A Matter of Time
Complex priorities, generational shifts, and evolving expectations factor into young physicians’ pursuit of balance between professional & personal life
M4 Jackson Lever places an extremely high value on spending time with his wife, Catherine, and daughter, Elizabeth. They are expecting their second child, a baby boy, in March.
While Jackson Lever, Class of 2009, was still considering what specialty to pursue after he graduates from The Medical College of Wisconsin, he sat down with a general surgeon for insight into a career in the OR. Lever asked him to describe his family, and the surgeon spoke glowingly about his children. When Lever asked, however, if the doctor had been there for their birthdays, their games, their speeches, the answer reverberated for the medical student. “No.”
“Just hearing that really piqued my interest in finding a field that would be conducive for family, where I could support my family, not only financially but also in terms of time, where I can be a little more flexible,” said Lever, whose concern for family has as many immediate implications as it does future ones. He is married with a 20-month-old daughter, and his wife is expecting their second child. “I have wanted to be there for every event and every going and coming of my family, and being able to have manageable work hours is huge.”
His focus on family was influential in his decision to choose a career in ophthalmology, a specialty with fairly predictable hours. Lever is among a growing number of younger physicians and future physicians who place controllable schedules and time for family and personal activities high on their list of priorities. Today’s generation believes strongly in finding a work-life balance, said Kenneth B. Simons, MD, Senior Associate Dean for Academic Affairs and Professor of Ophthalmology and of Pathology at the Medical College.
“They want to attend their children’s piano recitals and soccer games,” Dr. Simons said. “Medicine is a very demanding mistress, and it requires sacrifices. Some members of this generation are unwilling to make some of these sacrifices. It’s not a bad thing – it’s for a good reason, but it may affect the availability of care.”
Although all medical specialties carry unique sets of challenges, be they intellectual or schedule-related, there are a number of fields that are generally considered to have more manageable hours. They include anesthesiology, dermatology, emergency medicine, ophthalmology, pathology, radiology, radiation oncology and plastic surgery. Data from the National Resident Matching Program indicates a rise in popularity for these specialties and a high level of competition.
Nearly 33 percent of the Medical College’s Class of 2008 entered one of these fields. Less than 10 years ago, in 1999, only 24 percent of graduating Medical College of Wisconsin students was matched to one of these specialties.
Nationally, the 2008 Match numbers reveal the competitive nature of these desirable practice areas. Among specialties with at least 10 positions in the Match, dermatology, plastic surgery and radiation oncology all had 100 percent fill rates, meaning every residency position was occupied. The only other specialty where this was true was primary pediatrics. Additional high fill rates included 97.4 percent for anesthesiology, 97.9 percent for emergency medicine and 98.1 percent for radiology.
Certainly, growth is not exclusive to these fields of medicine. At the Medical College, internal medicine, for example, was up more than 2 percent in 10 years and is the most pursued specialty. Moreover, it may be glib to presume work hours are the primary factors in determining a career path, but consideration of schedule appears to be more common than in the past.
William Polzin, MD ’83
William Polzin, MD ’83, doesn’t think this generation places a heightened level of significance on personal time than those past, but in his opinion, most new physicians don’t want competing interests in their lives. Dr. Polzin is Associate Director of the Fetal Care Center of Cincinnati, Director of Maternal-Fetal Medicine at Good Samaritan Hospital and Vice-Director of its Obstetrics and Gynecology Residency Training Program.
“I did everything I wanted to do with hobbies, family, church, volunteering, travel, etc.,” Dr. Polzin said. “I just did several things at once. This leads to conflicts and disappointments, but that is part of life and part of growing up and maturing. I believe compartmentalizing arrests normal adult maturation. I believe this is why so many of our young physicians are chronically disappointed with their profession and schedule.”
M4 Marisa Chapman enjoys a hiking trip in Colorado with boyfriend Kevin Dunphy. She believes it is important to have time for personal activities.
Having realistic expectations for your time commitments is an important component for success, and Marisa Chapman, Class of 2009, is hopeful her hard work now will pay dividends later.
“There is an expectation that free time during residency training will be limited, especially as an intern,” she said. “While it is very important to me to have manageable work hours, I feel somewhat resigned to the fact that residency will be extremely time-consuming.”
Before attending medical school, Chapman worked a typical 40-hour work week for a Fortune 500 company. As an M4, she regularly puts in significantly more hours, but they are much more satisfying and meaningful to her. She says she has noticed an overall emphasis being placed on work-life balance in most fields of medicine, not just the so-called “lifestyle specialties.”
“My personal priorities factor into my specialty preferences to some degree, but I think I made the bigger sacrifice when I chose to attend medical school,” she said. “I went into this field knowing I would be giving up a lot of things – time with friends and family, a disposable income, starting a family before age 35, to name a few. I am very happy with my decision to become a physician, but I know that certain relationships and hobbies have often been peripheral over the last few years. My hope is that once I complete my training, I will be able to define a career path that allows for a good balance between work and home life.”
Kenneth Theriot, MD ’07, celebrates his residency match with his wife, Monica, and their first son on Match Day 2007. Dr. Theriot has since completed a transitional year and is currently an anesthesiology resident in St. Louis.
Kenneth Theriot, MD ’07, regards his chosen field of anesthesiology in the “upper middle class” in terms of lifestyle compared to other specialties. It doesn’t have the free time that some present but isn’t as demanding as others, and that came into play when he decided on his career, especially since he was married with children. But doctors have to find a good career match, not just a convenient one.
“As a medical student with a family, I looked a little closer at specialties that afforded more free time, however, in my opinion, the first and foremost factor that should be looked at when choosing a specialty should be which specialty is most enjoyable,” said Dr. Theriot, who is currently a resident in the Washington University Hospitals Consortium program in St. Louis. “You’ve got to like what you do. If internal medicine, family practice or even neurosurgery had done it for me instead of anesthesiology, that’s what I would be doing today.”
For the emerging generation of physicians, the search for a work-life balance begins in earnest during medical school. Time management has always been a critical part of successfully navigating medical school, but more and more students are adamant that their education and careers do not come at the expense of everything else they value. Much of this may be due to the demographics of today’s students, Dr. Simons said. When he graduated from medical school 28 years ago, there were 125 people in his class. Only two had children. Now, many Medical College of Wisconsin students are married and have children, he said.
Dr. Theriot had already been married for two years when he began medical school. He and his wife had their first child at the beginning of his M3 year. During his basic science years it had been much easier to spend time with his wife and socialize, but the addition of a child as his clinical years began made for much less flexibility.
Kenneth Theriot, MD ’07, is a husband, a father and an anesthesiology resident. Like most physicians and students of his generation, he seeks balance between his professional and personal life, so he can spend adequate time with his family – his wife, Monica, and their two sons.
The Theriots compensated by making sure they kept certain things routine, such as having dinner together at every opportunity and going to church every Sunday. Dr. Theriot’s internship consisted of a transitional year that gave him additional free time, which became especially important as his second child was born during that period. Now at a work-intensive academic institution for residency, he has more time pressure, but balance remains a priority.
“Demand from work and study have definitely increased. That being said, I still go to church every Sunday. I also volunteer with the Boy Scouts,” he said. “I think it’s important to have things to do besides just work and family obligations. The more you do, the better you get at managing your time efficiently.”
Although still in medical school, Lever can relate, especially as a parent.
“I think it’s easy to become entrenched in the dogma of medical school,” Lever said. “You forget how life can be funny and really have to avoid becoming a robot, and I think you do that by trying to protect time and do things you love to do. For me, it is to go running around Wauwatosa or volunteering with the Scouts.”
Chapman said it helps to make plans with family and friends in advance since it can be easy to choose sleep over socializing. The key is to maximize whatever time off you may have.
“It has taken me the better part of medical school to figure out a balance between school and free time, although I think the balance often tips in favor of school,” she said.
While myriad factors contribute to the experiences and expectations of new MDs, one draws a distinct line between past and current generations – the 80-hour resident work week. Physicians who graduated before the restriction was put in place likely had a much different concept of how much balance could be attained between work and personal lives. Current and future residents receive training in an environment that is more conducive to balance, though the topic still is somewhat contentious.
“[The shortened work week] clouds reality,” Dr. Polzin said. “It just doesn’t work that way in professional life, as a physician. Everyone in education has bought into the idea that it is better. The residents miss many opportunities, including how to work safely when tired.”
Edward Benzel, MD ’75, GME ’80
The decreased duty hour has caused instructors to focus more on the resident as a learner, which is good, but the changes also somewhat threaten the operating and outpatient experience, which is not good, said Edward Benzel, MD ’75, GME ’80
, Chairman of Neurosurgery, Director of the Center for Spine Health, Director of the Neurological Surgery Residency Program and Co-director of the Spine Surgery Fellowship Program at the Cleveland Clinic. He has observed that the expectations of residents have changed along with the hours.
“The reality is, however, that the work often still needs to be done,” he said. “This has caused good and bad things. On the positive side, the residents have been forced to become more efficient. On the negative side, some things don’t get done.”
Dr. Benzel sees the benefits of shorter work hours for residents, but also recognizes there could be a contradiction between having a desirable schedule and the very nature of the medical profession.
“All in all, the rule changes have probably been positive in my opinion,” he said. “The manner in which they are employed, however, may not be. Strict adherence to duty hour schedules, when indeed, the practice of medicine does not usually follow a schedule is a fault of the new system.”
In addition to the altered structure of residency training, there has been a commonly held belief that physicians born in the Boomer generation (1946-64) work longer hours and are more apt to define their identity through their profession than their Generation X colleagues (born 1965-79). Research conducted by Erin P. Fraher, PhD(cand), Director of NC Health Professions Data System, Cecil G. Sheps Center for Health Services Research at University of North Carolina at Chapel Hill, recently explored that concept.
The UNC team found that the average hours worked per week in patient care declined for the North Carolina physician workforce from 46.3 hours in 1980 to 42.1 hours in 2006. The researchers determined that this downward trend is attributable to a combination of age, gender and cohort effects. The impact of increasing numbers of women entering medicine is regularly noted in health policy discussions as previous research has shown that women are more likely to work shorter hours than male colleagues and have more stop-outs in their careers. Fraher’s data uncovered, however, that the difference in hours worked between male and female physicians is decreasing in more recent cohorts.
The statistics appear to support the notion that generational variations influence medical practice and have resulted, in part, in a reduction in work load.
Throughout his decades in medicine, Frank Van Lieshout, MD ’55, has seen the evolution of expectations and schedules. His life as a physician stands in contrast to what most new doctors experience today. He practiced general medicine in Little Chute, Wis., both in a small group setting and as a solo practitioner.
Dr. Van Lieshout worked nearly every weekend. He never worked by appointment – he saw whoever came in that day. He personally called patients with their lab results so he could answer questions. His hospital visits often led to overnight shifts at his prerogative. He also made about 5,000 house calls during his career.
“I made house calls all the time,” he said. “It was just part of my routine. I never thought of them as cost-effective, but they’re patient effective.”
His obligations were compounded by the lack of an emergency room at the time he practiced in that area. Community physicians were assigned to take emergency calls as they occurred. Dr. Van Lieshout also had quite a large OB practice, which added to his hectic life. “I would say I slept through the night one out of seven nights,” he said.
Separation between his personal life and his professional life was virtually non-existent. When he would take a fishing trip, patients would call his neighbor to see if he was home yet. When he and his wife would go out to dinner, he would be approached by patients either offering him a drink or asking him a question. He often had to dine in other towns. His workload certainly affected his time with his family. Though his wife understood his limitations, it was still very difficult, Dr. Van Lieshout said.
“My wife primarily raised our family,” he said. “I would try to go to some of the events the children were in, but it was very much hit and miss. That was one thing I had somewhat of a guilt feeling for – that I wasn’t able to do that when they had some achievement.”
As new physicians joined his group later in his career, Dr. Van Lieshout began to see how times were changing. Most could not believe the hours he put in or the number of patients he saw in a day and knew intimately. He always saw it as his obligation.
“If someone called me after hours and said their daughter was sick, I’d say ‘bring her in.’ Younger physicians will usually say, ‘go to the ER,’” he said. “I was available, and the availability factor was a big part of my practice. I figured that’s what I was there for in family practice. I would say ‘you can’t be in family practice and not answer your phone at night.’ Though, if I came into medicine now, I’d probably be doing it the same way (as the new generation) because I wouldn’t know the difference.”
Society may have changed, and the practice of medicine along with it, but one constant is that no semblance of work-life balance will occur without a commitment to making it happen. This may be most pronounced in families with two physicians in the household.
Neelesh A. Tipnis, MD ’97, and Sajani M. Tipnis, MD ’97 (shown with their sons Sacheen and Sameer), are both Medical College of Wisconsin faculty members.
Neelesh A. Tipnis, MD ’97, and Sajani M. Tipnis, MD ’97, met in medical school and were married during their residency training. Both are now Assistant Professors of Pediatrics at The Medical College of Wisconsin – Neelesh in gastroenterology and nutrition and Sajani in neonatology. They have two boys, 7 and 2 years old.
“I think we’ve been able to establish a very good balance,” Dr. Sajani Tipnis said. “We have a very active social life, are active with our kids’ schools and volunteer when we can. We’ve chosen jobs that allow us to balance our specialties and family.”
As a neonatologist, she is on call more than 100 nights of the year. This gives her more freedom during the day, and her practice partners at Children’s Hospital of Wisconsin, many of whom also have children, are willing to cover for each other so they can attend school parties or soccer practices. Who you practice with and your work environment can sometimes determine your flexibility just as much as what specialty you choose, she said.
“We’ve always made it work, even when we both had busy schedules – we had our first son when we were both fellows,” she said. “We always found a way.”
Although specialty choice, workforce shifts and practice model changes all factor into the prospect of establishing a balanced life, nothing is effortless. The onus is still on the individual.
“I don’t know what challenges there will be in the future,” Dr. Theriot said, “but once you have a specialty chosen, it’s all a matter of putting the most important things first, not shying away from a lot of hard work, whether at home or in the hospital, and taking time out to smell the roses every now and then.”