How I Chose Neonatology

Like many 3rd year medical students, my friend Clare is currently making a huge life decision: what specialty to go into after medical school. Although everyone’s thought process is a little (or maybe a lot) different from anyone else’s, she inspired me to share how I got to where I am and I hope someone thinks it’s useful!

When I started medical school I was absolutely certain that I was going to do something surgical and was pretty convinced I’d never want to work with kids. I remember telling classmates I wanted to do surgical oncology and almost as distinctly remember feeling like I didn’t really believe it myself.

During our first two years of med school we were all assigned a primary care preceptor that we worked with one week per semester for a total of four weeks, and I happened to be assigned ob/gyn and surprised myself by really enjoying it, partly because I thought I’d like getting to be in the OR as part of my job description. After that, I started getting involved in the ob/gyn interest group, started a Well Woman Clinic at the free clinic I was running, shadowed in labor and delivery almost every weekend, and when my classmates placed bets about what everyone would end up going into, there was a very clear prediction that this is what I would end up doing.

Then I got to third year of med school. I started out on pediatrics and felt a click, even though I tried to ignore it at the time. Everyone I was working with made me want to be a better version of myself and there was not a single person in the department who didn’t seem to enjoy coming to work every day. I remember feeling some disappointment because I thought that lumbar punctures were the most exciting thing they got to do in terms of procedures, but overall I really felt at home on that rotation and the standards were very high for my next rotation, ob/gyn. At this point I was expecting to like it even more and was so excited to get started.

The first part of my ob/gyn rotation was gynecologic oncology and thought I was for sure going to find the perfect fit – surgery and ob/gyn and interesting medicine! What could be better? But even though the residents all seemed like they wanted to do a good job (and one even liked it so much she received her match letter that week to stay at that hospital for gyn onc fellowship), no one seemed as happy as the pediatricians I’d just left. I thought the OR cases were long and dull and even the attending surgeons seemed to wander in and out during long, drawn out pelvic exenterations (google that only if morbidly curious) and outcomes for the patients were incredibly depressing to me. Ok, I thought, not gyn onc but I still am going to like ob/gyn in general!

I got to labor and delivery after that and did fall in love. I liked c-sections, rounding, catching babies, and going to triage and to emergency situations. But what I noticed was that my attention after deliveries was almost never given to the mom – she and her placenta were nowhere near as interesting as the actual human being that had magically just appeared in the room.

The rest of third year I spent comparing things against pediatrics, and briefly entertained the notion of family medicine so I could do both children and women’s health, but decided I wanted the option of further sub-specialization. I thought for about 2 seconds that pediatric surgery would be cool, but then had the worst four weeks of medical school on that rotation (no one seemed happy or well rested!) and quickly crossed that off the list. Anesthesia seemed appealing too, but I missed the opportunity for continuity of care and so off the list it went. I randomly really liked the neuro ICU (probably my favorite 2 weeks of medical school) which in hindsight was actually fairly foreshadowing, but couldn’t see myself taking care of adults only, forever. Or doing a neurology or emergency medicine residency. I never really considered psychiatry, derm, radiology, neurosurg, ENT, ophtho, pathology, internal medicine, or ortho, but did briefly flirt with the idea of urology or CT surgery after enjoying both of those rotations. I decided against them due to the lack of variety I’d end up getting to see.

So I matched in pediatrics and started developing my interest in health care delivery, which was something I’d first discovered I liked before med school when I was working at a free clinic and had picked up some experience in while running my own free clinic during MS2-MS4. Access to care and the way it affects outcomes is fascinating and at times disheartening, so I wanted to find ways to address it. I got so far as taking the LSAT with a plan to pursue advocacy work with a law degree, but found myself developing a serious case of imposter syndrome. Something just wasn’t quite right.

Enter the NICU. At first I’d been dreading it: tiny, fragile, confusing humans who are locked up in boxes which they don’t leave for weeks and months at a time. Kind of creepy when you think about it that way. The first month I was there I didn’t let myself even entertain the notion of a career defined by tiny humans, but I did love going to deliveries, doing procedures, and helping families take healthy babies home. After I covered the unit for Christmas and came back to the NICU for a second full rotation, I couldn’t deny that I was coming in early and leaving late and reading everything I could get my hands on in a way that I just hadn’t in a long time, and once I finally started letting myself believe I was going to do this forever, I felt like my whole personality changed and my imposter syndrome started to really quiet itself down.

Meanwhile, I’d applied for and gotten into LUCENT, which is a primary care track that meant I got extra elective time to do outpatient rotations and gave me protected academic time to work on projects that improve healthcare delivery for our underserved urban population. I loved that too, and liked the continuity a pediatrician has with patients that creates a fun and special bond. One of the attendings that I worked with (and continue to work with) is actually a neonatologist who follows patients in a high-risk clinic after discharge, and this helped me find the final piece of the puzzle that tied all my interests together. (Except inserting IUDs. I haven’t found a way to get to do that with this plan…)

Neonatology with a focus on outpatient follow up gives me just about everything I could possibly dream of, from critical care to primary care, intense and interesting inpatient experiences to expanded clinic appointment slots for complex medical needs, deliveries and code situations to advocacy opportunities for improved access to care for high risk patients, and unique transitional physiology to unique children with different developmental needs and personalities. I feel like I’ve found the perfect fit and want to encourage anyone who doesn’t feel 100% certain about forced career choices that there is a very strong likelihood that you’ll find something you love and excel in if you trust the process and stay open to new ideas along your path.

I know this is really long-winded but it took nearly six years for me to figure out what I wanted to do with my life after deciding to become a doctor, so the thought process was also fairly drawn out! If you have thoughts on specialty choices I’d love to hear about them!

Vaccine Hesitancy Counseling

I recently gave a morning report lecture on a case of influenza that I saw in the emergency room that resulted in really serious complications for the child. As part of the talk, I spent some time discussing the strategies I use to get my patients and parents to accept a flu shot, since not everyone is all that excited about an “extra” vaccine. I have posted a couple times on instagram about how important I think the flu shot is and have gotten a lot of great responses and some requests for more tips on counseling on vaccine hesitancy especially as it pertains to the flu shot, so I thought I’d share some content from my slides on here. I hope you guys find it useful!

Q: Does the flu shot actually work?

  • A: Yes. In an average year there is a 40-60% risk reduction on infection. Some years it is higher and some years it is lower, but even a 10% risk reduction is better than a 0% risk reduction.
  • A: check out the CDC’s list of studies published on how effective the flu vaccine is!

Q: Does the flu shot benefit society?

  • A: For healthy adults, there is not a huge economic advantage in getting the vaccine. However, for older adults, children, and people with significant chronic disease, there is definite economic advantage in immunizing. If you’re interested, there was a study published in 2008 in the Journal of Pediatrics about how vaccinating preschool-age children paid off in terms of number of days of work missed by parents and child hospitalization rate, among other important points (Eisenberg et al).
  • A: The Journal of Infectious Diseases published an article citing benefits of 75% reduction in cases of life-threatening influenza infection in children in 2010 to 2012 (Ferdinands et al. 2014)
  • A: herd immunity is more difficult to achieve with a shot that must be delivered annually in comparison to other routine immunizations like measles or hepatitis shots, but there is definite benefit when a higher number of people are immunized.

Q: What resources are out there to help pediatricians (and other interested parties) learn to counsel patients and families more effectively?

  • A: There is an incredible e-course that is free to AAP members on all types of vaccination counseling. Most points can be applied to the flu shot. If you’re more interested in the executive summary, check out this article from Pediatrics: Clinical Update on Vaccine Hesitancy (Edwards et al., 2016).

The AAP also published a list of common questions parents are likely to ask about the flu shot (starts on page 14, although the table of contents says 17). It’s nice to be able to anticipate their concerns and to validate what they’re saying, but also important to educate and reduce belief in some myths. Here are some of my favorites:

Q: “My kids have never had the flu!”

  • A: I’m glad to hear that and I hope they don’t get it this year, but avoiding the flu in the past is not a predictor of who will get the flu in the future. Getting vaccinated is the single most important thing you can do to prevent the flu. The flu kills up to 49,000 people each year and makes many more sick. Many of these deaths occur in healthy individuals. Even one unnecessary death is too many.

Q: “I got the flu shot and it gave me the flu” or “the year I got the flu shot was the sickest I’ve ever been.”

  • A: The strains of the flu that are put into the flu shot are killed viruses. The flu shot does not and cannot cause the flu.
  • A: If someone gets a flu shot in the middle of flu season, they may already have been exposed to the flu and be coming down with it or another virus (colds are very common during flu season and can vary in severity). Because the shot and getting sick happened ate the same time, they think the flu shot gave them the flu.
  • A: It also takes about 2 weeks for the body to build protection after the shot, so some people getting sick just before or during that time period blame the shot.
  • A: The most common side effects of a flu vaccine are soreness at the site of injection and sometimes a low-grade fever. Sometimes people who experience side effects think “they got the flu.”

Q: “It doesn’t work; my kid got the flu shot and still got the flu.”

  • A: While the flu vaccine is not 100% effective, we do know that those who are vaccinated and who later get a flu virus are less likely to get really sick, be hospitalized, or have serious complications.
  • A: There are hundreds of strains of the flu and there are only 3 or 4 strains of flu in the flu vaccine. Each year scientists determine the 3 or 4 most common strains of flu virus circulating and that’s what’s included in the upcoming year’s flu vaccine. There is always the possibility that the child could get a different strain of the flu than one that’s included in the vaccine; however, if that happens, the duration and severity of symptoms is generally much less.

Q: “The flu is not really that bad, no worse than a bad cold.”

  • A: Although it is sometimes challenging to tell the difference between a cold and the flu, the flu can have serious complications and even lead to death, especially for the very young, very sick, and very old. It tends to last for several days, keeping you out of work and your child out of school. Getting vaccinated not only protects you, but those closest to you as well.

Here are some other counseling techniques I have found to be particularly effective:

  • I remind families that I got a flu shot and did not get the flu. Although it’s purely anecdotal, parents often give anecdotal reasons of their own for not vaccinating, so I fight fire with fire.
  • Remind parents of kids 3 and under that their child is getting a smaller dose of the vaccine (but keep in mind that all first-time vaccinators 8 and under need two doses at least 28 days apart).
  • Share your personal concerns about close contacts. Is there a grandmother living in the home? Dad has cancer and is immunocompromised from chemo? There is a 4-month-old ex-preemie who is too young to get the shot? These people are at high risk from infection and you should do everything in your power to protect them, including immunization of your child.
  • Remind parents who try to say “he’s already getting other shots today, let’s do it later” that that means two days of feeling pain, plus anticipation of another shot. You’re already having a bad day today with other routine immunizations, why prolong your child’s suffering?
  • It takes somewhere between 30 and 100 flu immunizations to prevent one case of the flu. That sounds like a lot, but think of it like insurance – you wouldn’t not have house insurance just because it takes 30 to 100 people paying in for you to get a payout if your house were to catch on fire.
  • Remind parents that the Vaccine Adverse Event Reporting System exists, and while not perfect, it doesn’t suggest that the flu shot is any more dangerous than any other shot.

I think the most important point about all of this is that you should never let the flu shot be a question in your mind, or else it will be a question in the patient’s mind. When I changed my catchphrase from “so… do you think you might want to get a flu shot this year?” to “your child is due for routine immunizations today, including the flu shot” my “yes” rate increased astronomically.

Let me know what questions you have, or if you have other strategies you use that are effective! (And I’m sorry in advance if I delete your comment if it’s not polite or contains profanity. For whatever reason, anti-vaxxers sometimes tend to use rude phrases when responding to me on instagram on this topic. I definitely don’t mind hearing opposite points of view, I just expect it to be professional and kind on this blog!)

 

Being a dog mom in residency

At the start of my fourth year of medical school, I decided I really wanted a dog. I’d been thinking about it for a long time in a very serious way, but kept putting it off because I thought medical training and being a decent dog parent couldn’t mix. However, I did see several of my friends successfully finding ways to do it, and started dog sitting for some of them and even for a few of the residents at UNC. I loved it! So I made up my mind and thought where there’s a will there’s a way.

I started scrolling through petfinder and adoptapet to try to find the perfect pup. I wanted something very small (knowing full well that yes absolutely I would be that girl carrying a dog in a handbag), a boy, poodle mix, and young. I told my roommate I was thinking of making this big decision and she thankfully got on board with the idea very quickly and started helping me search. One Thursday morning while I was on an incredibly dull rotation that often meant I saw one or maybe two patients a day, this cute dog named “Rascal” showed up on my computer screen and I knew I had to have him. Having taken all of two days of excused absences in medical school to date at that point, I decided I would take a mental health day and go adopt a puppy. I met a stranger in a Dollar General parking lot about an hour and a half away from Chapel Hill, where I was living at the time.

((I didn’t tell my parents the details of what I’d done until much later because common sense would tell you that meeting a random stranger off the internet to accept a cute but unpredictable puppy in the middle of nowhere North Carolina would not be a good idea, but, you know, all’s well that ends well.))

He was very stinky so I immediately gave him a bath when we got home, and invited a steady stream of friends over the next few days to come visit him. What I did not really think out particularly well ahead of time was what to do when I was on 24 hour call and when I was heading out for week-long treks to interview at different residency programs. Thankfully my roommate and my parents were all very generous and willing to help out, but things definitely weren’t easy and I probably would have done at least a couple things differently with hindsight being 20/20.

I thought maybe I’d share a few things that I’ve learned with readers who are in med school or residency or some other time-consuming career about how to keep a dog alive and happy!

  1. Adopt a dog who is small, exceptionally cute, and nondestructive. I know it’s hard to predict an exact dog’s behavior (especially if you do what I did and make a very hasty decision), but it has been much easier for me to find co-residents and friends and attendings even who volunteer to help take care of him because he’s little and low-maintenance. The people even in my program who have big and more rambunctious dogs have had more difficulty.
  2. Puppy school. This is important. We just went to Petsmart and signed up for as many classes as we could and honestly had a lot of fun learning tricks and manners! Auggie made a ton of friends and came home exhausted after class.
  3. Potty pads are a very good idea. So are apartments with hardwood floors, because even though my sweet boy’s ability to go to the pad every time is actually astounding, his aim is not. But in all seriousness this has been one of our saving graces to have him potty trained because I’m not panicking at the end of a 14 hour day thinking omg he hasn’t peed all day!! He has and he is fine.
  4. Do not adopt a dog immediately before traipsing around the country for 15 different job interviews while on a q4 28 hour call rotation. You will not be home and you will miss your dog. The second half of the fourth year of med school (when all of that is over!) is a much easier time to work on potty training and learning to sleep through the night.
  5. If you’re in a stage of life where 24 hour calls in the hospital are a thing, find several people you trust to take care of your angel (which is made easier I think if you have followed tip #1). He will be fine (in fact, will probably have a blast while he’s hanging out with his dog friends) but you will really, really miss him. Just a heads up.
  6. Don’t let the fear of how difficult it might be stop you from adopting your new best friend! You won’t regret having a furry (well-behaved, quiet, adorable) new member of your family.

Let me know in the comments if you have other questions about being a dog mom in residency? And if you already have a furry best friend, tell me about them!

Blue Apron Review

A few months ago I decided to try a food-delivery service and after a lot of googling to find out which one would be best, I decided to check out Blue Apron! I’m interested in trying some others like Hello Fresh or Purple Carrot, but for now I’m really happy with my first choice. It’s definitely not something I see myself sticking with long term since it’s kind of on the pricey side for what you get, but it’s a ton of fun for now.

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The packaging:

The box is standard corrugated cardboard, but has a nice lift-up lid that opens and closes neatly. Inside is an aluminum cooler bag with two huge ice packs that consistently arrive quite frozen, even on a hot summer day. I have had the unfortunate experience of one of the ice bags rupturing and damaging the cardboard, but even so the food stayed fresh so it wasn’t a huge deal. The food from all three meals are mixed together haphazardly, but everything is individually packaged and the little “knick knacks” of each meal are collected together, along with little pamphlets that include nutritional information, which has been thoughtfully balanced by dietitians.

The food quality:

Everything is really fresh! It’s all stuff I would hand pick from the grocery store, and I am super picky when it comes to visual appeal of my produce. They do send an overabundance of garlic which I find a bit odd.

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The recipes:

I am not a good cook at all so I usually make at least one mistake in the recipes… like putting the wrong vegetable into an empanada or putting the whole portion of an ingredient somewhere I was only supposed to use half. So far it hasn’t been a big deal, but the recipes are definitely complex enough that if you’re a total novice like me, mistakes will probably happen! They also seriously underestimate the amount of time it will take me to actually do the cooking. Again, not a big deal because I find cooking to be pretty fun and therapeutic. I’m also learning a lot of cooking techniques and that’s been really nice too. As an aside, the recipes come on nice, 8×11 cardstock that you can keep and use again.

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The actual taste:

So far, I have seriously really enjoyed every meal I have tried! I think my favorite might have been the vegetable tartines with cucumber salad on the side. It was probably because there was a recipe included for amazing garlic sourdough toast that I will absolutely make again, but I also really liked the salad that was an elevated take on something my mom made for me a lot when I was growing up.

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Overall impression:

For $9.99 a pop (really, $6.67 since 2 servings is actually 3 for me), the amount of work it takes to prepare each meal is a little exorbitant, especially considering I could buy a frozen Amy’s or SweetEarth meal for less that $5 for a similar and way-lower-hassle amount of food. The ability to skip weeks and cancel at any time is helpful, and it’s purely from an enjoyment standpoint that I keep getting meals delivered. It’s definitely worth a try, particularly if you have a discount code!

This is not a sponsored post.

I’m Back!

Hi!

I know a lot of you from instagram have been wondering over the last year or two where my old blog went! I decided at the end of medical school to take a break from writing publicly as I started residency just because I wanted my online presence to be a little more subtle and grown up than it had been before. I have noticed that I really miss the creative outlet and wanted to start fresh, so here I am! Over time I’m hoping to migrate some of the more useful content onto this site, but I want this blog to have a more professional feel to it with less pictures in bathroom mirrors and more content that is actually meaningful and potentially with some educational value. Please let me know what sorts of things you’d like to read about, as I know there are a plethora of medical blogs and I want this to actually be worth reading in a sea of other writings.

I’ll put the disclaimer here and other places on the blog that any sort of patient care stories I share will have been changed and combined with other stories to make sure I’m HIPAA compliant and protecting the identities of the little humans I take care of. The essence of the what I write I hope will still capture the emotions and realities of being a resident physician, but if you know me in real life, just be aware that the things you know to be true about my life in person may not be always represented the same way in writing.

Welcome to my blog!