Link

Any one who follows this blog on the nuanced lives and careers of two surgeon moms should watch this. In its entirety. 

http://academicsurgicalcongress.org/aas-2017-president-address-caprice-greenberg-md-mph/

It is the Presidential address delivered recently by Dr Caprice Greenberg to end her term as President of the Association of Academic Surgery. She speaks with clarity and conviction on a topic of importance to both men and women across generations of surgeons. She provides data, vivid examples, and eye opening analyses about how and why women are professionally held back, not just in surgery but across specialties and other professional roles. 

Trauma Surgeon’s Ballad by Lin Manuel Miranda

Like much of America, my family is currently obsessed with everything Hamilton on Broadway. We jammed to the sound track all summer. The season culminated with a late August trip to the show which I described on social media as the best day of my life. Seeing the show, the actors, the set, and choreography, come to life with lyrics we had all memorized was such an amazing experience.


I cried.

Part of that was pinching myself that it was actually happening (NB: Tickets now that the original cast is gone are not that hard to find on resale sites but still cost quite a bit above face value.) And the other parts were one particular segment that just cut into my soul when I saw the character of Aaron Burr singing it.

I sobbed.

Let me provide you context. Burr is an orphan who is in love with a married woman. He has decided that with everything he has gone through, all of the losses he has suffered, he is willing “to wait” for the woman he loves. As someone who was taught to hate Burr by her high school history teacher who was a Hamilton scholar, this humanization of Aaron Burr was a bit off-putting at first. But the reason I simply could not stop the tears while experiencing the song with all of my senses as the show was not about the forbidden love story behind it, rather is was the commentary on death.

“Death doesn’t discriminate

between the sinners

and the saints,

it takes and it takes and it takes

and we keep living anyway.

We rise and we fall

and we break

and we make our mistakes.”

These words resonate so strongly with my trauma surgeon’s soul. We provide care indiscriminately, irrespective of race, socio-economic status, mechanism of injury, insurance, etc. And we lose people. Sometimes they arrive lifeless; sometimes our efforts fail. When that happens we are broken. We wonder if we could have done anything differently; did we make a mistake? But we have to go on “living” because there are more patients waiting. Some of them are sinners while others are saints and it doesn’t matter we treat them all the same. Then we wait for the next patient to arrive.

The title of the song is Wait for It.

The Hamilton sound track is still more or less played in a continuous loop in my home, in our cars, on my runs. And every time I hear this song I cry. I can’t help it. It simultaneously breaks my heart for all my patients who have died and provides me reason to keep coming back to this very emotionally challenging and physically exhausting profession. I know it was not Lin Manuel Miranda intent to write this segment of music (the lyrics and the accompaniment which is haunting) for the trauma surgeon in me but that has been it’s effect and I am so grateful.

And as for the burnout that is particularly rampant in my specialty, despite the tears from this particular song, the overall experience of seeing the show on Broadway was truly one of the happiest days of my life – a perfect way to spend a weekend off and return to work refreshed and ready to wait for it

Defining “Mommy Friendly”

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I had a familiar conversation the other day with yet another female medical student.

“I really loved surgery!” she said, “but I was concerned about the lifestyle so I decided on _______________.” 

Lifestyle, it turns out, almost always seems to be code for having a family (maybe it’s just the kind of students who are apt to seek me out as I have yet to encounter someone who is concerned that a surgical career will hamper their aspirations to compete in triathlons or become national fencing champions or write books for the general masses–I personally know surgeons who manage to work full time and do all of these).

The other day, I came across yet anther discussion board on what advice to give to women in search of “mommy friendly” medical specialties. There were lots and lots of suggestions, some were full time jobs with predictable hours and others were part-time jobs but not one of the suggestions was a surgical subspecialty. 

Not. A. Single. One.

Sigh. This makes me sad for my chosen specialty and for all the promising young women who will not go on to realize their potential as amazing surgeons.

I would be lying if I said that surgery is lifestyle friendly. In fact, anyone who has followed this blog for more than a millisecond knows that many of our daily woes outside of work arise from the demanding hours and high stress of our career choice. But the question is: What does mommy friendly even mean? This is not the same as the “mother’s hours” often noted as selling points in help wanted ads. There may be ways to go really part-time or certain very specific specialties that enable a woman to only have to be at work when her kids are at school I suppose. But I have to believe that mommy friendly is about more than just the hours.

I know, I know. You are just waiting for me to launch into the cliche of it’s quality, not quantity. But I won’t. 

Because the truth is I wrote all the words above nearly 500 days ago. It turns out I never finished because I don’t know what mommy friendly means when it’s used as an adjective for a career. 

Since I first wrote the beginning of this blog post, I have spent well over a year of my life as a surgeon and a mother. I even wrote an open letter to young women with the same opening line evidently having forgotten about this draft. That letter, now read more than 15 thousand times, doesn’t define mommy friendly either.  

Paid maternity leave. Private pumping rooms. Childcare. A promotion clock that doesn’t penalize for maternity leaves. 

To be sure any work place can provide these but do the amenities in and of themselves mean the associated profession is mommy friendly? Not if the backhanded comments or outright displays of resent persist. Often, the culture of the profession is at odds with these progressive work place policies. And these replies on what medical career to choose clearly indicate that the culture of medicine has not caught up to modern times. 

Luckily, however, not every one is reading the same message board. And so this week across the country a whole new crop of women begin training as surgeons. They are less a minority and more just reflective of the demographic of modern surgery. Hopefully, they will all become surgeons (there is still some attrition in our programs nationally) and some will become mothers. And my hope is that, together with the men they are training with, they will foster a culture in which is it no longer necessary to ask if surgery is a mommy friendly. 

Who do you save? The emotional impact of mass casualties.

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A 6 year old boy with abnormal pupils and gasping for breath.

A 26 year old pregnant woman with a gunshot wound to her abdomen.

A 54 year old male with blood pouring from a wound in his thigh.

Now add 43 more patients.

Imagine you are the paramedic at this scene.  Who do you take to the hospital first?  Who do you have to choose to walk past and leave at the scene while you take your patient to the hospital?

Now imagine you are the surgeon.  You walk into an emergency room with blood everywhere – covering faces, limbs, the floors.  There is a cacophony of sound – screams, cries, gasps, whimpers.  Where do you start?  Which room and which patient gets your attention first?  How many patients, calling out to you for help, do you have to pass by?  What operation will you perform and how will you perform it knowing there are nearly 50 other patients needing your attention at that very same moment?  Will you be right?  Will you save everyone you could?

As a trauma surgeon, these are the real types of questions that we are given when training for mass casualty situations.  And although the patient specifics listed above are not from the shooting, these are still the same thoughts that every single healthcare worker and all six trauma surgeons in Orlando right now have had and will continue to have for months to come.

26 operations in 12 hours.  I wish I could adequately describe the inhuman and superhuman effort that this represents from the trauma surgeons at Orlando Health, one of whom has been a friend of mine since high school.  When I first heard the news I immediately contacted him, letting him know I was thinking of him and his team, knowing exactly that this day will never leave him, or any of them.  I have written before describing the multitude of feelings involved when losing a patient… but this is just the tip of the iceberg when discussing a situation of this magnitude.

After the adrenaline surge, after the floors are mopped, the scrubs are changed, and the patients sorted through, they will pick apart this day – every last detail, decision, and action will be analyzed, examined, and questioned – and never forgotten by a single person who touched a patient on June 12th, 2016.

These six trauma surgeons have made a thousand decisions in the past 24 hours – the types of decisions that no one should ever have to make, but are unfortunately faced more and more by those of us in this field.

To the surgeons at Orlando Health – I know you haven’t slept.  I know you haven’t eaten.  I know you haven’t sat down in close to 30 hours.  I know you are mad, I know you are sad.  Stay strong my friends, we are all with you.

My thoughts and prayers go out to the victims, their families, the first responders and healthcare workers in Orlando – #lovewins.

 

 

 

The trouble with discourse that drives us apart in response to a death in the line of duty

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Cross-posting from the heenastat blog.


 

My heart sank when I heard the news that a local police officer had been killed in the line of duty. I was not on call that day but I knew exactly what the words “he was taken to a local hospital where he was later pronounced dead” meant. As trauma surgeons we provide care for those injured in senseless, often preventable ways daily. But when an officer is stricken it hurts in so deeply because we share a position with them at the forefront of the worst that happens in our society.

So when I heard the news I mourned for the officer, for his family, for his colleagues, for all of law enforcement, and for the people who tried so valiantly to save his life and would forever be asking themselves “was there something else we could have done?”

Let me assure you, there was not.

As with all trauma centers, we have a comprehensive morning report where we discuss all of our new patients: what was the mechanism, how did they present, what was done for the work-up and subsequent treatment? So it was clear that the trauma team did everything they scientifically or physiologically could in this case. In morbidity and mortality* terms, this would be a ‘non-preventable’ death.

Here’s the thing though, of course it was preventable. And we are all (as members of the community, as his brothers and sisters in law enforcement, as representatives of both sides of the criminal justice system, as providers in the healthcare system) asking this same question “why, why did a good man—a good cop, a good husband, a good father, a good son, a good citizen—die this way?”

In a statement to the press less soon after losing her son, the officer’s grief-stricken mother was quoted as saying there is “no respect for police anymore” suggesting perhaps that a pervasive devaluing of law enforcement by society might be at the root of her son’s preventable death. She was no doubt alluding to the national discourse evolving in recent years due to some high profile episodes where the actions of responding officers have been questioned. Some actions have been proven to be criminal by our justice system, as in the case of an Oklahoma City Police Officer who serially raped women he had pulled over, in other cases, however, the facts in support of criminal behavior beyond a reasonable doubt are less clear (e.g., Officer Parker of Madison, AL and Mr. Sureshbhai Patel; or Officer Wilson of Ferguson, MO and Mr. Michael Brown; or Officer Pantaleo of New York, NY and Mr. Eric Garner).

Clarity notwithstanding, there has seemingly been a shift in public rhetoric questioning of infallibility of those on the front lines of law enforcement. Sadly, in some cases the rhetoric has escalated to vitriol, rioting, and even directed acts of violence against law enforcement.  It truly is maddening that a man, fueled by the overarching discourse questioning police intentions and behavior, would then seek an opportunity to kill the police as in the case of Mr. Ismaaiyl Brinsley who gunned down Officers Wenjian Liu and Rafael Ramos of the NYPD, not during the act of apprehension or while committing another crime, but just because.

However, no matter what the headlines are, the overwhelming majority of our men and women in blue are good men and women who take on their duties with the best of intentions and model professional behavior. And so, when this good man’s mother cites this volatile discourse as a possible cause of his death—as much as my heart breaks for her—it hurts our community by suggesting a local conflict where there was none.

By all accounts, the cop killer in this case was a sociopath lacking any respect for human life or the laws of our society in general as evident by a lengthy record replete with charges ranging from cocaine trafficking, to assault & battery, to weapons possession. Those of us who are not career criminals might get tachycardic or diaphoretic during traffic stops but our natural instinct is to reach for our license & registration, not for our gun. A man with no moral compass felt cornered and so he fired; but, this was no more because he was cornered by an officer than if I had made some gesture to this armed and dangerous criminal during my nightly dog walk.

So, while a family, a profession, and a community mourn, I urge each of us to contemplate how the criminal justice system might have functioned differently to prevent this senseless tragedy but to avoid stoking fired up rhetoric that pits people against the police and police against the people. Discourse that drives us apart stands in the way of viable solutions to combat the socioeconomic and psychological factors that may drive one to a lifetime of crime in the first place and to take those who cannot be rehabilitated off the streets before another preventable death, be it of an ordinary citizen or a man/woman in blue.

______________________________________________

*Morbidity & Mortality, or M&M as it is called is a weekly conference held by surgical teams to review all deaths and complications in an effort to learn more about the systems-based and disease-based processes that led to the adverse outcome.

 

 

An Explanation: The #1 tool in your physician’s toolkit

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Cross-posting from the heenastat blog.


 

It was almost a formality, me rounding on that patient that day.

The obstruction had resolved. The nasogastric tube was out.   If the diet advanced as expected he could be discharged to continue his chemotherapy. He was not even my primary patient. He was on the heme-onc service so I wasn’t even responsible for the paperwork.

Yes, he was dying of cancer. That was not news to him. Nor was the nausea and vomiting that he had come to expect in the wake of periodic infusions of poison. That which was intended to kill the cancer cells also killed a little bit of his insides with every dose. But the distention and obstipation was new. He had not felt right 4 days ago and he had rightfully come to the ER.

His diagnosis was small bowel obstruction. However, one could not tell from the CT scan if it was due to adhesions from his cancer surgery some years ago or due to new tumors scattered in his pelvis which had in recent months made him the unfortunate bearer of the “stage 4 cancer” moniker. As if the side effects of chemo for his cancer recurrence were not enough, now he had to suffer through this. But he was better by the time I met him as the new attending on a consulting service.

My exam confirmed the residents’ optimism that the obstruction had resolved. It was likely adhesions given the swift improvement and I noted how the nasogastric tube works to relieve such obstructions to the patient and his wife. But I explained that we were not sure, based on the original CT scan, if the cancer was playing a role in impeding the flow of GI contents. Either way, as long as he was able to tolerate oral feeds he could resume his cancer treatment with the hopes that the same symptoms would not recur. He did not need an operation in the immediate future. The patient and his wife were relieved.

As I concluded my visit, I asked (as I always do) if there were any other questions.

“No,” replied the patient’s wife. “But thank you so much. In all our time here, no one has explained what was really happening. Thanks for making it so clear. We really appreciate it.”

________________________________________________________________

I know I have written about this before-about the power of clarity in the medical encounter.

But seriously, I was at least the 4th attending physician to meet the patient not to mention the countless 1st through 6th post-graduate year trainees who had cared for the patient before I met him. Yet no one had taken the few minutes it would take to explain why the patient felt so miserable and how an uncomfortable tube down his nose might help.

Understanding the disease process is pathophysiology 101. Explaining it to the patient is doctoring 101. Sure, doctoring 201 is the art of explaining it in a way that caters to a patient’s educational and verbal capacity without instilling fear; but that no one had even tried just made me sad as a physician and as an educator. Once again, I took solace in the fact that there was a resident with me to both observe the explanation and to witness the words of gratitude. Hopefully, that’s my way of paying it forward just a little bit.

So at the risk of sounding too preachy let me leave you with this: If you take care of patients, remember they and those who love them are humans in a state of crisis. Amidst the pain, the fear, and the uncertainty of what’s to come, taking a moment to offer an explanation for the suffering can go so much further than any medication or procedure. Consider it the #1 tool in your physician’s toolkit.

The Miracle Worker Gets a Hug

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Cross-posting from the heenastat blog.


 

The tension between the desire to provide the best care and the system putting up road blocks was building the entire day. As the surgeon advocating for my patient, it felt like the smoldering rapidly progressed to full on conflagration. And yet, the patient and his family were calm and full of grace.

On morning rounds, I told my patient that his hernia remained reduced but there was an area along the bowel that had been stuck the prior evening that looked worrisome on CT scan. His vitals, exam, and blood work were reassuring, I explained. There was no imminent rush, no immediate threat to bowel or life. However, it made sense to get this done as soon as possible. The patient, and his wife at the bedside, understood. I had explained a clear set of options for what to do about the hernia depending on a) how the bowel looked when we put the cameras in and b) based on my understanding of his baseline co-morbidities. He was a smoker with a chronic cough that exacerbated his hernia. I spent a little bit of time counseling him that this might be an ideal time to quit. Anything to ameliorate the cough during the recovery process and beyond would reduce the chance of recurrence.

Those words “as soon as possible” resonated in my head as the wait for OR time dragged on all day.  Circumstances were at a systems level well beyond my control; the absence of an immediate life threat meant I had no real leverage other than rants about patient satisfaction and costs of prolonged length of stay. This meant nothing given that there were patients who truly needed life or limb saving interventions, including one of my own who arrived at 5pm with free air.

This patient was too stable.

I had run up to his bedside a few times during the day with updates to the effect of “not sure yet…but you continue to look good…as soon as possible” He and his family–thankfully–were remarkably affable while I was becoming more and more agitated at the OR inefficiency in between urgent cases.

[I could write a dissertation on OR efficiency, or lack of it. And, certainly this is not a problem limited to my workplace. But that’s not what this blog is about.]

I was not on call that night. The OR could finally accommodate the case in the late evening. It went as well as could have been expected. The bowel looked great. The patient got the best case scenario of the options I had presented to him some 16 hours previously.

When I went to talk to the patient’s wife afterward in the waiting area it was almost midnight. She was exhausted from a day of anticipation. From two hours of anxiously waiting while her husband was in the OR. She gave me a giant hug and thanked me so profusely for sticking by him. “I know you have been here since so early this morning,” she said. In the moment of that most genuine embrace, the fire went out and the frustration of the day slipped away.

The next day, in preparation for discharge, the patient was exuberant. “You’re a miracle worker doc!” he exclaimed. “I’m done with the butts now. Forever. Thanks to you. And you fixed my hernia. You’re a miracle worker.”

It took me a while to figure it out since it’s been forever since someone referred to cigarettes as butts to me. The miracle was not that I fixed the hernia. It was that for the first time in 50 years he was motivated to quit smoking. His wife would stop too, she told me that day.

It was a tough day at work but this lovely couple thought I was a miracle worker deserving of a hug despite it all. No anger. No bitterness. Just genuine gratitude, a case that went textbook well, and some preventative medicine to boot. What more could a beleaguered surgeon ask for?

[Posted with patient’s permission.]

Hey Doc!

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Cross-posting from the heenastat blog.


 

“Hey Doc!” I heard the patient say as I blazed by Bed A.

Bed A is the ‘door’ bed. My patient was in Bed B, the ‘window’ bed. I had just met him; it was a new inpatient consult. For all the rules and regulations surrounding patient confidentiality, the curtains between beds do little to protect privacy since inevitably there will be audible conversations about symptoms, diagnosis, and management between patients and the doctors, nurses, or family who visit them.

The residents had already seen the patient in Bed B and were reviewing his case in detail with me between OR cases. I looked at my watch, contemplated typical OR turnover time for a moment, and decided we had enough time to get the consult done.

When I got to Bed B, I introduced myself to the patient and sat at the edge of his bed. I explained that I had already reviewed his story, lab data, and imaging and confirmed these facts. I stood briefly to perform my physical exam before beginning to scrawl on an index card. I simplistically portrayed the complex anatomic relationships between the liver, the gallbladder, and the pancreas and the series of tubes (the biliary tree) that connect these organs. I described how stones form when the balance of three ingredients (bile salts, lecithin, and cholesterol) in the viscous fluid (bile) made by the liver, and stored in the gallbladder, gets off kilter and how those stones can then cause blockages at various points along that biliary tree. I showed the patient where his problem was and used hash marks to explain the operation and what would be removed.

Before getting my patient’s signature on the consent form, I made sure any questions were answered and asked if he wanted me to call a family member to summarize the details. He said no and signed.

Conversations like this take time. Whether it is the 4 patients per 15 minute block in clinic or the patient who I am rushing to see between OR cases, I invariably feel pressed for time when talking to patients. But I do what I have to do, often skipping meals or holding in bodily functions while incorporating a brisk walking speed to keep up with competing demands, none of which seem to incentivize having thoughtful and thorough conversations with patients and/or their families.

After telling the patient in Bed B that I would see him in the pre-op holding area the following day, I upped my walking pace so I could run back down to the OR to my next patient. I had already taken too long and was anticipating the reprimand of the OR board. And that’s when I heard the patient in Bed A.

“Hey Doc!”

“Ugh” I thought to myself, “I really don’t have the time to find this guy’s nurse for his pain meds or to figure out how to keep his IV from beeping…”

But how could I not stop? He was addressing me directly so I paused and turned to him from the threshold to the room.

“Hey Doc! It ain’t none of my business or anything but I just wanted to say that there would be a lot less fear in healthcare if all doctors explained things the way you do.”

I was humbled by this man’s feedback. I hoped my residents were listening, both to the man in Bed A and to what had just transpired before Bed B.

I find it very irritating when students or residents peel away or talk among themselves, as if they are sick of hearing what I have to say, while I am having conversations with our patients. To me, modeling doctor-patient communication is my greatest gift to them as a teacher and a mentor. I want them to listen, to observe, to understand that every encounter is a chance to learn.

As we hustled back to the OR, I turned to the residents and proudly said “For as much pride as we surgeons take in doing the perfect operation or nailing a difficult diagnosis, what happened back there might have been the highlight of my career.”

An Open Letter to Young Women Considering a Career in Surgery

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Dear Young Woman Considering a Career in Surgery,

It was lovely to meet you the other day. Many times a month, a young woman just like you comes to me with similar interests and concerns. “I really love surgery,” she says, ” But I am afraid of the lifestyle and I really want to have a family.”

Oh, and thank you for also inviting me to speak at your seminar the other day on Women in Traditionally Male Dominated Fields. I have been speaking at similar panel sessions since 2005 when I was a bit of a novelty at my training program as a clinical PGY-4 with an infant daughter. Your collective curiosity on what my life must be like is of great interest to me because to me it’s just my life. It’s the only reality that I know because, like you, I was young (just a few days into my 25th year, just 5 days into my first ever surgical rotation) when it occurred to me that I really loved surgery. It was unexpected; but every day since then (from the remainder of that MS3 rotation, to my sub-internships, to my years in residency, to research and clinical fellowships, and to these past 6 years on staff) I have crafted a reality, as tenuous as it is, that works for me and my family in any given moment in time.

And I am here to tell you that you can do the same too if you, in your heart of hearts, can think of nothing more exciting than surgery as your professional passion.

People outside of surgery will tell you that it’s a career that is too hard to integrate with family life. They are correct that it is generally harder than other fields in medicine; but, ask yourself if you truly want a career in general pediatrics, or dermatology, or invasive cardiology or anything in between. If the answer for whatever alternate field(s) you are considering is no, then no matter how many fewer hours your profession requires, no matter how much more flexible those hours may be, your family will be left with a present, well-rested, yet bitter wife and mother.

[NB: I use the word integrate very purposefully here. Anyone from a demanding profession, surgery or otherwise, who tells you that work-life balance is possible is conning you. Your life will never be in balance. Something will always have to give: your work, your family, or yourself. It’s in how you integrate these things in a shifting, fluid professional and personal lifetime that you will craft your own reality.]

 

The same can be said of those who encourage you to enter surgery training but then offer that you may consider a career in breast surgery or start an exclusive vein clinic or choose some other presumably less time sensitive and/or less time consuming surgical practice to balance your professional work with your desire to have a family. Again, ask yourself  if you can truly be happy in such a practice. (I personally would be bored with only a few kinds of procedures in my armamentarium and the absence of physiologic chaos; but everyone is different.) You may not know the answer until you are well into your training; but, choosing a medical specialty in the first place, or a surgical subspecialty in the second, simply because you presume it will be easier for family life is fraught with potential for professional dissatisfaction. I promise you that professional dissatisfaction will always stand in the way of overall family life satisfaction. Always. Forever.

Finally, as hard as it might be to envision yourself as a surgeon who wants hobbies, and a spouse, and a smoking hot body, and children of your own someday,  remind yourself that divorced parents, widowed parents, disabled parents, parents with deployed military spouses, and parents with far fewer socio-economic resources than practicing surgeons, and trainees for that matter, somehow get it done. Every life has it’s particular challenges when it comes to parenting but surely being a surgeon is not the most insurmountable of them all.

So think long and hard about alternatives to surgery; but choose one only if it speaks to your professional soul. No matter what career you choose, you will likely spend more time at work than on any other aspect of your life be it parenting, self-care, love-making, you name it. Therefore, it is critically important that your choice of career light the fire in your belly to show up every day leaving behind, at least temporarily, everything else including your children. Because one thing is for sure: when you are practicing surgery, your head needs to be in the game. You cannot be distracted by guilt about not being with  your family or about delegating some of the more mundane aspects of childrearing or homemaking to others. You must love the work enough to drop the guilt and create practical solutions to raise your children and provide them with a safe and loving space in which to grow while reimagining whatever stereotypes you hold about being the perfect parent.

Because you know what: There is no such thing as a perfect parent, surgeon or otherwise. So there will never be any point in beating yourself up about it. Know that you will love your children more than you could have ever imagined loving anything, including surgery, but that you will still be a great surgeon. The two are not incompatible, but it takes some effort and creativity.

So, now that I have convinced you to choose the career of your dreams here are some thoughts on the effort and creativity it will require.

Do not underestimate the importance of choosing a life partner who gets the soul inspiring nature of your career choice. He/She may be another surgeon, or physician in another specialty, or a non-medical professional, or a skilled laborer; it doesn’t matter as long as your life partner understands that, when you are tired from the long days and nights, or sorrowful for the lost lives, or otherwise distracted, it is not because you love work more than you love them. Bottom line: as awesome as any career may be there is something messed up about your priorities if you really would choose work over loved ones. So your life partner needs to get that you aren’t messed up; you just have a demanding career.

With the demands of that career comes the need for a real partnership in planning life. That doesn’t mean a 50:50 split or a 80:20 split or anything conscribed; it means a constant openness to splitting however it needs to be split or not splitting at all to ensure that life outside of work happens. It means making the most of precious few waking moments together through physical contact and communication. It means having a very user friendly calendar/shared to-do system. It means providing feedback without judgment for the practical things in life and making space for shared emotional and spiritual needs. If you find yourself paired up with someone who can’t work with you on life this way, then consider dumping him/her. Seriously, it’s not worth trying to make them happy if they just don’t get this hugely important part of what makes you whole.

[NB: If a life partner is not your thing or things just don’t work out, that’s okay. The same principles of reimagining, outsourcing, and dropping the guilt apply. It’s just that your village, or metropolis as may be the case for some surgeons, has a different population structure.]

 

Choose your job based on both professional and personal needs. Training is finite and there is always an end from which to take on a new direction. However, even though many surgeons change jobs, think of your job as your forever job so you don’t accept a situation which will turn out to be toxic for you. Choose partners who will have your back, and you, in turn need to be willing to have theirs. Choose geography that at least satisfies some of your desires for commute time, distance from extended family, lifestyle, weather, etc. and makes life easier. You can’t blame surgery if your long commute destroys your soul, or if having your parents thousands of miles away makes you sad, or if humidity, piles of snow, or whatever your most dreaded weather phenomenon is drives you crazy, or if it takes a flight to get to your favorite past time of hiking, biking, skiing, etc. That’s on you and the choices you have made as a surgeon and not on the profession itself. Finally, choose a practice type and setting that will make you excited to show up every day (for me it was research, teaching, and a level 1 trauma center in a university based system).

If you do have a life partner and working is important to him/her, don’t pick a location that will railroad his/her career. As much as being a surgeon defines you, your soul mate is similarly defined. Please don’t create a situation where he/she will be susceptible to resentment about having his/her professional goals squashed. (I’ve been there. It puts a real strain on a marriage. It sucks.) It’s already hard enough to be paired up with you, a surgeon. Both your jobs may be equally demanding, or one may be more demanding; it doesn’t matter as long as together you negotiate a mutually satisfying life-long give and take about who prioritizes what and when depending on the stages of your respective careers and the ever evolving needs of your family.

When is comes to family, do not waste too much mental effort over-thinking when you should start it. Fertility, along with finding the right person with whom to test your fertility, is a complex and unpredictable thing. No pregnancy is guaranteed to proceed smoothly. Given these inherent limitations and unknowns, along with the demands of a surgical career, there is no perfect time to start a family. This is about as certain as death and taxes. I will spare you the perceived pros and cons to having children during training compared to while in practice. Just know that every time period poses challenges and every passing year makes infertility more likely; so if you are ready in your personal life to try to get pregnant go for it; because, if you choose to wait for a perfect time, you will be waiting for a very, very long time.

And, if having children in a traditional sense is not possible for whatever reason, there is also no perfect time for assisted reproduction, adoption, or surrogacy either even though the salary increase a staff surgeon or faculty job may be necessary for these options. In the end, whatever approach to becoming a parent will be required,  you will figure out a way to get through the challenges because you will have mentally and emotionally committed yourself to the idea of being a mother who also happens to be a surgeon.

[NB: If you choose to not have children-by this I really mean choose as there are myriad other mishaps of life and physiology that prevent women who want to be mothers from becoming mothers-, please do not make that choice simply because you want to succeed as a surgeon. You will never forgive yourself. Not ever.]

 

When it comes to family there are various options to manage childrearing and homemaking. A nanny, two nannies, an au pair, daycare, a nearby grandparent, a neighbor who is a stay-at-home parent, or various combinations of these may be required to keep your children loved and safe. It’s different for every family and I promise you that you will find what works for  you. It will be a source of stress but it is doable. And, no matter how much time others spend rearing your children on your behalf, those kids somehow know that your are their mother, that you love them in a way beyond any other love, that you would give your own life if it would save them, and that you also happen to be a busy surgeon. Trust me. They will. And, they will be really proud of the uniqueness of their surgeon mom. They really will.

When it comes to your home, be it your 600 sqft rental in residency or your 2500 sqft grown up home in a cul de sac, outsource any jobs you and/or your partner simply do not enjoy. I cannot emphasize this enough. You will, in fact, have precious little time with your family. Ask yourself how you want to spend that time. Do you want to being cleaning and doing laundry? Or do you want to plan a family outing? If hopping on your John Deere and showing your lawn whose boss on your Saturday off is a fun activity for you, then by all means go for it, otherwise someone else will be happy to mow your lawn for a fee. If you love cooking, knock yourself out planning, shopping for, and preparing gourmet meals along with the associated clean up, but if you don’t then find a meal service. You get the point. If you don’t love it and it can be done by someone else outsource it. Even on a trainee’s budget you should strive to rid yourself of any household obligations you abhor. (For me the $55 spent every other week during residency for cleaning was well worth never having to spend a day off cleaning a toilet and now the extra hours we pay our nanny to do all of our laundry has spared me a monthly power weekend of washing and folding 10 loads of laundry because we just could not get to it all with the many kids’ activities, call nights, etc. that prevent daily washing.)

Remember: as little time as you will have at home to spend with family, you must also prioritize time for yourself. Don’t expect it to just happen. Just as you schedule elective OR cases, you must schedule elective you time. It may not happen very often but if you don’t take the time for self care in the midst of the stresses of the job and the stresses of parenting you will be cranky and miserable to be around. How you spend time away from family when you have so little time with them will change over time and you may even develop hobbies incorporating your family (we have taken to family bike rides and kayaking trips as the kids have gotten older to combine wellness with family time) but remember to schedule things that feel completely selfish to you. A girls’ night, date night, a pedicure, reading a trashy novel, going to a Zumba class during bath/bedtime, or whatever you enjoy is totally not selfish but you will feel that way; so a good barometer for whether or not you are making time for self care is how selfish it feels. My advice is feel selfish at least once a month.

[NB: If your selfish thing is not a fitness thing then you have to also figure out how to fit that in because your patients and your family need you to be healthy.]

 

Being a surgeon is not incompatible with being a good wife, mother, athlete, whatever else; it’s just trickier. But, if young women keep being scared away from surgical careers then these same fears will linger generation after generation; we will never achieve a critical mass of women surgeons in the profession who can set good examples for one another and for future surgeons. With the same focus we apply in the OR and the same organization we bring to rounds and the same compassion we bring to patient encounters, we can create a life strategy that overcomes these perceived barriers for both a happy family life and a successful surgical career. The barriers will change depending on the stage of the career you love so much and the needs, wants, and development of what and who you love outside of work; but, take it from this surgeon mom: they are barriers to be overcome, not shied away from.

I am pretty sure that’s why you showed up at my door and asked me to that seminar, to make what seems impossible to you at the moment seem possible. Let me tell you: if I can do it, you can too. Go forth, be a surgeon, be a wife, be a mom, be good to yourself and craft a reality that works for you. Then, pay it forward so that someday these meetings and seminars might be rendered obsolete.

Sincerely,

@surgeoninheels

Not just a token surgeon-mom-wife-runner

PS. Here is some inspiration. Your potential in surgery is limitless. https://www.womensurgeons.org/in-practice/leaders-in-surgery/

PPS. The Association of Women Surgeons is an invaluable professional organization whose goal is to: ENGAGE current and future women surgeons to realize their professional and personal goals. EMPOWER women to succeed. EXCEL in those aspirations through mentorship, education and a networking community that promotes their contributions and achievements as students, surgeons and leaders. https://www.womensurgeons.org/

PPPS. I have been fortunate for the last 10+ years to be a part of the American College of Surgeons Women in Surgery Committee working towards improved gender parity, opportunities for professional development, and better work life integration in our careers. https://www.facs.org/about-acs/governance/acs-committees/women-in-surgery-committee

Grief

Featured

Cross-posting from the heenastat blog.


I have been waiting for a moment of joy in the profession that did not involve death to write again. It turns out that those moments are few and far between and I feel compelled to write a few words today. Writing, sharing, letting out the feelings I must keep at bay when I am with my patients and their families is therapeutic. 

Bearing witness to physical pain and emotional suffering is part of the job. The opportunity to ameliorate the body’s failure and to transcend the soul’s response are part of the allure of the work of surgeons, in particular trauma surgeons like myself. A good day at work for me–a day when I get to flex my life saving muscle and bask in the glory of my critical care prowess–is a bad day for anyone on the receiving end of my clinical skills and empathy, no matter what the outcome.

No one wakes up expecting to be at the center of a human tragedy. Yet, as trauma surgeons we are thrust into a peripheral role in such tragedies daily. In my typical week on service (a few nights on call, 7 days of rounding, two clinics, and reams of accumulating paperwork) the balance of patients with minor injuries, good outcomes, or major life saves typically outweigh those with severe life-threatening injuries at risk of high morbidity and mortality.  But this has been an atypical week.

These last 6 days have been filled with inexplicable events and unimaginable losses for my patients and their families. Car crashes, suicide, house fires, occupational hazards, animal attacks, physical abuse, interpersonal violence. The causes have been varied. The effects have been a river of tears flowing through a mountain of grief. The landscape of sorrow created by these tragedies has exhausted me far more than the overnights and the ~110 hours logged in the effort to provide round the clock trauma care.

As surgeons, we hope not to grow too used to it, not to become cold and unfeeling in the face of human tragedy. But we need some way to move on. This week, I feel buoyed by gratitude of surviving family members and the supportive words from fellow providers. The warm embrace and patience of those who love me and care for me during those few hours away from work have also helped. But with one more day to go, I am simply wishing for a quiet last day on service devoid of human tragedy. No more bravado in the trauma bay. No more delivering bad news. No more grief for the people in my catchment area. We all need a break.

[originally posted 3/6/2016]