Mind the Gap: How I Left My Academic Surgery Job

A lot of people in my life know that I left my academic post to spend a year crafting a new direction, one I fully expected to include ongoing clinical activity. That activity would be in my specialty as a colon and rectal surgeon with a focus on multimodal, minimally invasive, sphincter-sparing approaches to rectal cancer and minimally invasive surgery generally. The qualifier--and this is a big one--is that I wanted to position myself to understand and constructively address how to improve the work environment, how to feel and enact deeper connection in our work, how to thoughtfully surface tensions in the hospital and work with them rather than watching debilitating and demoralizing, often dishonest power struggles continue to reshape our service while burying the real problems.  Yes, well, I am the same person who decided to be a colorectal surgeon.  More to be said about the entwinement of underlying themes later.

What I did not share was why I left when I did and how that happened. Let me state clearly at the outset that this is my story. That means it’s how I perceived and experienced things, and that is what I am sharing. I’m not concealing identities, but I’m also not revealing them. This is intentional: they aren’t really important to what I want to say. These things are structural and happen, in different forms, all over. I have also taken pains at great personal expense to protect other people and institutions along the way. I didn’t talk about what instigated the change for a few reasons.  One was that I didn’t know how because I was having trouble constructing a narrative that made sense to me. The second was that I cared for and about the person who orchestrated a bad thing for me. The third is that I was scrutinizing myself to discern what I had missed or whether I had brought this problem on myself so that I could avoid making the same mistake again. The fourth is that I was ashamed and hurt and angry all at once which often interfered with being coherent. But the fifth is that I was afraid.  Let me explain.

Five years into my practice, I got a call one night from my boss just as I was turning off the light to go to sleep, which means it was after 10 pm. He told me I needed to come to a meeting the next morning.  “It won’t be a good meeting,“ he cautioned.  “Don’t talk, and we’ll figure it out later.” In other words, something unpleasant was in the offing, but he would help me solve the problem.  We were still a team.  We sat down the next morning with the nurse manager of the surgery clinic which had come under hospital control in the preceding year. She notified me that I would no longer have any support from “her” nurses because I was impossible to work for. When I asked what this meant (note that I spoke during the meeting) she made a clarification that was anything but clarifying: “We won’t be abandoning our patients.” Then she sat back, like the meeting was over. I puzzled for a moment about whether the nurses had patients that weren’t my patients or whether I had patients who were really the nurses’ patients who had gravitated to their reputation of excellence yet were willing to put up with mediocre doctors like me. These questions might sound a little ridiculous, but I usually try to see all sides of a problem. And I had just stepped into the Gap. 

Then I set about detailing what was being proposed, which basically meant the nurses would chaperone my office visits, be supportive of their patients, and take their phone calls, documenting everything to be sure I did my job, something had never been a seen as a problem before. There was the insinuation—one that was becoming increasingly common—that somehow the nurses were more committed to the patients and less compromised by personal gain than I was or other doctors are. It’s what seeps into care discussions when there is disagreement about a course of care or an order or timing. It happens when a nurse feels criticized or ignored and says testily, “I’m just being the patient’s advocate.” It’s presented as a way of carving out an identity, a purpose, and it draws a circle that leaves the physician on the outside. It’s aggravating, but I understand the need to define expertise and be respected for ones service. Somehow, in the Bad Meeting, I was aware this nurse manager had forfeited her parking spot in the structure next to our clinic so there would be one more space for a patient to park. I myself was reckoning with menopause and having forfeited starting a family because I kept thinking there was time. I never wanted my children to be without their mother in their early years; it just seemed wrong to me. I kept taking care of the work part first, trying to build my place of competence, respect and security. I often think of the surprising male nurse who joked with me that he’d become a nurse so he could marry a doctor. We laughed. I ascertained that the med techs would take vitals and turn over the rooms.  I would have to set up and perform any office procedures myself, write orders, schedule cases, provide instructions, arrange consultations, follow up on studies, be sure everything ordered before surgery had been completed and reviewed, and so forth.  In other words, I worked alone but with nursing supervision. I was also told I would meet with the Chief Medical Officer that day as well to discuss a complaint filed that I had said “fuck” in the clinic. It’s true. I did say that. Not like “Fuck you!” or “Fuck this!” More like, “What the fuck?!”  But still, fuck. Fuck nonetheless.

There had been no prior counseling or formal review as a prelude to the radical withdrawal of nursing support. It was not only unheard of to me generally but also baffling. How I would get everything done? How could I generate the revenue necessary to support my salary?  Most surgeons have a hard time staying on top of all our work even with a dedicated clinical assistant.  Because my boss had told me not to speak in the meeting and that we would sort it out later, I just tried to absorb the outlines of what was going on.  When the meeting ended, I trailed my boss the few steps to his office, and I sat in my usual chair by his door, which in reflection calls to mind Cinderella’s little chair by the hearth and Lesley Anne Warren singing wistfully, “In my own little corner, in my own little chair, I can be whatever I want to be,” except that just as the door shut, a hurricane made landfall in the office.  My boss unleashed an invective that, all these years later, a surgeon colleague remembers caused the clerical staff to knot together in a huddle by the office, taking shelter and gossiping. It launched with, “WHY CAN’T YOU SHUT THE FUCK UP?” and gathered force as he accused me of destroying our division and abusing all the staff we had ever hired.  He was red, neck veins standing out, spittle flying.  Years before, he had told me that OR front desk staff at his last institution had called the police on him once when he lost his temper and they’d had enough, and now I could see why.  “I HAVE BEEN TRYING TO GET YOU FIRED FOR A YEAR, BUT THE CHAIRMAN WON’T LET ME,” he yelled. That meant he did not have cause, and while I knew there was a process that could be activated to manage this, it didn’t really seem worth it to me: I simply didn’t like being there enough to fight.  I realized that his admission was so unstrategic that it substantiated how completely had lost control.  It also revealed that whatever he’d said to suggest we were a team who would figure out the Bad Meeting together was a lie. It would be several years before I would also realize he was the architect of this whole construct, using a tactic he considered employing to dislodge another surgeon in our section a few years earlier. This was just a tool in his kit, an apparently time-honored sleazy management strategy of withdrawing an employee’s support to make them so miserable they leave on their own and don’t have to be fired. It’s a test of endurance.  He had orchestrated this whole thing so it would look like he was my hero, helping me get re-situated after an unfortunate and locally unrecoverable misstep on my part. In all likelihood, the backfiring of his plan contributed to the explosion of anger.  He told me I had to write a letter stating I would not renew my contract, which was up for renewal in 2-3 months to commence a year later. “IF YOU DON’T SIGN THE LETTER,” he threatened, “I WILL FUCKING DESTROY YOU.” I sat very still, looking at him, looking at the floor, considering whether he could actually destroy me, what he would say, how that might play out. There were plenty of distortions in his diatribe, but were there also some truths? In a weird way, I accorded him some latitude in his behavior that I would never have allowed someone I disliked or had no relationship with.  Without making eye contact, I asked quietly, “Do you think it’s a good idea that you’re using the same language that is the reason for my meeting with the CMO today?” He was exasperated, but it took a little wind out of his sails. 

Was it just a week or two earlier that I had sat in this same chair, “my own little chair,” as he told me he was having trouble thinking of what wedding gift to give his prospective son-in-law? There are details to this story that are too personal to relay, but I don’t think it crosses a line to say that his oldest daughter’s fiance was adopted. I suggested that he give this young man something that had been his own for a long time, perhaps from childhood or passed down from his own father, something that would signal to the groom that he was being taken in as a son, incorporated into the family in an intergenerational way. In short, it should convey that in marriage he was welcomed and belonged now to the whole family.

In my next post, I will talk about some really interesting things that happened in the next year, before my contract ended, and how I decided what to do next. Then, before I relay the journey itself,  I will say something about some lasting consequences of this encounter and my approach to moving on. I realize this post-mortem is a little messy, but what I have come to understand in the intervening years is how often terrible things happen to us in our work as physicians that we never discuss, our isolation amplifying our distress and sometimes causing us to make poor choices in the fray.  We might survive, but could we do more than that? And how would that help us love our work and our patients more and say “yes” to each other as often as possible? Stay tuned.