anna in med school

Oooph.  This week has been a professional emotional roller coaster.

For those of you who know me personally or have been following this blog for a time, you know that I lean a bit toward the neurotic.  For example, some physicians were speaking near me about how this year there are more med students applying in pediatrics than there are positions.  As I looked visibly concerned, they reassured me.  I, in turn, rationalized that a little worry is what often keeps me out of trouble.

When applying to residency, I was careful.  I asked for letters of recommendation and started my application months before I could submit it.  I had my husband, mentors, friends, and colleagues read and critique my personal statement and my CV.  I scrutinized over the wording to the one-sentence answers of some very basic questions, some of which resulted in multiple emails between me, the registrar, and the director of student affairs.  And, when I submitted my application using a somewhat confusing and not always user friendly online system (which crashed the day we were allowed to submit our applications), I triple, quadruple checked that all my ducks were in a row, that my application had, indeed, been submitted, that every document was uploaded properly.

But I had this nagging feeling.  Though I had been offered some interviews, looking at the status of my application last week, something seemed off.  Finally I noticed a big problem: a very important document had not been assigned to the programs to which I had applied.  So, I had applied to programs, but the application programs had received from me was incomplete for over three weeks.  I still don’t know what happened.  Was this my error or that of the system?  My tendency to worry, to be a little neurotic, generally keeps me from making this kind of careless error.

I was tearful, disintegrating into an insecure mop in front of several residents (and possibly an attending) who were with me in the workroom as I discovered this error.  I feared that, seeing that my application was incomplete, residency programs would simply pass over my application.  I corrected the mistake, texted a few choice friends who generally give good advice on life, spoke with my mentors, and contacted the programs to let them know of the glitch and that my application was now complete.  My spirits were raised somewhat when I received an interview approximately 30 minutes later.

And then Step 2 scheduling happened…

There is a practical component to Step 2 of the boards (it’s called Step 2 Clinical Skills, or Step 2 CS), where a med student experiences 12 encounters with standardized patients that test the ability to perform a history and physical exam, medical decision making, and interpersonal skills.  It’s only offered in five cities, it is incredibly expensive, it takes forever to grade, and it has a high pass rate.  Penn offers its own version of this exam, also with 12 patient encounters taking up the same amount to time, but with a higher fail rate.  I passed this Penn rendition in April of this year, so I have not been stressing about Step 2 CS.  Many of my friends took it in the spring of their fourth year, and a lot programs only require that you complete the exam prior to graduation.

I had some trouble finding a window to take the exam and, as I was trying to cram as much as possible into the fall semester, I opted for a January test date.  Not 24 hours after I realized my application gaffe (in the middle of the night, actually, while feeding Evie), I discovered what I also should have noted months ago during my research into programs: that one of my programs requires the results of Step 2 CS long before I’ll be notified of my results.  (You can imagine the behavior that ensued at, oh, 4am.  My husband is a saint, I tell you!)

So now John and I have this crazy email alert system set up, ready to pounce on the next available test, in case someone bails last minute.  (Hey, if you feel like giving up a test date, will you let me know?  I bake!)  I might just fly to L.A. or Houston (two of the random cities other than Philly where the test is offered) on a moment’s notice if need be.

On the plus side, my lucky suit (my only suit), which did not fit so well around my birthing hips when we left for Charlottesville, miraculously fits again now.  And not a moment too soon; my first interview is this Wednesday!  The bad news is that I have one day to get it cleaned and a hem fixed.  I frantically whizzed to the mall during nap time today to buy pumps and hose, and am now starting to feel a bit more prepared.  (Pumps: still not a comfortable shoe.)

And then there’s this, sent by my love to cheer me up, in response to the question, “What would you like to tell mommy”:

When I entered medical school, I thought I wanted to go into geriatrics, in large part because of the profound impact my experience volunteering at a hospice group had (has) on me.  My youngest daughter will always allow me to think fondly the first hospice patient I cared f0r.  Her name was Evelyn, and she was a force of nature.

Though the idea of facilitating what might be end-of-life care for pediatric patients shakes my core, I’ve often wondered whether I might still one day work in palliative care.   This recent piece by Atul Gawande in the Times has been on my mind:

Medicine has forgotten how vital such matters are to people as they approach life’s end. People want to share memories, pass on wisdoms and keepsakes, connect with loved ones, and to make some last contributions to the world. These moments are among life’s most important, for both the dying and those left behind. And the way we in medicine deny people these moments, out of obtuseness and neglect, should be cause for our unending shame.

Peg, however, got to fulfill her final role. She lived six weeks after going on hospice. Hunter had lessons for four of those weeks, and two final concerts were played. One featured Peg’s current students, all younger children; the other, her former students from around the country. Gathered in her living room, they played Brahms, Chopin and Beethoven for their adored teacher. A week later, she fell into delirium and, a short time after that, died peacefully in her bed.

John just ordered Gawande’s new book, Being Mortal, and I am looking forward to when I might find a time to delve in.

On a similar note, if you haven’t read and watched the story of Brittany Maynard, I have no words:

We’re in Charlottesville!  On Friday we packed up the family and moved down to Virginia for four weeks so that I could do an away rotation at UVA in ambulatory peds.  We are thrilled to be here, but the process of getting down here was brutal, made worse by the fact that Ari was febrile for most of the weekend and I wasn’t feeling so hot myself.  But we are all on the mend and settling in.

We rented a lovely cottage-like old home not too too far from the hospital.  John is taking two weeks of vacation (though he is working hard to tie up [or tie together] a number of research projects and academic obligations), followed by a week of CME (continuing medical education) so we can be together.  The last week down here with the girls will be a bit of a scramble, but I have an overly generous friend swooping in to help out!

Day one pediatric primary care pearl: If a small child comes in complaining of a belly ache, when asked about the location, he will almost always point directly to his belly button.  As the stated location becomes further and further from the belly button, there is increased likelihood that there is true underlying pathology.

And regarding my heart: I am, now as always, so grateful for a loving husband who is an awesome father, two daughters somewhat willing to take things in stride and make adjustments, and nurturing, thoughtful, and trust-worthy childcare.  Particularly with Charlottesville making national news recently, I have been having anxiety about leaving my girls with new caretakers, neither of whom I had met prior to this Sunday.  I don’t think my kids could be in better, more loving hands.  (If anyone is looking for childcare in the Charlottesville area, let me know, I have some recommendations!)  Knowing that they are safe and happy has allowed me to focus on my education and take full advantage of the privilege it is to be here.

It helps that the caretakers aren’t shy about snapping pictures:

I started med school truly believing that I was meant to go into either geriatrics or women’s health.  Things change.  Since I am now most certainly going into peds (at least I hope some of the programs to which I’ve applied consider my application), I tried to cram as many peds electives as possible prior to Evie’s birth.  But now I’m at the tail end of my clinical requirements–I literally only require three more days  of clinic in order to graduate–so I decided this block to scratch an itch.  As a candidate for the Certificate in Women’s Health at Penn, I am required to take one elective in women’s health, but there are a number of reasons why I wanted this elective, for me:

1. Personal interest: the female body, it’s not simple.
2. On the first day of our reproduction course (first year), the course director said something to the effect of, “There will likely be, in one way or another, women involved in your life–mothers, sisters, wives, daughters, friends.  And, as a medical professional, you will be counsel to them.  It’s crucial to know the basics.”  Perhaps I shouldn’t be asked for advice regarding health care, but some do, and I am overwhelmingly flattered (especially since I’m married to a real authority).  I guess that roughly 85% of questions I field right now are ob/gyn related: My gynecologist says I have to have a colposcopy–what’s a colposcopy?–the description sounds terrifying.  Is it true that I can’t lift more that 35 pounds while pregnant?  Hey there, I’m having contractions, when should I go to the hospital?  Although I can always play the student card–as in, “this is just what I’ve learned, and you can’t take it as real advice, what do I know?”–that’s not going to fly as well when I have (hopefully) an M.D. next to my name.
3. Approximately half of pediatric patients are female, and adolescent females in particular (not to mention younger girls experiencing precocious puberty or abuse) require some of the same health and preventative care as older women.  I think what I’m learning this month is hugely applicable.
4. There was a period of my life when I thought ob/gyn was the field of medicine for me.  As much as every peds elective I’ve completed has reinforced my desire to go into pediatrics, I wanted a women’s health elective to affirm that I do not belong in that field.

I’ve enjoyed the last 3.5 weeks tremendously, though feeling a bit spread thin at times juggling family, now convinced that we will need more (likely live-in) childcare lined up during my residency.  And I do feel convinced that ob/gyn is not field for me, but I’d like women’s health to be an integral component to my pediatrics practice.

Oh, and I’m now terrified of my bone health.  When women hit 30, they’re no longer building bone as rapidly.  And all those years of multivitamins and calcium supplements have not been shown to help.  Today I bought my first container of Vitamin D3, 1000 IU softgels.  It’s a necessary component of bone health.  Although we get it from the sun in the summer (if we show skin outside), an endocrinologist once told me that, in the Northern hemisphere, we could lie naked outside all day during the winter and still not absorb enough Vitamin D.  I am also paying more attention to how much calcium I get in my diet–45% daily requirement in a cup of almond milk!

Since I’ve been awful at posting, a few from our last-day-of-summer romp through Chanticleer:

Oh goodness, either my arm or her neck just isn’t long enough for a proper carrier selfie…she looks concerned:

Yesterday was the first day we could submit our applications for residency.  The website went down at some point during the day and, by the time I returned from clinic, it provided a cryptic message that it was temporarily out of service and would likely be opened again at 9am today.

I reviewed my application one last time while pumping in the colposcopy room this morning.   I sincerely hope that I (and my fellow supporters who were kind enough to read over my application) caught all typos; by lunch time, I couldn’t critically look at my personal statement at CV any longer.  I hit “submit” at 12:48pm.

Now I’m just hoping.  Hoping that programs will want to interview me, despite a less than ideal step 1 score.  Hoping that I’m received well at interviews, that I appropriately show my passion for pediatrics and for the programs to which I’ve applied, that I appear confident without crossing the line to arrogance, that I show myself to be a capable future physician.  Hoping that I’m overwhelmed with joy on March 20, 2015, because I was offered a job.

Please, wish me luck!

And, speaking of capable, look who keeps working to improve herself in the roles of big sister and helper, insisting on carrying her sister’s milk to daycare…

It doesn’t freak me out that I’m 30.  What freaks me out is that it does not feel so long ago that 18-year-old Anna turned the corner of the Lawn across from Old Cabell Hall, ran into a bunch of Glee Club boys (we’ll let that sink in a moment), and was introduced by my boyfriend to “John, a pretty great guy.”  Blink, and we’re married (John and I, that is).  Blink again and it’s been five years and two babies later.  What, the what?

On my lunch break at clinic, I’ve been looking through posts of our anniversaries past: drinking our first anniversary dinner; happily celebrating two years, though I might have burst into tears at dinner out of worry that we would never have children; then spending both years three and four pregnant with thing 1 and thing 2.  We’ve had a good run!

Tonight we’re celebrating at Serpico, a collaboration between James Beard Award-winning chef Peter Serpico and restaurateur Stephen Starr.  The food looks incredible, but I’m also pretty excited for the cocktails, leaning toward the Midnight Society.  We had initially been thinking of going to a BYOB so we could bring our bottle of Barboursville’s Octogan, which we’ve been saving since we got married.  Just an excuse for our evening to continue when we get home to happily sleeping little ones, thanks to our fun, energetic, and kind babysitter.

Happy anniversary, John!  I can honestly say that I still love you more…than last year, than yesterday.  Excited for what our sixth year of marriage will bring!

Just remembered this gem of all the UVA singers, and my heart was glad:

I think I must have read a dozen articles of a similar message in the last couple months, each one scaring the bejesus out of me.  As this article explains, physicians are more than twice as likely to commit suicide than non-physicians, with female physicians three times as likely as male.  A staggering 9.4 percent of fourth-year medical students and interns reported having suicidal thoughts in the previous two weeks.

I don’t believe I have ever had suicidal ideation.  But, while I have been eager for the start of residency for quite some time (the first time I can prescribe a stool softener without the approval of an intern or senior resident–that’s going to feel good!), I can’t grasp how demanding it’s going to be.  I can only liken it to becoming a parent for the first time…but, for me at least, that was just one tiny human who, as challenging as she was, I’m not sure can overwhelm to the same degree as an entire floor during my first week of night float.

One particularly comforting excerpt, as I approach my hopeful employment:

It was over a dinner of Thai food that I finally opened up. One of my most accomplished colleagues in residency had complimented me on my clinical knowledge a couple of times during the meal. Sick of feeling like a charlatan, I told him about the trouble I was having with collecting clinical data and presenting it in an organized way on rounds. I confessed that I did not think I belonged in the program. He listened thoughtfully, and then uttered the three most beautiful words I had ever heard: “Dude, me too!”

This summer we elected to keep Ari in daycare despite the fact that I was home on maternity leave for nearly 11 weeks after Evie was born, and then another couple weeks between the culmination of my Frontiers course and my next rotation.  It’s a decision about which I felt some anxiety and guilt–sending one kid off to be looked after by other people when I, myself, was available; spending thousands of dollars on childcare that most mothers aren’t able to afford.  I acknowledge that it’s a luxury, let’s just start with that.  But here are a few of our reasons:

1. We don’t have family in the area, and John was back at work less than 48 hours after Evie was born.  Especially in the early couple of weeks when my body was still repairing, I appreciated help with a toddler so I could focus on feeding and keeping alive our new little barracuda.
2. After the initial period of repair, I still wasn’t sleeping consistently at night.  A nap during the day when Evie was sleeping felt necessary for maintaining my sanity, or at least my happiness.
3. Probably the most important: Ari loves being around other kids her age, and she loves her daycare, or “school” as she calls it.  I honestly believe we would have been doing her a disservice, taking her out of a stimulating environment only to have her be bored watching me nurse Evie every 90 minutes, not to mention the harsh transition of leaving for a few months and then returning again when I resumed rotations.
4. Tied for most important: I know Evie isn’t going to remember, but I think it’s good for her to also get some one-on-one attention.  I loved some of our tender, uninterrupted moments, just her and me.  And, if the weekends when John is working are any indication, Evie tends to feed and sleep much better if she isn’t anxiously anticipating Ari’s next onslaught of kisses or tickles or large packet of wipes…all meant in the name of love and attempts at being a helper, but distracting nonetheless.
5. With waiting lists as they are, I’m not confident we could have gotten her (or her sister) back in daycare when I went back to school.
6. Finally, I had responsibilities outside of family–residency applications, papers, certifications required for graduation from medical school–that required attention, and I certainly appreciated being able to spend several good, productive hours working on them during the day rather than relegating them to post-bedtime activities.

I’m not trying to defend our decision…well, maybe I am.  Bottom line: we had the option to have extra help, and we took it.  It felt like the right decision for our family, and I’m still working (a little) on not feeling lazy or like less of a mother for it.

I start back on my next rotation on Tuesday.  I really wanted to set aside some time with just Ari, which, between John’s crazy schedule and me putting last minute finishing touches of my residency application (available for submission September 15th!), proved challenging.  We found a window on Thursday this past week (I wish we had found more!) when John had the afternoon off and was available to take Evie, and I called the daycare to tell them we were playing hooky, taking a mental health day.

In the morning, with both nuggets, we took our time.  I think Ari must be going through a growth spurt, because she housed three eggs and two bowls of cereal!  Nothing felt rushed, and I sat back and watched Ari spend 20 minutes deciding whether or not she wanted to wear a shirt that day.  We went in to Crossfit for a WOD and then enjoyed a post-WOD sprinkle for a friend and fellow athlete expecting her fourth (!!).  In the spirit of Ari-day, we missed the group shot because I didn’t have the heart to tear her off the erg, but we couldn’t help documenting Evie and her matching “cousin”:

Solo Ari-day officially began after lunch, books, and nap.  I fed Evie one last time, passed her off to Daddy, and Ari and I were off!  We took a second trip to the zoo.  Although the company of the last trip couldn’t be beat, I’d have to say this trip was more enjoyable, sans 94-degree heat or a febrile, diarrheal illness.  And it felt good being able to let her call the shots…like spending a disproportionate amount of time just staring at the goats, because goats really do go “BAAAHHHHH!”  And so can my daughter.  (They go “baaah” a lot when there are several male goats fighting over a female goat in heat.)

On the way home, we stopped for froyo.  I was such a proud mama watching my baby use her spoon so well, not spilling a drop until the finale when she secured her lips around the side of cup and tried to pour the remainder down her throat (and then dark chocolatey brown yogurt got absolutely everywhere–in her shoes, in fact).  

Before heading in, Evie joined us visiting our neighbors and Ari’s most favorite canine named Dex, a bowlegged bulldog with quite possibly the largest head and tongue you’ll ever see.  Walking back up to the porch, John snapped the photo at the very top–I love it.  I seriously stare at it while nursing Evie in the middle of the night.  Our girls!  We just look so calmly content, rested, and well fed–a great moment at the end of a summer I’ll never be able to repeat.

It isn’t right for everyone (like my friends in a one-bedroom Manhattan apartment, neighbors on the other side of three walls), but the cry-it-out technique of sleep training worked wonders for us.  After three months of spending every night pacing the downstairs, gently bouncing the constantly swaddled Aurelia (facing in, facing out, football hold, side/stomach position, you name it), and another two months of total dependence on this godsend, John and I sat down (per our friend’s suggestion) to some of our favorite movies and a bottle of malbec, and we gutted it out.  It took about three days and a lot of tears (Ari’s and mine) and stress eating (me), but then our nighttime terror became a (knock-on-wood) good sleeper, reliably going to bed by 7:30pm and sleeping a solid 10-12 hours.

When Ari was about six months old, sleep trained for a few weeks at that point, she woke up crying in the middle of the night.  Instead of rushing to her, I waited about 5-10 minutes, and the crying subsided.  When I went to get her the next morning, I opened the door and was immediately hit by the stench of vomit.  Vomit all over her crib, all over her.  She was cheerful enough.  I, of course, felt a huge pang of guilt.  It took a fair amount of lysol and oxyclean and open windows to get the smell of partially digested food and stomach acids out of the room, but we all survived.

We’ve been lucky to have gone nearly a year and a half without similar incident.  Much, much more frequently than not, if we do go in to rescue her in the middle of the night, we do more harm than good and just rile her up.  Most of the time when she cries she’s not even conscious, and there’s very little we can do to console her.  So we wait, and it normally works.

Yesterday morning was our first Sunday in a long time in our own bed without John having to work.  I was just putting Evie back down after a feeding at 5:45-ish when I heard Ari start to stir and cry.  By 6am, there was quiet.

At 7am, Ari started crying again, this time more insistently, calling, “Mommydaddy!!  Daddy!!!  Mom-mEEEE!  DADDYMOMMY!!!!”  John took one for the team and rolled out of bed.  I rolled the opposite direction and closed my eyes.

But the cries didn’t quiet; if anything, they intensified.  After a minute I heard John turn on the faucet to the bathtub and high-pitched screaming followed, loud enough to rouse Evie (she can normally sleep through the noise of a jackhammer), who looked at me perplexed.

Poop.  I suspected poop or vomit.  Or both.

John confirmed the former.  It was everywhere–her crib, her stuffed animals and lovey tiger Neville, her books (the poor cat in the hat had it caked all over every page), the floor.  She had it matted into her hair and her pajamas, under her fingernails and IN HER MOUTH.  My poor daughter was literally eating her own feces.  When John discovered her, she was holding out her hands and crying, pathetically begging for someone to FIX THIS SITUATION.

She was bathed and changed.  Teeth were brushed.  As soon as we got 2 bowls of Multigrain cheerios and a couple eggs in her belly (I suspect a growth spurt, therefore increased food consumption leading to high poop volumes), spirits were raised, and she seemed to have forgotten most of the trauma from the morning.  Still, we tried to make the day extra special.  All was forgiven after our family outing to Melodie’s–iced coffee for us, a fresh croissant for her–followed by please touch.  We’ll also be treating her to some new books, because some, I’m afraid were poop-i-fied beyond repair–I didn’t even bother recycling them…can you recycle poop-covered literature?

Because it’s just been too long since we had a post about bodily fluids…

Will write more about our recent trip and epic wedding (so much happier than CIO epic fail), but just a few pictures of one of our favorite Philly families, transported to Virginia for the celebration.

And a choo-choo…

Guh!  She tries so hard now when you encourage her: “Cheese!”  Makes me think of these first attempts…

At the old duPont garden home:

It felt right to spend my mother’s birthday surrounded by orchids.