Letter to a Young Female Physician
Suzanne Koven, M.D.
May 18, 2017
N Engl J Med
This past June, I participated in an orientation session during which new interns were asked to write self-addressed letters expressing their hopes and anxieties. The sealed envelopes were collected and then returned 6 months later, when I’m sure the interns felt encouraged to see how far they’d come.
This exercise, in which the intern serves as both letter writer and recipient, both novice and veteran, offers a new twist on an old tradition. In 1855, James Jackson published Letters to a Young Physician Just Entering Upon Practice. More recent additions to this epistolary canon include Richard Selzer’s Letters to a Young Doctor, which appeared in 1982, and Treatment Kind and Fair: Letters to a Young Doctor, which Perri Klass published in 2007 on the occasion of her son’s entry into medical school.
When I started my internship 30 years ago, I wasn’t invited to share my hopes and anxieties in a letter — or anywhere else, for that matter. In fact, I recall no orientation at all, other than lining up to receive a stack of ill-fitting white uniforms, a tuberculin skin test, and a hasty and not particularly reassuring review of CPR.
Perhaps the memory of my own abrupt initiation explains my response as I sat at the conference table watching the new interns hunched earnestly over their letters: I was filled with longing. I wanted so much to tell them, particularly the women — more than half the group, I was pleased to note — what I wished I’d known. Even more, I yearned to tell my younger self what I wished I’d known. As the interns wrote, I composed a letter of my own.
Dear Young Female Physician:
I know you are excited and also apprehensive. These feelings are not unwarranted. The hours you will work, the body of knowledge you must master, and the responsibility you will bear for people’s lives and well-being are daunting. I’d be worried if you weren’t at least a little worried.
As a woman, you face an additional set of challenges, but you know that already. On your urology rotation in medical school, you were informed that your presence was pointless since “no self-respecting man would go to a lady urologist.”
There will be more sexism, some infuriating, some merely annoying. As a pregnant resident, I inquired about my hospital’s maternity-leave policy for house officers and was told that it was a great idea and I should draft one. Decades into practice, when I call in a prescription, some pharmacists still ask for the name of the doctor I’m calling for.
And there will be more serious and damaging discrimination as well. It pains me to tell you that in 2017, as I’m nearing the end of my career, female physicians earn on average $20,000 less than our male counterparts (even allowing for factors such as numbers of publications and hours worked)1; are still underrepresented in leadership positions, even in specialties such as OB–GYN in which we are a majority2; and are subjected to sexual harassment ranging from unwelcome “bro” humor in operating rooms and on hospital rounds to abuse so severe it causes some women to leave medicine altogether.3
But there’s also a more insidious obstacle that you’ll have to contend with — one that resides in your own head. In fact, one of the greatest hurdles you confront may be one largely of your own making. At least that has been the case for me. You see, I’ve been haunted at every step of my career by the fear that I am a fraud.
This fear, sometimes called “imposter syndrome,” is not unique to women. Your male colleagues also have many moments of insecurity, when they’re convinced that they alone among their peers are incapable of understanding the coagulation pathway, tying the perfect surgical knot, or detecting a subtle heart murmur.
A 2016 study suggested that patients of female physicians have superior outcomes.4 The publication of that finding prompted much speculation about why it might be so: perhaps women are more intuitive, more empathic, more attentive to detail, better listeners, or even kinder? I don’t know whether any of those generalizations are true, but my personal experience and observations make me sure of this: when women do possess these positive traits, we tend to discount their significance and may even consider them liabilities. We assume that anyone can be a good listener, be empathic — that these abilities are nothing special and are the least of what we have to offer our patients.
I have wasted much time and energy in my career looking for reassurance that I was not a fraud and, specifically, that I had more to offer my patients than the qualities they seemed to value most.
Early on, I believed that displaying medical knowledge — the more obscure the better — would make me worthy. That belief was a useful spur to learning, but ultimately provided only superficial comfort. During my second-year clinical skills course, an oncologist asked me to identify a rash. “Mycosis fungoides!” I blurted out, since it was one of the few rashes whose name I knew and the only one associated with cancer. My answer turned out to be correct, causing three jaws to drop at once — the oncologist’s, the patient’s, and my own — but the glow of validation lasted barely the rest of the day.
A little further on in training, I thought that competence meant knowing how to do things. I eagerly performed lumbar punctures and inserted central lines, and I applied for specialty training in gastroenterology — a field in which I had little interest — thinking that I could endoscope my way to self-confidence.
My first few years in practice, I was sure that being a good doctor meant curing people. I felt buoyed by every cleared chest x-ray, every normalized blood pressure. Unfortunately, the converse was also true: I took cancer recurrences personally. When the emergency department paged to alert me that one of my patients had arrived unexpectedly, I assumed that some error on my part must have precipitated the crisis.
Now, late in my clinical career, I understand that I’ve been neither so weak nor so powerful. Sometimes even after I studied my hardest and tried my best, people got sick and died anyway. How I wish I could spare you years of self-flagellation and transport you directly to this state of humility!
I now understand that I should have spent less time worrying about being a fraud and more time appreciating about myself some of the things my patients appreciate most about me: my large inventory of jokes, my knack for knowing when to butt in and when to shut up, my hugs. Every clinician has her or his own personal armamentarium, as therapeutic as any drug.
My dear young colleague, you are not a fraud. You are a flawed and unique human being, with excellent training and an admirable sense of purpose. Your training and sense of purpose will serve you well. Your humanity will serve your patients even better.
Suzanne Koven, M.D.
Harvard Medical School
Massachusetts General Hospital
Wednesday, May 3, 2017
The space that once gave me comfort has become a source of constant pain. I am a breast surgeon and just months ago my mother died of breast cancer. At my hospital.
Before she died, I felt blessed to be here, and to be available for her. My clinic adjacent to the medical oncology clinic, I checked our shared board and could track her through her day. I would pop in between patients to go to her appointments. If I missed one I walked 3 feet from my own workroom to the medical oncology workroom to chat with her doctor, my colleague. When clinic was over or I had a cancelation, I could walk down the hall to infusion and sit with her. I would stop at the coffee shop on my walk over to grab a cookie or snack for us to share. We would watch the Today show or some Lifetime movie while gossiping about any and everything. These were my sacred spaces. The places where I could be a part of healing, not just for my own patients but for my mom. A chance to be there for her. She has always been there for me, more than I could ever express. Even during that final admission, I could run to the cafeteria going the back way, I could tell all my family where to park, I helped navigate this monstrosity of a hospital, escorting everyone where they needed to be. Her team was my team and it gave me a feeling of purpose, and brought her a sense of comfort. For that I will always be grateful. But now I sit on the other side of this comfort. I walk on coals on the stone path from the parking lot to my office. Each of her last 4 days began with this walk. Every place is a trigger, every person I work with is both mine and hers.
The list is endless. Faculty meeting takes me up the elevator to her hospice room. I’ve now just stopped going, clinic always runs a “little late” and regrettably I’m unable to attend. The long walk down the main corridor to the OR or the wards or the ER, represent a piece of her final journey. I peek through the open door of the ER as I walk by, as if one time Ill see her there, in her pink pajamas on the night she arrived for that final admission. Each walk through the ICU I feel my walk to her room, sometimes I feel the weight of my daughters hand as we head to visit Grandma. I follow my chief on rounds and pray that today, I won’t have to see a patient in the very same space – one day I do, and I am undone. Each day I operate I lay before her, in the same operative room where she once lay, in a moment of hope. The hope I have for my own patients. Praying that their post operative story will be different than hers, longer and less filled with pain and fear.
Soon I will walk down the same corridor for a biopsy of my own, in the same room, the same hall, the same side, the same spot.
Retired from Medicine at 37: The Finances Behind Her Decision
Today’s article is a guest post from Valerie A. Jones, MD, a way early retiree who left behind a medical career at the ripe young age of 37. To learn why check out her post at OB Doctor Mom entitled Retired at 37: Breaking Up With a Career in Medicine. To learn about the finances that allowed her to do this, read on.
I am a 37-Year Old Retired OB/Gyn
Usually, when I tell people I retired from my physician career at age 37, they respond with shock. Some look at me like I am the most foolish person they have ever seen. Some with disdain (“all that medical education wasted”). Some doubt that my future will be secure without having a steady paycheck.
However, as it is only my close friends/family I discuss this with, they mostly respond with sincere happiness as they understand this is a life choice I made after much deliberation and know that it is the right decision for me and my family in pursuit of the life I want to lead. There are many factors that led to this decision and I have written about some of it in previous articles. However, this article focuses on the financial aspect.
Finances can be a tough subject for physicians. We are notorious for being poor money managers. Most of us don’t have the time or desire to commit to understanding personal finances in detail. Who has time to learn about 401(k)s, the stock market, and budgets while learning about anatomy, pharmacology, and immunology while in medical school? Or while working 80+ hours per week in residency?
Besides, we won’t be earning an attending physician paycheck for years. By the time we earn a real paycheck, we are so exhausted by the delayed gratification of our twenties that we want to splurge a little, right?
Obtaining Financial Independence
I don’t proclaim to be an expert by any stretch. However, I found the freedom that comes with financial independence to be life changing and something that should be attainable for all physicians.
I am not here to encourage everyone to retire in their thirties from medicine but to gain financial freedom. I hope you can continue practicing medicine into your sixties (if this is what you want), but to not feel trapped in a situation when encountering unsustainable job structure, illness, divorce, etc.
Of course, finances did factor into my decision to retire. I have three kids and wouldn’t stop working if I needed a steady paycheck to support them. Luckily, some decisions along the way helped me not to rely on this paycheck moving forward. here are many different paths to financial independence. Here are some steps that led me down my path to financial freedom and ability to retire early:
1. Kept medical school loans to a minimum
Yes, you do have some control over this. Most people outside of medicine are shocked to find out that medical students are essentially able to get loans for as much as they want. You can determine your own “living expenses” and someone will be ready and willing to give you this loan as medical students are typically good about ultimately paying it back (although years down the road and with a ton of interest).
I was lucky my parents paid for my undergraduate studies but medical school was on my own. I probably started my frugal mentality at this time. My husband, who I was dating at the start of medical school, would often make fun of me for my bare cabinets with canned green beans and ramen noodles as my main staples.
Of note, he also had loans from undergraduate school that we had to factor in as well. Don’t worry, we didn’t eat like that forever!
2. Started paying off loans immediately after forbearance ended
We paid the maximum amount we could, not the minimum required.
3. Lived well below our means
We continued living in my residency townhouse for a while, even after accepting an attending job.
4. Looked for job with highest earning guaranteed earnings
Many positions I was offered entailed low salary the first few years and then the potential for partnership and a jump in salary but not until 4-6 years down the road. This was downright scary to me.
What if I didn’t like the job? What if they never actually promote to partner?
The writing was on the wall for private practice in ob/gyn with soaring malpractice premiums and it seemed unsustainable to me for most of these private practices. I wasn’t willing to take the chance. I had also heard that many people may leave their first job after two years.
So, I figured why not at least get a large salary those first two years while I get a better feel for the landscape? Luckily, my job did not have a non-compete agreement, so I knew I would have options if I decided to leave (I actually stayed with my first job as I was initially very happy with my choice out of residency for about 5 years).
5. Maxed out yearly contributions to retirement vehicles
3(b) during residency, 401(k) with a new job (which also had a pension that vested after 5 years), and started a Roth IRA. I had to devote some time to learn about what all of these things are and why they are important!
My first child was born in residency, but I did not start a 529 at that time as wanted to maximize retirement account yearly contributions first. Once those were being maxed out, I started 529 for oldest child and then when subsequent children were born funded those too.
7. Lived off one income
I feel this one factor made the absolute most difference!! Certainly not all, but most of my colleagues are in a dual income household. We always lived off one income (mine) and paid off loans with the other. This always forced us to live within our means. This may be hard to accept initially as many physicians feel that the delayed gratification never ends, but trust me it’s worth it! I do have to admit, our one splurge was a nice vacation every year. “Work hard, play hard” is my motto and I probably wouldn’t have made it without those necessary times of respite to recharge. Travel is one of my passions.
8. Got Creative
For those who have a partner who does not have a career in medicine, there may be options opened for them since a physician job is very secure. You will always be able to find work as a physician and it is quite unlikely you would lose your job. In addition, health benefits are common with employed physician jobs and therefore you can take a big burden off your partner to worry about this.
This can free up some room for ingenuity with your partner if their job allows for different payment structures. Commission based jobs with a low salary and no health benefits may be unsustainable for someone supporting a family. However, if you use the idea of living off one person’s salary (your physician salary) and allow your partner to get creative it can really pay off.
Employers may jump at the opportunity for this type of pay structure which would have very little risk for them but could have huge potential upswing for the partner. We chose to take this risk. We couldn’t have done it without the stable physician salary/benefits component. It was possible my husband would make barely anything certain years or alternatively, make large sums depending on the work flow. Nothing was guaranteed to last and so any windfall that came from his work was immediately placed into debt repayment or kid’s college funds.
Financial Independence Changed Everything
When starting out of residency at my first attending job, I planned to continue to practice medicine until my sixties, cutting back on hours if needed, but I assumed my love for medicine would keep me wanting to work indefinitely. Several things changed my mindset, including financial independence.
Once I knew I didn’t “have” to work, I started to view my career a little differently. Maybe I wasn’t honest with myself previously with how the stresses of on call nights, sleep deprivation and increasing administrative workload were negatively impacting my life and health. It sometimes feels like you are on this treadmill that keeps going and you don’t have the time or energy to ever stop and think about what you are doing and if you are leading the life you envisioned for yourself.
Once financially independent, it became my choice whether or not to work. The frustrations of salaried work in ob-gyn, the negatively changing healthcare climate, and missing time with my young children was weighing on my mind. I wanted (needed) out for myself and my family.
However, I needed a push to get off that treadmill and realize what was going on. “Luckily” for me, I had a major health scare that also occurred at the same time that I reached financial independence. Decision made.
Now, the choice can be mine if I decide to ever return to medicine. I’ll never close that door completely, although I don’t see it in my future if you ask me now. There is so much out there I am still excited to explore.
[PoF: What do you think of Dr. Jones’ story? In a number of ways, her story parallels mine. Early retirement wasn’t a goal but became a rather enticing option once it appeared to be a genuine possibility.
While she has had some advantages that you may or may not have (financial help with school and a working spouse), that doesn’t mean you can’t do what she or I have done. It might take you a few years longer, but financial independence can be attained by age 45 or 50 for most physicians, and up to a decade earlier for others.
I want to thank Dr. Valerie A. Jones for responding to my request for this post and for detailing how she was able to put herself in this enviable position. Her original article explaining why she made the choice got my attention, but I still had questions. She did a great job answering them, don’t you think?]
I asked the simple question, what is the purpose of failure? Why do we have to fail? How come our instinct does not kick in innately to prevent us from undertaking these doomed activities anyway? Well, I asked this question years ago, and of course, I had no answer for over a decade. A few years later I ran into Dr. Myles Munroe’s quote: “When purpose is unknown, abuse is inevitable”. Well that’s great I thought, now all I had to do was find the purpose for failure.
Well in order to do so, I had to start by defining failure. Merriam-Webster defines failure as “a lack of success”. They, in turn, define success as “the achievement of an aim or purpose”. A glaring omission in both those definitions in the lack of the concept of temporality. Unless you are dead, you cannot declare yourself a failure or a success.
SUCCESS IS NOT A DESTINATION, WELL NEITHER IS FAILURE
Success and failure are not destinations rather they are ongoing themes in life suggesting that are more likely a mindset or a world view. These are not static concepts but they are dynamic concepts which are ever changing and need to be constantly put in context. You can fail in business but have a wonderful marriage. Would you in that instance consider yourself a failure or a success?
Well, the answer is neither, life is not that simple. Also, only time will tell. Let me give you an example Oprah ended her show on a high, everyone adored her and gave her a wonderful going away party. A few months later everyone was calling her network a failure and suggesting she quit.
What about Bernie Madoff? He was extremely wealthy and well respected in his community for most of his life but we all know how his things evolved. He is currently incarcerated and one of his sons committed suicide in the aftermath of the scandal. Should he be considered a success or a failure? Well again, only time will tell although he likely needs a miracle to turn things around at this point.
YOUR LEVEL OF MATURITY MUST MATCH YOUR LEVEL OF SUCCESS
Consider this, even if you achieve “success” at a given time point in your life, failure is still nipping at your heels. Have you ever heard of the saying “more money more problems?” (RIP Biggie…). Well, the problem is the more you have, the more you have to lose. One thing I know for sure is, If your level of maturity does not match your level of success, there are 3 possible outcomes; you will either lose the success, lose yourself or much worse lose your life.
TIME IS YOUR FRIEND
The one thing that everyone in this world has an equal measure of is time. We all get 24 hours in a day and once we become adults we all can choose how to spend our time. My advice to you is to put everything you experience within the context of eternity and suddenly you realize that things are just not that serious. If eternity is too long for you, consider everything you experience within the context of the average life expectancy which is anywhere from 60-80 years depending on where you live. 365 days x 80 = 29200 days. That is a really long time.
I personally refuse to allow the decision I make in one day affect or determine my worldview it just doesn’t make any sense. I personally have a running counter on my phone of the number of days I have been married. And whenever my husband and I have a bad day, I literally just pull out the counter and consider the number of good days I have had with him. At the time I am writing this article, I have been married for exactly 3405 days and I can say I have honestly had less than 300 horrible days. Now, does that mean I have a perfect marriage? Absolutely not! Marriage is hard and anyone who knows me can attest to the fact that I am not easy to deal with at all. Just imagine being married to a know-it-all ENTJ, yikes!
From a pure numbers point of view, you cannot let a bad day, week, month, year or even a decade sum up your life. A bad decade is still only 1/8 of your life and there are a lot more days left to consider. That will be like a making a business decision or a legal decision with only 1/8th of the facts.
THE PURPOSE FOR FAILURE
Now that I have debunked the concept of a failed life. Let me focus on sharing the purpose of failure. What you perceive as failure is really just an opportunity to re-strategize. And if you do not understand the purpose for this perceived “failure” you will abuse it.
Do not allow yourself to be ransacked by your emotions or feelings. One thing I have learned about feelings is the fact that they always change and they change without giving you any advance notice. You just wake up one-morning thinking and feeling different.
THE TRUTH OF THE MATTER
I wrote the statement below over a decade ago and I still stand by it.
“I am always floored by how many people I meet who think successful people never fail. Truth be told, most successful people I know fail more times than they are successful. Personally, I have failed at most things I attempted. However, I have learned that success is not a destination rather it is a mindset, a way of life, a certain perspective, a prism through which I view life. When other people see setbacks I see an opportunity to re-strategize. I firmly believe that failing is not designed to stop you, it is designed to give you an opportunity to re-strategize. So please stop misusing and misinterpreting your failures and start re-strategizing.”