I originally wrote this column just before Thanksgiving one year, and then updated it in 2012 after the tragic massacre of the Newtown first-graders. Now COVID-19 — and all the losses and grief that 2020 has brought — makes it only too relevant once again. For families who have lost a child, each holiday brings fresh grief, hurdles to face, and mourning for celebrations that will never happen.

The glittering commercialism and noisy cheer of any American holiday can be stressful for most of us. But for the parent who’s lost a child during the past year, facing the first of many holidays with an empty place at the table can make already unbearable grief so much worse.

No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or so we’d like to think.

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How are two-career households with children — let alone single-parent households — going to manage with daycare centers and schools closed, perhaps for a long time to come? What damage will this do to career progress and earning potential if one parent must cut back on work? Will childcare demands inevitably delay or derail partnership or academic promotion?

When I was a young mother — my two youngest children are only 17 months apart — life revolved around childcare arrangements. As newly fledged attendings, my husband and I both wanted to practice full time, and with the confidence of youth we assumed we could make it work. For a time, we had a live-in nanny. As the babies turned into children old enough for school, we still needed a full-time nanny for drop-off, pick-up, and the days when the kids were sick and needed to stay home. We accepted the fact that a third or more of our joint income would be spent on childcare and other support services so that we could both keep working as physicians and stay sane.

But what if there had been no school?

Today, it’s hard to fathom the impact that the COVID-19 pandemic is having on families trying to find solutions to their childcare needs with the closure of private and public schools alike. Who’s going to watch, let alone educate, the kids? A nanny, no matter how conscientious and loving, may not be a good educator. When one parent has to work less in order to supervise learning at home, often that job falls to the mother. What happens to her career?

The vicious downturn cycle

As of early July, the Census Bureau estimates that half of American adults live in households that lost job income this spring. Many anesthesiologists lost income too during the periods in March and April when elective surgery in many states went on hiatus to keep beds open for COVID-19 patients.

In California, the CSA surveyed members and found that 74% reported experiencing financial hardship this spring, with medium and small private practices faring worse than academic departments. There was no overall difference in perceived economic hardship between men and women in anesthesiology, though women reported being furloughed or given involuntary vacation more often than men: 41% vs. 26% of survey respondents.

When people lose their jobs or work remotely, demand for childcare services plummets. The National Association for the Education of Young Children reports that on average, enrollment in childcare centers is down by 67%. Many that were operating on a slim margin have already gone out of business. The centers that remain open to serve essential workers are facing huge additional expenses for staff, PPE, cleaning supplies, and duplicate equipment and toys to allow cleaning after each use. At least 40% of the remaining childcare centers are likely to go out of business unless significant government assistance arrives soon. People trying to return to work after lockdown — in anesthesiology or any other field — are having trouble finding high-quality early childcare.

“It’s much harder for me to find safe childcare to be able to work,” said one woman anesthesiologist in a private conversation. Another in academic practice commented, “It’s very stressful for the mom!” A third woman is worried because her current au pair leaves in August but the new one may not be able to enter the country due to the hold on visas.

Many of us assumed optimistically that the school closures of the spring would be short-lived, and that September would mark the end of “learning from home”. That doesn’t appear likely. California’s Governor Newsom announced on July 17 that most California public and private schools will not reopen when the academic year begins.

In some states, elite private schools have more latitude to reopen than public schools as they can afford to reduce class size and adapt to strict infection control regulations recommended by the CDC. But many private religious schools that serve less wealthy families were in financial trouble even before the full effect of the pandemic hit. The Roman Catholic Boston archdiocese, for example, has already shuttered 10% of its schools permanently. No one knows yet how many students actually will be able to return to school this fall.

Even if schools reopen where state government permits, it isn’t clear that teachers will agree to return to work. In a July 19 New York Times op-ed, a teacher wrote that she is willing to take a bullet for her students, but exposing herself and her family to COVID-19 would be like asking her to take that bullet home. “It isn’t fair to ask me to be part of a massive, unnecessary science experiment,” she wrote. “I am not a human research subject. I will not do it.”

In anesthesia, you can’t “phone it in”

What are women in anesthesiology going to do if schools don’t reopen? If your job is purely administrative, or you can run a preop clinic using telemedicine, you might be able to work remotely. But you can’t “phone it in” if your job is delivering anesthesia to humans.

“I don’t see how this school year is going to work,” said one woman anesthesiologist. “It’s a hot mess.”

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Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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My son has been accepted into medical school, we learned last week, and I must say I’m about as happy a mother and a physician as you could find anywhere.  For everything that’s wrong with the American healthcare system today, medicine is a wonderful profession and it’s still the greatest honor in the world for a patient to have faith in your skills and care.

It will be interesting to see how my son navigates the still controversial issue of how to manage family and “work-life balance”. How do you do justice to the trust that was placed in you when that invitation to medical school was extended?  That trust came from the college faculty members who recommended you, the medical school faculty who evaluated your application, the public whose tax dollars help support your medical training, and the patients–now and in the future–who will need you to take care of them.  No, that doesn’t imply that you’ve accepted a life sentence to work 80 or 100 hours a week until the day you retire.  But it does imply that all those people believed that you accepted the calling to make the practice of medicine one of the highest priorities in your life.

You’ll hear the argument that the desire for “work-life balance” is a generational thing, not a gender issue–that young men in their 20s and 30s today don’t want to work as hard as their fathers did at their age.  That may be true.

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This column was featured on KevinMD on August 13, 2012, and on the California Society of Anesthesiology website as an “Online First” selection on July 16, 2012.

Unless you’ve lately returned from a retreat at a remote Cistercian abbey, if you’re interested at all in women’s issues you’ve probably read Anne-Marie Slaughter’s recent article in the Atlantic, “Why Women Still Can’t Have It All”.  The author eloquently tells how she left her dream job in the State Department as the first woman director of policy planning in order to return to her husband, her two adolescent sons, and her tenured professorship at Princeton University.  The weekly commute to Washington proved impossible, and her family needed her.

Professor Slaughter’s article is well worth reading for its meditations on how difficult it can be to combine motherhood and a challenging career.  Her conclusion is that work practices and work culture need to change.  Unfortunately, her take-home points have little application to the life of a physician.  She quotes from Republican political strategist Mary Matalin, who wrote, “Having control over your schedule is the only way that women who want to have a career and a family can make it work.”

That certainly leaves me out.  If there’s one thing I don’t have as an anesthesiologist, it’s control over my schedule.

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