My Job, My Choice

There is an op-ed piece in the New York Times this week that has me and many of my female doctor friends up in arms.  The article, “Don’t Quit this Day Job” is written by anesthesiologist and mother of four, Karen Sibert.  You can find it here.

http://www.nytimes.com/2011/06/12/opinion/12sibert.html?_r=1

She writes of the doctor shortage and of the propensity for women in medicine to work part time, or not at all.  She urges women not to do this citing herself as an example.  She acknowledges that you can’t do it all, but feels that you can do enough.  She has some good points and on first reading it made me feel incredibly guilty for working part time and wanting to work even less. 

It’s true that there is a doctor shortage and that this will only get worse as an aging population that needs more and more medical care continues to overwhelm the number of practicing and training doctors.  It’s also true that resident salaries are paid for by the government, so therefore by you and me, the taxpayer.  It’s also true that there are a lot of women going into medicine and that many more women than men later choose to work part time or not at all.

However, there are other truths. 

Dr. Sibert writes,

“Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.”

When I decided to go to medical school I was foot loose and fancy free.  I was 22, single, and had no idea that any of my education would be government funded.  It was a choice I made freely and willingly with the best of intentions.  It never occurred to me that I would want to do anything other than work full time at this chosen profession.  If you had asked me then if I would work part time I would have said absolutely no.  Even 5 years later, married and starting my ophthalmology residency I would have said absolutely no.  I can remember hearing about a woman who had finished training before I started who was slowing down and thinking of quitting and I was incredulous at that choice after she worked so hard and so long to get where she was.  Priorities change, life circumstances change, and I don’t think it’s fair to hold anyone to a decision made at age 22 for life. 

As far as medical education being a privilege and not an entitlement, she’s right and she’s wrong.  No, you’re not entitled to a medical education.  You have to work damn hard to get one.  You have to take (at least for me) incredibly difficult science courses and do well in them.  You have to, at your own expense, take the MCAT; apply to medical schools (each with their own application fee) and travel, again on your own dime, to interview at these schools if you are lucky enough to be granted one.  You have to apply to a lot of schools because it is difficult to get in.  There are no loans or government help at this stage.  It’s expensive.  I once had to spend more than $700 to fly from Philadelphia to Chicago for an interview.  Now, that’s nothing in the grand scheme of medical school tuition, but for an unemployed student, it was huge.

Then you get into medical school and you have to work damn hard to stay in, all the while sacrificing time and money.  When my other friends were enjoying their 20s, going out with friends, travelling, socking away savings for retirement, I was studying.  Again, it was a choice I made, and my husband understood and supported it.  I was lucky enough to have grandparents who paid my tuition, so I don’t have medical school loans.  They paid in full for my privilege to go to school full time and then spend most of my nights and weekends studying for two years.  My husband had to do the laundry and the grocery shopping so he could eat and wear clean clothes.

Then for the next two years they paid so I could spend all of that time and more working in various hospitals learning my trade.  Although they paid my tuition, I paid for living expenses and books.  We paid with money and time. 

Then came internship, residency and fellowship.  I worked even harder.  I spent 5 years more away from my home than in it.  I had two children and went back to work 6 weeks after my c-sections and counted myself lucky to be able to take that much time off.  I cried with frustration at not feeling like I was doing anything right.  I felt like an inadequate doctor, mother and wife.  But still I soldiered on.  It was my “privilege”.

By the time I hit fellowship, lifestyle considerations were weighing heavily on me.  This is not popular to admit.  Medicine is supposed to be a calling, not a job.  Doctors aren’t supposed to expect a life outside of medicine.  It doesn’t have to be that way though. 

Dr. Sibert writes:

“You can’t have it all. I never took cupcakes to my children’s homerooms or drove carpool, but I read a lot of bedtime stories and made it to soccer games and school plays. I’ve ridden roller coasters with my son, danced at my oldest daughter’s wedding and rocked my first grandson to sleep. Along the way, I’ve worked full days and many nights, and brought a lot of very sick patients through long, difficult operations.”

Good for her.  But the argument that “I did it so you have to also” doesn’t cut it with me.  It’s the same argument that was put forward when I was an intern and resident hours were cut to make up for sleep deprivation that can lead to medical errors.  You wouldn’t let a pilot fly after being awake for 36 hours, why would you let a person prescribe medicine or perform a procedure?  “Because that’s the way it’s always been done” isn’t the answer.  There are good concerns for continuity of care for the patient, but those can be addressed and still allow for more humane work hours that benefit both doctor and patient.

I’m glad that Dr. Sibert was able to work and parent her children in the manner she chose.  I’d like to do the same in the manner I choose.  The priesthood isn’t an irrevocable choice, so why should medicine be?  If entering medicine is a lifelong, irrevocable decision then make it so.  Make it like the military with commitments and penalties for leaving spelled out the moment you begin. 

But that’s not how it is.  I appreciate the money invested in me by the taxpayers.  I provided good care during those years to any and all comers.  I slept, when I could, at hospitals.  I left the house before my children’s daycare opened and came home after it closed.  I abandoned my husband on weekends and holidays.  When I came home I was asleep more than I was awake so I could continue to do it all.  I think I have, at least partially, paid the taxpayers back.  And it’s hard to feel grateful to a government who thinks I am overpaid and connivingly so.  A government who thinks that every diagnostic test I order is done with an eye on the bottom line and not in the interests of serving my patients even though I get nothing, yes, nothing, in the way of financial remuneration from most of these tests.  A government that champions a healthcare system that actually penalizes me for spending time with my patients, getting to know them and being able to provide the care they need and for which they come to me.  I am in a subspecialty whose numbers are dwindling precisely because it is getting harder and harder to make a living at it.

Dr. Sibert talks about my moral obligation to my patients.  Yes, that is real and that is there.  But what about my moral obligation to my husband and my children?

There are issues here that every physician, whether male or female, needs to work out for themselves.  If there’s anything I’ve learned in the last year and a half since my brother died, it’s that life is precious and regrets are the worst possessions.  I’m doing my best to figure it all out as I go along which is all any of us can do.