Bitterness and Ob/Gyn, alas, does seem to go hand-in-hand. I believe that, first and foremost, it is an incredibly important, busy, special, and stressful job. True, most of our patients are healthy, but when they get sick, they can get sick quickly, and when healthy young women or babies get sick, injured, or die on our watch? That's especially devastating.
I can't think of a single person that went into Ob/Gyn as a bitter person who hated women, but at the end 4 years of constant sleep deprivation, sometimes another pregnant woman in labor is no longer a miracle, it just means more time spent away from fulfilling basic human needs like using the bathroom, or eating, or, most elusive of all, sleep! It is also seeing women, not only at their best but at their very worst, hours of staring at monitor strips, worrying about when to pull the trigger on a cesarean delivery, wondering, if it is too early that we will be blamed for "unnecessary surgery" and trying to get to our golf game or (God forbid) home for dinner, or, if too late, we will, much worse, have a sick or damaged baby (and possibly be sued for everything we have).
Women can be very difficult patients, who require a lot of communication, not a problem for patients who are willing to return to discuss issues, more of a problem for people who wish to stuff a year's worth of problems into a 10 minute annual exam. It's persistent 36 hour shifts, often skipping breakfast and/or lunch, and 72 hour weekends. It's adrenaline burn-out, hours of nothing followed by a harrowing roller coaster. It's constantly being second-guessed, by our partners, other physicians, the L&D nurses, the patients, the internet, the media, ourselves, even when we *know* we are practicing to the *standard of care* for our profession.
It's the malpractice, multi-million dollar coverage premiums to pay yearly, the threat of lawsuits for up to 18 years after the fact, shrinking reimbursement (universal for all physicians), trying to pay our staff and our overhead, having to fit more patients into the same hours in the day, trying to be a good doctor for them, trying to at least support our family since we can seldom be there to see them. It's medicine, surgery, primary care, and caring for two patients all rolled into one, and sometimes it eats at your humanity.
Sometimes, you come home at the end of the day so emotionally exhausted that you have little to give to the rest of your family. Sometimes the sadness of discussing a cancer diagnosis, or miscarriage, or fetal death lasts for weeks or days. Sometimes it is impossible to *not* take your work home with you. Sometimes we care *too* much, causing us to start separating ourselves from our patients, building a wall, becoming callous, so the better to protect ourselves.
Sometimes we deal with the stress in inappropriate ways: too much wine, snarky humor, or snappish answers. Likely, many of us are clinically depressed. Many of us have little time to exercise. Because women Ob/Gyns are women too, and usually mothers and wives, who feel guilty when we are at work and guilty when we are at home, just like other working mothers. Because, despite how much it sucks, we still really love our jobs, think pregnancy and birth is amazing, and wouldn't do anything else (even if we wish we could); because we care about mothers, women, and babies.
Kelley Stoddard is the co-author of Baby City, and a practicing OB/GYN.
A version of this article was initially posted in Mothers in Medicine.
P.S. If you read and enjoyed Baby City, please consider leaving a positive review on Amazon. We would truly appreciate it!
Thanks for sharing this. I wonder (as a naive soon to be MS3) does it have to be SO grueling? I applied to med school thinking I wanted to do OB. Now it is at the bottom of my list. I have had too many other issues come up (including personal health issues that mean I actually do *need* sleep). So it won't change in time for me and I am okay with crossing it off my list. But can't it be better than it is? … How? Are the problems about money? ...
ReplyDeleteHey there, this is the author of the above article, not just another random anonymous. ;) Unfortunately, especially since the 80 hour work week, there is a lot to learn in our specialty and not a lot of time to learn it in residency. This has led to a lot of "night float" or shift work mentality in residency, but that doesn't really translate to "real life" private practice. Does it have to be this way? I'm not sure, but I know that our specialty is evolving, and eventually may become 2 separate specialties entirely. There are hospital employed laborists that do similar work to in-house residents, but this is at the cost of doing GYN and office procedures. There is also the option of specializing into GYN only, doing annual exams and surgery, but this phases out the OB aspect of the job. Many of us started this path because we love both OB and GYN, and having the twain meet under reasonable working conditions is the Holy Grail of our profession. In order to practice OB, you have to do a certain amount of volume, just to cover your malpractice, so, in some respects, it can be a "money thing," but it isn't because we don't make enough "take home" money. It's because we need to make enough to cover ourselves from our highly litigious society. More OB volume, more call, and more time away from family, etc. etc. Most of us are working on it, but still don't have it perfectly. ~dr. whoo
ReplyDeleteDr. Whoo, why did you stop blogging? ;(
DeleteThank you for putting down exactly what I feel about my chosen career. After 10 years in practice, I am passionate, broken, torn, guilty, yet uplifted by the privilege of what I do. It's flipping hard.
ReplyDeleteThanks Dr. Whoo … Anonymous #1 again. … I am so thankful for you and the other dedicated and passionate (if burnt out!) OBs out there. I'm glad you are able to see the awesomeness of what you do through the haze of how you have to do it. I just wish for your sake it didn't have to be that way.
ReplyDeleteOne of your kind totally saved my daughter's life. She was a total rock star. … I had a long (long, long) labor. Had gone the nurse midwife route but nothing was really progressing. And then things started to get real … A story you know well, I'm sure. Evidence of fetal distress. And a very tired looking OB (or so my husband tells me, I literally could not see more than fuzzy outlines at this point) showed up. What I do remember, when she walked into the room she put things IN ORDER. Everyone snapped to attention at her words. She got that freaking baby out of me (vacuum extraction, third/final pull, complete with episiotomy … which she swore she rarely does - and I totally believe her.) … She was called in early on behalf of me. … I think it was 5 a.m. when she arrived (also according to my husband). … My daughter ended up with a collapsed lung but did very well and is now a beautiful almost 4-year-old. … I am certain if I hadn't gotten that particular doctor I would have ended up with a C-section … and of course not to mention outcomes much worse than that. She got it done, saved me a surgery, and most importantly got my baby out.
Based on that experience, maybe if I were a few years younger, I might still be interested in OB. But I'm already tired and burnt out just getting through the first two years of medical school. And the school part, for me, is easy. But life is not. … I have half an interest in health care management and politics. My real goal is to get through this. Get good at something. And then make SYSTEMS better for people like you. … So maybe I've lost one version of naiveté (the belief I can do it all and be a rockstar OB myself) and gained another. Good luck to both of us!
Also - Anonymous #1 again - I hear people point to the 80-hour-rule as a source of problems a lot. I don't buy it. (Which is not to say you and everyone else I have heard this from doesn't know a whole lot more about this than I do, at this point!) … But I think if we could ever take a step back and look at the resources we have and make some decisions, sort of from scratch, we could do a lot with what we have. But we end up so indebted to how things were done before we just have the patchwork (Kluge!) that doesn't work. Like you really are saying that when you have a bunch of talented, educated, dedicated people, and 80 HOURS of each of their time, and you can't come up with a system that both gets done things that need to get done AND imparts a worthwhile education that will serve them and their patients down the road? … Sometimes we need scarcer resources to make better use of them. … I am a total newbie, so I say all this realizing I will soon understand many of the whys. But for now I just question the whys. … I am SURE there is a way to make use of 80 hours of people's week AND impart a sense of what goes into full patient care and continuity (rather than the shift work mentality). … But also, shift work mentality is part of how hospitals are run. … Like most everyone working at a hospital except the top administrator and a few old school docs. So let's work with that and embrace it, rather than poo-poo it and say if only we had 100 hours of these people's time. … Anyway … this is just all 4 a.m. thoughts and not meant at all as a criticism of you … Just trying to work this out in my head.
ReplyDeleteVery well said. Not-an-OB/GYN here, but I believe your article would help even laypeople to empathize with the OB/GYN plight. I can't imagine the challenge of trying to learn enough from the new shift-work residency paradigm to get double-boarded in OB/GYN *and* sustain the rigors of real-life practice.
ReplyDeleteAnd yes, women are often much more difficult patients as we require more communication, and that takes more time, which doctors no longer have thanks to employer/hospital requirements, declining reimbursements, and increased documentation requirements.
I also think it's unfortunate that midwives take the low-risk cases leaving you to focus much more on higher-risk pregnancies and deliveries, or be called in late to try to save the day in low-risk deliveries that turn high-risk. Not criticizing them for taking the cases, but as a physician I think it's important to have a mix of simple and more complex cases. No one can work at full capacity 24/7 without consequences to both self and patients.
P.S.
DeleteI'm not just pro-physician well being -- I also think floor nurses should have some hope of having a "lighter" day with fewer patients once in a while rather than knowing that they will be sent home if every nurse working that day is not stretched-to-the-max with regard to patient load. This shift happened mid-way through my internship to help the hospital bottom line. I felt so sorry for the nurses, even though as an intern I took my fair share of abuse from the hospital. The hospital had the gall to request money for an Employee Giving Campaign to buy equipment and furniture for the hospital - can't imagine any of the residents or nurses cared to donate.
Charliesbird~ Amen and well put. Hang in there!
ReplyDeleteAnon #1~ Wow, I'm so glad everything turned out ok with your daughter! It's easy to look like we have all of the answers and things under control (by now we have pretty decent poker faces), but a thousand alternate scenarios are playing in my head at any given time. It can be deafening. I am not citing the 80 hour work week as a "source of problems" per se, just inadequate to properly cover the breadth of the specialty in the current allotted time of residency (4 years). There is a lot more ground to cover and a lot less time to do it, and yes, only hours and hours of patient care can prepare you for when it all hits the fan. Particularly in OB. What's wrong with "shift work mentality" is that your shift ends, but in private practice, your patients are always your patients. Your shift does not really end, even if you are not on call any more. Especially for the patients you know well and with whom you have developed relationships. You aren't just in a hospital, but in an office and OR as well. It's more broad of a specialty than at first glance.
PGyx~ Thank you, and I agree. The burn out rate for physicians is just getting higher, for many of the above cited reasons. We never have a "slow day" it seems any more. On one hand, that's a good thing for business and job security, on the mental health and well being side? Not so much. ~dr.whoo
Totally agree that burnout is a big problem. Many folks say, "Who cares how the docs [and nurses] feel," but when you're a patient it matters.
DeleteI'm not sure the absence of slow days is all that great for business. A big reason we're so busy is because of increased documentation and administrative burdens.
Not sure about your field, but I know in my field reimbursements have declined to the point that private practices are in jeopardy and salaries for hired docs will likely decline since the reimbursements have to cover salary, benefits, and administrative costs. Many patients have switched from private insurance to Medicaid ($18 for a level 3 visit in my state), so seeing more patients doesn't really help us financially.
Anon #1 again - Thanks, Dr. Whoo, for your explanation. The part that makes a lot of sense to me is the difference between your shift ending (in residency) vs. continued responsibility for your patient, in private practice. … And that is a loss in the training process. … And in my crazy long delivery - my wonderful labor and delivery nurse stayed well past the end of her shift with me. Something else I had no sense of until after the fact. The OB was a hero. So was the nurse. … And she went and visited my baby girl in the NICU. What a lovely woman. And for you and her and others like you, the one benefit to this high volume, you have touched and improved so many lives. I hope that brings comfort and peace to the little sleep you get.
ReplyDeleteI have to say, reading this excerpt makes me sad. I am an OB/GYN physician and work with an amazing group of providers - generalist OB/GYN physicians, midwives and laborists. Together we have created a practice model that gives us the best of both worlds - life at home and a life in medicine. I believe it is our team-based approach to care that is a success. We have had very few providers leave because we talk about and recognize the signs of burnout and we support each other. There is a better way.
ReplyDeleteYou ask us to understand how hard your life is...but then you take out your awful life on your medical students.
ReplyDelete