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an online version of the magazine Fall 2008
Features
A Silver Bullet for Blake with Photographs by Keith Weller  
 
  Many of today’s young physicians are eager to trade in long hours and professional status for “controllable careers” that allow them to be home in time for dinner. Does the quest for better balance mean better doctoring?

BY Linell Smith
Photograpy by Mike Ciesielski
 
 
 
 

On a crisp autumn day in 2005, physicians Tim and Julie Scialla sneaked away from their overbooked Hopkins lives for lunch in Federal Hill.

The conversation about the future was more intense than usual for the third-year residents. Getting ready to start fellowships, they were also preparing to become parents for the first time in March.

The dilemma: Someone’s pager had to give.

By the end of their meal, the couple had reached a decision. Tim would stay home for a year with the new baby while Julie completed her clinical fellowship in nephrology. Then she would enter the research phase of her fellowship, while he spent that next year as a chief resident. When the administrators in Pulmonary Care agreed to delay Tim’s fellowship, the Sciallas’ tag-team version of parenting-and-career was officially launched.

“Our earlier compromise had been that I would be a research fellow first,” Tim Scialla recalls. “But when I also got offered the position of chief resident, that just didn’t work with the schedule.”

By schedule, he means theirs. Back in the day, “the schedule” belonged to the academic medical institution. Increasingly, however, medicine is engaged in a tug of war with the Facebook generation of physicians who insist on balancing “controllable” careers with their personal lives. These “get a life” doctors are eager to trade in long hours and professional status for the chance to cheer at their kids’ lacrosse games and lead Girl Scout troops.

Some work part time or enter job sharing arrangements. Others choose predictable schedules as hospitalists, or take on other hospital-specific work. And, as the national physician shortage reveals, many pursue specialties that offer more money and fewer time obligations than primary care fields such as pediatrics.

Tim Scialla, 31, grew up with a deep respect for medicine thanks to his father, a cancer specialist. But he’s determined to share the parenting duties that mostly fell on his homemaker mother.

“My dad and his generation are from the ‘doctor as vocation, number one priority school,’” he says. “You had a family, which your wife took care of, but your career came first. My dad thinks it’s great that I spend so much time with our kids. When we were young, he couldn’t coach our games because his schedule wouldn’t allow him to be reliable. Both Julie and I want to be available to do those things with our children.”

He’s hardly alone. Today’s medical students view the search for a balanced lifestyle as a major consideration, according to David Nichols, vice dean for education of the School of Medicine. “This generation has a very substantial interest in having time for personal fulfillment and family,” he says. “The specialties that allow one to control the schedule better and do not require constant availability are highly valued—and I don’t see that changing anytime soon.”

This year, dermatology, ophthalmology, anesthesiology, neurosurgery, plastic and reconstructive surgery, radiation oncology, radiology and emergency medicine—specialties with mostly predictable hours—were among the most popular and competitive, according to the National Resident Matching Program.

Career preferences at Hopkins support this trend. Nearly 40 percent of the School of Medicine’s Class of 2008 is entering one of those fields. Twenty years ago, just 11 percent selected those fields. (And no one chose dermatology, plastic surgery, emergency medicine, or radiation oncology.)

Thomas Koenig, associate dean of student affairs, appreciates many of the ways the profession has changed since he graduated from Hopkins in 1989. As the physician workforce increases in diversity, he says, it has brought correspondingly diverse views of what a medical career can be.

“Maybe now people are feeling a bit more empowered to explicitly address concerns about the balance between work and family—however family is defined. And that’s important for students to consider,” he says. “If you’re not happy outside the hospital, you’re not going to be happy inside the hospital.”

Perhaps not surprisingly, doctors under the age of 50 are already working fewer hours than their older colleagues, according to a 2006 national study by the Association of American Medical Colleges (AAMC).

“Some of it is related to the gender change of the profession,” says Edward Salsberg, director of the Center of Workforce Studies for the AAMC. “Close to 49 percent of medical students are women and women are more likely to work part time or take time off to have a family.”

But the generational zeitgeist affects plenty of men as well. The Under 50 Physician Work Force Study shows that 66 percent of male physicians, compared to 82 percent of females, rate having family and personal time as a “very important factor for a desirable professional practice.” In fact, a 2005 study in Academic Medicine showed that male medical school seniors were more likely to choose a specialty with a “controllable” lifestyle (45 percent) than were women (36 percent).

Greg Hobelmann, his brother Todd, and Todd’s wife, Allison, illustrate the trend. All recently completed residencies at Hopkins, and all picked specialties with manageable hours.

A former chief resident in anesthesiology and critical care, 33-year-old Greg now works as a pain management specialist in a private practice in Baltimore County. A schedule of no evenings and no weekends, with few emergency procedures, allows time for his twin passions: his wife and three children and the sport of hunting.

Todd, 30, who was also a resident in anesthesiology at Hopkins, works regular hours at the operating room at Good Samaritan Hospital, plays golf, and plays the guitar. Allison, 30, is an emergency medicine physician at Union Memorial Hospital who enjoys the challenges of acute care and the flexibility of a 33-hour work week. She plans to share child care with Todd when they start a family. Allison says she tries to emulate Barbara Blok, the former associate residency director of Hopkins’ Department of Emergency Medicine.

“She was the epitome of how to be successful as a physician and be a great mom,” Allison recalls. “She was also very athletic—a great role model.”

The mission to find balance means that many young doctors no longer invest so heavily in defining themselves only as physicians. “Your life isn’t dictated simply by work anymore,” Greg Hobelmann says. “It’s dictated by a lot of things. You’re also a parent or a rock climber. You’re any number of roles.”

It’s unclear what this generational shift means, embedded as it is in the

1 Todd Hobelmann
Hopkins-trained Allison and Todd Hobelmann have picked specialties that allow them time at home together. They plan to share child care once they start a family.

complicated, and ongoing, transformation of health care delivery.

There are a myriad of factors that influence current career planning these days, including staggering medical school debts; reluctance to spend hours on paperwork; the time needed for coordinating specialty care and getting tests approved; high malpractice insurance costs; low reimbursement for specialties that aren’t procedure-based; mandated restriction of residents’ hours to 80 hours a week; the growth of a team-based approach to patient care; and increasing recognition and use of nurse practitioners and physician assistants.

However, the search for work/life balance also illuminates characteristics of people in their 20s, a group generally described as less career-driven than their “workaholic” Baby Boomer parents.

“This is the generation that’s taught from kindergarten on up to find ‘their passion,’” says industrial psychologist Wendy Kaufman, who owns Balancing Life’s Issues, a nationwide corporate training company based in Westchester County, New York. “The motivators are vastly different for the people in this group. They are really looking for meaning and purpose—it’s ‘What am I here for? What am I doing?’ Instead of the big house or the big boat, they want a job where they can go to every soccer game and also be the soccer coach.”

And they’re not shy about saying so. Kaufman remembers a young physician who abruptly excused herself from a training session at a medical center in New York State to attend her 3-year-old’s graduation from nursery school. “I was sort of taken aback because you don’t think of a doctor doing that,” says Kaufman, 46.

Not only are 20-somethings very organized, she says, but they also know how to set priorities and how to say “No”—a distinctive difference from previous generations, she says. Kaufman observed this gap recently when she assigned a group of doctors a simple exercise: Tell your supervisor that you have to leave work early for a milestone birthday celebration.

“The older doctors couldn’t figure out how to do it,” she says. “But the 29-year-olds had no problem saying, ‘I have to leave early because it’s my mother’s 70th birthday.’ It’s important to them, and they know it. They’re also willing to walk, if they have to, because they’re confident that their life will be OK and that they can find another job.”

Kaufman predicts that health care will become more collaborative, with teamwork allowing each practitioner more personal time.

However many physicians worry about how patients fit into such “controllable” career scenarios. Hopkins neurosurgeon Judy Huang, chief of cerebrovascular neurosurgery at Bayview, believes the “intense” nature of the doctor/patient relationship is changing, partly because mandatory restriction of residents’ work hours may have set a troublesome standard.

“It implies that it’s acceptable to turn over your responsibilities for your patients to someone else with a shift-work mentality,” she says. “That’s a dramatic change in philosophy. Most people who go into medicine are committed to doing the right things for their patients and to working however long it takes to get the job done. Legislating this forced turnover is a huge shift in the paradigm.”

Shorter hours, she fears, may also attract young people to medicine who are less dedicated to patient care and less apt to consider medicine as a “calling.”

Huang, 38, also directs medical student education in neurosurgery and carries the distinction of being the division’s first female faculty member. “I wouldn’t embark upon something I didn’t feel I could throw myself into, be committed to, and excel in,” she says. “I knew that surgeons are pretty secure [financially], but lifestyle and monetary compensation were actually very low on my list in choosing a specialty.”

Whenever she’s on duty as an attending physician at Bayview Medical Center, endocrinologist Suzanne Jan de Beur winces when residents complain about staying late because of unexpected issues with their patients. As the mother of two young children, she has spent a lot of time arranging child care to cover her own, often unpredictable, hours.

“When I graduated from Cornell in 1992, I think we understood that medicine is not a lifestyle career,” she says. “And there’s no way it ever would be because your patients are your priority. That means that there are many times you have to take care of a patient before you do what you want to do. Holding other people’s well-being is a huge responsibility.”

She recalls reprimanding the senior resident on her team for watching the World Cup soccer competition during the  day. “I was livid,” she says. “There I was telling him that there were patients to be cared for and that the World Cup could wait … I think it’s ironic that the attending will now often completely update the intern about a patient, rather than the intern being the person most intimately knowledgeable.”

Such a reversal of roles would have humiliated her when she was a resident in internal medicine at Hopkins, she says. Now, however, it’s no big deal—due in part, she believes, to the structure of residents’ on-duty hours.

“If we are training people in shifts and they don’t actually go into shift work—and internal medicine certainly isn’t that—I don’t see how they can suddenly become different, how they can build that internal identity that says, ‘This is my patient and I’m caring for him even if I have been up all night.’”

Although young doctors may not spend as much time in the hospital, people should never assume they care less about their patients, says Tom Koenig. He suggests that every generation has its own metrics for judging success … and that long hours on the job may no longer rank as one of them.

“I don’t know that I would define the most successful person at Hopkins as someone who spends 120 hours a week at work,” he says. “I think our students are willing to view success across arenas of their lives rather than in one specific area. Being successful in familial, social, and professional arenas is increasingly viewed as important.”

He points out that many young women have found role models at Hopkins who successfully balance careers and home lives. “Can you really be a very successful part-time academician? Historically, the answer was ‘No,’ but we have great examples of that happening now,” Koenig says.

Men are setting standards as well. When Tim Scialla requested a delay in his pulmonary medicine fellowship, he was treading ground familiar to department leaders. Each year, several of the division’s 30-plus fellows either start a family or add to it, according to program director Henry Fessler.

“By the time trainees get to this level, they have deferred a lot of their personal goals, particularly starting a family,” he says. “Our division has always tried to be as flexible as possible to help fellows achieve goals that aren’t just academic.”

Mike Boyle, the division’s director of education and fellowship recruiting, says that granting a delay isn’t about making life easy, it’s about helping a talented physician succeed.

Consider his own story: After finishing his residency at Hopkins, Boyle worked for two years, earning money to pay back loans, get married, and buy a house. Then he returned to Hopkins for his fellowship. “When I left, one faculty member said, ‘You’ll never be back,’” the pulmonologist recalls. “But sometimes you just have to be creative to make things line up with your priorities.”

After baby Wesley arrived in 2006, the Sciallas’ schedule was demanding

c jan
Attending physician Suzanne Jan de Beur's message to residents: Put patient needs before your own.

but manageable. While Tim stayed home with his son, picking up hospital night shifts several times a month to supplement their income, Julie plunged into her rigorous clinical fellowship in nephrology. On call every third to fourth night, as well as two full weekends a month, she took care of patients on dialysis and tended to pre- and post-operative kidney transplant patients.

The couple looked forward to the next phase of the plan: In July 2007, Tim would become a chief resident in internal medicine, Julie would enter the research part of her fellowship and Wes would go into day care.

Then Julie became pregnant again.

“She was the mother of a nine-month-old and pregnant while she was working in what is considered the hardest fellowship in medicine,” Tim recalls. “She was emotionally and physically exhausted by the end of the year.”

It was time for more creative revisions. Julie was able to delay the remainder of her fellowship to stay home with Wes and baby Audrey, who was born in August 2007.

“My mother was a homemaker and so was Tim’s … and that was part of the source of our hesitation about putting the kids right into day care as infants,” Julie says. “It’s been wonderful that we could arrange it so that each of us had some time at home with them.”

Last June, both children entered Bright Horizons, a daycare center for Hopkins faculty and staff that’s open from 6:30 a.m. to 6:30 p.m. Both young parents work nearby: Tim is doing research while Julie takes classes at the School of Public Health that will aid her studies of chronic kidney disease.

“We’re flexible enough right now so that if the kids get sick, one of us can go home with them,” Tim says.

At the moment, both physicians are considering careers in academic medicine. Tim says each carries “the average amount of medical school loans” (for a 2006 SOM graduate, the most recent year available, that’s $95,000.) So far, their debt has not influenced what shape their careers will take.

Paul Auwaerter, director of the clinical division of infectious diseases at Hopkins, is sympathetic to the career dilemma faced by young doctors with large debts. At 46, he has just finished paying his own educational bills and often takes on extra projects to help support his family of four.

He says infectious disease doctors face many of the same challenges as primary care doctors: Low-income patients, complicated cases, low reimbursements.

“Every patient I saw yesterday had four or more active problems, which means I have to sift through all their medical history, understand a huge amount of data, and communicate with other care providers,” he says. “Compare that to the work performed for a procedure that can take less time to accomplish but is reimbursed at a higher rate.

“That’s a dramatic difference in terms of time and intensity versus what you get paid. So it’s no surprise that some people with medical school burdens and two-income family demands might skew their careers toward something they enjoy that is also economically worthwhile.”

Koenig warns against assuming that students who choose “lifestyle” specialties are primarily motivated by money or weekends off. “In doing so we may trivialize someone’s genuine aptitude and desire to move one of those fields forward.”

Take, for instance, Allison Barker Larson, Class of 2008, who was recently accepted into a dermatology residency at Massachusetts General Hospital. The 26-year-old doctor wants to work within a university system and rise up through the ranks doing research—she’s interested in skin cancer—as well as excel at patient care.

“I feel I’ve been able to define what I want out of life,” she says. “So what do I need that’s going to keep me happy? Intellectual stimulation, something that provokes curiosity at work. Building a relationship with my patients in a way that I hope will also lead them to bring in their families. It’s having enough time with my family so that I don’t feel like I’m not a participant. And it’s time to do things for me.”

“In general, my generation is more focused on a balanced life, even extending that to how many hours it’s safe to be in the hospital and still take good care of patients,” she notes.

And although she’s heard “old school” physicians grumble about how they used to work longer hours, she believes they’re adapting. Some even see improvements. “They’ll say, ‘I think  things are better: You guys are happier and I think we’re all safer.’”

At least, she adds, that’s what they usually say.*

 

 


 

 
 
 
 
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