Sunday, December 19, 2010

Ten guidelines for medicine-life balance

Right now, this month, seven years out of residency with a part-time position at the refugee clinic and three and three-quarters children, I have work-life balance. It's somewhat precarious, something that could be toppled by illness or an unbearable colleague or a newborn, but I would rate my current satisfaction with both career and home life as high. Here are some philosophical and practical guidelines that I follow:

1. Accept that you can't have it all - at least not at once - but you can have a life that is rich and full and satisfying. I watch resignedly as other (childless) physicians at my clinic leave to spend months working in Afghanistan and Peru. I'm the mother that arrives late to the preschool Christmas potluck and sets a box of mandarin oranges next to the homemade cheesy noodle casseroles. My son's school uniform pants are embarrassingly short and I couldn't make a recent cross-cultural mental health conference because I'm home with my daughter on Thursdays. But I have kind, secure children and what is arguably the most delightful, rewarding patient population in the city. It's enough.

2. Be clear about your boundaries and don't apologize for them. I work Mondays, Tuesdays and Fridays. I can't start any earlier than 9AM due to school drop-off. I've had potential employers rework schedules and change clinic start times when I tell them my availability.

3. Don't compare your finances to others'. Recently, my six-year-old son asked me, "Where do you and Daddy get money from?" He was taken aback when I explained that we are paid for our work. All this time he had assumed we were going to work for pleasure and to help others. This pleased me no end. I don't want money to be the prime consideration in my decisions.

Every year the BC Ministry of Health puts out the "Blue Book", which lists what every physician in the province billed the Medical Services Plan. I've perused it before, but no good comes from seeing that my family physician neighbour bills more than five times what I do. I start to gauge the wrong things in terms of money; what are quiet days at home puttering in the yard with my four-year-old worth?

4. Say no. This may be the most important skill I've learned in the last five years. If I feel awkward saying no to someone's face, I say I'll consider their request. Then I say no by email. I don't bother with reasons or excuses. I came across a quote from one of Dr. Gabor Mate's books a few months ago that I think of almost daily: "Always choose guilt over resentment."

5. Write. I take ten minutes once or twice a week to document for myself what was memorable. This has a magical way of allowing what's important to rise to the top while the irritations of daily life drift away, affording perspective. Here's something lifted directly from a journal entry this summer:
Playland yesterday, Leif smiling as he soared through the air, Saskia looking non-plussed even when having a great time. It felt wonderful to give them a day of whatever they wanted, unlimited rides, mini-donuts, cotton candy, a snowie despite wasps hovering over the syrup spigots, eaten cross-legged on concrete in makeshift shade. They were good as gold. Felt strange to see legs dangling from a great height, delighted screams, ferris wheel buckets the colours of candy against the North Shore mountains, and think that the same world has refugee camps.
6. Consider exhaustion the state of having given, rather than having been taken from. A few months ago, as I rounded the bend to approach the Second Narrows Bridge on my way home from work, CBC's Rich Terfry on the radio and Ariana strapped in the backseat, I thought with dismay how overwhelmingly fatigued I was. I felt drained, spent, exhausted - and reflecting on these words I realized that resenting others having taken from me was passive and inaccurate. I had given what I had by my own choice. When considering Dr. William Osler's words, "Let each day's work absorb your entire energy and satisfy your widest ambition," anything short of collapsing into bed completely spent each night feels a waste.

7. Travel lightly. I try to apply minimalism to every aspect of my life. People remark on how tidy my home is, but the truth is that we have very little stuff. I decided two years ago to leave the HIV clinic to focus my part-time work at the refugee clinic only. We eat simply. Any commitments are carefully selected and for a defined period of time.

8. Hold an AGM with your spouse. Once a year, Pete and I hire a babysitter and take an evening to take stock of where we're at in every major area of our life: his work, my work, finances, church, where we live, parenting, friendships. We identify what's working, what needs to change and when we need to reevaluate. We like to feel that our choices are deliberate; we don't want to float up to our forties to say, "Huh! So this is how we live." I have such fond memories of these evenings, full of gratitude and brainstorming and collaboration, and everything recorded in my notebook.

9. Three projects. At any given time, I have three projects on the go that require one to two weeks to complete. One relates to work, one to home and one to something creative. For example, I might apply for a research grant, order a coffee table and frame some of my photos for our front entry. No new projects can be tackled until all of the original three are completed. (See zenhabits for more.)

10. Marry well. Pete (who works full-time in a non-medical field) is supportive, a non-complainer, hands-on with the kids and flexible around gender roles. We've both made sacrifices. He is undoubtedly the linchpin to my current contented state of mother-doctor.

I've loved William Wordsworth's poem "Nuns Fret Not at Their Convent's Narrow Room" since I studied it in English 103, particularly these lines:
In truth the prison, unto which we doom
Ourselves, no prison is.
I'm a mother in medicine by choice. I accept any challenges and restrictions inherent to this position, for this is exactly where I wish to be.


  1. Thank you, Martina.

    I'm curious as to why some physicians are listed in the "Blue Book," while others are not?

  2. Re: 3. Since their kids were old enough to ask, my brother and sister-in-law have been telling them that Mom and Dad work in order to pay for the house, food, swimming lessons, etc. I think it's brilliant; it's even defused a few tantrums. Their kids understand that work = money (even though their parents enjoy their jobs, too).

  3. WOW, This is pure magic and brilliance, the best thing I've read on MiM in the how many years since I first started writing here--2 yrs, I think??? I think I may have to print this for my fridge. Such fantastic perspective. I would put myself in the box of perpetually aspiring/failing Zen Buddhist, and these are the kind of posts that remind me it's possible despite a busy work and home life.

    Congrats on having found such wonderful balance and peace and a wonderful spouse to enjoy the space with you.

  4. WOW Martina, once again I am blown away by your carefully selected choice of words. Your life in a live with such deliberation in your life is nothing short of admirable and eviable! This article needs a frame!

  5. Agreed! Excellent writing once again.... "I'm a mother in medicine by choice. I accept any challenges and restrictions inherent to this position, for this is exactly where I wish to be" will be going on my bulletin board. (right next to my favorite fortune cookie fortune- "Impossible standards just make life difficult.") Thank you.

  6. This is a great piece & I think we are kindred spirits as we have almost the same schedule and same family set up. I also feel very balanced at the moment. Maybe it's a Canadian thing? :)

    I have a question for you though which I hope you take with the interested, not critical intent I mean. What is your answer when friends/colleagues/taxpayers wonder whether you kind of should be working more, and/or providing after hours care, or doing something a little...more...with your skills? You are very thoughtful and considered and I am curious to hear your take on this question -- I have mine too -- and like me I'm sure this is not unfamiliar territory.

    Again, not meant as a criticism, I am truly interested in your take on it. We have almost the identical schedule, except I do OB shifts as well.

    Also I hope you restart your blog when your newest one arrives!

  7. Wonderful post! I was particularly struck by item #6. I have never considered exhaustion from this standpoint. I find this concept very intriguing. I suppose the sports analogy is "leaving it all out there on the field." I may never look at the end of a long day the same way again.

    Thanks for giving me something new to mull over, and thanks for the attitude adjustment! :-)

  8. I love how intentional you guys are! J and I are taking a night away to Whistler and plan on spending the drive planning the year to come and taking some steps in that direction. Thanks for the motivation!

  9. Thanks for sharing you very intriguing ideas, I too am so in love and lucky to have married "well" as you say.

    I feel silly but I'm not familiar with AGM, however.

  10. Thanks for your kind feedback! I'm pleased that some of you found this useful.

    @Anonymous 6:33AM - Only physicians who bill MSP fee-for-service are in the Blue Book. Those who are salaried or paid sessionally by a health authority (my situation) aren't listed. Also - those are gross billings. That might roughly equal take-home pay for ER docs or anesthetists, but you can subtract a good percentage for overhead for most physicians.

    @Tempeh & Ange K - Thank you! But please don't think I'm gliding serenely through my days. There are still a lot of (literally and figuratively) messy parts to my life. I wouldn't need guidelines if my natural inclination were not to compete, compare, acquire, resent, overcommit etc.

    @Susan - Yes! I have been criticized for working so little (either for wasting my education/skills, or contributing to the Cdn family physician shortage, or having 'used up' a position in medical school [that could have gone to a man who would have worked full-time]). When I was first in practice (part-time, with one child) I faced disapproval from some for working too little and from others for working too much. I found myself feeling extremely guilty for both. Eventually this struck me as ridiculous, and I realized that no matter my choice I'd always face judgment from others, and I might as well make my own decision and not take so seriously what others thought I ought to do. No one's voiced any criticism of how little I work for a while now, though. Full-service practice isn't generally expected in the type of family medicine I've pursued (HIV outpatient, downtown eastside, refugees). None of the other three physicians at my clinic work full-time, either (and none of them have children). I do personally feel some chagrin that I've given up OB (especially), ER, surgical assists etc. Sometimes I do feel less a doctor than my colleagues up north doing it all. But to practice full service would come at a cost that I'm not willing to pay. I'm sure I'll expand my practice in the future. I'd love to hear your take. (This could be a whole post or topic week!)

    @T - I should have elaborated: AGM = annual general meeting

  11. Thankyou for this Martina- I love to read how you are doing this mother/medicine life.
    You've even made me think about doing some part time work at my local refugee clinic....

  12. I love how you are so content. This is really wonderful. Thank you for sharing. :)

  13. Thanks for a great perspective on so many areas - I agree, especially, that your take on the state of exhaustion is a terrific viewpoint. I also like the thought of having a defined time to look at all of the areas of your life and determine what - if anything - needs changing.
    Best wishes for a fabulous holiday season!

  14. Thank you. I had an amazingly difficult day today. I came in on a vacation day to take care of a very entitled patient. Instead of smooth sailing I got a lecture about things I have no control over. Reading your post gave me that 1-10 moment I needed to put everything in perspective. I too married well. Thanks.

  15. Re: working "underpotential" (whatever that means).

    I'm kind of where you are as well. I do find it makes a huge difference who you hang out with. Many of my parent friends (not all moms) work less than I do, and even including the docs among them I am actually among the busier. They say they can't imagine how I manage to run a clinic, teaching & OB.

    Among my work colleagues at the moment, however, I work the least of all the women, so look like more of a slacker. They can't imagine how or why I am home, by choice, 2-3 days a week with the kids.

    Over the years I've had the same experience though where I have simply found it's occuring to me less and less to even wonder what others think. I think this has come as I've gained confidence in my parenting/family role, and in my clinical/teaching role, and just realized that I am doing a pretty darn good job at both of them and that is what matters.

    I also think that having more than two kids freaks people out enough that they stop hassling you for not working more :)

    I likewise envision building things up over the years as well. Five years from now I will work different kinds of hours and be doing different things...

    I also find it helpful to be around docs who are before and after me in life stages, so I can look ahead for hints and look behind to try and shepherd younger colleagues along as best as possible. We have to look out for each other.

  16. Great writing, totally global perspective! I have sort of adopted a lot of your reflections into my daily life since internal medicine residency and through cardiology fellowship. As a mother of a 7 year old, step mom to a 12 year old and soon to be mother for a 3rd time it has been a tough 7 years but I would do it again in a heartbeat!
    From an in-training perspective, I let my program know from get go: My family comes first!
    I got this great advice from a mother of 3 and full time practicing cardiolgist " When you are at work, give 100%, when you are home, give 100%, make your time work for you, dont be a hero and dont expect concessions or freebies". Of course a good support system helps a lot. Thanks for a great article

  17. KC was wise to post her post and this one as the last two, I think if we had started the week with these I would have too intimidated to post!

    Thanks for sharing your thoughts and being a part of our group.

  18. You forgot number 11: good friends! This was wonderful perspective, Martina, and with your typical descriptive finesse. Mary and I thoroughly enjoyed this piece.

  19. Thank you so much for this, especially the William Wordsworth quote at the end!!

    I recently discovered your blog, I'm a pre-med undergrad student with the goal to go into pediatric reconstructive surgery. I also want to be a mother and have a family of my own, however, and I often marvel at how on EARTH I will be able to do it. This blog is truly inspirational and encouraging for me!

    Thanks for giving me a new outlook on the 16+ years of school I have left ahead of me, it definitely isn't a prison if I want to be there :)

  20. Martina, Just wanted you to know that I keep mentally circling back to this post. Precontemplative perhaps but I wanted you to know that I'm planning on implementing some of the techniques described. Thank you.

  21. @Meg - You're welcome! It's gratifying to hear that those ideas might be useful to someone.

  22. Thank you so much for sharing your quote, and final thought. I am a first year medical student with an 18 month old. People ask how I do it, and though I never have an answer, and usually just sigh, you answered it. We all choose what to do with our lives, the challenges are not a punishment but reward for following through on our dreams. Much needed study break motivation!

  23. Having recently found MIM, I am also recently finding myself again. I've been lost in the noise of residency and family for what seems like years, and the above slow-down guide is helping me do just that. It's all about what's important. All else falls to the wayside. Thank you FreshMD.

  24. Thank you for the wonderful article. I'm a 4th year medical student applying into Family Medicine and hoping to work with immigrant populations. Your writing is very inspirational and shows that happiness is what we make it to be and does not have to be dictated by others' ideas of success.


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