On Surgery and Babies

I often have patients tell me "good luck!" as I say goodbye to them and start to leave the room.  "Good luck," as in, good luck with finishing medical school... and then residency... and then, you know, the whole being a doctor thing.

I always say thanks, and I always mean it.

I never don't feel like I need a whole lot of luck to get through this, or at the very least a little of some really good stuff.  This afternoon, a patient - an older woman - went on and on about how wonderful she thought it was that there were so many more women going into medicine nowadays.  And I totally agree with her, but I also think that a big part of the reason I feel like I need to rely so heavily on luck for this whole being a doctor thing is because I am a woman.  Not for the medicine part by itself, necessarily (although God knows I could use that too), but for the entirety, the wholeness, of my life.  To be a woman in medicine and to still have the life I want, or something like it.  I have so much to say about this subject that I could write forever about it, and probably will plenty of times, but tonight I am going to keep it short.

All I know is, I have been reading this excellent book, and it is just fascinating and pulls you right into the crazy intense world of pediatric heart surgery, and envelops you with a sense of the insanity of that life and the courage and singularity of purpose it requires to do that work (and thank God there are people out there who can do it)... but they are all men.

They do amazing, incredible, miraculous, insane work, and they have schedules to match.  Still, many of them have families.  And I can't help but wonder... is it any coincidence that none of them are women?  Just kidding, I don't wonder that.  At all.  It is obviously not a coincidence.  

Anyway, here is another fabulous Dr. Chen column from the NY Times Well Blog, expounding on the topic much more eloquently than I.  Enjoy.

The Plight of the Pregnant Surgeon

By PAULINE W. CHEN, M.D.

February 23, 2012

Admired as much for her sheer talent as for her humility, my surgical residency colleague became pregnant during her last year of training. At about the same time her baby was born, another colleague, also in his final year of training, broke his leg in a skiing accident. Both ended up taking a few weeks off from work, he for his accident and she for her maternity leave.

A couple of months later, after both had returned to work, we learned that our female colleague had been asked to make up the time lost on her maternity leave, while our male colleague had not. Outrage over this decision spread quickly among the ranks; in hallways and call rooms we residents huddled together to condemn the decision of our elders. Medical students reacted, too, choosing training positions not in surgery but in obstetrics and gynecology or internal medicine, specialties where they believed they could have “a life” while training.

Many years later, what remains surprising to me is that none of us, including the woman herself, ever seriously questioned the decision or the senior surgeons. Despite our railings, we accepted it because, as one female colleague trenchantly observed at the time, “this is the way it is with surgical training; you just don’t get pregnant.”

I remembered this incident when I read a study published this week in Archives of Surgery, the first large-scale examination of attitudes toward pregnant surgeons.

Researchers from the University of Maryland School of Medicine in Baltimore sent questionnaires to more than 5,000 female surgeons who were in various stages of their careers, asking them about attitudes toward pregnant surgeons. Roughly half of the women responded. A vast majority reported a significant stigma attached to being pregnant, particularly during training. While younger respondents felt significantly less stigma than those who had trained a generation or two earlier, a sizable majority of the young women — over two-thirds of them — still believed that being pregnant during training could negatively affect or even jeopardize a surgical career.

And although female surgeons tended to be more supportive of their pregnant colleagues than men, they were also capable of being just as dismissive as their male colleagues.

“There isn’t much ‘kind and gentle, warm and fuzzy’ going around,” said Dr. Patricia L. Turner, lead author, an associate professor of surgery at the University of Maryland and a director at the American College of Surgeons. “The fact was that everyone — man or woman — could be hard-core and difficult.”

While women now make up almost half of all medical school graduates, only 30 percent of surgeons-in-training are female, a discrepancy that may be related at least in part to the fact that the most intense period of surgical training, which sometimes stretches over an entire decade, correlates to a woman’s most fertile years, her 20s and 30s. “You cannot not look at the impact of such training on childbearing and career decisions,” Dr. Turner noted.

Many of the surgeons who responded to the 99-question survey inserted additional pages describing their experiences. “It was like there wasn’t enough room within the survey for them to tell their stories,” Dr. Turner said. Some respondents recalled being told outright that they would not be able to finish their training if they became pregnant. Others described watching pregnant colleagues quit under the stress.

Several respondents recounted the pressure to take off no more time than what was allotted annually for vacation. They would work right up until delivery, then return to work exactly three weeks later, fearful that an additional day off might cost them their job or reputation.

Although many women also wrote about what they deemed to be positive experiences, these were not recollections of festive baby showers and congratulatory cigars. One respondent, for example, wrote about hiding her pregnancy for several months before finally approaching the senior surgeon in charge of the residency program. His response was matter-of-fact; he would rearrange the on-call schedule and her schedule to make it possible for her to take time off to have her baby. “The fact that it was handled like a non-issue and without screaming, yelling or threatening to kick her out of the program was perceived by this surgeon as amazingly positive,” Dr. Turner said.

There have been official efforts in recent years to improve the work-life balance of surgeons-in-training. Residency programs across the country have been working to limit duty hours to no more than 80 a week; and the American Board of Surgery, the organization that defines surgical training standards, has made some of its requirements more flexible. Trainees now, for example, can apply to take up to six weeks off for maternity leave or medical reasons without penalty.

Still, it probably will not be until those in the youngest generation of surgeons become well established in their careers that significant changes will occur. “Thirty years ago, people didn’t have the words to say ‘work-life balance,’ let alone say it was a priority in their career,” Dr. Turner said. “But younger surgeons, female and male, aren’t afraid to articulate that that’s important to them.”

“We are going to have to figure out how to mesh our training with the dreams this generation has for the other parts of their lives,” Dr. Turner continued. “Especially if we still want the best people to keep going into surgery.”

A Subject That Takes Up a Lot of Room in My Brain

The Changing Face of Medical Care

By DOREEN CARVAJAL

March 7, 2011

The plastic surgery unit at Chelsea and Westminster Hospital welcomes patients in a spare waiting room with padded blue chairs and a bright yellow lane of stripes running along the floor like a street intersection.

It is the crossroads for Dr. Shweta Aggarwal, a plastic surgeon in training, who summons her patients for consultations ranging from burns and breast reconstruction to tummy tucks and implants.

Across the Western world, it is her generation of young women that is transforming the once-male bastion of medicine, swelling medical schools and flocking to the front lines of primary care.

They wear the stethoscopes and wield the scalpels in increasing numbers: women make up 54 percent of physicians below the age of 35 in Britain, 58 percent in France and almost 64 percent in Spain, according to the latest figures from the Organization for Economic Cooperation and Development, which tracks the trend in more than 30 countries.

“It’s like social work — to be able to do something with meaning, to be able to help someone while you are doing a job,” said Dr. Aggarwal, 36, the mother of a year-old child and a holder of dual Indian and British citizenship. She graduated from an Indian medical school but said she chose to study plastic surgery in London because of better training opportunities and the flexible scheduling that it offered.

As the world marks a century of International Women’s Day on Tuesday, women in the medical field can pride themselves in having made huge strides.

Over the past three decades, the proportion of women in medical schools has risen in Europe, the United States, Canada, Australia and South Africa. Most medical schools in England have more female students than male, with almost 56 percent, or 5,170, in the entering classes last year. At the current rate, the Royal College of Physicians expects women to make up the majority of all doctors in Britain by 2017.

But the steady advance of women, generally lauded in the West and increasingly seen everywhere, has also left the medical establishment in Britain and other countries fretting about the future, provoking studies and sharp debates about the trend.

Will the feminization of medicine lead to losses in income and status? Will countries need to train and pay for more doctors to make up for maternity leaves, part-time schedules and job sharing, which are often sought by female doctors trying to balance work with their personal lives?

Some experts are intrigued by another question: Are female doctors offering lessons in more effective care-giving?

The National Clinical Assessment Service, which tracks and evaluates patient complaints in the United Kingdom, is urging further study of the differences. It issued a report last month that reviewed suspensions over the past nine years of general practitioners, a field that women will dominate by 2013. The figures, adjusted to reflect the composition of the total work force, showed that men were five times more likely to be suspended than women for patient complaints. They were also more likely to be the subject of complaints by patients.

“The $64,000 question is, Why?” said Dr. Alastair Scotland, the medical director of the assessment service. “We have some untested theories that women consult in different ways. They are less likely to take risks than men. Someone who is cautious and risk-averse is more likely to seek help and to talk through issues with their colleagues, interacting as a team.”

Some German researchers also detected signs of a female factor in treatment. A 2008 study in the Journal of Internal Medicine found that patients with Type 2 diabetes responded better under the care of women, showing more improvement in blood pressure and cholesterol counts and taking their medicine doses. The researchers said that female doctors were more likely to communicate well and involve patients in their own care.

The Medical Women’s Federation, the largest organization of female doctors in Britain, is reluctant to draw differences between the care-giving techniques of female and male physicians and resisted proposals at its own conferences to declare there are too many women in the field. In the view of the leadership, women are not taking over, but catching up.

“All doctors have changed the old patriarchal style of ‘I am the all knowledgeable doctor, and I tell you what to do,”’ said Dr. Fiona Cornish, a general practitioner who worked part-time while raising four children and is the president-elect of the M.W.F. “If one had to make a generalization, women are more cautious. Women spend longer talking to the patient and listening. If you listen well, you’ll get the right story.”

Some patients still have qualms despite the good bedside manners. “Men find many G.P. practices very female environments, for example, a waiting room full of women’s magazines and posters about women’s health issues,” said Colin Penning, a spokesman for Men’s Health Forum, a charity based in London that raises awareness about male health issues. He added that female doctors often practice fewer hours, making it difficult for men to break away from work to see them.

The first surge of female medical students in Britain started in the 1980s, and by 2007 young women accounted for 57 percent of entering medical students. By 2010, the numbers started leveling at about 56 percent. More men were pursuing careers in information technology, engineering and mathematics — fields where the ratio of women has barely changed, hovering at less than 20 percent, a Royal College of Physicians report about women and medicine says.

Experts suspect that men are drawn to higher-paying fields, like computer engineering, which requires less training.

Money and the gender shift trouble Dr. Bernard Ribeiro, the former president of the Royal College of Surgeons of England and a new British lord. At a conference of the Medical Women’s Federation in 2009, he raised the issue of whether there were too many female doctors.

Dr. Ribeiro said in an interview that he still believed that work needed to be done to save “the lost tribe of medicine,” which he described as men who are attracted to more lucrative ventures like the financial services industry.

“Medicine has moved from being a vocation, which is sad,” Dr. Ribeiro said. “Smart kids coming out of school are looking at medicine as any other job — what are the prospects and the terms of remuneration.” Dr. Ribeiro said research was needed to explore why boys are outpaced by girls at earlier levels of school.

Among female doctors who have finished their training in Britain, 44 percent are pediatricians, 49 percent are in public health and only 8 percent are surgeons, according to the Royal College of Physicians report. Within surgical specialties, women are drawn to delicate work such as plastic surgery as opposed to orthopedic surgery, which requires heavy lifting.

“Women choose specialties that deal more with outpatients and less emergencies because the jobs are more plannable, while men choose specialties that are techie and exciting,” said Dr. Jane Dacre, a physician and vice dean of University College Hospital Medical School, who also notes that young male and female doctors share the same desire to reduce hours.

Typically, female doctors find it harder to rise to leadership positions in hospitals and medical schools. They are also more likely to make less than their male colleagues. The British Medical Association detected a salary gap of £15,000, or $24,000, in 2009 between male and female doctors in the National Health Service.

With many women seeking part-time work, new organizational challenges are emerging, including the possibility that some countries will need more doctors. France and Germany, for instance, have warned about future shortages, as older male doctors retire and are replaced by women working part-time. The German Medical Association has called it an urgent threat, particularly in rural areas. In France, some doctors are trying to set up a pilot project for a “maison médicale,” or House of Medicine, where part-time doctors can parachute in to offer different disciplines.

“It’s difficult to get the work-life balance completely right. It’s part of the challenge,” said Dr. Beryl De Souza, a plastic surgeon at Chelsea and Westminster Hospital and a mother of three who works with Dr. Aggarwal and two other female surgeons, Dr. Effie Katsarma and Dr. Sherine Ravendran.

Dr. Aggarwal, the plastic surgeon, relied on her parents who came from India to help care for her baby. Dr. De Souza, whose husband is also a surgeon, also turned to her parents. Other women patch together strategies, sharing jobs and working less than three days a week. Some hospitals offer child care centers — not a solution for doctors on call late at night.

Late last year, the junior doctors conference of the British Medical Association called on the national Department of Health to start preparing for a demographic transformation by creating a regional system of job pooling.

Dr. Eleanor Draeger, deputy chair of the conference, who is training in genitourinary medicine in London and a mother of two, recalls that when she had her first child in 2007, four of the 11 trainees in her rotation left on maternity leave. In a rotation of doctors in a pediatric unit she knows, nine of the 10 women working there became pregnant last year and announced plans to go part-time after giving birth.

Most studies issued in England show that women ultimately return to work, increasing hours as their children grow up. As her four grew older, Dr. Cornish, the president-elect of the Medical Women’s Federation, did just that.

“I think most places are more family friendly now. When I started, I would be terribly nervous to say that I need to leave to go to a Nativity play. Now what really amuses me is that the men are announcing with great pride that they are going to a Nativity play,” she said.

But as female doctors pursue careers — and care for children and parents — some researchers in Spain and in France have found that female physicians are more vulnerable to the combined pressures of career and home life.

Last year, a study by the European Union of more than 3,000 French doctors found that women in particular had a higher burnout rate than men in emergency care. A lack of teamwork among medical staff members contributed to the meltdowns, according to the report.

“When you rush from one patient to another, you feel guilty for your family life. When you don’t feel that work is properly done, you feel guilty,” said Dr. Madeleine Estryn-Béhar, one author of the report and a physician with the Hôpital Hôtel-Dieu in Paris. “Social support protects from burnout. People who work well together have less problems.”