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Duality
PREFACE: In the late twentieth century, as more and more women entered the medical profession and became mothers, people wondered what it would mean. As might have been expected, there are many realities. For Julie Rosenbaum, who teaches in a primary care internal residency program, a major concern is how she and her husband juggle their jobs with raising young children. In a split-voice narrative, Rosenbaum details the dual focus of her days and how they interact. As she and her husband ponder what’s best, she reports that academic medicine is simultaneously pondering how best to work with and support doctor-parents. Then pediatrician and professor Anjali Jain tells what happened when her family moved from the U.S. to the U.K. and her special-needs child wasn’t well diagnosed or cared for by England’s National Health Service. As a doctor, she knew there was a problem; as a mother, she did all she could to find a solution. Eventually, she and her husband made a choice and found a solution—an American one.
Morning: as usual, I didn’t get enough sleep last night. The alarm goes off at 6 a.m.; I hear the baby stirring. I’m alone in bed. My husband left early to take the train into the city, where he works as an academic scientist. Today I’ll take the children to and from day care. Despite my multiple responsibilities at home and the office, each work day is bounded by the transitions where I transfer my children to and from the care of others. Even on days when my husband helps, which he does several times a week, I still attend to many of the details. Each transfer is a carefully orchestrated event where each detail must be addressed, from each piece of clothing to every morsel of food. Any deviation from the norm can throw the entire process and day’s productivity out of whack. At work I pace myself carefully, with close attention to the clock. If I leave the office late, I’ll be late to pick up the children, owe the day care center additional money, and bear the weight of substantial guilt and, perhaps, tears.
I entered medicine at a time when opportunities for women in the profession were soaring. As of 2004, more than 50 percent of entering students were women.1 But despite increasing numbers of women at lower ranks in academia, as in other fields, fewer women have achieved the highest echelon, including full professorships (16 percent), department chairs (10 percent), or medical school deans (11 percent). In fact, given the number of women entering medicine, the accomplishments at these levels are lower than would be expected.2 The reasons proposed for this discrepancy are many, including a glass ceiling caused by a lack of mentors, unsupportive environments, lack of flexible academic pathways, inadequate promotion and retention, and frank sexism.3 Of note: Women are also still paid less for the same work, even when adjustments are made for years of training, career publications, department type, and hours worked.4 Some have suggested that part of the gender discrepancy—in terms of achieving the highest academic posts—is because women choose to forgo professional opportunities as a trade-off for their parental obligations and pleasures.5 My three-year-old daughter, the baby, and I make it downstairs to the kitchen. Peeking at the clock, I prepare for the morning ritual. Today is Monday, always the worst day of the week, because in addition to everything else, I have to get the bedding bags to day care. One backpack per child, each including a blanket, sheets, a stuffed animal, and strategic changes of clothes, packed last night. The coffee is made; now I focus on the baby’s nourishment for the day. I fill four bottles with breast milk that I pumped last month, stored in the freezer, and defrosted overnight. Don’t forget the ice pack! Then I prepare the materials for the breast pump to take to work today. For this I have to unload the dishwasher. I need the breast shields, the four milk receptacles, and a fresh cloth for the handy-dandy, super stylish, and very subtle breast pump backpack. Can’t forget the ice pack! I know I could make my life easier by stopping breastfeeding at this point—the baby’s seven months old—but it’s not a compromise I’m willing to make. The baby starts to cry. I pick him up and do my usual comfort routine, but he seems less consolable than normal, although not hot. I hope this isn’t the beginning of something. My mind races. What if the baby’s sick and can’t go to day care? My husband’s already gone. My college-student babysitter has class today. My mother-in-law’s traveling. Perhaps this crankiness is nothing, and I can still make my faculty meeting and clinical responsibilities. Suddenly, I realize that my daughter isn’t at the table eating; this might throw off everything. I call her for breakfast. Where was I? My daughter’s lunch. My husband had prepared it the night before, and it’s in the fridge. Don’t forget the ice pack! I need to go the supermarket, but time’s the problem. I should be reading my pile of medical journals. I should be working on that manuscript I started before the baby was born. I should. I should... To redress the gender imbalance in academic medicine, several initiatives have been developed. These include mentoring networks, flexible career paths, and more robust parental leave policies. I benefit from an institution that takes part-time work seriously, allowing my progression on my academic clock to be prorated and where I received an additional year in my current term when I had my baby. Some of these policies, however, have had unanticipated consequences that, instead of leveling the playing field, have led to unexpected results. For example, some departments in other academic institutions made semester-long parental leaves available to both genders. Despite the just intention of these policies, reports emerged of men using these periods as if they were sabbaticals; they left the primary child care to their wives and used the freed-up time to further their publication records.6 A policy at Harvard Law School, which provides for parental leave with an explicit expectation of the parent providing at least twenty hours of primary child care during daytime and weekday hours, seeks to redress such abuses. Now the baby’s clearly unhappy. I remove his diaper to check a rectal temperature and find a foul diaper and a raging diaper rash. I verify that there’s no fever, and he fights me terribly as I apply diaper cream. I pick him up again, and he is sobbing uncontrollably. Is this just diaper rash or something else brewing? Is it safe to bring him to day care? Is there a communicable infection at play? What would I say to my coworkers? "My son’s diaper rash was out of control; you have to cover my teaching responsibilities this afternoon. Sorry!" I know many people who’d just give him ibuprofen at moments like these, bring him to day care, and hope for the best. My son continues to cry miserably and not let me put him down. I just can’t do this. What are my priorities, anyway? My daughter comes over and hugs me when she sees how upset I am. It’s an embrace like this that reminds you how unbelievably incredible it is to be a parent. Regardless of my proposed plans for the day, the baby needs some pain reliever; thankfully, he takes the ibuprofen easily. I sway with him as I eat my cereal standing up, giving a final warning to my daughter that it’s time to finish getting dressed and go to the bathroom before we leave. The baby starts to settle, and I again focus on departure. Beyond parental leave, further research has discovered additional aspects of the faculty/parenting challenge. Women with children have less successful academic progress than their male colleagues or women without children.7 Another qualitative study corroborating this finding quotes a female department chair who notes that women who have successful family lives do not seem as likely to ascend to certain levels in academia, that all women who have reached the higher echelon are "divorced or lesbians."8 In fact, an experiment involving volunteers pretending to be employers making decisions about hiring found that mothers, as opposed to fathers or female nonmothers, were believed to be less competent and committed and received job offers less often.9 When they did receive offers, the salary rate was significantly lower than for nonmother applicants. They were also deemed less likely to be promoted. We go to the living room, and I itemize. The baby’s bedding bag and bottle bag. My daughter’s bedding bag and lunch box. My computer bag and briefcase. My breast pump. This is ridiculous. We’re all dressed. I take the bags and baby to the car in two trips. With strange mix of relief and apprehension, I note that the baby is falling asleep as I secure him into the car seat. With both children strapped in, we’re ready to go. By the time I drop the children off, set up their things for the day, and commute to work, I’ve been up for about three hours. I’m absolutely exhausted and just want to take a nap. Finally, I take my seat at the faculty meeting. AFTERNOON: I enter the room with the intern at 4 p.m. He’s already presented his assessment of the patient’s situation to me, and I want to be present when he discusses our plan with her. I know that I must keep my eye on the clock and be walking to the parking lot by 4:15 p.m. My son’s done well at day care; the irritability was just a terrible diaper rash after all. I’ve attended to my responsibilities today, despite a slightly higher level of distraction than normal. After my departure, my colleagues will help the residents finish their patients, and I will pay them back on other days. The patient is a young woman who’s had four children by age twenty-three. She tries to run a hair salon out of her home. She is currently estranged from her significant other, who is not the father of any of the children. She has little family nearby and somehow pulls together help from friends to watch her daughters at key moments of her day. The intern’s assessed the young woman for fatigue and is concerned about her inability to sleep. He tells her that we’ll check her blood count and thyroid to eliminate certain physical explanations for her fatigue, but that we are concerned that she is depressed. Suddenly, a tear falls from her eye. She says she feels sad and stressed but that she believes depression is a sign of weakness. She won’t be open to trying medication as she thinks her family wouldn’t approve; she can’t be seen as having a mental illness. The intern looks to me with a fraught expression. I glance subtly at the clock. I only have a few minutes left. My options are to call the college student back-up babysitter or call in my faculty colleague to help the intern—but by the time I explain the situation, I might as well handle it myself. I might not be able to give the patient the explanation, time, or comfort that I think she deserves. Or my daughter will make me feel guilty for being late. Plus, the kids have already had such a long day in day care. So much for respect for the primacy of patient welfare, one of the fundamental tenets of the medical profession. I sit with the patient, holding her hand. We review some other options, including counseling and support groups; each seems impractical given the daily demands on her life. We confirm that she isn’t suicidal. We reassure her that we’ll work with her and try to help her get to a better place. I ask her to return in two weeks to review the lab results and see how she is doing. "I am just trying to do the best I can..." she says. I look her in the eye and say, "I know, I know..." Physicians are supposed to try to understand our patients’ perspectives as if we were standing in their shoes. Despite my daily challenges, I could never fully appreciate her struggle to care for herself and her children. As harried as I sometimes feel, I count my blessings and appreciate the resources and opportunity I have. According to an analysis of the work of the average U.S. mother, if you consider each component of a mother’s role (for example, housekeeper, cook, launderer, van driver, and psychologist), she would earn $134,121 a year in salary.10 The immutable work of the home still takes time and effort, and it doesn’t go away when both parents work. According to the U.S. Department of Labor, even in dual-income households, women continue to take greater responsibility for housework and child care than do men, spending close to an hour and a half more each day caring for their home and family and an hour less at work.11 The intern and I step out and quickly confirm the plan, and I grab my coat, computer bag, briefcase, and breast pump, wave to my colleague, and clumsily scamper out. Sometimes I feel compromised on all sides, as a parent, teacher, physician, and person. Once on the road, I give a hands-free call to the intern to talk about one more social work alternative for the patient. I watch the speedometer. Given the stresses of the day, I again contemplate if my husband and I have arranged our situation appropriately. I’m often overwhelmed with how much mental and emotional energy this topic consumes. Having a nanny would make the start and end of the day easier. But it would be substantially more expensive and subject our children and our work lives to major disruption if she quits, as we learned the hard way. And if we got more help, would I feel guilty spending less time with my kids? Maybe. It’s time to take more advantage of the college students in town for babysitting help, to find a nice, responsible kid with a car. Even with this option, however, we’ll have to work around vacations, finals, and health issues. No solution is perfect, and redundancy in the system is crucial. Each family works out its own balance and, importantly, makes adjustments each year as children progress through school. I’m almost paralyzed when I contemplate how to arrange my schedule once my children grow and have more activities that I’ll want to encourage and attend. Take a deep breath. Take it one year at a time. Take it one day at a time. Many women have given up on the notion that they can have it all, at least at the same time.12 We desire flexibility and alternative pathways, but also not to be discounted or undervalued simply because we are also mothers. We hope that our husbands can continue to contribute to more of the household activities through increasing job flexibility—as do they.13 Increasing fathers’ ability and time to be involved in their families might help our children’s academic achievement and social development.14 These changes, however, can be achieved only through leadership and workplace policies that create environments allowing men and women to be involved in their families without the weight of cultural biases that might hinder any parent from reaching his or her full potential, either as a professional or as a parent. Luckily, traffic is moving well this evening. I should be at the day care center almost on time. My children will likely be alone with the teachers; I’ll give each child a huge hug.
Julie Rosenbaum (Julie.rosenbaum{at}yale.edu) is an assistant professor at Yale University School of Medicine and teaches in the Yale Primary Care Internal Residency Program. In addition to seeing patients, supervising residents, and conducting scholarly activities, she is the mother of two young children.
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