Sunday, September 16, 2007

Medicine Hates Moms

Speaking of opening old wounds...I need to vent about Sophie Currier's battle against the National Board of Medical Examiners.

A few days ago an article in The New York Times told the story of a medical student, Sophie Currier, who requested accommodation for her need to express breast milk for her child during her board exams. Her request was denied because breast-feeding doesn't constitute a condition covered by the Americans With Disabilities Act.

Never mind that a mother's act of nourishing her young is one of the most natural and important activities in the world.

Never mind that doctors are duty-bound to inform patients and the public that "breast is best," at least in early infancy.

None of this matters, you see, because there are rules about how you're supposed to be as a medical student or resident, the most revered one being that if you're weak, you don't deserve to be involved in medicine. And if you've chosen to be a mom and a physician, in many medical minds, you're weak. Because now they'll be asked to actually acknowledge and be considerate of your needs instead of treating you like chattel - what a pain!

What else makes you weak, in the world of medical training?

Needing 8 hours of sleep every night. Needing to eat breakfast, lunch, and dinner and not gulp it down in 15 minutes. Needing bathroom breaks. Needing to take sick time off. Needing to sit down during rounds because you have multiple sclerosis or are nine months pregnant with sciatica. Being pregnant. Having children and needing reasonable time away from work to care for them. Having a learning disability. Having a physical disability. Not knowing how to do something without being taught. Not knowing answers to esoteric questions. Sometimes, even taking time to be kind to patients.

What makes you earn the coveted phrase of praise, "strong work," during medical training?

Being fast. Being slick. Having an assertive personality. Always knowing the answer, or at least expounding upon it with confidence even if you don't know what you're talking about.

I need to get off my chest some incidents from my own training that Sophie Currier's story brought to mind.

Comment from the chief resident in OB/Gyn (no less!) as she walked into the residents' lounge while I was discreetly, under a blanket, expressing milk for my son: "Anyone can just walk in here and see you, you know. You really shouldn't be doing that in here."

Underlying messages I heard in her hostile tone: Breast-feeding should be hidden from view. Women shouldn't bring their motherhood into medical territory.

Comment from a female faculty member in the presence of my pregnant friend: "It's irresponsible for women to have children during residency."

Message: medicine is more important than your family. You should rearrange your "normal life" around medicine. Women shouldn't bring their motherhood into medical territory.

Catcalls from surgery residents as I was expressing breast milk behind closed doors in the surgery call room: "Do it out here! Come on!"

Message (albeit facetious): even if you're doing something sacred, like being a mother to your infant child, ultimately to us you're just an object for our entertainment or use.

Request from me to the chief resident in surgery during an operation for which I was holding retractors: "May I scrub out to pump some breast milk for my son? I'm in a lot of pain."

Resident: "You really need to stay and finish the case."

A few minutes later: "This is really hurting a lot and I'm losing some milk onto my scrubs. I really need to scrub out."

Resident: "Oh, all RIGHT."

Message: well, forget about getting a fair or decent evaluation for the rotation. Oh yes, and please don't bring motherhood into medical territory.

Warning from OB anesthesia fellow to me: "When there's a lot of down-time between epidurals, you need to be careful what you're seen doing. Stick to reading anesthesia. When people see you addressing birthday party invitations for your doesn't look good."

Me: "Because that's somehow more offensive than sitting around and watching baseball or action movies, the way the guys do between epidurals?"

OB fellow: "I know it's not fair, but that's just the way it is. It's ok for them to do that, but it's not seen as ok for you to do activities that belong at home. I'm just trying to warn you about the way people see things in this department."

Message: Women shouldn't bring their motherhood into medical territory. It's WEAK (see weakness criteria above).

That department later tried to claim on written evaluations that I was a weak resident because my fund of knowledge was inadequate. I wrote back with a copy of the results for a standardized (read: objective) test of our progress that we had to take periodically, pointing out that my scoring above both the national average AND that hospital's average for OB anesthesia seemed to belie their claim: one cannot be simultaneously ahead of one's peers and behind them. After that they left my "fund of knowledge" alone but they tried many times on subsequent evaluations to claim deficiencies which I felt I did not have, and which I rebutted in writing with concrete examples. The bottom line was that I knew what I was doing and my patients were well-cared for. I am glad that stupid fight is behind me.

I passed all my boards, written and oral, on the first try, despite a diagnosed learning difficulty for which I couldn't get accommodations because I had done well enough in school and on past standardized tests. Clinically, I am careful and competent; my patients can trust me. I got through my training with two kids who are happy and healthy. I nursed both of them, not as long as I wanted to, but as long as I could. I was able to nurse my first child longer than my second, who was born during medical school; I was unable to express milk for him as regularly as I needed to during the rotations described above, and to my great sadness, my milk dried up early. (Message from the medical world: your physical and mental health, and that of your children, is not our concern - but excel in providing for the health of others nevertheless.) I wonder if medicine will ever pull its head out of it proverbial derriere someday and take measures to actively support mothers in their task of learning to become good physicians. It's too late for me, but I hope changes come, both in terms of breast-feeding education, which should be part of high school health curricula, and for women entering medicine now. If Sophie Currier's story is any indication, there's still a long way to go.

Addendum, c. 9pm: I found examples of anti-Sophie-Currier posts, for instance at Parlancheq and at Don Surber's blog, that made me realize the breadth and depth of ignorance, sarcasm, and hostility that exists over women professionals, doctors, and nursing mothers out there. Posts like these sound like they're written by authors who have absolutely no idea what taking the boards is like, and/or no idea what nursing entails. To authors that fit this description I say the same thing I said on a recent post to people who pass judgment against Mother Teresa without having lived an equally generous life. To those who actually know what they're talking about, from experience, but still find Sophie Currier's actions objectionable, I would say I can understand why using litigation to make a point as well as to effect reform might be off-putting to some, but I also hold that the medical profession has been unfriendly to family life, for both men and women, long enough and could use some very real and lasting changes, and perhaps a swift kick in the pants once in a while. (Incidentally, for the MANY people who have asked on other sites why she can't just pump the milk before the test, I have to ask: what is she supposed to do when the milk rapidly reaccumulates, as it would in any healthy nursing mother, and causes extremely painful engorgement during the first couple of hours of the exam, with another seven hours of testing to go, reaccumulating milk all the while?)
One more thought by Dr. Nancy Terres of Boston, from the Boston Globe op/ed section on "It is one thing for the healthcare system to endorse a health behavior such as breast-feeding, but quite another to change our own behaviors to make the goals possible for our patients. As a representative of the medical establishment, the NBME is sending the message to the public that we as healthcare providers are not all that serious about our health recommendations."

It takes energy and conscientious effort to do the right thing. It'll be hard for anything about the system of medical training in the U.S. to change without personal transformation, insight, compassion, and courage from the individuals running the show - those who are "teaching" the residents and controlling credentials. I hope it's not too much to ask.


Jillian Camwell said...

What a wonderful blog. It's refreshing to read your viewpoints. May I add you as a link?

Lisa Johnson said...

How ironic life can be. If anything, one would think that people in medicine would understand something like this even more than your average person. I think something similar happened with someone taking the Bar Exam, but I'm not sure what happened.

That's horrible that you had to deal with so many awful comments and just that general atmosphere.

T. said...

Jillian, thank you for coming by - and of course I would be honored to be added as a link!

And Anali - it's not that medical folks don't understand the facts, but rather that they don't appear to care about trainees' well-being at all. Just show up and do the work, that seems to be the prevailing attitude...

Mitch Keamy said...
This comment has been removed by the author.
Mitch Keamy said...

Well, t; all your examples are from surgical specialties, except your anesthesia one. In choosing our specialty, I don't know about you, but I didn't count on how brutish the society of surgeons could be. (I have a book about this-the Scalpel's edge, if you want to wallow) The Boston academic anesthesia community (with which I am unfortunately intimately familiar) took this model to heart, and tried to one-up it. Your experiences would have been different on medicine, psych, or peds. Or if you were away from the medically toxic northeast corridor. I shan't muse about whether surgeons are, of necessity, this way because of the nature of the work; I think they just tend to inhumanity, with the noble ones (that's you, Dr Sid!) standing out by contrast. I think the number of woman surgeons who lack compassion are less, but I know a few of those, too. And it's not just trainees and it's not just moms; "how you do anything is how you do everything." thank God that nonsense is in your past...

Patty said...

Wow. What an eye opener ... I had no idea!

(I went back to playing 3 weeks after our first was born and constantly had to express milk during rehearsal breaks ... this did bring back memories, some good, some bad. But never would I have been treated as you were.)

You should publish this somewhere. Oh. I guess this IS published now, eh? I hope it gets out there!

Parlancheq said...

My problem is not so much the idea that a nursing mother might get 20 minutes extra break time, but the way that Sophie Currier has put her story out there.

It is as though we are supposed to feel sorry for her. But I have trouble feeling sorry for someone who chose a combined MD-Phd degree + chose to have 2 young kids + already flunked the exam once. All that was Ms. Currier's choice/doing. Now she needs to live with the consequences of her actions. That's what life is about.

Ignorantly yours,

Jillian Camwell said...

That comment just makes it sound like women have to choose between a career and motherhood. It's sad that some people still think like that. Yes, women can make the choice to do both (some don't have the choice at all), and they shouldn't be punished for it or held to a different standard than their male co-workers.

T. said...

Jillian, thank you so much for making so graciously the very point I wanted to make - the "consequences" we live with as women who have chosen to combine family and professional life should NOT have to include the failure of others to be reasonable and considerate. Rising above attitudes of superiority and judgment (our own and others'), learning to be fully integrated human beings, showing kindness, and making the kinds of differences in the world that help others do the same: THAT's "what life is about."

T. said...

I have deleted a comment because it was obscene and disrespectful. I will not permit such violent communication on this blog. If any readers dislike my posts, that is absolutely fine - I suggest you stop reading them. I absolutely insist that all comments, including critical ones, be made with MATURITY and DIGNITY; please refrain from hurling foul language or disrespect at me or anyone connected to this blog. Thank you.

valleygirl said...

What a great post! It is disheartening to read about your experiences with medicine and breastfeeding/being a mom, but it was great to read how you persevered.

Anonymous said...

Your story is both touching and inspiring to everyone in medicine. Do not stoop so low, however, as to associate your awful experiences with those of Sophie's. They are not the same.
Motherhood is quite well accepted in medicine these days. I have known and personally worked with MANY residents who have navigated motherhood medicine Successfully on both front, I might add.
However, from my perspective, there is a balance to be maintained as a resident, as a student, as a physician. You have responsibilities to yourself, your children, your patients, your colleagues, and your profession. At any given point in time, you are choosing between them. That is an incontrovertible fact we all must accept as parents.
Sophie's request is not about breastfeeding. It is about the fact she feels she deserves an accomodation because of her situation. Accomodations in this arena and in others, for example, residency, affects other people. Tests, just like residencies, are about a collective experience for which uniformity in experience and fairness are top priorities. It is easy to dismiss this as sexist, anti-mother rhetoric, but the truth is, test conditions are, by necessity, uniform. An accomodation for her ADHD has already been made. She has failed this test once. There is a reason tests are timed. There is a reason tests are supposed to be uniformly taken. Now, if this is accomodated , what's next ? People with bladders below a certain size ? People with migraines. Women with severe pre menstrual dysphoria ?
What will happen in residency to Sophie ? Is it OK for her to take an extra fifteen minutes to do something that affects YOUR treatment as a patient ? The treatment of YOUR child as a patient ? Hmmmm. Not so obvious now, is it ?
Now just stop this nonsense. Your experience as a mother is NOTHING compared to Sophie's. You belittle that experience to even mention it in light of what this woman has accomplished. I cannot take them as seriously because she has received EVERY accomodation for her ADHD to the point of being almost unreasonable. I liken it to the NBA allowing me a foot stool and a 50 second jump start on the opposing defense so I can dunk. I deserve to play in the NBA even though I can;t run or jump.
Sophie is spoiled, used to being accomodated for her inconveniences. The idea that working a little harder for the 9 hours OVER TWO DAYS she will have to take this examination strikes me as simply ridiculous. And you cannot tell me this compares to ANYTHING you experienced. Again it would belittle your experience to say so. And I think you know it.

T. said...

To anonymous, from 9/20/07 @ 927 p.m.:

Dr. R, thank you for stopping by!

(Just kidding - I know you're probably not Dr. R, but you kinda sound like Dr. R.)

It's hard for me to know where to begin adding my two cents' worth to the remarks above, but let me start with the very last sentence. I definitely DON'T "know it;" I'm not really clear on what was meant by "it," to be perfectly honest.

First of all, I try not to compare my experiences to those of others, ever, because I firmly believe no one can ever truly know or understand, much less imagine, another's experiences. I started this post because of what Sophie Currier's story called to mind, not because I saw any analogies.

Secondly, even if I were trying to draw parallels during my reminiscences, I wouldn't in this case - and I hope not in any case - feel that I were belittling my own life. That is a rather presumptous attitude to take, if I may say so with all due respect.

I truly appreciate the support in some of the comments here but other remarks, and I mean this completely without rancor and without meaning to point fingers, struck me as harsh, presumptous, and condescending. I don't know Sophie Currier at all and wouldn't presume to guess her state of mind, motives, feelings, or judgments. But even if one DOES know her well, I suggest that other than providing an opportunity to insult or criticize, negative commentary about her character serves no real purpose in the advancement of discussion about broader social issues such as maintaining the integrity of standardized tests, supporting women who have chosen careers, discerning the not-always-black-and-white issues around professionals' rights versus their privileges, and figuring out when attempts to create fairness slip into unfairness, things which you so articulately brought up and which are among the truly important ideas surrounding this story.

Finally, though there are many points that could each engender countless hours and pages of discussion just from these comments alone, I'd like to remark on two things.

First, I'd like to point out that accommodations for ADHD, which as far as I understand allow for greater time actually working on test questions, interfere with test standardization far more than accommodations for breast milk pumping would, which would allow for additional time NOT to work on the test but to be on BREAK from the test (which, with the computerized system, is not standardized any more anyway - people can break whenever they want, within certain parameters). To conceive of milk expression as just "working a little harder over nine hours for two days," to my mind, communicates a failure to grasp the experience and commitment breastfeeding involves, at least as I experienced it and currently understand it.

Secondly, while I agree it's important to be careful over the question of "how far is too far," I think it's misleading and unjust to paint such a monolithic picture of people with special needs as categorically unqualified to provide competent patient care. There are disabilities that can be seen and diagnosed and more insidious, subtle ones, many of them ethical and behavioral, that NO physician can claim to be free of. If all applicants to medical school were required to be completely flawless - and I think part of anti-doctor resentment stems from resentment of doctors' imperfections; we are expected to be god-like without god complexes - we'd have some serious trouble finding doctors at all.

Perhaps that is our greatest flaw as a group - the arrogance of expecting ourselves and others to be SO perfect, and the uncompassionate tendency to cast stones at people when they are not. I think most physicians strive for perfection, and rightly so; but I think we all, doctors and patients alike, have a lot of growth ahead of us in terms of dealing with imperfection, in ourselves, in our colleagues, in "the system." We take up a life of trying to heal imperfections but forget that healing restores people, not to a state of perfection, but to new ways of being.

Anonymous said...


ZM said...

Well put!

Anonymous said...

Thanks for this interesting post. Lots to think about.

What would you have done had you been the lead surgeon in your example rather than someone who could easily scrub out?

From what I understand, the board is now not only allowing Sophie to take the exams over two days, but also to take the 45 minutes' worth of breaks each of the two days, but she is still appealing the case for more accommodations. Shouldn't this be, if not ideal, at least doable?

Sophie does come across to me as rather entitled. You for the most part do not

T. said...

Hi anonymous from 9/23/07 @12:15pm-

It's an interesting question.

I honestly can't say what it's like to be the attending surgeon, and perhaps it's not even right to speculate or try to imagine, but I'll offer my imaginings anyway.

Not uncommonly, in institutions that have med students and residents to start and finish operations, and depending on the type of surgery, the attending surgeon can join the surgery after anesthesia is induced, or scrub out to dictate the operative note next door while allowing the resident to close the incision (being immediately available, of course, in case of the need to scrub back in urgently). If that were my situation I imagine I would try to express milk in that window just before I had to join in or just after the main work was done, or during the wait time between surgeries when it's hectic for everyone else - the nurses, the anesthesiologist, the trainees, the pharmacy counter - to get the next patient in.

If I were a solo surgeon in private practice, I might try to do so while the anesthesiologist were interviewing the patient preoperatively, or again, during the lag time between surgeries. I can say from having moved up the ranks in medical training that I didn't have a single free moment as a medical student or resident, and sometimes couldn't even take a rest room break when I needed one, whereas once out of training there are noticeably more opportunities to do things like call one's doctor for a prescription, get a cup of coffee, or sneak in a little paperwork.

I think the real question would have to be, what would I have done as a RESIDENT in that situation? Residents have no real rights or power, and any complaints by them can be used as leverage against their advancement. Even now, though they are required to report violations of the 80-hour-work-week rule, few if any do because it could come back to bite them and they'd rather not cause trouble. It's like indentured servitude; it's easy to say "empower yourself" when you're not in a situation in which power and control over your career are held by others, but for residents self-empowerment just doesn't seem to be a ready option. Glad it's over!

Anonymous said...

Thank for giving one of my questions so much thought and providing such interesting information.

While you offer good insight into how you might keep on top of milk expression in various circumstances, I had meant for my question to address what you would do once already engorged and in pain, as you had been in your example.

The residency situation does sound grueling. I can appreciate that a little of that type of schedule might be good preparation for difficult situations, but that the system could use some change for the well-being of the residents, and perhaps the patients they treat as well.

My focus, however, was on not putting the patient in immediate danger. What if there had not been anyone to take your place in providing the retraction? What if you were a surgery specialist needed in a bunch of emergency surgeries at once?

It seems a lactating woman needs to choose carefully her environments, avoiding ones where she might be faced with situations like these and choosing instead one where she is generally likely to have situations with backup and lag time like the ones you describe.

T. said...

Hi again anonymous from 9/23-

I appreciate the thoughtful points you've made. Thank you for your reflections.

As for getting to the point of painful engorgement, two things came to my mind. First, when you gotta go, you gotta go. A similar thing happens with bladders, and at some point allowances have to be made for basic needs. Secondly, there is always someone who can replace the person retracting, and there is USUALLY a way for even a solo surgeon to scrub out temporarily and come back, given the right circumstances (like, a good anesthesiologist to keep the patient stable :)). I am unaware of any situation in which a surgical specialist would be required to bilocate. Attending surgeons at academic insitutions can oversee up to two NON-emergent surgeries at once, but emergency surgery is a one-on-one commitment.

It's true that a lactating woman might have to plan ahead considerable and be acutely aware of opportunities to take care of her needs. It can be done; it's just not easy! Thank you for bringing up these issues.

Anonymous said...

I just found your blog, and I'm enjoying the open-minded tone of your posts and (most) comments.

I certainly agree that not all special needs automatically disqualify someone from being a good doctor; however, I think that deficits in the core skills of any profession that are severe enough to require special accomodation are of concern. The most extreme example, of course, is a blind man wanting to become a pilot. This case is, of course, more nuanced, but I think that deficits in attention, listening, following directions, making notes of sufficient severity that others had to take notes for her in class (as reported in the news) would certainly interfere with the core skills of being a doctor. Your examples of needing to pump milk regularly, sit down on rounds, and sleep affect only the peripheral tasks. Isn't there somewhere we can draw a line and say: "Let's make accomodations when it does not compromise the integrity of the process of providing care (e.g. needing to sit due to pregnancy), and let's hold fast on the essentials (e.g. listening, reading, paying attention)"?

T. said...

Hi, Anonymous from 9/26/07@ 1:32 pm-

Thank you for your thoughtful comments.

Yes, of course, I agree that core skills for a profession should require little if any accommodation. But the reason I think there is room in the medical world for doctors with learning disabilities is because the core skills can vary so much depending on the medical specialty. I've learned there is something for everyone in medicine among all the possible specialties; each fits well with certain personalities and talents. Someone whose intellect / high function are clear from her academic accomplishments will probably be able to succeed SOMEWHERE in medicine, and do right by her patients, or her research, or what-have-you.

ADHD is often MIS-conceived, as I understand it, simply as an inability to pay attention, whereas it actually consists in part of a difficultly with FILTERING OUT stimuli. Attention over-supply is probably a more accurate moniker than "deficit;" from what I've learned, people with ADD have trouble SCREENING OUT details, so for example they are kept awake by the cricket chirping in the yard and the tick of the clock in the room, or notice the phone ringing AND the crying child AND the tv ad AND the whir of the dishwasher with equal intensity. High-stimulus environments thus actually work well for people with ADHD because they are able to pay attention to many details at once - so, for example, an emergency room might be a good fit. I don't know enough about the pathology lab to remark on the goodness-of-fit for Sophie Currier.

A woman once asked (on the same op/ed page I referred to in the post, actually): should people with learning disabilities even be admitted into medical school? The answer is, people with learning disabilities have been graduating from medical school and leading successful careers for years. But your point is well-worth remembering: medical students should be held to rigorous standards of competence, academically and clinically, which measures like the National Boards can illuminate only in part. I don't believe needing or not needing accommodations for a particular test format defines a physician's abilities; these can only be fully understood by getting to know the quality of someone's work and outcomes over time.

Anonymous said...

Okay, I'm hooked by this debate now.

Your point about needing special accomodations on the exam not necessarily meaning someone could not be a competent doctor is a good one, but how should we standardize this assessment? Your own experiences in residency (detailed in this post) suggest that the personal evaluation, although the most complete and accurate from a theoretical standpoint, is apt to be quite subjective and flawed in real life.

This topic really interests me, because I spent the last several years of my life serving in a very technical specialty (linguistics) in the military. As a slightly built female, I did everything within my power to maximize my physical capabilities, but I was no match for the linebacker-type males in sheer musclepower. However, I could dance circles around them in performing the technical and intellectual duties of the job. I always felt that it was impossible to judge who was the better overall "soldier", because each type had situations where he would shine and situations where he could let people down, perhaps fatally. During deployments, this really was illustrated by the failure of most linguists to provide accurate information (as well as the unfortunate tendancy, nutured by the structure of the language exams, to pretend to much more understanding than one has). These failures were never blamed on the soldiers, however, but on the difficulties of speaking a foreign language. When I was sidelined by a nasty bout of dysentery (and another female colleague by a ruptured ovarian cyst) or we were not as fast, strong, or resilient as some of our male comrades, these failures were blamed on our being "bad soldiers". Our leadership judged that being strong was a core task of soldiering, but being fluent in language was not a core task of being a translator.

The point of my ramble is: how can we define what the core tasks are, how can we assess what accomodations are reasonable, and how can we be consistent in applying these standards? Yes, the exam is not a representation of every facet of being a doctor, but does it not test a some very important ones? Isn't that the whole point? By making accomodations for attention span/distractability/special formatting, aren't we starting down a very slippery slope? In the military, there was a very arbitrary standard for the physical fitness test, but I think that, arbitary or not, we needed to draw a hard and fast line somewhere.

I think that Dr Currier's (she is a doctor at this point, right?) case could indeed be a "false negative", someone being excluded due to a standard when she could, in fact, perform well. However, I think that in high-stakes professions like medicine and the military, excluding false positives outweighs, to a large extent, the few false negatives that may result. (By the way, I was medically retired from the Army after the deployment, and I consider myself another one of those false negatives, but I support the military's use of the standard that excluded me.)

T. said...

Wow, Anon9/26, thanks so much for sharing these experiences. What rich food-for-thought here!

The slippery slope is both important and inescapable, and I think there are never going to be fully satisfactory answers or solutions. Ideally each individual should be evaluated in a well-rounded way, but that's pretty much impossible to do efficiently or reliably, as you pointed out.

I'd like to add, too, that slippery slopes include the slippery slope of where to draw the line in terms of deciding that someone has average / above average / below average cognitive abilities or talents. When does someone's difficulty with reading or spatial relations get classified as a "bona fide" learning disability? For all we know, there are TONS of docs out there in practice who would be classified as learning disabled or borderline IF TESTED but never get to the point of being tested because they've gotten straight A's in school all along. Conversely, there may be many people who perform brilliantly in school who would make HORRIBLE clinicians but who are not screened out because there's no obvious test for that.

Once a person is labeled, it becomes easier to add other qualifiers. "Learning disabled? All right then, you must be unfit for a career in medicine." If the label is never applied, then the judgment may never be considered. I think there is tremendous stigma around the labels like "learning disability," "psychiatric problem," and the like, and not enough recognition of the fact that these phenomena fall on a spectrum, and many of us may be well within that spectrum but label-free and thus allowed to find our own paths to optimal functioning.

I hope I have come across as someone who is enjoying and learning from the ideas you bring up. I want to keep an open mind and consider all facets of these issues, and I really appreciate the discussion.

T. said...

An addendum to the slippery slope theme: a similar question could apply to doctors and psychiatric issues. There are lots of doctors who suffer from depression, OCD, personality disorders, etc. Many of these conditions are known to affect cognition, yet suffering from a given disorder, again, doesn't necessarily negate the possibility of high performance in the physician. The question of whether and where to draw lines is never as simple as we'd wish it to be...which is why candid, respectful, informed communication on these issues is so important, and why I thank the readers here who have worked to shed light on various aspects of these topics.

Anonymous said...

Sorry to interrupt the conversation of two, but I have to interject a few thoughts.

There's a saying in psych school: Need therapy once a week? Pay for it. Need it twice a week? Pay for it. Need therapy three times a week? Be a therapist.

There is an inherent narcissism in the way most of us choose our careers -- we're drawn to what interests us, and what interests us is our own lives and the dilemmas from our youth that we just can't get over.

Psychology and psychiatry draw those who are fascinated by the mind -- particularly the workings of their own minds. Doctors and dentists often find their way to their careers because of a desire to heal...often inspired by their own or their loved ones' illnesses. Talk to a few special educators, PTs, OTs, or SLPs and you'll find a family member with special needs.

Now a few statistics: About 1% of the population has schizophrenia. Another 1% has bipolar depression (manic-depression). Just over 5% has clinical depression. Between 2%-15% of the population has some form of dyslexia (depending on the study and how you define it). Figure in ADD/ ADHD, autism spectrum disorders, personality disorders, other learning disabilities and there's HUGE portion of the population that's in the workforce dealing with one thing or another. Many more are undiagnosed. Most deal with these issues without ever telling friends or colleagues.

On learning disabilities and accommodations...Sophie Currier's extra time allowance is an obvious one because of the strict conditions of the test. (A test, btw, which many docs say has little relevance to the way medicine really happens.) In the real world, we all make accommodations to meet our own needs. A quick coffee break, a game of solitaire, a cigarette -- they help us focus on work. The guy who has to walk around in the back of a room during staff meeting but has great ideas? The woman who talks or moves her lips as she reads? The one who takes the stairs to avoid the elevator or orders dinner in to avoid the crowd in the restaurant? All functional folks who have a few quirks, but get along just fine.

As a patient, what matters to me is whether a doc can relate to me AND figure out my symptoms. Need to fidget? fine. Can't make eye contact? fine. Need a few extra minutes to filter out excess stimuli or to re-read that text/ journal article? me too, sometimes.

Sophie Currier is bright enough to get into and through an MD/ PhD at Harvard, and she's social enough to call in the media and courts to help her case. Sign me up for her practice...her ADD and dyslexia clearly haven't gotten too much in the way, except for on one arbitrary exam that doesn't even say much about how she can treat a patient or what she really knows about real-life medicine.

And yes, t., ADD is more about too much attention rather than too little. Often folks with it are quite bright, quick to make connections, and have incredible reading rates.

As for dyslexia, challenges with reading have little connection to intelligence. Da Vinci, Alexander Graham Bell, Flaubert, Walt Disney...all had it.

Don't be too quick to exclude folks with one trait or another from certain careers. Famous actors who stutter? Nicolas Brennan (Buffy the Vampire Slayer's Xander), James Earl Jones, Bruce Willis...

People who don't do well in any given profession -- even the high-stakes ones you mention -- typically bail out before they have others' lives in their hands. Start excluding folks based on labels or guesses about what they can or can't do, and you're back to segregation, Jim Crow laws, and forced sterilization of "mental deficients". Disgusting.

Set limits for yourself...let others choose theirs!

T. said...

speducator lvc - I appreciate your fire over these issues, which are ultimately about key things like judgment, justice, prejudice, value, competence, and safety. Underneath your vehemence I detect a spirit of great compassion and care for those with special ed needs, with whom you are clearly intimately familiar.

I'd like to thank you for bringing up the thought, only hinted at in previous comments, that the licensing boards' relevance to real-life medicine is often overestimated by people who haven't had to take them. Of the three licensing exams, Step III is perhaps the most clinically relevant and does try to simulate decision-making and action. The other two steps, though, prove only that you can sit and cram for a multiple-choice test, and navigate through the tricky wording in each question, the information on which may never come up in your practice, ever.

The specialty boards are somewhat more relevant. Written boards, again, tend to test knowledge base, while oral boards may be able to probe into decision-making and action under pressure. No format reveals a person's abilities completely, and some specialties don't even require both formats.

I know this from experience: they're tricky and ANYONE could fail them, even those smarty-pants people you see caricatured on medical shows. I have to assume that people who scorn Sophie Currier for not having made it through once are probably imagining these tests to be like the ones they breezed through in high school or college. They're not, at least, not in my opinion.

Thanks too, speducator lvc, for the interesting statistics and the tidbits about famous people who have overcome disadvantages. I especially liked your reminder not to box people into their labels, based on preconceived notions / assumptions / GUESSES about what they can and can't do. For some reason many people guess that folks with learning disabilities can't read at all or compute at all or get through school or function properly in their work, whereas in fact many of them are at the world's top universities and think tanks right now. We as a society really need to re-examine, talk about, and educate each other about our stereotypes and why they persist!

Erin said...

I realize that there are new posts on your blog, but I have only just read the article about Sophie Currier's request for extra time to pump, so I'd like to comment on what I read.

Great for her that she is being given accomodations for her dyslexia and ADHD. As a former first grade teacher, this happens all the time. It does not give anyone an advantage - it simply levels the playing field.

However, I do have a small issue with her second request for accomodations to pump. While I was teaching, I too was pumping breastmilk for my newborn son. I would pump before I left for work, during my lunchtime, and then again after school. This put 4-5 hours between my pumping sessions. Also, I pumped in my classroom sitting at my desk b/c there was no outlet in the teacher's bathroom behind my classroom. I had 25 minutes to eat lunch and pump. I did this for THREE months. Was it ideal? No. But I made it work. Again, for THREE months. Surely Sophie Currier can use her two 45 minute breaks to eat, use the restroom, and pump - for TWO days time.

I realize I'm sounding a bit harsh and for that I apologize. I'm just saying that many women put up with non-ideal situations for lengthy periods of time to pump breastmilk. Sophie Currier can do it for two days.

However, I do agree that if everyone agrees "breast is best" then it definitely needs to become a more breast-friendly place out there. So I guess that, despite my upset with Sophie's inability to deal with her situation, it is a good thing she has brought this to the forefront b/c it could stimulate change.

You can call me divided on this one...

T. said...

Erin, you say "many women put up with non-ideal situations for lengthy periods of time to pump breastmilk. Sophie Currier can do it for two days" - after all, you did it for months.

My question is, why should they HAVE to, as you say, "put up" with non-ideal situations? Just because you and other women have bit the bullet doesn't mean it's right for women to "put up" with societal lack of support. We do ourselves no justice by enabling others to marginalize our needs.

Lots of people in history "put up" with things that merely took a revolution in understanding and some physical adjustments to change (e.g. someone stopped putting up with giving up seats on the bus or not being allowed to vote). I realize it may be a little sanctimonious of me to compare this situation with the greater women's rights and civil rights battles that have occurred in the past, but this about more than a little nursing, I think. It REALLY wouldn't be so hard, at all, for people to support nursing mothers - really. That being the case, why is it even an issue? I think it's because women's rights haven't advanced as far as people think they have. In medicine especially, it's still very much a man's world, though not as bad as before.

I think the gender politics behind this nursing wrangle present a deeper issue than anyone, especially in the U.S., would care to admit. We insist we're not sexist any more, but believe me, I've seen it - sexism is alive and well, and the dangerous thing is that people who fall into the trap of it don't even realize it or refuse to acknowledge it. Denial is so effective at limiting progress.

As an aside, I've always wanted to think aloud, so to speak, about this: the U.S. can't even seem to put a female head of state up there. Why is that? We've had two in the Philippines. Sri Lanka, India, Israel, Indonesia, Ireland, Chile, Haiti, Burundi, Liberia, and a bunch of other countries have had female presidents or acting presidents. And in the U.S. it's only recently, in the last 10 or 15 years, that med school class ratios have been about 50/50 male to female, whereas in the Philippines med schools and law schools have been about 50/50 for decades.

Anyway, I digress - to make a long story short, I think "put up or shut up" is so inappropriate for women to accept, in any society, but especially in one that claims to be at the pinnacle of intellectual, technological, and politico-philosophical achievement.

Anonymous said...

I'm drawn back to this fascinating discussion yet again... Thank you, t., for this candid exploration of some sticky issues.

Speducator, you make some interesting points. I think perhaps I expressed myself poorly. What I was trying to ask was: how do we, as a society, balance the needs of the individual for a fair chance against the public safety. This one accomdation is quite small, and I'm not necessarily against it, I just don't know where to draw the line. In my own experience, when I returned from deployment and my performance started to suffer due to medical issues, it was a very slow process, and I had a very hard time picking a point where I felt I was more of a liability due to my disability than an asset. As the accomodations I need to perform my job mounted, I felt an increasing weight of reponsibility on my shoulders should something go wrong. Obviously, when my PTSD and other conditions prevented me from leading my team in a field exercise, I had crossed the line. I began to feel that there was no line, just a vast "no-man's" land between the perfect soldier (who does not exist) and the "scumbag" (as my dear commander called me) I had become.

t., how do doctors deal with this? It's certainly not possible to be a perfect doctor, and no one could reasonably expect someone to be, but how do you determine where "good enough" is? For me, in the realm of faith, I rely on the Spirit to tell me when I have done all I could, and I rely on the Savior to make up the difference. In the military, however, even my best was sometimes not good enough. I guess the difficulty is not so much in the accomodations for disabilities, but in drawing any line and saying "this person is qualified" and "this person is not". What are your thoughts?

Anonymous said...

A good friend married a man from Iran. She's a nursing mom, despite some early difficulties.

In hearing about all of the recent stories of discrimination against nursing moms (on airplanes, in stores, and now Sophie C), her husband commented that even in Iran, where women are forced to cover from head to toe, it's natural for a nursing mom to expose her breast to feed a child.

Pretty sad when Iran is setting an example for women's rights...

T. said...

First, a grammar error that's bugging me: I should have written "bitten the bullet" above. That's the trouble with trying to get thoughts down fast without rereading to edit! And to think, faulty grammar is one of my pet peeves! Grrr! :)

Anonymous from 9/17 @ 6:02pm:

Thank you so much for sharing your friend's husband's comment! You made my day.

Anon of 9/26 -

I think you express yourself beautifully. I know (trust me) that speducator was not ranting in your direction at all but rather at society as a whole.

Your struggle with the question of when and where to draw the line is just so tough. How indeed to tell if someone is "good enough?" I think written and oral boards, and the little "objective" tests along the way, are an effort within medicine to make that line perceptible. But I also think, like spotlights, they illuminate only certain angles.

One adage that my husband uses when I have certain doubts is, "the proof is in the pudding." Medical people / scientists would call that pudding something stuffy like "outcome measures." A good doctor has patients who have been well-taken-care of, and sometimes you can't see how THAT story is going to unfold until you start actually writing it...another reason the boards are limited and somewhat artificial.

The clincial years of medical school (3rd and 4th year in the U.S.) are like a preview opportunity. Med students get assigned patients to examine and evaluate and start to make decisions about. Those interactions and decision-making processes are monitored and, if they're lucky, coached / guided by more experienced clinicians. There's always a "real" doctor assigned to those patients too, of course. This way students can start practicing their practice, as it were.

But as to how to know at that point who can and should make it? Anyone can learn the material - and I mean that; anyone can sit in school, read the books, do the on-the-job learning on rotations, acquire the knowledge, and learn the mechanics of doctor-work. But I've seen qualities like compassion, respectful treatment of patients, kind speech, well-applied knowledge and judgment, astute observation, etc. valued less than "looking slick" at being a doctor, or not held as priorities at all. Perhaps it's just easier to hold physicians up to standards that can be pointed at or consistently reproduced.

Personally I actually believe character has a lot to do with it, and how do you measure that? My blog buddy Mitch Keamy reminds me, "How you do something is how you do everything." One of the best affirmations I got as a resident was the day a faculty member said, "You have what can't be taught, and you had it from the first day." Yet, how to pinpoint what she meant, and what importance to assign it?

Sigh...I know I am totally failing at providing a satisfactory answer to your difficult question about where to draw the line, and judge an individual "worthy" of the job or "not worthy." The truth is, a combination of qualities makes a good physician good, and no one assessment can capture them all.

The other sticky subject within this subject is this: we all know physicians we don't consider good, to whom we would never send any of our loved ones, but who are out there making a living at it, day in, day out. They've made it through all the hoops, though, so what now? I've seen the opposite, too: a good clinician's image altered by labels that a few people stuck on at some point and that didn't paint a just picture of the person's work and patient care. Then there's yet another sticky subject, which Mitch Keamy has written about extensively on his blog "The Ether Way": the "impaired physician," which usually means a recovering drug addict (but can also mean one with other behavioral and competence issues - see I am totally unqualified to discuss this subject, so I think I had better leave it alone.

I am deeply grateful to you for sharing some of your personal pain as well as your understanding of Spirit here. I gotta say, there's a lot about the military that reminds me of medical training, from the few anecdotes I've heard! Thank YOU once again for enriching this discussion of so many fascinating and important issues.

Anonymous said...

I understand from reading the posts on this thread why the topic has moved so fluidly between Dr. Currier and individuals with various sorts of "disabilities." (Dr. Currier's own dyslexia and ADD invite this comparison in some ways.) However, I think a woman who is lactating is not a woman with a disability.

To be sure, adequate provision should be made for Dr. Currier (and nursing moms generally) to express milk, just as adequate provision should be made for all test-takers to use the lavatory when they need to.

However, using the language of "disability" and "accommodation" with respect to a nursing mom strikes me as turning a natural human process into something abnormal.

And once we get to this point, why is the diabetic who needs to take insulin shots considered a person with a disability? If such a person were taking the test, can we agree that their need to manage their blood sugar level has nothing to do with their performance on the test itself? (Except maybe that it can interfere with getting accurate results if the blood sugar level is uncontrolled.) Why is diabetes a "disability?"

T. said...

I am so glad you have added your remarks to these comment threads.
I totally agree lactation should not be considered a disability. I also appreciate the astute point that using the language of disability law in discussions about supporting the activity of nursing creates a misguided association.

I abhor the word disability in general because as I mentioned on another post, people often conflate it with "inability," which is a mistake. There are ideed disease states severe enough to disable individuals, however (and as an aside, in certain instances diabetes can certainly be one of them in its later stages. But that's a whole other story).

One of the reasons we moved from discussing Sophie Currier's lactation dilemmas to discussing learning disabilities in the medical profession is all the nasty comments I've seen on other blogs / sites along the lines of, "Well, I certainly wouldn't want HER as my doctor with her ADHD and her dyslexia." This is ignorance and bigotry, stemming from a totally uneducated, preconceived notion of what learning disabilities are, the irony being Sophie Currier may very well be twice as smart as any individual expressing that kind of prejudice. Thought I can't say, I suppose; maybe all those folks have Harvard MD/PhDs too.

Anonymous said...

1) I am a male physician
2) Medical training is inhumane at times, and the attitude that this is acceptable needs to be expelled from medicine.
3) Boards test do not strongly reflect clinical medicine - Yet, based on my personal observation, those that cannot pass them tend to be doctors that I would not want to work on me or my family.
4) Go to the right pyschiatrist and you too can recieve a diagnosis of a disabilty.
5) I believe the advantage of extra-time is marginal. As evidenced by Ms. Currier's prior failure where she also received this accomodation.
6) Based on my personal experience with the Harvard/MIT MSTP program, it would be a folly to assume that acceptance into this program would have much indication with regard to your intellectual prowess (however, my apologies to many of those that don't fall into that catagory).

T. said...

Hi, anonymous male physician (9/27 @ 11:25 pm) -

1) Hello. Thanks for stopping by.
2) Absolutely.
3) An interesting observation. Failing may indicate possible mediocrity, yet passing does not guarantee non-mediocrity...Which again bolsters the point that the boards are highly imperfect as measures of a physician's "worthiness" for the job.
4) Perhaps, but it's not for any of us to say whose diagnosis is or is not valid, so we shouldn't dismiss those who have been tagged with it.
5) I would love to learn more about this.
6) It is folly to assume anything about anyone. It's likewise folly to read difficulty with learning, or with a particular exam, as an indicator of a LACK of intellectual prowess. Moreover, it's inconsistent to take one variable as a valid marker - she flunked, therefore she's incompetent - yet ignore or dismiss another variable - she got through a graduate program at a demanding university (regardless of your impression of the program). Can't have it both ways - either external measures and accomplishments should be counted as evidence of someone's abilities or they shouldn't, and if the evidence is somewhat complicated or contradictory, well...I guess we have to welcome ourselves to the real world, where not everything is so black and white, and people shouldn't be shackled into their labels so tightly that any clues about their capabilities are interpreted only in the shadow of those shackles.

MH said...

That must have been terribly during your residency. Mga Hipokrita!

Zenmom said...

Thank you for your thoughtful writing.

I am a staunch breastfeeding (BF) advocate and have been a volunteer breastfeeding counselor with our local health dept. for more than 7 years. I continue to be astounded by the two-faced lip-service on breastfeeding that is put out there by so many in the medical profession (yourself excluded) at the same time that they make those lovely pronouncements that babies should be exclusively breastfed for the first 6 months of life.

I was most pleased to read your insightful thoughts about the Sophie Currier issue. I see way too many mothers returning to work out of necessity (many just a few weeks postpartum) and not being able to continue breastfeeding, because their job will not allow them. They are not in the same position as Sophie Currier and do not have the luxury of filing complaints as they would likely lose their job. And while they may have the letter of the law on their side, it's cold comfort when there's no paycheck at the end of the week.

I am quite aware that there are militant BF moms out there who will sneer at any mother who dares to bottle-feed her child. As well, there are those at the opposite extreme, who, for reasons of their own, feel they must denigrate BF moms, whether out of ignorance, or out of justification for not having breastfed their own child. Somewhere in the middle there are those who both advocate BF and who understand that life is not fair and that some mothers must choose the lesser of all evils - i.e., a mother choosing to keep her job and supporting her entire family over being able to BF her baby. It is a shame, that in this day and age and in this society, for some, breastfeeding is a luxury.

I was long ago enlightened by Penelope Leach's little book, "Children First". Ms. Leach (PhD) writes about how much we, as an American Society, have, or more often, have not, put our money where our mouth is as far as putting the real needs of our "children first". She objectively compares social policy in the US with other industrialized nations and even to some developing nations, but I suspect this is nothing new to you.

Until the leaders in medical education start teaching about the real value of breastfeeding in our society, things won't really change - at least not very much. Women will still have to rely, for the most part, on other women for their support. Wouldn't this world be quite a different place if men had to do the child-rearing and breastfeeding? I hear you all laughing!

Disclaimer: Comment above not meant to offend the wonderful renaissance fathers who do the child-rearing and those who are solidly supportive of mothers.

You are a highly educated woman, in a position to speak, and more importantly, to be heard. I encourage you to continue to use your voice to help other women make better choices for themselves and their families. Quite apart from your work as an anesthesiologist, as a positive voice for breastfeeding mothers, you could make an immeasurable and positive difference in the lives of so many women and children.

The very best to you.