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.