OB GYN, Physician Training, retirement

Is it Ethical to Retire Early from a Career in Medicine?

Eight weeks after I delivered my 3rd child, I was diagnosed with a 4 cm lung mass.  Yes, you heard that right. For those in medicine, this is terrifying to hear as the first thing that comes to mind is lung cancer.  Lung cancer is notoriously hard to treat, typically fatal with a short life expectancy after diagnosis, and extremely unfair to a lifelong nonsmoker who has spent 12 years in the prime of her life dedicated to training to become a physician.

Luckily, I soon found out my situation was not as grave as first expected.  A PET scan leaned toward benign diagnosis (or at least consolidated disease).  I could temporarily push aside the paralyzing fear of leaving my 3 young children with no mother and focus on getting rid of this mass that was causing pneumonia, difficulty breathing, coughing for 2+ years, and go ahead with scheduling the thoracotomy.  After resection of the mass which was densely adherent to my pericardial sac and phrenic nerve, I lost about a 1/3 of my left lung.  To my amazement, after my ICU stay I left breathing better than I had been in years.  Benign diagnosis was confirmed.

This experience made me reevaluate my life and it stopped my “hamster wheel” of life I had been running on at a dizzying speed.  I viewed this health scare as a second chance at life.  I didn’t take this lightly as it almost seemed unfair that I got this chance to live while others who have a lung mass often have it turn out to be one of the most fatal of cancers.  Having to face the prospect of this potentially devastating diagnosis changed the course of my life. I was able to view my career for what it was and had become.

 

I had planned to work in my medical career as a physician indefinitely, or at least well into my 60’s.  It had always been my passion to work in obstetrics and I love my patients and the bonds I build with their families. It was never my intention to leave early, and it didn’t factor into choices along the way for my career.  But here I was, ready to retire in my late 30’s after several years of increasing disillusionment with the health care environment.  Apparently, I just needed this wake-up call for a chance to realign my priorities.

Loss of physician autonomy, pressure to increase productivity as opposed to quality care, and placing cost effectiveness ahead of best medical practice were weighing heavy on me.  In addition, the litigious environment in the US has become out of control and encourages frivolous lawsuits without any repercussions for those seeking damages without merit or basis for the claim.

I could no longer honestly tell myself that I was working so hard for the good of my patients, and I became cynical that my efforts were to the benefit of the financial bottom line of a health care system with its priorities out of sync with my own.  This is not specific to any health care employer, physician group, or hospital.  It is emblematic of the US healthcare system in general.  It is the reason I left medicine entirely and did not merely seek to work elsewhere. The problem is pervasive.

The decision to leave became a question of “why am I doing this, and for whom”?  I decided to retire early.

I have since learned that many feel this is not an appropriate thing to do in your late 30’s.  There is the argument that I owe a debt to society now that I have the skills acquired from all of those years of training. Or that the government paid for my residency salary and that I am indebted due to that.  Or that it is selfish to stop working to spend more time with my family.  There is the argument that it is not fair to leave my patients that I have been caring for over the years.
My response to the ethics of my decision to retire early: If you pay for the privilege of a medical degree and work hard to pay off this debt, should it be your decision if you want to continue to practice?  The government did pay my salary as a resident, which amounted to a little more than minimum wage for 4 years of 80 hour work weeks.  Do I owe something because of this?

As for leaving my patients, I actually do feel a little guilty about his one.  I love my patients.  I also struggle with no longer using my degree for clinical practice, something I worked so hard for.  We are already feeling the strain of physician shortages and this another thing that gives me pause.

In the end, the burden of practicing medicine in today’s environment no longer outweighed the positives for me.

Ironically, it’s my patients who hugged me and told me how happy they were for me to live the life I felt I needed to.  It’s my patients that spoke up (without me saying a word) about how the medical field has changed and that we are losing good doctors as the control of medicine is being handed to hospital administrators and politicians who are making choices about health care without a medical degree. It’s my patients that brought presents on my last days and thanked me for the care I did provide throughout my career instead of lament about what I “could” have done if I stayed longer.

It was a very personal and difficult decision for me to leave medicine and luckily, my colleagues who know me have been incredibly supportive.  On the other hand, one thing that has surprised me is the number of physicians contacting me who want out of healthcare but don’t know how, or can’t, get out.

How do we retain physicians? It is not by increasing salaries. Doctors aren’t in it for the money, we chose this profession to help people and save lives.  We do it by reforming the current health care environment and making this a profession that is sustainable.

Give medical decision making back to physicians.  Decrease the cost of health care by cutting out costly administrators and through tort reform.  This is the way to keep our best physicians and improve health care in our country for our patients.

Ultimately, is it ethical to retire early from a career in medicine? Or is it a bigger picture issue of how do physicians take back control of medicine so that we aren’t leaving at a time of shortage? This is a major concern for our country moving forward.

 

Maternity Leave, Parenting, Physician Training, Uncategorized

Best Time to Have a Baby as a Physician? It Depends.

Is there truly a best time to be pregnant, have a baby, and care for a newborn during a medical career? I’ve done the groundwork by having a baby in residency and two more as an attending. Here is what I found out along the way.

 

Is it even possible to have a baby during residency?

It was the end of a 24-hour call – I’m guessing similar to the ones most physicians in residency experience. Zero sleep, several high-intensity and stressful patient care situations, and a few graham crackers and ginger ale from patient waiting areas throughout the day to keep you going. When the call ended, the right thing to do was to lay down and get a few hours of sleep prior to driving home. However, your baby is waiting, and you haven’t seen her in 24 hours. You pumped milk in between admitting patients from the ER and a quick add-on surgery. You are desperate to get it home to see your child, so you rush out the hospital doors after carefully signing out to your oncoming resident.

 

Once home, you can’t wait to see your baby, your everything. Instantly, all stress evaporates and her belly laughs melt away the last 24 hours. Your husband gives you a quick kiss, hands off the baby that kept him up all night teething, and immediately heads out to the gym for an hour of his own much-needed downtime before starting his workday.

 

You lay on the floor to play with her and arrange pillows and toys surrounding her while you rest your head…just for a moment. The 24 hours of no sleep catches you and you realize you fell asleep on the floor next to your baby with no one else around. It scares you. Luckily, she hasn’t learned to crawl yet and is still content playing with toys. Exhaustion and exhilaration fill your days as a new parent/resident physician.

 

Time is lacking. Love is not. You will likely have to put your baby into childcare sooner than you would like. Six weeks maternity leave is pretty standard (but expect to use all of your vacation time for the year to cover it). You will also need to factor in additional calls before or after your baby is born to make up for the call you miss during leave. Your fellow residents will help by picking up the extra calls in your absence and will appreciate your reciprocity. As uncomfortable and painful as it is to take additional 24-hour calls while you’re pregnant, I highly recommend this instead of waiting until after the baby is born. Until maternity leave policies change in the US, this is what can be expected with having a baby during residency. More than six weeks off will likely involve adding time to your residency training. I actually agree with this as the high-yield information/learning obtained during residency will sustain your whole career; missing a large portion of it may put you at a disadvantage.

 

In the end, you will miss a few of the early milestones but will be reassured knowing that you will be available more in the future as an attending physician as your child grows older and is able to form memories of your time together. Plus, the days fly by as you are invigorated by your interesting days as a resident, while also knowing your life outside of the hospital is quite rich.

 

Your child will not suffer long-term consequences from you not being the one giving all the bottles during the day and tucking in for naps. You will be able to finish your training on time and have colleagues and program directors to help you cover the patients who need to be cared for in your absence.

 

The one person who may suffer a little bit is you. It’s hard to be away from your newborn while working 80 hours per week. So, why not wait until later to have a baby? Well, read on…

 

Yes, it is acceptable to plan your life and think about money

You may think this is backwards, but it actually makes more financial sense to have a child during residency than as an attending. I definitely don’t recommend finances to be the sole reason for having a baby during residency, but if you were thinking it didn’t make financial sense to do so, it may give you something to consider. We’re getting practical now. I personally didn’t factor in any of this when starting my family but realized the impact looking back.

 

You will be getting paid while on leave as a resident (covered through your accrued vacation time). You will have access to excellent health insurance coverage. It is not uncommon for your entire pregnancy and delivery to be covered by a $20 copay as a resident. Don’t expect this as an attending; if you aren’t seeing patients, you aren’t getting paid. It may also be difficult to find enough colleagues to help you cover your patients if you are in private practice. Most large employers will have some type of leave policy, but few will pay your salary while out.

 

As an attending I was able to take 12 weeks of leave, but it was unpaid. If you evaluate lost wages and earning potentials pragmatically, you actually come out far ahead by having a baby during residency. As an attending, you may be making 5x the amount of a resident, and 12 weeks unpaid leave is quite different than when a resident. When you don’t work as an attending, you don’t get paid. Why does this matter? Well, most of us right out of residency have six-figure medical school loans we need to repay as quickly as possible. Of course we don’t want money to be a factor in family planning, but sometimes it is, and it’s better to understand the consequences upfront.

 

The flip side to this is that, as an attending, you will have more income at your discretion. That income could provide a higher quality of childcare, and as mentioned earlier, help you enjoy more time with your newborn.

 

Why do we hate the term “advanced maternal age”?

 

time

Lastly, but perhaps most importantly, is age. In a recent discussion with other physician moms, more than half had gone through costly infertility treatments to complete their families. Some spend close to $100,000 for these treatments. Most of us in medicine are very driven people, who enjoy the rigors and challenges of our careers. We work diligently to make it through to the “light at the end of the tunnel” once the 8+ years of medical education is complete. However, once we can finally start to focus on family, children, and an existence outside of the hospital, we may have lost more than realized.

 

Far too many women may have missed out on their prime years of fertility by putting off childbearing. By the time medical school and residency is complete, most of us are approaching 30; add on a few years if fellowship is considered.

 

While 30 years old is likely not an age-related fertility concern for most, if you plan to have more than one child, it definitely could be. Around age 35, fertility starts to decline. In addition, if you do get pregnant, you are considered “advanced maternal age.” There is a higher risk for gestational diabetes, hypertension, chromosomal abnormalities, and miscarriage. Suddenly, you may find yourself longing for a second child, a sibling for your growing toddler, or a much-anticipated first child, but the answer may not come so easily. Physicians are fortunate to have stable incomes that allow us the opportunity to seek fertility treatments when needed. Ultimately, you will likely be able to complete your family, but it may be a long, financially, and emotionally exhausting journey through fertility treatments – and not the route you expected.

 

What really matters most?

Ultimately, the decision whether or not to have a child is very personal, and not every female physician desires this. However, the majority of female physicians do eventually become mothers. Our lives may become busier, but the dedication to medicine and our patients does not waver from the act of having a child. In some ways, I became a better physician after my own childbirth experiences.

 

The right time to have a child will be different based on personal values, support systems in place, and emotional readiness. But, perhaps we can help each other by being honest and open about what it is like to have children during a medical career. This way we can each determine the right time to expand our family, independent of pressures and expectations from outside influences.

birth plan, epidural, episiotomy, hospital birth, Physician Training

10 Things to Know Before You Have a Baby in the Hospital

 

  1. You might get sent home. If you show up pregnant with your first baby and it turns out you aren’t 4 cm dilated yet, you will get sent home because you aren’t in active labor. Please don’t cuss out the charge nurse.   Yes, you are in pain- we aren’t denying that.  However, there are limited numbers of beds on labor suites and we need to keep some open for people who will likely roll in right behind you and will deliver way before you. There are no appointments on L & D (labor and delivery) and you never know what will come in.  Space and open beds are the issue, not laziness of admitting physician.

 

  1. Limit it to 2 guests during delivery. More than that is just a distraction.  If there is an emergency, the last thing we want to be worried about is having enough room to take care of you appropriately without people being in the way. In a true emergency about 10 medical professionals will come barging in your room within seconds and if someone is standing in the way it prevents us from doing our job.

 

  1. Ask for the epidural early. If you plan to wait and see how it goes, likely you won’t have time to get an epidural before baby makes the big entrance.   Murphy’s law will dictate that every pregnant patient on L & D will need one at the same time and there is usually only one anesthesiologist, who will invariably be back in the OR with a C-section tied up for half an hour.  Don’t miss your chance!

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  1. You can have a birth plan, but please have it read as follows: I want to leave the hospital with a healthy baby and Mom.  Anything more than that and we get superstitious.  It’s just like the old wives tale about the full moon and people going into labor- there is no scientific evidence to back it up but we all believe it’s true and witness it happen all the time.  The longer and more detailed your birth plan, the higher the percentage likelihood you are to end up with a C-section. At least it always seems to work out that way.

 

It is true that you can expect to have more interventions and temporary discomforts while having a baby in the hospital as opposed to a home birth.  Expect to not eat when in active labor, have monitors strapped to your stomach and frequent vital sign evaluations.  In my opinion, these are small sacrifices to pay to ensure healthy baby and Mom.

 

 

 

  1. Contrary to popular belief, we love when you bring a Doula to the hospital with you! They help you through your labor, make sure your needs are met, and encourage you through pushing.  They are an OB/GYN’s best friend!

comforting

  1. Prepare to not eat food for a while. We are not doing this to be mean. We are doing this because having a baby is dangerous. At any moment you could become a surgical patient. If you vomit and aspirate, this could be dangerous for your health. Nobody wants to have a newborn baby, aspiration pneumonia and recover from surgery all at the same time.

 

  1. We are going to press on your abdomen/uterus after the placenta delivers. I have seen patients get downright angry about this. The reason behind it is that after the placenta comes out, the uterus can become very floppy and you can quickly lose a liter of blood. Massaging the uterus helps with the tonicity and also helps your doctor assess whether there is a problem or if more medications are needed to avoid a hemorrhage.  Just because the baby AND the placenta are out, there is still a need for assessment. You are almost done!

 

  1. Don’t try to rush the OB who is suturing you after you tear with delivery. Episiotomies aren’t routine anymore and are typically only done when medically necessary.  However, it can be very common to tear on your own with a first baby.  Let your OB take their time and do it right, trust me.  10-20 more minutes of meticulous care will be well worth it in the long run, especially if you were “blessed” with a 10lb baby.

 

 

 

  1. Send your husband to get your ice chips. Let your nurse focus on your vital signs, evaluate the fetal monitoring, and document your progress.  Your husband/support person should be the one getting you the much needed ice.  Besides, it will help your partner feel useful at a time when they are often struggling over lack of control and they want to help you in any way they can.

delivery.jpg

  1. You are in competent hands. A normal labor can turn into an emergency at any moment, even in a low risk patient.   In any given day, L & D will have a woman hemorrhage after delivery.  In the next room, the newly delivered baby may not be breathing. 2 doors down a patient just had a seizure and dangerously high blood pressures as her preeclampsia progressed to Eclampsia.  Down the hall a shoulder dystocia occurred.  This happens when the baby’s head emerges but the shoulders are too wide to deliver and asphyxia of the infant makes seconds feel like hours until skillful maneuvers can safely deliver the baby.  I mention these scary but common scenarios because the best thing about having a baby in the hospital is that you are surrounded by scores of people that are trained to handle these exact situations and do so every single day.

 

 

hospital birth, Parenting, Physician Training, Uncategorized

Mother’s Day on Labor and Delivery

Mother’s Day weekend is a great time to be the ob-gyn on call for deliveries at the hospital.  Of course, we physicians would love to be snuggled up next to our little ones on this special day.  However, the next best place to be is bedside with a woman about to become a first time mom.

The new mom is unaware how her life will change. Sure she has had countless advice from well-meaning friends and family. What diapers, breast pumps, sleep sacs, and toys are essential and how to handle the sleepless nights and messy house are all topics of endless conversations these days.

Labor stories abound and she has heard 50 different versions of what could happen during the process and how it didn’t always go the way it was expected.  Everyone has their own struggles and triumphs to share but most of the stories end with a healthy baby and a physically exhausted mom who may be hurting from delivery or surgical wounds but exhilarated in the way only a new mom can understand.

puppyhat

Little does she know, she will never be the same person.  Her body will never be the same.  Her heart learns to expand to be able to love exponentially more with each child she has. Her needs now become secondary to those of another, and she will gladly have it this way.  She experiences life with a different view and understanding of others and thinks of random strangers as “someone’s son or daughter”.  She finally has a better appreciation for her own mother and understands her love in a much deeper way.  To help deliver her baby and be a very small part of this transformation is a unique gift.  Watching it unfold as her newborn is placed in her arms for the first time is one of the most gratifying experiences as an ob-gyn, and for a moment everything is blissful.

But there is also a different group of women that are sometimes forgotten on mother’s day.

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On Mother’s Day, many other patients are also on my mind.  The patients who have struggled with infertility for years. The patients who have suffered miscarriage, possibly multiple times. The patients who have lost an infant shortly after birth, or many years down the road. This day weighs especially heavy on them.  It forces them to deal with their hurt.  It resurfaces pain and brings memories to the front of their mind that are always lurking in the background. I have been on this journey with many of them.

While celebrating the wonderful women in my own life and the people who are getting to experience the world of motherhood for the first time, I stop to remember and include the women who are forever changed by the short life of a child, pregnancy that ended too soon, or the indescribable desire to become a mother.

 

hospital birth, Maternity Leave, Parenting, Physician Training

Open Letter to a Child of a Doctor: To My Daughter on Her 9th Birthday

It was the end of my 3rd year in ob-gyn residency.  I was 39 weeks pregnant with you and doing a hysterectomy, my gravid abdomen being utilized as an “extra hand” to displace the large clamp nicely to the side as I pressed my belly gently against the table. I was doing surgery all day and loved operating and feeling your occasional gentle movements when in the quiet operating room as I was working. I knew my days were limited with us being one. 

It was sometimes hard to breathe with the mask covering my face from the natural air hunger that can sometimes accompany pregnancy. I would have the OR nurse gently loosen my mask and take a deep breath.  Worried about you, I wanted to make sure you were getting enough oxygen.  After my last case was finished, it felt so good to drive home and rest sitting down after standing all day.  This was my favorite time of day as you moved the most on my way to and from work while I was still and I could concentrate on just you.

Later that same day I went into labor and your Dad drove us back to the same hospital where I was operating earlier that afternoon.  He was nervous but I knew you were safe and we had a long journey ahead of us.

When you finally made it into my arms 19 hours later I was exhausted and exhilarated all at the same time.  Looking at you, I finally understood what it meant to feel like your own heart was outside of your body. You were perfection and I didn’t know how I could make something so beautiful. I still feel that way.

I spent a precious 6 weeks at home with you but had to return to work and help other women bring their own miracles into the world.  I hoped you would grow to understand that I of course always wanted to be with you, but also felt a pull to continue my path as a doctor.

That first year was tough.  I was working 80 hours a week and there were some days when I only got to see you an hour a day, or when on call not at all. Those days were torture. You were often asleep for the night before I got home. There may have been more than one occasion when I sneakily scooped you out of your crib while you were still asleep and rocked you in the middle of the night so that I could have that precious time with you.  I knew you were well cared for during the day, and it was me who needed this snuggling more than you.  I missed you so much during those times.

It got better over the years as my work load became manageable and I got to feed you breakfast in the morning and dinner at night. We would play before bedtime and I could see that you were thriving and my guilt for leaving you during the day lessened.  Your pictures covered my desk at work and your smiling face was plastered all over my bulletin board along with the babies I have delivered.

After you were born, I was also changed as a doctor.  Delivering a baby wasn’t the same.  I empathized more with my patient in pain, begging for an epidural. I understood the fear before a C-section.  The first cry from a baby I delivered brought me back to hearing your first cry every time.  Unfortunately, the losses my patient’s experienced also hit me 5x harder as I felt their pain as only a parent could.  I think you made me a better doctor.

 I’m sorry I missed your field trips at school.  I so wanted to be there but work requires 6 month notice for a day off and schools don’t often understand this.  I’m sorry I would forget to send you in with crazy hair on “crazy hair day” or miss a deadline for a book fair.  I was doing the best I could juggling surgeries, being up all night at the hospital delivering babies, and seeing patients in the office all day. Despite all that, you were always in my thoughts.

I hope when you are older you will understand the sacrifices and more importantly how much I love you.  You will know a different mother than your much younger brother and sister.  You will remember me coming home in scrubs exhausted after a 30 hour call.  You will remember me leaving your soccer game early to go to the hospital to deliver a baby.

However, I also hope this will help you to see that you can do it too.  Maybe not a career in medicine, but whatever you want to do.  I could see you as an artist, singer, scientist, entrepreneur… the list goes on.  Knowing what a fantastic person you are turning out to be lets me know that it is possible to be a good doctor and also raise a wonderful child. To have a career and also give your children the love they need.  I am fortunate that I will have more time with you moving forward, and I am so happy for that, but I don’t regret our past.  It has made us both who we are today and I couldn’t be more proud.

hospital birth, Physician Training

Who Will be Delivering Babies in the United States in Coming Years?

The American College of Obstetrics and Gynecology (ACOG) estimates that the U.S. will have between 6,000 and 8,800 fewer ob-gyns than needed by the year 2020.  Additionally, there is a possible shortage of 22,000 by the year 2050. 

What is being done about this problem?  Well, there are currently efforts to attempt to increase the number of residency positions.  There is also talk of having nurse midwives take a greater role.  While those are valid interventions, let’s take the issue much deeper, as that is certainly not doing enough to mitigate the problem.  Perhaps of equal or greater importance in the consideration should be retaining practicing ob-gyns and malpractice reform.

 The current work force in Obstetrics and Gynecology is aging, retiring early, and going part time at an increasing pace, all while the number of patients seeking care is exploding due to health care reform and population statistics.  While access to maternity care and women’s health services is vitally important, we need to have infrastructure to support the numbers or these women will have no ob-gyn to turn to despite having insurance. Even if the number of residency spots increases, the attrition of those already in the field must be addressed.

 Today, over 80% of physicians entering the field of ob-gyn are women.  Shockingly, if you look at hospital department chairs, academic medical institutions, and leadership positions in the field it is overwhelmingly male despite the preponderance of women who are practicing and are the future of ob-gyn. In order to appropriately assess the changes and adjustments that need to be made to the field, including what will draw in and retain candidates, we should be asking that very demographic that is accounting for the majority of ob-gyns. This means that women need to be “at the table” for discussions and interventions impacting our field. Women want to be invited to be a part of the change and are willing to step up to the challenge.

 As for malpractice reform, this is vital not only to obstetrics and gynecology, but the entire medical system.  Defensive medicine is valuable to no one and a waste of precious health care dollars.  In addition, increasing numbers of midwives to assist with a shortage will only be helpful if ob-gyns are willing to provide a supportive role.  As it is now, ob-gyns can named in a lawsuit by malpractice attorneys who seek damages for birth injury cases where a labor occurred at home.  These patients often arrive at the nearest hospital’s doorstep seeking help after a failed home birth or bleeding concerns. The attending ob-gyn physician must (and should) accept care for anyone arriving seeking help.  However, if there is a bad outcome, it must be somehow proven when damage occurred.  Was it during the unmonitored 30+ hour home birth or the 30 minutes from when the patient arrived to the hospital prior to an emergent cesarean?  Obviously, no one wants a poor outcome for the patient and blaming each other is not a solution.

 A solution is malpractice reform where a physician does not need to worry that if they are called to help in a complicated case that they will now be liable for whatever happened prior to their involvement with care. Certified nurse midwives, especially those working in a hospital or birthing center, will likely have a huge role moving forward in our field. There are many fantastic midwives who bring valuable assets to the table.  Ob-gyns should be willing and ready to work as a team for improved patient outcomes. 

 Lastly, malpractice reform is important because rising malpractice premiums are a huge part of why private practice ob-gyn is becoming a thing of the past. Understandably, it is hard for a practice to survive while paying $80,000 for yearly malpractice premiums, then staff, then rent for office space.  Somewhere the ob-gyn is expected to make a living, but the private practice ob-gyn is struggling. This is why new residents accepting jobs are looking for employed positions which will provide tail coverage and protection from this concern. While employed positions certainly have their benefits, one of the major drawbacks we are seeing is loss of physician autonomy and control over our field.

 Moving forward, physicians need to have a larger voice in reforms that are taking place in health care. Especially in the field of ob-gyn, female physicians need to be an integral and valuable asset to improving the field by working alongside the people currently contributing to the changes.  While the voices from our government, lawyers and insurance companies are important and necessary, they should not be muting the voices of the physicians who are the ones providing care for our patients and have the patient’s best interest most at heart.  This communication will be vital in continuing to have a robust ob-gyn work force ready to handle an increasingly complex and high risk patient population in the United States.