Thursday, March 15, 2012

when are we done with training?

At no other time in my medical training was I as confident that, with hard work and dedication, I could master the field of internal medicine as when I was a newly minted third year medical student.

Fresh from having taken the USMLE step 1, I interpreted my ability to recite the mechanism of penicillin resistance or the role of histamine in the immune response, and describe in great detail the unabridged and factual accounting of the patient’s forty year occupational history as evidence that, while I still had a ways to go, the practice of medicine could become as comfortable and familiar as reciting passages from a play or riding a bike. One day, I would just know it.

This is, of course, an exaggeration, but not one without merit as there is no other time in one’s medical training when one is so completely unaware of how little they know about medicine. Each additional year I've spent in training has only deepened my appreciation for that which is both unknown and unknowable, and despite this appreciation I still am occasionally horrified by lapses in my knowledge base. I resigned myself to the fact that my training will continue for as long as I practice, well after I am board certified in oncology and hematology. 

Many readers of this blog are likely familiar with Dr. Karen Sibert, whose name I first learned after she wrote an article titled "Don’t Quit This Day Job" that appeared in the New York Times. There were many strong responses to her criticism of female physicians who choose to not work full time, one of which appeared in this blog. She recently posted on her blog a piece titled "Give yourself a break - Don't have a baby during residency", which has also created quite a stir. This posting as been the subject of many blogger’s recent pieces and I don’t want to repeat some very well articulated responses – one of which appears here. Even the comment thread of Dr. Au's post contains interesting reflections on the competing obligations of medical training and early motherhood.

I have a different question, not related to work hours, coverage schedules, ticking clocks, or the financial or marital implications of having a baby during residency. My question is this - when are we really done with our training? It's a question I myself, still in my own training, am not in a position to answer. But I have serious doubts that the need to check current treatment recommendations, latest journal publications, available clinical trials, or consult physicians more senior than myself, isn't going to end when fellowship does. If anything it could get more difficult to maintain sufficient knowledge base once I am removed from the structure of a training program.

It is probably a good time to point out that I am not in a particularly procedure-heavy field of medicine. In the middle of the night and as a senior IM resident, most questions regarding the management of critically ill patients could be handled over the phone. As a heme/onc fellow I spend a lot of time reading and, obviously, consulting with my colleagues, usually during daylight hours. I am not sure if the same is true of more procedurally oriented programs such as surgery or anesthesiology, where perhaps there is a greater need for someone more senior to actually stand by you and aid in management. A person who might not be available once you have completed training. But I did once overhear a surgical attending loudly berate his chief and junior residents for not being able to answer a pimp question on neointimal hyperplasia, which struck me then, as it does now, as not a subject far more medicine-y than surgical. The attending went on to say (or really, more like yell) that his own residency training had become obsolete ten years after completion and that if they were not in the habit of prioritizing self directed learning now, they would soon find themselves without the knowledge base or skill set to safely operate in the community.

So, if you accept that the need to question what you do and do not know will never end, and that as a member of this field you are professionally obligated to avail upon yourself all necessary resources (including colleagues) required to provide your patients with the best care available, I wonder how relevant an end point "residency" is when trying to assess the ideal time to start a family (and again, I am not taking about call schedules).

I had my first baby as a second year medical resident. Yes, it was hard. But I learned to adjust the way I studied just as I learned to adjust every other aspect of my life. Social life, goodbye. Athleticism, goodbye. A working knowledge of current events, see ya. Mommyhood, marriage, and medicine were made my priorities then, as they would have if I'd waited until after residency, but at least by learning to restructure earlier in my career, I was doing so with the safety net of a training program rather than as a new attending.

For example, prior to becoming a mom, I had studied mostly in the evenings and weekends, usually beside my husband in whatever little apartment we shared at the time. That was simply not going to work with a baby at home. So, with IM boards looming, I requested the month of July (I was still a resident in July as I was paying back the time I had taken for maternity leave) to work on an outpatient rotation. I got up early to be at Starbucks at 5am and studied there every weekday morning until boards. No evenings, no weekends. And I was fine. More than fine. When it comes time to study for my oncology and hematology boards, will have a 4.5 year old and a 1.5 year old. Mornings in Starbucks might not be an option, but neither is not studying. I will have to adjust again.

Residency is important. Very important. But, over the course of our careers, it isn't an endpoint when it comes to the quality of care we provide our patients. Being a good doctor is no more a finite achievement than being a good mom. 


  1. I admire you for what you have done. Your list of sacrifices is my list of sacrifices. And crushing the boards in Starbucks at 5 am?! You are my hero!

    We are never done, for sure. But we can do it, full- or part-time, interrupted-maternity leave time, off and on again. We rock.

    I vote for Dr Siebert to do what Dr Au did in her spare pre-baby times: go to the book store, have coffee, preview book, have dinner and see a movie. And stop blogging about healthcare crisis in the US due to women-doctors.

  2. I just have to say that this is a very important topic that so many of us try to confront on all sides, however shallowly. Thank you for picking out one piece of the debate and exploring it in depth. We need more of that.

  3. Yes, learning in medicine is a lifelong endeavor, but that's part of what makes it awesome. (Probably the same could be said about parenting.) Regarding studying for the boards during fellowship, I scheduled vacation time for right before the boards and just crammed like crazy for two weeks. I have a friend who hired a babysitter for three months just to pick up her kids from daycare and take care of them from 5:30 to 7:30pm everyday so that she could stay at work late and study for the boards. You do what you have to do.

  4. I'm the anonymous above that studied for boards during vacation time. I forgot to mention that I had a 2-year-old and a six-month-old at the time who were in daycare while I studied. The night before the boards, I stayed in a hotel, even though the computer testing center was only ten miles away. This was so the kids would not be waking me up in the middle of night and interrupting my sleep before test day.

  5. Ha! I love the honesty. I should add that my mom was living with us at the time (meaning I was not abandoning my husband with the baby) and, despite my best efforst, I didn't make it there every single morning by 5. :)

  6. Great post!

    also, the part about the occupational history is so true, and hilarious!

  7. Definitely wish I had mine during residency. Being an older mother is not ideal. You are right-we adjust to anything but have to make sure that our families can also adjust.

  8. Dr Sibert is very short-sighted in her heartless ultimatums. One of the health care professionals who works with autism children said she sees a lot of doctor's children (who have chilren later in life) and a lot of older parent's children. If someone dedicates his or her life to medicine, their children should not suffer in the process. And ...obligations of training??.. I see none given the amount of debt residents accumulate. And who said if some woman gave a medschool spot to aspiring man that this man does not turn around and want to work part time too? But Dr Sibert being a woman wants to target women specifically. And who said raising children - responsible citizens for this country is not a noble job and obligation to society also?

    It looks like her unipolarized opinion is popular now, given new recent mantra in society and media: Expensive health care and lack of access are all fault of ... doctors. Primary care shortages are fault of greedy graduates.

    If polititians say it on TV, why not Dr Sibert? And NYT was probably so happy to publish it because, think of it: it is a doctor throwing stones in doctors!!! Wow, we do not have to blame them, they blame themselves! For average person reading on 5th grade level Dr Sibert is right, and average person now knows who to blame.

  9. I remember a man in my med school class telling me some guy was selling insurance for a living because they'd given me a spot in the class instead. I think that classmate has been working for an insurance company for a while now, and I, two kids and husband and all, am still practicing full time after 30+ years. There's always trolls--it's too bad some of them are our colleagues. We didn't pay attention to them then and we shouldn't pay attention to Sibert now.

  10. Thank you Red Humor for your lovely post. So true. And the comments re Sibert all well put as well. There are jerks everywhere. Even some women doctors are jerks. And turns, out, even some mother doctors too. Let's just not pay attention to them.


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