Personal Notes April, 2009

Balance

When one works 80 hours a week, there is no time for anything else significant. I will break this down to illustrate my point. There are 168 hours in a week. About 56 of those hours should be spent sleeping, leaving 112 hours. With 80 hours of work, one is down to 32 hours. That’s 4.5 hours per day to do everything else you want to do in a day. If you figure a half hour for personal grooming, an hour for meals (prep/obtaining/eating), 45 minutes for commuting, that leaves you 2 hours a day to wind down. It leaves you 2 hours for any hobbies you might have or businesses you need to conduct in those usually very oddly timed hours you’re left with. That’s just 14 hours a week for every other activity you might have in your life. In medicine we don’t expect this of you just for a year. This is most of your life. It’s a life almost completely dominated by work. And it’s a high stress life. It’s a life full of constant competitive examinations. It’s also a life where one misstep, one battle chosen with the wrong person, can lead to all of your hard work going up in smoke.

MD/PhD students are usually told they should find “balance”--the balance between professional obligation and personal fulfillment. I think there is no balance at 80 hours a week. There’s no time for balance. In my mind, the entire concept of balance in this career has become laughable. For MD/PhDs, there’s just a MD curriculum that expects you to be top of your class while doing PhD work. There’s a PhD experience that expects you to be as thorough as any other PhD student while completing your PhD work much faster. Then there’s an abbreviated fourth year and it’s time go off again to residency, where you can expect more of the same. You can be expected to continue with research and clinical work, being an expert in both, working hard in both simultaneously, well into your 40s. There’s no balance in this equation I just presented. From the time you start college to the time you get your first R01 grant, you are expected to be the best of the best. Everything from that 3.8x average undergrad GPA and 95th or higher percentile MCAT, to the high Step I and AOA to get the top “research” residency, to the 10th percentile funding rates of the R01. I find it funny that at every point everyone else is complaining. MD students complain about how hard it is for them, PhD students complain about how hard it is for them, residents complain about how hard it is for them. We do all of it. We have longer training, but with each piece condensed into a shorter part of time, and with multiple pieces on top of each other. There is no balance there. Well, unless you think balance is what I’ve found—an expensive as hell and hard to get bottle of beer in a city with crappy liquor laws and hopefully a food truck dinner.

The MD/PhD as an escape from indenture

Fortunately, there is one saving grace within the MD/PhD system--freedom from debt. That’s an extremely important freedom. Debt is hard to avoid because America was built on debt. Our current society pretty much forces workers to endure extreme hours for low pay, take on tremendous debt-loads in educational institutions, only to (hopefully) backload everyone’s salaries later in life so they can pay everything off with interest, enrich the financial system with all that interest, force them to work harder than they would otherwise while indentured, and perpetuate the system. This is the “strength” and “productivity” of the American worker and it’s nothing new. Over the centuries, America has brought over legions of indentured servants and slaves to build this country. With globalization, all the things that are easy to ship and tasks that are easy to perform remotely have been outsourced to third world slave labor and indentured servitude. But, most of medicine cannot be performed remotely. That’s where we come in as residents and fellows--the indentured servants of medicine. With a gigantic debt burden and no job prospects until completing a many year apprenticeship, medical students have no choice but to sign a low-paying, high-hour contract with an unknown employer through an anti-competitive match system that typically offers high work hours, little to no direct education, and no protection from workplace abuse. Fortunately, the medical student is only expected to sacrifice their twenties to this end. If you work hard you can have your Radiology or Dermatology residency and move on to a high paying career with flexible work-hours in your early 30s.

For MD/PhDs, we have been freed from medical school debt because we sacrifice our twenties and thirties (add to medical school and residency a PhD, mandatory often extended fellowship, and a more harsh research academic ladder) to the final goal of making less salary and working typically longer hours than our clinical counterparts. But I found something else in the MD/PhD package that few people talk about. Freedom. This isn’t about a couple hundred dollars more a month in your pocket because you aren’t paying back loans. It’s the freedom to do what good you want to do for yourself or the world. Without a debt ball and chain, the shackles forcing you through the system until the verge of infertility shackles you to a family, are suddenly removed. We’ll just have to ignore the fact that it’s still very frowned upon to step outside of the system and back into the real world for more than 2 weeks a year. It’s more time from obtaining your ultimate objective, if you still believe in that sort of thing. But freedom to explore is still there if you push hard enough for it.

Graduate school is your time for indentured work for a laboratory. A PI invests a small amount of money in you so that you produce a body of work to further the lab’s objectives and hopefully allow then the lab to bring in money than was invested in you. How long you spend in the lab and what constitutes enough work to be completed is determined by your PI and maybe if you’re lucky a committee. Just like in residency, there is no protection from abuse and poor training, your work and productivity, not education, are most prized, and it becomes very difficult to switch course once you have already started. I soldiered on through all of this, always believing strongly in what I was doing and why I was doing it. That is, until about half way through graduate school. The last year of my thesis became one of the most difficult times of my life. For those of you have read about me, you know that’s no laughing matter. As a child I was typically abused, ostracized, and alone. I felt that way again in graduate school. What is left in your soul when you spend that 80 hours a week fighting red tape and repeating the same menial tasks, while having nobody and nothing to look forward to except more of the same? For some it’s self-importance. For others it’s the promise of status and salary to come. I know what was left in my soul. Emptiness. As a medical student, the only out would be anti-depressants so that I could forget I had a soul in there at all. But, I had freedom from debt.

Escape

I wish I could tell you the professional details of that time. To do a thorough job would take a couple hundred pages and would burn every figurative career bridge I’ve ever crossed. So I can’t. I’m in enough trouble as it is. I feel like I’ve left you a hole in the background, and I’m sorry for that. To summarize, both personally and professionally I felt I was caught in a quicksand pool from which there was no escape. I was being swallowed whole into a life of solitude, constant work, and frustration. Fortunately, I was able to fight smart, work hard, choose some hard battles, and with the support of my MD/PhD program (to the ire of my PI and committee), I was able to propel myself out of my pit and out with a PhD. My efforts were non-trivial. I will have five first authored manuscripts (three are published now) from my thesis, a grant, my own patent application as well as my name on another patent, and a thesis much longer than any other MD/PhD student I’ve seen come out of my lab. But, I was held by forces I felt excessive and out of my control to push back my defense date until the last possible moment before returning to clinic. If I had stayed on track, I would have been editing my thesis, submitting papers, and expected to continue helping out in my lab after returning to the hypercompetitive and super important third year. All this with me applying to a competitive residency that constantly reminds me all my effort for that PhD doesn’t really mean much come match time, while AOA means a ton.

I’m not sure what happens to everyone else’s personal lives in an MD/PhD program. I felt completely isolated. My labmates didn’t like me for various reasons, and I was too busy to go hang out with them anyway. Many of my classmates got hitched, but I was never so lucky with women. I went on a bunch of blind dates that were miserable failures. I asked a few girls out that I knew in person, and while one went so far to laugh in my face, they all just never spoke to me again. Eventually, I tried to pool what little free time and spare cash I had into the activities I enjoyed like the beach, hiking, and skiing. It was still me by myself most of the time, but at least I was able to connect again to those things I enjoyed.

So when it finally came time to defend my thesis and go back to OB/GYN four days later, I wasn’t ready to go back to clinics. Whatever happened to my vacation time? I always had an approved plan to have a few months between defending and going back to clinics to go scuba diving. Somehow when it came time to actually implement that, suddenly the time disappeared. I wasn’t allowed to leave the lab. “That’s life,” people told me.

Yeah right. So, I modified my earlier plan a bit. The MD/PhD program insisted I had to go back to clinics October 26th. Nobody could hold me back without a good reason and then it would for an entire year. After that was set as a definite date for thesis completion, as opposed to the nebulous “wait and see and we’ll let you know when we think you’re done” approach that was desired by my committee, I started making plans. The end of October corresponds roughly to the beginning of ski season. A month before then, I told my MD/PhD administrator I wanted a personal leave of absence to begin in November. I got it approved by my director and the medical school. With the knowledge of only two of my labmates and a promise of secrecy, I finally left graduate school, but not for what everyone expected.

There was some planning involved in this. I was going to take any job at a ski area I could find, but in reality I ended up lucking into a part-time “post-doc” using the same sorts of skills I obtained in grad school and before. I would find in the world at large, unlike how I felt in grad school, that my skills are rare, in high demand, and highly respected. I found a cheap room in Salt Lake City on Craig’s List. I found a subletter for my apartment in Philly. I lucked into an all-Utah ski pass. My father, out of work as usual because of medical problems, helped me find the perfect car. It’s a red 1998 Subaru Legacy AWD wagon with 56k miles.

So one day in November, I packed Mr. Subie Car full of my clothes and my ski gear and drove across the country on I-70 to a region I had never been to before and knew nobody in. Growing up in a poor, dysfunctional family I had never been almost anywhere. I had no idea the plains were kind of a nothingness of straw colored grass and rolling hills that went on forever. I had never driven through anything that looked remotely like the Rockies. I found that even walking around at 10,000 feet after spending your entire life at sea level isn’t very easy. Out in the southwest, the locals comment the northeast is so “green”. I never realized the rest of the world wasn’t. I spent a few days in south Utah visiting the Arches and Canyonlands. It was as if the rocks took on their own lives and the colors were painted onto the scenery. I arrived in Salt Lake City just in time for about 3 feet of snow to fall in the huge mountains right behind my house.

Skiing

I’m not a very good skier. I think I had been skiing two dozen times in my entire life before this year, and most of that in the Poconos of Pennsylvania, which are completely laughable to anyone who skis anywhere else. I put snow tires on the car and bought a new set boots, skiis, and bindings. I was there for the day after opening at Snowbird. My housemate put me on the tram. I almost pissed my pants. The only way down that day was a run called Regulator Johnson, which is by far the steepest thing I had ever had to get down in my life until that point. It took awhile. That housemate never skied with me again. I don’t know how he assumed I actually knew how to ski. It took a long time to get used to it--these fatter, longer skis and the deep light fluffy snow that you sink into. I love it. It took me at least half the season to get comfortable, but there’s nothing like the feeling of fresh powder blowing all around you, smacking you in the face when you turn, coming down hills that seem deadly steep yet the snow practically stops you every time you make a turn. It was a new challenge for me in my life, a life that up until now had been minimally outdoorsy, that was tremendously rewarding. After well over 50 days this season of pretty much all-day skiing, I still love it, far more than the small scraps of reward medical school or graduate school has ever given me. Every time I was out there, it felt like freedom. Nobody was yelling at me, or giving me a hard time, or laying heavy pressure on me to do X thing or Y thing for them every day, or forcing me to beg for the simple things I needed just to do my job. It was just me—flying.

Life here is much different. It’s not like Philadelphia where everyone is a lawyer, a doctor, or a medical student. Here people are actually kind of surprised and interested in the fact that I’m a medical student. People are amazed I have a PhD. My housemates get high all the time, work normal jobs, and have no inflated egos. These are the people I grew up with, even if they shunned me then, it’s the type of people I’m used to and feel comfortable with. I’m connecting and making new friends again, especially in my new lab. It helps me to realize I’m not sure I could ever really fit in with the east coast, Ivy League crowd. You know, the kids that are fighting so hard to not be nerdy (either in an alternative ultra-snarky way or in a business-like too cool for school way) with their rigid cliques and party short-lists. Some of them are those brats that separately on two occasions asked me if I felt better than one of my ex-girlfriends because she was a Temple med student. It’s that world where a good time only means a crowded bar or a dance club. The rest of the city further than a few blocks from the apartment or the school is so scary it’s never ventured to. It’s not me. It’s like a whole world of emptiness. Millions of people whirring about, contented by their good looks and statuses in life, studying away supplemented by parent money and then working all of life away. For what?

Did I mention I’m not a very good skier? I’ve always been awkward and never been athletic. In grade school me being on a team in gym class meant our team deserved an extra player to make up for me. On day 2 of the season I fell on an exposed rock and broke a rib. On day 35, I mildly sprained my ACL in a ridiculous fall backwards down a rocky chute. I’m still surprised I wasn’t hurt worse than I was. But the final blow came on day 55. I got going too fast on a traverse and fell directly forward. My tibia and fibula broke completely against the front of my boot and I now have a long rod down the middle of my tibia with two screws to keep it there forever. My new challenge is to walk again.

Where to go from here

I am delighted that my skills are so in demand that I will continue to consult remotely and get paid my post-doc salary. This makes me very portable. I was planning to head to Thailand towards the end of May to get my divemaster certification. That has to be pushed back around a month due to injury. Oh well, but I’ll still be going. I return to Philly in October to resume medical school around the end of the month.

But this brings up bigger and more important questions for my own life. First, I really want to achieve balance. But remember, there is no balance at 80 hours a week. So this brings up some serious issues. First, it’s not the kind of attitude anyone within academics wants to hear. That includes the idea of me taking a personal leave of absence. What a strange guy I must be! Who would want me in their residency program?! You mean I’m not content as a sheep, fine to take my daily punishment from my superiors and pass it down the line to everyone else around me? GASP! BAD MEDICAL STUDENT! I feel like somewhere the big red light is going off. But with a system as rigid and deeply inculcated as this one, who needs thought police? When push comes to shove, I’m always expected to simply bow to the authority to those above me, and I never have. If I wanted to be a sheep in a cubicle, fighting for my own survival by making political alliances, brown-nosing, and marketing myself and my work, I would have gone into the business world.

But that’s exactly what I found to be academic research to be. I never expected this. I expected that if I was the most technically proficient and dedicated to my research I would be wanted and the career opportunities would just open themselves up. Now I’m being told that to even say I want a career more than 50% research in my chosen field will get me a laugh and a rejection. I’m being told I’ll have to work two times as hard in academics and get paid half as much for the opportunity to fight for grants that may or may not come. All the while, I’m not sure what happened to the science in there. Do PIs actually do any science? There aren’t very many that seem like they even understand what’s going on. It’s just write grants, be an administrator, and have your students do all the work. After grad school with enough ad hominem paper rejections, all the hiding of bad data, the technically proficient faculty all leaving or being kicked out, and the best salesmen being kept on, I wonder every day what happened to science. It’s not what I expected when I signed up for an MD/PhD program.

I’ve always viewed myself as a hard-working, challenge seeker who came up from nowhere and now has been everywhere. I thought people would care, but most don’t. I keep it to myself as much as possible now. The reality is you’re only as good as your last exam score or your last grant. I always thought if I worked hard I would be successful. I thought that if I treated people well, they would like me. I thought that if I was nice and I cared enough, I could make my own happy family. I don’t believe any of these any more. That’s what my time in the MD/PhD program has taught me. You can work hard, but it never seems hard enough to please your superiors. You can try to be friends with everyone, and be almost universally despised.

My Radiology mentor died at the age of 35 one night completely unexpectedly in his sleep. Coincidentally, it’s the same age my dad received his first transplant. He was extremely sick and almost died many times. By the time I’m 35, I won’t even be done fellowship. I’m 28 now. I’m the same age my father was when I was born, and several years older than my mother was. I’m still single. I may have been strapped in to a roller-coaster, but I think I’ll step off for awhile. I think all of you can see why. I don’t want to be 35 and say that I missed out on life. I don’t want to die and know that I spent it working for something that would never come. MD/PhD is an extreme in delayed career gratification, but I’ve found I can feel free to use the personal freedom we may not even know we have to find personal gratification. After three years of constant graduate work, a year of personal time makes good balance in my opinion.

I’ll be “Not in Philly” for a total of a year. It’s by far the longest I’ve ever been more than an hour from Philadelphia.

From Cottonwood Heights with an orthopedic boot on my leg,
Eric