Prologue: Advice

It was Saturday morning in my southern university town. I sat across the table from a mentor sharing coffee and bagels. He was a respected man in my church who had been a physician for years. He had a wife and children during his medical training. I was newly married, preparing to begin medical school.

“Do not put your life on hold for career decisions.” He advised, “There is never a good time to have children — there’s always one more step, one more graduation, one more achievement before settling down.”

My wife and I were preparing to move overseas so I could begin medical school in Israel. We both wanted children young. I grew up as one of five siblings, and we looked forward to a big family. I knew that having kids would change my medical education experience, but I had no idea how grateful I would be for the advice I received that sunny spring day in Alabama.

We moved in June from our lovely southern home to the Middle Eastern desert. Life was hard there, and our marriage underwent challenges that accompany the changing environment as well as the responsibilities of medical school. Once we found our footing in our new home we looked to the future. Our family was going to grow.

1: Recognizing My Limits

My firstborn son came into the world as a birthday gift to his mother in between semesters of my second year of medical school. He was nine days late, but his timing could not have been better. She labored in bringing him into the world, and we agreed he was perfect.

For weeks after his birth, he was our main attraction. Instead of studying, I would put him on our coffee table and stare at him for hours. He laughed within the first weeks of life, and I realized his laugh would become a source of vitality that never failed to move me. When classes started back, I couldn’t wait to see him again. I would feel that he had grown in the hours I left him. If it were possible to spoil a baby, we spoiled that child with round-the-clock attention and affection.

I had always been diligent. My father had been a graduate of the United States Military Academy, left the armed forces for the world of defense contracting, after which he went to work with his father in a small business, opening up two college textbook stores in different cities, starting a small restaurant, and helping my mom get a clothing boutique off the ground. Hard work was in my blood. Early in my marriage, however, I learned it might destroy me.

Medical school handpicks people like me; applicants aren’t daunted by one more hoop to jump through. We see a score and immediately plan how we can top it. Many people pursue medicine for compassion and humanism evident by the many physicians who possess these traits; but your work ethic, competitive attitude, and drive are groomed throughout the application process. We are repeatedly told to manage a certain GPA, meet a standardized test benchmark and be involved in research. Even volunteer opportunities are commoditized in the industrial complex of building doctors — spend a day with underprivileged children in order to put it on the CV.

Families, however, aren’t scored by GPA. There are no benchmarks in relationships. The economy of the home does not model the economy of the marketplace or university. It is special and sacred, setting it apart from those other fields. There are no awards and little prestige in family life exemplified by selflessness. The rewards are far greater than professional promotion, but they are primarily intangible — especially early on. In the zeal of youth, it is easy to seek the instant reward of benchmarks rather than lasting satisfaction in the home.

I was warned often about this temptation. I knew that the pursuit of perfection in my training could grow like a weed in our house. It would choke out other life and leave only a rapidly growing yet rapidly fading monument to myself. Prior to medical school, my wife and I had set limits on my studying so it would not over-run family life. I woke up early and studied through breaks so that come dinner time, I could put away my books. This caused me to miss extra-curricular activities. I had many lunches at my computer, spent the 15-minute breaks in lectures studying, and would run to the library during longer breaks in the day. However, when the dinner plates hit the table, the books hit the closet. At first, this was a trial for me. Why settle for a B when I felt an A was just as attainable? Over the course of two years of marriage, however, this balance felt more natural. By the time my son came into the world, the difficulty was manufacturing motivation to remain at the books rather than spend the time with my family.

This balancing act between school and family served as a constant reminder that I am mortal. Sometimes I would be forced to choose where I invested my time. I could not be the best in everything I did, and where I remained devoted would reveal my priorities. We all have limits. I was determined to be a good doctor, but having children this early in my training showed me my limits. I could be decent, possibly great, but engagement in anything requires sacrifice elsewhere. My life was not about me only.

Medical education gets progressively intense. The reward is a moving target. In undergrad, you jump through hoops to get into the medical school of choice. They raise the bar to get into the residency you select. By the time you are applying for a fellowship, it begins to feel like you are Evil Knievel jumping Snake River Canyon. This is difficult enough without that inner voice driving you to push the standards higher. My wife was thrilled to celebrate my test scores with me, but happier that I didn’t desert her and my child to attain a three-digit score that would fade a decade later. My firstborn son helped draw me away from pursuit of perfection and inspired me to be my best at work and at home.

2: Reshuffling My Priorities

My second son was born before I began my fourth year of medical school. We had a few rotations in the United States, so my wife had flown back in her 35th week of pregnancy, I joined her shortly before her 37th. We planned to have a week as a family before I started my rotations. My second son did not want to be left out of our time together. He arrived less than 36 hours after I got back to Alabama.

Life with an 18-month-old and a newborn was exhausting. One of my rotations was in anesthesiology. I would wake up around 4 a.m., quickly shower, fix a cup of coffee to go, holding off drinking it as long as I could. The final sips timed as I pulled into the parking lot, slightly more awake but still bleary-eyed. I would work until the early-afternoon, attempting to remain engaged and perform procedures — I was going to need letters of recommendation, after all — before getting back home in the afternoon. My second child was much more colicky than his brother, and so he would be crying when I came home. He had been doing it all day and the only way to keep him content would be for me to hold his warm body close against mine outside in the sticky late summer heat. We would be soaked with sweat together by dinner. After eating we would generally take an evening walk as a family, put the kids to bed, and my wife and I would strive to make an hour of adult conversation before collapsing into sleep ourselves, frequently interrupted by our children.

I could feel the strain on my family. I could feel the strain on my spirit. I knew that the rigors of medical training would not affect me only, but also touch my family. In the midst of this struggle I realized that regardless of specialty, residency is a time of even more painful adjustments. My children helped rearrange my priorities in selecting my residency.

Leading up to my residency application, I made conscious decisions knowing they might make me look worse to competitive academic programs. During the year as I traveled and interviewed, I needed to see the program had people with families who weren’t just surviving but were instead thriving. I looked for camaraderie, a lack of competition, and residents who possessed something rare in many programs — humanity.

When it came to that spring, I prepared to submit my rank list to The Match. My wife and I sat down to discuss our decision. While interested in prestige and opportunities for me, essential questions revolved around our family life. Which cities would she adjust to most easily? Which cities would offer support with kids? In which city could we afford living conditions big enough for our family? Which could we see ourselves in the long-term, to try and prevent another move as our children were starting to grow?

I knew that I would have different experiences than my colleagues by having my children early. I did not realize that would include the impact my children would have on my priorities. Regardless of when you have children, your perspective changes and you make different calls, even in your own career. It was beneficial for me to have a different perspective prior to making those decisions as opposed to having my decisions made and needing to change course painfully. My second son helped me reevaluate the crucial parts of my training and select a specialty and practice environment where my family could be cared for.

Interlude: Grief and Loss

When we first started trying to have children, we went through multiple miscarriages in the first trimester. The first stands out the most to me. We had been so excited about the baby that we told people despite promising ourselves we would wait until 12 weeks. My wife started bleeding around the eighth week. We convinced ourselves that it wasn’t true, but as the volume of blood rose, our fear took hold.

We walked to the hospital that terrible Saturday. She underwent an ultrasound — there was no heartbeat. The doctor told us it was likely a miscarriage, but that there was still a chance that the fetus had not developed a heartbeat yet. We clung to hope. That afternoon, tissue began to accompany the blood, and we marched back to the emergency room for a confirmatory follow-up ultrasound. This doctor did not speak English, and our Hebrew was infantile. We managed to communicate through a nurse as the doctor prepared my wife for the scan.

As her eyes searched the screen, my wife and I did not need her words. We knew that we would not have the baby. I remember the kindness of that doctor; she had sorrow in her eyes as she placed her hand on my wife’s knee.

We had more pregnancy losses in the year following. All early in gestation, but all painful. The uncertainty of knowing whether or not we would ever have a child hung over our heads. When something has gone wrong, you can feel that nothing will ever go right. The constant smoldering stress heaped on top of being in the first year of medical school and a new country. In the darkest of times, I was not sure I could complete my training. The burden I carried to class every day was about more than memorizing the Krebs cycle.

When students struggle, they are often blamed, but there are so many more reasons for it than meet the eye. I cannot express how grateful I am for friends and faculty who surrounded me, who were there for me, and who carried me amid the suffering. Students are often ripped away when they enter medical training, not having time for their faith communities or families. We made establishing a community a priority since we were living abroad. Those roots were necessary to process my grief and to be able to complete medical school. That lesson is something I have tried to communicate to anyone who begins medical training. You need a community to survive this, and struggling students may be going through more than just academic adjustments.

3: Reevaluating My Expectations

As I finished school and began residency, our life filled with change. As a consequence, we took a risk when out of town for my brother’s wedding, just after our second child was one year old. A few weeks later, my wife shared the news that our gamble would be a jackpot. The third boy would be in our family that spring.

We were thrilled with the news. So many of my colleagues were shocked when they found out I had children and questioned how I maintained balance. Truthfully, I couldn’t imagine how they did without children.

The system of medical education and training is broken in the United States. We assume that if someone wants to be a doctor, they must put every facet of their lives on hold for medical school and most of residency to accomplish that dream. We saddle our residents with 80-hour weeks and then question if they are becoming too “soft.” While community, family, and personal life can survive these rigors, it will not thrive. This is not a problem unique to a single program or specialty, but the reality of the world in which future doctors train and live.

Many professions demand much from their junior members, but none compare to the torment of our youngest physicians. We make them face death and disease each and every day. Some problems are diagnosed and fixed, but many aren’t, and they feel their own futility as their patients expire before them. I had a peer who once said that residency is learning medicine by taking care of the same 500 people over and over again. They cycle through our clinic, and back to the hospital, to the operating room, back to the hospital, to streets, to clinic, hospital, operating room, hospital, grave. All the maladies of a society with its political, cultural and structural violence against the weakest and most marginalized members pass through the doors of our hospital. We cannot fix the problems, but we are told to try our hardest. Don Quixote had greater success at toppling windmills.

The drive to be viewed as a “hard-worker” or “team player” is strong. There is some value in that. It is good to take up slack when colleagues need it. The flip side of that is a successful work environment needs to ensure that the need to work overtime is the exception, not the rule. I had to miss some things in my 80-hour work weeks of residency, but I stopped feeling guilty about leaving work when my shift ended a long time ago. The hospital is still standing, and my relationship with my peers is still thriving.

Part of having children was deciding that there are some things more important than my career and other peoples’ expectations. You can still be a good doctor and take your kids to their appointments, or see your wife’s ultrasounds, or change your schedule to accommodate their activities. You will always have to work hard to grow in medicine, but my kids demanded development as a human, as their father. I refuse to let my career consume my family.

In the same way, my family refuses to let my career consume me. I cannot come home, eat, shower, watch Netflix, and fall asleep reading articles. I have to participate in T-ball practices, meeting other parents who have no idea what the work environment of residency is like. I have to make sure my kids are behaving in church, sharing in the burdens and joys of other friends and families. I have to take my kids to see their grandparents, reinforcing and strengthening the bonds of my family. I have to free my wife from the constant joyful-yet-grinding work of motherhood so she can get coffee with friends, or even walk around the block for a few minutes of precious silence.

When you leave the hospital after 24 hours of crisis, in a confused fog due to insomnia and adrenaline, it is easy to fall back into automation. Follow the path of least resistance until the next shift. However, my family reorients me. They remind me that the greatest works we do are slow works. There is life, joy, and humanity outside the hospital, and they cannot fathom the hardships within. They distract my tired brain from the constant anxious pressure of patients, trusting my peers to care for the sick in my absence.

Soon after our son was born, my parents took me and my siblings and all our families to Disney World. I had been working in the emergency department that month, so I stacked my shifts, working the 15 required in 19 days to make the vacation work. Our youngest was only one month old. As anyone who has been at Disney with young children can imagine, we did not sleep on that vacation — but I wouldn’t trade those memories for all the career success or lazy beach trips in the world. My third born son taught me not to regret the chance to come home and be with my family, and to let medicine consume me.

4: Recognizing My Needs

Burnout began mounting in my third year of residency. I was tired. I had a few situations outside of my control that made me feel powerless. Financial strain was beginning to wear on me. My wife was pregnant at the end of the second year, but we had a miscarriage in August.

She became pregnant again. We were thrilled and excited to welcome the fourth son into our house. I certainly do not want to downplay that feeling. We wanted this child and were happy he was coming, but I was tired.

I have written extensively about the joys of children in residency. My family is precious. I would not have it any other way. There are challenges, however, associated with having children during this season of intense physical and psychological stress. After all, I was tired.

This coming child was a blessing in many ways. The insidious aspect of medicine is that it is a “greedy occupation.” You can give and give and give, and it will still hunger for more of you. You can give it your body, heart, and soul, yet it will still devour you. After all, medicine is based on the premise that you need it to make your life worthwhile. It does not need you. My exhaustion meant nothing to the machine of career. There were more opportunities, more conferences to present, more research to be done, more favor to earn.

While there are occasionally resources provided for our well-being, most frequently the impetus is on trainees to find out how to prioritize self-care. When my son was born during my intern year, I took one day off. When your whole world is medicine, that seems reasonable. I actually felt guilty, as it was my day to be on call and another intern had to cover for me while I went to his birth. This was not an expectation from my faculty or program, but it was one ingrained in me by the culture of medicine and medical training.

My children needed me at home; they had always needed me at home. My wife is an incredible woman. She had covered all the holes and coordinated all the events perfectly in my residency-induced absence. However, when she was laid up with morning sickness, and I was on elective rotations that did not need my service, I felt like I was being torn in half. Medicine wants all of us, even if that is an expectation we put on ourselves.

Children also demand all of us. Whenever I put my shoes on, my third-born, Moses, squeaks in his two-year-old voice, “You not go to work?” My heart breaks every time. My children are young, but I could have had them earlier. In that case, I would miss T-ball games, music recitals, PTA meetings. I joke with my wife after hard months that the kids may not recognize me, but I fear in my heart I am missing their childhoods. I know that I am missing the hard work of parenting. The sleepless nights I have at the hospital are nothing compared to the sleepless nights my wife has at home. The trouble managing potassium levels doesn’t compare to the trouble managing a rowdy two-year-old and infant.

People tell us all the time that we can have it all; that we do not have to sacrifice in our careers to have happy and fulfilling family lives. But if medicine wants it all, and your family wants it all, how can you satisfy both? If I decide projects do not need to be missed, conferences do not need to be skipped, work can continue as it has and I can survive with my kids. However, my goal is to use my life to make a lasting impression on my children. My goal is not for them to be functioning, but for them to be well. I want them to be whole, physically, socially, emotionally and spiritually. That means I have to fight this greedy profession. I will pass on many opportunities to further my career. I choose to miss networking events. I choose to miss many late nights working on projects.

It also means I have to vigorously guard my own wellness. This may seem selfish at first, but I also realize that my tank cannot be empty when I return home. They deserve the main course, not just the scraps of my attention. If I can’t find ways to make my working requirement healthy, then I can’t work there. Sometimes this is impossible, and then the challenge of coming home to children is having to dig deep and serve them, even in the midst of depression and exhaustion.

Now, as training draws to a close, I see that my children came with immense benefits as well as complex challenges. They were a strong support system. My kids grew me up and taught me about myself, my needs and my resilience. They were also a trial at times. They cannot be turned off or traded in, and in the midst of everything they are a constant reminder of decisions you make, whether they help or harm them. Kids don’t understand burnout, but they do help identify the root causes of it. My home must always be healthier than my work. My fourth son — while still in his mother’s womb — taught me that I could not tolerate a work environment that does not promote my well-being. He, his brothers, and his mom need me to be healthy to care for them.

Epilogue: Vacation

As I review this article, I realize a few things remain unsaid. First, I want to acknowledge that I am no expert here. This is my personal experience. I cannot emphasize enough how much my wife has done to make this possible, and if anything impresses you about this piece, it should be her. I know that having children is not wanted, appropriate or feasible for all trainees. I do not think they are required to make everyone excellent physicians. I am claiming they have improved my training, aided my decisions and helped me to maintain my sense of self in the midst of an incredibly taxing season. Second, many people are intimidated by the financial pressures of child-rearing in training, when pay is inadequate to support a family. My wife and I have made decisions about our finances to have children in our current state, but we feel comfortable walking that tight-rope because we know our families are well enough in the middle class to be our safety net if we were to have a catastrophe. Finally, I want to reiterate that while having children has been good for me, it has not been supported at all by the current state of medical education in the United States. The cost, lack of pay, repetitive trauma, and overwhelming hours of medical education all discourage trainees from starting families in the course of training.

I am finishing the initial draft of this at the beach. The windows are open, the waves are crashing, and the sun is flooding in. We are staying in a house with some other family friends.

The back porch looks like a bomb went off, with children’s beach toys and wet swimsuits scattered everywhere. The only times of quiet are nap time and bedtime, and even those are not without complications. Otherwise, this house is a bustling hive of constant energy and vitality. If you think managing a resuscitation is complex and stressful, try managing nine kids under the age of seven.

In order to make this trip happen, I have had to miss things. I was invited to present a workshop and poster at a national conference but had already made plans to be here. Anyone driving more than five hours with children knows you sacrifice sleep for a trip like this. I have a few unfinished research projects and I am responsible for establishing the resident schedule for next year, but I have put aside all work for this two-week trip.

This does not feel like a sacrifice to me. I was tired and this trip was necessary. Part of burnout is losing yourself in depersonalization and detachment. While my family has kept me anchored, I was suffocating. I am beginning to feel things appropriately again. Without my family, I would probably be lounging somewhere, sleeping a ton, eating pizza, drinking beer and watching TV. While that would be escaping, it would not be resting. Instead, I am hunting for seashells, building sand castles, letting waves crash on my head for the laughs, and in the quiet nap times catching up on writing and reading poetry. These are the activities of life. My emotional connections to my bride and children are a source of vitality, one I would be lost without. They have protected me.

I knew that children were a good thing. I knew they were a thing that I did not want to wait to experience. I knew that they were the result of love between me and my spouse. I did not know that they would change my aspirations. I did not know that they would change my priorities. I did not know that I could love a child so much immediately after knowing of their conception and feel the pain of their loss without seeing their faces. I did not know that they would keep me human amid a process that does everything possible to mechanize me. I did not know the depth of challenges their constant need would bring and how they would force me to prioritize my well-being. I know now that they bring all these things and so much more. I love them for these things, but ultimately because they are mine.

Nap time is over. Time to be alive.