An Open Letter to Young Women Considering a Career in Surgery

Originally posted at heelskicksscalpel.com

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

The Office Cleanse

Originally posted in heelskicksscalpel.com

I wrote a post this past weekend on doing nothing.

I think it was a successful strategy, albeit unintentional. I arrived fresh on Monday morning intent upon a full detox of my current state of academic and clinical affairs.

It was to start with the inbox. Somehow (well, I know how–too much spam targeting my clinical work, too much spam targeting my research, too many mass emails from my medical center, too many mass emails from my medical school, too many predatory journals,  too many published before print journal alerts, and well too many bogus unsubscribe links in the past), it has burgeoned to >3500 emails. Most were read but just had not be disposed of or allocated. In the ensuing 4 days I meticulously cut through these emails. I made choices not to be tied to past opportunities for knowledge or connection and got down to <10 rather efficiently.

In between I had several important meetings which were a good break from the task of purging all of these electronic communications. I also found a few almost missed opportunities and was able to take a break from the inbox to write a grant application due Friday and an abstract due Friday. I finally got around to editing a manuscript sent to me a few weeks ago. I updated my CV as with events/accomplishments I was triggered to remember by some of these emails.

Yah me!

When the inbox was a tamed beast it was time to shed more excess weight from my work life.

Though not really behind, I did not look for an excuse to wait another day to get my billing and coding done (yes, I was trained and educated to be a surgeon and a researcher. no, I did not go to school to become a medical coder. yes, I code and generate a bill for my own notes only to then have a trained coder submit them without ever having to code them for a portion of the fee). The electronic record came after that. Every time a resident gives an order over the telephone it has to be signed later. If it does not get signed, when the chart gets sent to medical records it becomes my job to sign the order. So on top of the discharge summaries, operative notes, etc. that I got of my front burner (yes, undropped bills and unsigned charts don’t really care what else must be done and there’s a stiff penalty looming so yes never on the back burner like say 3500 emails or a manuscript without a hard real deadline) I signed several dozen orders for the likes of “may go to x-ray off telemetry” and “okay to resume diet.”

And finally, even though I decided a few months ago to forego paper subscriptions to journals in so far as possible (mostly for the environmental impact but also to remove the possibility of visual clutter in my office; sadly, with this came a burgeoning of full journal contents in my inbox!) I had a pile about 5 inches high that I tackled. I read a few articles and scanned a few more after looking at each TOC and determining which were worth my time. I then filed some for my endnote library to keep for my future perusal. I have this thing about losing knowledge even if it was not mine in the first place (I think I got it from my immigrant parents). So if it shows up in my mailbox, it will get read lest I miss a chance to learn something I didn’t even know I wanted to learn.

And now, a mere four days after I walked into morbidly obese office situation, I feel cleansed and ready to tackle my real jobs.

I hadn’t planned on hitting the week this way. I did shift around my to do list a bit. I can’t help but wonder if it was the awesomeness of just doing nothing that gave me the pep to get through some of the most onerous stuff I have to do for my work.

Organized Surgery Begins to Battle Burnout

Originally posted in heelskicksscalpel.com

US surgeons are burned out and the numbers are staggering. Whether experiencing emotional exhaustion, depersonalization, or a low sense of personal achievement, 4 in 10 US surgeons exhibit signs and symptoms of burnout. Among neurosurgeons that number jumps to nearly 60%. Burned out surgeons are more likely to report substance abuse, clinical depression, and suicidal ideation. They are more prone to medical errors.

General Surgeon Lifestyles -- Linking to Burnout: Medscape Survey by Carol Peckham March 28, 2013
General Surgeon Lifestyles — Linking to Burnout: Medscape Survey
by Carol Peckham
March 28, 2013

Interestingly, academic practice, trauma sub-specialty, increased nights of call, longer hours worked, younger age, female gender, and small children at home were all risk factors for burnout. For those of you who are new to this blog, I am a female academic trauma surgeon who routinely works long hours and takes in-house call while my small children are at home.

To be clear, these data prove associations and associations do not equal causation; but still, it is sobering to think that so many who entered a profession to fundamentally improve the lives of others are themselves leading such troubled lives due to their chosen occupation.

Embed from Getty ImagesThe occupational hazards of surgical careers are multiple. We suffer moral distress when our patients experience complications or die whether or not an error occurred. We develop compassion fatigue by bearing witness to our patients’ collective and continuous suffering no matter how successful any individual’s outcome may be. Due to our long and often erratic hours, we suffer from chronic fatigue and sleep deprivation. The physical plight caused by fatigue is complicated by many hours on our feet and maintaining awkward postures in the operating room. By routinely putting our patients before ourselves, we often exhibit illness presenteeism. Not infreqeuently, we face the double bind of choosing between being there for our patients or being there for our family. Meanwhile, whether it’s catching up with billing and coding one day, keeping up with meaningful use another day, or spending days studying subjects totally irrelevant to one’s daily practice for maintenance of certification, delivering care in the modern error mandates many a frustrating task that ultimately does nothing to benefit our patients. Furthermore, there is constant fear of litigation that might ruin us in financially or reputationally. And so, it is not surprising that so many of us are burned out.

Emotional awareness (how are you feeling, how does what you are feeling impact your behavior, and how does what you are feeling impact those around you)

All is not dark, however. There are ways for us to be well and resilient. They require both individual effort and culture change. Importantly, they demand emotional awareness. When we understand how we are feeling impacts both our perceptions and our actions, we can act in a way that props us up rather than gets us down.

I was heartened this past week that the American College of Surgeons chose to put surgeon wellness and resiliency on equal footing with the likes of “what’s new in hernia repair” or “ethical challenges in geriatric surgery.” There were a number of educational panel sessions tackling burnout head on. Whether is was about bouncing back in the face of personal loss, gender discrimination, pathways to help surgeons recovering from alcohol abuse back into clinical practice, or managing fatigue, the program was replete with informative sessions on burnout avoidance. Mindfulness, time management, kinship, and down time were emphasized as was physical fitness.

And for the first time ever, the College had a fitness program. As that youngish female academic trauma surgeon with two kids who has struggled with tending to herself after spending her youth, college, medical school, residency, fellowship training, and early years on faculty essentially ignoring personal wellness, I was delighted that this change was happening at my profession’s annual meeting. It was something of a pilot test offering only a very early morning Zumba and a Yoga class, but it was a start. Sure many surgeons at this meeting probably went to the hotel gym or hit the lakefront running path but these efforts happened without the largest surgical professional organization’s imprimatur (hey I even got an American College of Surgeons yoga mat!) or beckoning. These surgeons are likely the 6 in 10 of us who aren’t burned out. But that doesn’t mean we should ignore the self-neglect of our brothers and sisters in the occupation. So this simple step of organizing these fitness events indicated to all attendees that the College both encourages and supports surgeons taking care of themselves. Embed from Getty Images

Making time for fitness has been shown to reduce burnout so I hope the College expands their offerings this time next year. I invite the College to challenge us surgeons to find time for wellness within the already overwhelming conference that offers 5 days of educational sessions geared at making us better surgeons technically and intellectually. The annual Clinical Congress of the American College of Surgeons has essentially had this format the entire time that I have been attending (every year for the past 12 years). With the pilot fitness program the College chose hours and days specifically to not interfere with this typical format. However, given that all the data shows that prioritizing wellness is a key factor in combatting burnout and that wellness takes on many forms, the College should offer multiple offerings–whether it is meditation, or high intensity interval training, or barre, or a knitting circle, or Zumba, or TRX, kick boxing, or spinning, or running– at different times throughout the conference thereby forcing us to prioritize just as I was forced to prioritize between “surgical jeopardy” and “what’s new in body contouring.”

Slide1It will be hard for us to make these choices but we need the practice. I figure its easier to choose wellness when there are no cases to be done or patients waiting in the ER or clinics to be staffed, when there are no lives at risk other than our own.

Fantasies of a Busy Surgeon Mom

Originally posted on heelskicksscalpel.com

  1. Driving past runners donning their night gear just shy of 6am as I head into work, I think, “I would love to be hitting the pavement every morning before work. My days always go better if they begin with run.” Alas, I just can’t make myself do it and be ready for work on time. And, after 12-16 hour days (when I am not on call, 26-40 hours when I am) I am usually too tired and hungry to get it together after work.  Embed from Getty Images
  2. Looking at this month’s calendar and seeing the school curriculum night this Wednesday and dinner with visiting professor next Wednesday and kids’ activities past 7:30pm every Mon/Tue/Thu/Fri, I muse “Wouldn’t it be great to actually go do that couple’s rock climbing class or attend the cheese making workshop one of these nights?” Between work, kids, and work-related travel the idea of making it out, just the two of us, at least twice a month has completely fallen by the wayside. Embed from Getty Images
  3. Seeing all the pictures of fabulous girls’ nights marching along my Facebook feed I contemplate “I would love to go for mani/pedis or finally try paint night with the girls.” Unfortunately, ‘the girls’ don’t exist in my life. Alas, a group of women (heck, even just one woman) in my age range with similar interests, who get(s) me, would love to hang out with me, and have/has a schedule that allows for regular get togethers with me just don’t/doesn’t exist in my life. Embed from Getty Images
  4. Waking up, yet again, in a little pool of drool on the couch with the DVR at the end of the show, I think to myself “I wonder what it’s like to not fall asleep during a much anticipated episode of a binge-watchable series or the football game or the Emmys…” Unfortunately, with my chronic sleep deficit putting me in a semi-recumbant position for any period of time soon leads to a slumber, mind you not a restful slumber just one that will subsequently mess up any hope I have of regaining a reasonable sleep wake cycle. Embed from Getty Images
  5. Having another frustrating call with my father about a health issue I think to myself “I would really like to be one of those children who goes to appointments with their aging parents.” I do my best but often work gets in the way (as it also does for my own doctor and dentist visits). So much gets lost in the translation between me, my parents, and their healthcare providers that I suspect that it leads to more stress and anxiety among all of us and the benefit of me having purposely settled near my family is lost. Embed from Getty Images

To be sure there are ways to overcome to all of these issues. My adult life has essentially been a series of work arounds to fit it all in. Some days I succeed and other days I just fantasize about what it would be like to not have to put so much mental energy into these work arounds so I could just let life unfold with me being the socializing, fitness buff, present mother, attentive daughter, and effective TV watcher that I dream of being.