Running Commentary—my life until now….

6-16-15
I have decided to use this page as a blog of sorts—a place to talk about things that are of interest to me; maybe a little about my family, my life, my work and my thoughts.  I have also decided that for now, I will not be opening this page up to comments, because I do not have the time that it would take for addressing those comments here. With a fairly new  business, several email accounts, a patient portal, and a Yelp account, I have so many venues to address comments from people who want my opinion or my response, that I have decided that THIS is not the place for that……sorry!   (However, if you feel you just must say something, or comment on what is written here, feel free to email me at the practice email address, Premierobgynnapa@gmail.com—-)

First a little bit more about my life, my background, and ultimately what led me to be here, in Napa, opening my own private medical practice—-

I grew up in Brooklyn, NY, and spent my early years trying to “escape”–(little did I know that Brooklyn would later be SO gentrified and SO hip–that it is now “THE” place to be!!) My parents were older, distant people, who (like many of their era) felt that if they put a roof over my head and fed me, that was considered adequate, if not excellent parenting. My father always wanted me to be a doctor.  I, however was completely against that idea. Consequently, I was not offered an opportunity to go away to school to study, or “broaden my horizons”…. since  in their opinion, only medicine, law, or possibly engineering were “worthy” of that type of expense. I just remember that I loved sports, loved taking care of people (always baby-sat, and worked in day camps as a teenager) and very badly wanted to leave home…….so I thought, what better way to combine all that?? I applied to a graduate school program in Physical Therapy that was far from home! And so it began……….

6-19-15

I applied to Physical Therapy schools all over the country, convincing my parents that Physical Therapy was “just like Medicine”–in reality I thought I could get to do all of the fun things in the world of health care, ie, design exercise programs, work on athletes, and help people heal after injuries……without all the responsibilities of being the medical person making all the decisions, and being the one “ultimately in charge”. They agreed, although they were not happy with the prospect of my leaving home. I got accepted “Early decision” from Boston University and was invited up to have the Campus Tour. I was hooked. Boston was SO far from Brooklyn in SO many ways… Potential Physical Therapists are the nicest people, and those of us that had gotten “early” acceptances seemed like a congenial bunch. I had planned a summer trip abroad, and was to come back about two weeks before PT school was to start. I secured a sublet before heading out of Boston and was all set.
Then I went on my trip abroad—a summer session at Universita Per Gli Stranieri (University for Foreigners) in Perugia, Italy (home of the chocolates and the Amanda Knox debacle) and then a few weeks in Greece before buckling down to two straight years of graduate school studies. The trip was amazing. I lived with an Italian family for 6 weeks, and spent three weeks in Greece, on a half-organized-half independent tour. I happened to meet a wonderful Greek tourguide (who may have met a different female tourist on each tour—who knows?) and was smitten. I ended up staying way past my planned time, (he was a tourguide and was able to change my return ticket) returning to the U.S. just ONE DAY before grad school started and horrifying my whole family in the process. (I guess, at some point it MAY have seemed like I was not coming home at all—sorry family–) But come home I did, reluctantly, and exhausted, to start a grueling course of study.

6-20-15

It was IN Physical Therapy school that I started to realize—-Hey, these classes are hard!  Neurology, Physiology, Anatomy, with dissection, Neuromuscular rehabilitation, and so many other science classes, that were beautifully intertwined with hands-on Physical Therapy classes, and courses on empathy, psychology, and patient relationships, made for a difficult 2 years of study.  I also worked (waitressing, my “go to” for pocket money) and had a pretty active social life. I met and became roommates with a friend who would become a lifelong pal and confidante (quite by accident). I loved everything about what I was learning, BUT, I had a nagging idea, that I actually might have initially wanted to go to medical school, but I was so busy talking myself out of it, and NOT wanting to go precisely because my father DID want me to, that I may have made a mistake.  Even though I was loving the people and the environment at B.U.’s Sargent College of Health Science, I secretly started seeking out information from medical schools, to see if I would even meet the criteria for applying to one.  The information I received was discouraging.  I had been a Health Education major in college, and hadn’t taken “Hard Core” science classes like Organic Chemistry, Physics, and basic Biology, although I had studied Basic Chemistry, Calculus. Anatomy and other things that were considered necessary prerequisites for medical school.  And then there was the MCAT—the medical school admissions test—how would I ever get through THAT?   I was discouraged, but decided to see if there was any way that I could take these classes WHILE I was in the graduate PT program.  (without telling anyone, just in case this whole plan fell through) I decided to take it “one thing at a time”, figuring it out along the way, and—well, if I never was able to apply or get accepted to medical school, I had a darn good profession waiting for me when I graduated with a Master’s Degree in Physical Therapy!

6-23-15

I sent away for several Medical School catalogues (no websites, no internet in those days—yes, my children, I am ancient)  and started to intertwine Pre-Med classes with my graduate school schedule.  I took Physics a few evenings a week while in my second semester, and actually did well enough to get a B in the class.  (One thing at a time, I told myself), and started investigating how I would be able to take Organic Chemistry with the least amount of pain possible—it was a year long course, and I was running out of time.  I found that Boston College, a neighboring, smaller school actually offered both Organic Chem classes over the summer session—that would mean taking ALL of Organic Chem (or, “O. Chem” as it was known) in eight weeks—all day, Monday thru Friday, to complete the didactic and lab portions.  At that point I made a decisive deal with myself:  IF I could take, AND PASS Organic Chemistry, with  high enough grades to consider using those grades to apply to medical school, THEN I would keep plugging on, with the ultimate goal of attending.  I buckled down, and got myself into a regimented pattern:  Chemistry class in the morning, lunch, Chem lab in the afternoon, go to the gym, go home, study, go to sleep. Wake up—and repeat….5 days a week for 8 weeks in a row.   Much of it was like speaking a foreign language–but I knew Chemistry was not my ultimate goal–I knew that I might have to USE the concepts in Chemistry in the future, like in understanding Pharmacology or Toxicology.  But my goal was to make it through those 8 weeks preserving my interest in all things medical.   Shockingly I got an A- and a B in the two classes, and returned to Physical Therapy school in the fall convinced that I might make this happen after all……but I still didn’t tell anyone what I was thinking.  (Probably I didn’t want anyone that I was in Physical Therapy school with, to think that I somehow believed that PT wasn’t “enough”, or that it was not a great profession (which it totally IS), and I didn’t want anyone from outside of school–other friends, or my family, to think that I “didn’t know what I wanted”, or, that I might fail if somehow these plans did not work out as I hoped.)

6/26/2015

….and then the inevitable happened.  One of the catalogues that I had sent away for, as I was “shopping” for possible places to apply to medical school got sent, quite by accident, to my family home in Brooklyn.  My father saw it in the mail, and immediately called me.  “Are you considering going to MEDICAL SCHOOL?”  he excitedly asked me.  I was totally caught off guard.  “I don’t know—maybe—no, not really—-WHY do you ask?”  And he told me that a med school catalogue had arrived in the mail, addressed to me, so he surmised I had sent for it.  I thought he would be upset at my indecision about what I was currently doing, and at the possibility I had wasted both time and money doing one thing if I thought I really wanted to do something else……but it was exactly opposite—he said IF I had really decided that I wanted to go, that he didn’t want the money to be the thing that kept me from going….that he believed in me, and that I’d make a great doctor, and that if he had to he would mortgage the house to help me out……   Wow …….just    wow.  I heard the excitement in his voice (and this—just from the arrival of a catalogue!!)  and I assured him that I was thinking about it and was grateful to even be in a position to consider it but I had a lot more thinking to do.  My mother, however, was not so convinced that this was a good idea (especially that “mortgage the house ” thing. )  But my father  (who was ill by this time, with kidney disease,) convinced her that this was what he wanted for me, and if I wanted it for myself, it should be done.

6/27/15

I went through my whole second year of Physical Therapy school absorbing what I could, doing a mix of classwork and “Clinicals”, those 10-12 week time periods where I would go to an actual Physical Therapy site and work—as a student, supervised, (for no pay–as a matter of fact I was paying–tuition–to attend)  and when I was done and about to graduate in June, I knew I was going to move back to New York—-Manhattan this time, to work as a Physical Therapist and to continue on my path toward applying to medical school.  I had met the person who would eventually become my (first) husband, and HE was in NY (although he lived in Queens, a lifetime away from where I was planning to be) and I knew I could continue to take the few remaining pre-med classes I needed at Columbia University in the evenings, at what was known as a “Post Bac- Pre- Med” program, for people like me, who wanted to go to medical school, but had studied something else in College or Grad school, and needed those all-important prerequisites to apply.  I moved into a one-bedroom apartment on the upper west side of Manhattan, where the one bedroom belonged to the person who was already living there, and I would live in the living room…..no privacy, a kitchen like a closet, lots of strange smells……but I WAS LIVING IN MANHATTAN !!!!—- so the rest really didn’t matter.  I worked full time all day at a private PT office, and several nights a week took the subway up to Columbia to study basic Biology with lab, and then Statistics, the only things that were still standing between me and my medical school applications.  I also signed up to take a class to prepare for my MCAT exam.  I was never great at taking exams, and now, my med school prerequisites had been spread out over years, with interruptions, so I had no idea what my retention would be like.  I strangely remember, that that was a good year.

6/30/15

I moved to Manhattan, prepared for my MCAT, and loved my job as a Physical Therapist in a small private practice.  I was dating my new boyfriend,  and felt obligated to tell him that I was VERY goal directed when it came to my career plans–I was planning to prepare, apply, then attend medical school– it was a long term plan that was likely to take at least the next few years to complete. As for what KIND of doctor I wanted to be– what specialty I wanted to pursue—I felt very sure that I would study the specialty of  Rehab Medicine, also known as Physiatry, or Physical Medicine.  That seemed the closest to Physical Therapy, where I could be evaluating patients after injury or stroke; designing exercise and rehabilitation programs, and using much  information I already had learned in grad school to further my career.  I took my MCAT and did well enough to not have to repeat it.  I applied to more than 10 medical schools, all over the country, ready to move wherever a school would accept me.  The entire process took about 2 years.  Unfortunately, during that time, my father’s medical condition worsened. He ended up on dialysis, and was basically house bound.  I decided I needed to stay as close to New York as possible to attend school.

7/2/15

I was granted interviews at several schools; only two were in NY–one in Westchester, north of NYC, and one on Long Island, in Old Westbury. Before actually going to any interviews, the school on Long Island sent me an acceptance letter–with a deadline.  It was NYCOM, the New York College of Osteopathic Medicine, and once I read the description of the curriculum, I knew that it was “THE” school for me.  The philosophy of Osteopathic Medicine is to look at the “whole person”, realizing that the physical, the emotional, the traditional AND non-traditional ways of looking at health and disease, all factor in to effective patient care. They believe that preventative medicine is critical, and that “laying of hands” on a patient in diagnosis and treatment is an all-important aspect of medical care.  Since I was already working in a field that involved “hands-on”, and required an intimate knowledge of the relationships between health and exercise, form and function, prevention and performance, and believing that medicine involved not only science but art—  I felt Osteopathic medicine was the exact mix for me.  (If you are unsure about what Osteopathic medicine is please see the “D.O.” Tab on this website.)

At the same time that all this was going on for me professionally, many things, happy and sad, were happening in my personal life.  My father became sicker, now on dialysis three days a week.  I began to wonder if he would ever see me realize HIS dream. He also realized that this might be the case, and he let me know in so many ways and in so many words how important this was to him, and how much he was dedicated to helping me achieve it.  When I showed him my acceptance letter he was just about ready to put it in a frame and hang it up.  (To keep myself humble, I kept all of my rejection letters, which started showing up, promptly after accepting my place at NYCOM)  I was also getting close to a decision time in my relationship…..my plans were set for school—was he in or was he out?  It is not my intention here to write about anything or anyone that I haven’t been given true permission to discuss, but suffice it to say that I made it known that I WAS going to medical school—I WAS going to be a doctor, and I WAS likely going to need to do a 3 to 4 year residency—I DID have a long road ahead of me, albeit with probably a bright future— and I WAS NOT going to sacrifice any of those things for a relationship.   That ALL being said–he was IN, and we  started to plan the wedding.

7/4/15

I have always been a very driven, organized, list-making kind of person—for good and for bad.  I had always felt that if I didn’t keep track of things, always crossing off the things on the  “To-Do” list, then the big fear was that nothing would ever get done.  Of course as I have gotten older, and realized that fewer and fewer things are in our direct control (therefore making all those lists, with the inevitable disappointment when not all things came true) was pointless, or at the very least, not 100% necessary.  But in the OLD days, when I was young, I hadn’t yet realized that–so plan away I did.  I knew I was going to be starting Med School at the end of August—so I had to “back track” from there, as far as moving in or out of apartments, getting things ready, and, looming largest of all, planning a wedding which was to take place in a hotel in Manhattan—MY choice of venue, but one that didn’t seem to make everyone else quite as happy.  My intended was from another country–so one of the things he wanted very much was for me to visit his country of origin– and as I had a real love of travel, and had never been there, decided to make that destination a part of our honeymoon.   And since we were getting married in July, he was starting a new job when I started school,and, looking toward the future, could not foresee a time where we would ever possibly have a block of time to travel again,(given my future plans)—we decided to get married in July, take a SIX week honeymoon, which included a visit to his family — and THEN come back and “start reality”.  Looking back now, I realize that the travel plans were strictly MY choice—I had been used to traveling on the cheap–had back packed through Europe several times, staying in hostels and cheap hotels, usually with no elevator, and making full use of the term “backpacking” as I often carried my entire load of travel gear ON my back.  Knowing that this would be a long trip, I assumed we should do the same–since we weren’t rich, and it was more important to ME to see more and spend less. I was kind of a “roll-with-the-punches” type of traveler—no air conditioning?  no problem–shower down the hall?  no big deal… Without going into details, suffice it to say, that the first (and ONLY) two days, which we spent, on a splurge (since it WAS our honeymoon) in a high- level hotel in Zurich, were obviously his favorite part of the trip.  He was not a “roll-with-the-punches” traveler…but not everyone has to be.   The rest, including the visit to Israel to visit his family, was fine– we were getting to know each other, and although long-term travel is probably not the best way to get to know someone, we returned happy to move into our small apartment, and start our life together.  I was excited but kind of scared to go back to school full time; I was worried about money but grateful that my parents were going to help us– and I had a good feeling about my decision and everything that had led me to the doors of NYCOM on that first day of orientation.

7/10/15

I’m not sure if anyone can ever be completely prepared for their first day of medical school.  My first impression was that there seemed to be students from all walks of life in my class—some looked young enough to be my children–or at least my younger siblings.  Some looked shell-shocked.  Some looked studious, and some, like me, were the “return to school” crowd;  people who had changed course, or changed their minds, who had studied one subject but really wanted to study another.  We “older” students tended to gravitate toward each other, satisfied in the thought that there were articles out there that said having “life experience” before medical school may somehow make us “better” doctors; more empathetic, more “relatable”, and possibly more determined to find the proper treatments for our patients.  My first class in BioChemistry was a serious reminder that my BASIC chemistry classes were long ago,  my organic chemistry classes were a summer’s worth of cramming.  and my recall for either was questionable at best.  But soon I got into the “flow” of the year—Histology, Anatomy, Physiology, Pathology, and Microbiology; so much information, and so much to absorb.  Medical school in those days consisted first of 2 years of didactic study—classroom lectures, without any practical way to apply that information yet to real patient care.  Actually touching patients usually came in the second two years—we were expected to cram all that knowledge into our heads, and then sort it out and use it when necessary.  The unique thing about Osteopathic medical school was that in OUR first two years, we also had regular sessions of something called OMM—“Osteopathic Manual Medicine” – clinical labs where we DID touch each other–learning to evaluate muscles, bones, ligaments, injuries, spines, necks, even headaches, asthma and abdominal pains, but actually laying hands on and seeing how that sense of touch helped in our diagnosis and treatment.  That was my favorite.  I met and became friendly with another “older” student, who had returned to school after getting her Master’s Degree in Cellular Biology– we studied together, learned how to evaluate each other’s spines, and drew blood from each other’s veins—that makes a particular type of friendship—one that has sustained throughout the years.

On the personal front, I was actually still a newlywed.  We were living in a small apartment not far from my school, and my husband had a new, stimulating  job.  Unfortunately but not unexpectedly, I spent a lot of time at school, and studying.  I also was still working, part time as a Physical Therapist  in evenings and on weekends.  My father unfortunately got sicker, and in February of my first year of medical school, he passed away.  I always kind of thought he had the strength to hold on until he could see me get married, and see me go to Medical School, and he passed away satisfied that he had seen both.

7/13/15

Along with my immersion into science and medicine, my major area of concentration during my first year of medical school was time—-specifically the idea of a “biological clock” that seemed to be ticking, ever-loudly in my head.  I was already almost 27 years old– and although now entrenched in the world of medicine, I knew that I badly wanted to have children at some point—probably a few of them if possible, and was well aware that medical school was likely going to put a crimp in those plans.  There is a very well-known “stress scale”  where it can be determined how high the level of stress in one’s life is—a certain number of points for every major life change, and then added together for a “stress total”.  Major life changes like marriage, divorce, a new job, moving to a new location, and a death in the family are all considered major stressors, racking up huge points.  We were already pretty high on the “stress scale” from all of our major life changes- and NOW I was thinking about adding another  MAJOR one?   My new husband was not thrilled with the idea of having a baby so soon, but I thought I was being practical– The first and second years of medical school were divided into  2 semesters each, and if I had missed any significant amount of time during any of those semesters, it would have put me an entire year behind my class, as all of those classes were only offered  one time during the year.  However, IF I could “arrange” to have a baby RIGHT after the second year ended, I could take off any period of time that I decided, and not be too far behind, since the third and fourth year were on a “rolling” basis– taken up by clinical rotations of various lengths, so I could rotate in and rotate out, only having to make up the missed work at the end.  Perfect (I thought)  !!   All we would have to do would be to TIME it right.  That was not particularly convincing to my husband, but I was on a schedule.

As we considered this (and I planned it), since we clearly did NOT have enough stress, we also decided to look for a house to buy. It had turned out that besides leaving me some money to relieve my medical school burden, my father had also left me a small amount of money to put a downpayment on a house.  (No WONDER my parents never really traveled or spent money extravagantly—they were saving it in the basement somewhere in case I ever really decided to follow THEIR dreams!)  While I was overwhelmingly grateful, I never really felt that they believed they were sacrificing at the time–my father always said he didn’t LIKE to be away from his own house  (and rarely went shopping without coupons!).  So we began the hunt for a house with certain requirements— several bedrooms, a big backyard, close to my school but also convenient to highways so I could travel to whichever clinical rotations I would have to get to in my third and fourth years of Med school, convenient to my husband’s job,and possibly with  a rentable space with a separate entrance  (what is known, on Long Island as a “Mother-daughter” set-up).  After a few months, we found something, and with my father’s nest-egg and my mother’s help, we closed.  Our move-in date was in November, in my second year of school.

7/15/2015

Moving from a small one-bedroom apartment to a house in the same town seemed it wouldn’t be too daunting a task–so we engaged  our extended families and moved furniture–and boxes–and more books than either of us had any time to read.  When we looked at our apartment’s-worth of furniture in our big new space, we realized what a big undertaking this was….and how much more work this was going to be. It took two days to move everything in and to start setting things up.  At the end of the move, we realized that we still hadn’t unpacked the kitchen stuff, so we ordered pizza.  I was never much of a big pizza eater–maybe two slices for me.  But I easily ate FOUR slices of pizza that day, commenting that “this move must have had me working  harder than I thought—–I’m still hungry!!!”……..then we looked at each other, and I went to the drugstore to buy a test.  I knew it from the pizza—I was pregnant.  I still had seven months of my second year of medical school to go, which would end on June 30th.  My due date?  August first.  The planning (among other things) had worked.  I would finish my second year of med school,while pregnant, deliver, and then stay home, on a “leave of absence” until I had the baby—then take 6 months off and start my third year clinical rotations in January.  Then I would do my second two years, which all consisted of hospital rotations, and not be too far behind.  I thought- “Who gets to stay home for 6 months with a baby?”–I felt lucky, and, best of all, my plans were working–my “to-do” boxes were going to be checked off.  (Looking back now, I cannot believe I was making major life choices and decisions in such a matter-of-fact, sensible way–as if I could have some sense of control if I just “followed the plan”…so many years and so many life experiences later I realize that I was kidding myself.  Things are often not in my control, and sometimes all the planning in the world cannot change that—-but at the time, it was the only thing I knew.)  My husband was not UNhappy– and soon got used to the idea that this actually WAS going to happen, and we were going to be parents.  Luckily I had a very uneventful pregnancy. Not one sick day, and kept working, studying, taking tests, and planning…no one could even tell I was pregnant until about 5 months along.  I remember approaching an ObGyn physician who came to give our class a lecture, and asking if I could be his patient–he was more than accommodating, but I remember waiting LONG hours in his office for my appointments, and thinking to myself  “I will never work this way when I become a doctor!!!    (major foreshadowing here……).  I finished my second year of school, 35  weeks pregnant, and said goodbye to my classmates, as everyone was about to head out in different directions, and would only be seeing each other in small groups in various hospital or clinic settings.  I heard all the horror stories about labor, and delivery, and pain, and blood, and had all the time in the world to contemplate them now that school was temporarily out.  In actuality, my delivery was NOTHING like I had heard about first babies.  I delivered more than a week before my due date, and it was so quick I had no time for pain meds, and almost no time for my doctor to get there.  My son entered the world before I even got to a labor bed…and before my doctor could change into scrubs…(my first experience with the fact that Obstetricians often discard perfectly good clothes when showered with the inevitable amniotic fluid/blood/meconium triad….)…Jacob  must have been so anxious to arrive!  And nothing that I had done—or seen—or learned, or read,  had adequately prepared me for how I was about to feel…..

7/19/2015

I tried to read all I could to ready myself to have, take care of, and raise a child. (can ANYthing really “Ready” one?)   As I mentioned previously, although my own parents ultimately helped me to “get where I was going”, and supported me financially as I pursued my dreams (and THAT was the way they let me “feel” their love), when it came to me feeling emotionally supported, their child-rearing left a lot to be desired.  I never felt able to talk to my parents about what my concerns were, always worried I would be disappointing to them, and NEVER felt that they spent any time considering or anticipating my feelings, especially at very critical times in my youth. ( to be fair, those types of parenting skills were not so popular at that time–parenting then usually went the way of “my parents did it to me and I came out ok—so…”..)  I was DETERMINED not to have my kids(s) feel that same way, and I knew that being the “right” kind of parent would start from a very young age.  So I set out to do all the things that were considered “best” for the baby from Day 1– including the idea that once the baby is born, the baby’s needs and wants take priority over everything–  (an idea that I have now come to realize is something that needs to be kept in perspective–but then, as a new parent, I hadn’t yet known).

So I decided to exclusively breastfeed on demand, and to use cloth diapers (yes–there is still “diaper service” available!), and to have as much physical contact with the baby as possible, and to wear the baby on my body as much as I could.  I read books by the current parenting gurus (mine was T Berry Brazelton) to get a handle on exactly how to “get it right”. I knew that being home full time with an infant for 6 months was a true gift–and I also knew that once I went back to my studies, chances were that I would be gone a lot, and busy and tired a lot–so I guess I felt I HAD to make the most of those first six months, so I would likely not feel so bad or so guilty when things changed so drastically down the road.  But being the “perfect” parent is not so easy.  Breastfeeding did NOT come so naturally, in spite of all the advice I was getting to the contrary.  Jake’s sleep patterns seemed non-existent– never sleeping for more than 2-3 hours at a time, and (seemingly) always hungry.  He seemed very gassy and inconsolable at times, except when he was in his carseat–only to immediately wake up when I would try to take him out.  (I now remember several times, guiltily letting him sleep in the carseat, strapped in, even after we had gotten home, knowing what would happen if he was disturbed).  I was reluctant to complain, lest this be a reflection on me and my possible poor parenting skills.  But there was NO debate about the deep, overwhelming way that I was completely and truly in love with this baby—I would have done ANYTHING to ease his pain, to make him happy, to entertain him, and to make sure he knew that I was there for him one hundred percent.  I couldn’t remember or imagine what life was like before him. We got into our own little pattern, spending the days and nights together in a big  “bonding festival”…..I often have thought that one of the reasons we have remained so close over the years is from those initial 6 months of bonding—-even though I know that there is really no medical evidence that that is true—-kids are bonded to their parents in many ways, through many experiences…. but those 6 months were precious and valuable to me.

About three months in, I began to have some anxiety, in knowing that in just three more months I would be returning to school, to begin my third year–the year of clinical rotations, also known as the “scut year”. (“Scut” is a term that we in the medical profession use to describe all the things that no one wants to do–draw blood, start IV’s, disimpact old people, run to the lab, etc etc, and at least in those days, the third year of medical school was full of those chores, intertwined with what was supposed to be the first real “hospital learning experience”, and the first time we would be touching patients).  I knew I would be working long hours, I knew I would be sometimes gone overnight (oh no!!), I knew I would need to start looking for a nanny for my son, I knew I would have to leave him in someone else’s care… and I knew that things were going to drastically change.  My husband was working full time. He adored Jake, but as is usually the case, whether through my own beliefs or just “standard cultural norms”, I knew that I would have the most responsibility for my son, even after I was once again working full time.  The nanny search had begun.

7/24/2015

I was completely at a loss as to where to find someone I could trust to take care of my baby.  I looked at ads, read about agencies, talked to friends and relatives—I was so afraid that no one would be good enough for me, or for Jake, or–really, how would I KNOW??  After a bit of investigating, the best thing that could have happened HAPPENED— a good friend of mine from college told me that her brother was married to a lovely lady from Ireland–a young gal that had moved to the US to take care of her (my friend’s) grandmother, then met her ( my friend’s) brother  and they had started dating.  They eventually married, and the grandma eventually passed away.  His wife-caretaker-Irish transplant was available to be a nanny—and not only that –she lived ONE town away from me, and did NOT want a “live-in” position!   I couldn’t have asked for more— practically a family member, experienced in caring for others, and wanting a daytime-non-live-in position!  I hardly had to interview her.  Charlotte was wonderful, caring, smart, and loving.  I KNEW I had to be comfortable with the idea that my son would need to be cared for and comforted by someone who was not me– and I satisfied myself in feeling that if he had MORE people who could comfort him, rather than fewer people who could, then the whole “separation anxiety” thing would be only MY problem, and not his.  I readied myself to go “back to the trenches”, with a newfound respect for mothers, emotions, needy individuals, and a good night’s sleep.  I continued to breastfeed whenever I was home, and to pump bottles in (what seemed like) all other hours of the day.(and night)  We DID switch to disposable diapers, since while I didn’t mind the fact that something or another was always dripping out and ruining MY clothes I didn’t think it fair to impose that on a non-family member……and these next months were the time period that I always refer back to when I say (and I HAVE said, often,) that motherhood really prepared me for residency. The consistent lack of sleep combined with constantly trying to learn new things, and putting the needs of others before my own were “givens” in both arenas. Being a third year medical student and having a six month old at home was a combination that I felt at times, very ill-equipped to handle.  But again, I got into a pattern, and at least for 6 -to 12-week intervals, (the length of time of third year clinical rotations)  I felt that same old feeling, “one thing at a time….and if I could handle this, I could probably handle anything”.   (I hoped)

7/26/15

The third year of medical school is when “everything changes”. You are expected to go to various clinics, hospitals, and office settings, and interact with patients, learn how to take care of them, gradually begin to have increasing responsibility in formulating care plans for them, AND learn and utilize new information daily.  You are also expected to master any number of invasive procedures, from suturing wounds, to cleaning out abscesses, to giving injections, drawing blood, and starting IV lines.  ALL while usually feeling completely inadequate if not downright stupid (and being reminded almost daily that you surely are BOTH).  When I was a medical student, there were several scary phrases that I heard circulating–   One was that “All s**t runs downhill…”, which meant that in the hierarchy of the medical world, at the TOP, were specialists, then regular attendings, then chief residents, then other residents, then Interns, then Fourth year medical students, (called Sub-interns), then microbes in the lab, and THEN,WAY WAY further down……… third year medical students….so when there was something distasteful to do, or someone to berate, the flow would be from the top down……eventually and always reaching the third year medical student.  It was a scary kind of hazing—that those on the higher rungs of the hierarchy seemed to embrace and enjoy—-since they had all been through it too.  (I THINK that things have gotten better in the past few years for medical students—but in general, this has been the way physicians have been trained and have gained their competencies throughout the history of medical education).  There is also a huge variation from one rotation to another. A surgical rotation may require that you stay overnight in the hospital several times a week, while a Psychiatry rotation may take place in an office with regular hours and patient appointments.  At any rate, each rotation was just 6 or 12 weeks long–so as I “steeled myself” for the year, I was relieved that I could probably take anything for a limited period of time.  The third year is also supposed to be the time to introduce medical students to each of many different specialties–so that if there was something that “grabbed them”, or held their interest then they might decide to pursue that specialty as a career.  I thought that I was quite certain which specialty I was going to go into–since my background was in Physical Therapy, I was sure I would become a Rehab and Physical Medicine doctor.  That was a specialty that required a year of some type of medicine internship, and then three years of a Physiatry residency; I would see patients who needed various types of evaluations and treatments for injuries, strokes, muscle, joint, nerve  and bone issues. It would be “sort of” like Physical Therapy, but I would be the point of first contact with the patients ( just a “by the way” kind of notation here– Physical Therapists in many states are NOW  able to see patients independently–without a doctor’s referral –but at the time I was a P.T., we were completely reliant on a referral from a physician to evaluate and treat patients. P.T is now a Doctorate level field, and much different from 20+ years ago)   I was so sure of this that I didn’t really make an effort to “plan” my schedule like so many other students did .  They planned so they would be able to rotate through places that might want to take them on as a resident  using their medical school rotations as a sort-of “audition”…it was common knowledge that if a medical student was impressive during his or her clinical rotations, they would have a “leg up” on others who applied for those same residency spots….but since there WERE no Physiatry rotations in the third year, I didn’t bother to plan. That was something I would be able to do in my fourth year, when the choices for clinical rotations were  greater, and electives were available.  The third year rotations were Medicine, Surgery (both 12 weeks), Pediatrics, ObGyn, Psychiatry, and Family Practice  (all 6 week rotations)  (Add it up–that conveniently adds to 48 weeks—-and there were several days we had to be “back on campus” of the medical school to attend lectures, or take some exams– we even had about 2 weeks vacation thrown in–but in general, my third year would go from January to December.  My fourth year would again start in January, and, (although MY class would graduate in June  of that same year, I would be halfway through my fourth year, and was told they’d let me “walk” at graduation, (empty diploma case), and I could finish up in December of that year.  Sounded like a plan.

7/28/15—-(an aside—–short post today—blogging from Mexico……poor internet and too many other things to do—like sit by the pool )

My first rotation was at a small community hospital on Long Island (which has long since closed its doors, as is the fate of so many community hospitals). It was a Medicine rotation, and 12 weeks long.  They had no residents, only interns and attendings, which meant the people “running the show” so to speak had just graduated from Med School 6 months earlier (remember, I was starting in January). and they reported directly to attending physicians, mostly who were community-based physicians with their own offices locally, who admitted patients to this hospital, and really loved to teach.  The interns seemed to have it really “together”– writing orders, diagnosing patient conditions, figuring out the best treatments for people to receive; I could not believe that they had become so knowledgeable and so efficient in such a short time. I learned a lot from them, and felt like this was a pretty easy introduction to becoming a “real doctor”.  Except for the ICU.  Walking into the ICU was scary — patients in critical condition, hooked up to so many different tubes and lines and catheters.  I could not keep things straight, and I began to realize that it WAS scary–to be totally responsible for someone’s life at a time when so many things can go wrong– I enjoyed the learning part but I found the challenges of this type of medicine too much for me, and I crossed “Intensivist” and “Internal Medicine Physician” off of my list of “What type of doctor will I be?”  ( Even though I already KNEW where my interests were—I thought I’d at  least give these rotations a chance to pique my interest, and possibly point me toward something else—although I doubted it.)  I learned a lot in those 12 weeks, including how to properly place an IV, (That if you don’t put pressure ABOVE the vein, you will end up dripping blood all over the floor before you get the IV tubing attached.)  How to take blood from an artery (an arterial blood gas test) and that arterial blood tends to spurt and squirt if you don’t use proper technique. (Lots of pressure–needle perpendicular to the skin, and make sure you palpate a pulse before you do it)  I learned that I would often need to change my clothes as blood, urine or other bodily fluids frequently damaged the ones I was in– and I learned that going home at the end of the day to a 7 month old who was still nursing meant my 8-to-10 hour days turned into 14- to 16 hour days, or more, and that the smiling face of a baby who is starting to recognize me at the end of the day is the best gift of all.

7/30/2015

My next rotation was Surgery–12 weeks of learning what general surgeons do, figuring out who needed which surgery, and how to best care for pre-op and post-op patients.  General surgeons operate and take care of a lot of things:  The intestines, appendix, gall bladder, thyroid, breast, stomach, pancreas, liver, certain things in the chest cavity, and many other smaller things like skin lesions and masses. I learned how to scrub properly in the OR– what NOT to touch, how to hand instruments to people, and how to hold retractors.  Lots of holding retractors.  Many surgeons think that is what medical students are for—holding retractors.  I learned the basics of suturing, and what type of suture to use in which kind of wound, and what to look for and worry about  in a post op patient (urine output, dry incisions, Pneumonia, bed sores, infections).  I have to say I really loved the precision of surgery– a patient shows up with a specific problem, and a surgeon can CUT it from his body—problem solved (usually).  I liked the feeling of being in control of a situation (Not that I, as a medical student was in charge of ANYTHING–but surgeons often are.)– and being able to “fix” things that were wrong.  I liked learning and bettering my suturing and surgical skills–even if I mostly was holding a retractor. I was paying attention to everything that was going on around me and I thought a surgical specialty was something I should keep in mind.  What I DIDN’T  like, however, were intestines.  I didn’t like stomachs or appendixes  (appendices?)  or anything that these surgeon actually operated ON.  I didn’t like the personality of most surgeons either, and I definitely thought that somehow, general surgery was NOT going to be the thing for me.

At home, around this time, we had decided to try to use the upper floor of our house to make some money, and we rented out the upper apartment, which had a separate entrance, it’s own small kitchen, and a separately controlled thermostat.  A young couple rented it, and we hoped for the best. We had never been landlords before, but were going to try.  Having two full time working adults in our family of three, while trying to include Charlotte on many of our plans and excursions was challenging.  It was perhaps more challenging that my schedule had changed every 6 or 12 weeks, and sometimes I was gone overnight.  My husband enlisted many members of his extended family when he was alone with Jake while I was working.  When I was home, I often wanted the baby all to myself so I could “make up for lost time”.  The entire plan was difficult.  I always felt pulled in one direction or another, and still being a student while “working” in a hospital meant that the learning was never done. Attendings would always expect us to know whatever we had learned and seen the week before, as well as to read up on conditions we were helping to take care of; also check patients’ lab work, XRays, and report back (through the hierarchy of course) our findings and results.  I often remember falling asleep with a baby nursing, a book open, and a half eaten plate of food, all on the same bed.

8/5/2015

I had now made it through half of my third year.  I was learning to juggle, however imperfectly, the demands of hospital and clinical rotations, the demands of a home life with an infant (who I was still exclusively nursing, although by now he was beginning to eat some solids), owning a home and being a landlord, and dealing with extended family on both sides.  My husband had a large family and I had a smaller one; we were always being invited to family functions, and often explaining why we (or, more often, I,) couldn’t attend.  My mother was still living in Brooklyn, not yet ready to leave the home she had shared with my dad–although she had hinted to us that one of the reasons she helped us buy our house, with a separate living space was so that one day SHE might be able to move in up there.

My next rotation was Psychiatry, a six week rotation which included outpatient office work, hospital work, and a week rotating through a “locked down” inpatient psychiatric hospital.  Although I was intrigued and interested in issues regarding mental health, psychiatric patients frightened me a bit. Meeting and trying to help care for patients that seemed like they would be dependent on medications and therapy for the rest of their lives just to reach a functional baseline was quite eye opening. I was raised in a time where “mental health” issues were not discussed freely, although now it is obvious to me that there were so many people in my family who suffered from various forms of mental illness–anxiety, depression, OCD, borderline personalities—an array of various diagnoses were living in our photo albums,and under our roof– and I can honestly say that no one ever got the treatment that they needed to help them live happier and more productive, functional lives.  Psychiatry was a completely different kind of rotation and a completely different kind of specialty– no matter how much medicine–how much treatment we were able to provide for patients, I never had that same feeling that I did in other rotations–that someone presented with a set of symptoms, the doctor could figure out what was wrong, and through a series of treatments, “fix” it—in psychiatry, I never really felt anyone was “fixed”—  just that we made them (sometimes)  a little better able to cope…and while I appreciated the importance of those with the expertise to specialize in the field.. I knew couldn’t make it my life’s work.

8/7/2015

During this time, my son turned a year old, and we decided to have a big birthday party for him in our backyard.  We invited tons of friends and family  for a BBQ, with a “jumpy house” for the older kids, kiddie pools, balloons, and a cake that Jake was only too happy to eat with his hands.  (and we were only too happy to take enough pictures of all that cuteness for at least three photo albums) I invited some of my medical school friends, most of whom I was not seeing with regularity since we were all on different rotations. (I was still mostly friends with the “returnees”, but with clinical rotations, a family and a home to take care of it was a wonder I ever spoke to anyone socially.)  I tried to keep up with my friendships–people I knew from my childhood, some from my college years, my best friend and roommate from grad school and some I met traveling– but there was no social media in those days–no Facebook;  people had no cell phones, so “keeping up” required a lot of effort, and inviting everyone to a backyard party seemed an easy way to catch up with everyone at once. It was—we had a great time and it was quite the  reminder that a BALANCE is so important– rather than a checklist of so many different things I needed to get done, I started to look at my life as a scale–a precarious one–where it was -so  SO important to balance all the various aspects and give enough weight to family, job, friends, and self— so that ONE aspect never became “all important”, to the detriment of the others.  A one year old’s party as a life lesson—who knew??

My next rotation was Family Practice, which I did in a clinic setting, with regular hours and no night or weekend obligations.  That, I discovered, was only one of the wonderful selling points.  I found that the doctors had to know a lot about a lot of different conditions.  I found that they all knew their patients by name, and mostly, knew their families and their major life events.  I found that they had time and took time to talk to their patients, and listen—REALLY listen, to their stories and their complaints.  And best of all,  that feeling of really helping people returned.  It wasn’t just prescribing medication though; it was a combination of things.  It was the art and science of medicine.  I saw patients with a wide variety of medical problems, (aches and pains, high blood pressure, diabetes, muscle and joint problems, headaches, colds and various infections, to name just a few) and doctors with various personalities, teaching styles, and funds of knowledge. But the one thing they had in common was that they all seemed (to me anyway) to enjoy what they were doing.  For the first three weeks I mostly followed the doctors around, watching, listening, and participating in the care of their patients, and in the second three weeks, I had my own patients, all of whom I had to discuss with one of the attendings or residents before actually coming to any conclusions about what was wrong and what we would need to do about it.  It was a nice lifestyle for six weeks, and I began to seriously consider whether Family Practice might be the specialty for me.

8/9/2015

After 6 weeks of what seemed like heaven, I was petrified to start my next rotation.  It was in Obstetrics and Gynecology, at a hospital in Brooklyn, more than an hour away from my house, and the first day I needed to be there at 6 am to make rounds with the residents.  “Rounding” at 6 am meant that the medical students had to be there at least a half hour prior, to “pre-round” or get ready and become quickly knowledgeable to discuss patients and their various conditions and treatments with the residents and the attendings.  The first day there, I could tell that everyone was exhausted.  NO ONE seemed happy to be there; they were overwhelmed and overworked. No one walked the halls, everyone ran around from place to place as if there was a constant emergency  (often, as I would find out later, there WAS.)  The rotation was divided up into three weeks of gynecology, including surgery, and then three weeks of obstetrics.  It required me to spend every third night overnight in the hospital for 24 hours, and then to remain to stay and work in the outpatient clinic on the day after the “all-nighters”.  This was in the days before there were mandatory laws about how many hours residents were able to work–but medical students were not considered in that equation anyway–we could stay–and work ( and hopefully learn) all hours of the day and night, whenever those above us in the hierarchy said that we should (and, recall, “above us in the hierarchy” was a list of just about everyone.)  There were about 16 residents in the program, 4 per year.  They each had designated areas where they were to be—Labor & Delivery, Clinic, Gyn Oncology, Reproductive Endocrinology, Family Planning, Gynecologic Surgery– as students, we were supposed to have exposure to all of these areas.  Besides residents, there were Physicians Assistants, Nurse Practitioners, and Midwives–it was difficult to keep track of who did what, what was responsible for what and who would be teaching me  (since, whatever their titles, they all obviously knew more than I did )  After the first few days I realized that many of the staff were really just too busy to do any kind of formal teaching.  If I wanted to learn these subjects I would have to attach myself to different residents and staff,  follow them around, make myself useful, and try to get something out of this rotation.

I have to say, I had a strong and natural curiosity to learn about all things in this field–for many reasons– first, of course, because I am a woman, and even outside of the medical field, always was an advocate for women’s reproductive rights and freedoms.—this would be the chance to see those rights at work.  Second, because I had already had the experience of giving birth, and knew what that process was like from the patient point of view, and, third, because I had been raised in a family and at a time where NO ONE taught or shared information about the human body or sexuality, and I was interested and curious to see how those in the field really educated women and girls so that they would be armed with proper information on these subjects.

I was in for QUITE the education…..in more ways than one.

8/18/15

……If I had thought before that  I knew what it was like to get little-to-no-sleep because I had a nursing, fussy baby—I REALLY started to figure out what that meant when I had to leave my house on Long Island at 4:15 am and drive an hour in the pitch black to arrive at the hospital by 5:30. I thought, “This is really inhumane”…(and made it my “note to self”   —one of many— that “NOT COMMUTING LONG DISTANCES” was going to be high on my list of things that would attract me to a job when I was ultimately searching for one..).. I arrived for my first day of what was to be the gynecology part of the rotation, and  we rounded on the patients who were scheduled for surgery that day.  The residents barely addressed the medical students, except to tell us what to do or where to go—also to look annoyed at us when we didn’t (or, even if we DID) know the answer to the questions they would ask us.  There was a long list of patients to get “Pre-Opp’ed”, and to be sure everyone (read, WE) knew exactly what kind of surgeries they were having, why they were having them, along with their histories, and what each surgery would entail.  I got to scrub in on (read, “hold retractors for”) such cases as Tubal ligations, Laparoscopies, and Dilatation and curettages.  I must say, I was really shocked that first day in the operating room, that once the patients were asleep, no one really seemed to treat the BODY that was to undergo surgery as if it were a REAL PERSON– I mean, I don’t know WHAT I was expecting, but no one had ever explained to me how they just move patients into the right position for surgery, like in stirrups, or completely naked, with no accord for their modesty-(of course the patients were completely unaware) -just making sure that they were in the right position for the procedure.  (I learned later that this is sometimes very hospital-and practitioner dependent—I often worked in hospitals elsewhere that placed paper over windows when gynecological procedures were going on, or strategically draped sheets over their patients’ bodies to preserve some modesty), and I had decided then (another NOTE-TO-SELF) that IF I was ever going to be doing those procedures, THAT is exactly what I would do too–because it just seemed RIGHT to me….

Something about these procedures intrigued me–I knew before this that I had liked surgery– but then the actual body parts that were being operated on didn’t seem what I wanted–but THIS—-THIS seemed more like what I would like to do somehow.  I didn’t find the residents–the people who were to become eventual attendings in this field, very compelling—and some didn’t even seem like this was what they wanted to do; I found out through listening to their conversations that several had wanted to go into other fields–Orthopedics, or General Surgery–but could not get residency spots in those specialties–so they “settled” for ObGyn….how sad—to spend all that time in school and in preparation, and then NOT even go into the field that excited you or interested you?  I did not realize then just how common that was…..but I knew I couldn’t—and wouldn’t travel down that path if I could avoid it…..

Some time in the second week of this exhausting rotation, I met an attending doctor who invited me to scrub in on his surgery—a hysterectomy, and told me that if I was well-prepared– knew the patient, the history and the details, that he might even let me do something more than hold a retractor.  I was excited by that and set about to study as much as I could, to meet and speak with the patient, learn about her history and her need for this surgery.  When we finally got into the operating room, I felt very well prepared.  It turns out the attending was in charge of this case, but he was operating with his chief resident, who was only months away from being done and going on to a “real job”.  Besides the two of them, there was only me scrubbed in on this case for some reason (usually there were several residents, an attending and medical students), and the case was a thing of beauty—surgical technique was impeccable– it was practically bloodless, and the attending, along with this resident, narrated every part of the case, for my teaching benefit, showing me various parts of the anatomy along the way….”This is the bladder….this is an ovary…”, and asking me the “pimping questions”…”what is the blood supply to the uterus?  What ligament gets divided in the first step of a hysterectomy?  What does the expression ‘water under the bridge’ mean?”   (it means the ureter runs under the uterine artery, and any medical student should know that).  At every point during the surgery I felt like I was falling in love…….with the whole teaching aspect of this–with the beauty of an exquisitely done surgical procedure, and, probably with the resident and attending themselves, as they were the first people in this rotation who treated me like I was an actual important part of their team—-they even let me place a few sutures in the closing part of the operation.  I was somewhat hooked.  I was lucky enough to have had a wonderful, exciting surgical experience that started me thinking about this field as a specialty—–in spite of what I THOUGHT I previously “KNEW” I would be interested in.

I had decided not to use the real names of anyone that I mention in this blog, mostly because I haven’t really asked anyone’s permission– and I do not want anyone to be upset with my depiction of them here.  However, I have decided to reverse that decision when it comes to one name–and that is the name of the attending physician who invited me into his OR for this hysterectomy.  His name is a bit unusual, his effect on my life direction so huge–and the name factors so SO heavily into a much later entry in this blog that I have decided to name him….and hope he somehow knows how forever grateful I am to have had him there for my introduction to gynecological surgery…so THANK YOU, Dr. Nick Khulpateea.

8/20/15

Included in this clinical rotation was a schedule of On-Call nights for all the medical students.  Every third night one of us had to stay overnight in the hospital and stay glued to our On-Call resident.  We were supposed to follow them around, help with all their nighttime rounds and take care of emergent events in the Ob and Gyn units, also known as “putting out the fires”.  Many scary things happened at night– PostOp patients who suddenly spiked fevers or started bleeding, patients who showed up in the ER in shock from ruptured ectopic pregnancies or who had terminations of pregnancies that went wrong; deliveries that turned into catastrophes.  Nightcall was NOT for “regular medical activity”.  The residents that I was “glued to” on my first few OnCall sessions made it clear to me that they were interested in several things:  Tending to as few emergencies as possible, and getting as much sleep as they could.  There was a Resident OnCall room, next to a Student OnCall room.  Students did not have beepers, (remember, youngsters, this was in the days before cell phones), and residents felt no obligation to wake up students to join them when they were called on to do something, so my nights OnCall at first consisted of my staying up and listening to any activity that might have been going on in the next-door Resident OnCall room, so I could quickly run after them and follow them to the emergencies.  I was used to very little sleep, and I found I actually LIKED the idea of having to figure out the circumstances of an emergency and make quick decisions to “put out the fires”; I felt that I learned the most from trying to watch and listen during those times.  I liked the quiet of the hospital at night.  I liked that there were no scheduled rounds, no random tasks to do that could wait until morning– there were just the emergent surgeries, transfusions, administering of medications, and admission of very ill patients that could only be taken care of, out of necessity, in the middle of the night.  Unfortunately, more often than not, when I heard the residents beeper go off at night, it was to answer nurses questions about orders that needed to be clarified  ( “Did you REALLY want me to give 25 mg of Terbutaline when the dose is usually .25?”—–” Did you REALLY mean to stop those antibiotics when the patient still has a fever?”– in other words, nurses, often correcting the mistakes of these still-learning, tired and overworked residents, who just MIGHT have written their orders in error).  And sometimes, when I did fall asleep in the OnCall bed (read, COT) I would wake up only to find that activity went on without me and I missed it, which disappointed me ( although  I was grateful to have gotten some sleep before facing an entire day of the outpatient clinic which followed each night of OnCall).

8/25/15

Outpatient ObGyn Clinic was another entity altogether.  Clinic was in a large ground floor area, with makeshift “rooms” created to be (somewhat) private by dividing them up with hanging curtains in between them.  There was an exam table, a rolling stool, a chair, and maybe a small table in each exam area, with various supplies and instruments piled up in each area.  There were many patients sitting, standing, and leaning, in the waiting area; women of various ages and in various stages of pregnancy.  The residents “ran” the Clinic, and many different people were seeing the patients, from what I could tell. There were midwives, physicians assistants, residents, students, and nurses seeing patients.  There was ONE attending physician, who was “The Consultant”.  He or she, would stand or sit in a corner, and as the patients were seen, each practitioner would come and present their case to the attending (mostly so they could write “discussed with the attending physician” on the patient’s chart—-and, YES, we were all writing on paper charts in those days— ) before finishing the visit.  It looked like a long, arduous process, and pretty disorganized;  the main goal was to have all the patients seen, and finish the Clinic Day as soon as possible, since most of those working in Clinic had been in the hospital since the day before (and definitely looked it).  This was, literally QUITE the education…….in how I did NOT want to see my “future” patients if I could avoid it.

There is a saying about medical training (one of many)  that describes in the most simplistic of terms, how medical education proceeds:  “See one, Do one, Teach one”, is often echoed throughout medical training programs.  This Clinic seemed to be the embodiment of this phrase.  I had NEVER done my own pelvic exam on a woman, let alone a Pap smear, or any other type of invasive exam—at least not while someone was awake and talking to me.  The first curtained-private-but-not-private exam booth that I went into with one of the residents, had a 30-something year old woman of Eastern European background sitting on the exam table with a gown that was too small and provided NO modesty, waiting to be seen.  The resident barely acknowledged her, looked at her chart, did what seemed to ME to be an invasive yet quick exam, during which he used instruments I had only seen but never touched, and gave her a prescription for birth control pills,  The whole thing was done in under 10 minutes, and he was on to the next one, with no time for questions  (I DO remember that he washed his hands in between patients though….thank goodness).  In the next room–the resident said, “Now YOU do this one”…..and watched as I awkwardly introduced myself to the patient, asked a few questions, and then, with the resident’s help, performed a pelvic exam and pap smear during which I didn’t have the slightest idea what I was seeing or feeling.  I thought, There has GOT to be a better way to learn how to do this”.

9/3/15

Although these weeks were difficult, and I was hardly getting any sleep, I was really learning things–and, for probably the first time, started considering whether this might be a specialty I might want to go into.  It wasn’t something I felt I was consciously making a decision about—it just sort of seemed that I was “finding myself interested” in everything that was going on.  I was watching how exams were done–I was doing them on my own–I was voluntarily and with no prodding, looking up answers to questions that patients were asking me, and I found the whole reproductive system fascinating–throughout all the different stages of a woman’s life.  I finally was able to venture into the “scary place” one evening—The Labor and Delivery ward–where I was told that I would be allowed to scrub in on what was going to take place in the O.R.  I went through the usual ritual of scrubbing, gowning, putting on gloves correctly; staying out of everyone’s way, and not touching anything blue-(which were the sterile objects) –repeating my name and my (piddly) credentials to the OR staff who needed to document all who were present in the Operating Room, every time.—  Then I stood at my place at the operating table—doing my usual retractor-holding—-and watching as the resident meticulously carved through the layers of the abdomen, asking me to identify the peritoneum, the fascia, the bladder…….when, suddenly, this was not like any surgery I had ever seen…..SUDDENLY…..he reached a hand into this woman’s uterus, and he was pulling out a living, moving, crying thing.  He was pulling out an ACTUAL BABY from this woman’s abdominal incision…. and I was mesmerized.  It had started out like SO many operations I had witnessed, from near and far, in many operating rooms, since my first exposure as a third year medical student—-but about four minutes into the surgery, it took a completely new direction…..this was not an appendix, or a gall bladder—or even an ovary or a tumor.  THIS was a live human being, being brought out into the world, kicking and screaming, covered in cheesy vernix and amniotic fluid…emerging from a sac that had been its home for the past nine months—THIS, I thought, was pretty freaking amazing.  I tried not to look like what I was feeling—-which was “Why is everyone in this room NOT saying ‘Oh My God, this is AMAZING!!’ “—because then I started to realize that NO ONE acted like it was amazing because they saw this every day—-at every hour of the day and night, especially at hours of the night where they’d have rather been asleep…….and some of them really didn’t want to be doing this at all, because they would have rather been orthopedic surgeons or anesthesiologists…… but all I could think about, during that C Section and for a long time after, was “How lucky are these people that they actually get to see–no—to participate in— THIS kind of thing EVERY day?!?”   Wow.

9-6-2015

By this time I was about half way done with my ObGyn rotation.  It was October, and all the students I had started  Medical school with were already in their fourth year rotations.  They were on schedule to graduate in June, as long as they all passed all of their rotations, and although I was going to be able to graduate and “walk the stage” with them, at the time of graduation, I still would have 6 more months of rotations to go before I would really be done.  My son was now 15 months old, our nanny-situation was still working, and I felt like I was getting into the routine of this rotation, starting to think about actually making this specialty my career.  My husband was NOT thrilled with my decision.  He did not relish the prospect of a residency, and then a lifetime of being away many nights, always having the beeper go off, knowing the life of an ObGyn (and family) would be MUCH more difficult and “unscheduled” than the life of a Rehab Medicine physician (and family).  As a matter of fact, it was hard to find anyone who was encouraging about possibly choosing this specialty.  The residents I worked with advised against it— my family advised against it—and the doctors I knew who actually PRACTICED in the field advised against it……..except one.  On one of my visits to the gynecologist who had delivered (um, who ran in and caught) my son, I mentioned that I was considering going into Ob Gyn, and he said something I will never forget—he said  “When I decided that I wanted to be an Obstetrician and Gynecologist, I knew I would never be happy doing anything else.  I’ve been doing it for 20 years, and I’ve never been sorry.”  I was not sure what to think of that— he had a wife at home, and several children that I knew about, so maybe HIS time away from his family didn’t matter as much.  He was extremely busy, (as witnessed by the HOURS I spent in his waiting room).  He seemed happy, and I made a mental note to ask him why his advice was so different than anyone else I had spoken to about my plans….  Meanwhile at the hospital, I was now on the OB part of the rotation— which meant morning rounds would take place in the Delivery room, where every room was occupied with women in various stages of labor.  Some of the patients were cared for by the residents, and some, by the CNM’s, or Certified Nurse Midwives.  We would round on everyone; our “posse”  consisted of a senior (3rd or 4th year) resident, a junior (1st or 2nd year) resident, a fourth year medical student, and several third year medical students, in a group, congregating at the entrance to each labor room, and listing out the pertinent items of information on the patient laboring inside– We were looking at the Fetal heart rate monitor, the medications that were being given, and the plan for getting the baby delivered.  We never did actually go INTO the rooms, and usually no one actually SPOKE to the patient who was laboring;  we spoke to each other, asked questions, took notes, and, after about five minutes of this, we went on to the next room (or, doorway to the room, as it was).  I found all this fascinating— HOW did these people know all this?  How did they know the babies were safe in there?  How did we know how and when each of these women were going to deliver?  Every once in awhile, interrupting our rounds, there would be a commotion inside or outside of a labor room—sometimes in the hallway, sometimes in the triage area  (an area which requires its own post) and residents would scatter, running off to the OR, or to some impending emergency, because babies in distress cannot wait——and our rounds would abruptly end, usually never to be completed that day, all the unanswered questions now left to me to investigate.  Once the rounds in the delivery room were over, there were post-partum rounds to do—which was my first experience of being the only medical person to sometimes see a patient that day—After realizing that I was a neat note-writer, who loved to pay meticulous attention to detail, the residents allowed me to see the post-partum patients alone– as long as I followed the list of things to do (“Make sure you feel her fundus to see that it is firm; Make sure you look at her vitals and report anyone to me who has a temperature above 99.9, Make sure you look at her post partum blood count and report anything abnormal; Make sure that there are orders written for pain medicine and stool softeners”  etc)  They were only too happy to sign under my name, as long as I “did all the paperwork”….I was fine with that deal, and felt like THIS was more of what I really wanted to do—TALK to the patients, hear their delivery stories, examine them, write about what I found—use an orderly, sensible list of “Things To Do”, to make sure patients had what they needed, and were well-cared for.  (Sometimes postpartum rounds took me upwards of three hours to complete—but, at least initially, no one was expecting me to be elsewhere– and I was enjoying it!—–Little did I know that hours of post partum rounds and long progress notes on low-risk, “normal” patients was NOT the norm, and unlikely to ever happen again)

9-13-15

As I became familiar with the goings-on in Labor & Delivery, and was staying longer hours, and every third night overnight, I became friendly with many of the “non-physician” staff– I liked the nurses, the Physicians Assistants, and the CNMs, ( midwives) who seemed to be caring for patients and delivering babies in a very different way—- they waited long hours with laboring women, patient as long as the babies followed a “normal” labor pattern and nothing became emergent.  Each one of their delivery notes, however, had to be inspected and “signed off” by a resident.  If one of their deliveries became emergent, or in need of intervention, the residents did have to step in and take over– usually resulting in instrumental deliveries (forceps or vacuum deliveries) or unexpected c sections.  The residents and midwives had a cordial – but – suspicious -at -times relationship….It seemed that the residents loved having midwives there to do deliveries, but hated having “more work to do” when a midwife delivery had to be transferred over.  I asked if I would be able to observe and participate in midwife deliveries, and the residents told me, “of course—-  as long as you do the paperwork!”  (impressed, I was sure,  with my lengthy and informational notes on the normal post partum patients).  So I decided to observe, lurk, and “stalk” the midwife deliveries, learning what the different stages of labor were, what all the “natural” interventions the midwives seemed to have at their fingertips to make patients feel better  and calmer in labor– very different that the other deliveries I had seen.  After observing deliveries from the far side of the delivery room a few times, I was beginning to sense the pattern of things that would occur with each delivery. Early on, things were calm…patients would sleep or read, or even eat and walk around….then things would get intense and loud….. Pushing would go on sometimes for hours, and at the moment the delivery was imminent, a flurry of activity would occur to get everything ready.  One of the times I was observing, the “flurry” started to happen, and the midwife said to me, “Come on over here–put on the gown and gloves”.  I did as I was told, and she pushed the rolling stool over to the edge of the bed where the event was about to occur, and told me to sit down.  I did.   She was beside me, still encouraging the woman to “push-2-3-4-5″…..using each contraction to gently ease the baby down the birth canal.  When the head, with a full head of hair presented itself, the midwife gently put her hands over mine, and helped me to guide the baby’s head out without allowing any tearing of the stretching tissues surrounding it.  We performed the “maneuvers of delivery”, bringing the baby into the world, head, then shoulder–shoulder– thorax–body–legs and feet.   I placed the baby, umbilical cord still attached, on the mother’s abdomen…… and in that moment, something happened. I do not know what it was. But I know it happened……  I was at that time by no means a religious person—not even that much of a spiritual person.  But when I lifted that baby, crying and slippery, onto his mom’s belly—–call it cliche  (and I know you will—–) but I FELT something–some sort of energy——I felt that THIS—–THIS is what I was called to do—–this specialty WAS my “calling”…….and I HAD to make it my life’s work…..it was really not up to me anymore…….but this specialty had chosen ME.

9/20/15

Once that had happened, it was like I knew I had a specific , single-minded course to follow over the next year; I was finishing my third year of medical school (had just one more rotation to go) and I had to arrange all my fourth year rotations, which had way more flexibility built in.   I could make my own contacts and spend almost 5 months doing electives—doing things that really interested me, and now I knew I wanted to spend them doing as much time in the field of Obstetrics/Gynecology and Reproductive health as I could.  The last few days of my third year ObGyn rotation were spent trying to “get” as many deliveries as I could, while learning about not only the “normals” but about all the things that could go wrong (and, surprisingly, there were many). I spent extra hours and extra nights in the hospital, and could hardly explain how it made me feel to become an important and integral part of the care of these patients. My newfound excitement did not “go over” well at home.  I was gone more, and my husband was not used to, or interested in, spending more time alone, or in being “Mr Mom” than was absolutely necessary.  It was difficult for me–and I didn’t know how (or IF) I was ever going to reconcile the fact that I LOVED being a mother, loved the family time—but ALSO loved and wanted to participate in everything that was going on in the hospital.  Every day I realized just how much I did NOT know, and how much more I would need to learn, and how much TIME that was going to take me.  But I also knew I would never be happy doing anything else– I had changed careers, spent hours studying, tried so hard to find a specialty that I could LOVE, and now I knew that this  was IT—so at that moment I decided that nothing—NOTHING   was going to deter me.  (Not well-meaning advice givers that warned against it—-not husbands who felt abandoned—-not friends who told me my child would suffer from not spending enough time with me——and most certainly not all the obstacles that I was not yet even aware were going to be placed before me….) I was back to my “To Do” list—and right now there was only ONE thing on that list—-which was “Become an Obstetrician and Gynecologist”.

9-29-15

My last rotation was Pediatrics.  I had previously been looking forward to that rotation, since I thought it was on the list of specialties that I could see myself doing.  I loved kids–always wanted to have a few of my own– and thought taking care of children and babies would be fun and interesting.  I quickly found out how wrong my thinking was.  Babies were fun.  Examining them was not.  Children were cute.  Doing painful procedures on them was not.  Pediatric outpatient clinics are NOISY—ALL the time..and sick kids pass their germs and sickness onto staff all the time..Sick babies in the NICU were heart breaking.  And the things that we see on a hospital Pediatrics ward can make you wonder what kind of world we live in—with childhood cancers, serious and fatal syndromes, and devastating injuries seeming like an every day occurrence.  There were some good parts—Pediatricians are definitely some of the nicest, kindest people, willing to teach, and mostly loving what they do.  THAT was nice to see.  Trying to figure out what the dosages of medications were for small people and learning how to do procedures with miniature instruments  was very exciting.  One of the responsibilities of the “NIGHT TEAM” pediatric residents (and, as an appendage, their medical students) was to attend deliveries that happened at night to examine and possibly treat or resuscitate any babies that were born.  I recall going to many deliveries with them, and ALWAYS being more interested in what was going on at the foot of the delivery bed, than what was happening in the baby warmer.  In this particular hospital, it was the pediatricians who did the circumcisions, although in many places the Obstetricians did those.  I learned how to do them on this rotation, and thought of it as a “crossover” talent that I was happy to add to my growing list of procedures to perfect.  During this rotation, I spent much time trying to arrange my fourth year rotations, since I wanted to do as much in the world of OB/Gyn as possible.  I arranged one in Maternal-Fetal medicine  (high risk obstetrics), one in Gynecologic oncology (specialty in cancer of the reproductive tract), one in an ObGyn Clinic  ( outpatient services in obstetrics and gynecology), and one in Gynecologic surgery.  Fourth year medical students were also known as Sub-Interns, so even though they were “less-than Interns”, at least they were one wrung up on the ladder from Third year students, so at least I was about to start my ascent.  I also had almost 3 weeks off in between my last third year rotation  and my first fourth year rotation, and it was around the holidays to boot.  My husband, son and I were going to take advantage of what I thought would be the last free space in my schedule for years to come.  We traveled, spent time with family, and were grateful for every moment.  I was ready, in January, to start again.

10/8/15

The first rotation of my fourth year was a four week stint in the ER.  The emergency room had always scared and excited me at the same time.  I had always wondered how doctors could make such spur-of-the-moment decisions that were also life-and-death decisions at the same time.  The excitement of having a patient come in, seriously ill, and watch the coordination of care that needed to take place to stabilize, examine, triage and treat this person (often, all at the same time) was amazing, and although I never really got “comfortable” with all that I at least learned how to prioritize and figure out how to properly evaluate and treat many of the patients who came through the ER doors.  One thing I was surprised to find out was that most of the patients who came through those doors weren’t emergencies at all….they were patients who had no primary care practitioners, or didn’t want to wait until the morning, or a weekday when a clinic or office would be open, or people who just weren’t sure if what they had was truly an emergency.  The unfortunate thing was, that once they entered the ER, every patient was treated as if they WERE there for an emergency—a full history and physical exam needed to be done,doctors were called in, diagnostic studies were ordered, blood was drawn.  Every effort was made to make sure that whatever problem the patient presented with, it would be completely worked up, and nothing would be missed.  Some patients even ended up being admitted or going to the operating room.  The trick was deciding who could safely go home (without coming back in worse shape) and who truly needed to stay.  The ER docs were supposed to be the experts at that—and some were better than others.  The nice thing was that the ER was “shift work”  ( one of the major reasons some physicians decided to go into the specialty in the first place)  The ER docs “put out the fires”–they have a wide range of knowledge in all the various medical specialties, and they don’t have to form relationships with the patients—just save some lives, stabilize the unstable, and send them to the appropriate endpoint, whether that be back to their home, the ICU, to surgery, a medical floor, or, sometimes, unfortunately, the morgue.

10/17/15

Once my fourth year got going, the time seemed to move very quickly. Every rotation was four weeks long, and almost all of them were things I had arranged myself, and was extremely interested in. I was on a different schedule than the rest of my classmates; they were already halfway through the fourth year, applying to residency programs, collecting letters of recommendation and making plans. for graduation.  I was going to join them at graduation, but my plans involved then continuing my fourth year rotations after the graduation, until December, when I too, would be done, and looking toward residency –but although I would finish in December,  all residencies started July 1, so  I would have another 6 months before beginning MY residency.  I began thinking about what I would do with that time.  My son was now almost 2; my husband was working at a new job on Long Island, and I was sure that I wanted to apply to only Ob/Gyn residencies.  I started looking at my options—just stay home with my son?  Work as a physical therapist?  Do a few more fourth year rotations?  Try to volunteer in the Ob department in one of the hospitals where I was considering applying to residency?  I was worried I would be “out of practice” if I hadn’t been somehow connected to medicine for that period of time.  Meanwhile, I was in my Maternal-Fetal Medicine rotation, in which I worked closely with high risk Obstetric specialists, who cared for pregnant women who had “problem pregnancies”.  It was a pair of physicians, a man and a woman, who were kind and brilliant.  They took care of women whose babies had medical complications and conditions, and women with their own medical conditions— hypertension, diabetes, Lupus, kidney disease, HIV, and any number of medical problems which made their pregnancies “high risk”.  I learned so much about what can go wrong in a pregnancy, and how the right medical procedures and care can sometimes help it to go right.  I learned how far medicine had come in intervening in pregnancies where babies had heart conditions, tumors, brain problems and something called “twin to twin transfusion”( which was actually one of those conditions where an operation done ON babies while they were still in utero could possibly make everything all better.)  I also learned that sometimes, there is nothing TO DO, and sometimes, as heartbreaking as it is, doing nothing is the appropriate choice—the humane choice.  This rotation was the happiest of happy and the saddest of sad.  It reinforced my decision to become an obstetrician so I would be an integral part of both.

Then I had what I thought was a brilliant  “AHA” moment!  Thinking about how much I loved staying home with my son for six months after he was born, I thought how great it would be to have ANOTHER baby at the end of my 4th year rotations, and then stay HOME AGAIN  (!) with that baby, in the six months before my residency started!!!  Genius!  When would there be another good time to have a baby?  “NEVER” I told myself–or at least not until I completely finished my residency and became an attending physician, more-or-less in charge of my own fate.  Residency was NOT a time where I’d be likely to be healthy enough, or get enough sleep to take care of a newborn, let alone have a reasonable period of time off to stay home and recover.  I had also heard endless stories about how the other residents resented when female residents not only got pregnant, but dealt with pregnancy related complications and had to take time off, then disappeared for an entire month for maternity leave!  (How dare they)  I certainly didn’t want to be the resented one!  So, what other choice did I have?   I had to figure out how to finish my fourth year rotations, and have a baby right afterward—preferably in  December or January—then have 6 months off to stay home before starting residency July 1st.  I just had to convince the interested parties, since time was of the essence.

10/24/15

My four week rotations seemed to go by pretty quickly; probably because they were shorter, less brutal and mostly things I was interested in.  A gynecologic oncology rotation was so incredibly interesting, watching women, young and old come for treatment for cancers of every part of the reproductive system:  Ovarian cancer, Cervical cancer, Uterine cancer, Fallopian tube cancer, Vaginal cancer and Vulvar cancer all had their own unique presentations and treatment plans.  There were cancers I had never even heard of—like Gestational Trophoblastic cancer (where cells that seem to actually start out as a PREGNANCY end up turning into a scary and deadly malignancy that sometimes goes unrecognized)…cancers of the ovary that were atypical and sometimes struck children, like Granulosa cell tumors, and (who knew?)  there are even cancers which originate in the placenta of pregnant women!  Spending four concentrated weeks in the world of gynecologic cancers was an incredible learning experience.  The doctors, and ALL the medical personnel involved in their care were some of the most empathetic, kind souls, and the surgeons were some of the most skilled and smart people I had met so far.  While extremely interesting to me, and influencing me in terms of my knowledge of preventative and treatment care plans, I was very sure that I did not want to go into this specialty, since it was not the “happy” specialty that I had come to associate with Obstetrics and Gynecology……I wanted to  have my patient percentages weigh more heavily in the “happily ever after” department, although I so much more appreciated and understood the absolute need for what these doctors did.  I knew I would need to find a place like this to refer my cancer patients to, and hoped that when I was ultimately practicing I would be lucky enough to find a similar group, when my patients were in need.  It was also very difficult to “leave the work at work” during this rotation–I often came home from work still thinking about what I had seen that day or that week in the hospital.  I had always been someone who had been very affected by patients’ stories and problems, but this one seemed to hit particularly hard.  I know that I came home during this rotation, sometimes a bit sadder, and sometimes unable to just “shed” the hospital and the activities there and just assume the role of wife-mother-daughter-friend, and whatever else I was supposed to be.  I may have been a bit more distracted than usual……so, not a surprise when it took awhile to hit me that I was feeling a little unusual when April of that year came along……..

10/25/15

One of the great things about my husband’s new job (besides the fact that it was interesting and stimulating for him) was that it had an on-site daycare!  It was called “Companies Who Care For Kids”, and was a little down the road from the office building that he worked in.  He would be able to drop Jake off there in the mornings, and pick him up at the end of the day, and visit him during the day whenever he had a break.  I thought this was great– the situation with our nanny was still good, but  Charlotte was now having her own children, and it became more difficult for her to follow our schedule, so we mutually agreed that Jake would start to go to the “Company” daycare, and we would utilize Charlotte when we needed some night or weekend coverage, or if there were times that he could not go to work with his dad.

In April of that year, while on one of my (few) non-ObGyn related rotations  (a required Medicine rotation)  I confirmed what I already thought was happening— I was pregnant again——my due date?  Christmas Day!  It was perfect—-as long as I stayed healthy, had no complications, was able to tolerate smells of sickness, could  make it through graduation, and was able to continue through my fourth year rotations to completion  (they were to end around the first week of December), things would all go as planned.  I was ever the optimist.

I told no one.  My rotation in May, the last one before graduation, was in Reproductive Endocrinology—in other words, Infertility—-how ironic.  Although it seems that helping couples achieve a pregnancy would be in the “happy” column of the specialty , in reality, it was actually one of the saddest of my fourth year rotations.  Watching people go through cycle after cycle of fertility treatments, ovarian stimulation, egg retrievals, surgeries, procedures  and medications, all aimed at the  goal of achieving a successful pregnancy and ultimately having a baby–when most ended in failure, was difficult to see.  When every menstrual cycle is seen as another failure, and when people bear the incredible expense of doing more and more in an effort to become parents, yet few do,  I could almost not help feeling guilty about how easy it all was for me.  I was grateful that I was not “showing”, nor suffering from morning sickness, or in any way  revealing that I was actually two and a half months pregnant, lest I would cause any of the patients more pain and suffering than they were already experiencing.  It was heartbreaking, and a bit difficult for me to participate in counseling these patients, since, how could I truly understand what they were going through?  This was a major realization in medicine for me– that being able to care for and treat patients depended NOT on whether I had ACTUALLY gone through what the patients were going through—but on the ability to place myself in their shoes, and give them the advice and the medical treatment and counseling that I would have wanted to have from MY doctor, if I were in their place.  I have NEVER forgotten this.

10/31/15

I made it through til early June, and went to graduation with my original Medical School class. It was great, and while I realized it was a great accomplishment, I couldn’t exactly feel the way my classmates must have, since I wasn’t really “done”.  Many of us had not seen each other in quite awhile, as we were all scattered on different rotations, and especially during the fourth year rotations,which were mostly arranged to accommodate individual students’ interests.  I realized that some of our original classmates were missing.  Some had dropped out during the last 2 years; one had actually passed away.  and one or two had failed some rotations and had to make them up.  I realized that most did not know that I wasn’t actually finishing the year with  the class.  I thought I looked pretty huge–at least bigger and more “pregnant looking” than I had the first time at about 3 + months.   (they say that’s a “thing”—looking and feeling “more pregnant” earlier on when it’s not your first time).  I guess that was mostly because I got my graduation dress (to wear under the graduation gown) in the maternity shop because nothing looked “quite right” on me.  My mother, husband, and son were all at the graduation ceremony, and many people didn’t even know I had had a baby right in the middle of things until they saw Jake. (And I heard comments from several people to the effect of “wow–I had a hard enough time just getting through the rotations–and you ALSO had a pregnancy and a baby in the middle of all that?”   Half in awe and half assuming I was insane. It was not the last time I would hear how unusual people thought it was that I was trying to “have it all”)……..at the time I just thought I was being practical.  I was getting older, and planned on having a bunch of kids—it had to happen sometime, and it had to be planned—-and so far it was all going according to schedule!

Everyone in the class had some vacation time after graduation–Residencies and Internships did not start until July 1st  (a scary, looming date for all medical school graduates)  Many of them had gotten spots at their preferred hospitals, and were both excited and anxious about starting “life after medical school”.  I was going on to the next 5 or so months of rotations, and was actually happy that I felt I was still in safe and familiar territory, being a fourth year Sub Intern for several more months.

My next rotation was a pediatric rotation, with a specialty in the Neonatal Intensive Care Unit.  I had actually arranged it because I was kind of afraid of the NICU on some of my other rotations.  I felt I needed to push myself past my comfort zone, and be around small babies, sick babies, scary babies, with many things that could and did go wrong.  I thought, if I was going to be involved in the care and delivery of babies that might need special care, I wanted to get a peek into the world that they (and the parents) would inhabit once they were delivered.  It was quite alarming realizing that some of the babies in there were more or less the same gestation of the one that was inside of me.

11-6-15

The rotation through the NICU was as scary as I thought it was going to be.  It was at the hospital where I had delivered my baby, and although he did not ever need to go into the NICU, I did know some of the nurses and some of the medical students and residents from other rotations, or from other areas of my life.  The rotation included staying overnight twice a week, and many emergencies took place for babies in the middle of the night.  The smallest babies that they took care of were no older than 26 weeks gestation  (37 and beyond is considered full term–so these were “micro” preemies), and the older babies had all sorts of medical problems which made day-to-day life in the NICU touch-and-go for many of them.  I will never forget the nights where babies “crashed”…tiny babies, whose medical issues really seemed to be incompatible with life, or at least with a “good” life—having so many procedures and tubes and medications— it seemed to put everyone in a real dilemma.  Did parents want “everything done”?  Did they understand what type of a life they were going to have with babies that had so many medical challenges?  Often, these decisions involved not only the parents and medical professionals, but counselors, clergy, and the hospital Bio-ethics committee, trying to come to a plan that everyone could live with (but often that NO ONE would really be “happy” with).  I learned a LOT every day—mostly about how lucky parents were who had “low risk” pregnancies and deliveries were, and about how many things could go wrong… and how difficult it was to decide what to do in those cases.

Meanwhile, I was in the process of choosing my own Obstetrician for my current pregnancy.  I was absolutely what would be considered low risk— not too old (AMA, or Advanced maternal age, was above 35, and I was not there yet), healthy, having had not only a prior healthy pregnancy, but an easy delivery just two years earlier.  Possibly because I was seeing so much “high risk” activity in the hospital,  I chose a very Low Risk Obstetrician that I met through local recommendations.  He had a solo ObGyn practice, so I knew exactly who would be delivering me, ( I LOVED the idea that he and his staff knew me; knew my family–although I certainly did not understand how someone could work alone as an ObGYN—this was an unpredictable life–how did he see his family?  How did he take vacations?–I made a “note to self” to ask him about things like that during my visits, so I could “sock it away” for the future)  and he delivered at a community hospital, where they only took care of low risk babies and moms.  My visits were very low key–I got to know everyone in the office; had all my blood work done, and was hoping and planning for a normal, uneventful delivery somewhere around Christmas time.

11-13-15

My next rotation was one I was looking very forward to, for many reasons.  (1) it was located so close to my house that I could walk there (if it were not late August in NY and I were not pregnant).    (2) It was an Ob-Gyn clinic rotation, so it would be daytime hours only.   (3) it was in the largest public hospital on Long Island, which meant I would be seeing a lot of everything,   and,  (4)  it was a place that I would highly consider doing my residency if I liked the program, and the people in the program liked me.  It was a four week rotation, like all the rest, from late-August on.  I was about 5 months pregnant and things were going well.  I was seeing all kinds of patients in the clinic– pregnant patients for prenatal visits, women who needed a general check up,  patients who needed pap smears and birth control, and treatment for infections, women suffering from painful conditions and infertility, patients who needed surgery……I didn’t know how the residents and other health care practitioners kept it all straight (remember–there were NO computerized records at that time, and everything was on paper).  I was still a meticulous note-taker, carrying papers and pads and small notebooks with alphabetized sections in them— I wrote down everything from how to use the intercom system in the hospital, to which birth control pill contained which dose of which hormone–and actually I also was prone to drawing pictures of things (like what an abnormal pap smear might look like, or what were the various phases of the menstrual cycle), especially when I was trying to educate or explain these things to patients.  I was able to see patients by myself, up to my capabilities, and there were various attendings and upper level residents around in the clinic to consult or to give advice when students, or one of the other (lower level) residents needed it.   The whole place did kind of remind me of the other clinic I had seen, as a third year student.  It was crowded, with people waiting around in lines, sitting on chairs, older people sleeping; signs up everywhere to direct patients  (Oncology clinic this way, Infertility patients that way—-so much for privacy laws and other people not knowing why you were there).  It was a bit chaotic, but I was doing–and learning , a great deal, and finally beginning to feel like I was getting “a handle” on what type of things I could talk to patients about, and what kinds of exams, tests and procedures I could do and order myself.  It seemed the big rules were this:  Do NOT do anything that would create MORE work for the residents.  Do EVERYTHING to make the lives of the residents easier.  NEVER contradict the residents, especially in front of patients, and one rule I developed myself—–find out which residents seem to be doing things in the way that makes the most sense to me, treating patients in the way I would want to be treated, and follow them around and learn from them so I could start to do things like them.  More than once I heard this advice from the residents:  “It doesn’t matter HOW you decide you are going to do it—but get a method on HOW to do it and stick to it, so that you never miss anything”.  This made sense to me, and played right into my sense of wanting everything to be orderly in this seemingly DIS orderly world we called “ObGyn Clinic”…..which was staffed with residents who were just trying to finish their shift from the night before and go home, residents on the surgical service who were just hunting for patients who would eventually need surgeries, ( they were nicknamed “the sharks”….)  and various midwives and PA’s who were just trying to give good care to the mostly poor, underserved, culturally diverse population that was Nassau County Medical Center.  I LOVED it!!!!!

11/22/15

Around this time, my husband, son, and I went to a backyard birthday party for the child of a friend of ours.  It was great to socialize with people who were NOT in medicine, and to remember there was a whole world out there with people doing all sorts of “normal” things–going to movies and restaurants, raising children, going on vacations—and having backyard parties.  This particular day was very warm, and my baby was moving a lot.  I remember feeling that I couldn’t keep up with chasing after Jake, who was now over 2 years old, active and interested in everything. I started to feel some cramping– and knew from my experience in the clinic, and from all the books and information I had read—that dehydration can cause cramping in pregnancy- and also that some cramping was normal, called Braxton-Hicks contractions.  They are normal cramps and contractions that occur as the uterus grows and the baby is active, but they do not come with any regularity nor enough force to cause labor, or changes in the cervix.  I hydrated, and rested, sitting in a lawn chair under a tree at the party.  I tried not to be concerned, and did not want to worry anyone who was around me. My pregnancy had been going perfectly– no complications, no abnormal tests, growth was normal on ultrasounds….I had no reason to think anything was wrong.  Besides, it was a Sunday–and I didn’t think it was necessary to bother my doctor for something non emergent.  But when the cramping kept coming in spite of resting and hydrating all evening and into the night, I decided I would call him the next day.  I went in to the Clinic where I was doing my rotation, but when I got there, I called my doctor’s office.  They told me to continue to hydrate, and come in later that day for a visit.  During my stint in the clinic that day, I realized that I was contracting pretty regularly, and although I tried not to think anything of it, I was surrounded by Obstetricians and Obstetricians-in-training, as well as nurses and Physicians Assistants, all of whom were used to seeing pregnant women in various stages of pregnancy with various complications, so when three separate practitioners made comments to me that I looked “kind of uncomfortable” I started to take note.  I left the clinic early, and went to my doctor’s office.  He wasn’t in the office, but his nurse practitioner saw me, did (not much of) an exam, and they took a urine sample from me.  They told me to hydrate, and rest, possibly taking the next day off to stay home, and they gave me a note for this.  I left there kind of feeling like, “Well, if they didn’t think this was such a big deal, I guess I shouldn’t either.”  I did stay home they next day—kind-of waiting for my doctor to call me, to reassure me–to tell me how worried-or-not-worried to be;  I wanted him to reassure me, or give me advice, or SOMEthing…..(and in that day, I made another LARGE note-to-self  about MY eventual future practice—-never leave a patient hanging when they are obviously worried about something……I mean, I KNEW it would be unrealistic for ME to call everyone every day to reassure them and answer everyone’s questions if I had my own office,—-but there are things that CAN be done in terms of returning calls and reassuring patients, even if someone else is speaking on my behalf…..).   I stayed home the next day, drank lots of water and rested…..and worried……every time I felt a cramp or contraction I worried…..and waited to hear from my doctor… who did not call me.  The next day I felt better, and went back to the clinic rotation.  I was sure whatever that was had been only temporary, and all was well now.  I made it to Friday, and then decided that it was strange that I hadn’t heard from my doctor by then, so I decided to call his office.  Imagine my surprise when I asked about my urine culture and found out that it was POSITIVE for an infection.  The nurse told me that they would call a prescription in to my pharmacy, and didn’t sound concerned at all——and as soon as I hung up the phone with them I had made a decision……..I suddenly did not feel so safe and low risk….I suddenly did not feel so well taken care of.  I suddenly did not feel like my “low-risk doctor” was right for me.  After agonizing for a few minutes, I boldly called the office of the High-Risk perinatologists that I had done one of my rotations at—I was practically crying on the phone, explaining that I was almost 29 weeks pregnant, and felt like “something was not right”.  I told them about the urine culture, the contractions, the perfunctory exam, and my fears.  And, bless them, they told me “come right in”.  I went there on that same day  (it was obviously the END of their day–on a Friday, and they STILL said to “come right in”).  They did an ultrasound, a thorough exam, with other cultures, and told me that my cervix, although not open, was 60% effaced  (or, more than half-way shortened–a NON laboring cervix should be 0% effaced)  and they were worried that the contractions I had been feeling were pre-term labor contractions.   They were very reassuring, but they told me that I would REALLY need to decrease my activity, stay well-hydrated, and do regular monitoring and exams to see if I would continue to be at risk for delivering early.  I asked them if I could transfer my care to their practice, and deliver with them.  They were SO kind, and so welcoming that I just about broke down in realizing the catastrophe I might have just avoided.  So much for “normal”.

11-26-15…….Happy Thanksgiving!

I was very busy “giving thanks” for having likely avoided a possible pre-term delivery, and when I returned to my clinic rotation, which was almost done by then.  I made sure to tell them that I would need to do shorter days, and perform many of my duties from a sitting position, with breaks in between for the bathroom and hydrating.  They were accommodating  (as they should have been, given their specialty training and knowledge of potential preterm labor problems).  I finished out the last week or so continuing to learn, see and treat patients, while also taking better care of myself and seeing my new high risk doctors frequently.  I made it to the early third trimester and had two more rotations to go– one was actually a mandatory “lab” rotation, where I was to work in a laboratory with a pathologist, looking at specimens that were sent by surgeons for identification and reporting.  Although it had never been my plan to  work in a specialty where I was not in direct contact with patients, I did feel it was important to know the “other side” of doing lab tests, biopsies and samples on patients—who is looking at these specimens and diagnosing conditions we were treating?  What were they seeing?  How did they know what diseases my patients had?  Not to mention that this was an all-day-sitting-no-overnight-shifts rotation that came just at the right time in my pregnancy. It was actually relaxing and calm.  It was interesting (sometimes)  and  boring (sometimes), and I found that pathologists and other lab workers are an interesting bunch—the things that excite them are surprising  and strange  (More than once, someone excitedly called me over to look at a bunch of cells under the microscope because he saw an exciting and unusual configuration  which led to some rare and interesting diagnosis.)  I was just, in a way, buying more time for the baby to grow and to think about my future.  My last rotation was to end around Thanksgiving, and my baby was due on Christmas Day—-so I would hopefully have the last few weeks after being (anti-climactically) done with my fourth year rotations (and medical school in general) to really rest and get ready for the new baby.  My pre-term contractions seemed to have gotten under control, with resting and hydrating—I was now also going for weekly monitoring sessions or NSTs  (non stress tests) to check on the baby’s well-being and check for regular contraction patterns that I might have not been aware of (although I doubted it—since I was so sensitive to contractions and constantly doing things to reduce their frequency and intensity).   My LAST rotation would truly be a test—–to see if I could make it through without this baby making its appearance.

12/12/15

At my 36 week prenatal visit, my doctor checked the position of the baby—head down, and ready.  He also checked me– and said that since the last time I delivered I was so advanced in labor before even getting to the hospital, this time I should not wait until the contractions were very very strong, or even very regular—I should call them and go in to the hospital when I was feeling “something” different–a sensation of pressure, or unusual aches and pains— even if I was just worried.  All so I would have a chance to calmly (?) get to the hospital before I was in advanced active labor.  I had just finished my last rotation, (Endocrinology, which was a clinic rotation with regular hours, and lots of days off….)  and although I was excited to be done with Medical school, I had only my family to share it with–as I was un-ceremoniously FINISHED,  had already gone through the graduation rite-of-passage, and would not be starting a residency til the following July.  I was just starting to think about applying for residency spots, when……at 37 +  weeks, I was trying to fall asleep, without much success, and I suddenly realized I WAS feeling “different”.  I felt a LOT of downward pressure and achiness.  I thought we should head over to Labor  & Delivery at least to get checked—it was 1 AM.  I called my doctor, who said to definitely go in, and my mother, who had been staying with us for just this reason, was ready to stay with Jake.  We drove to the hospital, which was about 20 minutes away, and I got progressively more uncomfortable as we traveled.  When we got there and checked in, I was uncomfortable but not tremendously so. My doctor came in and checked me—–and  told me I was staying——I was 6 centimeters dilated.  This is considered active labor, and based on my past experience, meant that I would soon be having the baby.  It was quick but not emergent.  I was laboring and breathing through my contractions, and the nurse came in to see how I was doing.  I told her I was okay so far, but I must have looked pretty uncomfortable, because suddenly she appeared with a syringe of Demerol  (Narcotic pain medication) and asked if I wanted her to inject it into my IV.  I never was much of a pain-medicine-user, and although labor pain is truly in the category of “other dimension” pain, I asked if she would divide it up, and give me half of the dose first, and if I needed the other half I would get it later on.  She was fine with that and proceeded to inject 12.5 mg of Demerol into the IV.  (usual dose was actually 50mg, but the doctor had ordered 25mg, since I really hadn’t asked for anything, and I, even in pregnancy, was a pretty small person, likely to be adversely affected more by the larger dose).  The nurse had just started to inject the dose into my IV, and before she even pushed in the total half dose, before I felt anything like relief, I felt something else…..I said, “I need to push”………and I did.   Four or so contractions later, at 5 AM, Danielle came squealing out into the world, tiny but perfect, and I only could think of the line in the Grinch movie, where my heart “grew three sizes that day”.  All my fears about not having enough love for another child went away  (Still wasn’t sure about having enough energy for another child, but wasn’t thinking about that at the moment).  I didn’t think about medicine, or travel, or exams, or residency applications…….I only thought about how thrilled I was, and how lucky I was to have this new, perfect baby right there, in front of me, ON me, and next to me……after all I had seen, in high risk obstetrics, and in NICU’s, and in perinatal clinics…and all I had been through to avoid them……I was SO overwhelmingly happy. And felt so lucky.  And was definitely and absolutely in love….again…..

12/20/15

In the whirlwind that follows after bringing home a new baby, it was easy to forget that the title of “Doctor” had just been bestowed upon me.  Except for being continuously sleep deprived and exhausted, I didn’t feel very “Doctor-y”.  I was so happy that I was going to have 6 months at home with my new baby—-but so afraid that the very real entity of “baby brain” would do much to eliminate all the wonderful knowledge that I had accumulated over the last four years.  I was going to try to NOT let that happen, because no one would want to hire a resident with baby brain.   We pretty easily got into a routine in those first few weeks– Jake was sometimes going to the Company Day Care with my husband, and sometimes staying home with us.  I truly think that at 2 & 1/2 years old, him having his own place to go and his own scheduled activities was  better for him–and for all of us in general.  I truly believe that old adage about giving your children roots AND wings– better for them to have their own activities and opportunities to go out and explore-even at age 2-knowing they have a safe and stable home to come back to. Nursing a baby on demand is kind of like having a full time job, and although I always felt I was a pretty capable person, managing a toddler and a full time nurser seemed a lot for me to handle immediately.  When my husband suggested that we take a trip–all four of us, to visit his family in Israel, I initially thought that it was an impossible task.  But when he pleaded the case that once I started my residency we would probably not have a chance to go see them for the next few years, I reconsidered.    Planning the trip was another full time job, and although I had traveled a great deal, planning to travel with a 2 yr old and an infant was a completely different story.  Looking back now, I really don’t know what I was thinking, other than perhaps equating babies to backpacks–and maybe just thinking I could do what I had always done–put the baby in a “backpack” baby carrier of sorts, and go about my travel plans…….how incredibly naive.   We boarded the plane for Israel with a 2 yr old and an infant, and all I can say is that it was ANYthing but a vacation.  We stayed in an apartment with not-great plumbing and no air conditioning.  We also had to walk up several flights to get to the apartment.  There were always tons of family around—and, while I appreciated all the love and well-wishers, and, for SURE, the “other people did all the cooking” thing—-it was very hard for me, since I was pretty permanently tied to a nursing baby, and although I am not squeamish about nursing with other people around, many other people were–so I spent a lot of time excusing myself from family meals and festivities to go into a hot bedroom and feed.  It also didn’t help that my command of the language was less-than-fluent, and although I spoke conversational Hebrew and could travel around by myself if I needed to, it seemed no one in the extended family was interested in answering  inquiries about how to buy a bus ticket or how to get to the library?  My husband was definitely NOT great at “noticing” when I was in distress, and I have to say, at that time, I was not great at making my needs known in a calm, non-confrontational way  (I have since gotten much better at that), so, needless to say, the trip was what I would call “Less-than-successful” and I practically MADE him promise that we would do another trip, very soon, where the goal would be nothing but rest and relaxation.  When we came back, I knew I had to dive into the world of applying to Residency programs, and I was about to get a big education on exactly what that process entailed.

12/31/15——Happy New Year!!!!!

Applying for residency programs as a married mother of two babies was not the same as applying to residency programs had I been in any other situation.  Residency application time is not a time to be “picky”, or “particular” about where one applies— it is so hard to get “matched” into a program, that the more potential places one can apply, the better the chance of getting into at least one!  The “match” process is performed through this crazy algorithm method that is supposed to ensure that each residency program accepts the best available graduating medical students for the program….but it is kind of confusing, very limiting, and often, not enforceable.  It goes something like this:  Graduating medical students apply to residency spots sometime in their fourth year of medical school.  After they apply, the programs review the applicants, and offer interviews to a select group of students.  After the interview period is over, the applicants and the programs each compile a “ranked list”—-the students make a list of the programs they would like to attend, in rank order, and the hospitals compile a list of the students they would like to have in their programs, from most to least preferable.  Once these lists are officially set and submitted, a computer goes about “matching” the candidates with the programs.  In March, a list is published, listing all the candidates that Matched with whichever program accepted them.  It is supposedly legally binding, that if a candidate matches with a residency program, they then MUST attend that program, so every program on the list must be one that a candidate would go if accepted.   In my situation, relying on the income of my husband to allow us to make it through the next few years, we had limited options on where I could go—and we needed to stay close to where child care would not present a huge obstacle.  I ended up applying to every ObGyn Residency program in a 60 mile radius.  That amounted to all of 8 programs…….not a great wealth of possibilities.  I didn’t even think about what I would do if I looked at that published paper that came out in March and I hadn’t matched!

I should have considered that possibility.

1/9/2016

The way that medical students found out whether or not they “matched” was a list that was published in a newspaper called USA Today.  EVERYONE knew which day the paper with the Match List came out, and everyone had been assigned an individual “match number”.  We were supposed to get the newspaper, look for our number, and next to the number would be the name of the hospital that we would spend our next 4  (or, 3, or 5—-or more) years training at.  The matches would be listed in numerical order, so even though the list was long, it could be easily narrowed down to a single area to scan for our number.   I remember these moments like it was yesterday.  The nearest newspaper stand was a short drive from my house and I woke up early to sit in the parking lot and wait for the newspapers to be delivered.  I saw the truck pull up, and unload the pile of papers.  I went right in, and bought the first one on the stack.  I brought it out to my car and prepared myself…..where would my residency be??  I quickly scanned down the list of numbers to get into the “neighborhood” of my assigned number.   I kept scanning.   And searching.  And scanned more slowly. And I realized……my number was not there.  I must have looked through the list twenty times.  The significance of my number not being there——of my NOT matching to a residency program—began to creep over me like a slow-moving illness.  I got nauseous……I got a headache……..It was suddenly so warm and so cold in that car at the same time……..and I started to cry.  Not a small, quiet sob—- realizing I was in a car, alone, with the windows up—at 6 am, in a mostly-empty parking lot……..I let it go……and cried and cried, until I felt there was nothing left to cry. I could not believe this was happening.  I HAD to get it all out before I got home and faced my husband, my babies, my mother……and I could not yet think beyond that very moment in the car.    When I got home, I felt stunned…like I was in shock, moving in slow motion.  I had worked so hard, changed careers, had a laser-focus when it came to my choices…and now it seemed that that may have been all for nothing.  I did not feel I was being dramatic.  It seemed that something I wanted so badly was not going to be offered to me, and I had no idea what–if anything–I could do about it.   It was 1993–there was no Google search for “What do I do if I don’t get into a residency program?”  But there had to be something I could do.  I just had to find out what it was……..

1/15/16

Once I composed myself, I got ready for all the questions that I was sure I did not have the answer to…..what was I going to do now?  Would I consider another field?  Would I just take a year off and reapply next year?  With all this swimming around in my head, I at least attempted to get some advice from people who had “been there”….other students and residents who had gone through the match, and really anyone that I knew, in all my hospital-medical-school-friend connections who could direct me.  It turned out, that there were likely to be quite a few people in my same boat—since the match system was somewhat circuitous– the algorithm sometimes seemingly unfair—there were likely to be people left without a matching residency spot.–Which meant there might also be residency programs that were left with unmatched spots!  It seemed obvious that “after-the-match”, there were people that couldn’t move, people that got ill, people that were unhappy with the prospect of going to a hospital that they had placed last on their lists.  I just had to know how to get in touch with someplace where that might have happened.  There were several ways to do this  (none of which were yet involving the internet or websites, since it was still the early 90’s).  One–was the old fashioned way-  I just got on the phone and called the Residency director’s office at every local hospital’s ObGyn department, as well as some that were not so local.  I figured, if someone was in need and I could get a spot, even one in Manhattan, Brooklyn or the Bronx, (none of which I had applied to) I would take it and work out the commuter details later.  (even though one of my earlier “notes-to-self” was that I did not want to work somewhere that involved a long commute—the prospect of working NOwhere made the commute seem sort of inconsequential).  I really got nowhere with those phone calls– it seemed everyone was quite happy with their choice of obgyn residents, and at least it seemed like all the residents were all happy with their hospitals.  The next way to find out if there were any “after-the-match” spots open was through a clearinghouse that was updated daily.  I would call a number, and a recording would list, in alphabetical order by state, which positions in which hospitals were yet left unfilled.  I was listening for three major details——“New York”…..”ObGyn Residency spot”…..and “PGY-1”  (Post-graduate year 1–the intern spot, or the first year of residency).  I heard all about “PGY 3 spots open in Columbus Ohio”, and “PGY 2 spots open in Arkansas”  but although I called that number 10 times a day (or more, as it was updated every time a resident dropped out of a program, and every time someone took one of those open spots), I NEVER heard all three of those qualifications in one residency description.  After a few days, I felt like I was going crazy.  I knew what I did NOT want——and that was to take a year off, or work as a Physical Therapist (if I even could), or end up in another specialty.  (Another note-to-self from the past—-“don’t go into a specialty that you don’t LOVE or you will be sorry for the rest of your professional days”).  But the reality was—if we weren’t going to move to Arkansas, and I still wanted to be a physician, maybe I had better look into some other pathway?  As the time went by (it was now April, and residency was to start July 1st) I had to get realistic about my options.

1/16/16

After considering my options, (or lack-thereof) and as the July first starting date neared, I had a serious conversation with my husband about what I should do.  He was completely, one-hundred percent against the idea of moving somewhere else just so I could get into an ObGyn residency program.  In a way, I understood that–we owned a house, had kids, needed stability, and he had a good job.  But weighing the idea of NOT going into the specialty that I felt I had to go into, based on my past few years of experience, against uprooting our lives temporarily for me to follow that pathway, made me into what I realize now, was kind of an unreasonable person.  All around me, I saw people moving  to accommodate their family members who had gotten coveted spots far away– I really wanted to hear my husband say that IF that were the only way I could become the type of physician I really wanted to become, he would find a way to make it happen.  But he did not.  He actually said that maybe it would be better if I pursued some other specialty— would it be so horrible if I followed my original plan and went into Rehab medicine?  Or Pediatrics?  Or Family Practice?  I couldn’t help but answer  “Not so horrible for WHO???”  I knew he was thinking about our future—a future of waking up at night to run in to deliver babies…of nights being away from home (and leaving him to play “Mr Mom” with two kids ) too frequently .  He was calculating what the eventual outcome would be for us as a family—- and freely discussed that the difference in income that I would make as an ObGyn would likely not make up for all the extra hours I would have to put in to become one.  My argument was always the same—-it wasn’t about the money…or the hours….or the nights….or anything else.  It was that THIS was the specialty I wanted, and THIS was the specialty I knew that I’d be happy in.  So the more I dug my heels in about that, the more we ended up arguing, and the more I felt (dramatically) that he did not really know me very well, if he could think I would be happy in some other specialty.  We were at an impasse.  I called the Clearinghouse number several times a day….nothing…..And the time was passing.  At the beginning of June, I got a call from a friend who had gotten a spot in a highly regarded Pediatrics program in a local Children’s hospital.  She told me she had started her Orientation meetings there, and heard that one of the other first year Pediatrics residents had dropped out before starting because her husband had gotten a residency spot somewhere else and they were moving   (SEE??)   She thought I might be interested in going into Pediatrics, and if so I should call there right away and tell them I was interested in the spot.  My first thought was to say no.  My husband, however, was completely on board with the idea—–I would be a great Pediatrician, he said—the hospital is very prestigious, he said— Pediatrics will be such a better lifestyle for us as a family, he said—-and,  having no other viable options,  I decided to call, finally feeling that maybe I had been a little selfish, not considering his feelings, and trying to plan as if I were a single, unattached entity —-and trying to convince myself that, maybe being a Pediatrician would be better for us  (and who knew if they would even take me??)   I called, and decided to be (almost) completely honest with them–I told them that I had decided I EITHER wanted to go into OB/Gyn OR Pediatrics, so I had applied to ObGyn programs for the match, since there were fewer spots, and knew that I could apply for Pediatrics programs “after the match” if I wanted to  (no one really wants to hear that they weren’t your first choice). I told them I had done several rotations in Pediatric situations, like the NICU, and Family Practice offices where they had children as patients. (I didn’t tell them that when I did a Peds rotation and we were summoned to the delivery room to attend a delivery I had a hard time keeping my attention on the baby and away from the delivery—-I didn’t think that would go over too well).  They must have liked me well enough on the phone, because they invited me in for an interview the next day.   I accepted.  And then went into full- panic mode.  What if they really do offer me a spot?  (I had been sort-of hoping that if I applied for a Peds spot and they said “No” I would be able to continue stating my case)…I just kept trying to tell myself that it would be fine—-let’s take this one-step-at-a-time as I had done so far all along in my Medical training— interview first, then decide.

1/22/16

I went for the interview and spoke to the Residency program director, then several residents, then took a tour, and then met with the Chairman of the department– and the whole time tried to imagine myself in their roles—caring for babies and infants and children….I had a thought—-maybe I would become a pediatrician and ultimately specialize in adolescent medicine—then take care of teenage girls– who truly need caring, competent practitioners who can really listen to them and create a nurturing, healthy relationship…..hmmmmm.  As I thought, and chatted, and interviewed, and discussed….I did start to convince myself that this wouldn’t be so bad.  And then came the question I was dreading—  “What would you do if you started your residency program here, and THEN a spot in ObGyn came up——?”  I was thinking about this and how to answer it.  They knew I had applied only to ObGyn residency spots—so OBviously Pediatrics was not my first choice.  They wanted to know that I was “in”…..that I would not leave in the middle and cause them to be short a resident and cause a problem for everyone else there.  I looked him right in the eye and said, “Once I start—I am not going anywhere—I will not reapply to the match, and I will not even call the clearinghouse to see if there are any other spots available.  I am the type of person who finishes what she starts”……and I really did believe it…..at the time…..really.

2/5/16

Quickly, it was the week before I was supposed to begin my Residency Orientation Week.  I had (mostly) stopped agonizing, and had accepted my career path.  I was enjoying the last few weeks of Spring with my family.  I knew that once I began my stint at the hospital it would be a long while before I would “come up for air”, and a very long while before I had any semblance of a normal life.  We had everything arranged—The house was ready.  Furnished.. Fully stocked.. We had arranged various baby-sitter/nanny/child care situations.  My mother was in the process of selling her house so that she could move into the upper ( but separate) floor of our house.  She made it clear that she was not “THE” babysitter, as she still had a full life of stuff to do– she volunteered, and traveled, and taught– but knowing that she would be there sometimes was going to be a relief.  I started reading all the Pediatric books and information I hadn’t read before, and started looking at my kids–and ALL kids I guess, as potential patients.  (What was that cough?  was it Croup?  was it Pertussis?  How would I know??)  I was ready………………………………………………………and then came the call…………………………………………………………………………………………………….

……. The call that was going to change my entire life, my career path, my belief system, my faith in the world, and  send me into a tailspin.

I picked up the phone ( It was ringing)   (I remember the EXACT words 🙂   “Hello.  You don’t know me, but my name is Tom.  I’m a resident at Nassau County Medical Center, about to start my fourth year, and I heard you were one of the applicants who wanted to come here as your first choice but didn’t match— am I right?”……and I thought…..Thanks for pointing that out……..Is he calling to rub it in?  What is he saying?  Why is he calling me?  I quickly said, “….yes…..”  He went on— “Our residency program has four residents per year……”   (which, of course, I knew —-I knew everything about that residency program since it had been my first choice   —-It was the one that was almost down the block from my house; the largest County facility on Long Island, and the one where I had done an ObGyn clinic rotation when I was pregnant with Danielle and needing to sit down periodically because of my preterm contractions……I even actually knew the guy who was calling me but I didn’t want him to think I was a stalker so I just kept listening….)   “We have been trying to get an additional residency spot funded for the first year, since there is so much more work to do for first year residents than for the rest of the residents….and until now we were never able to get approval, but I heard this morning that they are getting approval for another first year spot, starting this July first (which was in less than 2 weeks).  It’s going to go on the “clearinghouse” tomorrow, but if you were still interested……….”   INTERESTED??????????   I had no idea what he meant by a “one year spot”……I didn’t care about the “so much more work” thing…..My heart was racing.  I was nauseous… dizzy  — I ran out of my house and jumped into the car and drove the short distance to the hospital, and made it to the office of the chairman of the department at the hospital almost before Tom even hung up the phone on his end…..I saw him there……… I had a pen in my hand and, literally, said, “where do I sign?”.

2/7/16

…as if it were going to be just that easy…..  I found myself in the crowded office of the Chairman, (were they other potential candidates for this spot?  Were people being called??) meeting him for the first time.  He was an elderly gentleman, white-haired and a bit stiff.  He knew who I was, and Tom, the soon-to-be fourth year resident who had called me, was  there too, obviously advocating for me.  (It turned out Tom had gone to the same medical school that I had, and, besides knowing me a bit from my prior rotation, was really trying to get more people from our school into the residency program at this hospital.)  They explained in more detail what was going on:

The residency program at this hospital was always what is called a “traditional residency”– this means that there are four spots in each year of the program.  They expect, as long as the performance of each resident is adequate,  that all four residents would advance to the next, and then the next 2 years as well in the program, all graduating together from the residency program after the fourth year.  (Of course, things happen during residency, like people get sick, or move, or change careers, or drop out, or flunk out— but if none of these things happened, then each resident was basically guaranteed a spot in the program for all four years). Then,  there are some programs that are called “pyramid” programs, where there is so much work to do in the first year, or in the first two years, that the residency follows a path where the first year has MORE spots than the subsequent years– ie, Five spots in the first, then four in the second, and then, depending on the program, either four in the next two years, or even fewer.  In this type of a program, it is up to the performance of the residents which ones would move on to the next year.  Obviously this promotes competetiveness, and sometimes  bad feelings among the residents, as they know that they are being scrutinized and compared, and may be “the one” to lose their coveted spot in the next year of the program. ( Why would people help each other out if they would be helping someone else keep a spot over them?)  What they were telling me about THIS program, was that, now that they received funding for a new first-year residency spot, was that this would be different from a “traditional” OR a “pyramid” program.  The “extra” spot would give them 5 first year residency spots–  but the second year and subsequent years would still only have 4.  The extra spot would NOT be in competition with the other people who had already gotten spots in the first year in that program; it would be known by everyone that the extra spot was exactly that—a “one year” spot, which was NOT designed to go on to the second year in the program.  The other four residents would move on, and the person in the extra spot would have to do one of several things—either apply for a second year spot in another program (ie, go back to the “clearinghouse” and seek out a 2nd year residency position), or, if someone from the original first year class did decide to leave or flunked out or for some reason did NOT want to continue on in this program, the “extra spot person” (as I was beginning to think of myself by now) could take the vacated spot in the second year and move on.  OR  if no one decided to leave the program (or, had to), then they would guarantee a FIRST YEAR spot to that person in the following year—–yes, that’s right—they would OFFER this person a chance to START OVER in the program, repeating a first year that they had already done, but in what would THEN be a guaranteed spot for the next four years, taking five years to complete what was essentially a four year residency.     WOW.    Suddenly this didn’t seem like the best of choices…….. AND, they told me they needed me to make a decision NOW….because there were other people that would want this spot if I didn’t, and they needed an answer.   I felt like I was on an emotional roller coaster——I had JUST felt settled with my decision—-(felt kind of “medium”)…then I got this call (felt like I was so “up”)….and now, with this extra bit of info, I felt so “down”…… was THIS really what I wanted??   Was it fair to subject my family to an additional residency year?  I had about ten minutes to think about it…….

2/13/16

I must have looked like I was just about to spiral into madness……I KNEW what I wanted, and for every reason that I wanted it.  But my decisions were not just all about me, and hadn’t been for awhile  (There’s nothing like having two kids under the age of three to make that thought a laser-sharp reality ). I KNEW that moving somewhere else had been off the table….I KNEW that I was  THIS CLOSE  to starting on a (somewhat “easier”?) pathway toward becoming a pediatrician… I KNEW that this was an unbelievably unexpected opportunity that was GOOD-but-not-GREAT in the fact that it may take me a whole additional year to complete my residency and get on with life as a normally functioning physician…..I KNEW that my husband and probably everyone I would ever ask an opinion of would likely be against it…….  So…….I asked Tom what he thought….  (Tom—the person who I did not really know, but I somehow trusted, because for whatever reason and motivation, HE had called me about this opportunity, so I thought, in some way he may have my best interests at heart…..)  Tom said, “You should take the one-year spot, because every  year in the past 6 years, one of the first year residents has dropped out at the end of the first year….”  ( Information that I MAY not have thought helpful?!  Were they leaving because the program was horrible?  Were they picking poor candidates?  Were they overwhelmed? Abused? Not learning enough?)  Although it would make that first year spot more attractive, thinking that I would be able to “slide” into the abandoned spot—-I also had no guarantee that anyone would leave, so I could not make my decision based on that.

So, even though I was sort of unsure about my decision, after weighing the pros and cons,  (PRO:  I WANT to be an ObGyn,  It was right near my house. It was a busy county program with lots of volume,  so LOTS to learn.  SOMEone is likely to leave, even though there was no guarantee.   If I didn’t take it NOW, someone else would…..Oh, and, more important that anything else—–I WANT TO BE AN OB GYN.  —–CON:  It will likely take me five instead of four years.  Everyone will be against me, even angry at me.  I was NOT discussing this to death with my family,  or asking my husband’s opinion, so they probably had a good reason to be angry at me.  I had to tell the Pediatric program that I was out.  I was committing to a known difficult specialty that was likely to be hard on my marriage and my kids, probably for the rest of my life. ) —–  And with that extremely unbalanced list of Pros & Cons, weighing of course much more heavily in the “con” department (for any sane 30 year old person) , I did probably the most selfish thing I had ever done……..I signed the contract.   The combination of fear and elation were enough to make me  faint.

2/26/16

Now there was just the aftermath to deal with…..  As expected, once I explained the entire situation, especially the idea that I MAY have to do an additional year, no matter HOW I performed, my husband was less-than-supportive.   (That is an understatement—he actually told me he thought I was making a mistake, and I was somehow probably jeapordizing our marriage.  He actually used the statement “I am not planning to be “Mister Mom”, and advised me that we would absolutely have to hire babysitters, childcare, AND rely on relatives to take up the slack for me and my long hours  away from home).  All I could reply was that “It takes a village”…..I was already more-than-ok with multiple care givers being involved in my kids’ lives– I truly believed in the need for children to be comfortable with many and various people in their lives, and it was never MY idea to be “Ms. Stay-At-Home mom”, so whatever career path I had chosen, I knew there’d be many people helping us out.  I did not back down, but the conversation prepared me for what was to come—essentially not to expect his unconditional support in my decision, because he really did not support my decision at all.   OK. Point taken.  Of all the other people I told of my plans, there were a few medical school colleagues who were supportive—they seemed to understand the idea of “having to follow my passion”.  Other friends were happy for me but voiced their concern about how difficult it was going to be—– and surprisingly, my mother was very supportive.  Although her true understanding of “what was to come”, and what it was going to take for me to achieve my ultimate goal was somewhat limited. she seemed happy that I was happy.  And although she had already informed me that she was not “the full-time babysitter”,  she was now living upstairs from us and enjoyed being around her grandchildren at the times of her choosing.

I knew I had to tell the Pediatrics program about my decision as well.  I called the office of the residency program director.  I addressed the situation head-on.  I knew it would be uncomfortable, but I had decided honesty was best, and like pulling off a band-aid, I just wanted to get it done as quickly as possible.  I told him, “You know how you had asked me what would happen if I got an Ob spot once I was already IN the Pediatrics program, and I had said, that once I had STARTED I would not leave?—Well, since I haven’t yet started, I have decided to accept a spot in an ObGyn residency program.  I realize this puts you in a bad spot, and I’m really sorry, but I’ve gotten an opportunity that I cannot turn down”.  I didn’t go into details.  I just was quiet after that.   He did not say much, but did let me know that there were plenty of other people that would be happy to get the opportunity of having my spot.  I thanked him for understanding and hung up as quickly as I could.

Now I had about a week left to get ready for the next four (or, likely —5) years of my life………..

3/5/16

I got myself ready to attend  my two-day orientation.  There I would meet the other residents of various years that I was going to be working with. I would also meet many of the attendings, learn more about this residency program, the department of ObGyn, and the hospital in general. There was also endless paperwork to fill out since this was a county facility, and therefore I was essentially working “for the county”, which also meant that I was a “government employee”, with all its attendant layers of information-gathering  and scrutiny.  On the first day, I met the other residents that would be my immediate colleagues, the other first year residents that had matched into the program, and would be there for the next four years.  There were two men and two women.  I was older than all of them (no surprise), and one of them had even come straight out of a “combination” program, where he had gotten his Bachelor’s degree and his Medical degree in a total of 7 years (instead of 8) so he was really young.  They all seemed nice enough, and I had decided before even going in to the orientation that I was going to just keep repeating in my head that I was HAPPY  and LUCKY to have been given this opportunity; I was going to learn everything I could, work hard, and utilize my already-acquired maturity and life experiences to just try to get through it without resentment, or anger, or comparisons, or perseverating on my situation.  ( I had no idea how often I would need to keep repeating this to myself!!).

3/13/16

The first year of residency, also known as the Intern year, is always the most difficult.  We were “officially” now doctors, and unofficially a bunch of scared, confused, and soon-to-be exhausted glorified medical students who were hoping that someone would not only show us what to do, but protect us in the process.  There was so much to know, from how the various hospital departments ran, to how to interview and examine patients, to how to draw blood, place IVs, and deliver babies.  Every intern is supposed to be “joined at the hip” to an upper-level resident (a 2nd or 3rd year ) whose job was to make sure we were  (A)  learning the right way to do everything, and (B) not going to injure or kill any patients.  Each of the five interns was assigned to a different rotation, which were to last 4 months.  There was one of us assigned to Labor & Delivery, one on Gynecology, one on Night Float, one on electives (Emergency room,  ICU, Primary care Clinic) and the last one would be placed “wherever more help was needed”.  Each rotation had its own set of responsibilities assigned to it, and the intern on that assignment was the lowest ranking member of the team  (see the statement from a previous entry that “all sh** runs down hill”) and was expected to be the “point of first contact” in all patient care situations.  The teams in each rotation consisted of an intern, a mid-level resident (from the 2nd or 3rd year, depending on the rotation) and a 4th year resident.  Since the intern was the first contact, he/she was expected to do all initial evaluating, examining, and questioning— then present that information to the resident at the next level on the team; the upper level members would then (supposedly) teach the intern how to manage the case, and together they’d come up with a plan.  Of course as the year went on, more and more responsibility would be given to the intern, and by the sheer volume of patient care, the intern would start to feel confident and competent in his own decision-making, until the next year, where they would then teach the skills they have learned.

All of this, of course, describes what happens in  an ideal situation.  In reality, the quality of the teaching and the eventual competence of the residents would be quite dependent on the individual upper level residents doing the teaching.  There were many different personalities in a residency program with 21 residents at various levels, 8 attending physicians, and various other staff intertwined in the daily day-today running of a large and busy department of Obgyn.

3/19/16

My first rotation was (surprise) as the “extra” person who was to be placed in whatever situation required additional help.  This would sometimes mean being in the Clinic during the daytime, in the Delivery room when the Clinic was over or well-covered, and being endlessly called by the post-partum floor for orders and explanations.  It seemed to me that most of the residents were actually unaware that I was in a “non-continuing” position, and awkwardly wavered between treating me just like everyone else, and acting like they weren’t exactly sure what my role and responsibilities were.  I could tell that many of them definitely thought that I was in this position because I was somehow not as smart or not as knowledgeable as the other first year residents.  (I had decided ahead of time to be ready for that assumption, and not allow it to bother me—-much…)   But after the year got underway, it seemed apparent that all 5 of us were considered equally ignorant– and  held equally low-level powerless positions where we were (equally) expected to arrive early, to  work tirelessly, to stay as late as anyone needed us,  and to  have heads full of knowledge regarding every aspect of every last thing we were doing. We should also be willing and able to access that info. when “pimped” by anyone with more seniority and power, and the desire to see us sweat.

The fourth-year residents were three men and a woman. There was a huge variety among them when it came to teaching styles and personalities, and since each rotation lasted about 10 weeks, I got to know them all pretty well. The first one I worked with was the woman, and she immediately struck me as a very smart, very organized, no-nonsense kind of person.  She met regularly with the more junior residents, and made it clear what her expectations were.  In the first few weeks of the rotation, she rounded with us, and explained things clearly, and did quite a bit of teaching.  She also made me nervous because she was always asking questions about why we were doing what we were doing and definitely expected us to have answers at-the-ready.  After the first few weeks, she expected ME to round by myself on the post-partum floor, which I had (mostly) remembered how to do from being a medical student, and, after the next few weeks, she made it clear that she did not want me to report back any “normal” findings to her–that I should take care of all the run-of-the-mill stuff myself…….but she made it equally clear that when there was something she NEEDED to know about, I should know enough to report it to her for some direction.  So, my first lesson (of many) of the first year of my residency  was—— KNOW when there is something happening that someone above you needs to know about…..and KNOW when there is information that they would prefer you not bother them with…….(especially at NIGHT!!)

3/23/16  (I’m in Canada, ey?)

We first year residents worked long hours and long days– this was in the time before there was a limit on how many consecutive hours residents could work.  Before someone decided that overworked and sleepy residents are NOT who you would want taking care of patients, especially in emergency situations.  (It took someone dying in an emergency room to have the new laws implemented—and residency training was never the same again—-(Google “Libby Zion”).  Since there were five of us first year residents, and one was on the Night rotation, the other four would each rotate through being “on call” each of the four weekdays— which meant that Monday through Thursday, when the first year residents were done with whatever duties they were performing during the day (somewhere around 6 to 7 pm), ONE of us would then have to stay until 11 pm, (of course, along with an upper level resident to make sure we didn’t commit any horrible errors, especially in the first few months) when the night shift came on.  The night shift worked overnight until 8 the next morning, except for the first year resident, who then had to stay and attend the Clinic of the day until noon.  The 2 higher-up residents from the night shift got to go home at 8 am after night shift, to return at 11 that night. Weekends were a whole other thing.  A team of three were on call all weekend, Friday thru Sunday, when at 11 pm Sunday the night shift would return.  Since the first three months, I was on the “extra person” rotation during the day, my days were taken up, from 7 am to 6 or 7 pm, with whatever I was needed to do, wherever I was needed to do it.  (it was a lot of being told where to go or what to do).  Sometimes I’d be in the Delivery room all day, sometimes in Clinic(s), sometimes I would never make it out of the triage room in Labor and Delivery, and sometimes I would end up as the “extra person” in the operating room.  Each of us four had to stay till 11 one day a week, and take one full weekend on call per month.  I was away from home a lot.

I actually was enjoying the things I was doing and learning to do in the hospital.  Of course, I felt totally inadequate much of the time even though I had been around delivery rooms a lot as a student (and a few times, as a patient), but having the responsibility for so many things that were going on at once was a bit overwhelming.  I felt my age a bit–not that I was “old”,  (I was 30) or even that much older than the other residents– but my attitude about a lot of what I was being asked—actually what I was being TOLD to do, was different.  I had decided that I would never forget how close I came to NOT being here—to NOT having this opportunity.  I had decided that rather than complain I would learn. Rather than get upset, I would ask for explanations.  I decided that I would be a sponge. I would absorb everything I could.  I would stick myself to the residents and attendings that I wanted to be like–the ones who seemed to care and the ones whose patients liked them.  I would learn to do things like them, and make those “ways” my own.  It was not going to be easy.  Of course all the other first year residents knew that I was only going to be there for a year unless one of them left.  Or that I would stay on and repeat my first year if none of them left–and that would make them—ALL OF THEM—my superiors next year…. That made our interactions a bit awkward at times—but without saying anything to any of them, I had also decided something else— I was NEVER going to act in such a way as to make them feel like  I was not going to be a “team player” or that I wouldn’t coordinate or cooperate with them because I was too busy hoping that one of them would leave—I decided I would just DO.  MY.  JOB, as best I could, and let those chips fall where they may.

At home, my son was now 3 and my daughter was 6 months old.  They were both going to daycare at my husband’s job, as well as being cared for by a combination of other people, including my mother, my nephew, and Charlotte, our old and cherished nanny, who now had two children of her own.  My husband did what he could.  But getting two babies up and out the door to daycare, and coordinating meals and naps and playdates etc etc….was a lot to ask of anyone—and those were not the days where dads would just “strap on a Snugli” and be Mr Mom— even if they WANTED to.  My being on call entire weekends, and until 11 pm at least one weeknight every week meant I had that much less time to take care of things at home.  And once the kids were sleeping, I was often prepping for the next day’s patients, or surgeries, or just generally looking up information that I knew needed to be at the tip of my tongue.  I carried around endless notebooks, pads, note cards, and spiral pocket-books  (“The Resident’s Guide to Surviving the First Year”, and “The Scut Manual”, to name a few).  Needless to say, the stress level was on high. It was going to be a long four years  (or five…but I was trying not to think about that).

4/5/16

I was getting into the “rhythm” of the first year of residency  (if not-sleeping-much-waking-up-at-an-ungodly-hour-drinking-lots-of-coffee-working-all-day-then-doing-it-again” was a rhythm of sorts.)  and before I knew it, it was time to switch rotations.   My second rotation was an “off service” rotation, and I had to work on (yikes) the MEDICAL floors—   4 weeks in the ICU, 4 weeks in the ER and 4 weeks on the medical wards.  The hours were better, and the cases interesting, but every day I was there I understood better exactly why I had chosen the specialty I had.  The ICU was full of patients at the ends of their lives, usually fighting for their lives, with serious medical conditions–strokes, heart attacks, cancer, bleeding disorders, and organ failures.  I was learning to read complicated heart monitors, balance fluids and electrolytes, and write orders for blood transfusions.  I realized quite early that residents who actually belonged in the ICU never trusted us “off-service” rotators– what could an  first year ObGyn resident know about kidney disease?  Or Pulmonary problems? Or anything else, as far as they thought?!   Until they wheeled in a woman who had delivered a baby earlier.  Turns out–there was a patient who had brought in by ambulance at 35 weeks pregnant, seizing.  (And leave it to the FIRST YEAR Obgyn resident to know that a pregnant person seizing is ECLAMPSIA until proven otherwise )  {Eclampsia is a serious abnormality where a constellation of problems, high blood pressure, headache, clotting abnormalities, liver and kidney problems, cause neurological problems, possible brain swelling and/or stroke— it requires stabilization, delivery,Magnesium and other medications, and control of abnormalities IF we get to it quickly enough—and in time to save the baby}.  They were pretty amazed as I was the one directing which treatments to give, which blood tests to order, which medications to give……we managed to keep her from having more seizures, and from developing any syndromes which would cause severe bleeding— and she actually got to see and hold her baby a few days later.  I learned a valuable lesson about teamwork, and the  knowledge that as much as humanly possible I would love to never have to set foot in an Intensive Care Unit again– as a resident, an attending, and most of all, as a patient……………that place was scary—-but a little less so after I had been forced to “live” there for 4 weeks, in the place we (un)lovingly called  THE UNIT.

4/15/16

Even while off-service, I still had to rotate through the First-Year ObGyn on-call schedule– one weekday night until 11 per week, and one full 24/7 weekend out of every four.  The “on call” time was when I actually felt pretty comfortable.  Nothing “planned” was done on “call time”…no scheduled surgeries or scheduled cesarean sections– no elective inductions of labor;   although in the world of obstetrics, things may need to be done at any time of the day or night—and like an emergency room, the Delivery Room had to be ready to handle anything that could come “rolling through those doors” at any time of the day or night.  The on-call team always consisted of three residents—a first year, who would be the “point of first contact” for all calls from anywhere in the hospital; the “middle person” which was usually a 2nd year resident, as the 3rd years were mostly on “specialty” rotations like Gyn oncology or Reproductive Endocrinology  (infertility management) and a 4th year resident, who was ultimately responsible for what went on during the on call hours.  (Of course, which ever Attending physician that was on call was really “ultimately” responsible, but as time went on I was beginning to realize that there were rarely any attendings directly involved in patient care–there were so many residents around all the time that as things moved up the hierarchy of responsibility  (third year Medical student—-> fourth year medical student—-> first year resident—-> second year resident—-> third year resident—-> fourth year resident—–> attending  )  the problems were often completely solved by the time they reached the top.  “Officially”, the attendings were supposed to be contacted for all the events that were going on on the hospital floors–they were to be consulted with and reported to,  and all decisions were supposed to be made with their input.  But it was not long before I realized that some of them did not want to actively participate—they were more than ok with letting the fourth year residents “run the show”.  Others DID want to be involved and wanted to be consulted……and I needed to know which were which!

I felt that it was a lucky thing that I was a light sleeper ever since I had had my kids– it didn’t take much to wake me even if it seemed I was sleeping soundly.  We all wore beepers (this was way before cell phones) and on my weekends on call, there was an “on call room” where residents were allowed to sleep when not busy. Of course, first year residents were always the first to get up, since we were always the first to be called….from anywhere, at any time.  If there was a post partum patient who hadn’t yet had a bowel movement, we were called to order a stool softener.  If a patient’s IV fell out accidentally, WE got the call to ask if it needed to be reinserted  (and at certain times of the day, we would also be the one who had to come to the floor to reinsert it if that answer was “yes”)  If a post Op patient had some pain, we got the call to order something stronger.  For every call that actually seemed “necessary”  ( “Your patient can’t breathe!”)  there were about 10 calls for what we called “scut”…..things that probably didn’t need to be taken care of right then, but someone had decided that it could not wait.  The most important thing to learn on call was WHEN the call was something important, even if the person calling sounded the same as when they called the other 9 times.  (Like if a nurse calls and says “Your patient has only produced 25 cc’s of urine in the past 2 hours”, we BETTER know that that means we have to go evaluate that patient and find out WHY that is—not just assume that the patient simply did not feel like going to the bathroom…..Low urine output can be so many things–including internal bleeding, low blood pressure, poor kidney perfusion, a blockage of some kind, and many other dangerous things.  There is no room for assumptions, and no place for laziness!)  I will never forget the call I got once to come to the floor to evaluate a post-c section patient that was complaining about pain and “something moving” in her incision.   When I pulled back the covers, and removed her bandage— the entire c section incision was OPEN, and I was staring right at her intestines poking right through it.  At that moment, I said, “Thank goodness for the hierarchy”, and called my second year.

4/30/16

One thing that was definitely and unfortunately going on at home, was that I was beginning to see the truth in the idea that “If you’re not WITH me in this, you are against me. ”   What I mean by that is that, here I was, 6 months now into my first year of my residency.  I had worked SO hard to get here, and I had started an extremely difficult course of study and work withOUT the full support of my spouse.  My interest and real LOVE for everything I was doing, seeing and learning, was limitless.  It was also  exhausting, and all-encompassing.  When I came home, being a mother was ALSO exhausting and all-encompassing.  For what little time I was ever AT home, my time was spent trying to “re-acquaint”  myself with my kids— I KNOW that I over-compensated, and tried to spend every waking moment entertaining them, taking them places, planning activities, and just generally trying to make up for the lost time that I spent away from them.  Unfortunately, my husband sort of got “lost in the shuffle”….because in MY mind, HE was an adult—HE should understand that the kids needed me for blocks of time, to just “BE” with them and MOTHER them— I felt like I was always needing to make the time up to them, and then, I guess whatever small snippets of time were left, after hospital time, and Kid time, and sleep time, was then portioned out to time to spend with my husband— which, in looking back—was not enough. I remember once coming home, exhausted, after seeing the birth of twins—–(TWINS!!)  for the first time.  I walked in, exhilarated, wanting to explain and discuss and describe, everything I had just seen, and how interesting that was…….and I must have underestimated the number of times I had already done similar things, and the effect it was having on my husband……because his reaction shocked and disturbed me. “I am not interested in hearing about YOUR day”…..he said.  “I’m tired of everything, every day, being about what YOU did, what YOU saw——How about asking about MY day?  What I did?…..”  WOW.  I was upset, and sad, and angry— ( and, probably lost in my own delusional world—-Why wouldn’t anyone want to hear about these deliveries?  and about my time at the hospital?? )….I also felt I didn’t have the time or the strength to discuss and argue about this with him— my time at home was limited and I didn’t want to waste it this way—-so I quickly walked past him, and right to the living room where my kids were—- and put all my happy-and-sad energy to once again squeezing my limited “home-time” into some precious “kid-time” before I’d have to leave and do it all over again.  Looking back now, I know I was unreasonable.  Marriage–especially a marriage that at this point was still under 5 years old, with 2 small children, and the stress of owning a home,  and being in residency, needs work— it needs to be built up;  it needs to have mechanisms for coping and for solving problems, and for not going to bed angry, and for collaborating………in the BEST of circumstances.   But not having the time or the energy to build the foundation of the marriage from the “bottom up”  made it difficult, if not impossible to have a mechanism for working together to ensure that we were “solid”….I think we were just trying to get through another day, another shift, and another of my rotations.

5/14/16

When a first year resident was on “short call”, until 11 PM when the night shift came on, it was that person’s responsibility to know everything that was going on in the delivery room, take care of all post partum problems, take all phone calls from the post-op gyn floor for surgical patients, and to do all the vaginal deliveries which occurred on that shift (with less and less supervision as time went on).  A first year resident would also be the “second assist” on C sections, since most C sections were the second-year resident’s job, assisted by the fourth year resident, who was actually teaching and guiding the resident in performing the operation.  (There usually was also an attending close by but they did not get involved in the “hands-on” aspect of the surgery unless there was a major complication. )  One evening on call, I was paired with a busy second-year resident, and the one female fourth year resident  (I’ll call her “Dr. C”).  The second year resident had been called down to the E.R. to see a gynecology patient, as was part of her “on call” responsibility.  I was in the delivery room, when one of the patients who had been laboring all day was declared a “failure to progress”; a situation where she had been having strong, regular contractions for several hours, yet her cervix was not making any change, and it seemed that she was not going to have a vaginal delivery.   I did what I would normally do in these cases—“present her” to the Dr C, the fourth year resident—and explain, in chronological detail, the circumstances of the patient’s labor, and why I thought her situation warranted a C section.  It was not an emergency, and after some discussion,Dr C agreed with me.  It was then my job to go discuss it with the patient, explain the situation, obtain her written consent, and write all the orders that were needed to get the C section started.   I also needed to call the second year resident, so she would come to the delivery room to operate.  Within 15 minutes, the operating room was ready, it was buzzing with personnel— the surgical tech, the pediatric nurse, a labor nurse, several students, the anesthesiologist, and me.  The patient was wheeled in, and Dr C and I were scrubbed and ready…………….then from the outer corridor, one of the nurses called in to us and said that the second year resident was stuck in the emergency room—a second patient had just come in and had to be seen.  Dr C said, “No problem—We will do it.”  I took that to mean that SHE would be the surgeon, and I would assist her…..and no one said anything different.    The patient’s abdomen was prepped with a Betadine wash, and everything was draped—covered with a sterile blue drape so that the only area showing was the area where the incision was to be made.  The scrub tech was ready—we were all standing at the patient’s side— and when Dr C called for the first instrument—-“scalpel”, she said, I was shocked when the tech handed it across the table in MY  direction.  SO shocked, that I actually turned around to look behind me to see who she was actually trying to hand it to!!  Dr C said, “yes you—–you’ve seen enough C sections—you should be  able to do one by now!”……and although I immediately became incredibly nervous, there was really no time to think about that—there I was with a knife in my hand.  Over the next 45 minutes, Dr C proceeded to guide me, patiently (and sometimes not-so-patiently) through all the many layers of the abdomen, showed me how to place my right hand deep into the pelvis, into the uterus and under the baby’s head so it could be  gently lifted upward and delivered.  She had me call for my instruments, in the proper order, and name the anatomy, and order the correct medications, and decide which sutures to use, until we finally reapproximated all the layers we had opened on the way in.  It was exhilarating, and difficult, and exhausting…..and confirmed what I already knew—-that THIS is what I wanted to do.  (And what I didn’t know well enough—-the instruments I needed in the proper order, and called by their proper names!!)  Toward the end of the surgery, the second year resident returned from the ER, obviously happy that the C section went on in her absence–and almost too-happy to tell me “You did the surgery–now YOU can do the dictation, and YOU can write the orders”…..I looked at the clock—it was 11 PM—–and I couldn’t leave until all that was done.  Even though a new team would be in to take over, NO ONE would do someone else’s work! I was still floating.

5/28/16

There were 4 other first year residents.  Two men and two women.  All were younger than me, some not by much, and by halfway through our first year, we had all settled into our difficult and demanding schedules with an acceptance, and mutual understanding.  We were all pretty good about taking over on time from the first-year doctor that was “signing off” when the next one was “signing on” to a service or a rotation.  We all knew that no one was supposed to leave things undone, or “dump” as it was called, on the next incoming person—-that would make for bad feelings and possible retaliation.  I got to know most of the other residents by being on-call with them at various times.  Of course some friendships among the residents were developing, as well as some romantic attachments, Relationships which were NOT supposed to affect anything in the residency program,  of course  did at times.  Some of us socialized outside of work, or after our shifts had ended.  I was trying to create a balance between being friendly-but-not -too friendly because I often could not be social, and usually tried to leave as soon as possible after my work was complete–especially if I thought my kids might be awake=–but sometimes, especially late at night, and especially after a particularly difficult shift, where something unexpected, or tragic may have happened, it turned out, sitting with the only other people who could truly understand how I was feeling, to “debrief”, or to discuss what had just occurred, seemed better for me emotionally, than to go home, and have to keep it to myself.  The “black cloud” which inevitably hung over me through that first year was the fact that I was in the only “One-Year”  position, that was not going to allow me to continue on to the second year unless one of the other first year residents decided to leave, or was somehow asked to leave the program.  That had been clear from the beginning, but now that reality was really hitting me.  We had only another half-year to go, and no one was showing any signs of being on the way out.  It was January now, and new medical students were in the middle of applying for NEXT year’s first year positions already.  As the chairman of the department had promised me that I would be automatically considered for a first year spot in the following incoming class of first-years, I was wondering what they were going to do about the match?!  They had not gotten the funding to once again have five first-year positions, so there would only be four available match spots. Would they only offer three into the match so I would have the fourth one if I did not move up?  I liked, and trusted the word of the department chairman, but I wasn’t sure how he was going to be able to do that.  Sometimes when I passed through the administrative offices, I saw some medical students coming in for interviews.  I had no idea whether I was looking at people who would potentially be in my NEW year, or, if next year I would somehow be THEIR superiors, one step up the hierarchy ladder?!  I spoke to the department chairman about this, and he seemed to be sure that “it would all work out”.  (what did THAT mean?)   Some time after the first of the new year (this was now 1994, in case you have lost track)  the department chair abruptly left his position for some reason that I was not privy to. (illness?  scandal?  department disagreements?)  There were lots of assumptions and discussions, but no one truly knew why.  The chairmanship was taken over by an interim physician from the department of ObGyn in the hospital, while the search for a new chairman began.  This interim person hardly knew me, so I should not have been totally surprised when he approached me one day—–  “What are you planning to do next year?”  he asked me.  I, sure he was already aware of the situation I had been in, said “Well, if no one leaves the residency from our group of first-years,  I guess I will take a spot in next year’s first year class”.  To which he said, “Well, then you’d better get your application into the first year match, because we have a lot of good candidates, and nothing is for SURE”  !!!!!!!!!!!  (So in other words, he was telling me that my spot TO REPEAT my first year, in a program where I (thought I) was already proving myself,  was NOT automatic—I had to REapply into the match, and SEE if they may-or-may not pick me to repeat the first year)…..I felt as though someone had punched me in the chest.  I was back in the same boat from the year before–only THIS time, with no Dr Tom—who was finishing his fourth year of residency by now, and had no clout in the selection process—and no friendly elderly-department chair on my side.   I left that day and cried all the way home.  When I finished crying, I put my application in to next year’s match, listing THIS hospital—-the one I was already beginning to feel a part of, as my first choice.  I listed many other hospitals on my application, both near and far, knowing that the prospect of possibly suggesting we move elsewhere so I could continue my residency by starting the four years all over would NOT go over well at home.  I just decided to make it through the next 5 months of my first year, learn all I could, attach myself to anyone who could possibly help, plead my case……and hope for the best.  ( an idea I was not unaccustomed to)

6/4/16

My next rotation was one I was not sure if I should be dreading, or looking forward to—the Night Rotation.  During this rotation, there were three residents on what was referred to as the “Night Float”  : a first year resident, a second year, and a fourth year.  We would arrive at 11 pm, and take “sign out” from the three residents that were on call until 11, and the same hierarchy as existed during the days also existed at night—-I would get all the initial calls from the “floors”— I would be responsible for the delivery room, managing and delivering all laboring patients, and I would be the point of first contact with all nurses, and all patients with questions, or whose orders needed to be clarified or changed.  The BIG difference between night call and day call was that at night nothing elective was scheduled.  It was a shift of “putting out the fires” and learning to deal with anything that needed to be dealt with to keep things running smoothly until the morning came and the “usual” goings-on of the hospital started up again.  Things that happened at night were often emergent.  Women arriving in active labor that couldn’t wait til the morning– women who were bleeding and worried; women with fevers and in pain, women who were actually scheduled for elective procedures like Cesarean Sections during the next day but they broke their water or went into labor the night before…..the Labor and Delivery unit ran 24 hours a day.  Babies did not wait—and as a matter of fact, some nights were busier than some days!  The Gyn Emergency Room was the domain of the 2nd year resident— often there were women rolled in by ambulance, or showing up at the ER doors in acute pain or bleeding or with surgical emergencies— and first year residents were really too inexperienced to quickly evaluate and triage all of these cases…..although many patients who showed up in the emergency room in those days were not emergencies at all—they were women with minor infections, or who had had sex and then had pain or symptoms, or felt something unusual happen, and thought it could not wait until the morning.  When my second-year resident got summoned to the ER, she often would have me come with her if I was not busy in the delivery room so I could learn from her and see what she did, and so I would be ready to do these evaluations when (IF??) I became a second-year resident.  There were definitely a few episodes that happened during the night shift that affected me, and influenced me, and helped form my ideas about what type of physician I wanted to be.  Sometimes, early in the shift, the fourth year resident would go “make the rounds”, and walk through the post-surgical ward  to make sure things were quiet and nothing was “brewing”…..(He really didn’t have to, since if there was a question or a patient with a fever, or a medication to be ordered, I would have been the one to be called to take care of it-)- so he was doing this because he was concerned, and cared about patients that had had surgery, and wanted to make sure they were well taken care of, or “tucked in for the night” as he called it.  One night, shortly after 11pm, he  (I’ll call him “Dr M”) told me to come walk around the wards with him to check on the patients.  We went into the rooms of the patients who had had emergency C sections,  a patient who had received a blood transfusion after a particularly long surgery,  and some other patients who had been admitted for various problems over the last few days.  Then we walked into the room of a woman who looked to be in her mid fifties–but looked very ill.  She was thin, and frail, and when we approached the room, it was dark and she was quiet, although obviously awake.  When I got closer, I saw that she had several tubes and lines attached to her, and a drain coming out of who-knows-where, with fluid coming out of it.  Dr M approached her–she was obviously happy to see him, although weak.  They chatted for a few minutes, and he checked some numbers on her bedside chart—-noted that she had lost a lot of weight, and she told him she was having trouble eating anything.  When we left her room, Dr M said, “Come with me”  (and of course, I did what he said–he was the fourth year resident and I was nobody)— I followed him straight out of the hospital  (First year residents were NOT allowed to be “off site” when on call—but here he was, TELLING me to go with him) He got in his car which was in the doctors’ parking lot, and motioned me to get in too—-so I did…In the car he told me that that patient had cervical cancer which was pretty advanced, and on his Oncology rotation, he had seen and treated her several times…As we spoke, he drove to a nearby ice cream shop  (This was New York, and it was not unusual to find an open ice cream shop after midnight)  He ordered a large milkshake, and then we drove back to the hospital  (All I kept thinking was, “what if my beeper goes off for some major emergency?” but it didn’t.)  We walked back to that last patient’s room, and he gave her that milkshake—-and she just about cried…..this was her DOCTOR— and she realized that he just went out and brought her back something that she could keep down and make her feel better.. Like this was just something that your doctor DOES…….I was a bit in awe, a bit confused……but determined that if possible, THAT is how I wanted to make MY patients feel someday.  He didn’t even really discuss it with me– he didn’t really talk to me much……but that small episode had a big impact on me, and on my thoughts about what actually could be the “norm” when it came to patient care.    (Note:  I do not regularly go out and buy my patients milkshakes, for many reasons…..but you get my point).

6-13-16

The first year of residency was rapidly coming to an end.  There were only a few months to go—and I felt that MY burden was growing exponentially.  Not only did I have to deal with all the “usual” first-year-resident stuff—never feeling ready enough, never feeling knowledgeable enough– never feeling fast enough…..I also had to deal with my own unusual circumstances– REapplying for a spot in the next year’s first year match, ( both anxiously wanting and not-wanting to be a first year resident again, because, what were the alternatives????), as well as having a home situation that was tenuous-at best, lots of bills, and a now- almost 4 year old, and a 1 & a – half year old who needed the normal attention that children need…but STILL one hundred percent believing that I was in the RIGHT field for me—I loved everything I was still learning, starting to adopt my own learning and teaching styles as far as how I wanted things to be when this residency was over; I was even being approached by local physicians who had their own practices, telling me at times to “look them up” when I was done, because they were always in “recruitment mode” , looking for new physicians who might eventually be able to join their group at some future date.  ( Was this because they were looking at ME, specifically, or did they just always “throw the wide net out” among the resident physicians and see who may be interested in joining them and staying local to work when they graduated?  ( I CHOSE to believe they were seeking me out specifically, since THAT was what my ego needed at the time— there were SO many signals coming at me all the time that I WASN’T   good-enough-fast-enough-smart-enough-political-enough, “fill-in-the-blank-” enough, that if a few local docs approached me to “contact them” if I thought I would be interested in a job, then they MUST be able to see my value…..which was one thing that DID feel good.  Another thing that felt good was receiving some attention and praise from some of the more senior residents, for things like my organizational skills, my attention to detail, and that ever-present one, my HANDWRITING. ( my orders and notes were always legible and made sense……which was probably not something I thought was a big deal…but apparently it was—and IS , among doctors).

There were definitely a few things that stuck out to me in those last few first-year months, in terms of patient-care, and certain patients in particular.  It is said that the field of Obstetrics and Gynecology is  “The Happy Specialty”….where bringing life into the world is one of the best feelings and brings with it the most joy.  (Everyone remembers their deliveries….not so much their gallbladder surgery–or the surgeon). But although the happiness that comes along with this field can be SO great, the sadness that we see is truly heartbreaking.  When things go wrong in obstetrics, they are often horribly wrong….unexpectedly wrong….and result in damage and death that are devastating to all involved, including the health care providers.  I remember one particular case, of a young girl, maybe early 20’s, who presented one night during my night-call rotation.  She was about 22 weeks pregnant, and walked into the triage area of the delivery room, where I was the point of first contact.  By now, I was ” experienced” enough  (always in quotations, because NO first year resident has ENOUGH experience…just degrees of ignorance…..) to take note of several things about any patient just upon their presentation, as to how emergent their situation was….she walked in  —(good—she was not uncomfortable enough or symptomatic enough, to have had to call an ambulance, or be wheeled in by wheelchair or on a gurney);  but it WAS the night shift  (bad–because things that are not truly emergencies can usually wait for the morning. someone who decides to go to the hospital after midnight should at least THINK their situation is emergent…);  she was NOT making any noise, not moaning, screaming or crying–  (good– because that usually meant there was no unbelievably bad pain or symptoms that would make her do so);  there were no body fluids streaming down her legs or soiling her clothing  (good–because she was not bleeding, not out of control of her bodily functions, nor breaking her water right there before me), and her belly looked like the pregnancy was about 20-25 weeks along — (good—AND bad—because most things that were problematic for women in that early stage of pregnancy that were not in extreme pain were simple  (UTI’s, stomach bugs, round ligament pain, a musculoskeletal injury), but IF something were truly wrong or emergent  (preterm labor that was unstoppable, serious infection, rupture of membranes), that baby was certainly non-viable and things could get pretty bad pretty quickly).  So—ALL THAT was going through my head JUST as she was hitting the door. I went over to assess her– to interview her and do my exam, and formulate a plan based on my findings.  She told me she was 23 years old, this was her first pregnancy.  She had had regular prenatal care in our hospital clinic, and had had no complication so far.  The previous day she had started to feel some low level abdominal pain, that “came and went”, never getting really bad, but when it didn’t go away as she was trying to go to sleep, she thought she should come in.  That’s it.  The whole history.  Now it was up to me to get “the real story”—to ask all the pertinent positives and negatives that would help me decide how much of an exam I would do, how quickly I needed to do it, and what our next steps should be.  To my questions, her replies were—–no fever, no nausea, no vomiting, no pain with urination, no bleeding, no discharge,no recent sexual activity, no headache, no recent trauma, no change in the pain with rest, or with activity,  some recognition of baby’s movement, not much…….so  no real help in identifying the source of the pain nor what direction to go in.  Next– the exam, and to check the well-being of the baby.  I checked her lungs and abdomen,  –appropriate size for a 22-week pregnancy— and listened to the baby’s heartbeat with a Doppler  ( 140 beats per minute; normal);  and then I did the always-necessary pelvic exam.  (It had often been said by the upper-level residents—that  If someone presents to Labor and delivery with a complaint—they never leave without a pelvic exam-( “Even for a sore throat?” I had asked, horrified)- because the worst thing to do in triaging a patient would be that a pelvic problem, or bleeding, or labor, or an infection that would affect the pregnancy would be missed, because that part of the exam was omitted).  In this case, a pelvic exam would have been necessary anyway, since the etiology of the patient’s discomfort was still unclear from taking the history.  So I did the pelvic exam——and I will never forget what that felt like.  The pelvic exam is to check a patient’s cervix, for many reasons— to see whether it is tender (signaling infection)  or open (signaling preterm labor, or an incompetent cervix),  or to see if there is blood, or discharge, or amniotic fluid present, all things that would help answer questions about what was causing the patient’s symptoms…. But THIS time, when I did my pelvic exam, I did not know exactly what I was feeling.  When I was gently trying to assess the cervix, I was met immediately by what felt like a huge smooth water-balloon-like structure, that was filling the entire vagina.  While my fingers were still trying to locate what felt like a cervix, to assess, I felt something that startled me, because it was actually moving— definite little jolting, worm-like movements, that were separate from anything the patient was doing.   I am sure I did not keep my “doctor face” on–because I had never felt anything like this before.  I immediately called my second-year resident to come down to the triage area for something emergent, and she did.  When she did her own exam, she confirmed what I probably already knew–this was the bulging amniotic sac—coming through a mostly-open cervix– with tiny little legs in the sac, bending and stretching—kicking around, unaware that anything was going on that shouldn’t be.   But this was a true emergency.  Just because the patient didn’t LOOK emergent, didn’t SOUND emergent— didn’t mean her situation wasn’t truly emergent.  The second year resident quickly explained the situation to the patient, along with the several important decisions she would have to make concerning the future of her pregnancy.

—IF we did nothing, she would most certainly lose the pregnancy.  A 22 week pregnancy is not viable, and would not BE viable for at least a few more weeks (in the early 90’s, 25 weeks was considered the very beginning of viability— and that would be with the BEST medical and neonatal intensive care services available).  Her cervix was already about 5 cm’s open–and the amniotic sac, WITH body parts in it, was poking through the cervix, creating an “hourglass” .  If we did nothing, the sac would soon likely spontaneously rupture, and the cervix would  open spontaneously on its own, expelling the baby, which would be non-viable, ending her pregnancy.

—IF the patient wanted “everything done” to try to save this pregnancy, although unlikely to be successful, we could offer her to place her in a steep Trendelenburg position, with her feet elevated, and head down, allowing gravity to attempt to help the amniotic sac recede through the cervix, along with giving  her medication to relax the uterus, then take her to the operating room to place a cerclage, or a purse-string suture through the cervix to attempt to keep it closed for the rest of the pregnancy, or at least long enough to create a viable pregnancy.  The head-down position may not work, the medication may not work, the procedure itself could CAUSE a problem, like causing the amniotic sac to rupture, or can tear the cervix and cause bleeding or an infection, and even if initially successful, it would be weeks before the baby would be viable; and even THEN—the pregnancy could end at any time before viability, OR at the very cusp of viability, where the baby would be born with numerous medical problems from prematurity.

The patient needed to make these decisions quickly–time was of the essence— so her significant other came in for them to have a detailed discussion with the upper-level residents and the attending who was on call that night, so that plans could be made.   After a lengthy and detailed discussion, it was decided that the patient wanted choice #2—to have everything done to “save my baby”….  and we all went into action.

6-14-16

Since it was already almost the end of the night time shift, the procedure would be planned first thing in the morning.  There was much preparation to be done– IV fluids and antibiotics to get running; bloodwork to do as when anyone would be going to the operating room; an official ultrasound to measure just how big the baby was—how much fluid was actually there, and where it was, plus to check the placental location; also to assess if the baby appeared “normal”–did not have some major abnormality that may alter the patient’s decision to try to “do everything’, or that might affect the possible outcome;  medications to be given to relax the uterus, to give gravity some time to work to move that amniotic sac back into the uterus where it belonged.  Once all that was done, the patient was ready to be taken to the O.R.  Since I was a first year resident, this was not considered “my” case to do–it was the domain of the most experienced resident, and was to be guided by the attending physician.  The night-time fourth year resident was going to stay to perform the procedure, and as I was the one who had first admitted the patient, I was invited to stay to participate in whatever minimal way they may have needed me.  Here was a dilemma.  I would have been able to leave at 8 am, go home, spend the day at home with my kids, and relieve my husband from a day of having to pack them all together with their stuff and take them to the daycare at his job.  But this, I felt, WAS, in a way, “my” patient too–and to leave just as she was about to go into the operating room for a scary procedure after I had been there throughout the night with her, giving explanations, having discussions, doing exams, and making preparations, seemed like not only a “dump” to the next resident coming on-shift, but truly a break in her continuity of care  (one of the BIG complaints of many older physicians when residency was changed so that we would not be working too many continuous hours–was that patients would LOSE  their continuity of care when residents started doing “shift work”—signing in and out at the end of shifts instead of “seeing the case through” to the end).  I decided to stay and deal with the aftermath at home  later  (Lord knows, it wasn’t the first OR the last time I would stay on past my shift for something interesting, or from the  obligation I felt to “see it through”).  We took the patient to the operating room, and she was given a spinal anesthetic so she would be numb from the waist down.  She was also given enough sedating medicine so she was not so acutely aware of everything going on during the procedure,  & so she would be less anxious.  She was prepped and cleaned, and we were finally ready to take another look to see if this were even going to be possible.  I technically did very little more than hold a retractor and hand instruments to the resident— but we saw that the sac had almost completely receded back up past the cervix, and now we were looking at something that looked a bit like a donut, with about a 3 centimeter diameter hole in the middle, and looking right up into that hole we could still see the bottom part of that amniotic sac.  By putting gentle clamps on the cervical edges, the resident was able to ever-so-carefully place 2 purse-string sutures made of a permanent material, in-and-out, at various locations around the edges of the cervix, and in the end, tie them in a knot so they would keep the cervix closed if everything went as planned. It was fascinating.  There wasn’t much bleeding, no ruptured amniotic membranes, and seemingly, no complications.  The plan was to keep the patient in the hospital, on bedrest, until it was felt that there was no infection, no bleeding, no contractions, and that she would be able to go home on a similar regimen of greatly restricted activity.  We were not sure how long that would be–but the first 48 hours would be critical.  I finally got home after lunch.  (For although no one said this was “my” case, I was still the one to write all the orders, do the dictation, sign the patient out to the first year resident that was already on-shift for the day– and make sure everyone was clear on the plan before I could leave)  My kids had gone to daycare, as usual on a day that I was not home in time for my husband to leave for work  (which was pretty often).  I tried to get some sleep and ignore the laundry, the piles of toys,  the dishes in the sink, and the shopping lists that were all staring at me as I went past them, to sleep for a few hours before they would all be home, and I would be able to share some quality time with them, before putting them to bed, and getting ready to leave for my next 11 pm shift.

6/15/16

Two nights later, I was doing some paperwork on a pretty quiet night shift.  I got a call from the Antepartum floor, where all the pregnant patients who needed to be hospitalized prior to being ready to deliver, were stationed.  They were various patients with medical problems, like high blood pressure that needed monitoring, infections, and pre term labor.  This was where the patient who we had placed the cerclage in to keep her cervix closed was admitted as well.  Things had been stable since the morning of the surgery, and she was being closely monitored on strict bedrest, so when I was paged, and saw the extension of the Antepartum unit in my beeper, my heart skipped a beat.  “You better come here right away!” the nurse said– (never a good request to hear).  It seems this patient was asleep, and was suddenly woken up by a sensation of something wet under her in the bed.  She called the nurse, who pulled back the sheets and was shocked to see a moderate amount of blood mixed with what must have been a large amount of greenish amniotic fluid.  I RAN over to the unit, and in my calmest way possible, gently looked under the sheets as well.  I told the patient that this was not good, and we needed to get her somewhere other than a dimly lit hospital room, to take a thorough look at what had happened.  I called my more senior residents, and both of them came to the O.R. to meet us as I was wheeling her in, with the patient softly crying, on her rolling hospital bed.   We had the anesthesiologist stand-by just in case we needed him.  When we got the patient into the proper position to do an exam, there was no mistaking what we saw.  There was blood, and clots, and green thick fluid.  (Meconium, a sign of distress, is released into the amniotic sac when a baby is fighting to stay alive)…..but what we really saw—what really told us that this was the end for this patient and this baby—- was unmistakeable.  We saw two tiny, perfect, beautiful baby feet, like a doll’s feet, lying still, peeking out of the vagina.  And I started to cry.   I couldn’t help it.  I KNEW the odds were poor of saving this pregnancy.  I KNEW that this could have been the outcome.  I KNEW that a baby this small, this premature, was unlikely to make it through all the weeks and months of challenges after such a difficult start.  But it all just hit me when I saw the feet.

We had tried—we honored her request to have “everything done”….but even “EVERYTHING” was not enough.  It was not the first time I had seen a patient and/or her baby meet a “bad outcome”….but it was the first time I had been so intimately involved in every step through the life-and-then-the-death process.  On further inspection  (and with adequate anesthesia assistance), we could see that the cerclage DID tear through her cervix— it was causing bleeding from the areas that the stitch had just caused too much strain on the tissue that was determined to stretch and open.  And of course, connected to those perfect feet, was the tiny body of a tiny 22 week old baby— with arms, and legs, and fused eyelids, and mostly transparent skin,  lying silent, as if asleep, practically falling out of the open cervix once we cut the knots in the straining sutures.  The tiny, flat, bloodless umbilical cord was still attached to the placenta, which (luckily) completely and spontaneously expelled from the uterus as well.   We detached  the placenta, and placed the bruised but intact baby in a tiny open plastic box, with a tiny hat and blanket, since it was likely the patient would want to see her baby when we were finished.  We repaired the torn cervix, made sure there was no active bleeding, and no placental parts left in the uterus. We gave the appropriate medications, so there was no infection and so the uterus would remain contracted.  We called the clergy she had requested, and cleaned her all up so she could go back to her room, and spend some time with her family and her baby, and make some arrangements.  I told her I was so sorry that this had happened, and tried to remember that part of my care for this patient would be to talk to her about exactly what happened and that it was nothing she had done or didn’t do—to discuss what her risks would be for it to happen again; to tell her that next time she would need to have a cerclage placed early in pregnancy, as well as about other types of monitoring and treatments she may need .  I also knew she may need a therapist to help with the grieving process, or just to talk about it to me, or anyone else who was involved in her care.  But that would all come later……right now was just the time to try to process all this………and my beeper went off a few minutes later……..”The delivery room needs you—someone is about to deliver”…..

6/22/16

Time was passing.  The fourth year residents all had their plans made—one of them was joining a local private practice, one was going on to a fellowship (further training in a specialty area of ObGyn which would require an additional 2-3 years).  One was still looking for work, and one was undecided.  The match  list of new first year residents was published.  Not especially-surprisingly, MY name was on the list—I was  (yay) going to be a first year resident again, along with three other new first years. (They no longer had the funding for a fifth first year spot—no more “non-traditional” one-year resident spots like mine had been)   I felt stuck in a kind-of limbo…..happy that I now knew that I was going to go through the residency program, to its completion, and would eventually go on to actually BE an obstetrician/gynecologist; sad and frustrated that it was going to take me an additional year….happy that I was going to continue to work somewhere that I was comfortable and familiar with, and was close to my home…..sad and frustrated that I would now be subordinate to other residents who I had started the program with, and whom I was at least as knowledgeable and talented as……happy that all the waiting and the worrying were over…….sad and frustrated that once I started there would be no way to “speed up” my progress….to finish any sooner than ANOTHER four years, no matter what I did…………or was there…….???????   I thought about that quite a bit and decided I would explore every opportunity I may have to expedite the process if any existed.  Soon the schedules were being made, the new residents were starting their orientation—and one group that seemed to be very happy that I would be doing a “repeat” year were the nurses that worked in the delivery room.  There had always been a discussion among those who worked in Labor and Delivery—indeed all over the hospital— that the worst time to be in the hospital was ALWAYS in July…that’s when the new “crop” of residents would start, and as they were really just weeks past their last year of medical school, they had a WIDE variety in knowledge and skill levels, so there was basically chaos all over the hospital, as these new residents were put through the motions of having to stand on their own— write their own orders—attend to emergencies, and form relationships with others in the hospital while they assumed their new roles and responsibilities.  The schedule that was created had ME as the first “new” resident to rotate through the Delivery room.  ME–who already knew how to do a basic delivery….ME–who already knew how to write orders….ME—who already had relationships with some of the nurses and L&D personnel……and, most importantly,  ME—who already knew what I could and couldn’t do…when to call for help, what constituted an emergency, and when something was “over my head”  and I needed my more senior resident to come and assist.  These were valuable skills, that usually took a first year resident months to acquire.  Having me there, where I was essentially, skill-wise, a second year resident, as the new first year resident in the delivery room made everyone feel much more at ease….and as much as I was UNhappy to end up in my unique situation, I had to admit, it put me a bit more at ease as well.   JULY 1, 1994….I was ready.

7/7/16

Starting over again, doing my “second-first year” certainly had put me in a less-than-happy mood as July 1st came around.  I was frustrated that I was going to be essentially repeating things that I had already done, but with more knowledge and more skills that a first-year was expected to have, yet NONE of the perks of having been there already for a whole year.  (I still couldn’t tell anyone else what to do except for medical students, and, basically ANYone could tell a medical student what to do. )  My home life was pretty unhappy as well.  I can say now that I knew by this time that there were some serious problems there.  I knew that for many reasons—-I felt unsupported, both in my career choice, and in my parenting.  I was constantly being made to feel that I was “away all the time”, as if each new rotation was a surprise that my hours were terrible and that I was always in the hospital.  I adored all the time I was able to spend with my kids, but I felt the unstated (and sometimes VERY stated) resentment from a spouse that felt he had to do “all the planning” and “all the care-taking” himself because I could “never be counted on”— that holidays were just as likely to be without me as with me…. I actually started to  feel that I would sometimes just rather stay at the hospital past my shift to relax or to commiserate  with colleagues who were the only ones who could understand how I was feeling. And who wanted to hear about it… (Who would rather go home and be resented when I could stay there and be praised? Or included ?  Or needed? )  What probably made matters worse at the time, was that the Ob Gyn Department at the hospital was in the midst of implementing a huge change in the way we residents saw our clinic patients.  In an effort to make the clinic situation more tenable and more like “real life” (and less chaotic), they were starting what was called “patient panels”…so instead of any resident randomly seeing any patients that showed up in the Ob or Gyn clinics on any day, they were starting to “give” each resident his own panel of patients—like when a patient was pregnant and preferred to see a particular doctor  (resident), that patient would be given an appointment to come back only on the days THAT resident was in the clinic again.  We got to know the patients better, and the patients felt more like they had a connection to their “own” doctor.  It was great!  But the reason I say this created more of a problem for me, was that now, when I took care of one of my “panel patients” during their pregnancy, they would often ask if I would be the one to also do their delivery—-and this actually WAS now an option— we were able to “voluntarily” come in on our days off, or when we were just not on call, IF we said it was ok for them to page us when one of our panel patients was in labor.  And I actually said yes to most of them…..I figured, that, for many of these patients I would likely be IN the hospital anyway (since I was almost ALWAYS in the hospital those days)…..but I also let them page me for deliveries when I was NOT on call….and THAT was VERY difficult for my husband to accept—–which I totally understand NOW.  But then, I felt that I was going to “do my job”- (which I loved)–to take care of patients that I had formed a relationship with, that were asking me to continue that relationship and deliver their babies….but he saw it as me spending more time away, that was unnecessary–and it mostly happened at night….and limited our time together more than it already was.  We were at an impasse about that.  (and about many other things).  But who had the time to discuss it? Or argue about it?  And who had the energy?  But the resentment grew.    It wasn’t as though we never had any good times at that time.  But we both made many mistakes in our choices on how we decided to voice our discomfort—I avoided the problems.   He simmered.   We were both wrong.  And we were both unhappy.

8-1-16

As I was wracking my brain trying to figure out how not to do a “complete repeat” of my first year, I realized that after my first rotation in the Delivery room, I was about to (again?) have an “off-service” rotation, where I was going to have to work on the (gasp) medical wards, like the ICU and the Med/Surg floors.  I truly wanted to avoid this, so I requested a meeting with the chairman of the ObGyn department.  I had read all the guidelines and the rules, I told him; and I knew I did not have to do TWO separate medical rotations to “graduate” from the residency program.  When we ObGyn residents went “off service”, as a matter of fact, we were often not allowed to participate in patient care like a “regular” medical resident, because they felt we were not as skilled or as knowledgeable about medical matters. They often did not know what to do with us, and we were considered “extra” help, or sometimes even treated as a medical student, given lesser tasks or scut work to do to help  run their service.  When we did our “on call” rotations, we would come back to our own department and rotate into the call schedule with the rest of the first year residents, and felt more comfortable doing so.    Knowing all this, I asked the department chairman if, instead of going through another medical floor rotation, would it be possible that I rotate through a different rotation…?  One that OUR residents would need to rotate through to graduate, (family planning, or oncology, or even another clinic rotation) so I could have a worthwhile experience, not lose more  time, continue to be among my own “people”, and IF  by some chance a resident in a year ahead of me (now including of course all the other residents that I had started residency with) ever DID decide to leave, then I would still be able to (possibly) move up to take their spot?!  I wanted to just be prepared for any possibility.  He thought about this idea for a little while.   He told me that IF and only if I could find a way to NOT interfere with all my own duties in the ObGyn department, then I could approach these other departments and offer my services as an “additional” resident, so I could learn and absorb as much as possible…..(and what department would turn that down??)

8-13-16

The first and most important attempt I made at joining a rotation was in Family Planning.  Our residency had a very busy Family Planning service, that was located in a building adjacent to the hospital.  It was headed by a short Indian lady who knew more than anyone I had met about keeping women from getting or being pregnant if they did not want to be.  She was a strong advocate for women’s reproductive rights, and was always walking hurriedly down hallways, continuously lecturing us on “the beauty of the IUD”,or on how to make sure that women were informed about ALL of their options, ALL of the time.  She had so much energy, and was always willing to let the residents “run the show”.  I approached her with my ideas about spending time in the rotation as a first-slash/second year resident, and she was more than willing to have me join the rotation for as many hours as I could “volunteer”.  (Just as long as my presence did not take away from the experience of the resident that was already scheduled to be on that rotation….and in my experience, NO resident would ever refuse the offer of another resident to somehow lessen their burden)  The Family Planning Clinic was the place all women could go to find information and access to any type of contraception that was available; also to schedule permanent sterilization procedures (tubal ligations), and to terminate unwanted pregnancies.  It was a very busy clinic, seeing sometimes more than 40-50 patients in a day, and it was first-come-first served for initial appointments and intake.  Once a patient was seen for their initial consult by the Family Planning resident (or, the Physician’s Assistant, or Nurse Practitioner), they would be scheduled for the appropriate day and time for whichever tests and procedures they needed.  The clinic could always use one more person at  least, to do these initial intakes.  As far as actually doing the procedures—inserting IUDs, doing tubal ligations, and terminations of pregnancy—-that would be decided by the doctor in charge, and by the volume and scheduling.

This rotation was one of the first times during my residency that I really had to think about what I thought—what I really thought– about abortion. I had always been a fierce advocate for a woman’s reproductive rights—meaning ALL of their reproductive rights, including the right to terminate a pregnancy.  But this was the first time that I had had really close contact with so many women who were actually seeking the service.  It is easy for people to think (and I have heard people say  it often) that women who wanted abortions were just “lazy”, or ” irresponsible”, or “using it as birth control”…..but that is not at all what I saw.  I saw women who were being responsible—they were using birth control– often with a long term partner–and it had failed.  I saw women who had just recently had a baby, and found themselves pregnant again because a condom broke; I saw women who were pregnant from abusive partners, and rapes; I saw women whose babies had chromosomal abnormalities or birth defects; I saw women who, because of circumstances, or health issues, or poverty, or drug addiction, just could not have a baby at this particular time.  And of course their were women, who just simply did NOT want to have a baby…..  I had to think about what it means to have legal and safe options.  About why ANYONE besides that woman should be able to be the judge about what constitutes the “RIGHT” reason that a woman can and should terminate her pregnancy.  And to realize that there is no one else who should make that decision.  That women HAVE to be able to control their own fertility and reproduction—which means that they have to have access to safe methods of preventing or terminating a pregnancy in order to do that.  I am not old enough to recall a time before abortion was legal in this country.  But I know many people who can and have lived through that time… I  have spoken to them and have heard and read their stories.  And I KNOW that it is absolutely true that if these services were made illegal and unavailable, they would NOT stop happening.  They would just happen under much more unsafe conditions and women would start (once again) showing up at hospital emergency rooms sick, and septic, and dying from these procedures.   As long as there is sex, there will always be unplanned pregnancies.  As long as there are unwanted unplanned pregnancies, there will always be a need for safe, legal ways of terminating them.  It is NOT about what I, or anyone else thinks is okay for THAT woman, in HER circumstance.  As I met more and more women who came seeking  this particular service, I learned that, for the most part, they did NOT come to their decision lightly. They agonized.  They waited.  They discussed it, sometimes with friends, sometimes with family…sometimes with a counselor.  They were in pain, and weighing their options.  They made a decision, not knowing how it would affect them later, both physically and emotionally.  But shortly into this rotation, I became more and more convinced that it was part of my job to help them go through this process, and then help them NOT to end up in the same situation again.

8-21-16

While working in the Family Planning Clinic, I realized that this was really a specialty unto itself.  I learned how to counsel patients on all of their contraceptive options, assist in permanent sterilizations, and actually perform procedures like IUD insertions.  It was a very busy Clinic, and they actually kept it open in the evenings to serve populations of women who could not come in during daytime hours.  They staffed the evening Clinic with Residents and other Physicians who were paid as “moonlighters” — and I was asked if I wanted to moonlight soon into the rotation.  Of COURSE I wanted to—more exposure, more hours in a specialty that I needed to include in my training as a second year resident, and getting paid to boot?  It was a win-win situation as far as I was concerned.  (The only thing that made it less-than win-win was my being away from home even more hours than absolutely necessary– but the fact that I was going to be making more money seemed to make up for that small detail).  I was always thinking, “If someone in a year ahead of me suddenly decided to leave, I would STILL be able to move up—and into their position as long as I kept up as much as possible with the residents who were one year ahead of me.”  I was determined.

9-4-16

My second- first-year was halfway over.  I had spent 13 weeks in the delivery room and 13 weeks as a Family Planning “extra”, pretty much learning and doing everything I would have if I were actually a second-year resident.  Now came the wonderful Night Rotation, where I was to go in to work every evening at 11 PM, work throughout the night, “putting out the fires”, and usually staying until the next day’s morning clinic was over.  I KNEW this was the rotation with the most potential to screw up my body clock and my circadian rhythms.  Somehow, though, I wasn’t worried and was actually looking forward to it, since I knew that I would be home (almost) every night to have dinner with my family and to put my kids to bed.  Shortly after the night rotation began, my fourth year resident confided in me that the other fourth year residents had all wanted me on their rotations…..not because they liked me so much or because I was the brightest or most skilled resident on the service—-but because they knew that since I had already been through an entire first year of training, that I was likely to at least  be more skilled than the other first-year residents, who were often doing things for the first time.  The fourth-year night resident met me in the delivery room the first night of our rotation, where we took sign-out from the daytime team.  After going over all of the currently laboring patients, and writing our notes  (mostly ME writing all of the notes) she told me to meet her in the nursery—where all the “regular” babies were.  It seemed that there was a new policy, and all of the babies who were supposed to be circumcised, would be done on the night shift, and it was to be the responsibility of the first-year night time resident on rotation.  Since this was a new policy, I hadn’t learned to do that in the previous year (and I wasn’t that sure I wanted to do it NOW!!)  But my fourth-year (also called the “chief” resident) was pretty matter-of-fact about it, and determined to show me how to do it so that she could have me “see-one-do-one-teach-one”, as was the case for so many things I had so far learned to do.  It turned out, that it varied from one baby needing to be circumcised (or, “circ’ed” as we came to call it), to as many as 6, depending on how many babies were born, and how many families decided that they wanted it done.  It was not for me to comment, or discuss, or even speak to the parents about it  –(consents had been signed during the day, and were the responsibility of the daytime first-year labor and delivery room resident to explain and obtain—we just had to make sure there was a signed and witnessed consent on the patient’s chart before actually performing the procedure).

I met her in the nursery, where it really looked like a small baby-assembly line. Four babies in cribs were lined up, waiting their “turn”.  When we were ready to start, the nurse picked up the first baby, identified him by his name bands, and looked for the consent form that his mother had signed.  All was in place, so she next placed him on the appropriately-named “circ-board”, where his arms and legs were restrained  “so he doesn’t kick us when we have a scalpel in our hands”, she explained  (note to self, we do not want to be kicked by a baby when we are about to use a sharp instrument on his delicate boy parts)  She laid out all her instruments, and methodically and in sterile fashion, went through all the (many) steps of a circumcision.  It was interesting, and in the end, successful, but I couldn’t understand why they did not use any anesthetic when doing a procedure that obviously was uncomfortable—even painful for the baby.  She told me that it was thought that the baby was already so uncomfortable from being restrained on the board, that as long as the procedure was done quickly, there was not much additional discomfort for the baby.  I really didn’t think that was true, because as I watched her methodically perform the rest of the circumcisions that evening (trying to keep the steps in order in my head because I was sure that the next night it would be MY turn to do them), it seemed that every time a baby was touched by or with something that would seem to cause pain, the baby did scream louder and longer….how could she–and the nurses NOT  see that?  I wondered if there was anything they could do about that since not only was I uncomfortable with the idea of doing something to a screaming baby who was in pain   ( guess I wouldn’t have made a good pediatrician, since that is a lot of what they do)   I wasn’t sure if I’d be able to do it properly if I was always thinking about doing if faster to limit the baby’s discomfort.  The next day  I decided to call the pharmacy in the hospital to see if there was anything I could order to make it less painful for the baby–I was informed that they actually had an anesthetic gel that we could apply to the area of concern about a half hour prior to the circumcision that could make things a little numb and  less uncomfortable.  I told my fourth year resident about it, and she said, “OK— but you are going to have to go over there and apply it yourself”…..which was kind of her way of telling me that the nurses in the nursery were so busy that the LAST thing they wanted was MORE work–especially something they had to do on multiple babies, and keep the timing in mind so that it would be on all the babies at exactly the right time—a half hour before it was their “turn” on the board.  I decided to try it, partially because I thought it would make my job easier, and partially because I had a son, and would have wanted someone to do that for him in a similar circumstance.   (In reality, my son had had a bris–which is the Jewish religion’s version of the circumcision, done on the 8th day of a baby boy’s life, at home, during which the baby is actually given some wine during the procedure, so I guess THAT was our “anesthetic equivalent”……..I also didn’t watch it being done, just for the record….)

9/18/16

After thinking about how I could go about getting the anesthetic gel on the babies in the right interval of time, and in an effective and efficient manner, I came up with what I thought was a brilliant idea– and decided to carry it out starting the very next night.  I came in for the night rotation about 20 minutes early, and looked at the list of babies that were awaiting circumcision that night.  I put my plan into action, with some minor assistance from the nursery nurses (whom, it turned out, were all in favor of making babies less uncomfortable during their procedures ).  We kept it as “our little secret”, and when I returned later that night with my fourth year resident, imagine her surprise when, in removing the first baby’s diaper, she found a pacifier, full of anesthetic cream, parked strategically over the baby’s penis, allowing the medicine to take effect.  The hospital had special pacifiers that were given to newborns, which were shaped in such a way that when placed in a baby’s mouth, a finger could be placed in the hole, to hold it in place.   It was in this hole that I had placed the anesthetic cream, and then put the pacifier in place over the penis, held in place by the diaper.  Brilliant!  Numbing and protection in one!  It could stay there between 30 to 60 minutes, so that when we came to do the procedure, there was time for the anesthetic to take effect.  Maybe it was my imagination, but starting that night, the babies cried less during the circumcisions, and I made a note to myself to try to always get there on time to “place the pacifiers” (as it would come to be named; yet another job for first year residents—yay!)

9-25-16

Being away from home from 11 pm until 10 or 11  (or later) the next day, 5 days a week was disruptive to my home life in more ways than one:  Being awake while most of the “regular” people were asleep usually meant that the opposite would also need to be true—I would need to sleep while the rest of the world was awake.  So even though I would be home in the middle of the day, it was definitely hard to get things done like shopping, cleaning and cooking when I knew that in a few short hours I’d have to be back in the hospital.  I had to learn to force myself to sleep in the daytime; dark shades on the windows, lights off, no caffeine, and an effective method of “tuning out” all the thoughts in my head telling me how much there was to get done.  My son, Jake, was almost 5– in a pre-school a few half days per week, and still at the daycare at my husband’s job on the other days.  I thought it would be a good idea to get him used to the classroom situation, since he was almost ready for kindergarten, and there were several local preschools in our neighborhood.  With a complicated mixture of  babysitters, family members, my mother, my husband and me, we somehow worked out the schedule so that Jake could be dropped off and picked up daily from his activities, and I actually got to participate in the rotation, by waking from my nap (my “night time”, really), picking him up, spending some afternoon time with him before my husband got home with Danielle, who was still attending full time daycare at his job. Then we all had some time together before I left again for the Night Shift.  Things were tense in the marriage by this point.  My husband and I had very different parenting styles. We had very different styles of everything, it seemed, and no time or energy, usually to calmly discuss our differences or to try to put some kind of healthy plan into play for working out our many disagreements.  It always seemed that there would be a better, or calmer time later  for those discussions, so we put them off……and the resentment grew.  I started to wonder if our marriage was going to make it through this residency program, since I was only going to get busier, and take on more responsibilities, and have less time to “fix” what really was starting to break.  So I did what I always did at that time—as soon as my kids were asleep, I left.  I knew that it was a problem that I looked forward to going back to the hospital instead of spending my precious few moments in the company of the man I married.

10/4/16

Another rotation that I had to get through as a first year-( repeating) resident was a gynecology rotation.  This was the time where I would be a member of the team that would see gynecology patients in the busy clinic, taking care of everything from general, annual preventative care visits, to Pap smears, to checking for infections, diagnosing gynecologic conditions like fibroids, irregular bleeding, fertility issues, dealing with birth control….and on the other days participating in surgeries.  For a first-year resident to participate in surgeries really had a specific meaning– it was to -do all the paperwork that was needed for PreOp– making sure that all the pages were filled out and ready so that the patient was ready for the surgery they were going to have (this involved lists…and checking things off… and legible handwriting….and organizational skills–all of which I was very good at).  The clinic was bustling and busy, and the higher level residents spent most of the clinic time looking for patients that might end up in their operating room; they were all about the numbers….how many cases they could collect…how many names they could add to their lists.  In the second week of the rotation, a patient was awaiting my exam in a clinic cubicle, and when I first went in to see her, I thought she must be in the wrong clinic.  She was a young woman–about 35, and lying on the exam table she looked as if she was about 9 months pregnant.  Her belly jutted out as far as a full term baby.  I started my History-taking, and my exam— but was not sure exactly how to approach the large belly that was obviously the reason she was there in the first place.  Turns out, it WAS—- and the work-up began.

10/6/16

I started my history-taking, and exam-doing as I had with any other patient.  Got her information and wrote it down.  She was 38 yrs old, from Mexico but spoke English; unmarried, and had no children.  Had no complaints other than the fact that her belly felt “big”.  No pain, no fevers, no medical issues; heavy regular periods, and got “full very fast” when she ate.  When I examined her, I had learned enough to do a systematic review from head-to-toe….head, eyes, ears, neck, lungs, heart, abdomen…..her abdomen was huge….firm, protruding; not necessarily tender, but very obvious that this was not normal.  I wasn’t sure if she was aware of this mass that was filling her abdominal cavity–she seemed like it was just “there”.  It didn’t seem to cause her pain, but definite discomfort.  When I did my pelvic exam, it seemed it was a large, immobile, centrally located enlarged structure in the middle of her pelvis; I was still not skilled enough to know what I was feeling exactly— but I did what I always did, and “presented” her to my more senior resident, and told him that it seemed like this may be a surgical case.  His eyes got wide, and he said ” well, let’s go see.”  He was impressed with the size of the the mass, and how non-plussed the patient seemed to be by her situation.  Once we decided that this seemed to be a potential surgical case, we had to decide (I had to decide) what the proper differential diagnosis would be, and what the proper work up would consist of in order to get her to the operating room.  The patient needed lab work, and scans, and a discussion of what types of surgery were available to her, and why.  The proper people had to be assembled, and we had to be sure she was healthy enough to undergo surgery, and to be aware of the various things we might find.

Differential diagnosis of a large pelvic mass:

It could be Ovarian cancer, Uterine cancer, or a benign tumor on either organ.  It could be a large cyst, or a mass in her intestines, or a large abscess or infection.  It could have been a pregnancy related condition, or a cancer of the fallopian tubes or of the urinary bladder.  It could have been a foreign body or enlarged lymph node, or fibroids in the uterus, or several other unusual things.  My job was to do enough tests so that when we finally did take her to the OR we were fairly sure what we were going to find, who we needed there to help us, and what would happen to her afterward.  I made my list, and made my presentation,  set about ordering everything we needed, and explained all this to the patient in the best way I knew how.

10-21-16

After all the work-up was done, the day for this patient’s surgery finally came.  It was to be a case done by the most senior resident, with an attending physician, and me as the first assistant, along with a medical student who was rotating through.  It was me, the first-year resident, who had the major responsibility for getting the patient ready for the operation, presenting the patient to the fourth year resident, and assisting in the operating room with whatever anyone needed.  I was also supposed to be teaching the medical student along the way.  (Luckily I was now in a position to delegate some of the “scut” to the student–which I happily did, but I was still responsible for everything that he did).  The patient had had labwork done (tumor markers were negative, so it didn’t seem that we were going to find cancer in there, although that was still possible), a pelvic sonogram (which showed the large mass we were feeling was most likely a very enlarged uterus–seemingly the size of a 6 month pregnancy, only without a baby inside.), a CAT scan  (which showed the mass did not seem to involve any other organs, like her liver, intestines or kidneys.), and she seemed healthy enough to undergo a major surgery.  She had signed her consent to remove the mass, possibly her uterus, possibly one or both ovaries, “and any other procedure deemed necessary”.  (Yes, that is the way we had people sign their consents in those days— explaining that in case we found something unexpected in there once the surgery started, we had their permission to do whatever we needed to.  In the present day, we rarely would be able to have someone agree to just “leave it all up to us”).  We all assembled in the operating room, and I held her hand as she fell asleep from the anesthesia.  I was the one who had so far had the most contact with the patient, and it just felt right to me that I should be the last person she would see before going under general anesthesia   (I made another big “note-to-self” here—- that from that time on, I always made it my business to be the last person my surgical patients saw before they fell asleep. )  Once she was asleep, and uncovered, we could see that from her small frame, this huge round mass protruded even more than before,  making it appear as if she had somehow swallowed a basketball.  The fourth year resident and the attending went about discussing what type of incision they would need to make, and what their technique would be like, depending on what they found inside.  I was listening but not involved in the decision making.  They asked me several questions to see if I had prepared well for the surgery–what layers would we be cutting through?  What blood vessels supply the various layers?  What instruments would we be using?  Luckily I knew most of the answers.  If I hadn’t they would be likely to tell me to just leave the O.R., since that would have signaled to them that I really wasn’t READY.  Once the patient was prepped and draped, we were ready to begin.

10-29-16

Standing at the OR table was “the team”– In the Main  (Primary) Surgeon spot was  the fourth year resident, a tall, broad-shouldered man, about 32, who I knew quite well by then.  He was a kind of love-him-or-hate-him kind of guy; “rough around the edges”, as my father used to say. He liked to joke around, (sometimes inappropriately ) but was a good doctor and a very good surgeon. (I’ll call him Dr P for Primary)  Then there was the second year resident across the table from him–the “first assistant” as she was called–  ( Dr F )–she was a younger petite female–a no-nonsense kind of person, who actually had started her residency in my year, but was now one year ahead of me since I was repeating the first year.  We were friendly, but I was acutely aware of the fact that my role remained as a subordinate to her, whether I knew as much as she did or not.  (and so was she)  The attending physician stood off to the side, watching everything that was going on, but not feeling obligated to scrub in or put on gloves unless something unplanned occurred.  Then there was me; next to the first assistant– I was  also scrubbed in, designated as the “second assistant”. (in actuality, this is the equivalent of the “retractor holder”, the “suture cutter”, and, if you were lucky, the “closer”.  Once all the difficult part of the operation was done, they sometimes let the second assistant have the privilege of placing some of the closing sutures in the layers of fascia, peritoneum , fat, and subcutaneous tissue that all were closed individually in those days.  Whether or not the second assistant got to do any of that was completely dependent on the primary surgeon and the first assistant– how much they trusted you, how much they felt like taking the extra time to teach you how to do it all properly, and even, what mood they were in that day.)  Dr P made a vertical incision in the skin, from right under the patient’s belly button, to the top of her pubic bone.  From there, Dr P and Dr F worked together, in a series of planed and well-orchestrated moves, to dissect down through the subcutaneous tissue and the fascia, using a combination of a scalpel, electrocautery and other instruments.  Along the way they stopped to give me direction, or orders, or to ask me questions about the different structures we were seeing and the blood vessels, nerves and muscles in the area.  Once the fascia and the peritoneum were opened, there was no mistaking this huge structure jutting out in the midline–this was her uterus, about the size of a 6-month pregnant uterus.  I was amazed at how easily they were able to “pop” it out anteriorly, through the incision, as the top portion was seemingly not attached to very much.  We could trace her fallopian tubes, to the ovaries, and locate the various ligaments that were surrounding this huge uterus; they pointed them out to me while at the same time asking me what I would do here, or there–how I would proceed in a case such as this. ( I had studied this so I usually knew the answers, thank goodness)  They slowly and methodically interrupted all the blood supply to the uterus, each surgeon working on the structures on their own side, being assisted by the surgeon across the table.  After about 25 minutes, the entire structure was removed, leaving a big space where it had been.  I had seen a few hysterectomies before.  I tried not to let on how excited and how amazed I STILL was to watch something like this going on—and to participate in the process.   After it was ascertained that there was no active bleeding, they began the closure.  Dr P said to Dr F-  “switch places”, meaning she and I should rearrange ourselves at the table so that I was now directly across from him– which we did.  He proceeded to lead me through the entire closure procedure, allowing me to place all of the sutures, commenting on how I should hold the needle-holder, and the other instruments (“follow the curve of the needle” he would say….” “use your instrument to lift the tissue” he said….)  until the final stitch was placed.  The attending was long-gone by then, and the second year resident had scrubbed out to write the orders  (which I would have had to do when we were done– but Dr F was good that way)  I had glanced over at the anesthesiologist during the closure who was obviously annoyed that this was taking twice as long as usual because I was learning how to do it all—-but I didn’t care; and Dr P didn’t seem to care…. We finished, and I placed the bandage over the patient’s belly with a true sense of accomplishment.  I did not even realize how much my neck and back were aching me from standing in that position for over 2 hours.   (Note to self—–use a step-stool when all the other surgeons  are taller than you!!)

11-4-16

Things at home were tense.  We had become the kind of family that was just trying to make it from one day to the next.  We had an array of nannies working different hours since we were often gone and Jake and Danielle were now 5 and 3 years old.  My husband and I were mostly cordial to each other but I felt both of our resentments growing.  I was happy in the hospital; I was even happy working long hours and sometimes staying there overnight. I was still learning new things all the time, and was doing my best to leave work at work, although not always successfully. I ended up feeling that the only place I could discuss what was going on in the hospital, and how I felt about it, and “de-brief” after a particularly stressful or scary situation, was AT work, with my colleagues and fellow residents.  If I tried to discuss it at home, it was met with anger, indifference or silence.  The distance between us was growing. I kept telling myself that if we could just get through these residency years things would be better. I started taking opportunities that were presented to me to go to conferences, or dinners that were offered to physicians in my specialty.  These were the old days, where various drug companies paid for meals or trips, in exchange for talking up their drugs; the companies were only too happy to bring us samples of “newer” and “better” birth control pills along with an offer of a trip to a conference that was on  (what else?)  birth control!  It felt important, and special, to be offered these opportunities, and my social circle started to consist of other doctors and health care providers who were interested in the same things I was.  When one of the drug companies offered to send me to Colorado as a “Resident Reporter”, I jumped at the chance.  The offer was to pay for my travel, and lodging, to attend a national meeting of Obstetricians and Gynecologists as long as I wrote about things that I learned at the conference.  The other Resident Reporters would be given similar assignments, and then all of the reports would be published in a journal for those who had not attended the conference to read.  Traveling– for free—attending interesting lectures on topics in my field—and then writing about it?  Being published?  I was in!

11-11-16

It was almost the end of my second-first-year of my residency. I was friendly with the other residents in my year, and with the residents in the years above me, in spite of the fact that the four residents who were now official “second years” had started with me.  Of course I secretly hoped that someone in the year above me would still leave, so I could then slide into their spot, and continue on to finish in four years instead of five.  I had done everything I could to stay current, and be up-to-date with the various rotations that I would need to do exactly that.  So imagine my surprise and excitement when one day I was sitting in the clinic, in between the morning and afternoon sessions, and I overheard a conversation between one of the female second-year residents and one of the attending physicians.

” There’s an opening for a PGY-3 at Stonybrook”, she said.  (That was a University Hospital on the Eastern part of Long Island, about an hour away from our hospital)  The attending said something that was inaudible to me….but at this moment I craned my neck so I could hear the details of the conversation.  Female resident:  “Why should they care?  They have Rebecca; she can take my spot.”  “They don’t have to let you out of your contract” the attending physician said to her.  My heart started racing.  I understood from this conversation that this resident, who was just finishing her second year of residency (and who had started residency with me) was interested in leaving our program and going to another hospital, where there was going to be an open THIRD YEAR spot.  This would open up a third year spot in OUR program for the following year, (the spot she was vacating) which was exactly what I had been hoping and praying for over the past two years!  I wasn’t sure what to do!

I first went to the female resident herself when I found her alone, later in the day.  I asked her if she was leaving.  She told me that she wanted to, but the chairman of our department told her that he didn’t have to release her from her contract. (!!!!)   He was threatening to take action against her if she left.  She wasn’t sure what she was going to do, but she had to give the other hospital an answer soon.  I couldn’t believe it!  Here I was– capable–willing— waiting for something like this to happen—and they knew it—-yet they wouldn’t let her go???????    I went straight to the office of the chairman–who knew me well by now.  I sat outside his office and waited for him to return.  I.  was.  LIVID.

REALLY?”  I said to him— “She wants to leave, and you know I’ve been here just waiting for that spot, doing everything I could to be ready to move up to the following year and YOU don’t want her to go?”   I am sure he thought I was a lunatic, and disrespectful to boot— but I just could not believe that this was true!  “It’s nothing personal” he said.  “But it is a bad mark on a residency program when their residents leave.”  (WHAT?????)  I could not believe what I was hearing.  After a fairly lengthy conversation, I did get him to admit that he likely could not really take any legal action against her for leaving, and if she was determined to go, she likely would, and he would “consider” me for the open spot (along with other people who might apply for it)….and I once again walked away feeling that this whole world of training—this residency system, that I needed to get through to become the doctor I really knew that I could eventually be—- was crazy, illogical and unfair—- and I once again knew that, whatever they decided, I would live with it and move on, frustrated and seething, eventually reaching the goal of becoming an attending physician, in 4— or 5  years….whatever it took.

11-19-16

It had become pretty much the “talk” of the entire program–that this one person was trying to leave.  Everyone seemed to have an opinion on it– but the only opinion that really mattered was the person who was leaving…..and the chairman, who had the ability to either let me have her vacant spot….or not. I felt powerless.  The residency year was almost over– a new year would start on July 1st, 1995.  I kept on about my business, did my work, stayed on-call….and waited. It soon became a verified truth that she was leaving for sure.  I was encouraged to put in my application for the third-year spot, and I did.  And then I waited some more.  There were meetings that I was not invited to, and discussions that were had by attendings in the department, and residency coordinators, and third year residents who would soon be chief residents—- but eventually they came to the conclusion that I was hoping for all along.  They (reluctantly, it seemed) offered me the third-year residency spot for the following year, knowing that they would then have to fill my second-year spot for the following year.  (Turned out, they figured it would be harder to find a new third year resident than a new second year).  And for the first time in two years, I felt like I could breathe.

11-27-16

I sailed through the rest of the residency year, thrilled to finally be officially moving up (back) to my original plan of finishing my residency in 4 years instead of five.  The third year of residency would be difficult but better in several ways, as it was the “specialty” year; with rotations in gynecologic oncology, reproductive endocrinology and infertility, as well as high-risk obstetrics, and the requisite clinics and on-call duties to attend to.  My husband and family were happy for me, although no one could truly understand the elation and relief I was feeling right then. On one of the last on call nights as an exiting first year resident, I was sitting at a computer in the lounge area, when my second year resident, Dr R, came in.  “We need to go down to the ER”, she said– “a rape case came in”.  I immediately got up from my chair.  Somehow, in all the on-calls I had done, and in all the nights I had spent in the hospital, I had never been the resident who had been called to the ER to deal with a rape case.  This was likely one of the things I was missing from my training because I never had done a “typical” second year residency year—it was the second year residents who were mostly called to the ER, and I had only gone with the second year resident when I had no “first year” duties to perform (which was almost never).  This time, however, the second year resident, realizing that this was my opportunity for learning what to do and how to manage something like this, said she would accompany me, and it would be MY responsibility to assist her, and try to do most of whatever needed to be done.  (Which I appreciated, but which also scared me—–another “new” thing that I should know how to do but did not know how to do, which was an all-too-familiar feeling)

On our way to the ER, Dr R, the second year resident told me that when a woman came in to the ER after a reported rape, we were never sure what we were going to find, but we were always expected to do the same things– there was a very specific list of things that HAD to be done, both medically and legally.  In this case, we found a sad, quiet 25 year old, wrapped in a blanket, softly crying and sitting on a gurney.  Dr R and I stopped briefly at the desk outside her curtain, to get a brief story from the uniformed policewoman stationed there, and to pick up a Rape Kit– a box that contained all of the evidence-gathering materials that we would need to use to collect and log everything in a very specific way.  Dr R had been through this methodical procedure many times, so she knew what to do without reading the instructions that were on the box.  We went in to the curtained room, and tried to kindly and softly speak to the patient about what had happened.  I was documenting everything she said, and it was obvious that she had repeated this story several times already.  We listened.  She was out with her friends,  and everyone was drinking. She did not feel like she drank that much.  One of the friend-of-friends offered her a ride home–and the next thing she remembered was waking up somewhere outside, feeling bruised and missing some of her clothes.  An ambulance was called, and they brought her to the ER. It was not for us to decide what happened.  That was a police matter.  Dr R was very kind, but “official”.   She explained that in order to best create a case, we needed to collect as much evidence of what did or did not happen to her, and although much of it would be uncomfortable, we would try to work as quickly and thoroughly as possible.  She agreed, and we went to work.  We had to “break the seal” on the Rape Kit, and  there were ten different “collection envelopes” in the kit– each with their own instructions on how and what to collect.  Over the next fifteen minutes, we methodically collected swabs and samples, and hairs and cultures and scrapings from various parts of her body, and I truly understood how people could comment that sometimes the collection feels like an assault all over again, even when done by the most empathetic health care practitioners.  Every potential area where there may be evidence or DNA from an attacker had to be swabbed and probed, and placed in an evidence envelope in a certain way, and catalogued in a certain way so that the “chain of evidence” was not violated, and that eventually an actual case could be brought against someone, using these collections.  Her clothing had to be collected and bagged, so we gave her hospital scrubs to wear.  She had to be offered to be tested and treated for various infections/STDs, including HIV, since there was no way of knowing what she had been exposed to. A counselor came to speak with her and offer her follow up services when we were done.  The whole thing was overwhelming and scary.  I couldn’t imagine how many times Dr R would have had to go through this entire routine to be so automatic at it.  I also couldn’t imagine a victim having to go through this with anyone who had LESS empathy and kindness than she had.

Once that entire procedure was all done, Dr R and I were able to talk about the experience, and I asked her how she stayed unemotional while performing all of those horrible, invasive tasks, with the patient crying the whole time.  She told me that she just keeps telling herself that if she did all the collection properly and made sure during that entire process, to get all the evidence that would be needed to prosecute or identify someone, she knew she’d be doing the most to help this patient in the future—that if she were unable to “do her job” then it would somehow later on be her fault for not properly collecting the necessary evidence that would be needed.  She wasn’t unsympathetic; she just knew how she could do the most good.   I made a note-to-self to always be and do the same.

12-10-2016

Entering my official third year of residency, I was actually excited. I was suddenly going to be doing all the “third year” things that I had been waiting for.  The rotations this year would include Reproductive Endocrinology/Infertility, Gynecologic Oncology and High Risk Obstetrics, all higher-level, interesting subjects which would take me away from the day-to-day delivery-room goings-on, and there also was no Night rotation this year. I was moving into the role of a “senior resident” with all the attendant responsibilities and perks.    As July 1st approached, I was aware that there were certain physicians in my program, both other residents and attendings, who thought I might not be up to the task of suddenly moving “one wrung up the ladder” and into the more senior role.  I decided I could only work hard and do what I could to prove them wrong. I would still be doing on call evenings, and the occasional weekend, but this year was going to be more reasonable in terms of my lifestyle and the hours I would keep.

My first three months were spent working with a high-risk Obstetrics specialist, following him around to all of his consultations, learning how to do procedures like amniocentesis and fetal ultrasounds, and seeing patients in the high-risk Ob Clinic.  The Maternal-Fetal Medicine doctor is considered the specialist for pregnancies that are complicated by a variety of medical complications:  diabetes, high blood pressure, blood clotting abnormalities, genetic problems, multiple gestation to name just a few. There were specific rules and guidelines to follow in pregnancies that were considered complicated, and I wondered how  I would come to know all of the rules for all of the problems. The good thing was, there were guidelines to follow, and standardized lists, called “best practices”, to advise us of all the right things to do for particular pregnancies with particular complications.  As usual, I would carry around my notebook, which had all those guidelines and lists in it, so I would try to be sure I wouldn’t miss anything.

12-18-16

Spending a day in the High Risk Ob Clinic, which we did twice a week, was like a crash course in “What could possibly go wrong” during pregnancy. It was easy to think, in the “regular world”, that having a baby was as easy as getting pregnant, waiting 9 months, during which if you ate and drank the right things, and took good care of yourself, then between 37 and 40 weeks of gestation, a baby would be born, one way or another, and you would take it home, and everyone would live happily ever after.  NOT So in the “high risk” world.  In the high risk world, women had ailments and conditions that were likely to make them very sick or kill them or their baby in those nine months.  Women had medical problems that could–and often would– get worse during pregnancy– or be fatal, or create a situation where choices would have to be made– about how to live, what medications to take, and sometimes, about whose life should–or could be saved.  There were women with Lupus, with High blood pressure, with heart conditions, placental issues (too small, too calcified, implanted in the “wrong” place), with neurological problems, and mental health issues, and diabetes in all forms; this was the place to learn how to take care of the sickest of the sick……and then hope against hope that you never saw people this sick again. ( In the “real  ( post residency) world”)

There was a special clinic just for pregnant women with diabetes, which met one morning a week.  Diabetes in pregnancy comes in many forms. First there are the women who have had diabetes since they were kids–Type I diabetics, who had (hopefully) by the time they (somehow)  achieved a pregnancy, have learned how to control their blood sugars.  Most were on Insulin–some had Insulin pumps that they wore on their waist bands like a beeper,which constantly supplied their bodies with needed Insulin, like an external pancreas.  These women had a harder time getting pregnant, and staying pregnant.  They had to control their sugars for the whole nine months, and go for an endless array of testing.  They often acted like (and told me so) that they knew better than I did about how to keep their sugars in control, and how to adjust their pumps ( and they were usually right).  Next were the Type 2 diabetics; they were a different breed– usually overweight or obese, in varying degrees of sugar control, usually needed lots of counseling about their diet and lifestyles– because it was these that led them to the pathway of diabetes in the first place– too much sugar, too many carbohydrates, and not enough exercise– resulting in large weight gains, and many risk factors for heart and liver disease, all only made worse by a growing baby and a placenta. Their diabetes often got worse in pregnancy, and their risk for so many things was so high– miscarriage, preterm birth, c section, delivery complications, hemorrhage…. they also needed a lot of testing and surveillance throughout their pregnancy.  And then there were the Gestational Diabetics– Those patients who became pregnant, and either did not know they already were at risk for diabetes, dd not know they already had diabetes, or truly, “out of the blue” became diabetic just from becoming pregnant, where their placenta conspired to make it that much more difficult to properly metabolize their sugar–which led to a first-time diagnosis of diabetes in their current pregnancy. These women were often harder to take care of, because they were in denial that they actually had diabetes, or they did not realize just how many bad things could happen to them–and to their baby if they didn’t make some drastic changes in their diet and exercise habits. In the clinic, there was an attending who was a high risk (maternal fetal medicine) doctor, several advance-practice Nurse Practitioners, a dietician, and me.  It seemed the population needing the Diabetes In Pregnancy clinic was forever growing.  The patients would come in, weigh in, show the dietician their “sugar book”, in which they were to record the numbers that popped up in their glucometer when they tested their sugar 4 x per day. Then they would talk to the dietician for a bit about their sugars, diets, exercise programs, and then speak to the Health Education nurse, so she could reinforce why they needed to keep their sugar in control, and what types of things their baby would be at risk for if they didn’t.  Then they would see me, to make adjustments in their medication doses, including their insulin regimens, and then I would order all the additional testing they would require.  Everyone needed extra ultrasounds, fetal monitoring, blood work; the long-time diabetics required an eye evaluation, and sometimes a heart evaluation as well, since uncontrolled diabetes affects those organs in a bad way.  After hours of all this counseling and testing, I was usually pretty exhausted  ( and more than a little tired of feeling like I was repeating myself over and over). I did make many “notes-to-self” about taking care of pregnant patients: I realized that caring for patients with medical conditions in their pregnancies takes a “team” of individuals to ensure that all aspects of care are addressed.  Nutritionists, Nurse Practitioners, High Risk specialists, Counselors, and Pharmacists can and should  be involved and contribute to the care of these complicated and difficult patients.

12/25/16

I was really thinking (hoping) that having more reasonable hours in my third year of residency would somehow lead to a happier, more settled home life.  Unfortunately (partly my fault, I know now), I still felt resentful that my husband was not as supportive during this process as I had wanted him to be.  I got the distinct feeling from him that things would only be better, happier, and more supportive, if I would somehow admit that I was being ridiculous and unreasonable, that his job was just as important as mine ( which, at the time, I didn’t believe for a minute), and when I accepted a “real” job after residency, where I was bringing in the type of money that would “make up for” all my time away and bad behavior.  I was beginning to think that there was no undoing the years of resentment and bad feelings.  We rarely spoke to each other; we often spoke AT each other– who was going to take which kid where, what were the plans for birthday parties and playdates….rarely anything to do with US.  I still felt that I had worked so hard to achieve what I had professionally– I was able to move up into a third-year position, so my residency would only take me four years (instead of five) as originally planned. I was now in the process of scouting out what type of job I’d be able to have after residency was done, and I was feeling pretty accomplished, as various doctors, locally and far away, made contact with me to ask about my “after-residency” plans.  The dichotomy was striking– feeling  popular, accomplished and happy at work, and feeling resentful, insulted and blamed at home.  If something didn’t change there would be a point of no return.  My children were now firmly in school programs; kindergarten and preschool.  We had an array of baby-sitters and child care workers arranged.  Sometimes babysitters would stay overnight, following my overnight on call schedule, to just be certain that there would be someone in the house all the time who was dedicated to child care.  My husband had made it clear that he was not going to take time off or rearrange his schedule at work to be the “babysitter”, since HE was the one who was making the salary that we relied on to continue to live our (modest but comfortable) lifestyle.  I did not want to be so upset and angry all the time. I LOVED spending time with my children, and when I was home, we made lots of plans.  They had their own friends, and activities, and mostly needed shuttling around from one place to another.  I knew that I never felt like I had enough time with them, but I also felt that we had developed a strong bond, and they knew how much I loved and enjoyed them. I never tired of listening to their stories, taking them to petting zoos and parks, and generally just spending time in their company and watching them grow.  I felt that they might suffer if they were to grow up without both of their parents around them, so I decided at that time to do what I could to make our home life better.  I approached my husband about the possibility of us going to a counselor to discuss our issues.  I felt that the prospect of us talking to each other and trying to make things better was unlikely to be successful.  I was a proponent of therapy for problem solving, even though I hadn’t come from a family that utilized or believed in therapy  ( although they could have used some), and I thought we could use an emotionally uninvolved third party who could help us to look at ourselves, look at our issues, and help us create a happy healthy home and plan our future. The way I looked at it, how could it hurt?

12/31/16

During the high-risk Ob rotation, there was a clinic to attend three days a week; two days for high risk patients that had everything from high blood pressure to autoimmune diseases, to heart disease, and one day a week for the diabetic patients.  One other morning a week we would do procedures that were related to the patients we were seeing, and we would also do consultations on patients who may have started out as “low risk” patients, but were then developing problems that would change their status.  Before clinic, I would be responsible for making rounds on all of the currently admitted pregnant patients, on the antepartum service.  This floor was filled with pregnant patients in various trimesters, who had medical conditions and problems that were too serious to be taken care of on an out-patient basis.  I would go in to each patient’s room, speak to them, examine them, and then go over their most recent lab work, and other diagnostic studies.  I would discuss the plan with the patient, write all the notes for that day, and then present the patient to the high-risk Ob specialist.  (He, and I, along with several medical students, made up the entire antepartum service).  Most of the plans for these patients consisted of trying to control whatever medical problems made them ill and trying to get them to a far-along enough gestation that the baby would be able to be born healthy.  It was ever the balance, trying to keep a baby inside and “incubating” long enough for the lungs to mature, vs removing a baby from a maternal environment that was no longer allowing that baby to thrive. The balance changed daily—and sometimes hourly.

1/8/2017

Making rounds on the antepartum service, I would see all the patients that were pregnant and needed to be managed in an in-the-hospital setting.  There was one young girl who I will never forget– her name was Thalia. (she has given me the okay to use her first name)  She was 24 weeks pregnant with her first baby, and several days before she was admitted, she had woken up in a pool of fluid.  She came to the hospital, and it was determined that her water had broken, very prematurely.  In the Ob world, we called this “P.P.ROM”, or Preterm, Premature Rupture of Membranes, the term we use when the amniotic sac ruptures very distant from the baby being fully grown, and before the start of labor.  Once this is determined, there are many things we, as her providers must do— from counseling her about all the potential (mostly poor) outcomes, to doing many different types of tests to decide what those outcomes are most likely to be.  When Thalia was admitted, we had done many cultures to check for infection (as infection is the number one reason that water may break early), an ultrasound to see if there was indeed any fluid still left in the amniotic sac (as, sometimes, even when the water breaks, more fluid can reaccumulate), and many blood tests to see if there were any signs of other complications beginning to occur.  While we were waiting for all the test results to come back, we had counseled her extensively about what the possible outcomes could be once the amniotic sac ruptures too early.  Amniotic fluid has many positive effects on the growing fetus: The amount of fluid is a reflection of the function of the placenta.  There are chemicals in the amniotic fluid that help the baby’s lungs to mature properly.  It provides a cushioning around the baby to allow room for growth and movement of its body and limbs. It protects the baby from the world outside, and prevents infection. When the fluid is gone too early, so is the protection and the other growth and development benefits.  In addition, once the amniotic sac has ruptured, the most likely course of events is that within the next few days, labor will spontaneously begin on its own, in an attempt to “empty” the uterus, whatever the gestational age of the baby.  All this provided a huge dilemma for Thalia, and for the team taking care of her.  While, initially, most patients with pre-term complications want “everything done” for their babies, this baby was only 24 weeks old–which at that time, was on the cusp of being viable.  Even in the best-case scenario, with no other complications, a 24 week old baby would be looking at a LOT of problems on the outside—so this was something we all had to think about carefully.  We decided to wait for all the test results before making any decisions.

1/21/17

For a few days, Thalia remained in the hospital, on mostly bedrest, monitoring her vital signs and temperature, checking for signs of infection and waiting for the test results.  When those results came back, we had to have one of the hardest discussions with her that I have ever been a party to.  Her blood tests started to show an increasing White Blood Count, which was a sign of infection starting to take place.  Of course, the most likely place for an infection to be occurring was inside the uterus, since the amniotic sac was already broken.  But the infectious cultures, which were taken directly from the amniotic fluid would show us exactly what type of infection was going on– and two of the cultures were positive. (meaning there WAS an infection found there)  One was for gonorrhea, and one was for Herpes.  These are two sexually transmitted diseases that she must have gotten from her most recent partner, who got them from someone else.  The horrific news (besides the obvious news that her partner was with other partners, and incidentally had since left her…) was that either or both of these infections were likely to cause severe developmental problems in the baby- especially at this premature stage.  There could ( and likely would) be brain damage, developmental problems, possible blindness, lung, liver and skin problems, not even taking into consideration the extreme prematurity of the baby if it were to be born soon (which added probable issues with poor lung development, deafness, poor motor function along with other disabilities).  She was likely looking at a poor outcome no matter what happened.  In addition, Thalia was currently in a week of pregnancy that was considered “on the cusp” of viability, even in IDEAL circumstances.  When she entered the hospital, the idea was to “do everything” to keep her baby inside, gestating, growing, until it was old enough to live in the outside world with some assistance.  But now it seemed that although her water was broken, she had not yet gone into labor, and with the known infections and the likely outcome for the baby, the best option was probably to get the baby out of there before the infections affected HER well-being.  In ALL of this, one of the biggest dilemmas, was that IF we all agreed and decided that for Thalia’s benefit, the baby should be delivered, ( and it was likely to have multiple and severe disabilities, given its gestational age and current known exposure to virus and bacteria), what would we do if the baby came out compromised but alive, with a heartbeat ? At 24 weeks, the hospital would be obligated to resuscitate the baby and place it on a respirator, regardless of all of the difficulties it was likely to have.  If another patient had come in to the hospital in a similar situation (and I had seen a few by now), then of course we would do all we could to assist the baby in its transition to the outside world; warming, ventilating, feeding through a tube, giving medication—- anything to help an extremely premature baby live and thrive.  But in THIS case, where the baby, already compromised, and highly likely to suffer many long term, life-long disabilities, the thought was a little different. WAS it the right thing to “do everything” ?  Present at the serious counseling session that we had with Thalia were the High-Risk obstetrician, several pediatricians, including specialists in premature babies (neonatologists), a specialist in infectious diseases, and a counselor.  To make matters worse, Thalia told us that her partner was no longer in the picture; he had left her several weeks prior.  She was in no financial or emotional state to take on the life long responsibilities of a severely compromised baby.  We had to offer her options.

2/5/2017

The options were:

1- Continue to wait, hoping labor would spontaneously begin.  Since it seemed she was already moving toward infection ( baby already seemed infected,  since it was living in a place that had cultured positive for some pretty bad current infections. ) she may soon labor on her own and deliver the baby.  However, she was also beginning to have a rising white blood cell count, some tenderness in her abdomen, and a slightly fast heart rate (tachycardia).  Waiting was not the best option, since the patient could then end up septic, and very sick, or dead.  We advised against this.

2- Induce her to deliver, as usually a premature uterus that is already infected will be sensitive to our augmentation medications and she would likely go into labor and deliver the baby in a short period of time.  Getting the baby out was of course indicated.  The sooner the baby was removed from her uterus, the better chance she would have to avoid major infectious  consequences. The problem with this choice, was that once the induction of labor was underway, it would be very likely that the baby would not tolerate her labor contractions, being as premature and as compromised as it already was.  What if we see, on a monitor, that the baby was “crashing”, as we call it in Labor and Delivery?  Do we intervene and do a c section on a baby that was highly unlikely to survive, let alone to survive with any real quality of life?  Do we do a c section on an infected uterus that will more likely end up in worse infection for the mother ( now that we would have introduced a surgery on a uterus unlikely to respond well to surgery– there would be SO much bleeding, and maybe so much that she would end up with a transfusion, or worse, a hysterectomy?  and  then her chance for future pregnancy is gone….)  Along with the other possible outcome from this choice– if we induced her, and somehow the baby tolerated the labor, and was born vaginally, with any heartbeat at all, it would be resuscitated by hospital protocol.  Resuscitation on an infected micro-preemie,  would likely be painful, and ineffective, and excruciating for all.  And if the baby survived the efforts, then what?  Likely a long, drawn-out NICU stay with poor chance of survival, and many future procedures and long term problems.

3-A difficult choice to present, but an option— knowing all of the other possible outcomes, it was offered to the patient, to consider that the procedure could be a late-term termination of pregnancy, and there was a way to make sure that the baby did NOT come out alive and with a heart beat.  Then the resuscitation part would not be necessary. The monitoring would not be necessary.  The thoughts about other interventions would not be necessary.  If the baby were no longer alive inside her, then the procedure to remove the baby would be done with the patient fully sedated, so she would not have to experience labor; would not have to feel movements or be on a monitor in the process.  It would essentially be removal of an infected “nidus”  ( an area of focus where bacteria have multiplied, causing an infection) and then treating the patient for a very bad infection, until she was well again.  I listened, as the attendings discussed how this could be done.  ( up until this meeting, I really hadn’t known that this was a possible option).  They explained that they could use a medication that would essentially stop the baby’s heart while it was still inside her, and then immediately induce her labor until the now not-alive baby would be removed in a procedure that might be carried out with or without instruments to be sure the baby, and the entire placenta ( all involved in the intra-uterine infection) would be totally removed.  She listened, mesmerized, as they told her about this option; the explained that she could be totally sedated and comfortable throughout, and can be as aware or unaware as she wanted to be; that she would be in a room distant from where women were laboring and having their “normal” labors and deliveries, with all their attendant happy noises and celebrations.  No one was unaware that what they were asking—what they were recommending—was that she actively participate in ending her baby’s life, to save her own, and to avoid the other probable outcomes that they had described to her.  As this realization swept over her, she began to cry.  I almost did as well, just listening to the description.  She asked if she could think about it, and discuss it with her family.  Of course she could.

All I could think while we were waiting for her decision, was how incredibly difficult this must be for her.  Also about how there is so much debate and controversy on the subject of abortion–and of all the political protestors, both PRO and AGAINST abortion, how many of them have ever really found themselves in a situation like this?  Not many I would guess.  I again was so certain that no one —no one except a woman and her doctor should be able to decide this — no one can decide what is the “right” thing for someone ELSE to do in this situation.  This would  be a decision that would be agonized over, mulled over, cried over, played and replayed in Thalia’s head and heart probably for the rest of her life…she had all the information on all the potential possibilities…..and time was running out for her safety.

2/15/17

After thinking about all the possible outcomes, Thalia decided to go ahead with the termination of her pregnancy.  We explained how this would be done, and the High risk Ob specialist and I came into her room the next morning.  The procedure required the instillation of KCL–(Potassium Chloride-)- in an injectable syringe which would be inserted through her abdomen with a long needle, under ultrasound guidance.  The goal was to find the baby’s heart and instill the KCL into the heart. This would stop the heart from beating, and the baby would no longer be alive.  Thalia was sad, but resolved.  She had been considering what was about to happen ever since she had been given all the information about the possible outcomes. We once again explained the procedure, and had her sign consent forms.  Dr W, the high-risk Ob doctor, swabbed her exposed belly with Betadine.  It was my job to place the sonogram machine on her abdomen to look for the heart.  Looking at this sonogram picture I couldn’t help but think about how, usually, all anyone wants to see when a sonogram is done is that small flash of light, that proof that there really is a living being in there, with a heartbeat.  Usually everything changes in that minute that you see the heart beat.  But we weren’t looking for the heart beat to confirm a pregnancy, or as a cause for celebration. WE needed to see that heart beat so we could see where to stick the needle.  Once we instilled the KCL, we would watch that heart beat, watch it slow down…..until the light went out.  I stared intently at the screen. I turned it away from Thalia so she didn’t see or hear what was going on in real time, although she was well aware.  I watched the blink-blink-blink of the heart beat……and, as professional as I tried to be, when I saw that heart stop beating, the hair stood up on the back of my neck, and I had to turn away from the screen for a moment.  I knew that this was the best choice for her under the circumstances.  I knew that this was definitely the lesser of evils.  I knew that we were absolutely doing her a service, and giving her a choice in order to avoid potential sepsis and delivery of a severely compromised severely premature baby.  I knew ALL this.  And yet I couldn’t help but cry when I saw the light go out.  HOW could I NOT?  I thought of all the babies I had delivered.  I thought of my own babies.  I thought of all babies, everywhere.  I thought of my specialty—-the happy specialty……..except when it’s not.

2/18/17

Once that distasteful part of this multi-part procedure was done, the next part was fairly standard.  I had done it many times already during the course of my residency thus far.  When a baby is not alive inside the uterus, and is over 20 weeks in gestation, it must be delivered like any other delivery.  Medications meant to induce labor–strong, regular uterine contractions, were given until the contractions were frequent enough and strong enough to dilate the cervix, and the baby could be delivered.  In this case, however, there would be no monitoring, no pediatrician needed,  and no happy ending.  The patient was given strong sedating medications and strong pain medications so she could go through her labor mostly unaware.  She also needed other medications to counteract the side effects of the induction medications  (nausea, vomiting, diarrhea, fever), and antibiotics for the now- established infection.  There were family members that she wanted there with her as she drifted in and out of wakefulness, and various medical people came and went as well; nurses and counselors, and residents, and the high-risk attending doctor, all playing a part in her management.  After about 16 hours, even through all of her pain meds and sedating medications, we could tell that the delivery was imminent.  We had warned her that she may still feel pressure to push, and would likely still have to do some of the work of the actual delivery, and when it came time, she did.  It didn’t take much pushing to deliver such a small baby, and when it emerged, I looked at the small, lifeless body, that just lay there, still, as I performed all my usual maneuvers to detach it from it’s placenta as gently as I could. “Be Professional”, I told myself….. The baby had the distinct odor of infection, as did the placenta, reassuring me that we had absolutely done the right thing.  I handed the baby off to the nurses, who had already discussed with Thalia whether or not she wanted to see or hold the baby.   Luckily the entire placenta came out at once, which is not always the case in this situation.  If it hadn’t all come out I’d have had to try to get it out with instruments—something quite risky in a preterm, infected uterus. But, as if a sign that this poor patient had been through enough, there was no need for instruments, and there wasn’t much bleeding. There were just the formalities of examining the baby, and the placenta, treating the patient’s infection and discomfort, and helping her to heal, both physically and emotionally from the entire experience, which would take time.  And then a short time later there was a “debriefing”……a meeting for all the health care providers who had been involved in her care.  Whenever an emotionally difficult event happened on our unit, there was always an official meeting to discuss the treatment, the outcome, and how it affected everyone.  This was actually a good thing, because we tended to get so busy taking care of the patients in these situations ( and, rightfully so), that we often forgot to take care of ourselves, and to discuss the toll that these situations had on us, as healthcare providers and as human beings…..at least for me, the burden was a heavy one, and I was grateful to have somewhere to talk about that, since at this particular time, I felt I could not expect empathy or sympathy at home.

3-4-17

My next three month rotation was in Gynecologic Oncology:  The specialty of treating patients with cancer, pre-cancer, or or things that needed to be managed like a cancer, involving the reproductive system and organs.  I have come to find that many women think having a Pap smear screens them for all types of gynecologic cancers, when in actuality it does not.  Every part of the reproductive system can have its own cancer diagnosis; the uterus, ovaries, fallopian tubes, cervix, vagina, and vulva ( the external genital area) can all have their own, distinct cancer syndromes, and a Pap smear ONLY screens for cancer and pre-cancerous conditions of the cervix.  Finding, diagnosing, and treating all of the other cancers was a much more difficult job.  In the world of Obstetrics and Gynecology, it seems the happiness can be extreme– bringing new life into the world, helping patients achieve pregnancies, connecting with families throughout the life cycle; but the sadness can be just as extreme.  The types and varieties of gynecological cancers that are seen in a busy county facility were often serious and found in later stages. They were sometimes on young women with seemingly their whole life ahead of them, and with young children and families…….heartbreaking under any circumstances. There was one oncology specialist in the hospital, and three days a week there were clinics for women being treated for various pre-cancerous and cancerous conditions.  Once a week was specifically for diagnosis and treatment of abnormal Pap smears, and the other two days were to care for all other conditions on our service.  We did all the admissions, all the surgeries, and arranged all their chemotherapy and radiation treatments after cancer surgery.  There was a lot to learn, a lot to know, and a lot of stress.  When I came on to the service, there were three admitted patients.  One had just had her uterus removed because she had been diagnosed with uterine ( also called endometrial ) cancer.  In this “lucky” kind of cancer, as long as it is caught early, the solution is a surgical one–remove the uterus, and the patient is essentially cured.  She was ready to go home two days after her surgery.  The next lady was in the hospital for chemotherapy and radiation treatments after a diagnosis of cancer of the cervix.  Unfortunately, when she had been diagnosed it was late in the disease state, and surgery to “remove” the problem was not possible.  The best we could hope for was to try to shrink the tumor with whatever we had available to us, and although the cancer made her ill, the treatments were making her ill as well, and she was hospitalized multiple times for treatments.  The third patient was a patient with ovarian cancer who was getting ready for surgery.  In the “old” days, we used to admit surgical patients the day before their surgery, to “prep” them.  She needed lab tests, XRays, Cat scans, a bowel cleanse, and several other things to get ready for a major, 3 hour surgical procedure, where she would be “staged”; her uterus, cervix, ovaries, fallopian tubes and appendix would be removed.  Lymph nodes would be dissected and examined, and samples from various other areas within the pelvis would be taken and checked for cancer.  It would be my job to round on these patients, plan their treatments, testing, and eventual discharge and long term care plans.  I would be doing the surgeries with the Gyn Oncologist, and order their Post Op care.  I had a lot of reading to do.

3/17/17

The gynecologic oncology clinic was full of interesting patients in various stages of cancer care.  Every patient was either in the middle of being treated, or being followed up weeks, months, or even years after their diagnosis and treatment.  One young lady came in looking  a bit thin and pale, and I proceeded to do my exam, a head-to-toe evaluation, along with ordering the appropriate lab work and follow up scans.  I was pretty amazed that someone so young had had such a severe and unusual cancer, but I had thoroughly read her chart prior to her visit, and found that she had a rare cancer called Gestational Trophoblastic Neoplasia.  She had had a baby a few years earlier, and things seemed to go well at the delivery and in the post-partum period.   However, when she came for her post partum check up, 6 weeks after the delivery, her uterus was still the size of a three month pregnancy.  Nothing else seemed strange, and she felt well.  She was nursing her baby, so no one thought much of it when months after the delivery, she still hadn’t gotten her period back.  However, when she returned for follow up a few more months later, STILL without a period, and with her uterus still unusually large, her bloodwork revealed that she still had pregnancy hormones in her system.  After some more testing, it was diagnosed that she had an actual cancer that can develop from some “left over” cells that start to multiply in an unhealthy way, after a pregnancy is over ( it can also happen after a miscarriage, an abortion, an ectopic pregnancy, or without ever having had a recognized pregnancy. ) It starts in the cells that would normally develop into the placenta in a pregnancy.  Many types of gestational trophoblastic disease are benign, but THIS patient developed choriocarcinoma, the malignant form of the disease that is likely to grow quickly, and spread to other areas outside the uterus.  This patient had been treated with surgery ( a D&C, to clean out the uterus of any tissue), and then chemotherapy, and now needed to return to our clinic periodically to be sure she was completely and thoroughly rid of all of the cancer cells. Every time she came in, we examined her, drew her blood, and discussed with her what would happen if the blood tests revealed that there were still cells that were continuing to show signs that cancer was still present.  Until I saw her in the clinic, I never really thought of a PREGNANCY as something that could cause a cancer— but after seeing this patient, I added one more thing to the list ( which was longer than you’d expect) of “ways pregnancy can kill you”.   Once again, the HAPPY specialty!!

3/30/17

At this point, my children were 6 and 4 years old.  They both had planned and active schedules.  They both had friends and play dates, and after-school activities.  I started putting together an assembly of relatives, friends and acquaintances who would be willing and able to help me out in what was beginning to seem like a difficult situation.  When there is a lot to coordinate at home, and busy, working parents– in the BEST of situations, it takes lots of strategy. Working together to make sure that there is always someone responsible  to plan and execute all of the scheduled events, and be sure that children have all the necessary supplies, snacks and carpools arranged can be tricky even when the parents are on the same page.  But we weren’t even in the same chapter of the same book.  We often made individual and conflicting plans, did not check with each other, and had absolutely no coping skills to make any of it better when things went awry as they often did.  I remember several times being about to walk out the front door on my way to the hospital, and seeing my husband put his coat on, also about to leave.  “I have to go”, I said.  “You always have to go–who says I have to follow your schedule?” would be his reply.  I soon realized that I ALWAYS needed a backup plan.  He was just as likely to tell me he wouldn’t be there as he was to not say anything, and then not be there……I needed “on call” child care.  And we needed some serious therapy or soon this whole marriage was going to self-destruct.

4/2/17

At some point during my third year of residency, a financial planner came to the hospital to conduct a seminar about investing and managing money.  Although at the time, I didn’t have very much money saved, I knew that if we wanted our children to be able to go to college, saving, managing, and investing whatever money we did have would be a necessity, and those skills were never really taught (or mentioned) in medical school.  I went to the seminar, during which one of the topics for discussion was “How To Save for your Children’s College Education”.  Since I was planning to manage my children’s educational plans slightly differently than mine had been managed, I realized I had a lot to learn.  I took the financial planner’s business card and decided to call him.  Several weeks later, he was sitting in our kitchen talking to my husband and me about our present and potential future financial situation.  This was just an information-gathering session, to look at our financial histories, goals, and plans.  Although I couldn’t see it then, I was certainly hoping that when I was finally done with all these years of training I would be able to find a place to work that would allow me to be the type of doctor I wanted to be, while both paying me well, and allowing me to have some semblance of a normal family life.  I had no idea if that was going to be possible.  At the end of this meeting with the financial planner, he said to me, “So what are you planning to do when you finish your residency?”  I told him I really had no idea, but would be looking soon.  “My wife is a nurse practitioner in the office of an Ob Gyn doctor here on Long Island– they will be looking for another doctor to join them–why don’t you give them a call?” he offered.  I looked at him skeptically. I had already met several private practice physicians, and had not yet met any I would have considered working for or with; they just didn’t seem to be the right “fit” for me, for various reasons.  But then, this financial planner guy said something that absolutely caught my attention……he said, “The doctor’s name is KHULPATEEA”  I knew that name was unusual enough that there couldn’t possibly be several people with that same last name, so I asked him, “Is HE a doctor from Brooklyn? ( remembering my FIRST, unbelievably positive experience as a third year medical student at the hospital in Brooklyn, where a doctor with that last name allowed me to assist him on an abdominal surgery ).  “No”, he said,  “SHE is married to the doctor from Brooklyn.”  This intrigued me.  SHE was a doctor, married to a doctor that I thought was awesome, who had had a big influence on me at a critical time in my medical education.  THIS work situation might be worth a look, I thought. I took the phone number from him for future reference.

4/8/17

My next rotation was in Reproductive Endocrinology and Infertility.  This was the rotation where women who were trying to have a baby came looking for assistance when it seemed things were not happening naturally.  At the beginning of my residency, I had believed that there were likely to be few women who needed to seek help in getting pregnant, since it seemed there were so MANY women trying to avoid a pregnancy.  I had learned many and various ways to prevent pregnancies ( so many contraceptive choices) and eliminate pregnancies ( abortion management was an integral and necessary part of our training), that I couldn’t imagine that an infertility service would be just as busy.  Boy was I wrong!   On the reproductive endocrinology service, there were ALL types of patients, with all types of problems; women who had achieved pregnancies, only to lose them, sometimes multiple times; women who had few periods, or no periods, for various anatomical and hormonal reasons; women who had ovarian problems, uterine problems, husband and partner problems, histories of infections, and medical problems that had thus far been incompatible with pregnancy.  The one thing they had in common was for the most part, they were all seeking pregnancy, and every month and year that went on without one was viewed as a failure, causing emotional distress for the whole family.  The chief of this service was a brilliant man of few words.  We had a specialty “Repro Endo” clinic two full days a week, that was extremely busy.  It was the attending ( who usually sat in an office, waiting for us to come present our cases to him), me, a more junior resident, a few medical students, a Physician’s Assistant and a Nurse Practitioner running the clinic. Patients would start showing up in the morning, waiting to be seen.  Some were coming for the first time, needing the “full visit”, meaning a full conversation with an intake person, to see if they were an appropriate candidate to be seen in this specialty clinic ( Usually they were since they were almost always referred to this clinic from another, more general gynecology clinic, or even sometimes a local private practice gynecology practice).  After that, it would be decided which health care provider would see them, what type of exam to do, which, if any, labs needed to be ordered, which diagnostic studies to order, and which plan of management would be devised, after taking all of the information into account and presenting the case to the chief.  Some patients were there for follow-up appointments, to review previous test results, to get started on medications, or to start planning for surgery. I found that each new patient was an opportunity to learn more about the reproductive system, and to teach people about how things so often worked ( or in their cases, didn’t work) in concert to create a new human life.  It was always a little surprising to me just how much education people needed, and how many things people believed about reproduction that were either a little “off”, or even completely opposite of the medical science.  I vowed ( once again) to always include a HEAVY educational component in my patient care.

4/15/17

The infertility/endocrine clinic was very busy, and each case seemed complicated and provided an opportunity for learning.  I remember one young woman that I was interviewing, who presented for a first visit with us, after having been to several other doctors for help.  She was 30 years old, and had had 5 previous pregnancies, yet no live babies.  She had gone through a similar experience with each pregnancy, although each one ended at a slightly different time.  I thought about the fact that she had actually “peed on the stick”  ( as we called doing a home pregnancy test); got a “+” or a happy face FIVE separate times, and then had to endure the sadness and grief as each one of those pregnancies ended.  In three of them she had actually seen a heartbeat on a sonogram. In the other two, there never was one.  Since she had moved around a bit, she had been seen by several different doctors for the various pregnancies. She had had many tests, but no real answers as to why this was happening.  All she knew was that she was getting older, and the disappointments were getting deeper.  I took a detailed history from her, and reviewed all of her prior medical records.  I did my exam, and then presented her case to my attending.  We discussed all of the things that had already been done:  general lab tests for all types of infections and medical problems (thyroid dysfunction, diabetes, etc) ; a pelvic sonogram, and a hysteroscopy ( camera inside the uterus); a chromosome analysis on her and her husband;  so far everything had been reported as normal.  My attending advised me to be sure we do tests for autoimmune diseases, and blood clotting abnormalities, and also a Progesterone level, since low Progesterone could be a cause of early pregnancy loss.  I went back to the patient to explain the tests we were sending her for, and what we hoped to learn.  She said someone had once tested her Progesterone level, but she did not remember the outcome of that test.  When she returned the following week, I was ( sort-of) happy to tell her that we had (sort-of) found something that perhaps contributed to her losses– she DID have a slightly low Progesterone level, so we offered to supplement her Progesterone with suppositories while she was trying for another pregnancy.  We also found that she had one copy of a gene that caused increased blood clotting.  According to medical literature ( and according to my attending) having one copy of that gene is NOT known to cause repetitive miscarriages, so he did not recommend that the patient go on medication to “thin” her blood.  But I asked if I could present that as an option to the patient anyway, since she was so distraught about the prospect of another pregnancy and another loss, that she may decide she would like to try this type of therapy anyway.  I spoke to her and offered her both the blood thinners and the Progesterone, and she seemed almost relieved that she could actually DO something to try to prevent the same thing from happening again.  I explained how both of these treatments would work, and all of the associated risks; this patient became “my” patient– I advised her to keep in close contact with me, so that we could start both therapies at the appropriate times, and I could follow her closely.  She appreciated it, and I was intrigued…..

4/22/17   I am in Italia!!  Ciao!

One of the most common patient presentations we would see in the infertility clinic was that of a woman who had a very irregular menstrual cycle.  They would either have periods at very unpredictable times, irregularly throughout the month, or, sometimes skip weeks or months only to have a very heavy period after an extended time of nothing.  The thread that connected most of these women, and the problem that turned them into infertility patients, was that they were likely not ovulating on a regular basis, and, as my attending was fond of saying, “No ovulation= no pregnancy”.  After extensive workups on these patients, it was usually ascertained that they, indeed, were likely not ovulating.  The good news about this was that this was often a fairly easy thing to remedy, and if this was their ONLY problem, medication and timing were likely to successfully solve it.  I learned about a medication, called Clomid, which could be taken at certain times in the menstrual cycle to “super” ovulate someone; to force the ovaries to ovulate more than one egg per month, and as my attending liked to say, “More eggs= more targets.   ( He had a lot of sayings).  I learned how to educate the patients, with a set of instructions, a calendar, several prescriptions, and some drawings, making it very clear, how to count the days of the menstrual cycle, on which days to take the medication, which days to test for ovulation, which were the best ( most fertile) days to have sex, which days to get to the lab to have blood tests done, and when to do a pregnancy test.  Couples were sent home with very un-romantic, detailed instructions on how to “make a baby”.  Sometimes, they were successful, sometimes not. Those that were not would be back to the infertility clinic in three months, to go to the “next step”.  Those that had positive pregnancy tests would transfer over to the Ob clinic for further care.  I felt that the value of the detailed explanation, with the instructions, the calendar etc, was great, and decided to continue to use those tools as I eventually counseled my own future patients who had fertility issues.

4/23/17

I had decided to call the private practice doctor, Dr Khulpateea, to see exactly what work situation she had, and if she was even interested in offering me to join.   I called her one day toward the end of my third year of residency. I told her that the financial planner, the husband of her Nurse Practitioner, had advised me to call her. She told me about her working situation– she worked as a solo private practitioner, along with the Nurse Practitioner, and was planning, within the next year, to join practices with another, male ObGyn Physician, and then they, together, would be looking to employ a third ObGyn.  It was not far from my house, and she sounded like a kind woman.  (Plus, remember, I already adored her husband—so this was sounding not only like a possibility, but a very interesting and inviting opportunity–and the timing sounded great!)  I agreed to make plans to come meet her, and see the practice sometime within the near future, and we left it at that.

4/26/2017

As I was nearing the end of my third year of residency, it once again came time to be picking the new residents who would be joining our program in their first year.  We had all (those of us who were about to be Fourth Year residents, also known as “Chief” Residents) been in on the interview process, and on the discussions among the attending faculty and staff about the possible new residents trying to make it into the program.  There were many medical students who had been rotating through the hospital and many of them had applied for first-year residency positions.  Of course we wanted to have first year residents who would be smart, competent, and easy to work with, and hiring from a pool of students that we were already familiar with would make all of our jobs easier. ( Remember one of my very first realizations in the hospital—-all sh** runs down hill;  now that I was going to be a fourth year resident, there would be quite a large gap between MY responsibilities and those of a first year resident. I could tell the third-year what to do, the third year could tell the second year what to do, and the second year could tell the first year what to do. HOWEVER, I realized, most of the responsibility for running each service and each department would be up to the Chief residents, so having a competent crew down the hill at every level would be a huge asset in the day-to-day goings-on of the Ob and Gyn services.  I gave my opinion on who should “match”.  I was a bit biased in that I favored students who had come from my own medical school, remembering what Tom had done for me in getting me my first-year opportunity. Several of the students from my school had rotated through our department, and most of them were excellent performers.  I did come up against some opposition, since somehow some of the other residents and the attendings thought it wasn’t a good idea to have “too many students from the Osteopathic medical school”, in spite of the fact that my school was the closest in the vicinity of the hospital, and that we had taken on many excellent rotating fourth year students who were already living close by and had expressed an interest in our program.  In the end, we matched 2 from my medical school, and 2 from elsewhere.  I considered it a victory.

4/27/17

On one of my last nights on call as a third year resident, I was witness to one of the most shocking things of my entire residency.  It was about 10 pm.  I was sitting in the delivery room, at the desk, taking inventory of the patients that were currently in labor, assessing which ones would deliver before we signed out to the night crew at 11.  There were a few patients in early labor, one becoming active, and one who was just being monitored for her high blood pressure, not in labor at all.  I thought we would be able to turn all of these patients over to the incoming night residents, without too much activity going on in the last hour.  Then the “red phone” rang at the desk.  This was the special phone that the emergency room used to call us when they had a particularly emergent patient that they were going to be wheeling up to the delivery room in a hurry, usually because the patient had showed up in the Emergency Room in some type of dire circumstance, usually about to deliver, and the ER docs would rather that she did so on the third floor, with us, instead of down there on the first floor with them.  I happened to be the closest resident to the phone, and the rule was, the closest resident was to answer that phone when it rang, so we all could quickly get ready for whatever they were sending our way.  I picked it up, said, “Yeah– Dr Levy….what have you got?”  The ER physician told me a tale I had heard a few times before– that a young woman  presented to the ER with acute abdominal pains and vomiting.  She was a large woman, over 250 pounds, and spoke only Spanish.  They have translators in the ER, and asked her many questions, one very specifically being if she was pregnant, which she vehemently denied.  But as her pain started to get worse ( and, since they did a pregnancy test, which was positive, and since she “acted” like a patient in labor, they called us, and decided to send her our way.) She was being wheeled up to Labor and Delivery, on a gurney in the “Express elevator” and they brought her right to the triage area.  She was absolutely huffing and puffing like hundreds of other patients I had seen, and having had NO information about her, and NO idea exactly how pregnant she was, or what type of medical conditions or problems she had ( she obviously had not had any prenatal care, since she was swearing that there was “no way” that she was pregnant!)  Just as I was hanging up the phone, the noises from the triage area got so loud, that we knew a delivery was imminent. Right there, on the gurney that we normally used for evaluating the triage patients, her baby, all 7 + pounds of him, was born within minutes.  The first year resident, who was used to many types of “triage emergencies” by now, fairly easily did the delivery, clamped and cut the umbilical cord, and the baby was whisked away to be evaluated by the pediatricians.  The screaming stopped.  The flurry of activity which had just been taking place all around us had died down.  We decided to take the patient back to the delivery room to await the placenta and repair any damage done by such a quick and unexpected ( apparently, really unexpected!!!) birth.  There didn’t seem to be much blood, so we all took a breath, and started to ask, in our combined, best Spanish, all the usual questions we had not yet had the chance to ask the patient before.  She told us that she had irregular periods, and over the past 4 or 5 months had seen a few periods, not really sure of the dates.  She said she “always” weighed between 230 and 250 lbs, hadn’t noticed much weight gain specifically in the past several months; denied being aware of fetal movement, contractions, or water breaking; she had two other children, 10 and 7 years old, and no known medical problems  (although she hadn’t really visited the doctor on any  regular basis, and certainly not in the past several months.)  In the middle of this conversation while we were still getting her “prepped” to undergo removal of her placenta, which had not yet presented itself, and repair her bottom, the patient suddenly started breathing heavily again, stronger, and faster, and acting like she was once again having increasingly painful abdominal contractions. We thought it was a little unusual, but sometimes when the placenta is ready to deliver, contractions get strong again for it to be expelled.  But this much pain was unusual.  My first year resident, who was mainly responsible for this delivery and was sitting on the stool at the foot of the table suddenly yelled to me—- “Oh My God, Come over here RIGHT NOW!!!”  I went running, as I was over in the “non-sterile” area of the room, doing the paperwork and asking all the questions.  When I got to the edge of the delivery table, and looked from his point of view, what went through my mind, and what DID come out of my mouth was, “HOLY SHIT”…..because there were two feet and two legs—- another baby was about a quarter of the way out of this woman’s vagina.   I called for the fourth year resident, who had not been previously involved.  I called for nurses, and attendings, and pediatricians, and anyone else who could possibly come in to assist– and the patient was obviously and uncontrollably trying to push this baby out.   When I slightly regained my composure, I sat down on the stool, and repeatedly ran through in my mind everything I had been taught about delivery of a breech baby vaginally.  I had done several, always a second twin ( which THIS obviously was), and although it would be ideal to do it in a calmer, more planned set of circumstances, there was obviously no time to stop and think,  and the maneuvers were the same.  Hopefully, the first baby had “paved the way”  and hopefully this baby was smaller.  I quickly gowned and gloved, wrapped a towel around the lower half of the baby, which was out to about the waist by now, legs kicking.  I gently held the lower half in one hand, and reached up to “sweep” one arm down. I then turned the baby so I could do the same with the other arm, then lifted the baby in the air by its legs, flexed the chin, and directed the patient to push as hard as she could—-and POP!  Out popped the baby’s head.  The baby looked a bit stunned, ( as was I ) but started to cry.  All the help I had called for now started pouring in to the room.   There were residents, nurses, medical students, pediatricians, and an attending physician.  I held onto the delivery table for fear I would pass out. My adrenaline rush was so powerful I was visibly shaking.  The patient was once again quiet, and the flurry of activity began again.  All I could think at the moment was, unknown twins……breech vaginal delivery……..oh my God………all that paperwork……….and welcome to my fourth year.

5/7/17

As my third year of residency came to an end, I began to wonder if there was any possibility of saving my marriage, which, by now, was in pretty bad shape.  We didn’t talk much, and when we did, it was difficult to feel we were doing anything but trying to maneuver the kids and ourselves into plans that would somehow “work” to get us all through another day, another week.  We finally had a conversation about it.  I was strangely calm, mostly because I felt by then that I had accepted that we were either going to work it out, or not– I was unhappy but had no time to really think about how to make it better.  I realized my contribution to the difficulties, but at the time I honestly felt that I really could not do anything about it.  My life was completely dictated by things and people other than me. I had no choice in my residency hours, I had no choice when my children needed me….I get now that my husband must have had so much resentment from being  third  (or even farther down) on my list of important things I needed to pay attention to, but at that time, I just felt that there were only so many hours in the day…. I strongly suggested that we go to therapy to salvage whatever was left. He strongly suggested that we just “wait it out”– that if we just waited for this horrific ( in his words, not mine) residency to be over, we could be living a more “normal” life and  then things would get better.  ( I do NOT know why exactly he thought that once I became an attending, or was in an employment situation, I would have any more control over my life and my schedule…..) He really believed that many of our problems were financial  (with which I did not agree), and that once I was done with residency, and I would be making so much more money   (again–I knew I would make more than when I was a resident—but SO much more??  I didn’t believe that was so–at least not enough to cure all of our marital ills with money).  I tried to push him on the therapy thing, since I truly believed without it, our marriage would end with the end of my residency if not before.  We continued to have nannies, babysitters and family involved with our childcare–I needed a person ( or persons) I could count on to do school pick up since we both could not.  I needed a person to be sure that someone could be called in the middle of the day in case of emergency when our kids were at school, since we could not.  I was able to go to parent -teacher conferences, and assemblies, and even the Thanksgiving show where Jacob was dressed as a turkey– but we always needed third parties around because we were a two- parent family with two working parents, and because my schedule was unpredictable, difficult, and exhausting.  His schedule was very predictable, and limited….but he was angry…….and usually not in the mood to collaborate.

5/21/17

The first rotation of my fourth year, I was back in the delivery room.  As a fourth year resident ( also known as the “chief” –ALL 4th year residents were Chiefs), I would be basically in charge of everything that was going on in Labor and Delivery from 7 am until we signed out to the on-call or night crew resident team.  This was my last opportunity to perfect my skills for managing patients in labor. Although no one loves to take care of very ill or very high risk patients, with their possible poor outcomes, I felt it was very important to know how to deal with every and any eventuality when it came to labor and delivery so that when I had to do it “on my own”, as an attending, I would feel confident and certain in my management skills.  I was in charge of a team that included a first year resident, a second year resident, and numerous medical students.  There were Midwives and Physicians Assistants on the team as well, and there was usually an Attending physician around, but not exactly “on site” with us; they were there for consultations and assistance, but usually the chief resident was responsible for all the day-to-day activity and decision making.  July 1 started the year for us, as usual, and,as usual, the first year resident was pretty useless as far as really knowing how to “run” the delivery room.  I decided that If I taught the first year resident well, and thoroughly from the beginning, shortly he would be up to speed and take on his own responsibilities.  I decided to be very organized and “official” with the residents and students, so they would all know what they were responsible for and what was expected of them. ( I kind of felt like it was similar to raising kids!– set expectations, make them clear, make sure they are capable, then hold them to it)  I had also been named the “Clerical” chief resident, who was the resident who was in charge of making all of the on-call schedules, and basically being the secretary/note-taker/organizer/reminder person, responsible for all the administrative tasks ( there were so many things to keep track of) for the residents.  This was a job that was “awarded” (so to speak) to a resident who had shown organizational skills and would be capable of managing the schedules as well as making sure all members of the department were notified of on-going activities and deadlines within our ObGyn department.  I guess my endless lists (with my legible handwriting), and all the folders and binders I was always carrying around gave them the idea that it should be me, since I later found out this had been a unanimous decision.

I decided to set the tone on day #1— advised all members of our team that we would meet at 6:30 AM, a half- hour before we were to take sign out from the night team.  We would “Pre-round” and discuss things going on in the delivery room and on the floors currently.  There would be a discussion of responsibilities and of the current patients, along with some teaching going on at that time. By 7 am, my first year resident would need to be able to take  sign-out from the night team first-year. I was ready for an awesome chief year.

5/29/17

I really got into my rhythm of the fourth year quite quickly.  I very much wanted to delegate so much of the responsibilities of the running of the delivery room to my more junior residents. I was realizing that I had a hard time with that—with actually delegating responsibilities to other people, and then just being there as a consultant, to help and answer questions, just allowing them to figure out ways to accomplish things, without feeling compelled to “just do it all over again”, or to make them change the way they did it, to more of “my way”.  I slowly realized that not only did I have a problem doing this at work, but I also had a problem doing this at home.  THIS realization hit me pretty hard, since that actually made me aware that I played quite a large part in the issues happening in my marriage: I had a certain way that I wanted everything done, and had trouble delegating those things to other people.  Then I would hold them (including my husband) up to some ridiculous standard, and when they (inevitably) didn’t live up to that, I had no tolerance for their failings.  This was a cycle that repeated itself over and over. Once I started to recognize that in myself in many instances, I vowed to try to take a step back at home and at work, and try to force myself to be more tolerant of other ways of doing things— of different ways of doing things, as long as the end result was (maybe not exactly the same, but) similar.  I remembered what a resident once told me when I was a medical student, rotating through his clinic:  “It doesn’t really matter what WAY you decide to do something, as long as you develop a way–a method that works for you–every time, so you don’t miss anything”.  Now I was giving that very same advice to my junior residents and medical students.  I decided to teach them, assist them, counsel them, and take a step back so they could succeed or fail on their own.  ( It was great practice for raising teenagers.)

6/18/17

One of the things that was required of fourth-year residents was to come up with a research project to work on throughout the entire fourth year, finishing it with some interesting conclusions and a possibly-publishable research paper by the end of the chief year.  It would have to be presented to our peers, colleagues, students and attending physicians, at a “research day” in June, and one project would be chosen by the faculty as the winner both for its applicability to a patient population and our ability to create, assemble, complete and present coherent research.  Every resident also needed one of the attending physicians to be our mentor–someone to guide us on all the steps of the project, and, if published, someone to put their name on our paper as well. I was thinking about what to do, realizing we had such a large and diverse patient population, and so many patients passed through our doors every day, I could study many different topics, and collect lots of data to create a worthwhile research paper…….just had to think of what would be interesting and important……

During my fourth year of residency, there was a nurse (who worked in the hospital) that was actually pregnant with triplets.  I had never had the opportunity to care for such a high order multiple pregnancy, because in those days, in vitro fertilization and many other assisted reproductive practices were not as common as they are today. Also, I worked in a county facility, where we mostly cared for mid-to-lower socioeconomic status patients; those on Medcaid and government assisted health insurance, so unless a patient spontaneously became pregnant with triplets, we did not often see patients who could afford many of the procedures that would result in a triplet or higher order pregnancy.  However, since this particular patient worked in the hospital she opted to have her care at the hospital, and to ultimately deliver with us as well.  I learned a lot of lessons during her pregnancy:  Triplets almost always end up on bedrest by the 28th week or so; Triplets are almost always delivered by 33-34 weeks; 35 if they are really lucky;  Triplets need lots of monitoring;  They always require a C Section because of the possibility of poor positioning and getting entangled during the delivery;  The patients are at higher risk for hypertension, diabetes, preterm labor, preterm rupture of membranes and many other high risk pregnancy complications.  I also happened to be on call when she came in at 34 weeks in labor, and needing to be delivered.  The attending physician scrubbed in with me, and after four years of doing C sections as a resident, I was excited to be doing something I had never done before.  There were three separate teams assembled in the operating room, ready to take care of three premature babies.  There was an excited buzz going through labor and delivery.  The initial preparations were about the same as a regular c section– but after the first cut, nothing was the same.  When I surveyed the patient on the operating room table, I was quite amazed by the size of her very pregnant belly. 34 weeks with triplets looked like a pregnancy with a giant baby inside, and I really marveled ( for about the millionth time during my residency) at the body’s ability to expand for pregnancy and then contract back again ( usually) later on.  Once I made the incision into the uterus, and broke the bag of water protecting the first baby ( Known as “baby A”), things seemed to move both in slow motion, and fast forward all at the same time.  Baby A came out pretty easily, head first, crying, and was handed off to the first set of pediatricians.  We then had to quickly identify and move the next baby (“baby B”, of course), into position for delivery.  My first-assistant pushed gently down on the outside of the belly, to move a baby down so I could then break the second bag of water, and deliver the second baby, which I was also able to do, with a bit more difficulty then the first one.  “B” was also whisked away to be examined by the pediatricians on the far side of the room.  By this time, there was some significant bleeding going on and we needed to move a bit more quickly.  I started to feel the adrenaline reaction that I had felt so many times in the middle of deliveries or surgeries where my body started responding to the fact that things were getting serious and I needed to speed it up.  The attending once again started pushing on the abdomen to try to get the third and last baby into some sort of position for delivery.  At the same time, I reached my hand up inside the giant uterus that seemed more like a soft bloody rag rather than a muscular organ designed to contract to push its contents out.  All I could feel were small feet and legs, through the last amniotic sac, and the baby’s back was “down”  ( also referred to “back-down-transverse lie”, which is a difficult position to maneuver a baby out of for delivery as it requires a bit of pushing and pulling to get the baby into the right position).  I let go of the feet and pushed the baby back up and toward me, in order to get it into a “back up” position which would be easier for the delivery.  Once I did this, I was again able to grab the feet and pull them gently down toward the uterine incision.  Then I could finally break the third amniotic sac, as the entire operating room remained deadly silent.  Once the sac was broken, we could all see that the fluid was dark greenish, but not too thick, signifying that the baby had been under some stress and had had a bowel movement inside the sac, hopefully only fairly recently, during all the manipulation during the delivery.  I pulled the feet and legs through the uterine incision, brought out the hips, then quite automatically did the maneuvers of a breech delivery : hip, turn, sweep down one arm, turn back, sweep down the other arm, pull the feet straight up, flex the head, and pop the head out of the incision.  Baby “C” came out lifeless.  He didn’t move—didn’t cry, and didn’t seem to have any tone to his small body.  He was also smaller than the other two.  I speedily cut the umbilical cord, lifted this small rag-doll, and passed him off to the third group of pediatricians for what turned out to be a full resuscitation.  The adrenaline was high.  I was going as fast as I could safely go to clean out the uterus, sew it back together, order lots of medications to help the uterus contract, all while keeping one ear to the table on my right where they were working on the baby.  I was almost to the closure of the subcuticular layer when I finally heard a small, weak cry from the direction of the “C” team.  The baby was moving a bit, had a good heart rate, but needed help to breathe.  I thought I may need some help to breathe as well by that point….but I finished the c section, and waited to hear what was happening in the NICU, which is where all the babies had been taken by then, since at the very least, they were all several weeks premature.

7/9/17

Halfway through my chief (“administrative chief” ) year, I was well into my research project. I had decided to study what would happen to pregnant women who had some type of vaginal infection discovered in the first trimester.  We always checked pregnant patients for sexually transmitted infections, like Chlamydia, in their first trimester, preferably at the first visit– to see if we needed to treat them for infections that we KNEW would cause a problem for the baby if left untreated.  But I thought that there must be some consequence to the other possible infections that patients may have, but that we did not usually check for.  There are all KINDS of things that can be infectious is the vaginas of pregnant women; various kinds of bacteria, viruses, yeast…..the thought was, many of these things just “lived there”, especially yeast and certain types of bacteria; but they were not thought to cause problems.  I decided to culture ALL pregnant women for ALL possible infectious agents, and then compare the results with the outcomes of the pregnancy.  It took a lot of collecting, and a lot of list making. I had gotten one of the attending physicians to be my “research mentor”, who would help with putting the data together in some kind of coherent, publishable way.  Adding this to all my regular “Chief-ly” duties made my life very busy indeed.  I had spoken again to Dr Khulpateea, and to the male doctor who would be eventually joining her in practice ( as was the plan), to discuss my coming on board for an employed position after I graduated.  I was studying for the board exams, ( The written part was to be taken after completion of the fourth year of residency, the oral part would be two years later).  I had two kids still under the age of 8 and an array of nannies and childcare situations going on.  My mother was living in the upstairs of our house, and I was still working more than 60-70 hours a week at the hospital, and contemplating my stressful marriage situation.  It Was Exhausting.

7-22-17

On the home front, we had been going pretty regularly to see a marriage counselor/therapist and I knew if there was any chance of saving our marriage we needed to really be committed to listening to her and working on the things we discussed in her office.  We went together once a week. and we also were supposed to alternate going by ourselves as well.  I was very open to going to someone and talking about things that were going on, even though my family growing up did not really believe in talking about our problems,  or going to therapy.  My husband was kind of against the idea, but also realized that nothing would get any better if we did nothing. After going for a few months, I actually thought that things began to get a little better between us.  Our therapist had given us several “exercises” to try when things got very stressful for us, and we were giving them a try.  We even decided to take a trip with our kids since I had a week off from work around the holidays.  We went to Jamaica, and had a nice time; Jake and Danielle enjoyed being at the beach and in the pool. We had an okay time as husband and wife, but one thing I realized on that trip, sadly, was that I was NOT happy in my marriage. I realized that if things are not great on a stress-free beach vacation they probably never would be. I felt that we had very little in common and little to talk about.  All of our conversations revolved around our children, and there wasn’t much else.  I was sad. Maybe I was resentful that I felt he had made my entry into residency, and my time at my residency harder than it had to be–maybe I felt unsupported– maybe I wasn’t able to focus on anything except raising kids and being a newly-minted doctor with so much more to learn, so that I couldn’t – or didn’t want to exert the energy that was needed to keep a marriage together…..but when I came home from that trip I felt trapped.  I was unhappy and exhausted, and always busy, and confused.  I just was not sure what to do, but I agreed to continue to go to therapy to try to figure it out.  Then we went to our one fateful last therapy session. We went together, for one of our joint sessions, and things were going along as they always had–we were telling the therapist what kind of things had been going on in the past week or so…the usual…and my husband said, “I have a question–  we have been coming to you for months, now, and I don’t understand why she (pointing to me) is not fixed yet”.  I couldn’t believe my ears.   Apparently, since things had not gotten back to the way he wanted them to be in our relationship, the therapy was not working as he thought it should– to “fix” me, and repair things. The realization of what was likely going to be the outcome of all this hit me like a ton of bricks.  I still had to go to work every day, and I still had to learn, and teach, and deliver babies, and do surgery, and stay up at night, and attend conferences……..but now I also had to think about what I was going to do to extricate myself from my unhappy situation……and when.

7/29/17

I was beginning to realize many many things during my last year of residency– things that were going to be a permanent part of my professional life down the road.  I learned that I loved to teach.  I loved having students, and more junior residents “under” me who needed to learn lots of information from me, and I realized I was pretty good at providing them with that information in an effective and efficient manner.  I loved organizing these teaching sessions and illustrating my points with drawings, and providing them with written educational materials.  I enjoyed educating patients, and their families, and anyone who showed an interest in how I did what I did professionally.  I realized that if we expected patients to have better outcomes, then explaining their care and treatment programs in ways that made sense to them would help them to achieve those goals.  I realized that sometimes the best thing that you can give to patients is time, and empathy, and the feeling that someone is really interested in them, their care and their health.  I realized that true empathy and a good bedside manner is not something that can be taught in medical school, or forced–either you have it or you don’t.  I also realized that money was never my goal for choosing my specialty ( which I think I already knew).  I had about six more months to transition myself from a married mother of two, and (somewhat) protected resident physician, to a possibly- separated or divorced, single mother of two, ATTENDING physician in the real world, finally arriving at what would be, in many ways the end of a very long road.  Was I Even Ready??

8/13/17

In the winter of my fourth residency year, I was the Chief Gynecology resident for a three month period of time. I was in charge of all the surgeries and all the gynecologic care we provided to our clinic and hospital patients. I had a team of residents to supervise and teach, and students,  nurse practitioners and physicians assistants, all of whom were tasked with taking care of the  women on our service.  One afternoon, we were in the general gynecology clinic, taking care of things like birth control, infections and pap smears, when I got a call from the emergency room.  ( It was the second year resident’s job to evaluate any emergency gynecology patients, but if it seemed a patient might need surgery, I was consulted).  A young woman had come in to the ER with severe abdominal pain.  She was actually from out of town, recently married, and in NY on her honeymoon.  She and her new husband were out to dinner when she suddenly had such severe pain that she nearly passed out. She started throwing up, and an ambulance was called. She was currently in the ER being evaluated by my second year resident, and it seemed she might be a surgical candidate. I went down to the ER to see what was what.  The list of things that are gynecologic that can cause that scenario is short, but some of them would require surgery. It was also possible that this was NOT a gynecological problem, in which case we would be “turfing” the case to a general surgeon ( or whoever was in charge of the organ needing treatment or removal—could be urological, gastroenerological, orthopedic, or a number of other things).  The assumption was usually that women with pain had a gynecological condition until proven otherwise, and the resident had done a good job of examining and ordering the proper tests. The patient looked in moderate distress, in spite of pain medication. Her pregnancy test was negative, essentially ruling out something pregnancy related.  Her blood work showed inflammation but not necessarily a severe infection, and she didn’t have a fever.  Her cultures from her urine and vagina were negative. She had no medical problems,  had never been pregnant and had never had abdominal surgery. This ruled out a whole host of other problems– scar tissue, pelvic infection or PID ( pelvic inflammatory disease).  A  pelvic sonogram showed a large, leaking, possibly twisted ( “torsed” was the medical term) ovarian cyst…….so by all means we had of coming to a diagnosis, the ER physician and the second year resident agreed, this was likely a twisted large ovarian cyst, which was causing severe acute abdominal pain, and the solution would be surgery– we should take her to the OR and ( likely) through a laparoscope ( a small camera that would be placed through the belly button while the patient was under general anesthesia, and would allow us to take a look into the pelvic cavity, see up close what the problem was, and then deal with it via small incisions with long instruments. ) We then could either untwist it, remove the cyst, remove the ovary, and do whatever we needed to do to put this poor patient out of her misery.  I agreed after speaking to the patient, examining her myself, and looking at all the test results.  It seemed time was of the essence, since a twisted ovary and cyst could lose its blood supply and if we waited too long we would not be able to save it.  I contacted my attending physician, who of course needed to supervise all surgeries, and he agreed as well.  Orders were written, consents were obtained, family was spoken to, and the patient was readied for a surgical procedure.  I went to the OR with my second year resident and our entourage of students to await the patient’s arrival.  The patient was wheeled in on a gurney, already almost half asleep from the pain medication and the anti-anxiety meds that the anesthesiologist had given her on the way up.  We got her prepped and draped and got ready to “fix this”.  Over the past few years I had realized that there was something about surgery that really appealed to me because often it was black – and- white.  There was an ailment, or a diseased organ, or something inside the body that was just “not right”.  Surgery gave me the ability to remove, or fix, or correct what was wrong, and, usually, the patient would get better.  There was something satisfying about kind-of knowing what I expected to find when I looked inside someone’s body, and I knew what had to be done, and had the skills to do it. It required distancing myself from the fact that I had my hands inside someone’s body .  …..!!  I thought of it more as a science project that I had to put together, and when it was done, it would again work properly.

Of course, every once in awhile, things did NOT work out exactly like that…..and this patient was one of those times.  After preparing this patient for her surgical procedure, and arranging ourselves around the operating room table, I took the place of the primary surgeon with my second year across from me. The attending was scrubbed, but standing a bit off to the side.  I  infiltrated the area under the belly button with local anesthesia, and we lifted the sides of the indented belly button so I could carefully place the first trocar, the sleeve through which the camera would then be placed. We insufflated the abdomen with enough CO2 gas so that we’d be able to have a clear picture through the camera and we placed the camera, attached to a light source, through the sleeve.  We all turned our attention to the video screens which were placed strategically so that we could see what we were looking at inside the abdomen.  Once we got a good look, we all gasped.  The room got silent. What we saw was a large left sided ovarian tumor, and throughout the entire rest of her abdominal cavity we saw signs of a cancer, that had spread– onto her intestines, on the outer surface of her uterus, under her diaphragm, on her fallopian tubes– we barely saw any surface in her abdominal cavity that was free of what we could assume was spreading and metastatic ovarian cancer.  As we inspected the area with the camera, the attending and I, who had seen ovarian cancer like this before, were continually gasping at each new surface that the camera focused on.  I am sure the phrase “Oh My God” passed my lips, as I thought of how unusual this was, how young this newlywed was, how serious this was, and how her entire life had just changed in the blink of an eye. We put a call out to the gynecologic oncologist so that he could come to the operating room and decide what to do, and my attending spoke to ME about going out to this woman’s family to tell them what was happening, since now, we needed permission that we did not have, to do much more–and more necessary surgery than we had gotten the patient’s permission for.  I was dreading that conversation as I thought about heading  to the family waiting area.  How do you tell someone who just got married that his new wife had Stage Four Ovarian Cancer?

8/27/17

I waited for the gynecologic oncologist to come into the OR to give his opinion before going out to talk to the family, since I really did not know what I was going to tell them yet.  He arrived, scrubbed in, and did his meticulous oncologist-assessment.  Looking at her entire abdomen, taking his time, his serious and stern expression never wavering, he finally looked up and said, “Nothing to do.”  I wasn’t sure I heard him correctly. “Nothing to do”?  I thought he would immediately get out his scalpel and begin an extensive debulking surgery to remove whatever tumor was evident in her abdomen…..everyone knew that ovarian cancer, left alone, would kill someone in a relatively short time. It was just that kind of cancer.  In all I had learned, I knew it wasn’t like endometrial cancer, which you could almost always cure with surgery, or cervical cancer, which was now  rare because of Pap smears and treatment of cervical pre-cancerous conditions. Ovarian cancer was almost always discovered in its later stages, and most of the time is a death sentence, even with treatment.  I waited for him to continue…..and he did.  “The disease is just so extensive, that surgery is not going to help her.  The best we can try to do is to try some chemotherapy and try to shrink what’s already in there—and if she survives that, we may be able to operate later on to remove what’s left.”    And that—was—THAT.  I tried to wrap my head around that and come up with something that would make any sense to this woman’s family.  I knew that whatever I said was going to be devastating–and life-changing–and not really believable……but go find them in the lobby I did.  When I got there I saw her newly-wed husband, that I recognized from the pre-op area . ( back in the time where we all thought that the patient likely had a silly-old- ruptured ovarian cyst or a torsed ovary, and the worst thing I might have told him was that she had lost an ovary during the surgery.)  He stood up when he saw me, and I looked him right in the eye.  I owed him that.  I also sat back down, so he would sit, too.  ( all of this had been rehearsed and calculated in my mind on the way down from the OR….sit-when-delivering-bad-news……look -right-in-his-eyes…..).  When he saw my face, he knew something was not right.  “So…..when we went in to the operating room, we all thought that this was likely an ovarian cyst that was rupturing, or an ovary that was twisting, because these are the most likely things that it could have been in someone so young……” I began.  I was trying to tell the story, soften the blow, have him follow the words that would ultimately come to the conclusion I needed him to hear.  I could see him anticipating me tell him just which one of these things it had been……”But sometimes”, I went on, “we go in thinking one thing, but once we get in there, it turns out to be something else.”  Now I could see that running through his mind were likely things like, “Oh– WE thought it was an ovary, but it was really her appendix–or her gall bladder….so now you are here to tell me that you were wrong, and you had to take our some other organ……” but before he could even express those thoughts, I said ” and sometimes, we are all extremely surprised, because we find something that we had hoped it wasn’t, and something that is very rare, but we find it, and we have to change the plan.”  My voice started to fail me at this point, and I could feel a tear run down my face.  I knew I had to stop dancing around it, and just SAY it……and I knew the moment had come……. and he knew it. . “I am so SO sorry to have to tell you this—-but your wife has ovarian cancer.”  and then I stopped talking for a moment to let those words sink in.

9/9/17

One thing that I actually did not have to figure out– one thing that I of course already knew—-was that I was in what has always been considered the “happy specialty”. Delivering babies, helping people get pregnant, even operating on people and somehow “fixing” them– were all reasons for celebration. They are times for smiling, and bonding with patients, and families, and sharing good news…….except when it’s not.  Except when the news is bad, and there is no celebrating. When things go wrong– when there are “unexpected results” or “poor outcomes” as we describe them in medical terms– things go horribly, terribly wrong….and it can be devastating. I knew that this would not be the last time I would have to break bad news to a family and to a patient. There would be deaths, and compromised babies, and cancers, and unexpected test results.  I had not been great ( see past entries on my upbringing and my marriage) at “telling people exactly how it is”.  I really had no training, no role models and no medical school classes in “how to break bad news with empathy and kindness but at the same time making sure they hear the truth”.  I made it my business to become really good at exactly that, for the times I would ( inevitably) be in that situation once again.

I also had to do that in my personal life, I realized with some sadness and resignation.  I was coming to the end of my residency, and, I knew, probably, the end of my marriage.  I was unhappy. Therapy had not “fixed us”.  I was reluctant to pair the ending of the residency with the ending of the marriage, as I knew that it would somehow appear that the two were connected.  ( More likely I really did not have the time or the energy that it would take during residency to deal with the difficulty that would inevitably come with the dissolution of a marriage that involved bad feelings and two young children, but now I saw the light at the end of the tunnel, and the light at the end of my tunnel included separation and ultimately divorce.)  I don’t know why, but with my last vacation time, I had decided I wanted to take my kids somewhere that they could learn to ski.  My husband did not ski, but I loved it.  I had learned to ski during college, and while I was not an expert by any means, I was a “medium level” skier and absolutely realized that if kids learned when they were young, they were much more likely to love it and to be good at it than if they waited until much later, like I did. I wanted them to have that opportunity.  We had gotten materials in the mail on a great family-centered ski area in Vermont, called Smuggler’s Notch, near the Canadian border, and we decided to go up there for a week. I don’t know what I was thinking at the time as far as the marriage was concerned.  Maybe I thought we could have “the talk” while we were there.  Maybe I thought my kids needed to have a fun get-away which may be the last vacation we would ever take all together…Maybe I weirdly thought that introducing my husband to something I loved would give us something to share and weirdly, THAT would “fix” things that we could not otherwise mend.  Whatever the reason, we started planning for a winter vacation.

9/28/17

I actually remember it like it was yesterday– January 1997.  Six months away from the end of my residency and hopefully, the start of a whole new professional life. We drove up from New York, through Connecticut, Massachusetts, New Hampshire, finally arriving at the northernmost part of Vermont.  Eight or so hours, through the snow, with a 7 year old and a 5 year old was an adventure in itself– we had stocked the car with all kinds of snacks, toys, and a small TV on which the kids could watch movies . (There were no I-phones, no tablets at this time–) we had card games and travel games and many things to keep us all occupied. I actually enjoyed spending time with the family like that– I was a happy traveler and wanted my kids to be the same. The trip was all part of the fun.  My husband was more of a “let’s get there already” kind of traveler; feeling like he would only enjoy the vacation once we made it to the destination.  I can understand that in a way—-but when traveling with children, I always felt it was best to let the children’s agenda guide the travel plans….stopping for breaks when it seems they need it, eating at fun and interesting “kid places” so we would not very often have to  hear the inevitable “are we there yet?” from the back seat.  We finally got there, and checked in to our one-bedroom condo at the top of a very long hill.  It was beautiful.  Spacious, comfortable. There was a pool, and a family “fun” center that we could walk to, with activities for the kids, and several restaurants….a great self-contained “ski village”.  Best of all were the world-renown ski schools.  There were day- long lessons that both children could go to, where they would learn to ski all day, have lunch with their ski group and instructors, and spend the afternoons doing various fun winter activities.  This left time for my husband and myself to also learn/improve our skiing, and do other things that would be fun winter activities like snowmobiling, ice skating, dining out, swimming in the heated pool. My husband and I both spent some time in lessons, and also trying to do some skiing independently. We were having a good time together, and I am not really sure what came over me on the third day that we were there.  Turned out that Smuggler’s Notch was not just a “ski place where you can rent a condo for a week”……it was actually a Time Share.  After having the experience of living there for a week, and taking advantage of all the resort had to offer, they invited you to (a free) dinner, and gave you what is known in the business as “the hard sell”.  The representatives from the resort start by asking how you are enjoying the stay at this lovely resort. They show you plans for future building and expansion and have you speak to other families who have already bought space in their fabulous resort.  They ask you, “If you really like it here, wouldn’t you like to be able to come back every year?  To the same resort, and to “your” condo?”  ( Yes…..yes I would…….the kids love it– I want them to ski, it seems like the perfect place to come back year after year…….) . I must have been out of my mind…..I must have completely put the thought out of my mind that I was not sure what was going to ultimately happen to our marriage….. Maybe I actually did think that doing this—doing something together, might even save our marriage. I don’t know…. All I know is that when the dinner was finished, we had signed on to take on the debt and the mortgage of a piece of deeded real estate ( they do not deed timeshares anymore) in Smuggler’s Notch, Vermont.  Oh boy.

10/14/17

When we got back home to Long Island,  I spent lots of time contemplating the fact that we had probably made a mistake.  When you think the end of a relationship is coming, you do not do more things to bind you to the relationship—- you don’t have more kids, you don’t buy expensive things, and you don’t invest in real estate together —with a mortgage!  My husband had been working full time, and I had been working more than full time, as a resident, but with our own mortgage payments, and other expenses, and all the child care that we needed almost full time we really didn’t have much saved.  But we had potential!!  I was pretty sure I was going to join the private practice that I had interviewed at, and salaries for newly graduated ObGyn doctors were pretty good—much more than I had ever made at any previous employment. My last few rotations as chief resident were busy and exciting. I was invited to go to my annual ObGyn conference in the Spring, and happily planned to spend a few days in Denver.  I realized while I was there that I really enjoyed meeting and talking to, and learning from, other people who were in my field.  The lectures were interesting and the activities were fun–I had never seen so many people interested in women’s health in one place at the same time.  What was also really interesting to me was that I found that I missed my kids a lot—- but–quite tellingly—I did not miss my husband.  Our time together was tense, we were generally both unhappy and at a kind-of stand-still. I named this  my “Too good to leave but too bad to stay” time period  ( and I even read a book with this title at the time— which helped me to think about what my next steps would be). My husband was unhappy but never brought up any solutions to our issues—–I thought I was kind of making it clear that as far as I was concerned, there really weren’t any.  I went to work every day, and stayed later when my shift was over, reassuring myself that if my children were asleep, at least I wasn’t missing anything with them. I felt I needed to decompress at the end of a very busy day– I felt I was obligated to teach things to the younger residents, and I justified my long hours by believing that things would just not run properly at the hospital in my absence.  I know now that by NOT talking about how I was feeling I was sort-of giving my husband some false reassurances. If I did not SAY I was seeking out a lawyer I guess he could think I wasn’t.  If I did not SAY I was happier away from him than with him, I guess he thought that wasn’t true.  I was living in my own world– planning-but-not planning for the future, trying to take one day at a time, and thinking we would “cross that bridge” when we got to it……all the time thinking that HE could not be happy with this arrangement either.  Sometimes I came home, and the babysitter was there, and he wasn’t. He left no note–no message. I didn’t know (nor ask) where he was.  I took this to mean that maybe he really “got it” that we were supposed to be creating our own separate lives, which would be easier to completely separate when the time was right…..but of course  I was fooling myself.