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.

If I Had Been a Spider During Residency...

People have asked me how I deal with the sleep deprivation that's sometimes part of my job, and was a chronic, recurrent, unrelenting element of it during residency.

The answer is, while I was able to avoid developing a caffeine habit all through college and medical school, during my second year of anesthesia residency, when I was working in the ICU, I started drinking coffee.

It may have helped me GET THROUGH the nights and actually be able to TALK during rounds the next morning, but although I felt a little more alert temporarily, at first sip, I think there was nothing that was going to make me feel anything other than nauseatingly ILL after 18, 24, or 30 hours of being on my feet.

So instead of spinning webs like this (web of a drug-free spider):

The webs I spun might have been (and probably were) like this (web of a spider on caffeine):

(These particular pictures are on multiple websites, so I'm not really sure how to give them the proper attribution, but the website I got them from was this one.)

You know what I love? They needed a STUDY to PROVE that sleep deprivation makes people perform below their capabilities. Dr. Charles Czeisler, chief investigator of the study conducted at Brigham and Women's Hospital, discussed the results on NPR. "The traditional 30-hour shift is based on the notion that it's better to have a tired doctor who started with you that day than to have a fresh doctor. But we found actually that the tired doctors made many more mistakes," Czeisler said. Well, DUH. Impaired judgement. Compassion fatigue and mood lability. Less safety and satisfaction for patients. I really don't think we needed a study to point out the OBVIOUS, but perhaps we need it to document these consequences, as a necessary step in the effort to begin instituting some change.

I remember once overhearing a patient say to a surgeon, "I don't want anyone operating on me who's been up all night," and thinking, now is really not the time to try to buck the system. Did you write any letters of protest to your congress person or whomever, prior to showing up, decrying the use of torture to train physicians and transmogrify them from compassionate idealists to cynical, IRRITABLE, bitter, resentful, disillusioned bags of sheer exhaustion? Probably not. But you want the system, based on the insomnia of cocaine-addicted "father of American surgery," William Halsted, to change spontaneously and suddenly into something liveable and REASONABLE? I don't think so. This ain't Europe.

I think I might be sounding a little peevish right now. I think it's because I'm on call tonight and away from my family. Not all residents hate the sleep deprivation system as much as I did. Some need less sleep than others, and some cope very well with the arduous schedule. But I despised it, because I thought it was unnecessary and unhealthy for both physicians and patients, and thus unjustifiable.

Incidentally, my hospital's solution to residents' increased risk of falling asleep at the wheel driving home from a 30-hour shift? Cab vouchers. So, we were so tired we needed cab vouchers, but we were still expected to be at the top of our game making decisions about patients, cutting them open, sticking needles and wires into their necks, etc., the same day we were supposed to be taking the cab home?

It's true what they say, even about the Brilliant Minds of Medicine: ignorance can be educated, but stupid is forever. Although maybe not forever, in this case. Maybe if enough major errors are made, or enough patients die at the hands of exhausted physicians, this country's medical establishment will get the "wake-up call" it has needed since a cocaine-addicted surgeon instituted the system over 100 years ago.

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Addendum: the spider web images, thankfully, are in the public domain because they were produced by NASA, whose copyright policy states "NASA material is not protected by copyright unless noted" (see NASA copyright page and JPL image use policy.) They were created as part of this research paper: Noever, R., J. Cronise, and R. A. Relwani. 1995. Using spider-web patterns to determine toxicity. NASA Tech Briefs 19(4):82. Published in New Scientist magazine, 27 April 1995.