Times are changing.

It is happening all over the hospital. Fresh eyed young students arrive in their perfectly pressed short coats. They have just spent the summer studying for Step I of the boards, and can hardly conceal their excitement to touch real patients for the first time. Bewildered slightly older young interns wearing equally unstained long white coats, with pockets stuffed with crib notes. How to run a code, what dose of sleeping pill to give, normal lab values. Their arrival is like a breeze of fresh air.

Not too long from now the med students will look like hell- suffering their first post call days. When every cell in the body is SCREAMING to lie down and close the eyes, and it seems impossible that such torture will become a new way of life. The interns will no longer look frightened. With long lists of patients, hours of notes to write and endless check boxes to fill they will become engrossed in their daily tasks. They will awaken sometime in next Spring- and realize 10 months have passed.

On the flip side are the dinosaurs. Like me. Ten years ago I first set foot into the hospital. A decade of training. When I look around I remember the hospitals I entered and eventually conquered. Incomprehensible the number of patients I have laid my hands on. And then those who died, whose families I counseled. From the confidence of thinking you know everything, to the painful realization you do not, then pretending confidence (not to worry the patients), gradually evolving to the place where you really do know a lot and can do a lot- competently.

Yes times are a changin'. It is a new beginning.

On the road

I am officially on the interview trail. Must tell you it is SO much better this time around! They had a limo waiting for me at the airport, then delivered me to the hotel where I was given a suite. A suite! As I stretched out on the king sized bed with the high thread count sheets I called my husband. In remembrance of the difficult interview tours for residency and fellowship. Where I had to pay for every flight and hotel. I think I am still paying.... the cost was tagged onto my student loans... which are no where close to being paid off.

True there were some exciting adventures.... teaming up with a perfect stranger to drive 6 hours from interview A to interview B, then sleeping on no-longer-strangers couch a few day later for interview C. Being snowed in at Raleigh-Durham, forced to stay extra night at a shabby Motel 6, sick with fever and rigors. What misery! No story quite like Dr. G's (my OB/gyne). She came upon a laboring woman at the airport, and delivered the baby into her interview suit coat.

So I am keeping my mind open and hopes up to find the right place.

Report from Lobby Day

American Heart Association Lobby Day was Tuesday.

I crawled over Capitol Hill with 700 others, wearing red- and a fancy heart pin with LED lights that flashed on and off.

We lobbied for greater funding for NIH. Did you know that during the Clinton administration NIH funding was doubled, but then cut sharply seeing a flat line over the past five years. Accounting for inflation, we are now at a level of funding lower than we would have been without the increases in the 1990s.

NIH funding supports the majority of health related research. In my mind, this is very important because the alternative is drug company sponsored research. Pharmaceutical development is also important, but always driven in the direction of profits. Who would study the use of vitamins in the prevention of heart disease- the NIH that is who!

Last year only 12% of research proposals submitted were funded. That means 78% of scientists (people with MD and/or PhD) received a failing score- and were sent packing. Can we really afford to lose this much talent?

Furthermore although heart disease and stroke are the #1 and #3 killers in every state in the Nation.... of NIH dollars only 7 and 1% respectively are spent on heart research! We deserve a larger piece of the pie.

So Lobby Day was a success. I got to meet my favorite Senator and our Congressman. I spent the day with grateful patients. Far away from the hospital and research lab, I spread the word about something I care about- and got a little smarter through the process.

In a moment of introspection how did the state of research funding affect my decision to leave science? As generation X-ers we are blamed for being motivated by recognition and always looking out for ourselves. I am sorry, but after 12 years of extra training I cannot accept a job equivalent to what I could have done when graduating college with a BS in Chemistry in 1996. It is because I care that it has be so difficult for me.

Upside Down

When babies are very young they have the Moro reflex. It is also called the startle reflex. After hearing a loud noise the throw their little arms out and wave them back and forth. This is an involuntary reaction, and fun to elicit as a med student rotating in pediatrics.

If only there were an involuntary response for the shock that comes with the little surprises of adulthood. My conditioned response includes anxiety and worry- both old friends that I would rather be without.

Sixteen years ago I set a goal. Become a doctor. Four years of college, four of med school, four of residency and now four of fellowship. I made it. I am a doctor. A fairly specialized one at that. So how can it be that I have no earthly idea what I will be doing three months from now?!!

Listening to my heart of hearts. Deciding the bedside is better for me than the bench side. Next tossed out of this "Top 10" medical school on my little bottom. Oh boy. No I will not starve to death. I am certain that I will find a job. It is just difficult to pick yourself up from disappointment, and wrap yourself up into a presentable package to peddle around.

The first step to decide you are on the wrong path. Next step to find the right one? This time I am seeking joy.

Fateful step

Last Monday. My first day back in heels..... conquered the massive convention center. Back to the hotel at the end of a successful day- change into a cute black dress (and sensible black flats) ready for a fun night out in Chicago. Confidently stride out of my hotel onto Michigan Avenue. Rainy gloomy spring weather, typical of the Windy City. A warm evening, but wet from a day of rain. Three blocks from the restaurant. Thinking about the exciting people I met that day. Thinking of the big events in the upcoming week. Thinking of the nice glass of red wine waiting for me. Thinking of plenty things, except my step.... and whoa, right foot out, left foot back, hands in front, down I go. No, not the hokey poky. It was me, biting it on a wet sidewalk in Chicago.

A deep breath later, surveying the damage. Left hip- still there, no pain, good. Left knee, planted into one of those metal grates, ouch. "Honey are you okay?" a tall lurking man says voice straining to hold back a chuckle. "I don't know" I stammered as I stood up slowly and walked off a little less confidently. Pausing at the next street corner, surveying the damage- deep cuts in the knee. Considering the options, now two blocks from the restaurant I decide to seek the solace of friends- expecting other cards fellows assembled for the drug rep dinner.

I step into the restaurant with blood running down my leg and eyes welled- only to find instead of a group of friends- my program director and the drug rep. Welcome they say.... still not yet ready for complete sentences I get out.... can't- stay- dinner.... and the boss quickly realizes something is wrong. Now quite embarrassed about my state I accept his offer to hail a cab and I am on my way back to my hotel.

I find a Walgreen's. Purchase bandages, neosporine and as any girl would do in that situation- a pint of Ben & Jerry's for dinner. Nursing my wounds bloody and emotional I find solace in chocolate fudge brownie.

So I made it home safely. My knee looks rather gnarly, and my swim and bike routine has been suspended for the week. My hip was a little sore for a few days- but no major damage. Another lesson in humility- so much for big girls don't cry at work- all for sure I will recover from in time.

Physician Scientist: BUST

So I have news... that I am kinda anxious about. Looks like my days as a basic scientist are numbered. I am looking to make a change in my career plans. Tossing in the hat, there will be no K award application (although it is almost finished!)

I was supposed to get a faculty position last year. The division director was an the phone with the credentialing people- when it fell through. (NIH funding technicality, cannot be on training grant and see patients independently) Before my surgery I was told January 2009. Last week I met with the boss again- and the plan changed again. Now IF I submit a paper by this fall, I will probably be offered a Clinical Instructor position starting July 2009. I will have to do another fellowship year (yes 5th for those who are counting) for a total of PGY-9! None of this will they put in writing, and when finally appointed to faculty my salary will be a whopping $80K- no negotiations! BRUTAL.

Why do they do this? Because they can.
Who will ever go into academic research? Breed facing extinction.
What are they thinking? Fossils cannot think.

Now I am a good girl. I love academics, spent two years doing research- hung in there for the rough cards fellowship. But honestly I think this is my breaking point!

So if you trade the money you could make in private practice- the alternative is supposed to be prestige, security and intellectual interest. This "TOP 3 Med School" policy of continuously whipping young trainees lacks prestige and apparently security. Can you believe that I still cannot see a patient on my own and even if I do another 3 years of training I am not guaranteed a tenure track position?!! The last 2 years have been the toughest of my life- so bliss in the discovery of science is lost on me.

Options are:
nationwide search for academic science training/ tenure track position
local/ nationwide search for academic clinical position, heart failure and transplant
local search for private practice (part time?) general cardiology

I am having a little identity crisis right now. It is pretty scary.

One point for the pink team

Watching a professional in action. The men fear her. Stiletto heels, purple business suit and some serious chutzpa. Wow, I have never actually had my picture on a poster before- she said referring to the large advertisement we created for her visit. Yes the poster, the flier for lecture attendees, invite for tea with medical students planned for this afternoon. The details. It is my thing. Chit chat, however for me is a more deliberate effort. Our ride to the hospital from her hotel was casual. I was quite impressed when the people we talked about in the car received props during her talk. She chatted with me, and from my answers... this physician is interested in this, so and so taught me that, etc. This is the business of academic medicine. I suppose you do not become Professor without a significant mastery.

My favorite moment so far- last night at dinner. The indignation from the female faculty members when one of our fellows mentioned that the male fellows undress in our office. They choose to change from scrubs to dress clothes in front of us. Okay I know everyone stands around in their underwear on Grey's Anatomy- but this is real life and the locker room is right across the hall! Perhaps these boys feel more comfortable standing in their boxers surrounded by photos of cheerleaders and women with large naked breasts. Oh yea. This is what is posted in their cubicles.

So I spend time (and talent) fostering mentoring from women in cardiology. Why? Because the more I see of these successful, talented, gracious women the stronger I feel about my career, and life actually. But deeper even- I am out for revenge. Not an ugly kind- but just the type where the underdog good guy (girl) wins at the end.

Brooks Brothers Break-down

Please tell me that this has happened to someone else. This afternoon I cried in the Brooks Brothers dressing room. Idiot. So much for the "not loathing my body" mentality. And for the spiritual balance. Several professional projects coming to fruition, a big business meeting in Chicago this weekend. My larger than normal ass has been in yoga pants for the majority of the winter- and my super cute pant suits just do not fit.

As for the crying, two ladies were helping me. One asked my size, and I said oh I am not sure. I recently had surgery and gained weight, and I am not sure how things will fit. One said, are you on a diet now? Do you plan to loose the weight? Wow that thought hadn't actually occurred to me. Just give me the frickin' size jumbo fitted shirt for me to stuff under my interview suit from 5 years ago and let me get out of here!

A triple latte later I regrouped and boldly entered Ann Taylor. Found a nice black and white woven jacket. Will wear with white shirt and comfortable black pants. Found red jeweled necklace that will pop. Not exactly a suit, but will be passable.

So still reciting the mantra..... I am not my body. Cripes I am almost to the point where I can do enough exercise to get a cardio work-out. In the mean time it is excruciating- I would run and hide- if only I could run.......

The humble (limping) protege

It was a nice affair. My boss (fifteen years my senior) is a cardiologist, scientist, mother, and today Professor of Medicine. They gave her an endowed chair..... with all of the pomp and circumstance. There was a medal, a big one, that she wore around her neck as she gave her lecture.

The chancellor of the university, dean of medical school, chairman of medicine all said that she is an amazing scientist. They had her mother, father, brother, sister, husband, son and daughter stand up. They all were in the audience. For her introduction, "When a brilliant mind meets excellence in education and enthusiasm for discovery........"

It all-together was surreal. In surroundings familiar, I felt like an outsider.... being away for almost two months. Her accolades seemed to belong to a giant. For a moment seeming more like a coronation than lecture. Today she is the star. Somehow managing to find her way atop a pile of ego-centric, contemptuous, impatient, gender-biased men.

Surreal because I know this woman. I have been known to curse her. When she returns my writing nearly all red with edits, sends me back to the bench feeling my questions were ridiculously stupid, chastises me for spending too much time with patients and casually suggests I should repeat the experiment over the weekend.

But she is also the woman who hand-delivered home cooked meal to my house after my surgery.

What a challenge to be a successful woman. Here I am a critic, sitting in the privileged position to advance under her tutelage. Perhaps it reflects my own struggle. To find the right balance between kick-ass cardiologist, healthy/ fit athlete, and caring thoughtful friend.

A love hate relationship with the Professor. A love hate relationship with myself?

I am healing

Sitting at the kitchen counter eating my oatmeal with raisins, a searing high pitched tone grabbed my attention. The fire alarm? Cell phone out of batteries? Actually my pager. So funny. I did not recognize the sound. I have been into work twice now. On the second journey I opened up shop so to speak, which included turning my pager back on. There were times on call, especially my first year of cards fellowship when it went off every 20 minutes. Following the beep my laboradoodle Smokey looked at me..... eyes wide open, head tilted slightly, ears raised as if to say what the heck is that.... what have you done!!

I am walking without crutches for short distances. Sitting is more comfortable. The potty chair and shower seat have been sent to the basement. My plastic apparatus for donning socks still is essential. I have PT exercises that I do as frequently as possible, and I can tell my strength is increasing. My hip hurts. Not all of the time, but frequently. It does feel different than before the surgery. Stiffness mostly, but sometimes there will be a pull or cramp when I turn or twist a certain direction.

I also found the courage to get on the scale. My clothes (and bras) don't fit. I have been living in yoga pants for the past month. The damage? Twenty pounds. Ten since November, twenty since I stopped exercising. To my credit when I stare at my naked body in the mirror I do not exactly like what I see, but I seem to have gotten over the loathing. This is kinda huge for me.

Before the infertility, miscarriage, broken wrist, hip problem/surgery there was a sense of control. Focus on success, perfection. Consideration of every move, analysis of each decision as if I held the power, thinking that if I worked hard enough I could make things happen.

This blog is about this experience for me. Now I am healing. I certainly hope the series of terrible events that sent me off track are behind me. But if their purpose was to teach me a lesson, give me a life skill necessary for health and happiness- I get it, finally.

Big Gulp

I am not a big drinker. Sipper mostly. My favorite beverages with coffee at the top of the list, followed by a nice glass of red wine perhaps. On a long bike ride you should drink a water bottle an hour..... how much do they hold? About 500 mL, I imagine.

The day of my surgery and the night after I was wicked thirsty. Our hospital issues every patient a pitcher for water, with a huge straw that sits on the bedside table. Our heart failure patients have one. Four liters of water. I drank 4L of water in under 8 hours. I think it is the straw. It got me thinking, how much do our patients drink while they are in the hospital?

Water retention is a big problem in heart failure. Decreased pumping function of the heart, decreased blood flow to the kidneys. Kidneys see less blood, and therefore are unable to filter out excess water. At the same time they secrete hormones that increase blood pressure and stimulate thirst.

These measures are the body's way to stay alive. It backfires as the the weak heart is overwhelmed by the excess water. Handfuls of pills are issued to the patient with a failing heart- all to counteract this cascade. When swelling fills the legs and lungs patients are admitted for even more drugs, directly in the veins. An now as I am aware, a large pitcher of water with a mack daddy straw. Interesting what you can learn about medicine from a hospital bed.

First out of the blocks

I met with the division chairman. The conversation was rehearsed in my mind countless times. My preparation for this meeting- comprehensive. Seriously worried if I could pull it off, the honest truth is that I do not feel so well put together as of late.

The stakes were high. At this stage of training all fellows meet with the boss to discuss their future. This year several fellows have gone before me, all disappointed with the result.

My questions were: 1. Will this division support physician scientists who want to do research and heart failure? 2. Is there a future for promotion for me here (meaning if I stay will you promote and support my career)?

I did pull it off. I felt strong. Laid out my research plan, career aspirations, and described how I stand out from the pack. He mentioned my health problems, I said it was disappointing however I worked very hard despite my troubles- and am proud of my accomplishments.

He offered me a faculty position. My work has been the most productive, I show promise. YES. Slugging along, believing that I was making the right moves... they finally threw me a bone.

Results not yet available

Cardiovascular board certification exam. October 31, 2007. Results not yet available. What the heck is up?!?!! Admittedly I have been checking the ABIM website frequently. I am really scared that I did not pass. My life has made unexpected turns, disappointment over this test seems entirely plausible. I would be crushed. Practicing cardiology means so much to me. Or should I say being a cardiologist. Seems slightly absurd writing this as I wait (at 930 PM) for the centrifuge to finish spinning my cells so that I may suck off the serum and wash them with PBS (phosphate buffered saline). Seriously I could teach a 10 year old to do this. The big mystery and wonder of discovery is locked up in the PIs office. A delightful place where questions are met with a patient instructive tone holding slight condescension. Redirection sending me back to the bench where the process of wild guesses and repeated failure is not doing it for me. I am not a post-doc. I am not a graduate student. I am not a molecular biologist. I am a physician who has been training for 8 years since med school. I want to be a leader in academics, in cardiology. I want to learn and gain these skills- but am so tired of working days and nights for years and years, and after all of this time feel like I suck. Perhaps the drug induced coma or forced convalescence will bring some clarity.

Pre-op anesthesia

I have my pre-op anesthesia appointment in the morning. Taking a break from admitting patients to the cardiology service I pause to fill out my paperwork. It occurs to me that they are exactly the same forms. Random heart patient presenting with right sided chest discomfort and shortness of breath. Ortho patient (me) presenting with left acetabular labral tear with underlying pelvic dysplasia/ femoral impingement.

They ask if you have ever had difficulty with anesthesia. The truth would be yes. With my miscarriage I was a big girl and did not cry. That was until they dosed me with Versed in holding and then I sobbed all of the way to the OR. Two months later got conscious sedation to set my broken arm. I should have been asleep. Cry I did not, but more embarrassing I babbled about my weight, my calculated BMI and how I would get fat not exercising post broken arm. These experiences leave me feeling very exposed. Emotionally exposed- similar but not exactly the same as the exposure our patients experience in the cath lab while waiting for their groins to be prepped. The thought brings the memory of my hip injection, where I, completely awake was far less embarrassed than the resident who had the duty of preparing my groin for the injection.

These juicy details will not be shared at my appointment in the morning. Because I know what they really need to know is whether I, or a family member ever developed malignant hyperthemia with anesthesia. So I will check the box for no next to "difficulty with anesthesia", but pause to recognize that the physician is privy to only a small part of the whole story.

Planning a little arthroscopic procedure

Weakness kills in medicine. On a team of physicians the individual viewed as the weakest link is under great scrutiny.

The decision has been made. I need reconstruction of my femur and pelvis. It will correct the femoral acetabular impingement and acetabular retroversion. That is the bad news. The good news is that I will be spared a femoral dislocation, in favor of an arthroscopic approach plus anterior incision. Expect 4-8 weeks of crutches. OR date is January, which the orthropod says is good, to give him "a little more time to gain experience" with arthroscopic approach. I am sure he wishes he hadn't said that to me. But I understand where he was coming from, it is a new technology. Reality is this is a major operation, with major recovery.

At work I have begun to tell colleagues that I need "scope" of my hip to repair cartilage tear. I plan to leave it at that.

From the sparkle

I am trained to understand how infertility affects patients. It is a pervasive source of stress leading to personal and marital conflict. Women facing infertility experience loss of well being because their bodies have betrayed them and they feel helpless in the situation.

This knowledge provides no insight or reassurance. Clinical problems and the emotional response is more transparent when occurring in bodies not connected to your own.

Polycystic ovarian syndrome prevents me from ovulating, makes my complexion resemble a 8th grader's and will save me from starving to death in case of famine. As a teenager I thought it was great to only have periods 4 times a year but now I need drugs to ovulate normally. Since food is a relative abundance survival from famine is unlikely to come in handy- and I am left with a commitment to exercise and reality that if left unchecked I will will be obese.

So desire to start a family got me moving to lose weight. Stupidity led to falling and breaking my arm. Insanity pushed me to run early/ hard post fracture convalescence. Hip pain sent me to PT. Impatience landed me in the orthrapod's office. Protocol prescribed hip films. Black sharpie circled bone in neck of femur that should not be there. Nurse penciled me in for January surgery. Whoa. Log way from the sparkle in my husband's eye and dream of little ones.

Message for hip community

In my medical training I have watched patients and families deal with illness for years.

Over the past several months the experience of being a patient has changed my perspective. It is difficult to deal with pain, physical limitations and new knowledge of undeniable congenital skeletal abnormalities. Like many of you, I liked feeling strong, powerful and invincible. Dealing with my illness has been a struggle. I have been writing about my thoughts in this blog.

Crazy Busy Explodes

I am just sick. Nausea and dispair. Pediatric fellow late for work calls basic science research scientist husband. He comes downstairs to meet her, she runs to work. He drives car 4 blocks and parks it in usual location. She didn't mention the baby. He didn't look in the rear facing car seat. He returns to work. Seven month old little Sophia is found dead in car 4 hours later.

Too close to home, in more than one way.

Loss

My baby was due June 16th. Every time a colleague mentions their children reflexivly I think about the baby I lost. Seven month old baby, four months older than my child would have been. A sense of loss multiplied.

Similar Stuggles

In medical training others control your schedule. You are kept on a short leash. Pushing your limits despite mental or physical fatigue. My friends who have children share thier sense of guilt. Needing more time for work or home, always balancing the two. When interviewing I met a cardiovascular research scientist who balanced her medical career, laboratory, and family. When asked her advice she responded, "As a female physian you learn to juggle, trying not to drop a ball but knowing it will bounce. As a physician mother you keep juggling but the differece is now one of the balls (your child) is made of glass."

Harsh Reflection

Others tell me how lucky I am. They remeber their pre children days fondly. They say, "How wonderful it must be to pick up and go at a moments notice. You are so healthy and productive, these kids just take so much time!" Bitter for me. Waiting to start a family was a concious decision. Baby while protected in the lab was my plan. Infertility, left wrist fracture, hip cartlidge tear and congenital hip abnormality were not part of this plan. Few can understand the way married with children looks from my perspective. Disaster and loss haults the crazy busy life for Sophie's parents. Horrible pain and loss was not in thier plan. Where does that leave us?

Izzy and me

"Eleven months ago, Isringhausen slumped at his locker, admitting, "I can't keep going like this." Saturday, he could think of nothing better. Isringhausen didn't require a full hip replacement. Instead, doctors shaved bone from the neck of his femur, allowing him greater flexibility with his left leg." -Joe Stauss, St. Louis Post-Dispatch, August 2007

Jason Isringhausen underwent femoral osteotomy for femoral acetabular impingement last year. It was his second surgery. I can only assume his 1st surgery was to repair a labral tear. Now he is playing baseball, can't beat that (for a n=1 non-matched- non-blinded -non-randomized clinical study).

In was in medical school (my friends agree) I never heard FAI. Now the literature suggests it affects up to 60% of patients receiving hip replacements in older age.

In the 1970's cardiologists were newly diagnosing mitral valve prolapse as thought it was a disorder of epidemic proportions. Years of further study revealed that actual morbidity associated with MVP is very low- and the diagnosis has fallen out of favor. Conversely, the first patients receiving the (arterial) LIMA grafts at bypass did not know what the clinical trials would show...... however now it is proven standard of care. Thousands of lives have been saved by this surgery.

A favorite attending in my training program says about new medical techniques and technology,

"Be not the first, yet be not the last."

Impatient medicine

---- Mortality rate increases 2% per hour in ascending aortic dissection
---- 90 minutes door to balloon time for acute myocardial infarction.

Cardiology Board Examination Preparation Course, not for wimps. Lecture 13 hours each day and the Cleveland Clinic has this ridiculous commitment to healthy eating- so no junk food, coffee or chocolate allowed in the lecture hall. Some kind of torture.

What impresses me when reviewing my chosen field is the focus on rapid evaluation and quick, concise treatment. This is contrasted by my experience in outpatient orthopedics.

Symptom onset 4.5 months ago, physical therapy for 8 plus 6 weeks. Wait and see approach, will it get better? Will osteoarthritis develop? What will the long-term outcomes of currently favored treatment be?

Recognizing that being a patient, when trained to be im-patient is challenging.