Lean in: The subtle complexity of having it all in medicine

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 … until 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” 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.

Genevieve M. Boland is a surgical oncology fellow who blogs at her self-titled site, Genevieve M. Boland.

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