Division of Responsibility

I can't imagine what I would do with my life if not medicine. My sights were set on the field of pediatric oncology before I understood what residency was. Sometimes I daydream about living in a small cabin in Glacier National Park and educating tourists about the Grinnell glacier as they hike through the wilderness, but realize this is unlikely to happen. Some days, I feel that simply lying on my couch, at least for a few hours, might fill my soul the way my career does, but I suspect this relaxation and its implied happiness would be short lived. Despite each new acquaintance reminding me that they could “never do my job,” I feel that I was drawn into this position by a sort of spiritual siren. I have always felt that it was the field for me, yet I wonder whether motherhood would have been easier without the intimate knowledge that cancer could happen to me, my child, or my spouse, or whether being a pediatric oncologist might have been easier if I decided to forgo motherhood.

Being a pediatric oncologist and palliative care physician used to be much simpler for me. In the good old days as a resident, I resided in the hospital every fourth night. In my rare free time, I was still immersed in learning how to be a pediatrician. I realized during this time in my life that relationships with patients and their families were integral to my career plan. Then as a pediatric oncology fellow, I had more time to spend with my patients and families. I helped to make treatment decisions, and was constantly available by e-mail, phone, text, and pager. I attended birthday parties for patients, cried with parents experiencing cancer at its worst, and even spoke at a few patient funerals. I had fewer patients and learned what it means to invest in them, their families, and this career. I felt close to these families and I cared for them emotionally as I cared for them medically. I slept in the hospital, I worked weekends, I took frequent calls, and I lived the life of a scholar with no regrets. I was happy, fulfilled, and energized. I knew that my efforts made a difference in the lives of the patients I treated, regardless of their disease outcome. I had my life figured out, or at least I thought so.

Then came Graham. I was never sure I even wanted a “Graham,” but after marrying and becoming an attending, we couldn't wait to become parents. I never anticipated how my life and career would change based on the decision to become a parent. I now have another career—I am a mother to a beautiful baby boy. It's cliché, but I never knew how much I could love another person until I had a child. My heart has grown and expanded like the “Grinch” from Dr Seuss fame. I also never realized how becoming a parent would change the way I relate to the patients and families I serve.

Once Graham was born, after a relatively normal (based on my medically skewed perception) pregnancy and delivery, I never considered staying at home with him full time. I didn't feel like quitting medicine was an option. I also didn't consider what going back to work would look like for me or for my family. It was a given that I would continue my job as a physician, but perhaps a different physician than I had been before.

I had no concerns when I walked back into the children's hospital three months later. I was elated to be back, although I missed my son and feared that pursuing my career made me a terrible mother and left him a vulnerable infant. After my wonderful, but sleepless maternity leave, I arrived on the inpatient pediatric oncology ward to find a three-month-old baby boy with mixed-lineage leukemia (MLL)-rearranged acute lymphoblastic leukemia in my care. He was beautiful; huge brown eyes with exceedingly long eyelashes, a toothless grin, and a heartbreaking smile. His parents were smart, funny, and delightful to work with. They asked all the “right” questions and did everything they knew to heal their son. I found our conversations easy and personable as we had so much in common. In fact, I felt that outside of our professional relationship, his mother and I would definitely have been friends. Developmentally, our children were the same. We talked about sleeping and nursing—both issues that inspire camaraderie in new moms. His parents and I traded stories regarding the bliss that sleep brings and the torture of months of interrupted patterns. We talked about the smiles, the laughs, and the hugs. Although my expectations were of a long, happy life for my son, I'm not sure whether she could allow herself that dream. The heartfelt, guttural emotion of being a parent, a caregiver, was something we easily shared, yet I still went home nightly to my little family while they lived in the hospital. His father made Excel sheets of complete blood count (CBC) results, just like my husband does with our monthly bills. I struggled caring for him as I couldn't help but mentally trade places with them each day. My child was safe and healthy, but their child born days apart was suffering and eventually would not be cured despite the best efforts of all. It didn't seem possible to me, despite my knowledge and training, now that I had a child of my own.

I am now caring for a three-year-old patient with relapsed rhabdomyosarcoma who will die of her disease. As I tell her family about the new pulmonary metastasis on her recent CT scan, I feel overwhelmed and blessed and angry all at once. I honestly can't understand any of this and I know they can't either. It's hard to know that we share the love for our toddlers and the lack of control about what happens in this life. Despite this horrible news, they cuddle their daughter and, with grace and courage, ask realistic questions about how to prevent her suffering, what death looks like, and when she can visit the Disney princesses. All these questions are heartbreaking and real, and yet necessary and purposeful. I can barely breathe. I feel smothered by the weight of anticipated loss. They react as I hope I would—asking for treatments that will cure her and, if not possible, asking to be at home. Discussion of phase I trials or travel for expert opinion always comes as part of this conversation, but these parents want to know how to address these options with friends, neighbors, and church members. They trust the medical system and understand her disease and prognosis. They have seen their daughter suffer and trust that I would stop this if there were means to do so. The possibility of surgery to remove her tumor along with her orbit, her eye, part of her brain and jaw has been discussed, but due to the newly found lung lesions, even this radical, disfiguring surgery would likely not be curative. They love their daughter and they decline this intervention. They do not want high-dose intravenous, inpatient chemotherapy that will not cure her disease. They want comfort and time. They want to be together, at home, with her in their arms. I only hope that I would be strong and selfless enough to make this same decision. They ask me what I would do and I have no answer. Despite having a child the same age, having 11 years of training in medicine, and asking myself these same questions, I have absolutely no idea.

I thought that my strength was tested as a resident doing Q4 call and then as a nervous, new attending, but nothing has prepared me for having a toddler while watching toddlers die of cancer. I have ruminated about these issues for hours and days and years now, and have decided that I can only be what I am—a caring clinician and a busy mom. I am still surprised with the frank, palpable love I experience when parents speak of their child and the decisions they must make throughout their battle with cancer. I honestly feel that I am not strong enough to do it for my own child. I worry that I would fail. I worry that with all I know that I would not be able to make the decisions that I ask so many other parents to make. I doubt my ability as a mother sometimes when I see parents so able to protect their own children. But then I remember they never chose to be engrained in the medical system, they are finding their way like all other parents.

Through this process, I have also learned to be exceptionally thankful. When I am busy doing academic work or the mountains of paperwork inherent to doctoring, I don't want to be bothered. But I have learned to take minutes to watch a patient ring the bell signifying their treatment is done. I have watched children riding bikes through our hospital halls with trailing IV poles and giggles filling the corridor. I have seen pale, bald girls in Elsa costumes with huge, bright smiles and my heart has been healed, even on the “bad days.” I have seen parents making incomprehensible, loving choices for their children despite their own suffering. I think that each day spent with Graham is miraculous. I pray for miracles just as my patients do, although our miracles look exceptionally different. I pray that my child grows up healthy and happy, which in my medically biased mind is a miracle of statistics in and of itself. I remember when I am irritated or sad that he is healthy and alive. I know that his crying over the lunch he doesn't like or the necessity of brushing his teeth before bed is manageable and welcomed. I know when I miss a due date for a journal article or am not yet qualified to apply for a grant that I am at peace with my decisions. I understand there is a balance to life and despite decades of women proclaiming that you can “have it all,” I am skeptical that I can do that currently. I find comfort by imagining my family and my career on a seesaw and hoping that they have equal time soaring in the breeze.

I am part of a female physician “Mom” social media group that has ballooned to thousands of members. This is a safe space for doctor moms of all specialties to ask for toilet training tips, weep over dying patients, discuss the gender divide still present in medical training and practice, and to feel “normal.” These are 50,000+ strong women, most of whom I have never met, who know me better than many of the people in my daily life because they ARE me. They understand the guilt felt when staying late to comfort a patient or family as it means forfeiting time to console your own child or spouse. They feel the push-pull of careers in medicine and motherhood. They know what talking to a 30-something year old mother-patient feels like and how it feels to be spoken to as a 30-something year old mother-patient. They share the bond to “do no harm” and worry about their own children—many of whom have special needs or have been diagnosed with life-limiting illness. Cancer doesn't overlook physician families.

Unfortunately, cancer strikes the innocent, the loved, those living fully or getting their lives back on track, those with higher education and profitable careers, beloved mothers, fathers, and children. It does not discriminate. Children continue to be diagnosed with cancer each day and many of these children will die of this disease. As a provider and a mother, this is still unfathomable to me, but I choose to live this life full of joy and wonder. I choose to laugh at my child's jokes and correct his mistakes. I try to vigilantly be his mom while I delegate the responsibilities of his healthcare to his pediatrician. I make him broccoli, and I accept the futility of doing so. In essence, being a pediatric oncologist despite the long hours and emotional toll has made me a better mother and for that I am eternally grateful. As a mom and an oncologist, I want nothing more than for childhood cancer to cease to exist. I want to find the cure. I wish for no new diagnoses. I hope that more biologic treatments with decreased side effect profiles are found to eradicate cancer. I am willing to retire from this career early if I am no longer needed. Maybe the Forest Service is hiring.