Birth, death, and the finality of the Match

I went to see the movie "The Business of Being Born" the other night, it was screened at one of the universities to a crowd of 700 mostly crunchy women with big bellies or babes in slings. (if either of you are not familiar with the film, it's an american movie about "natural" birth inspired by Ri.cki Lake's home birth experience.) The movie itself was okay, but didn't really say much that was new. There were some nice shots of home births, and some interviews with women who had chosen different types of births, and interviews with midwives, doulas, and OB's. The only thing that rubbed me the wrong way was that the movie placed the blame for the US rate of maternal/fetal mortality on the medicalized birth structure and lack of midwives. Which may be partly at fault, but as Canada has nearly identical rates of surgical birth/midwifery care and a FAR lower rate of maternal/fetal mortality, maybe it has something to do with 50% of people in the US not having access to any health insurance, or prenatal care of any kind. Whatever.

What was most amazing about the showing though, was the panel discussion afterward with a midwife, a nurse, a researcher, a doula, an OB and a family doctor. It was one of those moments when I realized that I have lived in this town for a long time (9 years!) and i do know people in this community, even though I feel like an outsider most of the time.

The midwife said some nice things about the importance of surgical birth, and helped to calm the crowd who seemed to be about to eat the OB. She also said smart stuff about how all health professionals work from our own experience, and that choosing a profession has much to do with our own experiences of birth. Which I read as "you will not change the opinions of the obstetrician by logical arguments or passionate defenses of your positions -- she is not just defending her job, but also her own family, and her choices as a mother. Her role in her own family will trump the arguments of strangers, every time."

Which impressed me a lot. This was the same midwife who pissed me off during our prenatal class when MamaM was pregnant. At the time, she insisted that babies were all conceived in love and privacy, and needed their mother and father to be in a similar environment for their birth. She was so adamant that most of the other people in our class were embarrassed on our behalf and kept trying to correct her. It was very awkward at the time.

I didn't know the nurse or the researcher, so I can't give you any back story! But the nurse did mention that there were no nurses in the film, and that nurses can be helpful in a birth too! True enough, although in the states, most midwives are nurses first.

The OB was fascinating. I am totally impressed that she showed up at all, as not many people there were kindly disposed towards her to say the least. eek. She did throw the word "natural" around a whole lot, and only got heckled a few times. I was impressed when she said that she supports drug-free labours in hospitals. Which I believe, although I have also seen several births with her, and been on-call with her. I very clearly remember one night when a woman who had come in with a doula and was being followed by the family medicine team was labouring. The family med resident (who was probably 25) checked her, and was heading off - when the OB insisted that she rupture the woman's membranes. The resident refused, saying that because the woman didn't have an epidural, it would be unnecessarily painful, and she was progressing well. The OB retorted that the rooms were nearly full, and around here it is "active management of labour." To her extreme credit, the very junior resident put her foot down and said "she's my patient, and i am not rupturing her yet." Gah.

I liked what the doula had to say. I'd seen her around the hospital, but hadn't really heard her speak before. She made a good argument for having a doula for anyone who wants one, which would certainly improve outcomes for most women.

But what totally impressed me were the things that the family doctor had to say. I am entirely not objective on this point because 1) LittleE was born with a midwife and a family doctor in attendance and 2) This particular doctor has been a huge role model for me over the past 4 years. Every time that woman speaks, i learn something.

I remember 3 births with her: One was a c-section, which she attended just to be with her patient, which was awesome. The second was a baby who was born flat, and didn't start breathing on her own. She caught the baby, and placed her on the mom's belly for some skin-to-skin time. And at the point where all the other people in the room were about to burst, she calmly picked up the baby, and softly explained that she needed to give her a bit of air to perk her up. All was well, and the parents never knew that things hadn't gone absolutely perfectly. The third was a woman who was all alone, and spoke neither english nor french. I'd spent most of the day with her (and was mocked by the OB residents, but whatever, I don't really know what I'm *supposed* to be doing, so I just get the work done, and then do what I want to learn). I'd stayed late because she told me I could do the baby catching part. The woman had progressed very well until the epidural, and then slowed right down. She was pushing and pushing and wasn't getting anywhere. The baby had crowned, but was stuck, and his heart rate started dropping. She took the bold step of cutting the cord before the baby was born. Everything turned out well, but it could have been a huge disaster. The cord was wrapped around the baby's neck, and was too short for him to clear the vagina, and too short for it to be slipped over his head either.

After it was all over, the mom was breastfeeding well, and I was doing the repair of her smallish tear. This doctor was still a bit shaky after the near miss.

And she hugged my head.

Which was an excellent acknowlegement of our shared mortality and the significance of the day we had all spent together - the mother, an amateur translator (who really worked in sterilization or medical records or something), me, and this kick-ass doctor. I was really late getting out that night. (coincidentally, it was the night that we were meeting with the spuncle to ask him if he'd be willing to help us out in the procreation department another time).

And what totally impressed me the other night was that she mentioned death. Several times. And she was the only one who did. All of the other people in that room were either young women, or professionals who work solely with moms and babies. She was the only one who regularly sees death.

She pointed out that in the 1600's, when "natural birth" was the only choice, 1/10 women and 4/10 babies died in childbirth or shortly afterwards.

And I really think that it's an important dimension in the conversation about natural birth.

For a couple of reasons. Like, if having a natural home birth is difficult to arrange these days, a natural home death is often even harder. Another doctor I like a lot (Balfour Mount) gave a lecture to us, and pointed out that in the 1600's death was the province of women and children. Women were responsible for the rituals around death, and they and their children were who did most of the dying. Now it's old people who do most of the dying. And we can hide death by hiding age. If we stay young, we cannot die. But that is such a silly line of thinking. We are all dying. Each of us has the same number of deaths that all of our ancestors had. There's 1 each. Life is risky, and it will end. Not dying is not a reasonable goal. Preventing death may be possible in the short term, but is no way to live an entire life.

At some point, living needs to be valued above not dying.

A lot of the criticism of home birth is about the risk of death for both mother and baby. Birth is risky. Living is risky. People die. I am absolutely not saying that 1/10 mortality rate is acceptable, there is certainly a role for surgical birth and other birth interventions. But for many women, what is to be gained in having a birth on their own terms is worth the risk. It is a milestone that will prepare them for the task of parenting ahead. Give them the experience necessary to teach their children what it is to take risks, and make decisions in an uncertain world in awareness of their own mortality.

There is a fellow in my medskool class who does a lot of wild mountain biking. And was adamant that his wife would give birth in a hospital. I couldn't help but wonder if she would insist that he save his biking for the stationary bikes at the gym. After all - he would get the same fitness benefit, and not constantly risk head injury and his surgeon's hands!

At the end of the night, someone in the audience asked what family doctors do and don't do. She explained that 50% of women in Canada are followed by FP's for their pregnancy. She explained that she doesn't do cesarean sections, and that the best part of family doctors is that they can follow these babies, sometimes into adulthood, and journey with families from womb to tomb.

I know that I chose right about what to do next year.

epilogue: ran into the doctor outside the show, and she asked me where i'd matched. I told her. She punched my arm and said "f*ck you." Which was the perfect compliment.

Stripes and Plaids

I'm matched; Queen's Family Med!

whew.

MamaM and LittleE came with me up to the school, where some super kind american students (who don't have their match for aeons) put together a nice little ice cream feast for us canucks who found out today at noon. There were a few casualties in the lobby, but overall, only the contented came out for frozen treats. Happily, my entire little geek-gang all seem to have gotten our 1st or 2nd choices, and are pretty pleased. Which is good, because we plan to study for the boards tomorrow morning, and that could have been awkward.

I am especially glad that there was ice cream at noon as I am not joining the drunken celebrations this evening. I'm happy that i got to celebrate with everyone, and to bring LittleE to some of the festivities, which he enjoyed. Back in 2004, MamaM found out she was pregnant about 3 weeks after I was accepted into skool, so his growing up is in some ways a marker of how long my classmates and i have been at this silly business. My skool friends all remember me sitting through the 1st year embryology lecture on anomalies the day before MamaM's 18wk screening ultrasound, and also remember the announcement I sent out at his birth. Many of them still ask about "the baby" so it was kind of neat to have him there so they could see him all big and kid-like.

Overall, I think that my match is great. The program rocks, and I think it'll suit us well. I am of course sad to be leaving a lot of great people in a great city, and also sad not to be moving to that other less-great city with equally great people. . . But we seem to have struck the compromise of *not* living in a smelly congested city, while still being within visiting distance of the folks that we love in either place.

I have my fingers crossed that the transition will go quickly and smoothly, and that we will meet good people there too.

the uneventful

Waiting for my match results. Waiting for my follicles to grow. Waiting for MamaM to get home.

In the mean time, it is fun to watch the spawn use words that are longer than him. Here are some dinosaurs and laundry.

cusps.

Sorry for the extended absence. I've been trying to figure out where and in what i want to do my residency next year, and trying not to post that on the internet. y'know, like people who don't want to lose their jobs try not to do.

Also, trying to get pregnant (IVI #8 for those keeping score at home). Another one of those things that people trying to get jobs try not to post.

But the rank order list deadline is in a day or so, and i am running a deficit in the give-a-crap department.

I have that day or so to decide with MamaM where we want to live next year. In the running, (and for the record, still tied), are Kingston, Toronto, and Montreal. And in a particularly cruel alignment of the stars, I am expecting the verdict for this ttc cycle in about the same amount of time.

I am happy to share the POAS results with all and sundry, I will not be sharing the details of our rank list until after the match, which is at the end of next week.

astral projections, advice, derision would all be particularly influential at this time. feel free.

Ortho

I knew going into this that i didn't want to be a surgeon. Surgery is super-freaking cool, but i like my life. All residents work hard, but surgical residents are expected to graciously surpass most human limitations without really trying. They leave medskool and enter into the fiery furnace, and only emerge five years later. It is awesome to witness, but i cannot sacrifice my family and sell the better part of my 30's to do it.

So, I wanted a chill surgical rotation, and was less than thrilled to be assigned to a tough service in a hospital without digital x-rays.

Despite my expectations, it very much didn't suck. There were ample housestaff; and (impressively) they all shared the scut.

I'm not exactly in love with the OR, so i didn't see the staff very often, but i tried my best to carry my weight on the ward, and to deflect/deal with some of the minor stuff to make the days run well. And i got a lot of teaching in return. Especially on emerg-related topics -- like how to reduce a fracture, open fractures, and (surprisingly), brisk upper GI bleeds. I saw and assisted with a few total hip replacements, and saw a few minor trauma cases. I can see extremity fractures on x-ray, and know how to look for a shoulder dislocation (and got to reduce one of those too!). I can even classify ankle fractures to a certain extent.

And if nothing else, i was reminded of the blood supply to the hip, and the risk of avascular necrosis of the femoral head.

So, educationally it was good. But the most interesting was the gender analysis of it all.

Ortho is a manly-man specialty. There are certainly women in the field, but they still take a lot of crap, and mostly, it's men. And a higher-than-average proportion of very butch men. I don't usually think of myself as having a pronounced gender presentation. I don't identify as butch, and would even be out of place playing lesbian softball. That said, i'm equally out of place at a bridal shower or with a bunch of fags singing along to olivia newton john.

semi-androgynous library-geek maybe?

Anyways, once i'd changed into scrubs, and walked into the residents' lounge, my gender changed instantly. I have not felt so girly since at least high school. The legs i held in the OR were really heavy, i don't follow college football, i don't eat meat, and i really only hold one pint of beer when i'm out with colleagues. wow. I am 6 feet tall, i wear a size 11 shoe, and felt like the princess and the pea.

Until this rotation, i think i had also stopped believing in straight guys. And by "not believing" i'm not invoking some lesbian separatist utopia, more akin to not believing in the tooth fairy. I know a lot of guys who are heterosexual, but none who i would have considered straight -- guys who go to ani difranco concerts, guys who work in preschools, guys who date lesbians, guys who study ecofeminism, guys who change their name when they get married. Although they only sleep with women, they are hardly beholden to extremes of gender stereotypes.

And then i met the resident who i will call the Viking. Who disabused me of my pretentious notion that cis-gendered people could not be thinking folk who had examined their own performative gender AND fall to the extreme end of a gendered continuum (if there were such a thing). duh. I now believe in straight men. And if i ever lose another tooth it's going under my pillow.

(to be fair, i may have been one of the first poly bi-dyke mamas he'd ever met too. Call together was a bit like an intercultural surgical performance art workshop)

if people knew what their doctors were like in real life. . .

Geriatrics

I feel like i've been let off the ride, and i didn't throw up on anyone. phew.

The last (and more or less final!) two rotations were surprising. good-surprising.

Geriatrics was, predictably, slow-ish. Which was exactly what i wanted. I had tons of time to just talk with people, and to meet my own needs and then actually be available when i was supposed to be working. It was so pleasant, and then *I* was so pleasant! Patients kept remarking about how nice i was. Which i know is a defense strategy when folks are ill and vulnerable, but i also think it was because i honestly *am* nicer when i've slept, eaten, emptied my bladder and figured out that thing at the bank. And when i don't have to shoo people out of my presence because someone else is waiting. I could just, listen. And work at the pace people set for me.

One of the wisdom-chunks left for us this month was "whatever has taken 85 years to develop, will not be solved in an hour". which was a nice place to come from. (that said, the big challenge is discerning what has developed in the last hour, and really needs to be solved NOW)

I met some quality people, and had time to hear some of their stories, which is always my favorite part. It was kind of like, half internal medicine and half psych, which i figure is why i half really liked it. Fortunately, i happened to get a slow/light internal medicine half, which worked out well.

I got to do a little presentation on gay and lesbian seniors as part of the rotation, which was fun. Despite so much of the cool research on this topic having been done in the neighbourhood, none of them seemed aware of it. Which was both disappointing and lucky for me -- cuz i got to seem all fresh and up to date with information that had been sitting around the house for a few years. I learned a few things too -- like that after concentration camps in europe were liberated post- WWII, those detained for gay-ness had to finish their sentences elsewhere. I found that a bit chilling.

More soon on orthopedic surgery. and other stuff. cuz there is lots of other stuff. clerkship is ending, i am tasting glimpses of the time when i am no longer everybody's bitch.

power tools

I got to put a screw into someone's femur today with a very cool drill. How awesome is that?

skool

i've been negligent in recaps of my rotations lately. I'm still in school, things are generally still good. I'm getting a bit anxious about the residency appliance that i am in the midst of, and feel like whatever i say now carries more weight since i've (mostly) decided to what and where i am applying.

Anyways, The past two were Emergency med and pediatric derm.

emerg, as usual, was amazing and fun. I got to work at the trauma centre, and see lots of cool stuff. pedestrian vs. car, pedestrian vs. bike, pedestrian vs. airplane.

and the little guy never won. (though nearly always survived what i saw)

The teaching was amazing, I got to suture a lot, and to have respect for the cost of alcohol. I'm sure that taxes on booze do not come close to covering the health care costs, even just in the emergency setting. I was on nights the long weekend after frosh week (so maybe i'm biased) but there'd be mornings when nearly every bed was occupied by somebody sleeping it off after a fall, an accident, or just forgetting to breathe after a night of revelry. Morning would come, the barfing would subside, and the nurses would send people home while the beer stench slowly faded. It was so different from my elective in emerg last year, which was at another hospital which didn't get trauma, and wasn't downtown. There was very little EtOH, and way more 'weak and dizzy'.

Peds derm was a pleasant surprise. It was far from a slack month. I was there early, and usually stayed till fairly late. I learned tons, and had great teaching once again.

But i'd make a terrible dermatologist for many reasons. I'm far more about function than form. I'm not very visual, and i tend to make my diagnoses mainly on history. But i really like the fast pace, the attention to nomenclature, and the precision of it all. I also got to see a lot of interesting psych stuff which i wasn't expecting. Having worked for years with kids with OCD, I've only ever met one person with trichotillomania (compulsive hair pulling). But I saw so many kids in that one month. And other self-injury masking as organic. But we just referred all that to psych once we'd diagnosed it. Which was not so satisfying.

I was expecting it to be mostly eczema and acne, and there was some of each (though not nearly enough acne that i'd feel comfortable having a treatment algorithm in my head yet.) But there was also tons of weird and interesting stuff too. I saw a lot of mast cell tumors, which i'd never heard of before. (Mast cells are a kind of immune cell with granules inside that get released during an allergic reaction.) And a tumor of mast cells can have degranulation caused by physical trauma. i.e. when scratched, becomes a hive. weird.

But I now know what to do about eczema. ho-lee! And i am glad that i was there for the full four weeks bacause i got to see how well keeping the baby wet worked to clear it up. Kids who were eczemateously covered head to toe, put in wet pyjamas for a couple of weeks, steroid cream, a bit of moisturizer and voila - recognisable child. It was something. Messy, labour-intensive, and stunningly effective.

I'm going to be relieved and sad when this is all over in just 3 more 'blocks'. It has been a really nice time in most ways.

That said, i know that the upcoming weeks of orthopedic surgery are going to involve holding on, clenching my jaw and trying not to scream like a kid coaxed onto a roller coaster. ugh. I hadn't really missed the CBC Overnight waking me up. But i guess i'll become re-acquainted with Radio Prague or whatever canned show they're playing at that hour these days.

Emergency psychiatry

I decided to do this elective in order to rule psychiatry in or out, and because i love the emergency department in any case. I thought that it would be busy and challenging, and not too many hours of sitting around a hospital doing nothing but being bitter about missing the rest of my life.

This month well exceeded my expectations, and i'll give another list of points i came out of it with.

Families were really key in this department, something i've never really seen done quite the same way. Doctors are notoriously bad at predicting who is going to kill themselves. I don't know if families are much better, but it's comforting to everyone to share the risk of sending someone home and/or keeping them in hospital. We are all fallible, and working together can hardly make that worse. It was downright pleasant to be part of a team that thinks that way.

Power -- that a non-negotiated/non-consensual power imbalance doesn't really serve anyone. I'm going to get my french up to good enough to read the whole book that my supervisor wrote on the topic eventually. But from working there i finally got how relationships where people are stuck in roles that slot one person into being the protector or predator and the other person the one who is protected or aggressed are so very damaging. And how stuckedness in those unhelpful and inflexible roles are different from relationships where people are aware of their own autonomy and vulnerability, and choose to enter into relationships where power is not equal in order to heal or grow. -- It's another delightful paradox where unequal power distribution in a relationship is something can be both damaging and growth stunting and/or a place for real connection and healing.

Gay. What's with that? Patients, doctors whatever, i don't really get it. I'm sure somebody somewhere has written a paper on it which i haven't bothered to look up. Why is ER psych such a queer place?

I have way more of a "feel" for what borderline PD is now. And how borderline-y impulsivity is different from ADHD impulsivity. And the little gem about teddy bears. (Tho not all of those with teddies are BPD, most borderlines have teddies). I think that's one of the more useful tidbits i could never have picked up from a book.

And psych doesn't really smell that bad. There is no "peeling back someone's oozing folds in the middle of the night". It's a different kind of intimacy with strangers that is much less physical. The physician doesn't have gizmos or gadgets, and only her/his personality to work with. And being the tool exposes me and my own flaws far more than interactions that are mediated by my stethoscope.

predictably, no quick answers. gah. I'm sure it will all come clear after a few months of communing with CaRMS. . .

Obs/gyn

And the last two months were NOT easier. In case anyone was following.

It was split into two parts: one month gyne onc, and one month obstetrics. There is no happier place in the hospital than obstetrics. And with the possible exception of pediatric oncology, gyne onc is the most tragic. It was certainly the rotation where i've seen the most extremes.

I tried to get through the gyne part as quickly as possible. Medical or surgical, i'm not crazy about wards. There were some very nice surgeries, and surgeons who did beautiful dissections (can i say that?). and some really nice patients. But it was a string of horrible stories from fairly young women who've had their lives ripped away quite suddenly by ovarian cancer.

There was the occasional normal gynecology case as well. . . A few pregnant women who kept tossing their cookies and needed rehydration and a rest, the occasional ectopic pregnancy. It felt weird to visit them each day as if they were the happy cases. Excessive puking is hardly cheery (especially when you can't take care of your kids or hang onto your job) and i saw some tragic ectopics ending in infertility.

I have found that anything in large quantities becomes absurd. -- Like peanut butter by the drum, hundreds of gay choirs, big statues built by small prairie towns. And I end up with two separate perspectives -- as in both enjoying a spoonful of PB on my toast, as well as knowing that there is a high ratio of detergent to peanut butter required to clean it up when you spill a gallon or so on the floor.

Similarly with heart-wrenching stories in large quantity. Not that i can no longer listen to individuals, but that there is now a new dimension to tragedy that wasn't there before.

I feel lucky that MamaM also works in a "quantity suffering" field (she does rape crisis counselling), and that we can talk about it in those terms sometimes. At the end of a day of hearing horrible-ness one horribil-ity after another, i need some distance. Scale can give distance. And i'm getting through by living with someone who doesn't have to bring it down to an individual level all the time in order to relate to me. We can talk about traumatized vulva as a category (for example) without having to visualise our selves in that situation or remember the trauma of a loved one. . . We can do that too, but all the emotional bits get so intense, sometimes it's good to just sit with the absurdity of hundreds of foosty vaginas for a while before going back to face another day.


Obs was fantastic. But not too much sleeping. Babies don't have a lot of respect for sleep schedules. I wish it'd been earlier in the year, when i had a bit more energy, because obs call was the first time where i really got ZERO sleep overnight. I learned tons and saw tons. I caught a baby with only verbal support, I did most of a few 2nd degree perineal repairs. And i caught countless placentas and examined them. I'm reasonably accurate in examining how dilated a cervix is, and i got to try a hand-over-hand D&C.

I learned that:
* crocs without holes save you from wearing socks with bloody polka-dots

* no form of birth control is 100%

* TAB's - although safer than childbirth- are not benign, and don't erase a pregnancy (duh. obvious in retrospect)

And lots of other things i can't post on the internets.

Someday (like after the match is over) I'll write something about taking my progressive/radical politics to medskool, and obs/gyn will feature strongly in it. For now, two things:

1. In 2nd year, normal gyne exams were initially taught to us by a community-based feminist collective of volunteer patients/instructors.

2. Before medskool, I'd heard the stories about women going for surgeries who, when unconscious, became unwitting sites of gyne exam practice for lots of students.

That never happened.

It is still a teaching hospital obviously, but i only examined surgical patients when i was going to be involved in the whole case, and the staff were blessedly strict about only participating in deliveries after having met the patient.


Near the end of the rotation one of the other students asked me if i would want a family doc or an obstetrician to deliver my own babies. (neither wasn't an option). I got a shocked look for preferring a family doc. "But they're not experts, and things can go wrong!"
It looks like obstetrics is a surgical specialty that aims to keep patients alive, and preserve health and fertility. For me, sometimes, living is more important than not dying. And i have to believe that taking that risk is worth it for myself if i can ever hope to be credible in offering it to people i'm working for.

Next will be ER psych, and wow i need to sit down for a bit.

Internal Medicine

And right here, the year reaches it's lowest point. Maybe it was that sinus infection i had, or LittleE being miserable with a cold and preventing me from sleeping. this was the most difficult 2 months yet. And it was difficult because of me, and the way i reacted to stuff -- not because of the rotation. I was lucky to be in a stellar site with a great team. So i'll start off talking about what was great about this rotation. . .

* Kind staff who did tons of teaching
* Kind staff who treated nurses and other hospital employees well - who in turn paid it forward and treated us nicely
* Call where i got to make decisions - At night, most of the hospital is covered by one junior resident and one med student. I always felt like i had good support, and at the same time, that i was at least marginally useful for my ability to think and plan, not just fetch coffee or write dictated notes.

And mostly, i met many doctors who actually gave a shit. And realised that caring is not an exception, but the genuine intention of most. Which is kind of a weird "aha" to have, seeing as it's common to assume that doctors are generally compassionate people. And so i've had to disengage my cynicism with the system of health care - which has no capacity for caring -from the people who work here. And i find it remarkable that anyone who works inside this kind of a monster still has enough left of themselves to care.

But it felt like work nonetheless. Work - where I found myself wishing the day was through before it had really started. And i've reached a point where i have to start making real decisions about what i don't want to do. . . and spending lots of time on a medicine ward is up there.

I don't like medical futility. (And i wouldn't say that i saw much of it -- in fact i saw some really lovely end-of-life interventions) But the potential is certainly there to keep trying to fix the unfixable. I would much prefer to chat about folks' dogs or grandkids or whatever, and i hate having to redirect people back to the topic at hand... And i especially hate how talking about dogs and grandkids becomes an irritating obstacle between me and sleeping, eating, peeing, or going the heck home. I found that it takes very little to turn me cold and utterly uncaring.

And after 30 hours in the same socks, i can barely bite back a snippy tone, which is luckily masked in any case by the brokenness of trying to shout to hearing and neurologically impaired people in a second or third language for both of us. "EST-CE QUE CA FAIT MAL?"

And what i hold back at the hospital can come out at home, when all i want to do is curl up and sleep, and MamaM sees my return as her chance to have some of the load taken from her.

We knew this year was going to be hard -- time, toddler, money, and the limits of what a body can do in a day. But i think it's going to get easier now. At least i hope that we're in for a bit of a break. . .

psychiatry

I have so many great stories from this rotation, but none of them can i post on the internets. I can merely bore you with my own meandering thoughts.

My grade 8 teacher (whom i despised at the time) had some pretty good pedagogy in retrospect. (Even if she got it very backwards when she told me that my best friend was a bad influence on me). She taught us how to make decisions by listing columns of plus, minus, and interesting consequences to potential choices. Psychiatry is the first specialty rotation that i have really thought might be an option. and I'm starting to feel a bit of pressure to make a decision already as to where i want to go with this whole medicine thing. I'm also open to advice.

Plus:

* It's a lot like camp
* I know stuff already: i.e. for the first time in medical school, my past life counts for something.
* The day starts at 9ish and ends by 5
* really good stories

Minus:

if someone yells "is there a doctor in the house?!?" they wouldn't really mean me.
I learned all that anatomy. And for what?
I'm having dreams about psychotropic medications again already, and it's only been 6 weeks.

Interesting:

* From my (non-representative) vantage point, this rotation made psych look like the gay-est job outside of queer community organizing. weird.
* I had no idea how many people have delusions about gay-ness, turning gay, being targeted by gays etc.
* I found it kind of tender and elegant that all these gay-fearing folk were heard, comforted and re-educated by a roomfull of queers, dykes, queens, twinks and fags.

life's funny.

People tend to be drawn to fields where they have had important/emotional experiences. Like the woman with diabetes who works in endocrinology, or the person with crohn's disease who is looking at a GI fellowship, my experiences with illness and disease have overwhelmingly been psychiatric. (blah blah blah sublimation blah blah)

Easily, it is the residency that i would enjoy the most. But i worry that i wouldn't love it for the rest of my life... that no one would ever talk to me normally at a cocktail party. And that if i moved to a small town, i would have way too much information to ever have any friends.

I still have a few weeks to plan my electives, i'll keep you posted.

Pediatrics

Blogger ate my last post about pediatrics. I'll give a brief summary, but suffice to say pediatrics is not on my list of potential careers. which surprised me a bit. And made me realize how good it is that i had the chance to do this rotation before applying to the match. I've worked with kids for so many years, i just assumed that i'd go in that direction, but being a pediatrician is very different from all the other kid work that i've done.

1. Kids loathe and fear doctors. (and then scream and struggle and vomit in your general direction)
2. Parents are terrified when their kids are sick. (think cornered mama bears)
3. Daycares are the origin of whatever is "going around" (and then they bring it to the hospital...)

But the part that i really couldn't handle is that pediatricians cure things. Which is just not a place i can approach healing from. Deep down, i know that we are all dying. And that all medicine is really just a way to make suffering less, and to help us enjoy what little time we have on the planet. All medicine is different flavours of palliative care. Even in pediatrics. None of us can be cured of our mortality, or even of our sin. We've all got both, programmed right into us from the get go.

Some pediatricians are attracted to the field because children can be seen as blameless in their illness, innocent, and curable. When really, i don't think they are any of those things. Or, conversely, that adults who are ill are sick of their own doing, and don't deserve compassion because they brought it on themselves by smoking or eating badly or not exercising or having sex or not wearing sunscreen or whatever.

Sick people are just sick, illness is not punishment. And nobody gets ill because they deserve it.

So, no pediatrics for me. (As a residency that is; i'm hardly lacking in kid time in my real life, or likely in whatever field i eventually choose).

adolescent medicine

I managed to avoid the gastro and general grumpiness on the pediatric ward by having a month of adolescent medicine. I figured that teenagers and their problems would be a nice challenge after years of working with school-age kids with ADHD.

Adolesence is a time of such power. Between 14 and 20, people still have many years of good health to expect, their parents are usually still healthy, and often even their grandparents. Abstract thinking opens up a whole new way of looking at the world. And not having stuff or money to protect means that people are free to take risks and make choices based on their values, not on what rising interest rates might do to their ability to make car payments in the coming year.

Too bad we spend so much time and effort "waiting out" these years instead of helping youth to really live them.
I have a deeper dislike now for:
* worksheets and other time-fillers
* ridiculous arguments about hem lengths on uniforms
* teachers who confiscate books
* school hours that prevent community involvement
* advertising that encourages girls to disappear
* eating disorders that make girls disappear
* Alcohol, cutting and whatever else youth use to evade the pressure to disappear
* Sexual abuse that reminds youth that they aren't even in charge of their own bodies so they may as well give up trying to make an impact on the rest of the planet.

I know that working with teenagers always brings up one's own adolescence. I was worried about working with teens when i started. . . What could i possibly have to offer to the kids who had "typical" teenage problems with sex or drugs/alcohol/smoking or whatever?? I was such a teenaged geek! I didn't even have enough social wherewithal to find people who knew people who could get me any illegal substances. Which was probably good in retrospect. I was also such a wannabe badass that i would have gotten myself into some stupid messes that i avoided by having a strange but remarkably healthy peer group. Although, to that end, i was and remain earnest, gullible and more than a bit dense. There were probably people in my peer group who, unbeknownst to me, lived with eating disorders, addictions, STD's, and all the other ailments that are as common in this age group as diabetes and chest pain in old men.

Overall, a good month:

* days that start at 9 am.
* lunch
* teaching, supervision, and other luxuries not available to most of quebec medical students at the time
* I can do a gyne exam.
* I can do an eating disorder assessment in french
* I'm not great with eating disorders in any language.
* I still find boys with conduct disorder charming and interesting.
* Little kids fear, loathe and puke on doctors. Teenagers have parents and teachers to hate: the doctor provides contraception, and doesn't tell teachers or parents.
* A disturbing number of moms will side with their boyfriend/husband when their kid accuses him of sexual abuse
* Lichen sclerosis atropica - and other reasons doctors should include the genitalia of little girls in routine exams. If nobody ever looks, how can we know what is normal and what is a problem?

I start two weeks of neonatology in the morning, and a whole new set of anxieties (some of which aren't even attached to people who exist yet!)

Urban family med

That fall went by fast! So this rotation is not quite over yet, but i already have lots to say about what i got to do and learn.

1. the breastfeeding clinic awed me. It felt great to work with people in medicine where i didn't have to be closeted about the rest of my life. Not the lesbian part, i don't bother hiding that anywhere, but the extended-nursing, co-sleeping, hippy parenting that we seem to have fallen into. That clinic and the people who run it are hugely improving health. But they do it all sneaky-like. When things improve for a breastfeeding couple, it improves because of the strength and skill of the mother and her family, not because of the doctors or lactation consultants. People leave there empowered and with tools for lasting change in their breastfeeding relationships.
plus it left me with big baby pangs.

2. Adolescent medicine: not so scary anymore. which is good. cuz i start a whole month of it on monday. Sex, drugs & suicide provide a good balance to hypertension, cholesterol and diabetes.

3. palliative care: it's nice when the patient is always right. There is room for creativity. It's like a "more marginal margin" when all the hotshots are so busy curing things, that they don't bother to notice what progressive, radical, revolutionary, healing things are happening in the parts of the world most people ignore.

4. lunch. also dinner. also daylight. peeing. adequate rest. and time to study.

5. public health. It is going to take force of will to keep myself from this field. Feel free to remind me that i would hate working in an office, i would hate the bureaucracy, i would hate how slow everything goes. And MamaM would leave me if i had to write another thesis for another masters in epidemiology. upstream medicine just makes so much more sense!

6. one way mirrors. not as creepy as i thought. and people don't fear them as much as i would if i were a patient. It's nice to get feedback on what i actually said, not just what i think i said.


I'm doing a presentation tomorrow about trans health. I feel kind of dumb, because i don't really know anything about it. but then, I tell myself that I wouldn't know much about ear infections either - and this is more interesting. I'll add more to my list when it's over for real. Now I'm going to go snuggle with the little one. He's stopped saying "bye-bye MamaE" in the mornings, and now just looks sad and says "see MamaE again?". mmrph. This is going to be my first whole, entire weekend off since before i left for Shawville. and i'm going to spend much of it kissing his little blond head.

Rural family med

A mish mash of thoughts on my last night with free time before i leave to go back home.

I got to learn and see some interesting medicine up here. just after they finish telling me it's really just a glorified walk in clinic . . . suicide and a PE, enteric fistulas, a murder, and a really sick kid: all in one day! Combine such urgent problems with family-centred obs and palliatve care and the relative down-time of reminding people to quit.smoking.already. . . these rural docs have the makings of a really fun job.

After i finish my selfish daydream, i remember no one has yet asked LittleE if he wants to take on the multiple job titles of "doctor's kid" "minister's kid" and "kid with two moms" in a place where everybody knows your name. I know that there are queers in the country (They also have to use the emergency department at times! I saw them! They exist! They seem happy!) But i think we need to look for some normalizing relationships for the spawn before we make any big moves. (Any of the rest of you freaks or weirdos want to join us in moving someplace small?)

MamaM and LittleE are coming up again for my last two days here. i'm glad in the end that i'm close enough for them to visit. A month is a long time in the world of a todder, i'm thankful that i didn't have to miss all of it.

And as i was recounting to my "consoeur" last night how MamaM and i met and ended up in this silly pickle. . . i re-remembered again how much goodness that salty-dreaming-ocean-woman brings to my world. I could never have imagined that we'd be here in seven years. . .

tickets from the gender police

So, these past two months have been rather busy.
I've just finished four weeks in emergency medicine. Which i liked just as much as i had hoped i would. It feels great to have a goal again. Not that it will come as a great surprise to anyone who knows me that i'd love to work in a small-town emergency department. And I'm now happily parked in a hospital dormitory in Shawville, where i will hopefully get to try out the small-town part of that plan.

I was working in a non-trauma hospital emergency department on the day of the shooting at Dawson college. There was much excitement and bustling about, and preparations for an onslaught of injured patients which (fortunately) never materialized. The emergency department was quickly emptied of it's usual inhabitants, and the team preparing for the crisis was dressed up in crisis gear and awaiting ambulances. One fellow was left - on his stretcher and in a johnny shirt, and began gesticulating wildly at me. Since i was one of the few unoccupied medical-looking people I met his eyes, and he waved, yelling "excuse me! excuse me!". I rushed over and asked if i could help, and he looked at me intently and asked: "Are you a boy, or a girl?"
Are you for fucking real? i'm thinking in-my-head-with-my-mouth-closed. "I'm busy, but call me back if you need anything" I said out loud.

My other great gendered moment this month with the was on a trip MamaM, LitteE and i took to ottawa for a night off. We were having breakfast in the hotel restaurant, and LittleE was offering his magnetic smile to all the staff (which often scores him free food when we're out). One of the servers came over and told us what a cute little boy we have. We thanked her, and then she got all flustered in that way that people do when they fear they have mislabeled someone's gender. She apologised, and asked if he was 'really' a boy. We assured her that he is, indeed, a boy (for now). And besides, he is only 18 months old and it's never obvious at that age. She looked at us as if we were in on a secret and said "you never can tell these days." Then she turned to LittleE and said "You want to get some more fruit from your daddy??" I just grinned into my coffee and offered the kid more "ah-puhll, ya."

(I really can't take all the credit for my kid's fruity-ness. . . Nature or nurture, he's getting it from *all* sides)