“I suspect that some of the nearly 20 percent of physicians who have quit their jobs during this pandemic needed to feel this relief, too. They needed to feel the relief of having no plan. No ‘if this, then that.’ They needed to just exist in the now. Because who knows how long the now will be around anyway? Will we wake up one day and find that years have gone by without knowing it because we were so busy planning ahead for scenarios that never occurred?

This is not something that worksite wellness programs can provide or resilience training can foster. It is a reality of COVID-19 when you are caring for anyone who needs you, as much as (or more than) your patients. The miracle is that there are so many of us left in the workforce at all, riding the waves of uncertainty feeling like the only COVID contingency plan we can depend upon is ourselves.”

Margaret B. Nolan is a physician-scientist.

She shares her story and discusses her KevinMD article, “Am I a doctor or a contingency plan?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Maggie Nolan. She’s a preventive medicine physician. She wrote the KevinMD article “Am I a doctor or a contingency plan?” Maggie, welcome to the show.

Margaret B. Nolan: Thanks so much, Kevin. It’s great to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Margaret B. Nolan: Sure. I’m a preventative medicine and public health physician, and there are not that many of us; it’s not a very common specialty. The road I came from is a bit winding, because I began in public health and always knew that I loved treating populations more than single patients. I went to graduate school in social epidemiology, learned about the social factors that affect health, did some international work, and needed a clinical background to, I felt, really make a difference in public health.

So I went to medical school, and I didn’t click with any particular specialty. A lot of my classmates were really pegged as one specialty or another, and I floundered a bit. I loved medicine, but I didn’t fit any one place, and I didn’t know about preventive medicine and public health at the time. So I did some residency in family medicine, which was a really broad clinical base, and found my way into clinical research. I worked for four years at Mayo Clinic designing interventions for tobacco control, particularly in cancer patients and other high-risk clinical populations. So I learned a lot about research, and then I discovered preventive medicine, and I came to the University of Wisconsin to train here in their preventive medicine residency program.

So now I do what a lot of private docs do, which is many things at once. I spend half my time doing research in nicotine and tobacco as a physician scientist at the Center for Tobacco Research and Intervention here at UW. I’m also the associate director of our preventive medicine residency program, so I do some mentoring and teaching. Then I’m an editor at the American Journal of Preventive Medicine, so I get to read and write.

Kevin Pho: Like you said, there aren’t very many physicians who are preventive medicine specialists. So for those medical students who may be listening to this podcast, what kind of characteristics or interests should they have if they were to consider a career in preventive medicine?

Margaret B. Nolan: I’m so glad you asked that. I think one thing is a broad interest. Like how I was, there wasn’t one particular specialty where I really said, “I want to do this all day, every day,” but there were many that I enjoyed a little bit. I also am a big-picture thinker, and I think when you like to step back and look at things broadly, and think about systems instead of individual people, that’s a good sign that you may be a good fit for preventive medicine.

I should say there are many fellowships, so even if you do a residency in a different clinical specialty, you can still do a two-year fellowship and really gain a lot of the leadership skills and systems thinking of preventive medicine.

Kevin Pho: You mentioned that you had a background in family medicine, but you could also do an internal medicine background and then do a preventive medicine fellowship, correct?

Margaret B. Nolan: Correct. We actually have quite a few surgeons who maybe didn’t finish a surgical residency, did a couple of years, and then said it wasn’t for them and came to preventive medicine. I think if you’re interested in upstream causes, you kind of find yourself treating the same thing over and over and just wishing you could prevent it earlier and intervene earlier. I think that’s a good sign that you might be preventive medicine-bound.

Kevin Pho: All right, so let’s transition into your KevinMD article. It’s titled “Am I a doctor or a contingency plan?” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Margaret B. Nolan: Sure. This was an essay that was inspired by a conversation I had with a colleague in my specialty. He had a family very similar to my own; his wife was also a physician. I was speaking with him about his decision to leave his job to take care of his family during a time of COVID, and it really hit close to home. I came back inside after my conversation and spontaneously, furiously wrote this essay.

I think it was hearing a close colleague, someone very similar to myself, talk about making this decision that really brought to light how much mental effort those of us who care for dependents during COVID have spent trying to mentally navigate and plan in order to simply do the job that we’d been trained to do. I think many of us felt, particularly me in public health and my husband in pulmonary critical care, that we were trained for exactly this situation, like COVID, and we wanted to help. We had a great ability to do so and an opportunity to do so, but we had three young children.

I think the exhaustion of figuring out how they would be cared for, so that we could contribute and do the work that we were trained to do, was an enormous part of this that wasn’t being talked about very much. I found that it was maybe a reason that more doctor parents specifically were leaving their jobs. In addition to patient care, which is very important and has been discussed a lot as a form of burnout, I think this was another type of burnout that was simmering among a lot of people that needed to be heard. So that’s what this essay is trying to do: It’s just trying to give voice to that tension and that exhaustion, and I dubbed it COVID contingency planning.

Kevin Pho: So go into more detail. Tell us what you want us to know when it comes to this COVID contingency planning, about how caring for children would be an obstacle to doing what you would like as a physician. Give us an example of how that is an obstacle, or something that you want my listeners to come away with.

Margaret B. Nolan: Yeah, I think we’re discussing a lot about burnout prevention and resilience training in physicians, which I really think is essential, and I don’t want to say that’s not important in any way. But for people like me, who are considered essential workers in the pandemic in public health but are not treating COVID patients directly, so not front-line workers in that way, I think there’s a different type of burnout, perhaps, if you want to call it that. It’s not going to be addressed with a lot of the kind of political solutions we’re discussing.

I think the inflexibility of health care as a career when you’re caring for other people has always been there. It’s been there for other jobs as well, but specifically for health care, I think the last two years have brought it to such a light that many people are realizing that they have to choose a different career, right? The 20 percent of physicians who have left are very intelligent, driven people who can do other things that will allow them to have more flexibility to care for their families. I think the first step is talking about that, because it’ll help us to heal the workforce that still exists and be better prepared for whatever lies ahead, if that’s more COVID to come or something else.

Kevin Pho: Now, if you were in charge of a medical institution, or if you were in charge of policy, what would be your ideal scenario to prevent these clinicians from leaving work so they can care for dependents? What kind of ideal solutions would you like to see, specifically?

Margaret B. Nolan: I think some of that is happening, which is terrific. For those of us who can work remotely, allowing for that flexibility has really changed the landscape a lot for physician parents specifically. But then there are many who can’t work remotely. Two things. One, I think people are making personal decisions to move, to shift. My husband and I are moving to my hometown after we said we never would, and the last two years defeated us. We just cannot be without that support, and I think there are a lot of people thinking that way. That type of job shift can be very difficult; it can cost you career-wise. So acknowledging that there’s going to be this transition and shift as people readjust to what’s going to be feasible for them in the future, I think that’s part of it.

I think over time, what I’d love to see is flexibility that’s acknowledged throughout medicine. Again, it’s happened a little bit in pockets, but maybe no patients from three to four so someone can do school pickup, right? These small things really can change the quality of life and the stress put on health care parents.

Kevin Pho: Now, from talking to your colleagues or from what you’re reading in general, do you feel that a lot of medical institutions are doing enough to support physician parents to do some of the things that you would like to see?

Margaret B. Nolan: I think there were a lot of policies, especially early in the pandemic, that made it easier to do that, in the paid COVID time off and remote work. So I think that was there initially. I have the feeling that’s really rolling back. Particularly, and I don’t think this is specifically women more than men per se, because it was a male colleague of mine who stepped down from his job so his wife could focus on her career as a physician, so this is not only one way or the other. However, I do think most of the time women have chosen to step back more often than men during the last two years, and I know that we’ve seen that academically.

Now, I’m a physician scientist. I know academic positions and promotions; that’s going to be really hard to catch up on in scientific literature, publishing, and all of that. So I think we’re going to take a few steps backward, and institutions should make plans for how to support not just women but those who stepped back and stepped out a little bit over the past couple of years, to try to get them back in with what support they need.

Kevin Pho: We’re talking to Maggie Nolan. She’s a preventive medicine physician, and she wrote the KevinMD article “Am I a doctor or a contingency plan?” Maggie, as you reflect over the pandemic, over the last few years, and having had to manage caring for your family as well as your professional life, what are some things that you’ve learned over these years, God forbid, for the next pandemic, or as advice for other clinicians who may be in similar positions like you? What have you learned over the last few years?

Margaret B. Nolan: I think the main thing I’ve learned is that giving voice to and acknowledging the difficulty is really important. I have a lot of friends, particularly from medical school, who are in dual-physician households, and with this piece, most of them said they cried as they read it. I think it really shows you the power of just writing down on paper, or what you do, Kevin, with communicating in all different forms. It can do a lot to have people feel less alone in this and be more brave, more courageous in going forward, knowing that they’re not alone in the struggle. I think that’s what the conversation with my colleague did for me, and it inspired me to write this down for other parents who are going through it.

I think what I would say is that none of us, no matter how long we have trained or aspired to be the physicians that we are, is just a doctor or a nurse. We’re husbands and wives and daughters and sons. We’re parents or caregivers for people who may need us as much as or more than our patients. So that tension, though it’s always with us, has been so front and center, I think, in all of our lives over the past two years. Just validating that exhaustion is a really important part of moving forward and seeing how we can do it better the next time, if it needs to happen.

Kevin Pho: My final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Margaret B. Nolan: I think that really highlights it. Particularly for the doctor parents in your audience, I would just say that whatever you have been struggling through over the past two years, you have been steering this nation through a pandemic and raising tiny humans at the same time. Whatever that has been, however that has been for you, you have not struggled alone. Even very highly intelligent, motivated, brave people like all of your listeners have been defeated. They can feel they’ve been defeated by COVID, by the experience of caregiving during COVID. I think that’s the main message that I want to send: That’s OK. That’s a valid way to feel at this point, and it doesn’t mean we can’t be resilient and recover.

Kevin Pho: Maggie, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Margaret B. Nolan: Thank you again, Kevin. It’s a pleasure.