"If I wanted to get married and have a family, being an oncologist was going to be impossible."
K. O. is associate medical director at one of the largest HMOs in the Midwest. She is forty-two, married and has two children.
When I was graduated from high school, I got my associate degree in nursing, got licensed, got a job and left home. At first I worked on a general medical/surgical unit, then I moved to Washington, D.C. and became an oncology nurse. I did oncology nursing for almost three years, working with a group practice of internists in Washington. Then I became the oncology assistant, doing all the chemotherapy patients, and working very closely with one physician.
When you're working in one specialized area, you get good at knowing at what blood count or platelet count the patients get chemotherapy, so I more or less started managing the patients. At times I felt I knew the patients better than he did. I was the one who went in when they were having problems, with either medication or coping with their disease. We had a lot of young women with breast cancer and it was easy for me to relate to them.
I got very interested in the whole process of delivery of health care and the lack of psychosocial support for these women. Many of them were going through divorce, husbands were leaving them, and they were depressed and facing death and major issues in life. Because I felt they weren't getting what they needed from the medical system, I started a support group for them. I got a psychologist to work with me and we met in the practice's office once a week.
Eventually I got to the point where I thought: I could do this. I know how to handle these patients, and some of these doctors really don't. They may have had the medical knowledge--I didn't appreciate how much energy that took at the time--but I felt a sense of my competence to handle complex medical problems in a more dynamic way than the patients were currently getting. That was when I started seriously thinking about medical school.
Once I had made up my mind what I wanted to do, school was not a problem. Previously I hadn't had the commitment. I had done well in nursing school, but I basically cruised through. So I thought, If I can get all A's in basic sciences, I can take my MCATs.
Meanwhile I had gone on a vacation to San Francisco and had fallen in love with the city, with the Golden Gate Bridge. I thought, I'm a nurse, I can get a job anywhere. That's what my mother had told me and that's why I went to nursing school. So after I finished a summer of organic chemistry and some biostatistics I moved to San Francisco. I got a job as a nurse and continued school at UC Berkeley.
People told me nurses have a harder time getting accepted to medical school because they have such a non-traditional background. I took classes that fit with my work schedule--at the University of San Francisco and at UC Berkeley, plus there were my classes back in Washington, D.C., and I had taken some classes in the Midwest. So I had a very unusual transcript. My MCATs in basic sciences, although they were reasonably good, were not what people who take four years of sciences straight through in college get. I got an offer from Stanford and UC San Francisco, and George Washington and Georgetown because I had connections in Washington, D.C.
My choice, UC San Francisco, was a wonderful school. I got state residency, which was incredible, considering the tuition people pay at private schools. I ended up staying there for eight years, through medical school, internal medicine residency and then a year on the faculty. A lot of people in my class had a degree in biochemistry or some basic science, and they could test out of certain classes. So each quarter they might have two or three classes and I would have four, which were all brand new to me.
The first two quarters of medical school I thought I was going to flunk out. Of course I didn't come close, but you had this overwhelming fear: I'm never going to be able to do this. At UC, the level of detail they expected you to memorize was quite high. And even though you knew from nursing that it was unimportant and that you'd never use it, if you didn't memorize you wouldn't pass the exam.
What kept me going was that in the clinical arena everybody else didn't have any idea what they were doing. They were very uncomfortable with sick patients, which was nothing for me. I was completely at home. My medical school emphasized clinical work. From the first day we put on our white coats and went out to a doctor's office, a group of four of us. Everybody was amazed that I could go anywhere, talk to patients, talk to doctors, talk to the office staff.
The down side of being a nurse was that you tended to act like a nurse. I was always helping the patient--wheeling people around and getting people into the bathroom--when everybody else was off studying or preparing a case presentation. At times there were other things to be responsible for. I was always much later leaving the hospital than my colleagues. Patients frequently thought I was a nurse. It was hard to change roles.
At some point you go through a transition. If you don't, you're going to be held accountable for not getting that work done. I don't think I stopped being a nurse; I transferred into a new role until well after medical school, and probably until after I finished my residency.
I always thought I would get along with nurses better because I had been a nurse. Though that's true with some nurses, there are a lot of nurses who resent you because you're a woman physician. That surprised me. My male colleagues could go up and say, "I need an EKG" and the nurses would do it. If I would say, "Could you order something for me?" they would say, "Why don't you do it?" It was hard getting used to their not treating me the same as my male colleagues. Sometimes they'd actually treat me poorly, which was a real shock. I learned not to take it personally.
I felt much older than a lot of my classmates because almost all the core peer group had four years of college, four years of medical school and on to internship and residency. They'd never done anything. I had done a little traveling, I had lived in different places in the country alone and gone off by myself and gotten an apartment and met new people. I'd taken care of all these dying patients, where I'd talked with them about what's important in life and really basic issues that these medical students hadn't even thought about, they were so sheltered and lacking in basic life.
I wouldn't want them at my bedside if I were really sick, because they didn't have a clue about taking care of a sick person. They'd go in to see a wise eighty-year-old woman and they'd talk to her like she was a two-year-old. If a patient died, they'd panic. Having been a nurse, it was a different experience for me.
My internship was the worst year of my life, no question. UC San Francisco was a very competitive residency. I knew I was a good medical student, and my attitude was that I should go to the best residency I could get accepted in. I was delighted to stay at UC. I loved San Francisco. I had a large group of friends there by that point.
But it was grueling. We were on call every third night, and worked seven days a week for an entire year. We took care of twelve to fifteen incredibly sick patients at a time. I'm pretty high on the perfectionist scale, and I never had a sense that I'd done everything the way I'd like to. It was overwhelming.
I tried to resign. I walked in one day and said, "I quit. Here's my beeper. I can't stand it." They wouldn't let me. They said, "No, no, you can't do this." I said, "Yes, I can." There was way too much work for one human being to do. There was loads of responsibility that you weren't used to. I was always tired. I always had that feeling you get the day after you come down with the flu, of wishing you could crawl into a bed somewhere and sleep for a week.
My second and third years I started to enjoy my patients and my colleagues again. I liked my work, I was learning a lot, I was more confident and I wasn't tired all the time. I wasn't grumpy and irritable and short-tempered all the time. I felt I was the kind of doctor I'd always wanted to be.
It was amazing how little I would spend. I wouldn't eat out. I'd buy clothes that were comfortable, that I could wear all the time. I'd get a couple pairs of corduroys and a couple turtle necks and a pair of loafers. I got into a totally non-consumer-oriented lifestyle. I rode my bike a lot. In San Francisco there are tons of things to do that are cheap, so when you did have time you could walk on the beach or go to the Presidio. I like to do outdoors things--I'd go to Golden Gate Park and run.
Everyone was broke. It was nice to get a paycheck when I first started my residency, but my friends and I felt our lifestyle never changed that much. When you had more money, you bought a new clock radio, but you had a clock radio before. You'd get a little bit nicer car, but you had a car before. Things gradually changed but you weren't any happier than you used to be. You just spend as much money as you have. For me the difficulty was the commitment of time. That was always the stress, not the money.
When I went back to medical school, I was going to be the great oncologist who would sit at everybody's bedside. I went to some of Kubler-Ross's workshops when I was a nurse and I was impressed with her. When I went through residency I realized what the reality was: if I wanted to ever get married and have a family, being an oncologist was going to be impossible.
If I was taking care of acute leukemia patients, they were going to need early morning rounds and late night rounds after I was done with my practice. As a resident I saw the realities the oncologists I worked with were living. In fact they invited me to go into the oncology program at UC because they knew I had such a strong love for it and for the patients. But in my heart of hearts I knew I was not going to be able to do that. It would be my whole life.
I reached a point in my early thirties when I realized I wanted to have kids and that I had put that on the back burner for a long time. There it was staring me in the face: I couldn't be an oncologist and have the kind of family I wanted to have. After I did internal medicine for three years, I turned down a fellowship in oncology and went into general medicine. I took a position on the UC faculty and then decided to get married. My husband and I moved back to the Midwest. We've been back here for eight and a half years, and have two kids.
My husband was from the Midwest. He had already made the decision to come back to the Midwest before I met him and had bought a piece of property back here. About two and a half years after I met him we moved back together and got married. I had no intention of coming back to the Midwest. If I hadn't met him I'm sure I would still be at UC, or at least practicing in San Francisco, because I love the area and I was very happy there. I grew up in the Midwest, but left at twenty when I graduated from nursing school.
When I came back I took a staff position in a very large group practice. Each of the medical divisions has six or seven physicians, so the call schedule was every sixth night or every sixth week-end. It was very reasonable call compared to many private practices where you're on call every second or third night. When I interviewed I met several women who took one or two days off a week. They kept a smaller practice than some of their colleagues during the time they had young kids at home. That was appealing, to work where that was acceptable, where culturally that had already happened and I didn't have to be a the first one to do it.
I got married, started my job and got pregnant all within two months. I had my daughter within the first year of taking that position. They allowed you a six week maternity leave and your vacation, which was four weeks, all together, and then if you wanted to take any additional time you could do that without pay. So I took off ten weeks with my daughter and went back to work 80% of full-time, which meant I had Wednesdays off.
For the first two and a half years my father-in-law took care of my daughter. Then I had my son, took another ten weeks off, went back to work, and kept taking off Wednesdays. I still had to work every fifth or sixth weekend but my husband would take care of the kids on the week-ends. About six months after my son was born, it became clear that my father-in-law was having a hard time keeping up with two. My daughter was a complete jewel but my son was very active and cranky. You never knew what he wanted.
After much discussion my husband decided on his own that he was going to stay home with the kids, that he didn't want to hire someone. His mother had been ill when he was young and he had spent a lot of time with neighbors and aunts because she had been in and out of the hospital with a back condition. He said, "I don't want that, and I don't want you to give up your job. You can't easily take off for a couple of years."
He's a plumber, and he said, "No one's going to miss me for a couple of years." So we decided to try it, and if he went crazy, or didn't like it, we would start looking for someone. He still works one day a week outside the home, and he has a very active hobby that takes him out of town six or eight weekends a year. That seems to keep him more or less sane with two little kids. My son is only in school two and a half hours a day. My husband takes the kids to school and picks them up and makes dinner most nights and more or less keeps things running on the home front. And I work full-time now.
He's currently working in the import-export business one day a week. He makes a fair number of phone calls and does some computer work at home. He's planning to gradually increase his work. With my income we're not going to starve. It's important for one of us to be with the kids and give them a secure period in their young years.
My husband is one of these people who've had a hundred careers. He's a musician. He traveled all over the country for a couple of years. He's been a plumber. He was in advertising. Now he's in import-export. He's going to school part-time taking history courses. He's got plenty of time to do other things, and it's only going to be for another few years that he'll be in a part-time arrangement.
He likes the flexibility of working out of the house. Probably he would like to do something where he's at least part-time at home, so the kids can do the things they want to after school, and we wouldn't have to rely on babysitters and latchkeys. My daughter is seven and my son is almost five.
They come to each of us for different things. If somebody's sick, it's always mom. If they need their hair shampooed or their nails trimmed, it's me. If they want to build a fort, they go to their dad. If they want to do artsy-craftsy things, they go to their dad. He's much better at that than I am, and he's more patient. He's a real creative type. He's the musician, and they get out the guitar. They're all taking French lessons together. He's trying to learn French to get a history degree. Lately they're doing these French tapes and walking around the house speaking French.
I'm more the disciplinarian, the one who says, "Okay, it's nine o'clock," or "Okay, you've got to put your toys away." We have different roles but they're complementary. And Grandpa spoils them. He comes over and loves them and hugs them and thinks they're the two greatest kids on the planet. I've got the best of all worlds. I get to go out and do what I'm good at, and then come home and they're well cared for, they're thriving. They do things with my husband I would never do. If I was home I'd be cleaning the house, getting things organized, but he sits on the floor with the Lincoln logs and builds a fort with them.
My husband frequently thanks me. It's like the childhood he never had, being able to be home and be with his kids. He'll be very happy, in one sense, to get back in the external world more, but he sees this as a temporary situation and why rush it? He's not a Type A person; he's into enjoying the moment.
Gradually you go from being who you were, to being a doctor--which is a strange role--to being a doctor who's you. For a while I thought you had to act real professional with your patients, never touching them except to do a physical exam. I started thinking, This is the person I am and patients will self-select. If they don't feel comfortable with you, they'll go see another doctor.
So I began to incorporate my basic personality with my practice style. If a patient was upset I would put my hand on their shoulder, or if they were crying I would give them some Kleenex and move next to them, so that maybe my knees were touching them. I'd get next to somebody and have contact with them, specially when I'm talking to them about things that are real scary. People open up more if you're physically in contact. And you can sense when someone feels uncomfortable. When they are, you try to give them more verbal feedback but don't get close to them.
One thing in medicine was a shock to me, coming from San Francisco back to the Midwest. San Francisco was much more egalitarian, at least in terms of being a woman medical student or a woman physician. All of us were abused as interns and residents, so I didn't feel singled out because I was female.
But as I moved to the Midwest and as I had more time in the medical system, I began to see a lot of inequality in terms of women being promoted or not promoted in the department, and women residents being singled out for awards versus the men. It became clear to me as I stepped back and as I got older that positions of power or authority or awards or recognitions were being given to men and not women. The Midwest is much more conservative than San Francisco.
But I think it's true nationally. There's one woman chairman of an academic department of medicine in the United States right now. Even once you've proven yourself, you're not given the promotions and the positions that you deserve. As things begin to stratify, I've seen time after time men who had two or three years of experience getting promoted and women who'd been there seven or eight and were excellent people, being totally overlooked.The men say, "She's got two kids" or "She's busy," like the woman wouldn't have time for these positions, being the head of this committee or the president of an organization. It's just excuses. No one asked the women if they were interested. As women physicians mature in various organizations, there's a real discrepancy in how they're being recognized.
I've made a lot of noise about that over the years, and I've talked about it to people in the organization I'm in, because I'm appalled that it's continued so long. I think it's going to continue for quite a while. I do a lot of administrative work and I was in charge of the residency program, and very often I was the only woman in the room. Clearly people were uncomfortable at times with me being there. They would have liked to make old boy jokes and derogatory comments about women residents who wear the cute outfits, without a woman being present. When they realize you're in the room they get embarrassed. They realize they said something they shouldn't have said while you were there. They get more and more sensitized, and then they get very defensive about how they're behaving.
For a long time I thought, Golly, I'm a woman and I'm a physician, and I came up through the ranks. I'm so lucky. Who am I to complain? As you get older you think, Well, screw them. You see a couple men get recognized for what you think is pretty minimal effort, and you can't miss the discrepancy. I still believe that if you work hard and you're talented, you eventually will get recognized, and you probably can get wherever you want to go, but you have to work harder than other people to do it.
There's a fine line between being competent and being seen as aggressive. If a man does something, everyone says, "Oh, he's a real go-getter; he gets things done." If a woman does it, they say, "Oh, she's so aggressive. She's always stepping on everyone's toes." People frequently say to me, "You're very outspoken. You're really direct." If you want me to get the job done, then I'm going to have to be reasonably direct, because that's how I see being most effective. If you don't do it, they'll complain that you're not getting your job done, and if you do it they complain you're being a little bit pushy.
Every woman I talk to who's in any position of administrative authority recognizes that the best thing is at least to get the job done, accept the fact that some people are going to think you were a bit more assertive than they thought was appropriate for a woman. You try hard not to offend anybody and still get the job done, but there's an incredible double standard still. Sometimes the women are harder on you than the men.
I've found that most of the time people are very clear about end of life issues and what they want or don't want. Doctors don't even discuss it with them. They decide what they think is right for that person, and they think the patient doesn't want to talk about it. They think the patient is going to get very upset. In fact the patient is not going to get upset, the doctor is going to get upset. Studies have proven that.
I talk to almost all my patients about end of life issues while they're well, while they're in the office, while we have a chance to talk about it. They're very grateful that I bring it up. It gives me a chance to understand their values and how they see life and how they see death. We start talking about how they were raised and all kinds of wonderful things come up that are very interesting to talk about and ways to get to know your patients well, and nobody gets upset. I've never had a patient say, "Oh, I really don't want to talk about this. Why did you bring this up?"
We do way too much, because we haven't asked ahead of time. We haven't helped people clarify their own issues. You say, "Well, let's talk about it a little and then why don't we talk about it another time. Maybe you want to talk about it with your family or your friends or your minister. If you don't decide, somebody else is going to decide for you, and they might decide something you wouldn't want. I can document that we talked about it and that this is what you wanted, whether it be a living will or a documented conversation. We need to do something if you want to have control."
Now some people don't. Some people say, "I don't really care. It's all in God's hands. I'll live with whatever happens." That's fine. But other people have very clear ideas about what they want to do. It's a decision that has to be made prospectively and not wait until you get hit by a truck and everyone says, "I don't know what she would have wanted. I'm not going to pull the plug."
When you talk to people, just any old person off the street, it's amazing how they come up with these very sophisticated views of the world, with very clear values. My patients have taught me more about spiritual belief than I ever knew. People tell me all about their church and what they believe in and how they've witnessed family death. They're very articulate. Some of my patients don't have an eighth grade education but are very clear about what they want.
I've told everybody in my family who will listen what I want, and documented it in writing, because I know my husband would keep me alive forever, and I don't want that. I said, "Don't you dare stuff me and put me on the mantle." He said, "Oh, you're too quick to pull the plug. The first day you'd ant me to pull the plug." I said, "No, but there is a time where it becomes clear that the person has a one out of ten thousand chance of turning around and that's when you don't keep them in the ICU for another two months."
We do way too much. We cause an incredible burden of suffering for families by prolonging things, whether it's in pediatric intensive care or adult intensive care. We'll keep babies alive who are going to go on for months and then die. So I have strong feelings and I'm sure a lot of it comes from my oncology background.
A lot of doctors in their fifties and sixties aren't happy because medicine has changed a lot. They went into medicine almost as entrepreneurs, private practice folks who wanted to be independent. Now there are all these regulations, and people telling them what to do. I know people who only stay because they have five more years until they retire. Or they still have some satisfaction in areas of medicine but say they would never do it again.
I'm not offended by a lot of the change that's being proposed, that's driving some people out of medicine. Things are changing for the good of the whole community. Some people are going to lose. I personally am appalled by the physicians who are making half a million dollars a year and working twenty hours a week. They had their day and good riddance.
I actually see a fair number of young people, too, who don't belong in medicine. As the residency director for eight years, I saw people who had gone to medical school because they were good in science and their folks thought it would be great if they were a doctor. And here they are, looking at sick people every day, and it's not what they thought it would be. They really wanted to be scientists.
I try to get those people to go back to the lab, to do some basic science research, or steer them into areas where they're not going to harm any patients. Because you can see they're not going to be very compassionate physicians. They don't belong on the front lines. They misinterpreted what the lifestyle was going to be. Over the years I have actually counseled quite a few people to move into another type of medical environment.
For me it's a perfect match for my skills. I would never hesitate to do it again. There are days when you hate it, but I've enjoyed every environment I've been in and it's given me opportunities I never would have had in other areas. It's wonderful to be in a position where you can do things well, where you have an aptitude for them.
I don't have a lot of creative talents and I'm not a wonderful musician or artist, things other people might be good at. I feel how lucky for me to have landed where I am good at what I do. I'd do everything over except the intern year, but I'd even do the intern year again if it was the only way I could finish.
The only thing I really don't like in medicine right now is the malpractice. Malpractice is an incredible burden for physicians. It's out of control. There are some physicians who have had several lawsuits against them, and these are good people who are hard working, who are honest, but they had horrible lawsuits here people clearly were looking for money. It's a devastating personal event.
Malpractice I would like to see change because it's going to drive good, honest, caring people out of medicine because they can't handle the obnoxious legal system. They're treated like criminals. People don't care what they're doing to physicians: They insult them in public at these depositions. A seasoned sixty year old internist may be just the person you need when you're sick, so I would hate to see those people retiring early. If my family was sick, that's who I'd want to take care of them. I'd hate to see a bunch of young rookies the only ones out there.
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