Monday, April 29, 2013

Overuse injury

After a three month running hiatus due to the indomitable combination of bad weather (I hate treadmills) and work busy-ness this past winter, I decided last month to pick up my running routine right where I had left off in December.  Two weeks later, with aching ilio-tibial bands and tarsal tunnel syndrome in my left foot, I was forced to stop to allow these overuse injuries to heal.

I knew that I should have started gradually.  Just walked for a week or two, or alternated walking and jogging the first few times out.  But I didn't want to have to wait for my body to re-acclimate to the demands of running.  I just wanted to go.  I readily admit to pushing myself harder than I should sometimes.  Even when I know better, I always want to believe that I am physically capable of more than I am.

Unfortunately, this same tendency creeps up in my work life.  I tend to dive head first into projects without taking the time to think, first, about how big the project might truly be.  I set task deadlines that my brain thinks are reasonable but that I soon discover are impossible.  Despite having lived through these scenarios multiple times, I still keep creating unrealistic "to do" task lists.

List fatigue is the overuse injury of my work life.  And, every time I pile too much on, I am forced to stop, reassess everything, and plug it back into a more realistic schedule.  I hate having to stop working just to figure these things out, just as I hate having to stop running to let IT bands or shin splints or tight hamstrings recover.

I think that ambition and perseverance have many positives about them, but they can be a double-edged sword.  I'm now using a "couch to 10K" app to force me to increase my running time gradually.  I have used this method before with success, and maybe, some day, I'll use it at the get-go next time I have a running hiatus.  I have to admit that my feet and legs are much happier for it.

If only I could find a "couch to work" app, I'd be all set.

Friday, April 26, 2013

Supporting a couple with infertility #NIAW

Before my husband and I joined the 1 in 8 couples in the US with infertility, I don't think that I would have thought much about how to support a friend or family member with infertility.  Not to mention that society's infertility taboo can make these conversations difficult for everyone involved.

Hopefully these resources will make them easier:

I'll start off with's great advice:

RESOLVE New England expands on a few of those ideas:

The "I'm Not a Fertile Myrtle" blog gives a more personal spin:

This page provides excellent perspective about how to talk about your pregnancy/baby with an infertile friend:

Scroll halfway down this page from Band Back Together to read "How to Help a Friend with Infertility:"  I really like how this section emphasizes listening to and validating the infertile friend's story.

It is my sincere hope that these "infertility etiquette" resources will help break down the barriers among friends and family that often accompany an infertility diagnosis.

Wednesday, April 24, 2013

What does infertility feel like? #NIAW

Before having to deal with infertility myself, I had never even thought of pondering this question.  I knew that there were some people in the world who had trouble getting pregnant, that some of them needed medication or procedures to get there, and that some ended up childless or adopting.

Before having to deal with infertility myself, those facts were impersonal and emotionless. Honestly, I probably would have struggled to understand "what's the big deal?" if someone told me they were devastated by infertility.

I know better, now.  I know, for me at least, what infertility feels like.  

It's like being half a person.  My body may never swell with new life.  Even though all of our testing has been "normal," I still feel that something is wrong with me, that I am somehow broken or defective.  Am I still a woman, if I can't do what women are biologically created to do? 

It's like a constant shadow, slippery and elusive.  Multiple versions of my future continually morph and change before me.  I hesitate to make plans for 6, 9, 12 months from now. What if we actually do get pregnant?  What if we don't?  Will we need to plan around a cycle of IVF, or will we have given up?  Cruel hope persists, though despair returns with every unsuccessful cycle.

It's like the death of a dream.  I fight to avoid grieving for the child we may never have. Would that child have had my husband's hazel eyes?  My stubborn chin?  Played a musical instrument?  A sport?  Been a doctor, like us?  Or might that child have had some talent neither of us could have imagined, making it all the more miraculous?

A few weeks ago, as my husband and I struggled to deal with the end of another unsuccessful cycle, some part of me began to rebel against these thoughts.  As spring began to make itself known here, I realized that I was making the stakes too high with each cycle.  Failure was becoming too devastating.  I had to accept, truly and deeply accept, the possibility that we will be unsuccessful - that we will not have a biological child.  The battle between hope and despair was sapping my soul, and I was tired of feeling so paralyzed about the future.  And, somehow, by the grace of God, I decided to stop fighting the grief and embrace it.  

I still want a child, and my husband and I are not ready yet to stop trying.  Accepting that it may not come to be, though, has greatly reduced my emotional exhaustion. Don't get me wrong - it's still a challenge.

But it's time to widen my focus back out to the innumerable blessings in my life.

Monday, April 22, 2013

Join the movement: Bring infertility out of the shadows #NIAW

First comes love
Then comes marriage
Then comes baby in the baby carriage....

But what if that carriage is empty?

For 1 in 8 couples in the US, an empty baby carriage is a painful reality.  My husband and I are part of that "1."  We watched our friends build families while we faced disappointment, month after month.  After a year, we began to seek help as to why our dream wasn't coming true.  Like 20% of couples with infertility, though, comprehensive medical testing did not reveal an answer.

We decided that we weren't going to share our struggle with friends and family.  It was just too personal, too intimate.  We feared becoming objects of pity and, instead, kept our fear in the shadows.  We reserved our tears for the darkness after we turned out the lights at night.  We forced away the ugly jealousy that engulfed us when a friend or family member announced a pregnancy.

Slowly, though, a few of our friends sensed the masked despair behind our childlessness. They shared their infertility stories with us, stories we had not known much about (as they all, happily, had children by this time). The sense of relief that rushed in when they welcomed hearing our story was profound.

I started searching for others.  I found blogs like Life Without BabyInfertile Myrtle, and The Infertility Voice.  I read Silent Sorority.  I scoured The National Infertility Association's website,

These narratives showed me that, somewhere along the way, our silence had morphed from privacy-protection to shame-avoidance.  Keeping our story untold meant that we had bought into society's unspoken infertility taboo.  The shadows were becoming intolerable.

April 21-27 is National Infertility Awareness Week (#niaw).  I'll be sharing resources and information on The Singing Pen this week in support of #niaw and the millions of other couples with an empty baby carriage. With my husband's full consent, I am adding our story to countless others in hopes that we will all step out of those shadows together.

Infertility is not a curse, a judgment, or a penance for some prior sin.  We did nothing to deserve it.  It is a medical condition that, like many others, medical science still doesn't fully understand.  It cannot diminish our accomplishments or lessen our worth.

And we must refuse to allow it to define us.

Thursday, April 18, 2013

Resident work hours

When I was a fourth-year medical student in 2002, I signed up for an intense "sub-internship" rotation in Family Medicine.  My goals for this rotation were two-fold: first, I wanted to make sure that I was ready for intern year and, second, I needed a good letter of recommendation to match into a good Family Medicine residency program.

On this rotation, I was essentially treated like the other interns.  I had patients assigned to me and was supervised by the senior resident on the team.  I took ownership of my patients, made treatment decisions, and even wrote orders (all approved and co-signed by the senior resident, of course).  I took night call (along with the same senior resident).  In short, I lived the same life that the interns did, just with more supervision and guidance.

The interns on the service took q5 night call, meaning that every fifth night they each stayed in the hospital admitting patients and responding to emergencies.  So, like the other interns, every fifth night, after working the full day (since 7 am), I stayed in the hospital overnight.  The next day, I worked my regular day, typically leaving around 6 pm.

As you can imagine, these 35 hour shifts were not a whole lot of fun.  Some nights I only got a couple of hours of sleep.  But I slogged though, I learned what I needed to learn, and I got that letter.

When I started residency in 2003, the ACGME began to limit resident work hours. Studies had shown that brains that had been awake for 24 hours functioned like brains exposed to a blood alcohol level of 0.10 (legally intoxicated in most states).  Anecdotes abounded of mistakes made by tired residents.  So, during my residency, I was only permitted to work 80 hours a week, no more than 24 hours at a time, and I had to have 10 hours off between shifts.

Mind you, 80 hours a week is still tiring.  But I felt that these limits were reasonable.  I had accepted, long ago, that the goal of residency was to become a competent family doctor.  I knew that residency was my one opportunity to establish a foundation of skills for my whole career, and I was willing to put in the work to get there.

A few years ago, though, the ACGME decided that further limits were needed on resident work hours.  Fueled by a report from the IOM, the ACGME decreed that residents needed to gradually adapt to working long hours during residency.  So, now first year residents may only work 16 hours without a break.  Senior residents, by contrast, have far fewer restrictions.

I was skeptical of this change, but figured I'd wait to see what would happen.  Interns would now have additional time to sleep, study, and recreate.  With this additional rest and study, surely they'd provide better care.  And, surely they'd be happier, right?

Well, Dr. Pauline Chen in the NY Times this week challenges this notion:

Now, two years after the 16-hour mandate was established, studies on the outcomes are being published, and the results reveal one thing....
Contrary to expectations, these studies have shown that interns have not been getting significantly more sleep. Moreover, they are not happier, nor are they studying more. In one national survey, nearly half of all doctors in training disapproved of the regulations altogether. Another study revealed that interns were spending less time in educational activities because the additional time required for such conferences and lectures would push them over the 16-hour limit.  In addition, there has been no significant improvement in the quality of care since the work limits took effect. 

These findings ring true for me.  Limiting shifts to 16 hours means that everybody has to work more shifts to cover the work.  A full 24 hours off is far more restful than just 12 or 18 hours, but with more shifts that happens less often.  Additionally, with these more frequent shift changes, handoff errors may be happening more often.

It's my fervent hope that the ACGME reverses the decision on 16 hour shifts for interns, but in the meantime, I'm trying to help my residency program respond by authoring a new, longitudinal patient safety curriculum.  I'm currently wading knee deep in best practice articles about handoffs, quality improvement, and other tenets of patient safety.  If you have any useful patient safety resources, I'd sure appreciate hearing about them as I put this together.

Because, at the end of the day, the discussion shouldn't be just about the residents - our patients must be our utmost priority.

ACGME = American Council on Graduate Education
IOM = Institute of Medicine

Monday, April 1, 2013

The Seasons of Residency

I've been a Family Medicine residency faculty member for nearly 5 years, and I've come to observe the yearly cycle of a residency over that time.  Reminding myself of that cycle helps me weather and celebrate the peculiarities of each time of year...

July-September: Adjustment
Every resident's role changes on July 1.  For the first-years, it's their first day of being called "Doctor."  Second- and third-year residents have increasing responsibility for supervision, and their outpatient responsibilities grow.  Even though many in the lay public will joke that July is "National Don't Go to the Hospital Month," the fact is that residents are never more tightly scrutinized than these early months.  We faculty watch everything, every decision, every order, that the residents are doing.  These are the days of intern presentations that take twenty minutes and nervous second-year seniors who page for confirmation that their plan is on the right track.

We welcome these calls and the long presentations, though, because this is the time of year when residents welcome our teaching the most.  Our pearls and presentations keep residents in awe, and they can't get enough feedback, both encouraging and corrective.

October-December: Recruitment
Fourth-year medical students start interviewing at residency programs, but in Family Medicine, sometimes it feels like we're the ones being interviewed.  Although interest in Family Medicine has been rising, we often still approach recruitment with nervousness. Not filling in the National Residency Match Program will wreak three years of havoc; a common saying goes that "two bad matches in a row kill a program."  The nation's Family Medicine residencies are all vying for those best and brightest, and they all roll out the snazziest red carpet they can afford to attract them.  Good residents = good future family doctors in the region, since most family docs stay within an hour or two of their program after graduation.

So, for three months, every day will bring another applicant to our program.  We take them out to breakfast and lunch.  We rearrange our schedules to meet them during the day.  The residents take them out to dinner and e-mail them afterwards.  Everybody, faculty and resident alike, is in best behavior "company" mode.  Meeting a great applicant and hearing that there might be mutual interest allows for imaginations of the happiest kind about the future, and that's what sustains you during the times when all the wining and dining gets a bit tiring.  One thing became crystal clear to me during this past interviewing season, though: Family Medicine's future is looking bright.

January-March: Dysthmia
True, most programs will still have a trickle of applicants into January, but most will be wrapping up.  It's dark when you drive to work and dark when you drive home.  It's impossible, especially, for the interns to believe that they still have just as much of their intern year left as they have finished.  The light in the proverbial tunnel is too dim too see. Everyone is tired, sad, and dysthymic.  Some resident in your program will invariably threaten to quit medicine and go work in a coffee shop/department store/ice cream parlor (most of the time, they won't, even if they really did mean it when they said it).

Teaching during this time is often a struggle.  The residents just want to slog through their work and get a break.  Our emphasis often morphs into support and validation mode, reminding our learners just how far they've come in the last six months - even if they don't see it yet.

April-June: Cruise Control
The match list is out!  The interns are cheered by the rows of faces on posterboard in your office, the faces of the applicants who will be replacing them in three months as they move up the ladder to become second-years.  The days are longer, the sun is back, and the residents' confidence starts to catch up with their skills.  The third years have signed contracts (or matched into fellowships) and are pleased with their secured futures.

None of the residents are calling you as much anymore; though you miss getting to help them, you're also proud of their growing independence.  They ask harder questions now when they do ask, not just "what" and "how" questions but the "why" questions that will make them such great docs.  Graduation for the outgoing third-years and orientation for the incoming first-years are planned simultaneously.

And, just like that, July 1, "New Year's Day" for residencies, dawns again.