The Silver Lining of a Devastating Academic Surgery Work Conflict: Five Discoveries
In my post, Mind the Gap, Gap originally described a gap in understanding, a gap in known reality, and a gap in relationship with my boss. Over time, Gap morphs into a story about navigating an unintentional clinical gap that developed as I prioritized my life with my significant other and as I grew more committed to understanding the dynamics of “dysfunctional” physicians, the painfully unintelligent, narrow characterization and treatment of the problem, and emerging data that roughly half of the physician workforce suffers from an occupational illness as do medical students in advance of even beginning regular clinical activity. I also wanted to know why hospitals instead of enhancing the wellbeing of everyone who enters them are depleting, isolating, and disempowering. It’s not just about dealing with sickness; it’s about how we deal with sickness, health, and each other. And finally, I wanted to understand and remain connected to my own calling to medicine. It was no longer possible for me to ignore these things.
In the year of the Bad Meeting and the strange, explosive unraveling of a boss I had regarded and trusted as a friend, practice partner, and mentor, I had to re-map the entire terrain of my life. Some of this was already in progress as I slowly made the transit into and through menopause. Menopause made it impossible to ignore my body and a slew of changes taking place. From declining visual acuity to hot flashes that broadcast stress in ways I found exposing and embarrassing, my private experience seemed more visible. The definitive closing of the long chapter of fertility made me reconsider my idea of myself as feminine, desirable, and fulfilled, and also made me face that I had forfeited by postponement having children, experiencing that miracle and perhaps being alone and uncared for in my later years. I also realized that life ends. I, like everyone else, have a finite amount of time and energy to achieve my life’s work. Was it selfish and unrealistic or ungrateful to feel that there was something more to do? I had so much to be thankful for already. Would yielding to the gravitational pull of these ideas fuel desperate behavior—like my boss’s? Had it already? Would it yank me off the straight and narrow path I had worked so hard to be on into poverty and oblivion?
These nagging doubts and criticisms were heavy burdens that made me wake up in drenching sweat at 2 am most nights but did not silence the call. I needed to discern the work more clearly, what I later heard described as the song each of us has that only we can sing. Medicine was so fully integrated into my being that I felt it at the core of my identity. It had been the organizing principle of my life since childhood, my anchor and lifeline. This is part of what felt so offensive and even shocking to me about the nurse manager’s insinuation that she or her staff had a stronger commitment to patients than I do. Can we ever “undo” being a doctor? Once we have entered into the privileged relationship with others, can we go back? It strikes me that it is, like parenthood, a rite of passage: we cross a threshold and there’s no return. At the same time, I felt my song included more than the science and business and clinical practice of my surgical domain even though I was grateful for what I essentially stumbled into—or was perhaps guided to—in the years between leaving my general surgery practice in Alaska and refining expertise as an academic subspecialty colorectal surgeon.
Despite my feeling that there was something more to do, I wasn’t sure exactly what it was much less how to accomplish it. This is weirdly indecisive for a surgeon. The confrontation at work accelerated and intensified this process both physically and psychologically. I have felt that my whole life is a quest, but the new sense of time closing in on me created almost unbearable pressure and fear. It seemed to me that deliberation was a luxury I could no longer afford; I couldn’t tread water and wait for clarity the gift of clarity that I had received at other critical times in my past. After a lifetime of being gifted with a solid direction founded in passion and curiosity, I was now unsure yet had to find a way forward. Maybe this would be the moral equivalent of an exploratory laparotomy when an operation is performed to make a diagnosis rather than because of a diagnosis. It certainly felt that way sometimes.
In my first post about this transition, I mentioned making some surprising discoveries in the year between the awful meeting and the end of my contract. Here they are.
1. Kind affirmation of a more familiar favorable perception of me accentuated rather than mitgating the Gap. When I met with the Chief Medical Officer about the “anonymous” nursing complaint about saying fuck in the clinic, it was a stark contrast to the morning’s meeting. He was standing when I entered the office, and as he turned to face me, he received me with puzzlement, “You, Lauren? You’re one of the good ones. What are you doing here?” And I thought, “Yes. Exactly. What am I doing here?” It was a kind, warm invitation into a difficult conversation on a difficult day. I softened, which allowed tears and bewilderment to start surfacing despite the imperative I felt to maintain composure. Still, I had no idea how to answer his question. Ostensibly, I was there to discuss the problem of saying fuck and intimidating or offending coworkers, but that did not begin to touch on how I actually got there or even the long list of things that culminated with my saying that word that day. I also did not know how much he knew or whether he had endorsed this whole plan for me. I thought of my experience during and after the 1989 San Francisco earthquake which caused a section of the Bay Bridge to collapse and freeways to pancake. It took a long time for me to trust bridges and overpasses or to park in concrete structures, and I still think of it with almost any bridge crossing or while parking. As it had during the earthquake, the ground had shifted on this day and become uncertain. I told the CMO I would make a list of the things that were weighing me down and asked if we could meet again to discuss them more coherently.
It is only in the rearview mirror that I consider this to be a silver lining discovery. In literature, I learned it as “the shock of recognition,” that moment of confronting uncomfortable and undeniable truth, although I guess this expression was written by Herman Melville to talk about the experience of being in the presence of genius. I’m still sorting out what’s in the Gap and why and how things affected me as they did, but it has been a rich vein of gold to mine.
2. My list of issues was 17 pages long. They ranged from apparently trivial (why was betadine removed from the clinic) to complex (how can our incredibly hard work and the thought process we spent years cultivating be effaced by a list of billable diagnoses and templated electronic medical record notes signed at the time of the too-short visit), and I never showed it to the CMO even though we met again. I was afraid my list confirmed I had lost my mind. Which conjured the Gap. When I think of the 17 pages now, I ask instead, “How did I ever let my list get to be that long without deciding—insisting—for the sake of my own sanity that something change?” Part of the answer was that I never really wrote it down and presented it to myself before. Another part of the answer is that I, like many of us, think the endurance test of medicine includes suffering. It’s almost our proving ground to suffer. And finally, why look too closely at a list we don’t believe we can change?
3. It may be necessary, responsible, and honorable to compose a practice life that embraces our whole life. In the first meeting with the CMO, when I said I didn’t know where to begin describing the troubles I was having and remarked on how difficult it had been to compose a personal life while building and maintaining my practice, he commented on having watched his wife, a pulmonologist, fashion her own path. His pondering somehow rendered this as a professionally credible option, at least in internal medicine, but why not surgery? I had my doubts, but it planted the seed that people would and could do this. Now I call this writing our Personal Practice Prescriptions. I do think doctors pay a price for this, but we pay a price either way. This offhand comment became part of what pulled me into a different future: a commitment to changing this and creating more options. And, remember, I already had experience leaving a cult!
4. It wasn’t so bad being freed of the nursing staff in the office. It cost me some productivity, but in many ways, it saved my mind. I had more direct contact with patients. There were fewer people to explain things to, fewer intermediaries with their own agendas. I didn’t have to rely on people who were unreliable or have expectations that would be disappointed. I no longer felt like I was whistling in the wind. All that staff create a lot of overhead and frankly often don’t deliver what we want. It’s part of what pisses us off. That said, I have had wonderful, instructive, dependable, work partnerships with nurses in office settings, the OR, and on the wards. It just never happened in this academic practice.
5. I was able to consider what kind of safety net I needed to step into a professional future that captured my imagination and heart. I have long contemplated the culture of medicine, beginning in adolescence, continuing through my undergraduate studies and my master’s degree earned as a student of the UC Berkeley-UCSF Joint Medical Program (MD, MS), and through my training, re-training, and practice. Partway through the year, I was attracted to and picked up a book called Creative Confidence, written by two brothers who also run an interdisciplinary program at Stanford University called D-School (“Design School,” a play on B-School). This program teaches people how to think outside the box, share process with others, and build confidence in our creative abilities to solve problems. What did I need to feel sufficiently secure to finally try to describe a more functional, healing culture of practice? What might I contribute?
For me, the safety net was an academically credible holding position for a year, a kind of sabbatical that also provided a suitable entree for talking with people about my project. Visiting Scholar seemed like a good start although I knew that role is typically offered to people who have mastered a body of knowledge and are invited to share it at a host institution. I assumed I would not be paid as a visiting scholar unless I had time to get an independent grant, which I didn’t. I would have to negotiate this differently. I did secure this holding position at another academic institution, and that mentally paved a way forward for me. At least I thought I did—my safe landing dissolved on my arrival in New York, so I had to invent yet another new way forward.
