Lessons I’ve learned along the way.

This is a topic I never thought I would champion – being a female physician. I think gender is only one small part of who we are in the world, but there are some clear themes that come along with being a female physician. Many of these, I’m sure, apply to other physicians who are not phenotypically consistent with their field. So while most of this blog is focused on female docs, I hope that many others can relate to the concepts.

A lot has changed since I started training and social media has been a big driver of this change. It has allowed groups who previously were the minority to reach out to one another and form communities (albeit electronic ones) that plug in like-minded people and allow them to communicate, commiserate, vent, and support one another. I think this is great progress. I was subscribed by a friend to the Facebook group PMG (Physician Mommy Group) and was surprised by how much support these women were offering to one another. The topics posted range from weird rashes and clinical questions to advice on marital troubles, critically ill children, how to negotiate your contract, etc. The members represent a disparate group of women, but ones who share a common profession and a common life experience as mothers. It’s really great that this group exists and I can see the positive impact it has in allowing doctor moms to support one another. We get each other in ways the parents of my daughters friends never will understand me and I’m glad there’s a forum like this.

Another new trend, facilitated by social media has been the movement led by a female trainee who began the tweet phenomenon of #ILookLikeASurgeon. It’s clear that there is a growing need to address the broad expanse of who we, as physicians, are. The stereotypes have begun to be broken down. Our work force is becoming more heterogeneous (although we’re not done working on this yet!) and technology has allowed us to reach one another and acknowledge our similarities. As a young, female academic surgeon mom, I realize on a daily basis that I don’t fit the stereotype of a surgeon that many people have. But moments like this, when a community comes together to declare ourselves – boldly and joyously to celebrate our diversity – this is a moment that I love. We are owning our differences and distinctness while joining with one another to raise awareness that things have changed. The world has changed. I have found great comfort in the comeraderie of these internet groups. I may not know these people personally, but I definitely relate to them. I hope we can continue to raise awareness amongst ourselves and others as to who the physicians and surgeons of the current generation (and our trail-blazers) really are. So keep it going!

These trends got me thinking, and I started this current blog to revisit the topic of being a female physician and a surgeon-scientist mom. I can only speak from my own experience, but I hope that some of what I’ve been working to figure out will be applicable to others who may not feel that they represent “the norm” in their field. I wrote an article several years ago about my own personal crossroads during fellowship after the birth of my daughter. I had a shocking realization that this abstract concept of work/life balance actually had some meaning to me since bringing a little human into the world. I wanted more time for myself and my family – something I had willingly given up when choosing to pursue intensive and lengthy surgical training. I posted the following: http://www.kevinmd.com/blog/2013/04/lean-subtle-complexity-medicine.html and got great feedback from many female physicians (and doctor moms). I’ve been asked several times for an update, to fill in the blanks as to what happened to me in the interim, and I finally feel like I’m in a place that I can take a moment to comment. I do not pretend to have all the answers. I am still figuring things out for myself each and every day, but I can list a few things I have learned along the way.

  1. I am doing the best I can.

This statement sounds ridiculously simplistic and in many ways it is. But over the last year, this statement has become my mantra. I don’t know how many times I have found myself saying aloud (or silently to myself) that I am doing the best I can at any given moment. That’s not to say that each moment is a lesson in success – that is an absolute lie. But I can honestly say that at a minimum, I’m doing the best I can in each particular situation.

I left fellowship and started my first attending job pregnant with our second child (and mother to a 2 year old). I finished my training, packed up our apartment, moved across the country, bought a house, moved in, started my 2 year old daughter in her first school (shockingly stressful), started my first job as a (pregnant) attending, and had a son three months into the new job. I can honestly say that we packed a whole lot of life-altering changes into a ridiculously short period of time. I’m not sure how graceful and easy each transition was, but I can certainly say that I got through it and am still breathing. Nothing critical was lost. No patients were harmed. My children appear by all benchmarks to be happy and thriving. And despite some crankiness and bickering due to sleep deprivation, I think my husband and I still love one another. But the only way I got through many of these days was by telling myself that despite all my perceived inadequacies, I was doing the best I could. That is all that we can strive to do. I will never be perfect. I am human. At some things I will succeed and at others I will fail, but I’ll keep going.

  1. It’s ok to fail. In fact, you will fail. It’s a fact. 

This is a natural transition from the previous point above. If you aren’t failing, then you aren’t trying hard enough. It’s ok to put yourself out there, to take (calculated) risks, to allow yourself to stretch. And it is totally expected and acceptable to fail at these tasks or not reach every goal that you’ve set. Do not despair – keep trying. Challenges only keep you growing. But use the failures to teach yourself something. The old adage that insanity is doing the same thing over and over and expecting a different response is true. Don’t make the same mistakes over and over. Use each failure to modify your approach to the next problem. Each moment will not be your most amazing, but eventually the lessons from each failure come together and allow a sudden leap forward. So forgive and remember (this is a book worth reading: http://press.uchicago.edu/ucp/books/book/chicago/F/bo3622913.html ).

Today I read this piece and it really resonated. http://opinionator.blogs.nytimes.com/2015/08/12/murderer-in-the-mirror/?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0. Part of what we sign on for is to manage difficult situations and to take responsibility for people’s lives. Most days this is gratifying, but some days it just sucks. I am half way through one of my toughest work weeks so far. I was responsible for a surgical complication and it’s still keeping me up at night. I’m sure it has taken at least a year off of my life. This is the responsibility we take on as physicians who are entrusted with people’s lives and health. It’s an awesome responsibility and we can only do the best we can (see #1 above) and we all know that at times, we will fail. This same lesson goes for our family lives, for our academic lives, for our personal and private goals. And to these I have the same response: repeat #1 above, dust yourself off, and keep going. We’ve all been there.

  1. If you think other people have it all figured out, you’re wrong.

Although I started off this diatribe thanking social media, it is also to blame for propagating misconceptions about others and their success. The selfie-stick driven culture, which feeds off the need for social acceptance is the downside to this increased connectivity. More and more people (and children, which terrifies me) are feeling pressure to be perfect and live up to an idealized expectation that is sold to them through cherry-picking of life moments as presented through Facebook, Twitter, or Instagram. Everyone wants to present their best, well-groomed, curated, cropped and retouched self-images. Do we post ourselves with bad skin, messy hair, in a dirty house wearing pajamas? Not as far as I’ve seen, but I’m sure that I have many more of those days than I do as a well-groomed, effortlessly happy mother with beautiful kids on a sandy beach. The lives we see in the media and on our own social media feeds are well-intended, but misleading half-truths. No ones lives this impossible dream. We are all struggling, we all have worries, and every day is not an amazing photojournalistic spectacle. Don’t be drawn in – you can never win. This game is rigged.

  1. You can not do this alone – we all need help.

Many of us are tough ladies/gents. We are the people others look to for answers. Sometimes this makes us believe we actually need to have all the answers or must be strong for everyone else. This is not true. Even heroes and leaders and “triple-threats” need help, guidance, and support. This comes in many flavors and will vary as a function of time. Sometimes we need emotional help, intellectual help, physical help. If you try and do it all yourself, you will fail big time (more than the allowed failure I give you for #2). There are only so many hours in the day and days in the week. Each of us needs to figure out what is critically important for us to deal with and what we can get assistance with. Outsource jobs. Ask for help when needed. Support can come from many directions and need not be the same for everyone. It can be in a tactile and physical way (e.g. hire a housekeeper) or it can be remote and via strangers (e.g. join a support group). Help doesn’t have to come from family or immediate friends. Find what works for you. But seek out the help that you need and never be afraid to ask. We all need it.

  1. There are always creative solutions to every problem. Don’t get stuck in patterned ways of thinking. Don’t lose hope.

Part of what leads to despair and hopelessness is the feeling that we have no options or solutions to a given problem. As a life-long optimist (on the majority of days), I believe that there is always a workable solution to most problems, but you may have to think outside of your usual scenarios to find it. This is when #4 above comes into play – others can help you see solutions you might not find for yourself. One of the biggest gifts my parents gave to me was non-linear thinking. They instilled in us a belief that there were many ways to get to a given goal and there was never a point at which something became impossible. It was up to us to find new and creative ways to solve the problem. When my career counselor in college told me not to apply to medical school because I wouldn’t get in, I actually became more dedicated to doing it than ever before. Do not let people set your limits for you and don’t believe that if you can’t do it the traditional way then you can’t do it at all. Be creative. Find others who think the same and enlist their help. You can do this.

  1. Hard work feels good. You are making a difference.

I know many of us would not have pursued medicine if we hadn’t already internalized this lesson. It is no accident that we chose this profession, a marathon of delayed gratification. So I am not trying to preach to the choir, but rather point out that nothing in life worth having will come easy. We chose this road to help patients, to add value to the world, to make a difference. Each of us is doing this in many small and large ways each day. I cannot guarantee that every day a patient is going to say you saved their life or made the quality of it better or will even say thank you. Many days you will feel beaten up, bruised emotionally and physically. But know that you are doing meaningful and good work. And that the hard road is still a good road. Find friends to help you along the way, find mentors and guides. And keep going. There will be days where your patients give you flowers and cards with gratitude. There will be days that someone knits a sweater for your newborn child. There will be days you are awarded the grant you’ve been working on. There will be many days you send patients home free of their disease or relieved of their symptoms. Not every day is amazing, but the overall trajectory is. Remember the good days.

  1. Release the burden of other people’s expectations. Answer only to yourself.

This one is really hard. Many of us have chosen this path because we like challenges. We enjoy breaking boundaries and exceeding others expectations of us. I am not at all proposing that you lower your expectations. That is an absolute mistake. Don’t modify your goals because certain days are hard, but make sure you stay true to your soul and your own goals/mission. And start to tune out the external voices and listen to your own voice more. Check in with yourself regularly. After having my daughter, I realized that it was critical for me to find some balance between this career I had chosen (and love) and this small person who embodies my unfiltered and unmeasurable love. For my own sanity, I needed to find a way to make peace with these components of my life. And I realized that there were parts of my chosen career I could live without in order to make my home life work. I realized I could be very happy if I narrowed my clinical practice somewhat. This was not the job description I set out to find, but it’s one that works perfectly for me. I took an academic surgery faculty position with a dedicated research component and a more narrowly focused clinical practice. There are parts of a complex general surgical oncology that I miss – the big cases were fun. But I am happy. I love my patients, I sleep well at night, and I see my children every day as much as humanly possible. Through my research I have a chance to change the way we practice and I am exceedingly grateful to have found this opportunity. But find what works for you and forget what you think others expect of you. Their wishes and expectations are transient, you will live with the life you choose.

  1. Learn to live with guilt.

This lesson is true for most of our lives, but really becomes a palpable reality after having children. And this lesson is not just true for physicians, but for all parents. The stay at home moms are going to feel guilt for their inadequacies, while we feel guilt for the amount of time we work and are not with our children. If you care enough, you will carry this baggage with you. And no matter what road you choose, this emotion will plague you. The good news is that is stems from the fact that you care. Recognize it is there, that it is natural, and move on. I reassure myself every time I find myself going down this rabbit hole of guilt about my children that (see #1) I am doing the best I can each and every day. That is all I can reasonably do.

  1. Life is a series of compromises. You can’t have everything simultaneously.

I remember the day my residency director explained this to one of the new attendings, a recent graduate from our program. He made this statement, slowly and pointedly with his characteristic southern drawl. “You know all that sh*t in life that you want, that people tell you you deserve to have? Well you can have it all……(long pause)……But you can never have it all at once. You will get it, but it will be averaged over your life. You need to accept that you are only going to succeed at a few things at any given time.”

Amen. I hold this lesson close each and every day. You must choose what matters to you most and make the best of the rest. The only advice I can offer is to check in with yourself routinely. Because what is most important to you is going to change over time. Do not make a decision and then set your life on autopilot. Stop and reassess constantly. It’s ok for your goals and priorities to change, just make sure you allow your life to change with them. Don’t get stuck doing the job you wanted 5 years ago, do the job you want today.

  1. Enjoy the small moments and successes.

None of us would have succeeded if we sat around congratulating ourselves each day. Most of us are self-critical, which has allowed us to challenge ourselves to keep growing and evolving. Continue to do this. Please. But now and again, stop, breathe, look at your kids, think about the patients you have helped. And allow yourself a moment of satisfaction. Not everyone has the fortitude to do what we do. I am so lucky to have the opportunities that I have, the support (both at work and at home) that I do, and to have healthy, happy, lovely children. My fortune is not lost on me, but I have to remind myself to cherish these moments and be grateful. Because my life is better than I deserve. I can only try and live up to it and give value back. So allow yourself to be happy, to appreciate your life, and then try to use that energy to get up and go another day.

Our divided selves.

Someone recently asked me how, as a physician, I could see death every day and not be depressed by the sadness of it all. This is something I have thought much about, but have never really taken the time to articulate. I explained that for me, there exists two different parts of myself that sometimes polarize when I’m at work. There is me, Genevieve – lover of the humanities, mother of a sweet daughter, and sappy movie watcher; then there is me, Genevieve – surgeon, physician, and crisis manager. These two people live side-by-side and exist at all times within myself, but I have learned to channel the person who needs to be present at any moment. I’m not saying that this is the best way to be or that there is not some other way of remaining fully integrated at all times, but I have not found it.

I remember distinctly that when I started medical school, I felt an earth-shifting movement away from some of the things that life had contained before. The infusion of unnecessary drama into situations, while never interesting before, became quite intolerable. As I lived and breathed the highs and lows of other peoples lives each day, I no longer understood why anyone would want to create drama when it was not otherwise there. I was just tired at the end of the day – emotionally and physically – and all the small elements of living were placed into proper perspective. Small fights over perceived slights were silly, long reflections over clothing or physical items seemed empty. I had a daily, visceral understanding of how short life was, and the minutiae became clearly that.

Yet, I sometimes do wonder if this parceling of our selves, our emotions, and our minds into these divided states can result in some negative fragmentation. Are we packaging and hiding moments that we never take back out and learn to deal with – these difficult pieces of our every day? I frequently apologized to non-medical friends when they were around my resident friends, as we quickly slipped into work talk every time we were out for dinner or drinks. We would recount some disastrous situation or another, sharing our moments of conflict and turmoil. Of course, we never couched it in those terms. Instead we would laugh about some story of unhappy endings, told with much head-shaking and dark humor. Yet in retrospect, I think this was our way of making sense of each day – our decompression and impromptu therapy sessions.

However, even with this decompression time, I don’t think many of us take time to consider the impact of what we experience in our jobs on our psyche. This is not an essay to complain about how medicine makes me sad. I love my job. I love my patients, and I am happy to serve in any capacity during the trajectory of their clinical course. But a casual question asked by a friend has brought back a lot of these thoughts that I had put aside in the business of life as a resident/fellow. Yet, somehow I knew this was all very important. Even as a resident, I remember making of list of moments where I felt myself dividing into two separate people in order to keep moving and get the job done. I have always loved writing and purportedly made these notes to eventually tell these stories some day, but I think I was also purging these experiences from my day. Unintentional catharsis.

I will never forget the cries of the parents of a young man who committed suicide as they cowered in the corner of the trauma bay while we unsuccesfully resuscitated him. Their gut-wrenching apologies, never heard by the patient himself, remain with me to this day. I still remember the patient who came into the EC with a leaking aortic aneurysm, obviously ill but still talking and chatting – a pleasant Italian man who proceeded to die abruptly on the OR table that night. To this day I am still affected by the child who came in unconscious with a depressed skull fracture, abused by her stepfather – a moment where the horrific nature of the situation made me physically ill. I think sometimes of the teenage terminal cancer patients I see routinely, who are dying in front of their parents eyes. They sit surrounded by their family whose lives have been taken over by this sickness, and as a parent myself I mourn for everyone in the room. I still remember the patient who I allowed to die in front of me, as I struggled to find anything or anyone who could help. And I see every day the many patients who die in the ICU, intubated, sedated, as they slowly drift away in a sea of infusions, ventilators, and invasive procedures.

I do not lament my choice of career – I love my job. It teaches me so much on a daily basis – it makes the minor inconveniences of life just that…. minor. And as I told my friend at the beginning of this essay, I take consolation in the fact that I’m helping people in their time of need. As a surgical oncologist, I generally see patients at a time where we may at best offer them a cure and at worst some meaningful time with their families. But the reason I ruminate on these issues now is that it is really fascinating that we, as physicians, live this life of high magnitude decisions and moments, and we are never trained nor counselled as to how to actually exist like this. I find it amazing and a credit to those in the profession that so many “normal” people can slowly exit the life they know of movies and cars and nice restaurants and go to work every day dealing with the critical moments of other people’s lives. And yet so many of us do this… and this life we chose as a physician becomes the norm.

On a personal note, I will confess that this splitting does not go away just because we are outside of the hospital. I remember when my father was dying of urothelial cancer. He was always a fit and slim person, and up until the rapid deterioration in which he died, we did not know he had diffusely metastatic disease. He might have suspected he was dying, but he shielded it from us and as his family members we never knew until the end. Looking back, I remember seeing him a month or two before he died and having a transient thought that didn’t even register until much later. A thought just popped into my head one day and then disappeared from consciousness. It occurred to me that if I were seeing him as one of my friends or colleagues, I would think that he looked cachectic and as if he was dying of cancer. As his daughter, I saw only my thin dad – his body habitus an exension of his long history of exercise and health maintenance. But obviously in some recessed part of myself, unrecognized, I knew that he was dying. It was not a part that registered in my forebrain, nor a part that even made sense until later. But that divided self was there even in my own time of tragedy – a part of me knew what was happening even though the human side of myself had absolutely no clue.

This also gives me insight into the difficulties of patients and families in comprehending the complex process of illness and dying. Despite what you may rationally know, neither you nor your family are experiencing this as your logical selves. Each person is seeing the moments from the perspective of a loving child, a spouse, or as the patient themselves. No one can retain perspective and clinical distance when you are in the thick of it because underneath it all we are all still human with the emotional and complex layers of perception and understanding, or misunderstanding, that comes along with it.

I used to be so incensed when I would be called in consultation on a patient who, despite being on a Phase I trial of an experimental drug, had no idea that they were dying of cancer. I thought these physician were clearly negligent in their duties and were obviously not educating patients appropriately about their disease. I thought, with a sense of moral superiority, that it was criminal that no one had spent the time to properly educate the patients about their situation or the fact that they were dying. This was reinforced by a recent article in the NEJM in which they demonstrate that the majority of patients undergoing palliative chemotherapy believe that their treatments are curative.

Patients' Expectations about Effects of Chemotherapy for Advanced Cancer — NEJM.

When I read this article in the NEJM, I believed that I again had found another example of how we as physicians had failed our patients. And this may sometimes be the case. However, I had the opportunity to discuss this article with the head of Palliative Care at MD Anderson, and he offered me some perspective which I did not have on my own. He pointed out that while it is true that we may often fail to appropriately communicate difficult information to patients, there may be other times where the patients or families have an inability to hear this information, even when clearly presented. This fact does not exonerate us from our responsibility to help these patients and continue to educate them throughout their clinical course. It does not remove our responsibility to clearly communicate without hiding behind unintelligible jargon. Yet for me, it does point out that while we do need to improve our communication skills during end of life discussions, we may also want to spend our time and energy on repeatedly communicating with patients over time, as the patients and their families slowly absorb the reality of the situation that they find themselves in. Having been a family member in denial, I am sympathetic to their plight.

Finally, as a physician I have to wonder if I can create a framework in my own life and career in which I integrate the polarized sides of myself so that I can be calm when everyone else in the room is not, but also remain connected to my patients and to others. I think many physicians are self-learners of this skill over time, a testament to themselves and the strength of their character. But I know many others who have separated their two selves so far that they no longer feel the pangs and heartache of their patients’ lives. I don’t believe that these physicians do not experience these feelings in some recess of their soul, but they have become compartmentalized and distant, which is apparent to everyone around them. I think to truly wade through the day to day of being a physician, we need to let these disparate selves come together now and again – in the quiet moments. Because we need to be whole people, not fragments, in order to truly heal ourselves and others.

Layers – how one learns to cut. Chapter 4: MUSCLE.

As the surgery proceeds, we encounter each layer one by one. There is the excitement of the unknown – each person is different, each surgery is different. The complexities of individuality are apparent during each operation. But the unkown is countered by the familiarity of routine. The vast majority of the time, the layers are encountered as you expect them, often pristine and unadulterated. This is when the beauty of nature is most apparent. When you deviate from the midline, as we discussed with the fascia, you encounter the muscle. These encounters may be inadvertent or they can be purposeful. Just as surgeons have various tools with subtle differences and specific names, so too are there different incisions suited to and specific for various operations. The subcostal incision, while often relatively small, is poorly tolerated as the muscles are unsympathetically transected. This incision is necessary for exposure…. but it is not the easiest in terms of recovery. On the other hand the intimating-appearing midline abdominal incision can be very well-tolerated. It’s not always size that matters, it’s geography too. Depending upon what incision you have chosen, your encounter with the muscle varies.

I can not say that I have a “favorite” muscle, in fact I like many of them for different reasons. The rectus abdomini, your midline vertical pair, play a big role in body physique and appearance as well as strength. The lastissimi, your broad back muscles function not only to assist the shoulder joint, but also offer structural stability to the body. There are the muscles of the lower extremity that are the workhorses of locomotion. Yet even these strong muscles, with shortened names made famous by body builders and work-out enthusiasts (“lats”, “quads” and “delts”) are surprisingly gentle and frail when their protective fascial covering is removed. The muscle fibers when exposed can tear and fray. They can be thinned out and shred during surgery. They are easily transected by scalpels and cautery. I find this delicacy endearing and somewhat satisfying – a lesson from life and nature that true strength comes in various forms and that functioning within a system, as a team, is far superior than the capability of each component on its own. The whole, as we all know, is greater than the sum of its parts.

Do not get me wrong – the muscle, particularly as a pedicle with nerves and vessels, has tremendous healing power. These muscular flaps are revered as surgical tools. Reconstructive plastic surgeons spend their entire careers manipulating muscular flaps to replace large tissue defects after injuries or other surgeries. This is how many women get breast reconstruction after mastectomies, or abdominal wall reconstruction after an injury or illness. As a surgical oncologist my job is to remove cancer even at the expense of neighboring tissue, if that is what is required to get the cancer successfully out. And thankfully, our friends in plastic surgery know how to put it all back together to preserve function. So these muscles are not the equivalent of a bully, strong-appearing but hiding an inner weakness. They are work horses of strength, integrity, and function. But on their own, broken down into the individual fascicles of which they are composed, they lose some of this cohesiveness and their underlying delicacy is exposed.

I think this is often the case within the macrocosm of illness, just as it is reflected in the microcosm of tissue. There is a joke in surgery that the tougher the exterior, the slower the recovery. This speaks to the various types of strength that exist within the world. There is obviously the physical brawn, but there is also the emotional resilience, the intellectual flexibility, and the psychological understanding. These are strengths often under-represented by our physical appearance. I pay homage to the fragility of life, people, tissues and revel at the contrast of expectation to reality each time I gingerly sew muscle to muscle. I counsel myself to “approximate not strangulate” as I gently pull the muscle fibers together just close enough to heal but not hard enough to tear. And I remember that we are all a mix of strong and delicate, functioning most perfectly as a whole not as an isolated unit. And I try and remind myself to build myself and others when I can, to respect the body when it is vulnerable, and to allow it the utmost harmony with itself and the world around it in order obtain optimal function. This is not possible all of the time, but the lessons learned from the bodies of others reminds me to keep trying in my own life, and to encourage each patient and family to keep trying as well.

Productivity, Efficiency and Errors

There has been an explosion of interest in the etiology of and effect of medical errors on patient safety. The ACGME initiated work hour restrictions for residents with an intent to improve patient outcomes, and guidelines on these topics abound. Similarly, the growing interest in simulation centers has focused on their role in minimizing errors by learning in a “safe environment, away from patients”. However, there is another component of improved patient care that these interventions are ignoring – factors to increase physician productivity. These same simulation tools could potentially be leveraged to study the process of delivering care not to prevent mistakes, but to improve results in other more subtle ways.

The issues of complications and productivity seem like sides of the same coin, and I believe they are related. I also realize the practical utility of addressing errors first. Complications are readily identifiable, adverse events can be a focus for strategic interventions, and these variables are far easier to measure than productivity-related goals. However, I feel that they are only one side of the issue. And minimization of errors is not the only way we will improve the quality and consistency of patient care. In order for these safety-related interventions to work, they must go hand in hand with efforts to improve productivity, accuracy, and focus. I believe that those who study errors are aware of these needs, but I feel as though the public conversation has become so skewed to the negative end of the spectrum that we have lost some other components in the dialogue.

Productivity has certainly been mentioned when it comes to changes in the health care system. We, as physicians and health care providers, are being asked to transition to a system that will be based on outcomes, both good and bad. The focus is turning to bundled care, where each intervention or specialist is compensated for the overall outcome of the patient, not for their individual efforts. One could argue that this is shifting the discussion to productivity, however I would argue that these interventions are more focused on efficiency rather than productivity. While similar, these processes are not necessarily the same thing. Both efficiency and productivity are closely tied to cost and time variables, as well as negatively correlated with errors or complications. In the arguments for streamlined care, there is an assumption that productivity will increase as efficiency improves. This is the reason I am making this distinction – because the interventions needed to increased productivity may not be the same as those which maximize efficiency.

In the Oxford English Dictionary productivity is defined as: 1. the state or quality of being productive; or 2. the effectiveness of productive effort, especially in industry, as measured in terms of the rate of output per unit of input.

Efficiency is defined as: 1. the state or quality of being efficient: greater energy efficiency; or 2. an action designed to achieve efficiency; or 3. technical the ratio of the useful work performed by a machine or in a process to the total energy expended or heat taken in.

While there may be a relationship between productivity and efficiency when defined as a ratio of input to output, the difference lies in the approaches generally taken to achieve these goals. Historically, efficiency interventions have focused on minimizing unnecessary steps – i.e. maximizing useful work while maintaining the same baseline input or energy expenditures. Productivity on the other hand increases output through other means. These can be very complimentary processes, and the only reason to make this distinction is in order to guide interventions that focus on process improvement. In medicine, we are working to make ourselves more efficient – minimize unnecessary studies, limit needless interventions, streamline processes, eliminate superfluous steps. However, very little has focused on improving productivity. Everyone wants their trainees, employees, physicians to do more with less time, but there is a scarcity of data on how to improve the production of meaningful and quality work.

Anecdotally, I can describe to you my own experiences in work and productivity. As a surgical resident at a busy academic center and now a Surgical Oncology Fellow at a leading cancer hospital, I have spent almost the last decade of my life attempting to increase my own efficiency and productivity. Hand in hand with these goals has been a focus on minimizing the errors I make or identifying errors that are impacting my patients. This indoctrination begins during your time as a Surgical Intern when your mantra is “trust no one” and you triple check your orders and those placed by the overnight team to find errors that might have occured. You then graduate to the Surgical Senior Resident responsible for “running numbers”, which means reviewing vital statistics and lab values every day in order to make sure no small detail is overlooked, and finally you arrive when you become the Fellow responsible for preparing patients for the OR, responsible for understanding their clinical course leading to this day, the steps of the procedure to fix their problem, and the necessary details to manage them in the post-operative period. My life to date has been a struggle to safely manage patient data while having an increasing responsibility for patient care as well as an increasing patient load. It is an exercise in fastidiousness and detail, and it is a necessary one. I have been palpably aware of the role each data point plays in understanding the big picture of a patient’s clinical status. And I have followed these data points and learned to correlate them with the feeling I get when I examine and assess a real person. It is a subtle skill and one learned over time. Our entire training structure is focused on safety and minimization of errors, so I do not devalue these elements one bit.

Yet, it was not until I took time out of my fellowship for research that the concept of productivity finally occurred to me. Until now, I have been frantically plowing my way through the tasks of each day – data review, patient assessment, orders, paperwork, operative cases, more orders, more paperwork, then patient-reassessment and data review, then preparation for the next day, and on….. It is often hard to keep ahead of your days and I always felt that I was just treading water or that my grip on certain services was tenuous. And now, since taking some time for research I find my return to clinical duties far less frantic. Much of that has to do with the fact that although I am taking call or managing patients, I still am not back on a full operative schedule. I also worry less about pleasing people and more about the task at hand – a luxury afforded to me with some distance. I do have time to prepare, to read up on all the patients, to reference my analysis of their issues with a search of the literature on their disease and subtleties of management. I would like to believe that we all finally graduate from our programs and reach this place of calm as attendings, but I am somehow doubtful that this magical moment occurs. I am not implying that we all need to work less, operate less, or lighten our clinical loads. But what I have found is that in slowing down my pace somewhat, I have become more productive in what I am doing. I regained focus when the background noise was turned down. I was no longer rushed. It was not that I did not have the same amount of work to do in the same amount of time, but the stressors contributing to the need to hurry had been removed.

This brought to mind the famous study of Darley and Batson in 1973, which examined altruism by setting up an experiment with seminary students enrolled in a religious course. They completed questionnaires about their religion and then were asked to move from one building to another for the lecture to continue. On their way from building to building, they encountered a person slumped in an alley in need of assistance and examined what would happen. The one variable in this experiment was the amount of urgency the person felt in getting from one building to the other. They were then judged on a scale of helpfulness to the victim from 0 = failed to notice to 5 = refused to leave or insisted on taking him somewhere. Interestingly the major distinction between helping and non-helping behavior was in the hurriedness of the subject. In all, 40% of seminarians helped the victim, but in a low hurry situation 63% helped as compared to a high hurry situation where only 10% stopped to help. They did note that many subjects who did not stop appeared distressed or anxious upon arrival at their destination, to me speaking to their internal conflict. They weighed more heavily the tasks in the forefront of their mind over what they felt in a more subtle way was the right thing to do. I think we are all susceptible to this dilemma. I have found myself rushing by situations in which I would normally help when I have been pressed for time or under psychological stress to do other tasks. I am not proud of this fact, but believe it is one we should be aware of. If your resident/physician/care team member is pushed for time, their ability to process and receive messages from the current situation may be impaired. This is of far greater import to address than to add strategic napping to their day.

I do not claim that the solution to all our safety and productivity problems is to just slow down or to offer yoga and meditation to your surgical team, but when I reflect on my residency and fellowship I realize that over time the tempo is not sustainable and we all become tired. This is not the fatigue you hear about in the work-hour conversations, readily corrected by a brief nap. It is the chronic exhaustion of too many tasks in too short a timeframe in situations of conflicting responsibilities. I think this creates a similar situation to the altruism experiment with discordant signals being received and processed. In these types of environments, whether in the hospital or in the classroom, it becomes easy to relieve yourself of “unnecessary” tasks such as patient interaction or teaching or altruism and focus solely on doing more cases or meeting required benchmarks of your program – those things monitored by the ACGME or emphasized by your residency. Instead, increased productivity and improved quality needs to arise from patient-centered care, and that is a focus we should not lose.

I certainly do not think that the work hour restrictions are the solution that we are looking for. I think they have caused a host of other problems with pass-offs, lack of continuity, and a higher burden on attending surgeons for patient care. I agree with the intentions of improving patient care, but I wonder if there is a way of training and educating ourselves that may be more efficient, more productive, and more humane as well. I must admit that currently I am not only more productive during my clinical days, I am also a nicer person. I have a few seconds to spend time with patients, to get a better history, to acknowledge their fears, to pay attention, and to not resent them for making me do my job. That is the part that I found insidious and sad – I started down this path to help people, but became tired and distant along the way. Each day our patients are at their most vulnerable – they are sick, weak, and often facing their own death and mortality. The responsibility is on us to guide them through this process, but to do that requires clarity of vision that we may not always have.

I believe it is not only rushing that is a problem. There are several states of being associated with errors – rushing, frustration, fatigue, and complacency. Each of these states are readily identified in surgical residents, and yet we have chosen to only focus on one – fatigue. I propose that we institute a process-oriented approach using errors as the final readout but addressing factors contributing to these other states as well. There is something to be said for having the time and encouragement to read, plan, prepare, and execute. Not in your spare time, but as an emphasized goal of training. My personal goal is now to pursue this slower, more focused path – one that co-exists with empathy. I think we should train high performers who are whole people too. It would be a shame to strive for excellence as a surgeon, only to lose our skills as doctors and healers.

Reverberation

A lot can happen in half a century. This is the span of time that separated my father’s graduation from Jefferson Medical College from my own. He was a product of his time – a young man born in the early 1930s. This was the time of the Great Depression, as the world recovered from World War I and unknowingly was preparing for World War II. He grew up in a working-class suburb of Philadelphia, populated by mostly Irish and German immigrants. He was second generation Irish, the child of parents who created a life for themselves against great odds. His parents met while working in an armory in Philadelphia during World War I and his father went on to become a judge in the Orphan’s Court of Philadelphia. He lived at home throughout medical school and took the local transit (at that time an above ground trolley) to and from his parents’ house to center city Philadelphia each day. He entered his residency at Graduate Hospital in Philadelphia, only to have it cut short when he was drafted into the Navy. He served on the USS Franklin Delano Roosevelt and remained a Navy man his entire life. During his medical training at Jefferson, he saw Dr. John Gibbon perform an open heart surgery using the newly created heart-lung bypass machine and this event changed the course of his life forever.

In contrast, I was born in the 1970s – a bicentennial baby. I was the child of academics, and the youngest of 6 overachievers. My father was a cardiothoracic surgeon and my mother an artist. I grew up in a household filled with conversation of medicine and art – a lovely dichotomy. My parents were avid travelers and that element infused our entire childhood. My first memories are in Taiwan, where we spent the summer of my 4th year of life while my father worked at a teaching hospital. Many of the family stories were set in Africa, Taiwan, Vietnam, Haiti, or Guatemala as a result of my parents’ adventures living abroad. Our household was alive with conversation, debate, and opportunities for learning. I think back fondly on my father, who encouraged our many and varied interests. I have stacks of articles he lovingly sent me over the years, highlighted and with Post-It notes attached pointing out some idea of interest or another. These articles were drawn from surgical texts, the New York Times travel section, and any other source you could imagine. There were articles on Iceland next to articles on necrotizing fasciitis next to articles on the latest music trends. He supported all of my interests, but the one he and I shared most deeply was our love of surgery.

I graduated from Jefferson exactly 50 years after he did – we were the classes of 1956 and 2006, proud members of the Alpha Omega Alpha (AOA) honor society. Our differences reflect both the generations from which we came and the changing tides occurring in medicine. During his time, Jefferson was a male-only school. He spoke of the attendings herding “their boys” through anatomy lab. On the other hand, my class was the first class in Jefferson history to be 50/50 male and female. Not only our gender spoke to the changes over time, even our degrees reflected a shift in perspective. As an MD/PhD he used to tease me that I was a doctor of the new millennium, and he was not entirely wrong.

When he trained, the patient services were smaller and patient stays were longer. There was no outpatient surgeries, no work hour restrictions, and many of our current sub-specialties were still a part of general surgery. His life spanned many historic events, and this taught me that history is just your life or the life of others, seen in retrospect. He went on to obtain specialty training in cardiothoracic surgery at Parkland Hospital in Dallas and was the fellow on call when John F. Kennedy was shot. He remembered seeing Jackie O. entering the hospital carrying a piece of JFK’s skull and the grim looks on the faces of the treating team. Instead he was on the team who treated Governor Connally (the other victim in the shooting), and a few days later he was called to put a chest tube in Lee Harvey Oswald when he was taken to the hospital after being shot. Listening to him describe the technology at the time, I found it hard to fathom. Pacemakers were large towers and had to be wheeled from room to room. Open heart surgery was in its infancy and laparoscopy did not even exist. Due to his early exposure to cardiothoracic surgery, his fascination with these techniques dominated much of his career despite remaining a general surgeon at heart.

What I respect the most was that he did not fight change, but instead embraced the evolution of medicine and surgery. He greeted each new discovery with excitement, and he loved to see me growing up in a new system, different from that which he knew. As a child of the new millennium, my training was in world of sub-specialization. Open heart surgery was routine, transplants were common, and laparoscopic surgery was the norm. We characterized cancers from a molecular standpoint and targeted therapies were de rigueur. As an MD/PhD I was training to be a physician scientists, not a pure MD. This approach to medicine in combination with research and clinical trials was also different from his era. My world was dictated by evidence-based medicine gleaned from prospective, randomized trials. The contrasts between our eras were significant, however some things never change. Surgeons love surgery. Physicians love medicine. And doctors love their patients. On these matters, we were exactly the same.

He and I used to talk every few days about life, training, medical personalities, and hospital dynamics. He remained an active physician almost until the day he died. He stopped operating, but still remained administratively active and was a resource to the junior surgeons when they found themselves in uncharted waters. He loved his job and it kept him going on a daily basis, and this was a love we shared. As an academic, he was the one person who tirelessly read every article or chapter I ever published, regardless of the topic. He lovingly read (and highlighted) my PhD thesis – perhaps the only one besides me who read it in its entirety. I remember his joy on the day of my graduation – his daughter with two hoods. He listened with great interest as I described the adventure of residency interviews and the match, and he was there with me when I found out I was going to Massachusetts General Hospital for General Surgery. He reassured me that a girl from West Virginia could teach those Harvard folks a thing or two. He relived his intern year as I described to him my experiences – from my first day in the OR to my first independent chest tube for a tension pneumothorax. He counseled me to remember the feeling of success and accomplishment of saving someone’s life, since the feelings of success are rare and fleeting. As he said, we will always remember every patient we harmed or did not help. So he encouraged me to remember the ones I did help on occasion. As I progressed through my residency, I described to him my first hand-sewn anastomosis and my first whipple. He shared in every step along the way. He was my confidant, my advisor, and my unfailing cheerleader.

During my second year of residency, he was diagnosed with urothelial cancer after noting painless hematuria. This was followed by various procedures and treatments culminating in a cystectomy that was aborted when nodal disease was found intra-operatively. I was in the recovery room with him when he awoke, and I was the one who told him that he had not been resected. I remember vividly his comment that his odds were almost as grim as pancreatic cancer. As usual, even post-anesthesia he had a piercing mind. That said, he never focused on the negative, we moved on, and he willingly proceeded to chemotherapy as recommended. He did not make it to 5 years as he had predicted, nor did he make it to my residency graduation – one of his dreams. However, he did make it to my wedding, the March of my chief year of residency. He walked me down the aisle, we had our first dance together, and he sent me off on my honeymoon with a hug and a kiss. When I saw him 2 weeks later, he was in the final stages of dying from liver failure – he deteriorated fast. I was with him for that last week, sitting at his bedside, telling stories, holding hands. And I was there in the room when he died.

I think 2011 was the biggest year of my life to date – I got married, my father died, I completed my chief year of surgical residency at MGH, I moved to Houston, I began my fellowship in Surgical Oncology at MD Anderson, and I got pregnant. I’m not sure there are many other life-changing events I could have crammed into a single year. It was intense, lovely, hard, sad, joyful, and a time of immense growth. In some ways having so many things going at the same time made each of them easier to handle. It is only now, later, with some time for reflection that I am able to put all the pieces in their appropriate places. But it is still a work in progress.

When I think of my father, James Pius Boland, I will always see him as a selfless person – one who gave not only to his family, but to his community as well. He was a gentle leader, a quiet soul, a deep and piercing mind, and a sweet loving dad. Our worlds may have been very different, but they were also very much the same. He said watching me live my life helped him relive his own – we shared a common thread and a common set of experiences. He embraced the changing world, he encouraged me to be a part of the new thinking and approach. He was my most die-hard advocate. He knew that my career, this path, would not have been possible during his time and he was so proud at how the world had changed. He encouraged me to chart my own course, to be true to my soul, and to be an individual. But he also reminded me to use my talents to serve others. I will never forget that his final words to me were a reminder to keep the faith and protect the vulnerable. These are words that I take to heart each and every day. I am certainly my own person, but I am also an outgrowth of the person he was. He made my path and my progress possible. And I am not alone, he played this same role for many trainees during his 30 years as a surgeon and educator in West Virginia – both residents and students alike. He was greatly respected, and also greatly loved. And it gives me consolation to know that his ripples live on, even though he no longer does.

Layers – how one learns to cut. Chapter 2: SUBQ

This dialogue has started at the surface, but we will not remain there long. We next move into the subQ or subcutaneous layer. In surgery with one swipe of the blade we are beneath the skin and into the subcutaneous tissue. To most, this is a layer of little value. It is often barreled through, pulled under tension, or considered insignificant. It is composed of fat, blood vessels, and connective tissue. It is of little consequence to a surgeon – we never sew it back together when closing a wound since it will just reapproximate or heal on its own. However, it too is a layer worthy of discussion. The subQ offers insulation to the deeper contents of the body and is a source of nutrients to the surface. It may be almost invisible in some and you can get lost in it in others. Even on a CT scan, one can determine the thickness of this layer, unconsciously factoring it into the mental calculations as to the ease or difficulty of an operation. It is a reflection of a person’s life – your nutritional baseline, the world you come from, and even your socio-economic status.

When contemplating the purpose of insulation we realize that some are born with it while the majority of us acquire it over time. One group of people have just a thin layer which brings them into closer contact with the world around them – for good or bad. If the skin is punctured, there is no layer to protect the deeper structures, there is less of a buffer to injury. However, others have acquired an excess of insulation. A layer so thick that they start to lose connection with the world around them. All senses, experiences, movements are filtered through a thick layer of tissue – buffering to be sure, but also creating distance of subject from experience. There is no right or wrong as to how thick of an insulation we need, although somewhere in the middle may be the place of maximal harmony.

So how does one find the middle? This seems like a silly question to ask – of course, we are all aware of the midway point. We can mentally separate objects into halves and readily, almost subconsciously, read symmetry. So how could you ever get lost finding the middle? I contend that this act of centering is harder than we allow ourselves to think. In surgery, you can ask any junior resident how easy it is to find the midline. Piece of cake, right? However, I have seen many residents struggle as they chase the wrong path off of the middle and into the periphery. In a large person with voluminous abdominal fat it is easy to lose yourself and end up tracking into an unintended area. So how does one stay on course? The answer is that you read the subtle signs, you let the tissue tell you how to get back. You use traction and counter-traction to your advantage and allow nature to guide you along the way. When done correctly the tissue separates exactly in the center and points you to precisely the place you want to be. If you follow these rules, you will never get lost.

I find this a beautiful and reassuring concept – that the natural order is there if we allow ourselves to see it, or hear it, or experience it. In surgery, as in life, there are many conflicting issues to balance. You can focus on the step before, or the upcoming step and lose touch with the now. No one sets out to get lost or make a mistake, but it happens. And it is usually at a time when conflicting messages or signals are being processed. I believe we all have the ability to appreciate the truth or to make the right decision – no one purposefully goes astray. But sometimes the other elements, other voices, other issues distract us from going where we intended to go. So how does one remain in the here and now? How do we remind ourselves that even small steps have meaning and maintain a trajectory that leads us where we intend to go?

I have found in my own life that rushing, hurrying, or pushing headfirst through the tasks in my day may not be the best way to go. I notice that in the rush to cross things off my list, to move ahead, to cram it all into my busy day I sometimes make mistakes or do things poorly merely because I am rushing forward to get it all done. Even if you were to measure my productivity in a day, those with the most meaningful accomplishments are often the more calm, measured, and manageable days. I’m not saying that as a surgical resident, barreling through the hallways to get all the patients seen, orders in, preop patients marked and prepared for the OR to get the case started on time isn’t a necessity. But I would contend that there are steps in the system that could be optimized to allow planning, thought, reflection, and a less harried and more purposeful day. I believe that this may be a good thing – for safety, productivity, learning, and knowledge consolidation. We focus a good deal of time and energy on resident fatigue, but there is little if any talk about the other behavioral issues that can affect patient safety – rushing, frustration, and complacency. These are common topics in safety literature, but are poorly represented in the discussion of medical errors or residency training.

In 1973, the famous study of Darley and Batson examined altruism by setting up an experiment with seminary students enrolled in a religious course. They completed questionnaires about their religion and then were asked to move from one building to another for the lecture to continue. On their way from building to building, they encountered a person slumped in an alley in need of assistance and examined what would happen. The one variable in this experiment was the amount of urgency the person felt in getting from one building to the other. They were then judged on a scale of helpfulness to the victim from 0 = failed to notice to 5 = refused to leave or insisted on taking him somewhere. Interestingly the major distinction between helping and non-helping behavior was in the hurriedness of the subject. In all, 40% of seminarians helped the victim, but in a low hurry situation 63% helped as compared to a high hurry situation where only 10% stopped to help. They did note that many subjects who did not stop appeared distressed or anxious upon arrival at their destination, to me speaking to their internal conflict. They weighed more heavily the tasks in the forefront of their mind over what they felt in a more subtle way was the right thing to do. I think we are all susceptible to this dilemma. I have found myself rushing by situations in which I would normally help when I have been pressed for time or under psychological stress to do other tasks. I am not proud of this fact, but believe it is one we should be aware of. If your resident/physician/care team member is pushed for time, their ability to process and receive messages from the current situation may be impaired. This is of far greater import to address than to add strategic napping to their day.

During training we were taught to respect the forces of traction and counter-traction. Push and pull. Back and forth. Surgery is an art that requires a partner and optimization of this paired act is a goal to strive for. Many of us can relate to working on a project, playing an instrument with a band, dancing with another, or playing a group sport. All of these require action and reaction and we all can relate to the satisfaction that comes when the forces align and you are in harmony with your partner, your teammate, your patient, or the process itself. Time ceases to have meaning, all other stimuli or forces are tuned out and you are perfectly focused on the task at hand. This is surgery at its finest, but we must eliminate the background noise and allow our practitioners to find their center in order to move this process forward. As physicians, we create our own insulation to allow us to do our job, to see what we see every day and still continue on. However, we need to manage this dynamic carefully and be wary of creating a chasm rather than a buffer.

Layers – How one learns to cut. Chapter 1: SKIN

The act of touching a stranger deviates from our social norms. We are taught to be friendly, close, but not to touch. Personal space is a valuable commodity, perhaps even a personal right. This makes the act of violating the social agreement so difficult to the unititiated. If you have ever seen a medical student examine a patient, it evokes the palpable discomfort of a teenager discovering their body – curious, nervous, embarrassed, but eager. As physicians, we snicker at their discomfort, shake our head at the novices, but they are doing what all normall, well-socialized citizens would do in that situation. They feel awkward knowingly and willingly breaking the unspoken social agreement that you do not touch strangers. As we move through medical training this awkardness rapidly fades. The discomfort of seeing naked strangers becomes routine. Touching strangers, examining them – this too becomes just a part of the job. It ceases to be odd until you try and explain your daily activities to a non-medical friend or loved one. Only then do you realize the isolated and special world that you live in, one that exists outside of the typical social norms.

Getting used to the role is facilitated by the garments that we wear. These coats are for the benefit of the patient, to be sure. They equate the white coat with doctor, and they realize that the interactions they have with us are private, professional, and for their own good. The garments assist in defining the roles. It is not me, a small young female, examining the patient, it is their doctor. There are some physicians I know who like to “step outside of the role” and wear a suit or casual clothes. This approach may work for them, but for me, the coat (or scrubs) defines boundaries and allows the relationship with my patients to proceed. We have created a layer to slowly separate ourselves (people, citizens, strangers) from our roles (doctor, patient, surgeon).

Beyond the mere touching of bodies comes the more complex issue of invasion – performing procedures, the act of surgery. Again, we challenge ourselves to detach from what we know societally and to allow ourselves to break from the idea of causing discomfort in order to facilitate the broader goal of healing or cure. When learning to do invasive procedures on an awake patient, you realize the depth of the doctor-patient relationship. You both put aside your natural inclinations to run from these acts and instead you trust one another. Most physicians will not forget their first NGT, foley catheter, central line, chest tube, or surgical incision. Some of these are smaller invasions, and some are larger, but they are all a challenge to your role as citizen and a testament to your role as a physician. In order to allow these actions, we create barriers to buffer these experiences. Some of these barriers are for protection or to create sterility, but I believe they also serve a dual purpose, which is to allow us to separate ourselves from the patient as a person and to focus soley on the task at hand.

As I walk from the hospital ward to the operating room, I shed my white coat at the OR hallway. I put aside my physician role and I become a surgeon. I don my surgical cap and grab a mask and am on my way to a part of the hospital accesible only to OR personel. This is not a place for medical doctors, physical therapists, or nutritionists. This is the operating room and you must slowly peel away your other roles to enter. Here in the OR you create a fresh barrier – you don not just your surgical mask and hat, but your surgical eyes and mind. You greet the OR team and the patient and then once the patient is asleep, you clean them and begin the process of draping. Depending upon the surgeon, this can be a simple and functional process – clean, drape, create sterile field – or an obsessive and compulsive routine. But again this draping, this creation of a physical barrier, allows us to separate ourselves mentally and visually from the patient as a person and focus on the patient as on organ system. We block out everything except the operative field. We focus only on what we are there to do, not on whom we are doing it. We adopt our surgical mindset. And this is what allows us to cut. What under other circumstances would be a violation becomes a noble act of healing.

Once the incision is made, we encounter the most complex layers of all – the physical layers of the human body. Our focus today is on the skin – this most superficial of layers, but don’t be fooled by its fragility. Do not dare underestimate the power of the skin. Without the skin we would die. This thin layer is an active agent in our lives, and it is an amazing, dynamic, living system. Your skin reflects and accumulates your experiences, it is a living record of your life, your exposures. It can heal and regenerate but it also has a memory. The sun exposure you had as a child lingers on in the cells of your skin. The scars you acquired climbing a tree as a youth remain. Your skin is a living, breathing, fossil record of your life. But one that is not stagnant, it is one that can heal. We do not wear every scratch, injury, or tear forever, only the deepest injuries leave marks. Some consider these blemishes war wounds, others unsightly reminders of past traumas. To me the skin is a meaningful reminder of the life lived, and a reflection of our experience. It changes with age from the miraculously resilient skin of a newborn to the sagging, paper-thin skin of the aged. But to me each wrinkle holds a lifetime worth of laughs, frowns, or looks of puzzled bemusement.

To treat the skin as a simple layer that must be pierced in order to dig deeper is to miss the tactile, physical, and also figurative barrier we wear on our outsides each and every day. The skin is our largest organ and without it, wounds can not heal (see skin grafts), without it thermoregulation is lost and fluid balance is in disarray (see burns), and without it we can not protect ourselves from the environment (see epidermolysis bullosa). It is delicate, but incredibly strong. As a surgeon, I have the honor to pierce that layer at each surgery. Some treat the skin incision as a rapid swipe of the scalpel, while others treat it with respect. Regardless of the setting, it is the first layer we encounter and the last one closed at the end of the procedure. We do not announce “incision” when we cut the fascia or the muscle. It is always announced at the first moment that the scalpel begins to cut the skin. It is the only remnant that the patients see of their surgery, for good or bad. It may be superficial, but it is very very deep.

Layers – How one learns to cut. PROLOGUE.

The posts in this blog, labelled as “Layers” are the culmination of ideas I have been pondering since starting my surgical residency in 2006. I have been struck on countless occasions by the layers of social, psychological, and literal meaning that are infused in each patient encounter and each day in the hospital. It is a thing of great beauty and a reflection of the human experiences on so many levels. I intend to create a book, broken down according to the layers of the body, but discussing not merely the physical but the deeper figurative layers of this art of medicine and surgery.

I may intersperse these chapters with other blogs on other topics, so I hope this does not become confusing. Please bear with me if these chapters seem random, stream of conscious, or otherwise hard to follow. My goal is to tie them all together in the end, but until that time feel free to follow along as I go.

Am I more than my gender?

As an intellectual female surgeon, I have always resented being pinned down by my gender. Throughout medical school, I refused to join “Women’s Societies”. I felt that these were excuses for disillusioned women to get together and complain that the reason they were not succeeding was their gender. I, on the other hand, did not feel limited by my gender nor did I hide it. Instead, I relished it. I felt that the merit of my work, my intellect, my skills were the factors that had led to my success. I did not need to apologize for being a woman, nor did I need any favors because of it. During my surgical residency at Massachusetts General Hospital, I wore pearls every day, even to the OR. I loved the contrast of what I did (i.e. cut people open) with who I was (i.e. a woman), and they became my trademark. I did not feel that I needed to be manly or tough or unfeeling in order to succeed. I could be feminine and “touchy-feely” and still compete because I had the necessary skills. I believed that there was value and honesty in being true to yourself, so I tried to own it. I patted myself on the back for retaining my femininity in a man’s world as I effortlessly kept up with the boys. I didn’t need women’s support groups to succeed, I just needed to try. I got irritated when my boyfriend (now husband) sent me articles on how to succeed as a woman because I felt these recommendations didn’t really apply to me – I was an individual not a gender stereotype.

Sigh…. unitl I had a child.

I finished residency at MGH, started Surgical Oncology fellowship training at MD Anderson and I elected to take a research year during fellowship, ostensibly to build up my academic portfolio, but with the dual purpose of having a child. I became pregnant during my clinical rotations and life as a pregnant fellow continued on somewhat normally. I was able to operate and continued to do big cases. Throughout my pregnancy, I had staunchly refused to leave the OR for bathroom breaks, although several female attendings ignored my refusals and made me break scrub to get a quick snack and use the restroom. Secretly, I was eternally grateful but I would never ask for special treatment. Finally when I was getting big enough to make the OR staff uncomfortable (i.e. 8-9 months pregnant), I transitioned to the lab. I entered my research time with a goal of organizing my projects and tying up loose ends before my daughter arrived. When she finally did arrive (1 week late), I took 2 months of maternity leave which was a wonderful time and absolutely necessary.

I have no complaints about my treatment by the faculty and staff – I received nothing but support and congratulations. My fellowship was accommodating with my time off and there was no subtext of resentment among the other fellows or faculty. So at this point you must be wondering what is the focus of this blog (i.e. what’s your point, lady?) The problem was not with the pregnancy, nor the time off. The problem starts now. I am back at work with a 4 month old daughter.

Until this moment, I have never had any constraints on the time I could dedicate to my work. I started the day before 5am and came home when the cases were done and all the patients had been seen. My husband has a flexible schedule and my work never interfered with our relationship. But after my daughter was born, my schedule suddenly was much more difficult to navigate. The lab has afforded me flexibility that would not otherwise be available during my usual clinical rotations, but this too is quickly coming to an end and my rigid clinical schedule looms. So here I sit, at an impasse. I am looking forward to my career, my life, and the culmination of 5 years of college, 8 years of medical school (MD/PhD), 5 years of residency and 3 years of fellowship. And now of all times, my plan has begun to unravel. Unlike the typical, post-baby female dilemma I read about, my decision is not will I or won’t I work. The question is what will I do.

I still intend to pursue an academic career, I have not “dropped out” of surgery, but I finally feel the impact that my gender is having on my career. I’m sure as my daughter gets older, these issues may fade somewhat. I will remember the value of my career over these precious moments of her development. It will not be her first ____ (fill in the blank – rolling over, steps, words, etc.) that I am missing while I am at work. It will be something more complex – I will miss her plays and games and recitals and I will miss being the thread that ties her days together – because I will be away a large proportion of the time. I always believed I was tenacious enough to have it all, but the problem now becomes what is “it”? Is the goal a full operative schedule with big, complex cases? Is it time with my family? I originally went into medicine to help people, to make an impact in each individual life. So I struggle with the question of whether helping is enough, even if each case is not as challenging or the disease focus becomes quite narrow. Is it enough if it affords me a predictable schedule and the ability to be home before my daughter goes to sleep each night?

I was one of these residents who rolled their eyes at “lifestyle choices”. I truly believe that being a real doctor requires sacrifice, that it is a vocation. And this belief has not faltered, but I now am concerned as to what is being sacrificed. Do you want a doctor who will be there for every event of your hospitalization, but has given up on his/her own family? Do you want someone who works all day and night, but forgets to tend to their own needs or those of their loved ones? My daughter now means more to me than I have ever meant to myself, and I don’t know how to prioritize that into this life I have constructed.

I have read many articles on work/life balance for high achieving women in general, and for female physicians specifically. Honestly, I haven’t quite decided which side of the fence I come down on. I have listened to Sheryl Sandberg’s TED talk several times, and it resonates with me on some levels.

I kept her in mind and heeded her advice to “Lean In” when choosing how to manage my pregnancy. And it worked. I realized that staying active up until my daughter was born was possible and the opportunities that I had fostered before I left were there when I came back. I did not take a less challenging road, and I was glad for those decisions. However, the choice now is not to lean in or out, but which lateral direction to bend. And the decision I make now affects not merely the next few years of my life, but perhaps my whole future trajectory. I still wonder which way I will go and the jury is still out.

As much as I enjoyed Sheryl Sandberg’s encouraging words, the words of Anne-Marie Slaughter from her article Why Women Still Can’t Have It All – The Atlantic come back to haunt me as well. She discusses the challenges facing women in what to me feels like a more honest light. I think Sandberg’s points to “sit at the table”, “make your partner a real partner”, and “don’t leave until you’re gone” are extremely valuable and worthy of discussion, but they do not encompass the complexity of the issue, nor does she make the claim that they do. But I appreciated Slaughter’s honesty in discussing the dilemmas faced by working women today. She comments on the half-truths many of us live by – 1. It is possible if you are just committed enough. 2. It is possible if you marry the right person. 3. It is possible if you sequence it right. I have been guilty of propagating many of these half-truths myself and am finding my own logic a little faulty right now. I stand by my commitment to my work, so cross off number 1. I am married to a wonderful, supportive husband with a flexible schedule and an inherent knack for child rearing, so goodbye to number 2. And number 3 is a no go as well – I delayed having a child for work, and we planned my pregnancy as best nature would allow to coincide with my research time so as not to inconvenience anyone at work or to miss out on anything. So here is the truth, it remains a struggle because inevitably we all do go back to work, with the same surgical schedule as before but now with an entirely new urge to finish at a reasonable time in order to spend time with our families.

Unlike the work environment Sandberg discusses, where women make a binary decision to “lean in” or “lean out”, medicine is more subtle and more complex. There’s no such thing as part time for most physicians. In addition, in medicine there is a difference in the duration and timing of training, as well as the structure of the workplace even as faculty. As physicians we spend the majority of our child-bearing years in residency/fellowship training and accumulating an inordinate amount of debt, which our resident/fellow salaries do not allow us to pay back until we are gainfully employed. Therefore, in our mid to late 30s, we depart our suspended animation pathway and enter the real world, only to find that we are 10 years older than the majority of our peers who did not choose medicine as a career. So in this environment it is rare to find that women leave medicine altogether, instead many females switch specialties in order to accommodate their lifestyle. By this stage we are pretty embedded in having a career, the variable remains what kind of career? In contrast to the business environment described by Slaughter, in which one of her proposed solutions to this dilemma is to “redefine face time” and potentially work remotely, there is no similar option in medicine. This means that unlike Slaughter’s proposed work restructuring in which a woman can dictate her own schedule, new mothers are subject to the schedule dictated to them by their clinical rotations as residents or their patient volume as attendings. Therefore, a female physician can exert her lifestyle choice by attempting to choose a specialty or sub-specialty that accommodates her needs. We have all begun to see a migration of both women and men towards fields that allow them to maintain some semblance of work/life balance.

In surgery, many women become breast or endocrine surgeons for this very reason. Unlike many other surgical schedules, these fields offer relatively predictable and reasonable schedule demands as compared to other surgical fields. And some would argue that unlike business, in each and every field of medicine there is the inherent work satisfaction that stems from helping patients in need. So is it a rationalization or a smart move to shift the focus of your career from one group of patients to another if it allows a better balance in which to grow as a whole and unified person? Adding to the complexity of the choice is that there are many ways in which to be successful in medicine and the definition of success may vary depending upon who you speak to and at what point in their career. Is success counted in patients helped, in case volume, in personal satisfaction, in monetary compensation, in faculty appointment, or in academic prowess?

Of course it is more complex even than this long ramble suggests. I find myself asking what is it about the majority of surgical environments that make it less appealing from a work/life balance perspective. Certainly there are the transient issues – how do I do an 8 hour case if I can’t break scrub to pump because I’m a breast feeding mom? It’s an odd issue I had never considered until now, but it is one that is easy enough to overcome. More difficult are the deeply embedded and long-lasting cultural undertones – what signals are we giving and receiving amongst our own community of physicians and surgeons? And how do we change these messages?

I do not want to fall into the ranks of those who complain because the system is too hard, but I do now believe that there are challenges inherent to being a working mom and a female surgeon that are specific to my gender. I agree with Slaughter that changing the culture of the work environment is necessary if we want to affect meaningful change – as she said, let’s “revalue family values.” There may be many fields of medicine in which it is acceptable to speak of leaving early to go to a child’s game or recital, but this is rarely the case in surgery. At most large academic centers, it is not acceptable to mention choosing your family or children over a long day at work. That is not to say that surgeons do not go to their children’s recitals or sporting events, but very few, if any, advertise it. I shamlessly believe that it should not be considered weakness or lack of dedication if we are to attend our children’s events or be there for their important moments. Indeed, it would be grand if we could, as she says “redefine the arc of a successful career” to allow benchmarks such as the success of your family life reflect as highly upon you as the volume of your case load or number of patients. We are healers, entrusted to impact the physical and emotional well-being of our patients, but we must first address ourselves before we can assist them with any significant impact. It’s time to put on our own oxygen masks before helping those around us.

I have debated if my ego can handle the inevitable transition that occurs when you become “just a ___ surgeon” who cares too much about life outside of the hospital to do real cases. The jury is still out. I write this not to offer advice as a sage career woman, but to offer solidarity for those who feel the same. I do not have the solution, and at this point I don’t even know what my own future holds. Yet, standing at this crossroads has made me face the unpleasant fact that I am not immune to the challenges of my gender, and that these differences are real and can make life hard. I cling to the advice my mother has given me since I was a child, “that there is nobility in the hard road and giving yourself to others is worthwhile.” In that vein, I want to serve my patients tirelessly and with passion, but I also want to service my family and the needs of my daughter with that same ferocity. I want her to know the love that I offer my patients each day and which makes me come to work before daylight each morning. But I want her to know this love directly, not from a distance.

The missing piece….

It is interesting that most Medical Students will tell you that they chose medicine because they are lovers of humanity, that they were destined to help people, and that they want to contribute to the greater good. Yet, somehow, the process of training itself has the potential to leech part of that enthusiasm from you. I am not a naysayer decrying the fall of medical education or the newer generations. I do not dismay that these losses are permanent ones, necessarily, but they are common in medical training.

I finished Medical School an eager and overachieving MD/PhD and leapt right into my Surgical Internship at Massachusetts General Hospital. I pre-rounded every morning, kept my patient list tight, and set out with great enthusiasm to be the best intern that I could be. It was wonderful – I learned much about sickness and how to care for patients. I enjoyed my days in the OR learning basic skills and my afternoon rounds chatting with the families, despite the hectic load of inane tasks I had to cross off my intern list. I felt like a doctor for the first time and I loved it.

I can’t say that the love ever went away, but I look back on those 5 years of residency as a blur. I moved up the ranks of residency from intern, to junior, to chief resident. At each step I basked in the crazy life I had chosen – overloaded services, constantly running ORs, and long days. This is what I had signed on for. Most certainly, we would all complain and roll our eyes at the lives we had chosen, but it was the camaraderie of the trenches. Our shared dark humor made it more tolerable. I don’t think I lost my humanity during that time, but I certainly became very tired. And with tiredness comes the subtle process of dropping all the “unnecessary” tasks from your day – talking to patients for more than 5 minutes became a burden, patient phone calls a nuisance, and pages from inexperienced nurses almost intolerable.

And while this process of residency was going on, life just continued to happen. I met my husband in my third year and we got married my fifth year. My dad, himself a surgeon, was diagnosed with cancer during residency and yet my life and work continued. I saw him through attempted surgery for unresectable disease, chemotherapy, and eventually death from liver metastases. And yet, a week later I was back on Night Float because things keep moving and there was no one else to take my place. Still, I loved my job. I believe as physicians we are making the world better and helping people in need. And for those people, I could set aside my own mourning and sadness and come to work each day. However, the tiredness continued to creep in. Despite my own experience from the patient’s side, I felt the daily time pressure to see more patients, do more cases, and to lighten up on patient interactions when possible. There just wasn’t enough time to do it all, so choices had to be made.

I started fellowship in Surgical Oncology at MD Anderson, a place that I felt contained many good physicians who also cared deeply about their patients, and I jumped right into the surgical schedule. Days were long on many services, but the call schedule was much better than residency and the eternal weeks of home call and non-stop pages were manageable overall. I reassured myself that I was still a caring person, and I was still doing what I loved. Yet, living on someone else’s schedule and being 36, well-educated, and still an assistant takes its toll on your psyche.

And then I had my daughter, Sylvia. I got pregnant during my first clinical year, elected to take a break for research, and had my daughter at the start of my research time. Everyone was very supportive and I took 2 months out before starting in the lab. Being in the lab, an environment in which I was no longer the skilled technician, was humbling and made me miss my job as a clinician. However, I did not miss the surgical schedule and I was delighted to have more time to spend with my daughter during this precious time in her life. Despite being in lab, I continued to take in-house call each month, and was surprised when I found that it suddenly had become much less onerous.

The patient calls with concerns at night no longer left me gnashing my teeth and muttering under my breath. The nurses calling with small questions about medications did not leave me irritated. And the patient interactions left me satisfied and wanting more. I realized suddenly that I might have regained a piece of my previous self that I hadn’t even realized I was missing. And this realization led me to question where and why I lost that piece along the way. If you ask my patients, they may say that I was never unkind, always had time to chat, and was not cold or dismissive, but I can assure you that compared to my own baseline, I certainly was. I know we can never be charming and caring and wonderful all the time, but I realize that the way we currently live our lives during our training certainly takes a toll on our humanity. Regardless of how nice you are, those pages or consults or phone calls are always an irritation when your whole life is one sleep-deprived, overworked blur. And it makes me wonder how much better this system would be, how much better we all might be if we didn’t do this to ourselves.

I’m embarrassed to be typing these words, and I feel as though I’m betraying my people, my surgeons, my residents and fellows. I was one of the many rolling my eyes at work hour restrictions and “lifestyle oriented” people. We considered ourselves real doctors in a sea of the less dedicated. But I’m not sure I believe all of that machismo anymore. I certainly do not think that the ACGME work hour restrictions are the solution that we are looking for. I think they have caused a whole host of other problems with pass-offs, lack of continuity, and a higher burden on attending surgeons for patient care. But I do wonder if there is a way of training and educating ourselves that may be more humane. I offer only observations, not solutions because this is a tricky situation. Yet I must admit, I like this doctor that I am becoming now much better. I have a few seconds to spend time with patients, to get a better history, to acknowledge their fears, to pay attention, and to not resent them for making me do my job. That is the part that I found insidious and sad – I started down this path to help people, but became tired and distant along the way. I have seen the kind of physician my father was, and I am making the conscious decision to shift my momentum and be that kind of doctor as well. His final words on his deathbed were a reminder to me to “keep the faith and protect the vulnerable.” Each day our patients are at their most vulnerable – they are sick, tired, and often facing their own death and mortality. The responsibility is on us to guide them through this process.

For now, I am regaining that undervalued part of myself that I lost along the way, but I want to figure out how to retain it permanently. Because it is not only “my missing piece” that I have found, but also increased productivity without all the background drama, anxiety, and stress. I have seen not only an improvement in my attitude, but also in my technical skills. There is something to be said for having the time to read, plan, prepare, and execute. So now my goal is to continue along my newer, slower, but more focused path. I want to find a way to allow all of us to be high performers and remain whole people too. It would be a shame to strive for excellence as a surgeon, only to lose my skill as a doctor and humanist.