he day began the same as every day had begun for the last few months. But it ended very differently, with a choice that I would come to regret.
I was tired — exhausted, actually. It was the cumulative fatigue from too little sleep. My two young children interrupted my sleep at home; my pager did the same thing at the hospital. It was the type of fatigue that envelops the brain in a dense fog, altering the way you see and hear the world around you, the type that deadens your ability to think clearly and process efficiently.
The alarm clock woke me at 5 a.m. for my shift as the senior resident on call for a busy general medicine service in a large, urban hospital in Chicago. I mindlessly got ready and drove to work, leaving behind my 10-month-old daughter, 3-year-old son, and pregnant wife.
A few hours later, while in the middle of hearing about a patient newly admitted to the hospital, I received a page from my wife. I called her back, expecting a generic morning update on the kids.
“I think I’m miscarrying,” Becky said in a muted tone that understated the impact of her words.
In my worn-out state, it took a few moments to process what she had said. Like water rising as a wave forms, confusion surfaced first. As the swell of emotions picked up momentum and power, feelings of sadness and loss crashed over me. Prompted by a fleeting thought of being saved from even more sleepless nights that another baby would bring, guilt washed over me. As the waves passed, I was left with loneliness.
I was so far away from my wife at the moment when she needed, we needed, to be together. I did something I had never done before during medical school or residency: I called the chiefs and asked them to get someone to cover for me. Not long afterward I was home at my wife’s side.
We sat together. We talked. We cried.
But as the hours passed, the notion that someone was covering for me — doing my work for me, admitting patients with my team — made me increasingly tense. And as the sun began to set, Becky turned to me and said, “It’s OK. Go back to the hospital. I’m all right.”
And I went back.
My stomach still twists in knots when I think back to that moment. How could I have walked away? How did the culture of medicine lead a tired and emotionally exhausted young doctor to leave his wife, who had miscarried just a few hours earlier, to care for two young children on her own?
My stomach still twists in knots when I think back to that moment. How could I have walked away?
Did it start in medical school? As med students, initial thoughts of self-doubt and feeling like imposters slowly faded as we internalized subtle — and not-so-subtle — comments from faculty. “You deserve.” “You belong.” We were told we were on a path to a higher and more noble calling, with great purpose and responsibility. Something bigger than ourselves. Whether from self-doubt or self-importance, we were driven to study. We spent hours reading and learning, dissecting and memorizing. We prepared for finals, mini-boards, and shelf exams.
While doing so, our old friends, no longer enmeshed in academia, enjoyed the perks and freedoms that came with new jobs and real incomes. We were too tired and too immersed in our narrowly focused world to connect with them. And as the dynamics started to shift in those friendships, we became a little more isolated.
Did it continue when we took on clinical rotations? The residents we looked up to as role models were always present and available. They taught us clinical pearls, confidently ran codes, and calmly handled emergencies. They were described as “strong” so we emulated them, making ourselves present and available for our assigned patients and potential procedures. We wanted to be noticed, to be evaluated, to be appreciated. Those traits were deemed positive, earning merit. Reading a book for pleasure, enjoying a run along the lake, and being emotionally and physically available for our partners and children weren’t skills that made it into letters of recommendation.
Did it continue in residency? We took on more responsibility for our patients. Admit them, document them, draw their blood, administer antibiotics, check the labs, update their families, and plan their discharges. To-do lists had to be checked off before we could sign out and go home. We would work 26 days in a month, seven of them spent working overnight, nonstop from one day into the next. We were allowed to keep four or five days a month for ourselves.
But those days off didn’t make up for being physically and emotionally absent for the other 26. Not being home to take out the garbage or help with laundry. No-shows for friends’ birthday parties. Too tired to take turns rocking a child back to sleep in the middle of the night. Exercise or making a home-cooked meal was often out of reach when just keeping our eyes open for the car ride home from work was considered a win.
Did it continue in fellowship? Being on service or working in the clinic wasn’t enough. There were patients to recruit for clinical trials, night classes to attend, and research to do. We needed to write more chapters and apply for more grants. That’s what our mentors and department chairs did. In the meantime, we weren’t there for our own children’s scarlet fever or recurrent strep throats, their first steps and first words. What free time we had was often spent moonlighting as we tried to keep up with ballooning school loans, mortgages, and college savings for our kids.
At every step on the path to becoming physicians, the messages were clear: Be present. Be available. Be visible. Leaving early is weak.
The students, residents, and fellows who stayed the course were dedicated and serious. Our overseers evaluated us not just on our skills but on our perceived dedication.
In the process of struggling to be ever-present and available for others, we often ignored ourselves. It shows. In one systematic review, more than one-quarter of resident physicians had symptoms of depression (depending on the study, it ranged from 21 percent to 43 percent). In another systematic review, this one among medical students, the prevalence of depression or depressive symptoms was 27 percent, while the prevalence of suicidal ideation was 11 percent. And those numbers don’t address other mood disorders, such as anxiety, or the dysfunctional and harmful coping mechanisms of alcohol and drug use. It’s not surprising that there are many struggling or failed marriages among physicians, as well as rampant burnout.
In medical school, students are taught about cells, tissues, organs, and systems. They learn to write histories and perform physicals. They are preached to about antibiotics and antihypertensive medications. But where in the curriculum are they taught to care for themselves? When during residency programs are residents told to go home and be there for their families? When during fellowship is physician wellness placed on the same level as grant writing and lab techniques? Why is focus on family merely tolerated by our peers, instead of modeled and emulated?
To be fair, there are some mentors and role models who show physicians-in-training not only how to set appropriate limits and boundaries but also that it is acceptable to protect our home lives from our work lives. But in my experience they tend to be outliers, their solitary voices often drowned out by the masses.
The culture of medicine promotes as a binary choice either spending time at work to care for our patients or spending time with our families. That’s a zero-sum game. But it doesn’t have to be. We need a culture that promotes both.
So far, most attempts to normalize and humanize medical training have focused narrowly on specific issues such as work hours and work environment. We need to go beyond that and change the culture of training new physicians. Setting appropriate limits and boundaries, as well the concept of physician wellness, should be as prominent in the curriculum as human pathophysiology. Throughout medical training there is an emphasis on developing lifelong learning skills. These should include behaviors that will foster lifelong wellness.
There are only a handful of times in my life that, given another chance, I would do things differently. My choice to pursue a career in medicine is not one of them. I love this profession and the unique opportunities it provides to help people in powerful and meaningful ways. But I wish I could go back to the day during residency when my wife miscarried. I would have chosen to let someone else carry the burden of my work responsibilities for a bit longer, and stayed home with her.
Jeremy Topin, M.D., is a pulmonary and critical care physician at Northwest Pulmonary Associates in Chicago. An earlier version of this article appeared on his blog, Balance.