"This time around my life is about my work."
Amy Richards trained in family medicine in Texas and now practices in a small community. She is forty-one years old and lives with her female personal and professional partner.
In senior year of high school I had been thinking of getting married to a boyfriend who was in the Air Force. I had always been a bright student but I grew up in a very European family and I honestly did not get much guidance from high school counselors or my family in the direction of going to college. It was assumed that I would primarily marry and be a wife and a mother.
I decided not to marry that guy but I had figured out that I wanted to have a meaningful job. A key factor in my decision to become an RN was that I wanted to get trained quickly into a job that would allow me financial independence and job security. My parents were lower middle class, and I placed a high priority on achieving financial stability. I wanted a meaningful job in a helping profession and I had to be able to afford the education and the attendant costs. My parents had just bought a home three blocks from the college and I could walk to school. I had no car and shared rides to get to the clinical experiences.
The subject matter was intellectually stimulating and being a nursing student gave me a role within which I could meaningfully interact with others. I was a bit of a social wallflower and didn't make small talk easily. I was the youngest of a handful of eighteen to twenty-two year olds. The majority were thirty plus. In nursing school I didn't do the light-hearted things college kids do.
I had excellent instructors and during my nursing training I acquired communication skills which were the foundation for what I do today with patients. I was able to prepare for and process nurse/patient clinical interactions in our "pre- and post- conferences," which were invaluable. To this day I recall those sessions with gratitude. I literally grew up in that environment. It was warm and caring and yet professional. Our (occasionally tough) instructors crafted a safe place for us to deal with our human and emotional responses to clinical setting experiences. This was blended with teaching basic science and clinical, both medical and nursing knowledge, plus the physical skills and techniques to care for patients.
In that sense my nursing school instructors surpassed my medical school instructors. Only in a family practice residency with a family practice faculty did I find a similar focus and breadth in clinical education, i.e. working with the whole resident as a human and a doctor to treat the whole patient.
My first real job was at a large county hospital, on the chest medicine ward and ICU. There was a three month orientation training program. Four of the young nurses from my program rented a house. This was my first big city experience; I was naive and white and raised in a suburban area. Issues of poverty and race and professional insecurity all arose daily. I found myself dealing with heavy, stressful challenges that were more than I was ready to take on.
I was on duty in the ICU at the time of a disaster. I was terrified but managed to keep my professional cool. Ventilator patients didn't have any oxygen and had to be bagged. That experience was my own disaster and I left ICU nursing to work at a residential treatment facility for incorrigible and juvenile delinquent girls. I lived three days a week with my folks and four days a week at the apartment attached to the infirmary there.
Within a year I married, so the people at the home changed my job into a five day a week one and I moved in to live as a newlywed with Daniel. I liked the psych skills that I used. I liked actually living at the home, and getting to know the kids and the other staff members. But after a while I missed acute care nursing. I was also crazy to get out of the metropolitan area and move to the mountains. So Daniel and I moved and I took a job as night nurse in a community hospital ICU.
That was a pretty tough time for me, at least professionally. The daytime charge nurse was rigid and traditional about the nurse's place in the hospital. I was rapidly becoming a late-blooming hippie, and a feminist, and an anti-establishment rebel. Most people would have perceived me as fairly conservative yet, but I felt I was really pushing the limits. I questioned my most basic assumptions regarding how I had lived my life up to that time. All this while of personal exploration I did manage to keep doing my best and learning more, attending critical care conferences, and being a damn good ICU nurse.
I was the first one to notice my significant dip in enthusiasm and diagnosed my own personal and profession burnout. At that time I went through some upheavals in my marriage and divorced my husband. We had only been married about a year and a half. I chose to stay with the job as a focus of stability while I went through other personal changes, exploring and expanding my borders into unknown territory. For four years I lived alone a block from the beach where I cultivated an intimate relationship with the ocean. I spent a lot of time doing beach walks and self-analysis.
A very dear friend introduced me to Ayn Rand's work and I read everything that she wrote. I worked to develop a foundation of values from which to map out my aspirations into future goals. I ended up discovering a lot about my core self. I embraced Aristotle's definition of happiness: "The exercise of vital powers along lines of excellence in a life giving them scope." And I resolved to be happy.
One of the things I discovered was that my finest and most intimate sharing both on an emotional and sexual, as well as spiritual, level was with women. It gradually dawned on me that I was in love with one of my best friends. She was married, so I continued to live alone and have lots of time by myself and very little with her. I lived in a high intensity state with all these things going on. I had other friends and family contacts, but I focused on reevaluating my life.
One day I was watching the sun come up during a quiet hour on duty in the ICU and I realized I needed to live as if I would continue to live alone for the rest of my life, have to support myself, have to have some long-term investment in a career. Everything I'd learned and established for myself in the past few years had to find expression. I couldn't look ahead to a life of marriage and kids, with my job being secondary, as I once had.
Because of my burnout I had considered quitting ICU nursing and going back to med/surg floor nursing. When I shared this with my friend, she said that was like Michelangelo deciding to draw cartoons. That hit me over the head. Through the years I've remembered that analogy. This friend was incredibly empowering. I had never had someone who had the intellectual ability and emotional investment in me to really look at me and mirror back the best of what she saw.
Suddenly I knew I could be a doctor. From my European background I had always looked at instructors and doctors as somehow nearer to God than me. Having interacted with docs and come to know them as people in my role as ICU nurse, I now realized they were human. They had learned things that had given them the power of the doctor position and those things were learnable by somebody like me. At the same time I decided I could be a doctor, I knew simultaneously that I would. The first person I told was my friend, and by virtue of my telling her, I knew I'd solidly committed to really do it.
I've told many people since then that that was the closest I'd come to the God within voicing a command and an idea at the same time. Although I realize not everybody in medicine has come into it by being called, for myself and for many physicians that I know, even in this day of medicine being a business, there are many people who have been called to service in medicine.From the very beginning when I went into medicine I had the intent of coming out as a family doctor. And not only a family doctor but at some point a family doctor within a village-size community where there would be some basic skills one could utilize and have a role as a healer even if all the transportation systems shut down and we couldn't get supplies. Also, I liked the whole concept of family medicine in its approach to patients, which is longitudinal, which is comprehensive, which has breadth, which has an investigative mode--clinical problem-solving at the outset.
The patients come to you right off the street. As I interacted with pre-med and medical students, I knew I didn't have the propensity to get my referrals from my colleagues. My true skill lay in working directly with patients, being their first point of contact with the health care system.
In medical school I relished the opportunity to only be responsible for learning. I love to learn, I love to be a student. I got a lot of questions answered that had been mulling around in my mind for years. I'd hear an instructor review something about pulmonary physiology and suddenly I'd get answers to questions I had about several patients I had taken care of. It was like a gold mine for me.
I was at Baylor College of Medicine in Houston, Texas, where they pamper their medical students. They're tough on you but they make you feel special. They were very supportive and I felt rich with the opportunity to learn from all these people and to get government loans to pay my living expenses and to have tuition of $400 a year. The real cost of my education was a lot more than the $400 a year.
Sometimes I had to unlearn what I did as a nurse, which was to stop at a certain level of questioning and think that was enough, or to make a hunch or a decision about something that was going on and think that was enough. Drawing on my experience I would come to these rapid assessments of the highest probability of what it was and want to act on that and not do the whole long differential diagnosis, which goes on into infinity. That was a nursing bias.
Medical school was great. Internship year for me was hell. The physical demands, the staying up demands, were incredible. In medical school I had met a dental student, moved in with her, and had established a long-term relationship. She graduated from dental school when I graduated from medical school, but she went into the Air Force and was stationed in Florida while I went to another Texas city in a family practice residency. So I lived alone during my internship and found it incredibly stressful. I was lonely.
At that point I had not quite come out to my peers and being a lesbian in the medical training process was rather difficult. The male-female sexual harassment issues didn't hit me as much because I wasn't a very good target for anybody's energy. I wasn't trying to get any dates or get any lays or get anything from any of the men and somehow that was communicated to them. They knew I was all business. But when I came home I didn't have my partner there, and there were some emotional stretches that were difficult. In my second and third years she was stationed to my city, so it was a lot easier.
During our Balint groups I had the opportunity to process what I experienced as a person in patient/physician relationships. This was the closest thing to the pre- and post- conference I had in nursing school. You process the experience with the your same-level residents, and a social worker or psychologist, psychiatrist. It was during one of those sessions I came out to the rest of the group as being a lesbian. After that it was a whole lot easier because people knew it and it was manageable. It was fairly accepted.
I became co-chief resident in my last year. I was always pushing myself to excel and to do the best I could, not so much to be better than other people but to really put out maximum effort at work. In the medical profession that makes you a workaholic.
When my partner in the military was going over to Germany, I realized I couldn't continue to live the kind of closeted life her being in the military required. I wanted to get back amongst more liberal people and to get out of the big city and into a more natural environment, because nature really sustains me. As it turned out a new love relationship established itself in my life and I had to make some choices. I ended up moving to this small community with the woman who is my current partner.
She's also in family practice partnership with me. She was a resident a year ahead of me in Texas. At that time she was married and basically so was I. It wasn't until much later that we became friends, after both of us had been working as MDs. She grew up in a small community and went back every summer to see family there. She'd vowed if she ever got the chance she'd choose this area where we live now.
That's been interesting, the move to a small town: two women living together and practicing together and hoping they won't run you out of town before they find out that you're damn good doctors and they want you. Fortunately the latter happened. The practice is just the two of us family physicians. The county we service is about 100,000, although the towns themselves are smaller. There are maybe 80 docs on staff at the one hospital where we practice, so in many ways there are a lot of similarities between the hospital where I work now and the community hospital where I worked as a nurse in ICU.
I don't particularly want to socialize with other doctors and other doctors' wives. I don't have much in common with them. So we have sought social connections with an entirely different set of folks, the art community, the other professionals, more feminist pagan women's spirituality, eco feminism, greens people, a different kettle of fish. Other docs have a little aloofness with us, which is okay.
At one point I watched Robert Bly being interviewed by Bill Moyers, the video on the men's movement. It moved me so much because I realized these guys probably never really talked with each other at that level, sharing real feelings. So I invited several guys I thought might be open to it to come with their wives and significant others to see this video in my home.
It was a time of some pain for all of us, adjusting to the devaluing of physicians and doctor-bashing happening. A lot of these guys were hurting. They came, they saw the video and were very moved. It must have helped them articulate some of their feelings because they went on to develop a men's group of doctors that met on a regular basis, and still does meet. Naturally I was excluded by being a woman.
What I enjoyed most in nursing was the communication with
patients, and I certainly have an opportunity for that in my
practice. As a family physician I have hands on care of patients
in the office, in examining them and talking to them and touching
them. In the hospital I make rounds. Sometimes I miss having an
entire shift where I work with one particular patient. Mostly I'm
glad I don't have to do that because I was tied to that ICU. I
couldn't step out, only had so much time I could take a break. As
a doc I relish the ability to set my own hours.
Even though private practice is extremely difficult in this day of managed care, I am committed to keeping the autonomy I now have as a physician. We cover for each other, so it's better than solo practice. We also have a PA [physician's assistant] working with us who's really good. So it's a mini group, small enough that we can make our own decisions. I don't have to put in for time off. I just say, I'm going. The down side is that any day I'm not there, I'm not generating income. I don't get paid vacations and paid benefits. In a way I miss that, having somebody who's going to write my check. I'm more at risk and responsible for paying other people's paychecks.
I know what nurses do from the inside out. Most other docs have never really paid attention, unless they're married to a nurse, to what exactly nurses do and what is the nursing perspective. They've never been talked to as another nurse, hearing complaints about the bullshit that nurses get from doctors. They've never been on the nursing side in that age-old conflictual relationship between physicians and nurses. And I have. It makes all the difference in how I approach and interact with the nurses.
I really value what nurses do. I know they don't just carry out my orders. They generate things on their own, things I can't do as a doc, because I'm not there with the patients the way they are. A lot of docs haven't got a clue about that. They think a nurse's primary responsibility is to follow a doctor's orders, and maybe do some other stuff that's not as important. My style of taking care of patients and interacting with the staff reflects my different knowledge.
Women are treated as second class citizens in medicine. We don't fit into the "Old Boy" network. They may relate to us as a colleague or as another professional, but we're not one of the docs like a male doc coming into a new environment. And then on top of that to be lesbians! There's a hierarchy about being normal, and there's a hierarchy about being a woman and there's a hierarchy about everybody else, like relating to nurses as if they were somehow less than doctors. A lot of doctors talk team approach but they don't believe it. You have to believe it to convince people and get their best effort.
Nursing likes to project itself as ministering to the sick who are in a bed. There are a lot of sick people who are not in a bed who, given the thrust toward primary care, would benefit from the kinds of intervention that take time in an outpatient setting. There are educational, preventive medicine-type things which nursing could embrace as a major role. Physicians have little time to really devote to that level of patient teaching and often it's given to medical assistants who don't really have the background.
I have a better understanding of the ancillary health care personnel because I worked with them more directly as a nurse, especially the respiratory therapy and physical therapy folks. I solicit and actively listen to people when they give me feedback from their perspective, because as a physician I can't understand everything about that patient's care when I'm coming in and making rounds. When I was a nurse it wasn't that I minded that I had to take orders from physicians. It was that I wanted those orders to be intelligent and to be open to modification and feedback from other health care members. As a doctor, unless I understand and communicate well with the rest of the health care team, I'm missing out on an opportunity to take care of patients.
One of the problems with American medical care is it has too many specialists and nobody's running the show when the patients are in the hospital. Somebody's got to put the whole picture together. When I have patients in the hospital, no matter how many specialists are on the case, I continue to follow that patient. All the specialists know that if they're going to write orders and be involved in taking care of my patients, I will review their orders. I will be the coordinating person in the health care team.
The Amy who was a nurse, even as good as I was in ICU, didn't have the ability to make decisions about patients' care the way I thought I did then. Nurses can be upset and say, "Jesus Christ, I'm the one who really knows what's going on with this patient. Half the time when the residents come in they're asking me, `What should I do in this situation,' and I'm telling them." Residents should learn as much as possible from the nurses who take care of the patients, but the nurses aren't really assuming responsibility for that patient.
Nurses aren't legally or morally or ethically the primary people the patient's family, the patients themselves, or the lawyers look to if something goes wrong with that patient's care. Now granted, if a doc does something stupid, the nurse is responsible for speaking up when the nurse disagrees. But in general our health care system is set up for doctors to be the most educated and the most responsible.
Gradually I'm integrating into the community and being a community physician. But at a recent conference it became clear to me that I'm moving further along than just private practice, which I'll continue to do, to trying to work in a leadership role in medicine.
Physicians who have a perspective of clinical medicine are being asked to provide a physician perspective at the management level of health care. I'll probably eventually end up there. I certainly have the ability to be a visionary and go beyond what I'm doing now. What I like is that I've come from the grass roots. I've come from nursing and doing that for a while, and doing primary care medicine for a while, and I'm sure I'll continue to do that because I love it so much. But I'll also try to help administer some of the delivery of health care in a compassionate and yet cost-effective and equitable way.
What I learned when I talked to a psychic is that this time around my life is about my work. I struggled for a while to decide if I was going to have a child, which is hard enough to do in a straight relationship. It's even harder in a lesbian relationship and interestingly I picked two partners, one right after the other, who were not particularly excited about the idea of raising kids.
My choice not to have children was not easily made and at times still brings tears to my eyes. I'm not saying no one should be both a mother and a physician, or a father and a physician. But having children significantly compromises what you can do. Thank God I've got a brother and a sister who share my niece and nephews with me. Even with them I don't have as much time to spend as I want to because I'm truly committed to multiple levels of being a doc, being a care provider, and being a community citizen.
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