Having two teenage daughters and an 8 year old son, it can be difficult to get agreement on an activity during the rare moments when we have free time. I’m fortunate that all my children enjoy going to see a movie in the theater as much as I do and, for the most part, they are able to agree on what to see. Because of this, I have been able to see most of the recent animated movies without guilt or shame. Without my kids, I would have had to order the movies “on demand” and watch them in the privacy without the scrutinizing eyes of others wondering what a middle-aged guy is doing at a “family oriented” movie alone. I actually experienced this judgmental stare when I was on a long flight and watched The Secret Life of Pets. The person next to me gave me that “look” which I repaid by being very slow to get up and move when they needed to go to the bathroom. Judge not lest ye be judged.
Anyway, if you have not seen The Secret Life of Pets, it centers around the anthropomorphized experiences of house pets when their owners leave for the day. The story centers around Max whose life is turned upside down when his owner adopts another dog (Duke). On a walk, Duke and Max through unfortunate circumstances get sent to the pound only to be saved by a jaded bunny and their friends.
As an intern, I used to believe that when my attendings were not in the OR or clinic, that they were out enjoying free time or hours in their office writing, reading, or thinking great thoughts. I felt that in many ways that their life of leisure was due to the blood, sweat, and tears of my fellow junior residents who managed all of the inpatient issues, took first call every night and weekend, saw and wrote up many of the clinic notes and consults, dictated the operative reports, made sure the x-rays were printed for the OR and that everything was just right so they could walk in and talk to the patient in clinic or perform the surgery without worrying about anything else. While the attending physicians were off at some exciting national or international meeting, me and my fellow worker bees were left behind to do all the work.
My resentment extended to my more senior residents and fellows as well. I always felt like the work (I’m using a nicer word here- this is a family friendly blog) rolled downhill and while everyone was heading off to the OR to do exciting cases or learn about evaluating complex patients in clinic, I was left on the floor dealing with the “scut”. I dreamed of the day when I would have more control of my time to do with it as I saw fit instead of countless people telling me what to do and when to do it. I felt that my life would get better as I moved up the resident food chain because I would have more freedom and flexibility.
But with great power comes greater responsibility. As I moved from junior resident to senior resident and chief, I realized that there was not less work, only different tasks and pressures. Interestingly, the one sentiment that has continued to stick with me as I have progressed in my career is a strong distaste for shoving menial work to more junior members of the team. I’m no saint, but I had such a bitter feeling about being asked to do work that could have often been done much more efficiently by the one scutting me out that I swore that I would avoid meaningless delegation if at all possible. There is nothing more demoralizing to a team than when the leader is not willing to roll up their sleeves and share in the work.
However, my experience as a senior resident and the added responsibility of making clinical decisions about inpatients, supervising the more junior residents, doing research and writing papers, applying for fellowships, studying for in-service exams, and being prepared for surgical cases and clinic taught me that while I could do everything, I was never going to survive if I did not learn to delegate some responsibility. However, I would never delegate something that I could do quicker or easier and would only delegate things that I could do better if I felt like it was a learning opportunity for the junior resident. A perfect example of this is what we used to call FedEx. Often the last cardiac case when I was an intern would end late in the day. The cardiac fellow would typically call the intern to help close the chest. Of course, in the beginning, I thought this was really cool. The big needles, the bone goo, twisting the steel all made me feel like I was doing something. But for the fellow this was their opportunity to leave the OR and let us transport the patient to the cardiac ICU which was typically a 30-40 minute ordeal. By the time I was done FedExing the patient to the ICU, it was late and I still had to run the patient list with the fellow and update them. Needless to say, I have avoided this scenario happening in my OR.
As a chief resident, while I was top of the food chain, I was also on call every other night for most of the year responding to calls from my interns and junior residents about issues on the floor or ER consults. At that point, I dreamed of being a fellow where I would be seeing the patients and helping with the operations that I wanted in my future practice. I would have time to do research and write papers. I would have more time on the weekends to spend with my family and resume some hobbies that I let go during residency. I might even be able to get errands done during the day. Don’t get me wrong, I loved my fellowship. My surgical skillset and confidence as a surgeon expanded rapidly and I was able to generate ideas, do research, and publish on subjects I found engaging. But it also came with additional responsibilities that I had not experienced before. I had my own patients in clinic and the OR that I was responsible for. My clinics were full of a variety of patients and looked nothing like the clinics I helped with during residency which had highly selected patients based on the surgeon’s expertise. I would come in late at night or on the weekends to help manage complications and take people to the OR for emergencies. I needed to ensure that my academic productivity was good so I could be competitive for a strong academic position. I had the pressure of interviewing for jobs, negotiating with Departments and institutions and after long years of being underpaid and overworked, hoping to find a position similar to the one I felt my attendings during residency had- lots of interesting patients and surgeries, great staff and residents to support my clinical work, residents and fellows to mentor and collaborate on research, the opportunity for funding and leadership, time to spend with my family and pursuing outside interests- in essence a dream job that doesn’t exist.
Well, in many ways I have been fortunate. I have continued to be able to progress on my career path. I have awesome residents and co-faculty/partners that I work with. I have a clinical practice centered around my areas of expertise. I have been able to assume leadership roles and expand my skillset beyond clinical medicine. But just like every step of the way I have described, this part of my career is not easier than the steps that came before. While I have more control over my time, increasing clinical expectations and oversight by the Health System require that I account for all of my effort. Much more of my time is spent doing office work than I would ever have dreamed of. There are also activities that attendings must do to continue to progress in their career that while enjoyable, add more complexity to life than a resident or fellow experiences. These include a wide array of teaching responsibilities that you are constantly judged on by residents, medical students, and other learners. There is also the growing desire to be able to get home and be there for your kids who are growing up so fast, who need your help with homework or simply to shuttle them to their next activity. Finally, increasing expectations of local citizenship to the Health System or to various organizations add more responsibility and time that can fill every nook and cranny left over.
Then there are the changes that are brought on by the growth of an academic medical center. I rarely work with the residents in clinic and see patients at several clinical sites. In addition to the main hospital, I operate at a community hospital. While I get to work with advanced practice professionals, it is not exactly the same as working with residents (although I still get to see them in the main hospital OR). Learning a different electronic medical record, different physicians to call, different culture all add additional stressors that I never experienced as a resident.
I am not complaining. I am lucky and I know that. My driving point is that our perceptions starting at the bottom is that the system is built like a pyramid scheme and you only have to persevere and make it to the top to enjoy the benefits. But the life of an attending is not a secret life of excitement and adventure like some animated movie about animals. My life is definitely better in many ways but it is no less stressful and I have more responsibility and accountability than I had at any other point. So I would like to end this with a few brief points and lessons learned. If you are a resident reading this and are cynical or bitter about the pyramid of organized medicine, I hope these words will give you some comfort.
First, remember, as cliché as this sounds, that life is a journey and not a marathon. It does you no good to focus on some fantasy future and not appreciate the good things that you have in the present. Sure life may be tough but you will miss so many good things if you are just trying to work your way up the next step in the food chain. A lot of my angst and extra hours of work were related to positioning myself for a successful next step. While I am happy where I am, I sometimes wonder what I missed getting here. A corollary of this is that your career does not need to be a straight line to the top. Circumstances change throughout a career either because we, as individuals, change or certain opportunities become blocked and other doors open. If you constantly focus on “what next” thinking, you will miss the opportunities that come from taking the detours.
Second, remember that while career progression comes with benefits, it also comes with more responsibility and accountability. No matter who you are, medicine is a life of service to others, most importantly patients but also to those above us and below us in the hierarchy. To believe that getting to some predetermined destination will make you free and happy is truly magical thinking. Rather, embrace that you chose a profession where your work benefits not only yourself but ultimately patients and the small frustrations become just that, small.
Finally, delegate appropriately and avoid buying into the pyramid scheme. Hierarchies exist for a reason but they should not exist to serve the people at the top. Rather, as I have learned, they should exist to appropriately align experience with responsibility and accountability. The person at the top of the pyramid should have the most accountability and responsibility in service to everyone else. But our pyramids need to be flatter and there needs to be greater overlap between different steps. One way to do this is to avoid delegating everything downhill. Sure, the people at the bottom are the least experienced and skilled but if you only give them the most menial and time consuming tasks to perform, then you should not be surprised to generate bitterness and perpetuate a culture where those who climb continue to push more work toward the bottom. The daily grind must be broken up by opportunities for the most junior people to stretch themselves. In addition, accomplishing tasks yourself flattens the pyramid by sharing burden, validating the importance of the work, and disrupting the hierarchy. No one should be above what it takes to get things done for our patients in healthcare.
Thanks for reading this and please feel free to share any comments or thoughts with me.