Being true to our younger selves

My alarm beeped at 5:00 a.m., and I was instantly awake. I roused my sister, and we donned our jeans and rubber boots before heading outside in the dark. Gravel from our driveway crunched underfoot as we hurried to the barn, banged on the wall to encourage the rats to hide, and flung open the wooden door to retrieve the feed and hay for our mares. We sat on the steps waiting for them to finish their breakfast, anticipating the joys of our daily trail ride. The air was already warm and thick with humidity in the Mississippi summer, and if we didn’t get the horses on the trail with the sunrise, it would be too hot. Tack on, we mounted and sauntered down the road, taking an easy pace for the first hour through Mr. Buddy Crawford’s pastures to the beautiful old pine forrest trails. The mystical beauty of the morning and perfect harmony with my horse, Naomi, filled me with joy every day of the summer. As we emerged from the woods, a long straight stretch of unused cornfield made for the perfect runway, and my sister and I raced our horses across. Naomi responded to my voice command, “GO!” with unbridled enthusiasm, and the thrill of galloping across the flat grass course was like no other. At the end of the ride, I could tell she was just as happy as I was. This horse was my soul-mate; she came when I called, sensed my moods, and would follow me anywhere. She was easily spooked, but I knew all of her quirks. We returned to the barn and went about our day, watching the antics of our goats, dogs, and cats, and always looking for more adventure.

At this phase of life, around age 8-10 years old, I simply knew who I was, what I wanted, and what I liked. Shortly thereafter, around middle-school, my self-consciousness soared while I became thoroughly confused about what I liked and wanted. Unfortunately, that “phase” of life continued through high school and in some form through college, and young adult life. I made decent decisions for majors, friends, career, life-partner (ok an astonishingly fantastic decision on that one!), but I didn’t have that effortlessly pure, distilled sense of who I was. I also didn’t realize that this was the case, until I faced my own big monstrous burn-out during residency. This topic deserves it’s own post, which I will eventually write, but for now suffice it to say that it took months for me to work through the challenges associated with it, and when I was finally emerging from those doldrums I had a burning question constantly on my mind: What would my 10-year old self think of me now?

It was hardly a rhetorical question, and I had lots of answers. First of all, I would have been appalled at the lack of book-reading happening. As a child, I devoured stacks of fiction-book series. I read in my room, in the car, in the yard, in trees, at night, first thing in the morning, on the bus…I was a bookaholic. If I recall correctly, I was into several equestrian stories, maybe had just finished all the Boxcar Children, Baby-sitters Club, Chronicles of Narnia, and Saddle Club books. Anyway, at the point of my burn-out recovery in residency, i hadn’t read a novel since 4th year of medical school, when I read one chapter each night of War and Peace to help me fall asleep; it took me about a year to finish (short chapters) but I loved the ritual.

I also would have been perplexed as to why I didn’t write more. I always enjoyed journaling and writing stories, and even through high-school and college I nurtured the interest and skill in writing. I took AP English and was an English major in college; I wrote all the time. Even as a math (double) major, I wrote an honors thesis (on Non-Euclidean Geometry), which is just to say, I worked in writing at every opportunity. As a med student and resident, I never wrote anything except daily notes and H&Ps.

The next one was even more painful to admit to that little girl of my past…I had grown up into a woman who was too busy for a dog. This was a profoundly sad realization, and was decidedly the catalyst for springing me free of the burnout and depression because I made his resolution: “If I’m too busy for a dog, I’m just too damn busy and something has to give.” I decided then that this would be one of the barometers of my life to keep things in balance. And I adopted, and got adopted by, my soul-mate dog Ramble. (If you want some insight into how low I felt at this point in life, listen to the song, “Too weak to Ramble,” by Dr. Dog, which inspired his name.)

My first hike with Ramble, when the sun literally and figuratively came out for me.

Maybe one last big one would have been participating in humanitarian work and travel, essentially being connected to current events. I had picked cardiac surgery as a specialty and was pretty determined to not fall back on what I felt was a commitment to that field, but increasingly I felt that trauma surgery was so much more intricately connected to the community and current affairs, which I was very interested in. I did go on a trip with a cardiac surgery group (Novick Cardiac Alliance, which is a fantastic organization I will write more about in future posts) to Ukraine, and learned a lot there about delivering superb quality, highly advanced surgical care in a developing country, but I was much more interested in what was going on with the folks being bombed at the border than with the cardiac stuff. I hadn’t really made being an activitist in global health topics a priority with my time and efforts to that point; I was just trying to “get through” training.

Me in Kharkov, Ukraine, with a tiny patient in the ICU awaiting her procedure. We had to hold/bounce/jiggle her to keep sats up before surgery.

Ramble and I went for hikes every weekend that I was free from work that spring, summer, and fall. His influence on my life was profound, and taught me to be open to sharing my time and energy with the right people (and creatures). I also wrote a couple of articles for a local independent journalism group. I picked up some good books to read. I started the first Global Surgery Journal Club at Mayo Clinic in Rochester, and networked with some awesome surgeons and residents who had similar interests. I’ve never had a recurrence of burnout or depression. 

So many people go through similar growing pains in their early 30s, it’s almost a cliché. But the transformation was real, and was about taking back my life in small ways, and stopping that utter neglect of all the things that made me “Me.” But where am I going with this long,  long post? What’s it got to do with Indie Docs, or Global Medicine?

Learning about myself, what I genuinely like, how I truly want to spend my time, has been a challenge and has developed some skills of insight. It almost feels like a muscle that started out pretty weak those few years ago. It can be quite stressful to trust myself to step off the prescribed path of daily routine or academic medicine, and even more-so for choosing a really unusual career narrative.

Josh and I have discussed the subject, “What do we want our lives to look like in 5 years,” countless times, and we are still discovering the answer.

Fortunately, through her interview on the ChooseFI podcast, I discovered Jillian from Montana Money Adventures. I started working through her mentoring worksheets, and I was blown away by the insight they provided me. I asked her permission to use the worksheets as topics for discussion here, to which she has graciously agreed. So in upcoming posts and maybe on some podcast episodes, Josh and I will use her mentoring worksheets to answer the questions of how we are purposely designing our lives, engineering our time and finances, and thinking about the future in order to be true to our most quintessential goals (doing humanitarian medicine!)

I gave birth to a beautiful baby girl this past week. I’ve designed my year so that I get lots of time at home by taking a research position rather than an attending job. I’ll be doing some locums assignments as well to keep my skills sharp and gain experience, but doing this “off-year” was one decision I made that may have been different than what most surgeons would think is the right way to spend my first year out of training. With our unique circumstances, and how much fun I am having with my girls AND with stretching my skills as a researcher, and I’m secure in knowing that I made the best decision for us.

The ability to answer these simple questions of what we really want in life will be central to making sure we make the right decisions about what jobs to take this year, particularly in order to facilitate our bigger goals of making humanitarian medicine a major part of our lives. The decision could enable us to have the freedom to pursue many global surgery projects, or strap us to confining responsibilities.

There are trade-offs to every scenario, pros and cons to weigh, futures to consider (the girls’ in addition to ours), and plain old money questions. But all of those specifics take a back-seat to the simply being able to know and do what will make us happiest and give us the deepest sense of purpose.

With the help of some great mentors this year (stay tuned for that!), I am certain that we will find the right path.

Indie Docs: The Podcast!

Our first podcast recording.

Joy has really been the catalyst behind getting this website site started. On a drive home from Minneapolis one day, she started talking about an idea for a blog that could serve as a resource for people interested in global healthcare. She had done a lot of research, figured out how to obtain the domain name, start the website, etc, but she couldn’t figure out what to call it.

She was so excited about the concept; honestly, I didn’t think one thing or the other about it. I liked the idea, but didn’t intend to get involved much. But because I could tell it was important to her, I participated in brainstorming names, trying to help her dig-in to what was driving this desire in her to make a website and blog. Eventually, we came to Indie Docs, combining the thought of indie music (the liberated, do-it-yourself attitude that has changed the music industry over the past few decades and resulted in many of our favorite bands and tunes), and, of course, the concept we are hoping to achieve of being free to pursue global health projects. Like I said though, I thought of this website as her passion project, not mine, or even ours.

Part of my–dare I say it–disinterest, stemmed from the fact that at this time I had commenced my final and toughest year of training as a chief resident. Combine that with the fact that we have a little girl, and at the time, another on the way (who is now here as of September 24th!), and trying to find a job, I didn’t have much mental energy for other things. But Joy’s enthusiasm is infectious and, within the seed of her idea, I started to see the many possibilities in it.

I’ve always been a big fan of talk radio, mostly NPR shows like This American Life, Fresh Air, and Radiolab; eventually I have found my way to podcasts, of course, and I devoured Serial, S-Town, Malcom Gladwell’s Revisionist HistoryMissing Richard Simmons, and many, many others. It’s such a populist art form and a brilliant way to tell stories, share ideas, and explore all the little nooks and crannies that exist in our world. I mean, 15 years ago, would anyone ever have produced a radio show about figuring out why Richard Simmons has disappeared from public life? Or spend a whole series on telling the life-story of an eccentric paranoid genius in Sh**town, Alabama?

Stories have always influenced the direction I think I want to take in life. When I was young and watched Karate Kid, I wanted to take karate. When I saw Top Gun, I wanted to be a pilot. I abandoned both pursuits eventually (made if further in karate than in becoming a pilot). Maybe growing up is choosing a story that inspires you, and sticking with it. It was the story of Paul Farmer as told by Tracy Kidder in Mountain Beyond Mountains that led me to become a doctor. It’s the stories we were both raised on of Jesus physically ministering to the poorest, least powerful, least cared-for that I think serve as the bedrock for why we want to work in global healthcare.

Truthfully, we are just now figuring out how to enact both of these sensibilities and, other than becoming doctors, we haven’t done that much in the way of caring for the poor other than a couple of short-term trips, relief efforts from afar, small amounts of charitable giving, etc. We’ve been trying to get through school and training, but now that we are finishing up with that part, we are starting to look at each other as we enter our mid-to-late thirties and say, If not now, when? And  beyond that, How do we start?

I don’t know how or when the idea of doing a podcast for the site came to my mind. There was no inciting event, or thunderbolt from the sky. I’ve always tried to learn the stories of people working in global neurosurgery. When I was a medical student, I went to the CURE hospital in Uganda, and learned about Dr. Ben Warf, who was the first neurosurgeon I came across that showed me neurosurgery was not only possible, but could thrive in an low-resource setting.  When I go to national neurosurgery meetings, they almost always have a session on international neurosurgery efforts, and I am amazed during the presentations by the intelligence and effort of people like Drs. Kee Park, Dilan Ellegala, and Michael Haglund who are changing the paradigm of global neurosurgery. My former senior resident, Will Copeland,  made the decision to go right out of residency to live and work in Kenya (with his wife and six kids!), and has shown me it’s really possible.  Joy and I think these stories, and stories of people like them, hold the key to figuring out how we are going to achieve our ambitions of joining the global health community.

And so the past few weeks, I’ve learned about microphones and pop-filters, Garage Band and Zencaster, how to use the Seriously Simple Podcasting app for Word Press (how to use Word Press at all really), how to register a podcast with Apple, make a logo, and on and on. I’ve also learned that I am as passionate about this as Joy is, that it is our project. We set out together to become physicians, and eventually a neurosurgeon and trauma surgeon, so we could gain skills we enjoy and that would be useful in global healthcare. Now we are setting out to discover how to employ them, and as part of that, finding, sharing, and learning the stories of people who are already doing just that in a variety of ways.

The podcast will include episodes in which Joy and I tell our story as it unfolds, interview others about their experiences, and reflect on how these interviews are shaping our thinking about what we are going to do next. We have several great interviews lined up already, starting with Sean Dupont, a general surgeon who Joy did residency with, who is just getting started working in Niger,  as well as Will Copeland and Kee Park, both of whom I mentioned above. We will talk about how they manage their lives and families, finances and careers, and what inspires them to do the work. Stay tuned!

~ Josh

 

 

When it hurts to rescue: perspective from the other side

In college I had a list of things I wanted to do before I got married or graduated. One of them was to be a counselor at one of those fun outdoorsy mountain camps. I got my chance right before my senior year, and I was really pumped about hiking to Blue Ridge peaks, making camp-friends, and mentoring youngsters. The pay wasn’t great, but they offered an extra $15 per week for life-guards, so I signed up for their Wilderness Lifeguard Certification course. I knew that the requirements included an initial test of a 500-yard swim, so I conditioned ahead of time at the local YMCA where I was a spinning instructor. I arrived for training to our lovely mountain lake in late May. The waters were frigid. They were so cold, we were told to get out of the water every ten minutes to let our core temperatures warm up to avoid hypothermia. The time came for the 500-yard test, and I confidently lept in the water and stretched out for freestyle swimming. As my face broke the surface of the frigid lake, my respiratory muscles immediately spasming so that I snorted icy water into my nose and mouth. I lifted my face out of the water while trying to maintain my stroke and choked out a mouthful of water and heaved in a very brief, shallow breath before the spasm made me cough again. With a bit of grace from the instructor, I was allowed to gain my composure before proceeding with the test, and with all my willpower and concentration focused on breathing between the chest spasms I managed to finish. Further challenges included deep lake dives to the bottom for a “sweep,” that resulted in one of the other trainees bursting an eardrum, and my first personal experience with true, all-consuming claustrophobia and vertigo in the pitch-black lake bottom. If I had known how to quit, I would have. I struggled on the final to haul a guy 100 pounds bigger than me out of the lake, but I passed my certification.

A few weeks later, I reluctantly led a bunch of little girls on a white-water tubing trip along with 5 other lifeguards. There were about 30 campers, from 6 to 17 years old. My reluctance was due to what I considered unsafe river conditions; heavy rains had increased all rapids by 2 classes, and the river was so swollen with torrential currents, and I didn’t think the little girls and weak swimmers could handle it. Alas, my strong opinions were over-ridden by the other guards, who suggested that we have a system where I “tested” the tubing route as the front lifeguard and then made the decision. I struggled to traverse a rapid as my foot got caught between two large rocks, and looked back to try to wave off the other lifeguards to indicate that I was right, we shouldn’t be in the water! But the wall of campers in inner-tubes coming towards me confirmed that it was too late. I had to abandon my float to rescue one girl who flipped out, and another got passed me. She was swept beyond the deep pool that should have been the exit point on the brief tubing course. I caught up to her and we slipped down a small set of rapids to the next deep pool and I hauled her out. At this point, I was pretty mad, but out of sight of the group. I planned to march up the bank with her and demand everyone get out of the river. I was rehearsing my speech when I heard calls of help from the far side of the river.

What happened next inside my brain is completely inexplicable to me. My conscious thoughts were loudly in denial: They cannot be our campers; they are boys; they do not belong with our group; I do not have to get back in that freezing water. But they were our campers and I found my body moving, first toward my safe camper on the bank asking her to run and get help, and then into the water. The river bank was covered in softball size smooth, slippery rocks. Every step I took, I stumbled. I finally got to water deep enough for me to crawl like a salamander toward them, and I was horrified as they crossed my horizon from left to right. I struggled and crawled and pushed, and finally caught the current. They were gone. I desperately swam down the river, crashed over a rapid, and looked for them. It was another set of rapids before I caught them. Each time I slid over the rocks and crashed down the drop, it hurt. It hurt my feet, my back, my knees, and my legs. I caught the girls and hung on to both of their tubes; somehow they had stayed together. I remembered in our white-water training we were supposed to keep our feet up so that they wouldn’t get stuck between riverbed stones and result in our ankles getting snapped as our bodies got jack-knifed by the current, but I was completely powerless to stop myself from trying to put my feet down to slow us. We met rapid after rapid, and each time I was holding onto the tubes and skidded down the rocks on my back with my head forced down under the tubes and water surface; I braced myself for a blow to the head that I was sure to come.

In the midst of all the turmoil, my brain still somehow made room for thoughts of blame and disbelief, and I was filled with a furious rage like I had never known before. I was angry at the pain and the fearful thought racing across my mind of, “THIS is how people die on rivers. We could all 3 die. THIS is how it happens.” I tried to steer us back to our bank, but made no progress. As I got a brief respite from skidding over the rocks, I looked far down-river, and I’ll never forget what I saw: 100% whitewater. All of the wide-open river in front of us was a churning and rocky field of rapids. I panicked and kicked as hard as I could toward the far bank. One of the girls got pummeled on the back by a large rock and almost popped out of her tube. I held her and her tube and the other tube, and kicked. We landed in an eddy. It all stopped.

I trained my eyes to the water for campers, expecting more victims to be floating down. My rage grew. Beaten up, we hiked barefoot a mile or so downriver, across a bridge, back to our group, and I expected panicked colleagues and a hero’s welcome. Heck, I half-expected some helicopters to be canvasing the river looking for us–it felt like we were gone for hours! What greeted us instead was disinterested blank stares and the phrase, “Oh, we didn’t realize you were gone.” Needless to say, I lost it. I must have said something fairly scary, because within a few minutes, everyone was out of the river, headcount was done, and we were in the vans. I fumed. How could they not even know we were missing?

It took me a while to get over my anger and to stop ruminating about the close-call, but what I ultimately learned was a really profound lesson. As uncomfortable, and frankly horrible, as that experience was, I realized in discussing what had happened with the other lifeguards that I would not have wanted to trade places with anybody.  If someone else had made the rescue instead of me, I would have been crazy jealous. Of course I wish it had never happened, but that’s not reality. It did happen, and in some form or fashion it will happen again. At this point I was heading toward med school, and I decided then and there that I wanted to go after those people that I would encounter throughout life that need rescuing. As a trauma surgeon, in a literal sense “rescuer” has become my chosen vocation.

Residency was at times pretty uncomfortable. Med school, too. I never reached the level of acute suffering, and certainly not personal endangerment, I felt on the river, but I remembered that experience and was emboldened to persevere. My medical missions experiences have also been uncomfortable at times, like when I got norovirus 15 weeks pregnant in Guatemala and needed 5 liters of normal saline before I stopped feeling dizzy. Or sleeping on army cots, working in heat, and failing to fix everybody. My experiences are a mere pittance compared to what our colleagues in war zones and refugee camps endure as they risk everything to rescue as many as possible.

Advocating for a cause is also frequently uncomfortable. Sometimes I still feel like I’m yelling into the abyss of disinterested blank faces trying to convince people that we should be doing something different. Especially in situations that I feel are dangerous or risky, this can be frustrating and draining. In the global health world, the need for advocacy is infinite and immediate. I think this may be among the main stressors of the field. Many worthy causes, and our passion projects, will suffer from lack of attention and support, but it will be up to us to make a strong case for why people should care about what we do. Indeed, people’s lives depend on it.

I suspect the “rescuer trait” is common among humanitarian medicine providers. However, I have also encountered many people who are unprepared for the discomfort and the pain that come with this lifestyle, and it shows in grumpy attitudes, intolerance to local culture, slow progress, and early burnout. I have to admit that I myself was not prepared for the discomfort involved in a river rescue, or even in being a lifeguard at all. We need to carefully prepare ourselves for reality rather than just hoping the mountaintop experiences to put enough wind in our sails needed to fuel the mission. We need to be mindful of our inner conflicts as we encounter difficulty, and support one another as we process new challenges. We need to work to recognize when a colleague needs to talk about it, and lend a sympathetic ear.

My little adventure in the beautiful Blue Ridge Mountain planted this seed in my mind, and I hope that as my professional ambitions take me through some arduous experiences I keep the perspective that it is my privilege to be the one jumping into the river.

Change is always bad, until it gets good: Lessons from the Quality Academy at Mayo Clinic

I am spending a year as the Trauma, Critical Care, General Surgery Research Fellow at Mayo. I have time to focus full-time on projects that will hopefully make a difference, expand knowledge, and really help our patients. I have aspirations of completing a couple of Quality Improvement projects, which is a very particular type of research with roots in sophisticated industries that have developed complex strategies for minimizing risk and errors. I have attempted a project before and essentially got nowhere, as I didn’t even know where to begin. So I signed up for the Quality Academy, which in true Mayo fashion, was an efficient, information packed, slick course that gave us all the tools we needed to get going on our projects. We covered a broad range of topics, and I was inspired by many of the thought processes and exercises presented there, but non stood out to me as more profound that the so-called “Change Despair Curve.” It looks something like this:

Image result for change despair curve

(Credit: https://betterleadership.wordpress.com/2010/02/05/the-valley-of-despair/).

 

Now this was not the exact curve in our presentation, but it’s essentially the same. The curriculum stated that any change, whether personal or institutional, small or large, is accompanied by this same terrible transition by all involved parties. Even if the change is obviously positive and gets unanimous support at the beginning, there is a valley where everyone is bummed.

The reason I thought this was so profound is that I have seen it play out in my toddler’s reaction to 100% of suggestions I have made to her in the past 6 months or so. That’s not an exaggeration. I say, “Banana?” and she gives me a tortured expression and says, ‘NO DON”T WANNA NaNeeeI!!!” before her face softens and she holds out her hand for the gift. Every transition, change in our momentum, new idea, or suggestion of any change in the current activity and state of affairs is met with initial resistance. So of course I smugly thought, “Ah motherhood, giving me yet another edge in the professional world,” and gave myself a mental high-five.

This curve  represents the challenges we will all face as we try to do good in the world by changing the status quo. All stakeholders will eventually get sore with us and with our ideas. We will get depressed about our projects and moving and traveling and starting new ventures. We will have to convince ourselves and colleagues that the change is worth it, over and over again. With perseverance, what is there on the other side of the difficulty is higher quality projects and a life of more purpose and impact.

I encourage every professional interested in global health to get acquainted with the principles of Quality Improvement, as we should be held accountable for proving the quality of any new endeavor or change we implement. We need to show that the change and resources required are justified, and having the right tools to do this analysis is part of the job description of a humanitarian physician. If your institution does not have resources available to get you started, email me at joy@indiedocs.org and I will send you everything I can to help.

What life-lessons have you learned from something like “Quality Improvement?” How important do you think quality research projects are to the field of global medicine? Please leave comments below!

Interested in humanitarian medicine? How to choose a specialty.

A Daunting Choice

The decision to select a specialty in medical school is one of the most exciting and intimidating moments in our careers. Many factors and external influences weigh in, even among students planning for more conventional career paths than us with global health ambitions. In the context of global medicine, won’t your specialty have different presentations of disease and treatments, as well as potential projects for research? Certainly, your case list as a plastic surgeon in the U.S. will look quite different than in a developing country. Some specialties have been involved in the public health realm for decades, like pediatrics and infectious disease, while others are recently emerging as population needs have been brought to light, like surgical oncology. So how do we commit to just one specialty?

How We Did It: The Path to Specialty Isn’t Always a Straight Line

As Josh and I entered medical school, we had many discussions about our big-picture goals and what specialty we should choose. We talked about the fields with big impact factors, thinking seriously about fields like obstetrics and infectious disease, as these areas seemed to have an obvious impact on large populations and seemed to be popular choices for others interested in humanitarian projects. Like many students in our class, we attended all of the interest groups for medical specialties, largely for the usual free lunch offered, and I genuinely could see myself doing a variety of things as 3rd year approached. Once into my clinical rotations, I mostly felt happy and immersed in whatever rotation I was on, with a few notable exceptions. I preferred the hospital to clinic settings, and preferred high acuity to chronic illnesses. I enjoyed working fast with high intensity.

Because I had amazing mentors in the field, I decided to pursue cardiac surgery. At the same time, my husband was strongly favoring neurosurgery; he talked often about how he worried that his specialty would not be useful in underserved areas. My perspective was that we should just choose the fields we were most passionate about, and make a way to provide the care where it didn’t already exist.

We had many conversations that seemed to go round and round about these topics. Nearly every car ride lasting longer than 15 minutes, this was the discussion. What should we become? Was that choice consistent with our hope to become humanitarian physicians?

Our 4th year, Josh did a sub-I month at a Cure Hospital in Uganda, working with the neurosurgery staff. This rotation helped solidify his confidence that there was plenty of potential for global neurosurgery projects.

We both matched into our dream program at Mayo in Rochester, MN. He in neurosurgery and me in general surgery with intentions to pursue cardiac. I went on a trip to Ukraine with an amazing organization called Novick Cardiac Alliance, and I saw first hand a successful project to elevate care in an underserved country. They had similar projects all around the world, and I loved hearing the accounts from the nurses, intensivists, and surgeons, about their different locations. This experience was formative. It showed me first hand that sophisticated, cutting edge, and resource-intense surgical care was possible anywhere. However, the irony of this trip was that the actual cardiac surgery that was happening was less interesting to me than the bombing of the Ukrainian city of Donetsk 50 miles away, with possible traumatic injuries that needed tending, and the illusion of cardiac surgery as the perfect fit for me began to crack.

In the cath lab in Kharkiv, Ukraine.

Within the year, I decided, definitively, to switch to Trauma and Surgical Critical Care as my specialty. It’s a perfect fit for me for many reasons, and is certainly one of those fields that has relevance in any setting around the world. Trauma is emerging as a hot topic of discussion for global surgery funding and improvement projects, as it is the leading cause of death and disability among young people. I do admit that this is one of many aspects that attracted me.

One detail I would like to mention, but not dwell on (I’ll save the long story for another post), is that I personally experienced a traumatic injury in a motor vehicle accident in high school, which was extremely formative for me. It undoubtedly changes my perspective when caring for my patients. However, I resisted going into the field of trauma surgery for a long time even though it weighed heavily on my mind. Having pondered this for a while, I think that I was rebelling a little bit against the idea of letting this negative experience steer my life in such a way. Ultimately, I think that the influence of this incident will enrich my passion for the field and help me to connect with my patients on a personal level.

Another attractive aspect about my field is that because it encompasses trauma care, surgical critical care, acute care general surgery, and elective general surgery, I can be quite flexible in how I work. Not to mention where I work. I can vary my schedule, and every week can be a little bit different depending on if I’m in the ICU, covering Trauma, or doing elective cases. Personally, I think that any job that was the same schedule, 9-5, week in and week out, would lead to burn-out for me. I like variety.

Josh has never waivered from his decision of neurosurgery, and he has had the benefit of observing one of his former chief residents, Will Copeland, MD, move his family to Kenya to work at Tenwek Hospital. Dr. Copeland is doing outstanding work there and is a great role model for Josh.

Observations

As I was discussing this post with Josh, he quickly surmised, “I think I know someone in every surgical subspecialty doing humanitarian work.” We are lucky to be in a place where our colleagues and friends have these shared ambitions and have launched into humanitarian careers around the world.

I’ve also benefited from many connections in social media, particularly Twitter, where countless organizations representing the full variety of medical specialties are represented. Online journal clubs are becoming more common, as are twitter-hosted journal club discussions (@MayoGlobalSurgJC for one example). To see the many excellent accounts I follow on twitter, see my list under my profile at @IndieDocs1.

Summary

In the end, I chose the specialty that suited my personality and interests, as did Josh. The simplest way I can describe my decision is that I chose what sounded like the most fun to me, and I’m very happy and confident with the choice. I took into consideration personal as well as professional goals. There is no doubt that we will both have abundant opportunities to serve patients and elevate local surgical care if we remain dedicated to that cause. Therefore, the answer to the topic, “How to choose a specialty,” is both simple and complex. Pay attention to the little thoughts and reflexes in your mind as you encounter diseases and treatments in each field, and be honest with yourself about what truly interests you. Allow your past experiences to form the type of doctor you are going to be. Be open minded about the possibilities of providing advanced-level medical and surgical care in low and middle income countries. Seek mentors and role models, but don’t choose a specialty solely because you like or are encouraged by your mentor. Pick what you can do all day every day, and also what will allow you to have a sustainable lifestyle and work schedule.  Don’t be afraid to change directions as you obtain new experiences and perspective. If you choose a specialty in which you can work passionately and sustainably, you will undoubtedly have a significant impact as you serve your community.

What weighs into your decision for pursuing a specialty?

Do you have any additional insight or suggestions for young trainees?

Please comment below!

Two-resident-and-a-baby household: Logistics and finding balance

Excuse the chipped nail polish.
Yep.

June 30, I walked out of the OR around 8:30 p.m., finished my floor work, and turned off my pager, placing it into a pre-addressed manila envelope. I changed clothes and walked out of the hospital for the last time as a  General Surgery Resident at the Mayo Clinic in Rochester, Minnesota. It is surreal to have this challenge behind me; 6 all-consuming years of my life including my Surgical Critical Care Fellowship, not to mention medical school and the preceding marathon of hard work and stress. I started this website near the end of my residency and had planned to do a post on our crazy dual-residency routine (my husband Josh is a neurosurgery resident), but with board prep and trying to wrap up a million tasks on the to-do list, I never got around to it. Still, I think sharing what life was like these past few years might help someone else navigate their own rocky trail, so I thought I would share some of the more pragmatic aspects of how Josh and I managed our day-to-day routine. In the spirit of Indie Docs, I would like to emphasize that no two lives or routines look the same, and this is all about cultivating our best life and thriving where we have intentionally and stubbornly planted ourselves.

First, we needed quite a bit of help and intentionality to make having a family work. I researched possible childcare options before deciding to start a family; I could not even mentally commit to becoming a mother without having a workable plan. I honestly didn’t think it could work until I researched the au pair programs. I was surprised to realize that the program was affordable, particularly in comparison with the larger full-time daycares (with extended hours) in my city. Having someone live with us was essential since we were often both on-call. I planned to return to work after 6 weeks, and the au pair couldn’t start until the baby was 3 months, so I reached out to family members to help me and was so blessed that my aunts were able to move in with us for 6 weeks to fill in the gap. Looking back, I wish I had considered just slowing down and staying home; I didn’t even seriously look at the finances and just assumed I needed to get back to residency. This was a very hard time physically and emotionally and not something I ever advocate for families and babies, but I digress.

Finally home from work.

The au pair program limits work hours to 45 per week, so we needed daycare in addition to the au pair. My husband had a stroke of genius in finding our daycare. He searched for all the childcare licenses closest to us, and just started cold-calling them based on proximity. Less than a mile away, in our neighborhood, was a wonderful lady with decades of experience and an opening! Once we hit that 3 month mark, we had our au pair and day care established. For the next couple of years, the routine was essentially the same; I left home around 5:30 or 6, our au pair would keep the baby until 8:30, drop off at daycare until 3:30, then keep baby until we got home around 6:30 or 7. My husband and I did our best to stagger our call nights, but there were plenty of nights when the au pair knew she was also “on call” and we would wake her if we both got summoned to the hospital.

Next for my working-nursing-mom spinning-plate trick: I was hoping to breastfeed as much as possible, but I honestly expected to need to do a combination of formula and breastmilk. I even had a package of formula on hand when we got home from the hospital, just in case. I was lucky enough to have a great supply, and I managed to keep a schedule that allowed me to pump enough milk to create a surplus before going back from maternity leave and then more than enough to keep up with day to day demands for the next year. I’ll be candid here, I was freakin’ proud of myself for making all that milk and for having the discipline and determination to keep going through the year. I’m happy to share my specific schedule with anyone interested, but in general terms it took a lot of time, energy, and so so many calories. I ate more at this time of life than I could even have imagined before. I pumped while getting numbers, while dictating, answering pages, patient phone calls, reading…I may have also nodded off a time or two at 3 a.m. in the ED pump room. I also dealt with a few unsupportive colleagues and staff. One OR assistant told me not to tell him when I was going to pump because it was gross, to which I replied, “Well, considering you are alive, I’m assuming YOU were also breastfed around 50 years ago, so that’s a tad hypocritical.” He laughed and was very protective of my pump-time afterward. On the other hand, one of my attendings never ever wanted to hear about it and wouldn’t even give me 5 minutes between cases (she wanted me there for turnover) to hand-pump in the restroom (I attempted this out of pure desperation because I was in engorgement agony), and I got two bouts of mastitis on her service. Despite the challenges, it was worth it to have the bonding time with my baby and feel like I was providing for her even while we were separated so much by my work schedule.

As a money-saver, (and probably also as me wanting to go the extra-mommy-mile as over-compensation for working so much, ahem) we use cloth diapers. I had help with the laundry from my au pair, but honestly the effort expended on this routine was minimal. I would much rather do a load of laundry than rush out to the store to grab a pack of diapers. We used disposables for travel and at night. After getting used to the routine and realizing how much money you can save even using cloth diapers some of the time, it’s hard to believe that cloth diapers aren’t a more common part of life for most families.

Whenever we had a weekend off together, we were intentional about trying to spend time outdoors. We got into camping during the beautiful Minnesota summers, and we hiked as much as possible.

Camping on the bank of the Root River

I used either a woven wrap or a Beco baby-carrier for hikes. We also have a big Osprey baby carrier gifted to us by a neighbor for serious backpacking, which we’ve only used a couple of times, including for a music festival (Eaux Claires).It was pretty awesome for keeping the baby strapped in and comfy while we carted her around from stage to stage.

Eaux Claires music festival 2017

Admittedly, we didn’t get much time to ourselves for the first 18 months or so, as we were constantly trying to maximize our family time during golden weekends. Having an itty-bitty is stressful for many healthy relationships, and we are no exception. For 10 years together before our first child, Josh and I thrived on spending lots of time with just the two of us, and suddenly we had almost none. One revolutionary change we’ve made in the last 6 months is having date-nights, which has been wonderful for our relationship.

The days and nights over the last couple of years have gone by in a blur. I could not possibly be prouder of my little girl or of my husband. She is thriving with her routine, and she is incredibly loving and affectionate with us, our animals, and her many baby-dolls. Josh is in the thick of his Chief service time now, but I have opted for a research fellowship with a flexible schedule this year in anticipation of baby #2 arriving in September. I know that I will always cherish having this short, precious time to spend with my girls while they are tiny, and it will help me feel eager and ready to take on my first position as a trauma surgeon after Josh graduates next year.

Moving forward as physicians with humanitarian-focused careers, we will need to remember how to focus our time and energy on what truly matters to us. I’ve discovered some amazing resources to help focus our priorities by Jillian at Montana Money Adventures. Mrs. Montana has created some wonderful mentoring worksheets for focusing time and resources that I will be utilizing and sharing here at Indie Docs. Many thanks to Jillian for sharing her wisdom and for being open to allowing us to document how we are utilizing her worksheets.

Until then, I hope that catching a glimpse into our world can help someone realize that having a happy family is possible even with our career demands. In fact, you can be an extended-breastfeeding, cloth-diapering, baby-wearing, semi-crunchy-granola mom AND a surgeon! The key for me has been accepting our reality and feeling satisfied in my efforts (no guilt) and cherishing the precious time I was able to spend with my baby. Also, asking for plenty of help, especially in the realm of childcare, was key. In turn, my hope looking ahead is for a happy future of global surgery work, travel, and a happy family. For me, that’s what Indie Docs is all about.

 

Enjoy this hilarious, heartbreaking, and candid tribute to nursing moms…

The Reality Of A Working/Breastfeeding Mom Sucks

Work, travel, exercise wardrobe in one? The holy grail of trousers.

#GirlMed indulgence here. Thanks to Natalie Wall over on Twitter @nataliemwall, who gave out the tip that these “On the Fly” Lululemon pants could be worn to clinic, I have found the workhorse everything pant.

I was reluctant to drop the $100 on them but totally justified it by thinking they could also work throughout my maternity wardrobe needs.

It is actually and practically true that a 26 week pregnant resident can:

Top is Old Navy $6 active apparel that I’ve worn approximately seventy-billion times over the past 3 years, pregnant or not.

1. Bike to work in these pants (mostly downhill).

2. Put on a blouse and flats (I also paired with a nice black sweater, and a lab coat for procedures) and look professional while rounding on patients

I will never have Natalie’s style, but I try.

3. Do a HIIT workout in these pants after work (after this 26 hour day, I actually I just rode my bike home, ate cake, and went to bed).

4. Wash and then re-wear on any trip in any airport.

5. Wear multiple times per week if really not dirty/sweaty and changing into scrubs immediately upon arriving to work.

6. Wear home and immediately get down and play with toddler…no harried suit-stripping on home re-entry :).

So one pair of pants can work in virtually any setting of my life short of a cocktail party. I never have cocktail parties, so…Awesome. Money, time, and closet real-estate well spent. I’ll be living in these pants for the next 14 weeks for sure. I might even get them in olive-green!

Announcement: Humanitarian Travel Scholarships through Doximity

Many physicians reading this are familiar with Doximity, a professional social media site that publishes articles ranging from scientific papers to editorials. Most of us are also keenly aware that finding funding for humanitarian medical travel can be very difficult and time consuming.

I’m very happy to share that Doximity is now sponsoring travel scholarships for humanitarian projects. The process is a simple application, and currently 80% of projects are approved! To check out their website and apply, follow the link.

 

Happy Mother’s Day…Getting out of the “Mom Box”

I have to admit that I really feel like I have it all. I complain about my crazy and exhausting life sometimes, but I wouldn’t change it. I have the residency of my dreams and I’ve reached the end of my Chief year (Holla!!!), the man of my dreams (you’ll appreciate this more in a minute), and a beautiful and fascinating baby girl. I even have a borderline-magical beast of a dog that will get his own post one day, but suffice it to stay he’s my hero and definitely one of my besties.

There is a detail in here that is actually quite vexing to me, and it’s the mom part. We were married for 10 years before having a baby, and during that time, I was pretty hard core anti-motherhood. I read and related to articles examining the decision to never have kids. I was “not maternal.” I couldn’t talk to kids. I was impatient. I didn’t like clutter or messes. I was 100% career driven and proud of it. So what happened? Well, I slowly started to get to the point where I didn’t want to choose between a career and a family. Certain aspects of motherhood started to appeal to me, and for half a dozen little reasons that aren’t important, I decided I wanted a baby. I figured out that an au pair would be essential and also doable with our money and space. So I became a mother, fully expecting a tsunami of life-altering invasions of time and privacy that would leave me grouchy and struggling to maintain sanity. That’s what all the advice focused on, right? How to “survive” the first year. How your life as you know it gets destroyed by a baby and you deal with it for 18 years.

Well that’s not how it happened. From day 1 to now day 600-and-something, it’s been fairly awesome. Truly, I’ve loved it. I’ve given up lots of sleep, yep, and breastfed forever, pumped countless time between cases, felt the push and pull of work responsibilities and fatigue, but I’ve never felt like it wasn’t manageable or that it destroyed my life. It’s been fine.

How is this possible? Well, firstly I would say that I have no shame about asking for help raising this little angel. Yes it would have been more enjoyable to stay home more, I fully admit, but that’s not the path I chose or was meant for, so I enlisted the help of my two aunts when Eddy was an itty bitty (6 weeks to 3 months) and then an au pair plus day care as she got a little bigger.  She loves day care and our au pair, so even though her day from 6 a.m. to 7 p.m. routinely is with them, I don’t get stressed about that. Secondly, Josh and I have equal parenting responsibilities. I’ve observed that in many families, even where the woman works full-time, the mom is the “dominant parent,” responsible for much of the mental burden of planning and decision making among the family. Josh simply doesn’t have the reflex to push that stuff onto me, and for the most part I let him do things his way. Admittedly, Dad-style can be less polished (like when the baby’s clothes don’t match or fit and are out of season), but is reliably more efficient. I’ve actually adopted some of his techniques and been happier for it!

From the beginning, I have had a routine of bathing Eddy and safely co-sleeping (according to pediatric safe sleep guidelines), and so we spend all night together. This has helped me feel like I wasn’t missing her so much and I think it also strengthened our bond and made nursing much easier at night. I think another key has been that I learned a parenting style from my Mother-In-Law, who had a very late in life baby, that allowed for a full range and display of emotions from the little one without taking it personally or even reacting. I joined a gentle parenting group on facebook that reinforced these principles, and I think it saved my sanity and helped me maintain patience. I got into a discussion one time with a friend who was absolutely miserable trying to stay firm with their 1 year old over sleep training, and in that discussion I created a new mantra, which is “If snuggles solves the problem, there really is no problem.” I will fully admit, this philosophy is as much about my happiness as my child’s.

I’ve been thinking about parenting in the context of pursuing humanitarian work and the Indie Docs lifestyle quite a bit. Josh and I have talked about the best way to raise our kids and make sure their education doesn’t suffer. In the process the topic of being flexible has come up, as has different parenting cultures. Josh sent me this article the other day: Secrets Of A Maya Supermom: What Parenting Books Don’t Tell You, and it was a great article talking about how skewed our idea of parenting is in Western Society. I love the author’s imagery of how we have put parenting, motherhood, in particular, but this is relevant to the many stay-at-home Dads I know, in a box and expect one person to do it all. It’s not normal or necessary, and I think it generates a lot of anxiety and misery among parents. Of course, reading the article I felt validated in my parenting style (after being called “crunchy” a few times in various contexts) and in my skepticism of some parenting advice I was hearing over and over (like hard-core sleep training, we can have that discussion another day).

Perhaps more relevant to Indie Docs per se is the fact that we will demand a lot from our kids as we pursue this mission in life. They will need to understand that a huge portion of our time and money goes to help others. They will have to be flexible and adaptable to other cultures, and will likely sacrifice some aspects of the prototypical American kid existence from a social or sports context.

Now to inject some reality that life is not a fairy-tale. I got mastitis 3 times on a rotation where my attending would not let me pump. I was so tired one time that I came home and while holding Eddy to nurse her, I hallucinated that it was raining inside my kitchen. I’ve gone on a job interview just to have a night away in a hotel, and I felt FABULOUS after getting that night of undisturbed sleep. I’ve let the au pair feed Eddy her dinner while I hid in my room either power napping or vegging out for 20 minutes. Our marriage has undergone a tectonic-plate-shifting adjustment, and I had to delve into relationship podcasts and articles to try to undo some of the damage done by the paucity of quality time we had together. Going back to work when Eddy was 6 weeks old was one of the hardest things I’ve ever done in life, and her sleep habits only got worse over the next 6 months when she was waking up every 2 hours to nurse. But we coped and managed and continued to enjoy the moments and milestones along the way.

Fortunately, I did not experience postpartum depression, or have a colicky baby, or have any major medical concerns that would be much more challenging and beyond my control.

This is a huge topic that is both paramount to life as a physician parent and in related to upcoming big decisions about where and how to raise our kids. I hope to become more open minded in how I guide my little one through life, and most of all I hope I can maintain the inner peace that motherhood has brought to me. And to any reluctant trainees contemplating whether it’s worth it, I can offer my anecdote that having this child in my life is the most interesting, entertaining, and warm-fuzzy-feeling-inducing thing I’ve ever done. As The Ruth Bader Ginsburg has said, having a career and being a mother gives balance, and one helps you find respite from the other. I hope everybody finds their tricks and techniques that can make this huge responsibility wonderfully enjoyable.

Happy Mother’s Day to all moms out there making it work!