lives might irrevocably change that day. The mother of my 5 year old patient couldn't have possibly imagined how their morning bike ride would end...with her son severely brain damaged after being hit by a van. I could tell you more of what I saw this week but that's not really the point. I walked out of the hospital at the end of the week yearning to see a happy healthy child. In fact, I craved it.

I've seen all of these things before and have been able to deal with them in stride, just like every other day on the job. But last week it got to me. Those kids got to me. This week, for every night that I walk in my front door and my husband and two dogs are there waiting for me, I will give thanks for that day.

Let's Face It. I'm Ridiculous.

I just got off the phone with a dear friend of mine and she was updating me on a situation she and her husband have been struggling with for awhile now. The theme underlying this struggle is regret. That awful shoulda-woulda-coulda feeling that we have all been humbled by more than a few times. It's a painful place to be. In short, they are strongly regretting their choice of residency program. They feel that they don't fit in with the people, the program is not family friendly, and they don't have the social support they thought they would. This is all compounded by the fact that they have a young daughter and residency at even the greatest program is still not a conducive environment to spend lots of quality time with the fam. I listen to her frustration and hear her talk about all the places they liked that they could have gone but instead made the misguided decision to choose this particular program and my heart aches because we both know that they have to grit their teeth and survive for the next 2 years. Just surviving is no way to spend your days. I've done it. It ain't pretty.

I'm embarrassed to share with you a regret i've been struggling with. When I tell you this, you will roll your eyes and then I will feel better that you think I'm ridiculous because that validates the fact that I should just let this go. And sometimes I need someone to roll their eyes at me so that I stop taking myself so seriously. Here it is.

On my first day at my new job, I was at morning report and the residents were presenting a case that had been seen in the hospital the week before. It was one of those puzzling cases about an adolescent girl, a soccer injury, and neurologic symptoms. Everyone is calling out potential diagnoses and tests they want ordered and focusing generally on the injury. All along I'm thinking "this sounds like something i've seen before, I know what this is." I want to open my mouth and say the diagnosis because no one has said it yet but we are in a big room with all sorts of attendings and residents and my department chair is sitting right next to me. I keep picturing myself croaking out my diagnosis and then the room going quiet and everyone turning to look at me and thinking "who the heck is that and why is she so stupid?" My heart is racing and my face is red and hot and I want to say it but my mouth won't open and my hands are trembling and then I give up. The residents go on with the case and show the answer and you know what? I was right. All I remember from that day is thinking over and over about what would have happened if I had said the answer. Do you know how much mileage I could've gotten out of that one right answer?? How awesome would that have been to outsmart everyone, even the department chair, on my very first day on the job? Awesome. Alas, I didn't open my mouth for fear of looking stupid and I regret it. I think about this at least 3 times a week. I keep hoping for another chance at morning report to reclaim the glory but those times happen so few and far between. I might never get another chance to look that mysteriously brilliant. Is this a ridiculous story? Yes. Will this ever happen to me again? Sadly, it probably will. (cue eye rolling)

Niche is a four letter word

Here's an honest to goodness conversation that just took place between my husband and I.

Me: I'm feeling inadequate today.

Him: Why?

Me: Because I went to our division meeting today and everyone seems really really smart. Much smarter than I am.

Him: Well, they have more experience than you. I'm sure they think you are smart too.

Me: No, I don't have much to contribute during the meetings. Also, everyone has their niche that they are working on. You know, one person is doing global health, another is palliative care, another is family centered rounds. I don't have a niche yet. And what's worse is that I don't know how to get one! I don't have one singular passion to focus on. What if I can't figure out my niche and I just languish here in this job and I never get promoted?? I need to start being productive and adding to my professional portfolio!!

Him: Ummmm, you've only been there a month.

Me: So?

Him: So, you've only been there a month.

This conversation is what happens when a perfectionist like myself lets a little insecurity take charge of my brain and graffiti it with the word "should". I "should" be more productive. I "should" be uber-accomplished. I "should" be a rock star. I am reminding myself (with you as my witness) that it is ok to get settled into a new job for the first several months. It is ok to be inexperienced and still learning. It is ok to not be perfect. It is ok to take a breath and relax. It is ok to just be. Just be.

A Shout Out For Skills

You know that feeling....that feeling where you make a decision because you think it is the right one and then everyone comes down on you and wants you to change your mind? That's not a good feeling...especially on your first day as a hospitalist in a new hospital. It's better when the decision is to not have dessert and then everyone tells you you're silly for cutting calories and you should enjoy life and just eat the freakin' dessert. Much better. But I digress...

To set the stage in the vaguest possible way, I decided based on the clinical history and the impression of my colleagues when this particular baby was admitted, that I would treat for 14 days with an intravenous medication. I stress relying on the impression of my colleagues because it was a situation where I came on the scene on day 4 of admission and the baby looked very different to me than she did when she was admitted. I have faith in my fellow physicians and it does take a leap of faith to base a difficult treatment decision on a physical finding no longer present. For various reasons, this baby had to complete the entire 2 weeks of therapy in the hospital. You can imagine how the family received that news. Here is a rough approximation of how that conversation went as if you were only listening to my end...

"Unfortunately, the baby has to stay in the hospital getting this medicine intravenously for the next 9 days."
"Yes, I know all the tests were negative."
"Yes, I agree she looks great and has a normal exam today."
"I do feel strongly that this is the necessary treatment course for your baby."
"I know it is a hardship for you to drive here when you live an hour and a half away."
"You have a 2 year old at home? Wow, yes that will be tough for you."
"No, I won't change my mind on this."

It was difficult hearing the nurses whisper about what an inconvenience that was for the family and how sorry they felt for them. Difficult because I felt responsible for that hardship, it was ultimately my decision to make. A comment on a recent post of mine mentioned celebrating "the moments when I own my skills". I read that comment on the night that this happened and it reminded me that my responsibility is to ensure, as best I can, the health and safety of that baby. I own that responsibility and am grateful everyday to have the opportunity to practice my skills in this awesome career that I chose. That is something to celebrate. Thanks for the reminder.

Spare the Rod...Please

Can we talk about something sad? Not sad so much as vile and disgusting. Call it whatever adjective you will, but I have seen 4 cases of child abuse in the hospital in the past 3 weeks. These range from a broken leg in a toddler caused by 'falling off the bed' to a 3 month old beaten to within an inch of his life. When I see these children, I can't fathom what they did to incur the wrath of an adult punching, slapping, and shaking them before they even have the means to run away. It makes me sick and, i'll admit, I do pass judgment on the alleged perpetrators before they have been 'proven guilty' by a court of law. I'm human. And I have dedicated my career to ensuring the health and wellbeing of those in our society who do not have the means to advocate for themselves.

So I thought it timely when I ran across an article about spanking and domestic abuse. A study found that children who were at the highest odds of being spanked were those whose parents were aggressive towards each other. This aggression took the form of slapping, kicking and emotional abuse such as not letting the partner see his/her family. The article suggests that spanking is part of an overall 'environment of violence' in US families today. Essentially, child abuse like i've seen over the past weeks is likely a continuum of abuse stemming from the parents, who likely suffered abuse as children, who were abused at the hand of their parents, and so forth. Spanking is an act that I don't believe children can separate in their minds as discipline vs. physical oppression of another person for purpose of control. Hence, the link to abuse. The AAP has this to say about spanking:

Corporal punishment is of limited effectiveness and has potentially deleterious side effects. The American Academy of Pediatrics recommends that parents be encouraged and assisted in the development of methods other than spanking for managing undesired behavior.

I wish that I could build a dam to block the river, but instead i'm throwing life preservers to those who are drowning in the rapids.

The Voices in Your Head

I had this attending my intern year who would always send us in to see a patient and then ask, when we came out of the room, "sick or not sick?". I spent my 3 years of residency honing that skill, that gut feeling supported by experience and clinical knowledge, which allows me to assess a patient within minutes (sometimes seconds) as perhaps someone who needs more critical care than I can provide. To this day, I ask myself "sick or not sick" anytime I see a patient on the floor.

I had the opportunity to listen to this voice last week. Another physician from a hospital a couple hours away transferred a patient to me billed as more puzzling than anything. They had run multiple tests and thought they had a diagnosis and were ready to discharge her when her symptoms returned and gave them pause. I accepted the transfer and proceeded to wait for her arrival to the floor. However, there was something nagging at me. Something about the story was troubling me but I tried to reassure myself. After all, she had already been in the care of another physician who I'm sure has more experience than me. Surely they would have noticed and ruled out the very things that were scrabbling around my brain and causing me to have my 'nervous stomach'. Right??

As tends to happen on a Friday afternoon when the residents are all at lecture and I am finishing my first week on service...I walk into the room as soon as she arrives and my 'gut voice' is screaming "sick! sick! everything you thought was going on IS going on!". My gut voice doesn't have much tact, but she is phenomenally insightful. I'm learning that I should really listen to her more often. Thankfully, I had the support of the critical care team and specialists right away and she was taken to the critical care unit, where she remains today. Looking back, I should have been more focused and skeptical in my questioning of this other physician. I should have trusted my instincts and told the ICU about the patient and my suspicions before she ever arrived. As a young and fairly green hospitalist, I am quick to defer to others' judgment. This experience taught me that I can and should rely on my clinical assessment. I may not always make the right diagnosis right off the bat, but I can tell sick from not sick and that is the first step. Now I'm the attending who sends my interns into a room and asks "sick or not sick?".

Checking In (Or Taking A Break From Flogging Myself With Impunity)

Just finished my second day of my new job. Wait, has it only been 2 days?! Oy, yes it has. Not that things have been awful. On the contrary, things have been wonderful. But you know how it is when you come off of a loooonnng vacation and jump right into busting your hump and trying to look like you know what you're doing? I'm there.

My first night call is tomorrow night and i'm a bit freaked out. Not so much about the medicine....more about the finesse it takes to practice said medicine over the phone. I haven't done that in awhile so I will be exercising certain clinical muscles that are flabby with disuse. And speaking of flabby muscles....i'm not sure how I did this as a resident. By this I mean work all day running around the hospital maintaining control and order with a professional yet pleasant demeanor while fitting in teaching AND learning 'on the fly'. And then fit in a quality workout and cook a well balanced dinner. I did this as a resident, a mere 4 years ago, and I have no idea how. Because i'm certainly not doing it well now!

I'm currently propping my eyelids open and doing PREP questions on the Pedialink website. Must. Learn. Everything. But i'm not putting any pressure on myself....

Not So Lonely Only

I've done lots of important things lately. Let's see....I've moved to a new state, bought a house, bought a car, bought a lawnmower, am starting a new job, reached advanced maternal age, and made pancakes with beer in them. Did I mention I moved to Wisconsin? See, now the pancakes with beer thing makes sense.

With all these big changes, what do you think is next on everyone's mind? I'll give you a hint. It starts with b and rhymes with maybe. Dang people, give me a break. I'm crossing things off the checklist o' life as fast as I can. So I started thinking...when is the perfect time? My husband has an advanced degree and is moving forward in the academic science world. I am starting a new career as an academic pediatric hospitalist. There's no downtime in the near future for us. And by near future I mean 10 years. We've looked at each other various times and said "we want to have kids right?" and the answer has always been "yes, but not right now." Both of us have career goals we have yet to meet and are looking forward to reaching those goals. I personally love what I do and can't imagine not being a pediatrician. It has become an indelible part of who I am and I won't apologize for that. Ever. So how do we fit a family into that mix?

Fortuitously, as i've been struggling with this question, there appeared on the cover of Time magazine an article about the trend towards stopping at one child. The article focused on couples' reasons for stopping at one and the debunking of the myth that only children are maladjusted, social misfits who are selfish and secretly long to fill the hole left by the lack of siblings. Until I read this article, I didn't realize how much my personal bias against only children was a product of this very myth. Having one child makes sense to me. Economically, personally, intellectually, it is a compromise and a way I can wrap my head around the concept of having a family and the career and life that I currently love. I wonder, how different would it feel to know that this pregnancy would be your only pregnancy and this sleepless infant stage would be the only one you would go through? Would you complain less and enjoy more? Would you wake each day with anticipation of the milestones knowing that your experience would be limited to this one child? Just food for thought. I'll be chewing for awhile...

Celebrity Deathmatch: Oatmeal vs Pop-Tarts

I've come up for air, bought a new computer, completely unpacked and now i'm ready to start this new year of blogging. I might even get a little fancy and start posting pictures too so watch out.

Last time I wrote I said we would discuss finding your niche in your career/job in my next post. But I changed my mind. Work is far from my thoughts and I just can't make myself think about starting my new job right now. Fair? Fair.

A report published recently by the Trust for America's Health and the Robert Wood Johnson Foundation stated that 16% of kids ages 10-17 years are obese and another 18% are overweight. You only have to walk around the mall this summer to see the uncomfortably tight t-shirts and jean shorts kids squeeze themselves into to get an in-your-face glimpse of our Western diet wreaking havoc on the health of our future generations. Did they ever really have a chance?? Why eat plain oatmeal and fruit when you can get fiber and "7 vitamins and minerals!" by eating a strawberry frosted Pop-Tart?

My husband likes Pop-Tarts and, I confess, there were many nights on call when a package of these tasty toaster pastries called my name and I listened. I figured they can't be that bad because they have fiber and real fruit (!). So I read the ingredient list and here is what I found:

ENRICHED FLOUR (WHEAT FLOUR, NIACIN, REDUCED IRON, THIAMIN MONONITRATE [VITAMIN B1], RIBOFLAVIN [VITAMIN B2], FOLIC ACID), CORN SYRUP, HIGH FRUCTOSE CORN SYRUP, DEXTROSE, SOYBEAN AND PALM OIL (WITH TBHQ FOR FRESHNESS), SUGAR, CONTAINS TWO PERCENT OR LESS OF CRACKER MEAL, WHEAT STARCH, SALT, DRIED STRAWBERRIES, DRIED PEARS, DRIED APPLES, CORNSTARCH, LEAVENING (BAKING SODA, SODIUM ACID PYROPHOSPHATE, MONOCALCIUM PHOSPHATE), MILLED CORN, CITRIC ACID, GELATIN, CARAMEL COLOR, SOY LECITHIN, PARTIALLY HYDROGENATED SOYBEAN AND/OR COTTONSEED OIL†, MODIFIED CORN STARCH, XANTHAN GUM, MODIFIED WHEAT STARCH, COLOR ADDED, VITAMIN A PALMITATE, RED #40, NIACINAMIDE, REDUCED IRON, PYRIDOXINE HYDROCHLORIDE (VITAMIN B6), YELLOW #6, RIBOFLAVIN (VITAMIN B2), TRICALCIUM PHOSPHATE, THIAMIN HYDROCHLORIDE (VITAMIN B1), TURMERIC COLOR, FOLIC ACID, BLUE #1.

I don't know about you but the words modified corn starch and xanthan gum get my salivary glands working overtime. Note the 2nd, 3rd, 4th and 6th ingredients are some form of sugar. Our bodies are not engineered to handle mainlining simple sugars in this quantity. How many natural foods (aka real foods) contain so many different forms of glucose already broken down and speedily available? None. Even fruit has fiber and vitamins to enhance the slow release and absorption of glucose. Is it any wonder that kids, when bombarded with Spongebob characters extolling the virtues of Pop-Tarts (fiber! 7 vitamins and minerals!), are no longer satisfied with the humble whole grain?

We can't fight the food manufacturing industry as a whole. We as pediatricians have tried and have found it to be a sisyphean task and one that will take years and billions of dollars to sort out. So, here's my challenge for you. Think about what you are eating today. Really look at it. Is it a 'real' food? Or one that has been processed and shaped into something that approximates something in nature with its nutrients stripped and then replaced chemically one by one? For just one day, eat real. Taste food the way it is meant to be tasted. Forgo artificial sweeteners, microwave meals, 'fortified' white foods, and any foods that are called the same thing in any language e.g. Cheetos, Big Mac, etc. When you go to the grocery store, shop only the perimeter. Check out a local farmer's market.

If we don't start modeling a way to eat healthfully and humanely no amount of healthcare reform will save us from the catastrophic public health issue gaining steam on our watch.

Excuses Get A Bad Rap

Ok, before you yell at me for slacking off, let me tell you where i've been. Since my last post, i've

1. bought a house
2. bought a car
3. filled out a forest worth of paperwork for 1 & 2
4. been getting ready to move with all the annoying minutiae that entails
5. driven back and forth from Chicago to Madison no less than 5 times
6. been scheduling "I want to see you one last time before I leave" dinners and lunches
7. watched our good friends' two lovely dogs
8. vacuumed up 2 pounds of dog hair that our two lovely dogs and their two lovely dogs shed
9. ran a 10 mile race
10. tasted the best ice cream on the planet. No joke. It's at Southport Grocery and Cafe if you're ever in Chicago. I think about it everyday, multiple times a day. I only wish I had found it sooner. My thighs are grateful that I didn't.

My next post, if you want something to chew on before hand, is going to be wondering aloud about where I want to make my niche in my next job. Everyone needs a niche. Or so i'm told. For now i'm wondering when I can eat more of that ice cream.

Savory and Sweet

Growing up, my mom would often warn me to "be careful, you're wishing your life away" when I would wish fervently for some day in the future to be the present. I would just roll my eyes and think "yes, that's exactly what I want to do...wish this waiting part of my life away so I can get to the good stuff". As i've gotten older, I am more aware of the preciousness of time and how it seems to have sped up as the years have gone by. But, I still catch myself 'wishing my life away'. You only have to read my last post to witness the evidence of that.

For months now, I have longingly thought of the day when I wouldn't have to work nights anymore, when I could move on to the next phase of my life and next exciting career opportunity and feel like I was truly moving forward instead of casting about. And now that moment is here. And I feel sad. Could it be that when I was so focused on counting the days (nights) remaining I ignored the fact that I was developing friendships with the people who surround me and support me and make me laugh during those long nights? Did I not realize that the very smiles I look forward to seeing on a regular basis are the same smiles I will miss the second I walk out the door, the same smiles that make this job so much more than just a job?

When I step out into the sunshine tomorrow morning after my last shift I will be excited to move on, excited to begin my new career in a new place where I plan on raising a family together with my husband. But for now, I will be happy here, right now, in this place. I will savor the smiles, and be grateful I had the opportunity to be here at all.

Four

I have four night shifts left. Four. That's all. After two long years of nothing but nights...I have four left. I try not to obsessively think about those nights and how they might drag on and on and be the most painful of my nights at this job. I try to boost myself up and think "only four nights left!" with a gleefully insane grin on my face. My husband tried to rally me with an analogy about a frog and boiling water. I understood the relevance but I don't think anyone else would. That's why we're married. It doesn't always work. The rallying part I mean.

But then I have an experience like I had the other night and it slams me back into the here and now and pushes me to think of each day (and night) as a gift. I have the privilege of coming to work at night. I love being a pediatrician. I am able-bodied and (fairly) young and I have a job and am secure in the knowledge that my loved ones are safe.

A few nights ago, we were notified of the impending delivery of a term baby with a congenital heart defect who would require immediate transfer and eventual surgery. The parents were my age and they had a 2 year old little girl at home. I met with them shortly before the delivery and answered their questions. Composed yet anxious, they told me they had not found out the sex of the baby so it would be a surprise at the delivery. Hours later, we stood in the delivery room watching as the husband coached his wife and she pushed like a soldier. I found myself holding my breath as the baby slowly slid out - head, then shoulders, then belly. No, I wasn't nervous about the cardiac defect or the resuscitation or whether we would have to intubate the baby right away. At that moment I was completely caught up in what my friend calls "one of life's great surprises". The dad threw up his arms and yelled "It's a boy!" and they started crying and we started cheering. He was pink and screaming and perfect. For that short window of time, those parents forgot all about the trauma that was inevitably awaiting them. For that short window, they were a healthy family of four. It wasn't until the OB brought the baby over to us that anyone even remembered that we were there, or why.

Two hours later, after mom had recovered and I had put lines in and we had started the prostaglandin drip, they arrived at his bedside. The transport team that would spirit him away in an ambulance arrived shortly after with their 'hospital in a bed' and started preparing for what would be the first of many dangerous journeys for this little boy. I watched as the mom sat in her wheelchair beside his bed and looked at him with a sadness i've never felt. The look seemed to be saying "If only I could put you back in my womb where I could protect you and keep you safe from all of these prying hands and we could have our quiet moments together before we go to bed and first thing in the morning and I feel every movement you make and I love them all." I watched her as they loaded the baby into the isolette on wheels with all of its attachments. And I watched her as they wheeled him out of the room and into the hallway and the nurse wheeled her in the wheelchair right behind him. I couldn't tear my eyes from the beauty of the moment. Just then a nurse grabbed my attention and asked me to clarify some orders on a different baby. And then I turned and the family of four was gone.

Alex, I'll Take Tattooing and Body Piercing for $200 Please

I fully intended to blog last night. I really did. But I ended up spending 3.5 hours taking an "open book" test on the computer for my Wisconsin medical license. After that, words kept sliding around on the screen and I felt like my eyes were carp shooting. Weird analogy, I know.

I have to admit, I didn't really take this test seriously. Until I started reading the questions and paging through screen after screen of subheadings such as Application for and issuance of special plates and Credential denial, non renewal and revocation based on tax delinquency. I paged back to make sure I wasn't actually taking the bar exam. Of course the questions based on these subheadings weren't all hard. Many focused heavily on controlled substances. For example, my personal favorite question was "Nasal inhalation of cocaine before performing an appendectomy is an example of unprofessional conduct. True or False?" Now, I know they tried to trip me up by saying 'nasal inhalation' instead of the more common term 'snorting' but I think if this came up for a vote the medical licensing board would frown upon that particular scenario. Another one was "In addition to maintaining meticulous chronological records of the dispensation of controlled substances, a physician must also record the name of the substance. True or False?" Umm, difficult to call your record keeping meticulous if you don't even note the name of the drug you are recording isn't it? Unless of course you are in a situation where giant insects are flying out of a thick mist that has blanketed your town and you need to race to the pharmacy risking being snatched up and rolled into a giant cocoon just to get some narcs for your hurt companions back at the grocery store. Then record keeping goes out the window. That's the reasoning I used to outsmart these test writers and select the correct answer.

I'm proud to say that I passed the test with a 97% despite the craftiness of the medical licensing board and my inability to pin down the relevance of the questions to my particular practice of medicine. I shouldn't be so negative though....that might be construed as an example of unprofessional conduct. :)

Lying Fortune Cookies and the Women Who Love Them

For some reason, working at night makes me hungry. So hungry that I can't seem to stop snacking. It's bad. I don't get hungry like that at home. Why must I be so hungry at work? Tonight I found myself scrounging at the bottom of my lunch bag and I came up with stale fortune cookies. I won't lie. I ate them. I'm not proud.

One fortune said "You will be successful in whatever you do." Really? That's good to know. I was worried about that. Especially since i'm starting a new job this summer. Maybe I should actually start training for that triathlon i've been planning to do for the last 8 years. Sweet. But how do I make sure that this fortune cookie is not just blowing smoke...in my face? After all, what does it have to lose? I was going to eat it one way or another so why not just lie? I'm paranoid like that. Don't judge me. I decided to look into this whole idea of success. Where did I turn? To the business world. Those people do nothing but focus on being successful. Here's what they taught me.

Success is a choice we must make daily. In other words,
1. Decide to do the different every single day. Ever notice how much more you see when you take a different route to work? The different is a minefield of discovery. Leave your comfort zone, if only for a little while.

2. Just ask. You can't win if you don't play. When you don't ask for what you need, the only answer is no.

3. Learn something new everyday. Kindergarteners do it. Why can't you?

4. Be active. This one is my personal favorite. I love exercise and being healthy. I've never found it especially motivating to lounge on the couch for hours watching tv, much to the disappointment of my husband!

5. Choose carefully who you hang out with. Surround yourself with people who you admire and respect. Do a quick friend and colleague check. Do they make you a better version of yourself? If not, consider seeking out those who inspire you and minimizing interaction with those who don't. I know, it's easier said than done.

When Everyday Feels Like Wednesday

For those of you who don't know, the ACGME and RRC began enforcing resident work hour (also called duty hours) limitations in 2003. The highlights are that residents can admit new patients for no longer than 24 hours straight but can continue to work another 6 hours to finish up their work and/or participate in educational activities for a total of no more than 30 consecutive hours worked. The weekly work hour limit is averaged at 80 hrs/wk over a 4 week period with one day off in 7. I got used to the look of horror when I told non-medical people that the new work hours were great, we only had to work 80 hours a week now.

I happened to begin residency in 2003 and was therefore part of the "80 hour workweek" class. Defending ourselves against the onslaught of disdain from our senior residents and attendings became the norm our intern year. We were seen as privileged, lazy, and not concerned about patient care and learning. We, however, didn't know any differently. We were forced to compress our considerable intern workloads into 80 hours a week without the support of faculty members and try to learn how to be a compassionate physician at the same time. Oh, and learn enough pediatric medicine to not look like a buffoon on the wards. Although I championed the benefits of the duty hour regulations, over the course of my 3 year residency I realized its shortcomings as well. It provided an easy cover for those residents who wouldn't have valued educational initiative anyway and evened the playing field between those residents who would not walk away from 'loose ends' and those who had no qualms about doing so on a regular basis. Now we all had to be comfortable signing out work until we could come back in the next morning.

Now as an attending, I see a permutation of the duty hour regulations affecting the residents I currently supervise. They seem to have lost the pride in patient ownership that I remember feeling as an intern. Residents now have been forced to evolve into number crunching, note writing, order entering and work hour tracking doctors in training who actually spend the shortest allotment of their time at the bedside. I am constantly amazed at how much medicine is now practiced in front of a computer screen.

The reason I bring this up is not to play the "when I was a resident" game and disparage those trainees coming up through the ranks. It isn't their fault the duty hour regulations exist, just like it wasn't ours in 2003. But I heard something disturbing the other day. On a listserv to which I subscribe, a post was written about new regulations that will further cut down on the number of hours residents work. In that model, more of the daily work will fall on the attendings so the residents will still have time to attend educational activities as well. I fear that if this keeps happening, a pediatric residency will need to be extended to 4 years from 3. And from what i've been reading, this fear is warranted. However, I fear more the pediatrician who graduates from residency and is adept at studying and attending lectures but has no idea what to do with a difficult family or an acutely ill patient!

This issue will be revisited again and again in this blog in the upcoming year, especially as I transition to an academic pediatric hospitalist position and work with residents and medical students full time. And yes, I did just say that I will be writing this blog for another year. Thanks for your support!

Even Uncle Sam Wonders When You're Getting Married

I've been married for a year and a half. I told a friend this weekend that I feel more passionate about my husband now than I did 2 years ago. And I plan to feel even stronger 2 years from now. Yes, I plan that sort of thing. You know the saying "Failing to plan is planning to fail"? I might as well have that tattoed on my arm. Where did I learn how to be married? I don't remember ever hearing about marriage in school. My pediatrician certainly never brought up the topic of marriage during my yearly well child checks, even as an adolescent. So where do children learn how to be successful married people as adults? The popular vote would be that we simply learn by watching our parents. But what if our parents are divorced? Are we simply doomed then to be unsuccessful at marriage ourselves? It seems to me, as a pediatrician concerned about the future wellbeing of the children for whom I care, that I should be imparting some sort of guidance on thriving in a happy marriage. But does it even matter? As it turns out, it does.

Research has found that children raised by parents in healthy marriages have certain benefits not seen in those from unhealthy marriages. Those benefits include the following:

More likely to attend college
More likely to succeed academically
Physically healthier
Emotionally healthier
Less likely to attempt or commit suicide
Demonstrate less behavioral problems in school
Less likely to be a victim of physical or sexual abuse
Less likely to abuse drugs or alcohol
Less likely to commit delinquent behaviors
Have a better relationship with their mothers and fathers
Decreases their chances of divorcing when they get married
Less likely to become pregnant as a teenager, or impregnate someone.
Less likely to be sexually active as teenagers
Less likely to contract STD's
Less likely to be raised in poverty

A healthy marriage benefits society as a whole too. Consider this. The Deficit Reduction Act of 2005 provides funding of $150 million per year for healthy marriage promotion. Healthy marriage promotion awards must be used for eight specified activities, including marriage education, marriage skills training, public advertising campaigns, high school education on the value of marriage and marriage mentoring programs. I've seen this campaign in action in the form of posters on the bus that read "He's not always Prince Charming, but he'll always be your prince" under a picture of a man yawning in a woman's ear while spooning in bed. Sweet. I've often wondered about the point of that poster. Now I know.

For more information, check out the Healthy Marriage Initiative on the Administration for Children and Families section of the Health and Human Services website.

From Farm to School

Remember the days when you could (and did!) eat anything you wanted and not give a hoot about nutrition, your carbon footprint, your pant size? I remember those days well. I'll confess...I was never one for healthful eating. Thankfully I was always active in sports so my weight was never a problem. But I think about the way I ate as a child and teenager and I cringe.

Once or twice a month my school had "hot lunch" days. We didn't have a cafeteria so we all brought our lunch routinely except on those days. Those days you could bring your money in a sealed envelope with your name on it and get a nutritious choice of Burger King or Pizza Hut. Wow. I guess they thought since we brown bagged our lunch most of the time we could afford a little artery clogging fat lest we forget the joys of empty calories and processed, overpriced, low quality food. In high school, my friends and I routinely ate fries, chicken nuggets, and this mysterious deep fried bean and meat burrito thing. From the school cafeteria. Am I the only one disturbed by the idea that our schools are promoting eating this way??

Millions of children everyday eat lunch and sometimes breakfast at school. The government invests only $2.68 per day for each school lunch. Some of us remember the "four food groups" model of nutrition: meat, milk, fruits and vegetables and breads and cereals. Meat had it's own quarter of the pie!! Thank goodness we've graduated from that 1958 embarrassment to the "food pyramid" of today. But we're still a long ways off from impacting the eating habits of children in this country. Although I cringe at the crimes i've waged against my body with my poor noshing past, I am committed to lead my children to another way of living and eating. That is why I am very much behind the goal of Chef Ann Cooper and The Lunch Box initiative to lobby Congress to invest one more dollar in every child. Without a change in the obesity epidemic affecting our children, they will have a shorter life span than you and I. Shameful.

My Olfactophobia

So, I survived the whole winter without getting sick. I evaded seasonal flu, H1N1, RSV and even a bocavirus or two. I religously wash and sanitize my hands, at work and at home. In fact, I drive my husband crazy nagging him to wash his hands right when he gets home from work because A) he takes the bus B) he works with Pseudomonas (that's not a person, but a nasty bacteria) and C) I have a strong aversion to smells on hands, even those that aren't my own.

Despite all of that....I came down with a raging cold that bloomed into a sinus infection just in time for my annual "March Madness" vacation. On antibiotics and breathing freely, I am back at work 2 weeks later. And back to blogging. Now just in time for the historic health care reform passage. Atul Gawande, of whom i've spoken before, writes a thought-provoking editorial for The New Yorker calling on physicians and communities to take responsibility for the success of the reform and the repair of our damaged health care system. The battle has just begun.

The Top Five

My husband and I, when we were first dating, used to play the "top five" game. You know, when you ask each other for your top five books, movies, teams, songs, bands, etc. It was a great way to get to know each other and the game served to ease us through the awkward "chatting with you over dinner before this bottle of wine kicks in" phase. (so glad that's over!) In fact, we just played this game and listed our respective top five Stephen King novels (over a bottle of wine coincidentally). I happen to be a huge fan of the author and my husband, well, was more of a fan in junior high than now. But we can't all be highbrow with our literary leanings.

There was recently a fascinating editorial published in the New England Journal of Medicine regarding "top five" lists. The premise is this:
The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.

Working in a neonatal intensive care unit, where we routinely keep babies alive artificially and often for great lengths of time, I witness firsthand the miracles of medical technology. And the failures. And the ethical dilemmas. And the extraordinary costs of doing things because we can. I also witness my friends in general pediatrics working long hours and fighting everyday to spend enough time with their patients and families under the constraints of billing and 'moving them through'. It's no secret that the 'doing' specialties are reimbursed far more than the 'talking' specialties. Technology pays. An interesting spin on the healthcare reform debate...

Thank God for Unanswered Prayers. Because I Said So.

Let's be honest here. There was once a time when I naively believed that as professionals we would look out for each other and treat each other with respect and kindness. That was until I was offered my first real employment contract. This was about two years ago, after I had decided to leave my fellowship and was floundering about trying to figure out what the heck I was supposed to do with my life. In the process, I had interviewed with a private practice in an affluent community, a community health center in an underserved community, a private practice in a middle class community, a pseudo-academic peds hospitalist group, a community peds hospitalist group, a neonatal hospitalist group and an ethics fellowship. Oh, and I tried to submit an application at Borders but my husband wouldn't let me. I was clearly a bit directionless. That being the case, when I was offered a position with a private practice, I jumped at the chance to settle into a life polar opposite to what I was living as a fellow. After getting the contract (a 20 page monstrosity) I decided to have it looked over by a lawyer simply as a formality. That flip decision ranks as one of the most important in my life to date. Who knew? This blog, my friends, is dedicated to the road not taken and I hope that a little tidbit from here makes a difference to at least one little starfish...

Lessons I Learned About Contract Negotiation, Part 1:
1. Don't treat yourself to a celebratory dinner and bottle of wine until the ink is long dried on the contract that you successfully negotiated to your liking.
2. Spend whatever you have to on a lawyer experienced in physician contracts to look over yours. Just do it. Please.
3. Don't be so enamored with your base salary that you ignore how your raises and bonuses will be determined. "Physician's base salary will be reviewed and adjusted if necessary" does not cut it. If it's not in the contract, it doesn't exist.
4. Tail insurance coverage = big deal. Typically, the tail is about twice the cost of the annual premium. So, if the 1st year premium for you is $6000, the tail is $12000 for that first year. In many practices, until you become partner/shareholder (more on this later) you are responsible for the cost of your tail (or a portion) if you leave for any reason. This is why some say that joining a private practice is like getting married. You better be damn sure that's what you want or else it will come back to bite you in the tail (I couldn't resist). This could potentially be thousands of dollars you will owe the practice when you leave. Ouch!
5. Restrictive covenants are standard nowadays. They are otherwise known as 'non-compete clauses'. Make sure that they don't prohibit you from practicing anywhere else in a reasonable drive from where you live. E.g. a radius of 7.5 miles in Chicago is pretty rough. In Phoenix? Not so bad. Get out a map and use it.
6. Termination. It could happen to you. The following sentence is a red flag "Employer may terminate this agreement immediately if...Physician engages in conduct that, in the sole discretion of Employer, is detrimental to patient care or to the reputation or operations of Employer." Wow. That basically says that they can make up a reason not to like you and fire you immediately. Here's another one, "... the other party shall have no rights to cure or contest the termination of this Agreement." I can't even contest it?? This clause smacks of the "Because I said so" mantra of my mother when I was young.
7. Here's another one of my favorites. "Physician agrees...not to make any disparaging remarks to any third party concerning Employer or any of its officers or directors...throughout the term and at all times thereafter." Really? You mean I can't say anything nasty about the unreasonable and freakishly controlling contract you offered me? I can if I didn't sign it. ;)
8. Clarify your vacation time/CME time/sick leave. Especially if you see a rule like this one. "Excused time for illness extending more than two days requires a consultation with your primary care physician." Ignoring the obvious fact that you are a primary care physician, when was the last time you needed a note from your doctor to prove you were ill? Wait, am I actually reading that application for Borders? Sadly, no.

That wraps up Part 1 of contract negotiation, otherwise known as "Learning from my Almost-Mistakes". The statements quoted above may or may not have a basis in fact. They may or may not have come from a contract I was once offered and still have if only to remind me of how close I came to misery. That lawyer charged me $800 to review my employment contract. Pricey? Sure. Priceless? Absolutely.

Crazy, But That's How It Goes

Whoa! Where the heck have I been?! Don't ask me, I don't know. Well, I do know. I was in Las Vegas. Vegas baby! Pretend I didn't just write that.

It was so nice to take a sunny break from the (not so bad this year) Chicago winter. Vegas had me dehydrated from drinking, sore from walking, poor from shopping, pissed off at slot machines and completely ready to come home after 4 days. Fabulous. Oh and note to self...spending said Vegas vacation with dad and his significant other makes time with my husband scarce and precious. Along with my sanity.

So I get back from vacation all tanned from the sun and glowing (still) about my new job and the following exchange occurs:
Neonatologist: So Angela, I hear you're leaving us.
Me: Yep, I sure am. I'm moving to Madison!
Neonatologist: Wow, you look so happy about it. I'm sorry Bill (boss) had to run you out like that. But you know, we are so tired of taking call and he hired a neonatologist to take your place so that means fewer call nights for us. I'm sure you understand.
Me: Uhhhhh, what? No, I wanted to leave. I wanted to find another job. Did you just step off the crazy train lady?! This was me! All me!! Are you freaking kidding me?!

Yep, true story. Mostly. Except the part where I freaked out. That took place in my head. With that i'll leave you with a website I file under "Things I Adore". Dang it's precious.

Like A Wink and A Smile

Something pretty awesome happened today. I typed in the website pedjobs.com, as I do at least weekly in my ongoing job search, and I realized...I don't have to anymore. Because I have found a job!! And not just any job, but the job description I would've written for myself had I been asked 6 months ago to write a description of my ideal job. Yep, it's that good. Maybe even a career maker. Am I being a little effusive? A bit too optimistic and naive? Maybe...but you know what? I'm going with it. Not often in life do you get to thank fate and your lucky stars and your own perseverance for giving you exactly what you wanted. So for the time being i'm walking around on clouds and reveling in my little corner o' the world. It's pretty darn sweet here.

Social Networking = Free Money

Seriously people. The social networking craze has gotten out of control. There is now a facebook fan page for everything. Even my favorite egg and cheese bagel sandwich has a fan page. And Clark Griswold. Pretty soon ostriches will have their own fan pages and twitter feeds and maybe sell some stuff on etsy.com. Or maybe not.

But (there's always a but) here's one social networking site that will earn you some cold hard cash. Or at least some plastic. The caveat is that you have to be a member of the AAP. So mom, while I appreciate you faithfully following my blog, the rest of this post will not apply to you. Go put your feet up.

Here's the deal:
Log onto the YP Connection website and create a profile (just like facebook)
For the next 7 weeks, you will be awarded points for logging in, joining a group, leaving a comment on a blog post, etc.
The first week the person who gains the most points by being active on the site will get at $50 American Express gift card. The awards will increase each week and the final week the grand prize will be a $400 Am Ex gift card.

Can it get any better than that?! Well, yes it can. The ultimate reward is that you will have become an active member of the Young Physician community and networked your way across the country. Maybe you'll find a new job, a new book or a new 'special someone'. But you'll never know if you don't check it out. Check it out.

Who I Am Not

I've got something to vent about and I'm going to use this blog of mine to do it. Are you with me? Here we go...

In the midst of this job search that has become the white noise of my life for the past 6 months I have realized something. And no, it's not the futility of fitting all of my toiletries into 3oz bottles and putting them in 1 ziploc bag. Although that's true. I've learned that physicians can be as a group some of the rudest most unprofessional people. Sad but true. And since I'm a pediatrician and dealing with other pediatricians, you know I am referring to the nicest of all specialties, pediatricians. I know, I am surprised too.

I write this as I sit here in a not unfamiliar position of waiting to hear from a physician who I was supposed to speak with an hour ago to discuss a job. This is the second (maybe third?) time I have been in this position. Is it so hard to remember an appointment to speak with a professional colleague? If you are running late, I understand. But I have been waiting for an hour. Not cool my friend, not cool at all. And to everyone who decides that an email is not worth answering for a couple of weeks, even if it comes from a very nice and talented physician and contains a letter of interest and a CV? This blog post's for you. What about those who say "I'll get back to you at the end of (blank) month" and then the end of the month comes and I have to send a 'friendly email reminder' (or two) that I am still here and still waiting and still interested in your opinion of me and what I have to offer despite now feeling like I am the gum on the bottom of your shoe. Shame on you.

I can't change the behavior of my colleagues. But i'll be damned if I will forget what this feels like. And when the situation is reversed, as it will be someday, I will acknowledge the efforts of young pediatricians trying to advance in the scary and often intimidating world of medicine. I will remember that we as physicians are not above simple manners and kindness and be humbled. Until then, I believe in karma and gut feelings and the healing power of red wine and chocolate chip cookies. And i'm a better person for it.

In Over My Head

I had to do something today for which I felt totally unqualified. It had nothing to do with my patients or procedures but everything to do with my lack of years in this field of neonatology. I've explained before that I am a general pediatrician (and proud of it) who wears a neonatology hat for a living. At this point in my career, I feel pretty darn comfortable with it too. Gone are the surges of adrenaline everytime the phone rings and we are called to a delivery. Gone is the should I call for help or should I tough it out on my own internal struggle. I no longer feel like a minor leaguer playing in the majors. Until today.

Today I was asked to speak to a woman pregnant with twins at 23 weeks gestation about what to expect if she were to deliver in the next 24 hours. I don't need to give you the statistics, but the chances of these babies surviving is small and the chances of them surviving without any disability is slim to none. The gestational age is so early, in fact, that we give the parents the choice of whether or not we attempt to resuscitate the babies at delivery. Parents are completely within their right to allow the infants to pass peacefully, without the long and painful torture of hospitalization and a certainly uncertain outcome. So, I was asked to speak to this couple about their long sought after twins and help them to come to a decision. They would listen to what I had to say and then make the hardest decision of their lives.

There I stood, armed with my statistics in hand and a description of what constitutes a major disability vs a minor disability. I had all the information I needed yet knew absolutely nothing. I watched them listen to my words with tears in their eyes and struggled to keep my own opinion and my own bias out of the inflection of my voice. I wanted so badly to say, "I don't know what you are going through or how you feel but here is what I do know, because I see these babies day after day and month after month and I see their parents at their bedside for every setback and procedure and infection and I see the weariness in their faces and the strain on their marriages and I see their children with tubes and lines and tracheostomies and open abdominal wounds and blindness and blown veins and I see how overwhelmed they are at the prospect of taking their developmentally disabled and medically complex child home with a list of specialist appointments to be made and I see. I see. And I know you can't possibly know what to expect based on these statistics that i've given you. I know and i'm so sorry."

The truth is that I read them the book when what they really needed was to hear the story. The truth is that I don't want them to make their decision based on what I tell them. The truth is that I felt that my hands were tied and I don't have the experience or courage to tell them what I really want them to know. I just pray they make a decision that brings them peace over the coming dark months. Regardless of the outcome.

What I Believe Today

This is what I am loving today. Take it and use it however you see fit.

"Do not let your fire go out, spark by irreplaceable spark, in the hopeless swamps of the approximate, the not-quite, the not-yet, the not-at-all. Do not let the hero in your soul perish in lonely frustration for the life you deserved, but have never been able to reach. Check your road and the nature of your battle. The world you desired can be won. It exists, it is real, it is possible, it is yours."

ayn rand

Be. Look. Love.

Happy New Year! My first post of the new year and I have to tell you I am already so excited about what 2010 will bring. For starters, there seems to be love in the air. Do you notice that when things are happening to the people around you you are forced to hold a mirror up to your own life, whether you like it or not? It's been happening to me. My best friend recently met a man about whom she is completely crazy. I've never heard her gush about anyone like she gushed about this guy. I've told her so many times that she deserves the best and I'm not sure she ever really believed me. I hope someday soon I can tell her "I told you so." My college roommate, like a sister to me, recently visited me here in Chicago and brought her new boyfriend along. Second verse, same as the first. They seem so happy together and in love. I left them feeling at peace that she had found someone who finally would see her as the special person she is. And then some. I had dinner last night with a good friend who, after three years of dating, is still amazed at what a fabulous person her boyfriend is and feels blessed to have him in her life. Precious!

A few years ago, I would have held up a mirror to my life and felt....lacking. I had done it over and over again as a naturally competitive person and as my toughest critic and own worst enemy. And now? Now I look at the love of my life and feel an overwhelming sense of gratitude that we found each other. I no longer wish to be anywhere or anyone but here and who I am. So as we feel our way into this new year, I am comforted knowing that my life and the lives of my dearest friends are pretty dang rosy. I can't ask for much more than that.