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.
“Not again,” we all silently sigh when the page comes through. He arrives under lock and key and stays that way no matter what our plan. Every trauma surgeon and nearly every resident has previously participated in his care over the years.
He has a life sentence.
The abdomen is socked in. There is no more retrieving the foreign bodies piercing his abdominal cavity. We have been there and done that. If something is visible on the outside we can pull it out. Now we just have to hope whatever was injured causes a process that walls itself off and does not cause too much physiologic compromise.
But what about the psychologic compromise? He does not wish to end his life; that much is clear. But he is looking for escape. The lure of the secondary gain is strong. He has admitted to us:
The food here is better.
The nurses are cute.
I don’t want to be near the pedophiles.
With our incarcerated patients, it is not our place to address these cries for help. We can’t imagine the fortitude it must take to clandestinely acquire a sharp object and then meticulously drive it through the abdominal wall into whatever organs lie beneath; but, we must stay focused on the anatomic issues and potential complications.
He is screaming at us now. The guards tell him to calm down. Now it is his words that pierce our ears:
You have to cut me open.
Please put me to sleep.
I am not a bad person.
As trauma surgeons we view all patients as equal. They all deserve the same compassion and high standard of care no matter what the circumstances of the injury, no matter what the personal status of the patient. We never, not ever, inquire as to the circumstances of the crime(s) for which the patient is serving his sentence or how long the sentence is. None of that matters. He is our patient and we provide him the best care possible.
Today the best care possible is to provide minor bedside care with local anesthetic to remove a foreign body. To calm him down I take his hand while the residents work. I lock his eyes so he will stop trying to see their sterile field. I ask him about himself. I am not sure why but it seemed like the natural thing to do.
He tells us where he grew up. He describes his childhood. He takes a sentence to describe his crime and then speaks more in detail about how the next 37 years of his life sentence led to today. He says:
I wasn’t always like this.
I used to be normal.
Now, this is the only way I know how to cope.
The self-inflicted stab wound will be fine. No hospital food needed. No bedside care from nurses needed. But before he goes back to his bunk with the pedophile, I tell him that we are sorry things turned out this way for him. We wish him luck trying to cope better but we fear he won’t be that lucky.
“Please don’t cut off my pants,” he pleaded. “I am homeless and they are my only pants. Please.”
He could say these words as we were conducting our initial assessment in the trauma bay so at least he was hemodynamically stable with an intact airway at that moment in time. However, he had arrived seconds earlier with potentially life threatening injuries as a level 1 trauma activation. Based on the location of wounds that were visible on his torso this was a real possibility so we needed to quickly conduct our secondary assessment. That meant rapid exposure by taking the trauma shears, one on each pant leg from my assistants, as we examined him from head to toe, front to back, in every crevice or crease that might hide a wound.
I looked him straight in the eye and said “Don’t worry. We will get you a pair of pants but right now we have to take care of you.”
Straight in the eye.
He relented. How could he not? The pants were already cut off even as I made eye contact. The process takes just seconds in the hands of a coordinated trauma team.
He was a very polite young man. He didn’t yell or kick or scream. He followed all of our instructions. He quietly told us his health, social, and family history. He told us he was scared. His life story mirrored that of many of our trauma patients: food insecurity, lack of affordable housing, few resources for education and job training, addiction, interpersonal violence, an endless vicious cycle. He was caught in that cycle and it was obvious that he was heartbroken to be there. He wanted a better life and tonight in the trauma bay, without his pants, he had failed once again to break it.
I always say that I was attracted to a career in trauma surgery because I am part surgeon and part social worker. In reality neither I nor the social worker employed by my hospital to help patients in need of socioeconomic support have much to offer our patients with these very real struggles. The policy level changes and investments that would bring grocery options, better schools, safe and affordable housing to our most underserved areas are not in our control. Even for those patients who want to make a change there are too few addiction treatment beds and job training programs. While these issues are clearly predictors of health, they are managed partly (addiction services) or entirely (basically everything else) outside of the healthcare system.
Yet every day we see the ravaging effects of socioeconomic insecurity on our population’s safety and well-being when they become our patients. We open the trauma bay doors and provide the full armamentarium of modern medicine to save a life acutely while feeling powerless to save lives at the societal level*.
We finished examining and working up our patient. He was not going to die that night and could be discharged. Discharged where? It was 3 in the morning. The social worker could give him the address of a shelter in town. There might be a bunk free. She could refer him to addiction treatment. There might be an available bed. A local non-profit might intervene in the light of day if we could make the connection. But we had no way to guarantee that this man, who was lucky to be alive, would not simply just slip back into his otherwise unlucky life after discharge.
Oh, and there weren’t even any pants to give him. The social worker’s closet of donation was empty of men’s pants it turns out**.
This was not something the trauma team to could bear. We might not be able to provide our patient with better groceries, housing, or addiction treatment to this man who in all of his words and actions as our trauma patient showed us a deep hope to be in a better place in life; but the least we could do is provide him the dignity of a pair of pants to head back into his unfair reality.
So we pooled our cash on hand, asked him what size he wore, and waited until the local Target and Kohl’s opened***. The next morning the light in his face and the sincere words of gratitude when he saw his new jeans and a back up pair of track pants and shorts felt like as much of an accomplishment as stabilizing the unstable patients who had entered the trauma bay earlier or the exploratory laparatomy we had done.
“Thank you. Thank you. Thank you,” he said. “I really need these. Thank you.”
He needs so much more. But this was the least we could do.
*NB: Most trauma centers do provide targeted injury prevention like helmet, seat belt, or firearms safety education through small investments or grant funding but these typically address to specific injury mechanisms rather than social policy.
**Men be like the ladies and cull your closets seasonally; donate to your local trauma center.
***If any Kohl’s or Target folks are reading this consider donating items or gift cards to your local trauma center.
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.
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.
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.”
It 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.