life or something like it

OK, so let's talk about this:

Some of you may remember an Op-Ed in The New York Times this past summer, written by Dr. Karen Sibert, entitled "Don't Quit This Day Job." If you haven't read this piece already I strongly recommend that you do, because I think it can spark a lot of good dialogue on the topic of work-life balance in medicine and what it means, personally and on a systems level, to find that balance. I wrote a response to that Op-Ed here, and we all discussed and discussed and discussed that some more. In particular (I've been doing a bit of traveling and speaking this past year and as a result have had the pleasure of spending a lot of time with doctors in various stages of training--pre-meds, med students, residents, fellows, what have you), I find that young doctors are especially hungry for dialogue on this topic, which seems to be foremost on everybody's minds and yet often discussed furtively, behind closed doors.

Dr. Sibert has recently started blogging as well, and posted a piece today entitled, "Give yourself a break--don't have a baby during residency." An excerpt here:

Overheard in the OR—a surgery chief resident ruefully explaining to a senior surgeon why no intern or junior resident was available to scrub in on his case. “Everyone in our department is either pregnant or on maternity or paternity leave,” he said.

The senior surgeon just shook his head. 

From my vantage point as the anesthesiologist on the other side of the drapes, I thought to myself, “Really? What’s wrong with these people? What would give anyone the idea that residency is a good time to have a baby?” When I look back to what it was like to deal with pregnancy, give birth, and look after an infant, all I can say is that internship was easier. After all, as an intern—even in the bad old days—I had some nights off. 

Yet having a baby during residency is increasingly common among male and female residents alike. For women especially, it sounds perfectly awful. We’ve all heard the stories—pregnant residents struggling with nausea and fatigue during long nights on call, or vomiting into a trash bag in the operating room; new mothers trying to breast-pump in the hospital locker room during a half-hour lunch break. 

One possible response is to argue that senior physicians should be more sympathetic to pregnant and nursing residents, and give them longer lunch breaks. This would be in keeping with the kinder, gentler world of limited resident duty hours and mandated nap times. 

But it’s equally fair to consider that residency might be a bad time to have a baby.

Even with today’s work hour limits, residency training in any field involves stressful days at work, limited control over your schedule, and frequent nights on call. It’s hard to get nutritious meals on a regular schedule, even if a pregnant resident could stomach the food in her hospital cafeteria. Nor can she get enough rest. Anyone who’s been pregnant can recall moments of such profound fatigue that she would kill for an afternoon nap, and a resident can’t simply lie down when she feels like it. Can this be a healthy way to go through pregnancy?

(Read the full blog entry here.)

So, a little background to catch everyone up first, just to show that I have some perspective of which I speak on both sides of the "when to have kids" quandary.  I got pregnant with Cal the fall of my second year of Pediatrics residency.  I can't speak for every Pediatrics residency experience, but to be a resident at the Children's Hospital of New York was a very intense experience--lots of call, tons of ICU time, patients on the general wards that would have been on the unit in any other hospital, it was (and I think I can safely say this now) much more difficult than my anesthesia residency, even on the "best" months. Cal was born soon after I switched into Anesthesia residency, after which point I began in earnest the balancing act that is having a child during training.  (Because, you know, that's the real difficult part--not so much the pregnancy, but the part where you and your baby are actually in two separate places.)  I spent the entirety of my first trimester with Mack finishing up my Anesthesia residency, and he was born about five months into my first job out of training, when I was a junior junior junior (junior) attending.  Now I'm about three and a half years into my post-graduate career, working full-time and more or less settled in my current job situation, and as you know, our third child is due in July.

OK, so to sum: one pregnancy early in residency, one half-in-half-out-of residency pregnancy, and one pregnancy as an attending.

First things first: Dr. Sibert is right on a couple of points.  It is more difficult to have a baby during residency, for many of the reasons that she mentioned and more.  I can't argue that.  I lived it.  It's a daily challenge.

But here, now is a partial list of just a few other things that are also more difficult during residency: Being in a relationship.  Being a good partner to your spouse.  Spending time with your friends.  Calling your parents.  Keeping up with current events.  Making time for your hobbies and creative pursuits.  Studying for your boards.  Reading a book for fun.

I wouldn't tell you to not do those things either.

Right, so in part I jest, because obviously the choice to have a child during residency (and that is what we by and large have as privileged, educated ladies and gentlemen: a choice--that is, unless certain members of the Republican Party intelligentsia have their say) is obviously a huge one that should not be taken lightly.  Nor do I think it is one that people do take lightly, or look at as just another point on their "achievement checklist" (as per Dr. Sibert's blog entry):

In a way, the determination and single-mindedness of physicians may help to explain why they have children during residency. Having a baby becomes part of the achievement checklist. Finish college—check. Finish medical school—check. Score residency position of choice—check. Find life partner—check. A baby becomes the next item on the list, and residents often feel additional pressure from parents and in-laws who are anxious for grandchildren. For the young female resident who’s been a bridesmaid in her best friends’ weddings, it can be hard to watch them all start having babies without feeling the urge to have one of her own.

No, I don't think that it is a decision that people make on a whim, or a life milestone that people fall into secondary to intertia or because of societal expectations or because their parents are screaming for grandbabies.  Remember, these are people who to this point have been through between four to eight years (give or take--if we're talking about medical residents) of post-college education and training, who knew what they were getting into (med school isn't exactly something you end up doing by accident), knew that it was going to involve a lot of hard work, and make choices to live their lives outside the hospital a certain way. The life of a medical resident is not a "Cathy" cartoon, after all. (I'd say my life is closer to a Calvin and Hobbes strip, actually.)

Would I tell all med students to try to have baby during residency? No, of course not, that would be ridiculous. But equally ridiculous, in my mind, is the blanket statement that no one should have a baby during residency. These are individual choices that people have to make for themselves given their specific circumstances, where they are in their lives, where they're looking to be in the future--all with more nuance and interpersonal variability than can be covered with any overarching recommendation. What I would say on this issue is the same thing I tell people when they ask me if they should go into medicine in the first place.

"You can do it. But you have to want it."

You have to want it. It comes down to that. Very few things in medicine are easy--and if I may venture, very few parts of parenthood are easy.  (In most ways, like I said before, the pregnancy is the easiest part.  Never again will you be able to have this much control of your offspring, nor will they ever again be so portable!  But I digress.)  You have to know exactly what you're getting into, you have to know your own limitations and what you're going to have to do in order to make a more difficult than average situation work...and you have to want it.  But you can do it.  It can be great.  And you and your family can thrive.

Joe and I (and I say this just as a personal anecdote--everyone's situation is different) went through a kind of specific calculus when we decided to have kids during residency.  And our calculus, basically, was this: "What exactly do we do with our time when we're not at work?"  Well, we were medical residents living in Manhattan.  Obviously we worked long hours, and we not infrequently worked for 24 to 36 hours at a stretch.  We weren't big partyers, and since most of our friends were also medical residents (and therefore pretty busy as well), most of our free time we spent with each other.  We'd eat out, get coffee at the bookstore to read free books preview books that we intended to pay money for, go to the movies, occasionally splurge and go to a nice restaurant or go see a play. And this was fun, having that kind of relative free time, and a little teeny bit of disposable income.

But then came the next question, "Are we willing to give some of that up--have less free time to do adult things and spend more time doing baby things, as a family?"  Yes, we decided, we were.  Also we considered, "Are we making enough money to have a baby?" Yes, we decided. It would be tight, predominantly because of childcare costs, but we could make it on what amounted to a single salary after paying for a nanny.  "Do we have enough time between us to take care of a baby?"  Again, like with the financial resources, we would be tight, but we thought we could do it.  (It helped, I think, that we had a dog for a few years by this point--the juggling act of allocating time and responsibility for the care of another living thing was good training for us in terms of the childcare calculus.)   In other words, we went through the exact same decision method that most other couples go through when deciding to start a family.

And finally, the last question, "Do we really want to do this now, or do we want to wait until later?"  Later was, I think, kind of an indistinct entity.  When, exactly, is the best time to have a baby in your medical career?  Everyone has different opinions, but I will tell you this as someone who has basically tried it a lot of different ways: it's never a good time.  It's always going to be inconvenient.  There's always going to be something making it difficult, and there's always going to be conflicting demands on your time, attention, and resources.  With Mack, for example, I had just started my first job as an attending anesthesiologist, and Joe was a newly minted fellow who was taking call every single night, including weekends and holidays, for a year and a half straight.  Thing 3 is set to be born this July, and I don't think I can even anticipate what that's going to be like--three young kids at home, two parents working full-time, lots of expenses, both of us taking night call. Also, to be honest, I'm going to be seven years older this time around than when I had Cal, and I worried (and continue to worry) about the byproducts of my sad old aging eggs.  The "perfect time" to have a baby is a myth.  So you have to do your calculus.  You decide if and with whom and how you you're going to get there, and you decide how much you want it, and when.

Joe and I wanted it.  We wanted Cal, we wanted Mack, exactly when and where and how they came about.  They made things harder.  But they also made things better.

Now let's also talk about the fact (because in many ways having a child as a medical trainee is very different from having a child in any other professional context) that you have to want to be a good doctor too.  That's an important part of it, just as important as the other half.  As a trainee, especially, you have an awesome responsibility to your patients and the future of your medical practice, and you have to figure that into your plans as well.  You have to make time for your education, and having a lot of responsibility outside of your work does not excuse you from your responsibilities while you're there.  There's no half-assing this one--people in the hospital need you too.  You have to put in the time and you have to give that sweat and blood the same as everyone else--in some ways, you have to put in more than everyone else.  But that's part of knowing what you're getting into as well.  Like I said: you can do it.  But you have to want it.

I have seen the argument again and again that having a child during residency makes you a sub-par doctor and a sub-par parent.  I would beg to differ, of course, but how I'm doing on those two fronts is not really for me to judge.  My patients and my colleagues decide how good of a doctor I am.  My kids will decide how good of a set of parents Joe and I are--maybe not right now, because they are both young and therefore still think we are awesomesauce--but down the road, ten or twenty years from now, they'll be able to tell us.  Still, we try.  We knew what we were getting into and we work hard and we try to do our best.  And if I may say, I think we're actually doing pretty OK on both fronts.

On such weighty, personal topics, I would never tell people what to do purely based on my own experience.  (In fact, the only real advice that I can give unreservedly to all medical trainees is: learn at least a little Spanish, and buy some comfortable shoes.)  But I will gently remind you that no matter what stage of training you're in, medicine is just one part of your life, not your life in its entirety.  You'd be surprised how easy it is to forget that.

No doubt residency is hard.  Being a doctor is hard.  But know what you're getting into, get as much information as you can, and thus armed, decide: do I want to do this?  Am I equipped to do this?  Do I have the support to do this?  And then make your choices.  Reading opposing viewpoints is good.  Reading different people's experiences is good--it's largely why I wrote my book, and why I continue to keep this blog, year after year.  Talk it over with your partner, your friends, your colleagues, your mentors.  All these things will inform your choices.  Live your life in whatever configuration, in whatever order you choose to live it in.

And then let the rest of us know how you're doing it too.

(Edited to add: I would love to hear discussion on this issue from all sides, and I'll thank my excellent readers in advance for keeping things collegial--in particular towards Dr. Sibert, who I don't know in person but is obviously a professional colleague in the world of anesthesia. We don't all always agree, but how boring life would be if we did.)