You can’t phone in your job as a physician

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.

I’m expected to be in the hospital every day in time to set up my drugs and equipment, evaluate my patient, and have the patient ready to go into the operating room at 7:15 a.m.  Since our practice does not employ “physician extenders” such as nurse anesthetists or anesthesiology assistants, I’ll be with my patients continuously until the day’s surgery is finished.  Unless I have a life-threatening domestic crisis at home—something like an actively hemorrhaging child or rising floodwaters—no one is going to show up and offer to take over my cases so that I can go home.

One section of Slaughter’s article is titled, “Changing the Culture of Face Time”.  She argues that time spent in the office isn’t always necessary, and that being able to work from home “can be the key, for mothers, to carrying your full load versus letting a team down at crucial moments”.  She mentions video-conferencing as one way to manage working off-site.  A clever mother can even use her smart phone to call in to a meeting while watching her child at a playground.

But if your job involves “face time” with a patient, it’s different.  Telemedicine is championed as a great way to extend the range of some physicians, like radiologists and dermatologists, when visual and interpretive skills are required.  But if I need to insert a catheter into someone’s artery or jugular vein, or a breathing tube into the trachea, I can’t see any way to do that from home.  Just as soldiers speak of “boots on the ground”, most physicians have to be at the bedside or the operating table to get the work done.

Physicians aren’t alone in needing to appear in person.  Nurses, traffic cops, beauticians, mechanics, dog walkers, personal trainers—all of us have to be on site to do our jobs.  There is no way to phone it in.  Nor do most of us have the freedom to be “open and indeed proud” if we defer a task for child-related reasons, let alone leave early whenever we choose.  For most people in hourly positions, that would be a sure route to losing wages or getting fired.  In this economy, men and women would be eager to snap up any vacant position whether or not it offered flexibility.

Has the culture in medicine changed at all over the past 20 or 30 years, since women began to comprise a greater percentage of medical school classes?  Certainly it has.  Having a baby during residency is commonplace now, and I’m told it is almost “de rigueur” in dermatology residency programs.  It’s politically incorrect to question whether or not pregnancy might have a detrimental effect on learning, or confer an unfair burden of extra coverage on the other residents in the program.

At the top of the medical pyramid, male physicians have started to play the trump card of work-life balance quite brilliantly.  I’ve had the dubious pleasure of working with a plastic surgeon whose marriage was plagued with infertility issues.  He would routinely come in late on the days his wife was ovulating, oblivious to the inconvenience he caused to the operating room personnel—mostly female—who were obliged to clock in on time and wait for him.  A thoracic surgeon on his second marriage, with two small boys, often drives his sons to school at 8 a.m. though his first case in the OR is scheduled at 7:15.

If there’s such a thing as a work-life balance abuser, the blue ribbon goes to one orthopedic surgeon at my hospital.  He likes to go home, have dinner with his wife, and tuck his children into bed—all reasonable things to do.  But he then books his emergency hip fractures for 8:30 or 9 p.m.  This means that a host of other on-call personnel—anesthesiologist, OR nurse, surgical technician, radiology technician—are held hostage in the hospital waiting for him.  Work-life balance only works in this setting if you’re the one who gets to call the shots.

What would I do if I were in a position to control the OR schedule?  For a start, I wouldn’t schedule the first case of the day before 8:30 a.m.  I think it would be wonderful if all the people who work in surgery could have breakfast with their families and see their children off to school.  My children are grown now, but I remember so well having only a moment to say goodbye in the morning while they were still snug in their pajamas.  It would have meant the world to have an extra hour.  But the reality of life as an anesthesiologist—then and now—is to be in the operating room ready to go, often before dawn, and heaven forbid that surgery should ever be delayed on our account.

Perhaps we shouldn’t complain.  Work-life balance, after all, is a first-world women’s issue, and even within the first world it’s primarily a concern of affluent white women.  Most women of color, and for that matter women of any color who lack the advantages of money and education, seldom have the luxury of obsessing over whether to work, how much to work, and whether or not they’ve achieved optimal work-life balance.

Yet I agree with Professor Slaughter that we could do better.  I don’t think that working less is the answer in medicine, because there is so much to learn and so much experience needed to do a merely competent job, let alone a great one.  But maybe something as simple as starting the OR schedule an hour later could make a difference to a great many families.  Maybe we should eliminate grueling 24-hour calls altogether, and divide up the work day differently.  Medicine may not be as flexible as other fields, but there’s a chance that with enough good will and effort it could—perhaps—become more humane.



Dear Ann-Marie,
Thanks for posting this article on your blog. I read Dr. Slaughter’s article on, one of the best web sites for in depth thought on the internet. We all have too many choices to make in life. Medicine is extremely demanding for all. I could do nothing other than read about and practice medicine for 24/7 and still not be devoting enough time to my career. Then to be a good father, mother, all extremely difficult. The only way a woman or man can have almost everything but not everything is 1) to have the money to pay for excellent child care when your children are young and 2) control over your schedule. We have 11 gastroenterologists in our group and two of them are women. They both work part time and our group has allowed them to design their schedules to meet the needs of their families. One doc works 4 days a week from 9:30am to 2:30pm and the other works from 9:30am to 5pm three days per week. The late morning start is so that things can be taken care of at home. Both docs are married to other docs that work 10-12 hour days. Choices, choices, choices. I do not believe in the concept of having it all and Super Moms and Super Dads. Thank you. Geoff Braden MD


Dear Dr.
I just came across your blog and am enjoying your thoughts and insights. As an internist in part primary care, part hospitalist practice I do not have much control over my schedule either, but have orchestrated my life carefully around my familys needs – I chose to work for an HMO with lots of time off benefits and sick leave which can be used for children’s orthodontist appointments and such, and my day starts with peeling them out of bed and making sure they have something reasonable for breakfast, and the moments of sleepy soft faces are priceless. For this very reason I chose primary care, instead of surgical or specialty training, which no doubt would have been more lucrative and stimulating, but also more demanding of personal sacrifice. You ask in a different article why women would chose to preferentially go into primary care – and in my mind that is precisely why. You can’t have your cake and eat it too. Just my two cents. Cheers, Eva V. , MD




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