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 kids...it 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.

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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?)

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One more thought by Dr. Nancy Terres of Boston, from the Boston Globe op/ed section on boston.com: "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.

Doctors Who Write

Last week I read the following poem, by Warner V. Slack, M.D., on the blog kept by Paul Levy, President and CEO of Beth Israel Deaconess Medical Center. Dr. Slack kindly gave me permission to share it here. It's arresting, inspiring, and profound. I am grateful for writers (and doctors) like him, who stop and think, and who make the effort to see, the first task of any artist (or physician).

ENCOUNTER ON THE STAIRS
By Warner V. Slack, MD

Next to Children’s Hospital, in a hurry
Down the stairs, two at a time
Slowed down by a family, moving slowly
Blocking the stairway, I’m in a hurry
I stop, annoyed, I’m in a hurry
Seeing me, they move to the side
A woman says softly, “sorry” in Spanish
I look down in passing, there’s a little boy
Unsteady in gait, holding onto an arm
Head shaved, stitches in scalp
Patch over eye, thin and pale
He catches my eye and gives me a smile
My walk is slower for the rest of the day

***

One of my most sacred "academic" values is a reverence for story and language. As in the case of being a "person of faith," being a person with a deep love of the arts and humanities can sometimes be marginalizing in the medical world. Medical training, in fact, can be a desert for those who thirst for really good writing, as a Time article once affirmed, so when I find a poet like Dr. Slack, I feel like someone who has taken a long-awaited cold drink of water on a scorching day, or who has found a breezy spot under shade trees in an otherwise arid landscape.

I especially admire those who can write poetry. Of all literary forms, I think this distilled form is the most challenging - all that meaning to cram into an itty bitty space! Not a word out of place! Next hardest, I think, is the short story, also a distillation of meaning without the wider "wiggle room" afforded by novellas and novels.

I found this wonderful paragraph by Stephen J. Dubner on the subject of doctors who write:

"So why do these doctors write so well, and so much better (to my mind, at least) than other non-writers? Perhaps there are elements of doctoring that lie in harmony with writing: peeling back the layers to get to the core of an issue; confronting the obvious but being willing to look beyond it; learning where to 'cut in,' of course; and, more than anything, recognizing that this object before you – in one case a human body, in the other a manuscript – is on a certain level a miraculous object with the power to astound, and on another level is a complex, dynamic system which can (and must be) reduced to a schematic, laid out on paper or x-ray film."

We learn as medical students that the most important resource for our healing efforts is a thorough history of our patient. Story, story, story: it's not only what makes us human, but also what drives us and helps us excel at our humanity. I thank Dr. Slack, and his intellectual / artistic / spiritual ancestors and colleagues: Anton Chekhov, William Carlos Williams, W. Somerset Maugham, A. Conan Doyle, A.J. Cronin, Walker Percy, Ethan Canin, Sid Schwab, and so many other doctors who write (or writers who doc!), for their gifts, and their balm.

Who's Afraid of the Big, Bad...Resident?

Today was supposedly the worst day this year to have to go to the hospital. July 1 is typically the first day of the training year for all residents and medical students across the United States, though there are a few programs that start their year in the last week of June. I imagine that most people who know this and have a negative attitude about medical trainees look upon hospital admissions in the month of July with a mixture of dread and disdain.

There have been various writings, from The Underwear Drawer, a blog by anesthesia resident and talented humorist Michelle Au, to an article in The New Yorker by Atul Gawande, about doctors who, with some guilt over the hypocrisy of it, request the most senior person available to attend to their loved ones. I've had a different response. Yes, I want the best care for my family, always, and of course I wouldn't want my young children to be poked endlessly by novices who couldn't get a blood draw or an IV. But when I was an intern and someone asked me where I would take my children if they needed medical care, I immediately named the hospital where I was training, even though I knew residents did all the legwork. I knew my colleagues at the time, and I knew they were unswervingly meticulous about evaluating their patients thoroughly and competently.

And when I was an anesthesia resident and needed to bring my son to the E.R. at Children's for stitches, the senior pediatric resident there, who knew I was an anesthesia resident, asked me if I wanted the attending physician to do the stitches, to which I replied, "No way, I want you to do it." I knew he had been doing procedures day in, day out for the last three years while his attending physician looked on, made suggestions, and signed the chart. So in some sense I was doing the same thing Drs. Au and Gawande wrote about doing, and asking for the most experienced, competent clinician to take care of my son. But I didn't automatically decide that the pediatric E.R. resident was inadequate to the task, like so many people do, a priori.

Having been on both sides of things, I think residents are misunderstood and too little respected. Residents are M.D.'s - doctors - which means they have more knowledge than the average citizen about medical matters. Their education as residents is for acquiring sound judgment and comfort with procedures in a particular specialty - the kind of judgment that can only come from experience. Fellows are those who undertake a subspecialty after completing residency in a specialty. Attendings (short for attending physicians) are done with training.

Someone commenting on Dr. Au's blog compared being approached by residents to being "accosted by idiots." I could go on for a long time about people who make sweeping generalizations about groups (i.e., prejudiced people), but suffice it to say, I found this statement completely offensive in its attitude and content, and unfair to the many resident physicians in this country who provide outstanding care for their patients.

Of course no one wants to be a pin cushion for people learning to start IV's the first week of July, and right now the only way to learn is to practice. As a resident I did let my students start IVs on me, and I wasn't mean or whiny when they missed. The path to perfection is woefully through many hills and valleys of imperfection. And people forget, it's not always a problem with the person performing the procedure. I've seen cardiac anesthesiologists struggle with IVs after decades of doing them expertly. Some people do have terrible, terrible veins. Just like airways. Even the best laryngoscopist encounters that pulse-increasing, difficult airway once in a while.

Personally, and I've written this before, I think simulators are the way to go for certain elements in medical education, like procedures and group dynamics. Repetitive action by muscles makes those muscles and muscle-brain connections more capable. Ask any musician. Of course, in medicine there has to be a STUDY to prove something even that obvious, and those studies exist. They show, of course, that simulation of procedures increases competence at performing those procedures. What a shocker. (Kind of like that study that showed that sleep deprivation - a recognized form of torture, I might add - diminishes the quality of care provided by the sleep-deprived clinician {typically, an exhausted resident}. Like, DUH.) The one simulator I've been dissatisfied with is the intubating mannikin. Intubating that thing is NOT like intubating a human being at ALL.

Sometimes I play a game in my head that involves finishing the sentence: "There are two types of people in the world..." By now I have a long list, which I may post some time, but tonight my mental entry is, There are two types of people in the world: those who respond to students with understanding and patience, and those who respond to them with frustration or contempt. The former probably make better teachers, at least from the students' perspective, in terms of "making connections" with or "reaching" students. I've found that the medical world is littered with many examples of the latter - perhaps because responding the first way takes some genuine humility and a spirit poised for compassion. But there's hope - after all, it's called the practice of medicine.