new scutmonkey: the 6 stages of overnight call

This may be a slight retread if you follow me on Twitter, but one particularly bad night on call about a month ago, I posted a poll surveying the worst overnight call phenomena. After that...well, after that it was just a matter of drawing the thing.

Here, panel by panel:

For those who are curious, I've been meaning to get back into cartooning for a while now (despite the long hiatus I've actually drawn comics...well, basically my whole life, since I was a very small odd child with too few friends and a bit of a defensive sense of humor to match), but as I noted previously, making these comics does take some significant amount of time. I mean, at least the way I do it, which is extremely analog and old school, it involves many inefficient, labor-intensive steps.

Joe actually got me one of those Wacom tablets about a year ago because I've been yammering about drawing more since forever. He thought, quite logically, that a tablet might be a good tool that could input the my drawings directly into the editing software. It was such a thoughtful gift, but...I don't know. There's something about the tactile sense and resistive friction of drawing with specific tools, and I'm picky enough as it is about my writing implements.

I did try to do a sort of quick and dirty YEARS ago, with this "colonoscopy face" comic...

...which I deliberately did on a yellow notecard just to force me to treat the exercise it casually. I briefly considered doing more things like that--just casual, tossed off, straight ink to paper, no erasing, no post-processing cleanup, nothing. But the fact is that I don't like things that are careless and tossed off. I want to do things how I want to do them, and how I want to do them necessarily takes a certain amount of time. It just does.

Anyway, everyone has their weird outlets. Writing and drawing stupid comics are mine. I hope you liked this one.

vintage scutmonkey: doctor id

This is a rare bird indeed, in that it is the one Scutmonkey comic that I never disseminated widely. I in fact never completed this strip. This string of panels originally ran with the tag line, "To Be Continued..." but I never followed it up, because...I don't know. I think it just never felt very funny to me. Don't get me wrong, for someone who has worked in the Peds ER, there is a decent dose of acerbic humor in there, but on the whole, when taken with the other comics I wrote, it felt...kind of darkly bitter. A little too much dark, and a little too much bitter.

In retrospect--and I don't think I needed that much distance from that time to realize this, I think I even realized it at the time--there was a point in my first year of Peds residency when I was likely borderline clinically depressed. It was circumstantial depression, certainly--I think many of us were at the time--but nonetheless it was a period of my life that both imprinted deeply and which I don't remember well. Day blended into night, one rotation blended into the next, there was very little time, very little spontaneity, very few genuine sparks of joy that I can recall. This had very little to do with my residency program per se (to this day I have nothing but good things to say about my Pediatrics residency, which turned out some of the finest doctors I know), but had everything to do with the nature of residency itself, which somehow, despite all best intentions, tends to bleed the humanity out of the young people training to take care of human beings at their most needy and vulnerable. It's quite a paradox, when you think about it.

So despite the fact that I cringe a bit reading this now, remember the place I was in when I wrote this, I'll republish this nubbin of a comic from the archives anyway. But I will also link these two things.

One is this older blog entry I wrote seven years ago, entitled, "It Gets Better."

The lowest point in my residency was in January of my intern year. I was a Pediatrics resident back then, doing a month-long rotation on "Team 2," which is what we called the general inpatient pediatric team, with a focus on the patients on our liver transplant service. 

It was a very long month.

I'd get to work at around 5:45 every morning to pre-round, and invariably leave after dark every night--not difficult, considering that, in January, it seemed like it started to get dark around 3:30pm every day. I was there much later than that, of course--most nights I'd leave around 7:00pm, unless I was on call, in which case I'd leave at around 10:00am the following morning. We'd have pre-rounds and then rounds, then attending rounds and work rounds, followed by teaching rounds and radiology rounds, with time at the end of the day for sign-out rounds. Twice a week we'd have Grand Rounds and Chief of Service Rounds. How we ever got anything done with all this rounding, I'll never know. How I ever got to spend time with any patients in between all these rounds is even more of a mystery. It just felt like a day of endless, endless scut. Losing the forest for the trees. It would be a day full of writing down numbers and pagers beeping and phone calls and faxes and entering computer orders, and not nearly enough time practicing medicine or spending time with patients. And then I'd go home and collapse and wake up at 4:15 the next morning to go in and do it all again... 

And let's get this straight. I liked residency. Really, I did. Yes, it was hard, and yes, I was tired basically all the time, but I expected that, and now that it's over, most of my memories are affectionate. Residency, like medical school, was full of stories, and many of them, in retrospect, are funny--not at the expense of patients, but at my own expense, because Lord, how serious and inexperienced and bumblingly well-intentioned I was! But that first January of my intern year, I was very close to being clinically depressed. It just all felt so grim and featureless and endless, and I felt more and more like I was just some kind of task-programmed automaton, not like the doctor that I thought I was supposed to be at this point.

I wanted to quit. Not just quit being a Pediatrics resident, but quit medicine altogether. I was unhappy. I didn't like my life. I wanted to be done. I know that this comic was intended to be a joke, but there were time, real times, when I passed by a Gap or a Starbucks or whatever, saw that they were hiring, and seriously considered stopping by to fill out an application. At least they don't make you take call at The Gap, folding chambray button-down shirts at 2:00am. 

Now I'm going to tell you a secret. Everyone who has been through a residency has felt this way at some point. Everyone. 

Maybe you're feeling this way right now. So here's another secret. There's more to life than this. Even though it feels like residency is your life, it's not. There's more to life. There's more to you. And it gets better.

It gets better.

The second thing I would like to say is this. I am not a great person, and I know this. The people who work in the Peds ER are...incredible. Phenomenal. Superhuman. It is one of the rotations during my residency--both residencies--where I learned the most, and one of the rotations from which I have retained the most indelible memories. There's a chapter from my book, and though this is one of the less sensational excerpts (you would have never centered an episode of ER around it, for example), it's still the one that sticks with me the most.

...[T]here are some subtle changes of the twenty-four hour cycle that, to the experienced eye, can give some clue as to what time of day it is, but otherwise, days and nights in the ER are all pretty much the same, a constant stream of low-grade urgencies punctuated by the occasional heart-stopping emergency. 

In fact, the only event that allows me to reliably tell time in the ER is the 3:00 a.m. sandwich drop, wherein a café across the street, just prior to receiving their bakery-fresh goods for the morning, drops off heaping mounds of day-olds for the patients and staff of the Peds ER to pick through. Walk through the Peds ER at three thirty in the morning and you will find leftover yogurt cups lined with soggy scrims of granola, see patient attacking chicken salad wraps, and watch ward clerks turn away from their work stations to deal with a mouthful of cheese danish. "Try the turkey sandwich," the attending urges a floridly tattooed teenager with the air of insider knowledge, "the bread is really good." 

At these times, the ER feels like it could be anyplace where unlikely company is trapped together for an interminable wait. The DMV, the passport office, an airport terminal after all outgoing flights have been canceled due to a storm.

Anyway. Dr. Id. We don't often immortalize the worst of ourselves in amber, but it's still important to remember that there was a time when that person was there. Is still there at times. And to remember the small moments of happiness and good humor, no matter how inconsequential. And to know that it gets better. To know that you get better too.

It gets better, and you get better too.

sunny side up

It's hard to know what triggers certain memories in your brain, and I can't figure out what made me think of this today, except...maybe it was the weather. Today was gorgeous: sunny, clear, and mild. And on days like this, as strange as it sounds, I often think about the opening sentence of the 9/11 commission report; how it was so much better written than a government report had any right to be, how evocative that first sentence was, and how perfectly it set the scene for what we all now know was going to happen. "Tuesday, September 11, 2001 dawned temperate and nearly cloudless in the eastern United States."

But what I was thinking about today was not September 11th, but September 12th, 2001. I was a third-year medical student on my pediatric urology rotation, and while I don't quite remember the details of what we had originally scheduled to do that morning--maybe it was clinic, maybe we were supposed to round on the patients that were all hurriedly discharged the day before--but obviously whatever plans we had were truncated or canceled. We had no patients from "Ground Zero" yet (this, of course, was well before the days that it would be referred to as "Ground Zero," most people I knew who were working on site seemed to refer to it as "The Pit"); most who survived to get to a hospital were mostly concentrated downtown. So we had almost nothing to do that day, and somehow, that was one of the worst feelings of all. So what happened that morning of September 12th was this: the two senior residents on the pediatric urology service took me and my co-medical student out for breakfast, at a shoebox-sized greasy spoon diner near the hospital.

It was really a very odd morning. I know that it must have obviously been strange the nation over, but if you lived in New York in the immediate aftermath of September 11th you will understand what I mean when I mention this particular strange disconnect of knowing that the entire world had just imploded right in front of you, feeling with equal certainty that we were all probably going to die, and yet looking out the window and seeing that everything, at least up in Washington Heights, looked exactly the same. Like: out there, on the street, where it always stood, was the bagel cart. With bagels on it. And you'd look at the bagels, and then think about what you had just seen, which was the two largest buildings in the city crumbling to dust literally as we watched, and something would just break inside your brain, because how do those two things exist in the same world? Because on one hand, September 11th happened, and then on the other hand, here we were on September 12th, alive, at a diner...eating eggs. Everything looked and felt and smelled and tasted the same as it did two days ago, but also, at every table and booth, people were reading a copy of The New York Times with the most gigantic headline that I can remember seeing in my lifetime.

It was really...very disorienting.

Now that I'm much older, I so appreciate the simple mercies of those senior residents, and the implicitly understood comfort that they knew they could convey in that small act of taking us out for breakfast. I also know, having been a resident, that even these small gestures were not so small--I know now how little money residents make and I know now how young residents really are, even though, as a third-year medical student, I felt at that time that there was something adult and comforting about them and if they said that we were going to be OK and so we should order and extra plate of hash browns for the table, well then, I guess we would be OK. I know now that they must have been as scared as I was. I know now that they were trying to help me feel better, and in doing so, help themselves feel better, because...well, that's how it works.

And that's pretty much what I came away with today, in sudden flash of memory as commonplace and pocket-sized as the events around it were explosive and consuming. That sometimes bad things happen, and you can't really fix them; but in small ways, you try to fix them anyway.

mud weekend

When I decided to go down to 60% at work, I figured the easiest way to do so (for the ease of my group and for my own personal budgetary calculus) was to do 60% of everything. That is to say: 60% of days, 60% of call, 60% of weekends, as well as my share of holiday call, which is distributed on a rotating basis. (For example, this year I worked the fourth of July. Last year I had New Year's and Labor Day; the year before that, Christmas.) I considered briefly a work configuration in which I didn't take night and weekend call, but it was a surprisingly easy decision against that. First of all, there is an element to the kind of work that you do on call--emergencies, surprises, coping with limited staffing--that presents unique challenges, and I think that by continuing to do practice anesthesia under that subset of circumstances will keep me, you know, sharp. And the second, more pedestrian reason is that the additional pay cut for not taking call would be more than our family can afford at this point.

So! Huzzah for call! The good thing is that, because of some strange quirk in the schedule, my weekend call for the last third of the year was fairly front-loaded, meaning that once we get past mid-October I won't have very much (or really any) weekend call until after Christmas. The bad part of this is that I'm currently in the middle of a stretch in which I am on call every other weekend for a month and a half. Sigh. C'est la guerre. 

I don't really mind--I'd rather be on call now than later on in the year anyway, especially once we hit that Halloween-Thanksgiving-Christmas stretch and seemingly every weekend is programmed to the hilt with Fall Festivals, canned food drives and Winter Wonderlands wherein you pay $3 to shoot Santa out of a cannon. (That's accurate for a school Winter Wonderland festival, right? I don't know, I've never gotten to attend because I've always been working. Other possibility: pelt cans of Coca Cola at a guy wearing a polar bear outfit.) 

And still, even at its most dense, this call configuration is better than during my Peds residency, when I was on call some portion of three out of four weekends per month. Remember those days? When having a "golden weekend," rare and exalted as a unicorn, simply meant that it was a weekend that we weren't at work? Current medical trainees: it gets better. Soon (not that soon, but sooner than it seems to you at this point) you will look back on these days with rueful affection and wonder how the hell you used to live like that. And then you will dive into your swimming pool filled with gold dubloons and the grateful tears of your patients and swim around like Scrooge McDuck.

OK, that last part is not true at all (and at some point I would like to talk more about this: the notions that society has about how doctors live and how many of us--especially those of us who started in practice within the last 10 year--actually live) but I'll save that for another day when I have more time and am not rushing to get ready for work pre-call. However, I will leave this here, as an illustrative example and a thanks. Thumbs up to all the people who identified those geriatric shoes in my last entry as Clarks Wallabees--they cost more than $100 when purchased new, so, you know, out of my budget. But then I looked on eBay (highly recommended an online searchable thrift store--you can really find some very nice items on there if you're fairly specific about what you're looking for and don't mind the pre-owned factor occasionally) and scored this lightly worn pair in my size for less than $26.

I am now one step closer to my life goal of becoming Carl Fredrickson.

Thank you again. Carry on.

just the two of us

I'm in a Starbucks with a pumpkin spice latte and my laptop now like some goddamn stereotype. Man, even I hate myself right now.

Starbucks always makes me think of working hard. I studied for all my board exams in Starbucks-es, from Step I at that Starbucks on 103nd and Broadway all the way up through my Anesthesia Oral Boards at the location on Monroe and 8th. The difference between Starbucks-es in New York and Atlanta, by the way? The Starbucks-es in New York serve you much, much faster.

I also wrote my entire book at the Starbucks on 29th and Park, which if you need to do work is (or at least was five years ago) an ideal Starbucks--huge, a preponderance of large tables, with a strip of power outlets around the entire outer wall. Oh, another difference between Starbucks-es in New York versus Atlanta? People bring work to Starbucks-es in Atlanta of course, but usually it's more like a rest stop, or a place to have some coffee and kill time between appointments or tasks. In New York, people set up shop. I read once in an article that Starbucks aimed to make their coffee shop locations into "virtual living rooms," places where people can kind of hang out in an armchair and meet with friends--hopefully buying large quantities of overpriced food in the process--and I think that there's likely no place where this is more true than in New York, where a lot of people frankly don't have actual full-sized living rooms in their apartments.

I mean, I brought my laptop there, and maybe my bookbag, a manuscript envelope, assorted miscellany. But there were people who brought full desktop computers (24-inch monitor AND the tower), the entire contents of their law library, extra desk lamps for those darker corners of the store. During my final year of residency when I was trying to finish my book by the July 1st deadline, I would take one day per weekend that I wasn't on call, leave Cal with Joe, set up base camp in one corner of that Starbucks and just sit there for eight, ten hours at a time. I would buy one coffee and get something cheap(er) but filling, like an egg salad sandwich. And then I would sit there and bust ass, looking up only occasionally if something interesting was happening, like the police coming in to extract homeless people that refused to get out of the bathroom--something that happened with alarming frequency. When I left, usually in the early afternoon, my hair and clothes would reek of smoke from the coffee roaster, as though I'd just smoked a billion cigarettes.

This has been Starbucks Talk. I'm your host, Michelle Au.

Anyway, the point of this post was not to talk about Starbucks (and it goes without saying that I have no affiliation with Starbucks, not only because I don't run paid ads on this blog but because this is such a small blog that STARBUCKS DON'T GIVE A SHIT WHAT I SAY), but to catch you up on Mack.

When I decided to go part-time, one of the first things that pushed me to consider scaling back at work was the fact that Cal was already halfway out the door to college, but the things that made me actually decide to make the leap was Mack. Because see, the thing with Mack is that...he's fine. He's always just fine. Cal's the oldest, so he often gets a lot of attention because of his school and activities (Cal recently joined the Lego Robotics team at school, and to say that Mack is inelegantly jealous would be kind); and of course Nina gets a lot of attention because she's a baby and needs us to do every damn thing for her. But Mack? Mack is always OK. He can do a lot of stuff for himself. He can play nicely by himself or with his siblings. A lot of the things he needs (a glass of milk, help reaching something high) Cal can often troubleshoot, and does, especially if I'm tied up doing something like cooking dinner or putting the baby down. He's happy, he's pleasant, he's not really that high-maintenance for a four year-old. And that's how I think he ends up getting ignored a lot. Classic middle-child syndrome.

And the thing with Mack is that he's just so reassuring with how normal he is. Cal was by all accounts kind of a weird child (he's much better now, warm and social and adaptable in ways we could only dream of when he was Mack's age, when he was...less so those things) but Mack has always been like the textbook illustration of Boy in Early Childhood. He like sports and wrestling with dad. He plays pretend and makes up little playlets with his stuffed animals and action figures. He's sunny and affectionate and snuggly and fun. Even his drawings are textbook--every human looks like a happy scarecrow with vertigo, all stick limbs with five fingers on each hand, clubby feet, smiley face. Every house has a chimney, every flower has six petals, and there's always a sun with beams shooting out in the corner.

(The reason that I make such a big deal about the drawings is that Cal's drawings at this age were--well, they were pretty weird. He was always good at drawing inanimate objects or landscapes, but when it came to drawing people, his drawings were just odd. Even when he was five and beyond, he'd sometimes draw people missing limbs, sometimes missing heads, and when he did draw a head it would be tiny, like a pinhead, with no face on it. NO FACE. What the hell, young Cal? Anyway, long story short I started introducing Cal to comics and gave him a little key of facial expressions so that he could draw his own comics and so the reader would be able to infer the mood of each character and thus the thrust of the story. So that's not an issue anymore, but still, I will admit that there was a period of time where I was worried that this was the first sign that we were raising some kind of sociopath who was unable to read human emotion or something.)

(And yes, I also see how telling it is that I just spent a paragraph talking about Cal in a entry that I ostensibly started to talk about Mack, but see, that's the thing! Cal was so weird and attention consuming! And Mack is so normal and easy! That's exactly why it's so easy to set him on autopilot-parenting and exactly why he's going to quit his tutoring job and join a violence gang because his parents never paid attention to him! I mean, probably!)

One of my main goals now that I have more time is to spend some time with Mack, just the two of us, one-on-one. I had to take him to the dentist two weeks ago, an expedition that I billed as our "special day" (in that yes, we were going to the dentist, but he could skip school for the rest of the day and afterwards we could go the playground and then have lunch together wherever he wanted! And also: free toothbrush!) and the degree to which he was excited about his "special day" with me was unreal. He talked about it literally every day for the weeks leading up to the appointment, and he seemed to especially relish the fact that it would be just for him, that Cal would have to go to school and that Nina would have to stay home, and weren't they going to be so jealous? There really was nothing that extravagant about the day at all, so the special thing for him wasn't so much the activities or skipping school or the Chick-Fil-A for lunch, as the fact that it happened at all. For half a day, he was my only kid.

So anyway, something that I've committed to doing is to try and have a special day with Mack about once a month--or at the very least, a special morning or afternoon. We'll just do something low-key--making Rice Krispie treats, going to the playground, doing an art project--but just something that we can do alone without Cal being there asserting his own superiority in gluing pompoms ("I used to do it like that when I was four too, Mack...but you'll get better at it. I mean, probably.") or without Nina there needing all of my everything. And maybe we won't even need a dentist appointment as an excuse to do it.

Parenthood, right?

Wright State University Boonshoft School of Medicine, commencement address, May 24, 2013

Good evening and congratulations to the Class of 2013!

I graduated medical school almost exactly ten years ago today (which sounds like a much longer span of time than it actually feels) so naturally when I started to write this address I thought back to my own med school commencement ceremony, or what little I remember of it.  Particularly I tried to recall the invited speaker we had that year and what pearls of wisdom he imparted, so that I could frankly plagiarize them and pass his pithy truths off as my own.

The problem is, I can’t remember anything he told us.

Our med school commencement speaker for 2003 was Jimmy Breslin, a reporter for the New York Post and certainly a more illustrious figure than I.  And he had a very well-written speech—I mean, probably he did, because again, I can’t remember—but all I really do recall is that he spoke a lot and he spoke for a long time.  And I remember thinking to myself, as I sat there in my academic regalia, sweating under the layers of polyester like one of those cook-in-the-bag microwave meals, that this man and his endless speech were the only things standing between me and my medical degree.

(He did eventually stop talking, by the way.)

I can’t convey to you what an honor it is to be invited to share this day with you all, which with the possible exception of this address, is likely one of the most important and memorable days of your life.  So when I sat down to write this speech, I had only two goals in mind.  First goal: to give you real advice that you can actually carry with you for the long road ahead.  And my second goal: keep it short.

Now, as a fourth year medical student, you probably already experienced the fact that the world is teeming with people all too eager to give you advice.  Much of the advice from senior doctors in particular will be strangely centered around when, how and if you should eat, sleep, and eliminate during residency.  (Clearly people have strong feelings about such things.)

But as a fairly junior attending physician myself, the idea of giving you all advice outside the realm of the purely practical does feel a little presumptuous.  The field of medicine is constantly changing—maybe now more than ever before—and I can’t pretend that I know what the future will look like any more than you can. Therefore, I only have one piece of advice, so as to make it easier for you to remember, and that is this:

Remember who you are in this moment.

And who, exactly, is that?  At this moment, you are a fourth year medical student, just minutes away from being granted your medical degree. You are proud, and you should be.  You are excited, and you should be. You are a little apprehensive about what comes next—intern year, residency, the hours, the new responsibility. That, you should be too, but I’ll not belabor the point—other than pregnancy, there’s no condition about which people like to recount horror stories more than medical residency.  Finally, and perhaps most importantly, you are still idealistic. I hope, at least, that even at the end of medical school you have retained the idealism that brought you into medicine in the first place.

And why did you go into medicine? I’m sure there are a host of different reasons, phrased in a number of different ways—but I think, and I hope, that it all boils down to this: you want to help make the world a better place, one patient at a time.  And right now, this seems like the most obvious thing in the world, the thing that has powered you through years and years of books and finals and 4:00am scut rounds done on no sleep and an empty stomach.  You’re doing all this not just for yourself, not solely for any kind of personal glory or reward, but to help other people.

Remember who you are in this moment.

Older doctors, particularly the more cynical ones, will speak of idealism as though it’s a bad thing, some sort of marker for naivite.  But I’m going to tell you this right now: idealism is never a bad thing.  And idealism seasoned with experience is maybe one of the very best characteristics a doctor can have.

Remember who you are in this moment.  A young doctor on the cusp of doing great things.  Some of these great things will be large acts, the majority of them will be small, but all of them will stem from who you are in this moment, who is someone with the energy, idealism and work ethic to make the world a better place.  With all the pomp and circumstance of this particular day and all those that preceded, it seems like the concept of service would be difficult to forget.  But believe me when I tell you that forgetting is the easiest thing in the world.  I have forgotten it many times myself.

Because there will come a night on call during internship when you’re going to feel beaten down and tired and regretful of having ever gone to medical school in the first place. And right when you manage to sit down, the first time that you’ll have had a chance to sit down all night, the charge nurse on that floor will yell at you for sitting in her special chair. And right then, you will forget who you are in this moment.

Or during residency, you’ll have a patient who will push all of your buttons.  And that patient will be loud and belligerent and unappreciative and will say things that make you feel inadequate even after the hours and hours of work you’ve put in trying to take care of him. That patient will make you angry, unsympathetic, and when that happens, you will forget who you are in this moment.

Or there there will come a time when you’re an attending, after you’ve been working late for the fourth evening in a row. This will be the one day that you have any hope of getting home to see your spouse and kids before bedtime, and right as you’re finishing up your dictations and ready to hit the door, an emergency case rolls in that no one can staff but you.  And that particular evening, you will forget who you are in this moment.

Cynicism is a protective adaptation.  It is a shell that doctors build around themselves after they feel that they’ve worked too hard, seen too much, been burned too many times.  It’s a way for doctors to broadcast to their colleagues and to the world at large that they’re so expert in the human condition that nothing surprises them anymore.

But don’t be that person.  Don’t be the cynic.  Be for the rest of your career as you are today, someone who doesn’t tuck your idealism away like an obsolete relic of your years in training, but proudly wears it on the lapel of your white coat. 

Be ready for everything you think you know now to change. Be open to new experiences. But always remember who you are in this moment.

Congratulations to the Wright State University Boonshoft School of Medicine Class of 2013.  Congratulations, doctors. May each of you have a long, fulfilling career filled with interesting patients, challenging days, and a lifetime of surprises. The rest of us have been waiting for you, and are so happy to have you join the team.

Now roll up your sleeves and get in here. We’ve got a lot of work to do.  

spotlight on specialties: anesthesiology

Sorry, I'm a little bit in remiss in that I didn't post this link up earlier, but here's a link to the AAMC article on the field of anesthesiology, for which I was interviewed along with a number of much more distinguished and accomplished colleagues. If you're interested in the field of anesthesiology, either as a potential career or if you just want to know what exactly it is we do all day, check it out.

An excerpt:

“Anesthesia is hands-on, fast-paced, and has tremendous capability to make a positive impact on our patients’ lives as anything else we do in the hospital,” says Dr. Au. “In my opinion, it's one of the most interesting, most exciting fields in medicine, and I firmly believe I have the best job in the world.”

I've said it before and I'll say it again here because it's appropriate: it's a difficult juggle to balance work and family, but it's all the more difficult because I do indeed love my job.  If I didn't love what I did at the hospital as much as I love what I do at home, my choices would perhaps be easier, though maybe not as satisfying.  So really, in the end we should be grateful for the difficult choices, and the chances we have to make them.

(And on an unrelated note: the above photo panel is from pictures I took with my phone during residency--isn't it amazing to see how far cell phone photography has come?  Wow! The future! hovercrafts that fold up into briefcases! And etcetera!)

great and lesser expectations

I had Cal three weeks after starting my training in anesthesia--a highly conspicuous move that I think indelibly branded me for the rest of my academic career as "that pregnant resident"--so I think it's fair to say that I have some insight into the assumptions that people tend to make about people mixing family with a career in medicine.

In most ways I imagine it's not unlike mixing family with any intense or high-powered careers--look at all talk that Marissa Mayer's pregnancy incited after she was named the new CEO of Yahoo. (Aside: I'm not saying that my career is anywhere near as high-powered as that of Marissa Mayer, just that the case is emblematic). Particularly in the field of anesthesia, where I'm in the room but often lurking in the background or behind a drape, I've heard a lot of conversations about medicine, other physicians, and things that fall in the rubric of "lifestyle choices"--conversations that maybe weren't meant for me to hear.  But as a result, and as a result of living my own life, I can say for sure that women in medicine (physicians in particular) who choose to have children during the most active parts of their careers suffer under what I'd describe as a handicap of perception.

Perception. Not an actual handicap, but one of perception. There's a Chinese saying that my dad always uses that roughly translates to, "When you're walking through someone else's pumpkin patch, don't bend over to tie your shoes." (OK, that's a very rough translation--I don't think the parable from which the saying was taken originated during a time when shoelaces were a particularly popular feature of Chinese footwear.) What it means is: if you're in a setting that breeds suspicion, try hard not to do suspicious-looking things, no matter how innocent they actually may be. Because you may be just tying your shoes in the middle of that pumpkin field, but a casual observer might be inclined to think you're actually stealing those pumpkins.

I think that in medicine (and perhaps in the working world in general but what the hell do I know, I've never had a real job doing anything else) people are quick to assume things about working mothers, not too many of them flattering. I'd like to say "working parents" because believe me, I'd love for us to get to a point where there is actual gender parity on the issue (to be fair, I do think that Joe and I do have gender parity when it comes to parenting, but...we do have to leave our household occasionally and interface with the world) in the year 2012, this is still more of an issue of perception for working mothers. The following is a list of some of the things that some people are quick to assume about women with children who work outside of the home.


1.) We don't work as hard.

2.) We complain when we do have to work as hard as everyone else.

3.) We want special favors and allowances in the workplace because having kids somehow entitles us to them.

4.) We are unreliable because something's going to come up with our kids and we're either going to leave our co-workers with the extra work, or sometimes leave our jobs entirely.

5.) We just don't care as much about our jobs as our counterparts.

5.) All this is somehow inevitable.


The problem with other people's perception, especially those colored by preconceived notions, is that there's very little that you can do about it.  It has very little to do with you, and sometimes even very little to do with reality itself.  And that perception can be insidious, like a Chinese finger trap--the harder you struggle against it, the tighter it binds you.  (Yes, again with the Chinese.  WE HAVE A RICH CULTURAL HISTORY, OK?  Actually I have no idea whether Chinese finger traps are actually Chinese, or just "Chinese," like fortune cookies or General Tso's chicken, but whatever, it's not germane to the metaphor.) You want for all the world to defy the lowered professional expectations that people have of you, to prove them wrong, but sometimes it feels that the harder you try, the more you're reinforcing them nonetheless.

So what I think a lot of female physicians with kids do--and what I know I certainly do--is overcompensate. You do it all and then some. You work even harder. You try to never complain about your schedule or your hours while you're at work. Not only do you not ask for special favors, you embrace situations that allow you to prove that fact. In other words, you try to work as much and as hard as everyone else, and then you go a little bit farther, just to make sure. You try to be above reproach.

Sometimes this works. Sometimes it doesn't.

I think often now about Michelle Obama, particularly during the president's first presidential campaign, and how hard she and her team had to work to control her image.  The reasons people might have a negative impression of her are perhaps multifactorial and not entirely flattering of a portion of the electorate, but there seemed a point where every little thing she did or said, no matter how innocent, was misconstrued as playing right into her detractors' expectations.  (The endearing but now notorious fist-bump comes to mind.)  Sometimes it feels that way to me too.  Representing not only myself, but working mothers in medicine as a group, I am very aware of trying to present myself, present all of us, in the best possible light.  Again, overcompensating.  I think this explains a lot of my personality at work, which I have often classified as "aggressively pleasant."  As in: I will be easy-going and pleasant to work with if it kills me.

Sometimes this gets pretty tiring.

I also will note that there's a segment of people who will respond to this blog entry with the opinion that I and others like me are far too sensitive about these issues, reading meaning into things that have no meaning, turning mountains into molehills.  I am perfectly fine with people responding however they want (as someone who has been writing online for more than a decade, I think that if it's your right to publish something online it's the right of your readers to respond, even if they disagree with you) but I also think that actually being a working parent in medicine, a working mother in particular, lends you a perspective that you don't have access to otherwise.  So saying that we're overly sensitive to the issue of low expectation or perception bias is, to me, a little like a straight person saying to a gay person that they're being too sensitive about homophobia, or a white person saying to a Latino that they're too sensitive about racism.  Or, maybe, like Mitt Romney condescendingly telling poor people that they just don't work hard enough.  If you don't know what you're talking about, sometimes it's best not to talk.

I would love to hear your own stories about whether or not you feel that working parents in medicine are stymied by lowered expectations or perception bias, and what you all do in your lives to roll with the punches.  Because though the natural (or perhaps easiest) reaction is, "Screw 'em! Who cares what people think?" (this is Joe's response, for example) the fact of it is--I do care.  I care what people think of me in my career.  I care not only about being a good doctor, I care about being perceived as a good doctor.  I care not only about having a good work ethic, but about having that work ethic be a key part of how people see me. I care.  Maybe not as much as when I was in training (when I wouldn't even have dared to write a blog entry like this at all, for fear that I'd be seen as "whining") but I still care a lot.  So until I stop caring, or society changes as I continue to hope it will, I guess I'll keep walking through this field, head up, eyes straight ahead, and try not to look like I'm stealing pumpkins.

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.)

tripping to the light linktastic

First off, you guys knew there was virtually no way that I couldn't respond to this Op-Ed in The New York Times from this weekend right?  In case you hadn't read it, a quick excerpt to whet your appetite:

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.

I recently spoke with a college student who asked me if anesthesiology is a good field for women. She didn’t want to hear that my days are unpredictable because serious operations can take a long time and emergency surgery often needs to be done at night. What she really wanted to know was if my working life was consistent with her rosy vision of limited work hours and raising children. I doubt that she welcomed my parting advice: If you want to be a doctor, be a doctor.

(Italics and bold face I added for emphasis, but the words of the actual article are reproduced verbatim.)  So! Thoughts? I had a few. And I posted them here. I hope this doesn't count as some sort of cop-out substitute for an entry, but as both article probably highlight, the role of a physician parent is fairly busy, and there's only so much time in the day for writing, as much as I might love to do it.

For those somewhat less interested in the issue of out-of-home-working parenthood, here is a video from this weekend. As you can see, Cal went from being somewhat nervous in the water to staging his own underwater Cirque du Soleil.

And finally, remember to check out the awesome JetPens and book giveway in my guerilla marketing contest! Don't stress, your entry doesn't have to be anything XXX-treme, it could be as simple as starting a Twitter word-of-mouth campaign or sharing a link to the book on your Facebook page! Just e-mail me with a link to your entry to officially enter the contest! (This is just so I can keep track of everyone.) They're really good pens, guys. And it's a pretty decent book too, on an issue--the balance of medicine and parenthood--that clearly needs to be shared and discussed.

That about sums it up.  Hope you had a good Monday!