Having kids in residency – a perfect storm

I just read an article by a fellow female physician. A well-written and brave piece about putting her life on hold to become a surgeon. After the many rigorous years of training, she finds herself at age 38, without a partner, going through the difficult and expensive process of trying to freeze her eggs with the hopes of one day having a family.

This had me reflecting on my own training years which were quite different. I got married after my second year of medical school. My husband was also a medical student but while I was in Chicago, he was in Milwaukee. We thought we’d spend the last 2 years of med school living apart and seeing each other when we had breaks, but after a few weeks realized that wasn’t going to happen due to our crazy schedules. So we decided to find a midway point and live together. This meant a 1-1.5 hour daily commute for each of us; sometimes waking up at 3 am to be in the hospital for general surgery rounds by 5 am.

By the day of my med school graduation I was 5 months pregnant. I had my first child a few months into internship year, scraped together vacation and sick days to get 4 weeks off at home with her. It was rough. I’ll never forget my first week back in the hospital – people would congratulate me on the baby, and it took everything in me not to cry – every time.

I was dedicated to full-time breastfeeding. So with working long days and taking every third night call, that meant stealing away to pump every 4 hours, which was often hard to manage. My husband or nanny would bring the baby to me on call nights so I could nurse her and hand over the pumped milk. That year was a blur.

When we moved to Cleveland for our residencies, we were focused on having a short commute and found a place near the hospitals. But a month later, we found a great nanny on the other side of town. After emptying our last box, we packed up again and moved 30 minutes away.
I can’t begin to talk about how hard residency is with a baby. Everything gets short-changed. Time with your kid. Time studying for boards. Time training. And most of all, your physical and mental health. It was like slowly dying.

I worked very hard, was selected as chief resident, and aced my boards. I felt compelled to apply for a fellowship even though I was newly pregnant with my second. I applied and matched into a competitive spot. But when the time came, I knew with every fiber of my being that I had to stop running. I just could not imagine doing it all over again – starting fellowship only to have a baby a few months in and then struggle to juggle it all, including research. So I committed a professional faux pas; I withdrew from my spot post-match leaving the program without a fellow. I felt very bad about that part of it, but to this day 15 years later, I don’t regret that decision. I worked in a clinic part-time that year, and it gave me a chance to find a little balance and spend time with the new baby and my then 4 year-old.

Looking back on those years now, with my eldest being a freshman in college, second in high school, and youngest 12 years old, my main memory is sleep deprivation and emotional exhaustion. It was so hard being away from my kids and trying to prioritize my training. But in many regards I was lucky to have been able to do it that way. It was extremely difficult for me, yet I think my kids fared well. They had other loving care givers, and by the time they were old enough to need my daily wisdoms and guidance, I was able to work part-time and give them more of me.

Residency training is physically and emotionally draining. Add to that the challenges of new motherhood, and you have a perfect storm. Approximately 5 years after residency I was gifted a massage, my first ever. I distinctly remember that half-way in, the masseuse, a former Egyptian olympic athlete, said that I didn’t have a single muscle in my body. I was devastated, a former athlete myself. It took a long time to get here, but I’ve spent the last 5 years recovering, prioritizing fitness and my emotional well being, things that are often neglected during medical training.

Women in medicine face myriad challenges. Delaying starting a family until after training or trying to do both simultaneously both involve a lot of sacrifice. In reality, we don’t often have the privilege to voluntarily choose one over the other. Life happens and we struggle to keep up with it. In retrospect, I don’t regret the path I’ve chosen, both as a physician and as a mother. Each has come with its own set of joys and challenges.

Overnight Hearts

As I was lining up mason jars and adding dry ingredients layer by layer for overnight oats, I got to thinking….

It’s pretty cool how just by adding liquid and leaving them overnight, these hard, dry ingredients turn into a creamy, delicious concoction the next morning.  The oats soften, the chia seeds swell, and everything mixes together to make something new and better.

So I started thinking about myself. How can I set things up for myself so that I can rest, rejuvenate, and be a better version of myself the next day.  Overnight oats are all the rage.  They are easy to prep, healthy, and a great way to start the day.  How about overnight me?

I’ve read a lot about having an evening routine to help prepare for a restful night’s sleep.  No screen time for the last hour.  Take a hot shower or bath. Keep lights dim and home quiet. Pray or meditate.  Do some deep breathing exercises.  Gentle stretching. 

Most of us know the restorative physical and mental benefits of sleep. Yes, we often sell ourselves short, because we are staying up late to get work done or just have some quiet unwinding time; waking up early to get more work done, have some reflective alone time, exercise, or get a jump on the day some other way.   

 But something we may not take into consideration are the emotional benefits of sleep.  With toddlers it’s obvious, when sleepy, they often have a total meltdown.  With adults that can happen too, but it’s usually more subtle. I often find my mood getting increasingly depressed as my sleep deficit grows.  I have less energy and less joi de vivre.  

Another emotional benefit to sleep is mending hearts, à la the old adage, sleep on it. Sometimes if I’m very upset about something, letting it sit overnight softens the situation.  I may be ready to fire off an angry email that night, but the next morning I can write something more thoughtful and nuanced.  I may feel hurt by something someone said and feel like cutting them off, but the next morning I’m read to forgive and allow for reconciliation. 

Closing the lids on my mason jars, neatly filled with a variety of dry ingredients, I’m thinking about the potential softness and sweetness of overnight hearts.  Here’s hoping I can take a deep breath and slow things down when necessary, sleep on it, and handle it even better the following day. 

Your Success is in Who You Surround Yourself With

There’s a smile behind this mask 🙂

While I was in the operating room today, doing my favorite dance, i.e. cataract surgery, I realized something… my success as a surgeon is in large part due to the staff assisting me in the OR.

Firstly, there is a surgical technician who sets up all the instruments and hands them to me during the case.  A good surgical tech anticipates the surgeons actions and has the next instrument ready.  When I’m working with a surgical tech that knows me well, it flows beautifully. I’ve barely reached my hand out for the next instrument and it’s already there.  I don’t have to ask for anything, she has already prepared what I’ll need next.  This wordless exchange is seamless, and we can carry on conversations about myriad topics while we do this graceful dance. It’s often a fun surprise when the patient, who is usually in a twilight sleep, chimes in on the conversation from under the drape.

In addition to the surgical tech, there is also a circulating nurse and a nurse anesthetist (or anesthesiologist) in the room with me.  The circulator does just that – circulates – almost non-stop to prepare everything between cases, bring the patient in the room, and fetch whatever is needed during the case.  An ideal circulating nurse should be efficient, while attuned to details, friendly with the patients, while maintaining professionalism, and helpful to the surgeon.  I have been lucky to work with great nurses, and it’s part of what makes my OR day the highlight of the week.  The anesthetist does the critical job of keeping the patient alive and comfortable while I operate.  It’s important to me that my patients have a pleasant and painless surgical experience, and that is achieved by good anesthesia, not too light, not too heavy.

As mentioned in my Clinic Culture post, the staff helps set the tone for friendly and compassionate patient care, and this is very true in the surgical setting, as well.  Everyone the patient meets from when they enter the surgery center to when they arrive in the recovery room post-operatively impacts their overall surgical experience.  As the surgeon, I am only one link in this chain of kindness.

Even outside of surgery and clinic, my success is related to the people I surround myself with, both actually and virtually.  Therefore, I try to surround myself by people that remind me of my purpose in life, my goals, and generally encourage and support me to the best person I can be.  This applies to family and close friends, but also to virtual friends and connections on social media.  They can promote and amplify the best side of me, or if I’ve chosen wrongly, they can really bring me down.

Look around and ask yourself, do the people I spend the most time with reflect the true me, the best me, or the person I strive to be…  If not, it may be time to reach out and make new connections.  Although it takes time and effort, it’s well worth it.  I speak from personal experience, as this past year I prioritized developing social connections that bring me joy, not only those that I feel obligated to maintain, and it has made a positive difference in my well being.

There is an Islamic saying attributed to the Prophet Muhammad ﷺ that states: Try to have as many as possible true friends, for they are the supplies in joy and the shelters in misfortunes.


Clinic Culture

Everywhere you go has its own culture.  Merriam-Webster defines culture as: the set of shared attitudes, values, goals, and practices that characterizes an institution or organization.  In my clinic, I have worked hard to establish a culture of compassionate care, where we consider the humanity of everyone that comes in, and we work hard for each patient.  We serve our patients in whatever ways we can, and we try to go above and beyond the job and what is expected of us.

Our clinic culture is not established primarily by me, the physician.  But more so by my staff, who I value and treasure.  They are on the front-lines, seeing patients before I do, fielding calls and queries, and doing most of the behind-the-scenes (often grunt) work to care for our patients.  It warms my heart when I hear them take a few extra moments to ask a patient about their family member, make a phone call to check on a patient that missed their appointment, set aside samples for a patient that can’t afford a needed medication, or sit on the phone for extended periods of time to arrange a sub-specialist appointment for one of our patients.

If we recommend something for a patient, an over-the-counter treatment, a lab or radiology test, a visit with a primary care doctor, we make sure they have the tools they need to get that done before they leave our office.  Most of the time, we do the scheduling for them, so that things don’t get left undone.  We care about our patients, and we wouldn’t recommend something that we didn’t think was important, so we follow through.  Similarly, any instructions I give patients, I write down for them and make sure they have a large-font print-out to take home with them.  I also spend a lot of time on verbal instructions, because I truly believe in patient education.

All of these efforts do take a lot of time.  For that reason, I strive for efficiency in other areas, to save time for what matters most – the human connection.   For everything I write,  I use shortcuts, like dot phrases in Epic EMR or pre-printed sheets that I have created where I can circle what is relevant to each patient.  For verbal instructions, my staff will often help by repeating or reinforcing what I have explained.  Additionally, one of the main reasons I’ve created the my website is to give patients another place to hear things explained, in case they forget after the appointment.

I believe that with time, effort, and the right group of people, every clinic can transform their culture to one that puts patients first, offers compassionate care, treats the whole person, and emphasizes patient education.

Managing Bias

“I like your hijab”

As a Muslim woman who wears hijab, I have dealt with more than my fair share of bias.  Now that I am almost 20 years post-medical school, I have developed many strategies for managing this in the physician-patient relationship.

During my 3rd year of medical school, I was so happy to finally be out of the lecture hall and into the hospital halls. I remember rounding on patients once with one of my fellow 3rd years, a male. We were both wearing our short white coats, differentiating medical students from residents or attendings.  We walked into the room of an elderly white woman, who was talking on the phone when she saw us come in.  She quickly said to her conversation-mate:  I have to go now, the doctor and his nurse just walked in.  I don’t think she noticed the color drain from my face!

Until now, there are days when I call a patient into my exam room and routinely introduce myself as Dr. Diab and they say, “Oh you’re the doctor?”  Many of them later explain that they think I look “too young” to be a doctor.  Or one of my frequent favorites, “you look like a school girl.”  Over the years, the comments about my youthful appearance no longer make me feel small and inadequate, they actually put a smile on my face. 

Reasons why patients assume I’m not a doctor:

  1. I don’t fit a stereotype.  Many people still assume doctors will be older, white males.  I have been holding my breath waiting for this trend to change.  In 2019, there will be more women entering medical school than men. But even prior to that, the percent of females was almost equal to males.
  2. I wear a scarf covering my hair.  Many elderly patients associate the head covering with either being a nurse or being a nun.  I have often been called “sister” in the hospital elevator.
  3. I look “too young” to be a doctor.  This one surprises me because by the time we are attending physicians, we have completed 4 years of college undergraduate work, 4 years of medical school, and depending on the field, at least a few more years of residency, and often time more for fellowships.  I am surprised that any of us look young after all that!

Ways that I combat patient bias:

  1. Despite many of my colleagues shunning the traditional white coat, I always wear it.  I feel it distinguishes me from other staff in my office and establishes me as the physician.  I also dress professionally under the white coat.
  2. I no longer wear solid white head-scarves (hijabs). I choose neutral colors or something with a nice pattern.  Somehow I think people are less likely to assume I’m a nun this way.
  3. I always introduce myself as Dr. Diab.  Even when patients later ask me what is my name, I say Dr. Diab.  In return, I address any patients age 60 and up as Mr. or Ms. unless they ask me not to.
  4. I behave in a professional manner.  I carry myself with a serious but polite air.  I speak in a formal tone at the outset of the interaction. I am open to the occasional joke or personal anecdote being shared from either side, but my default is formality.  Patients that I’ve known for years slowly become like friends, but that comes with time and shared personal exchanges.
  5. I value patient education.  I spend a lot of time explaining to patients about their conditions and their treatment.  I feel this empowers them to make better decisions and follow my recommendations.

As I have gained more experience, confidence, and competence over the years, it shines through clearly to my patients.  My positive patient interactions far outweigh the negative.  The other day, I was so happy when a white male in his 60s said, I like your hijab!  Apparently, he has a thing for paisley…  as do I.


A Medical Mission


In the summer of 2018, I had the opportunity to travel with a non-profit organization (SAMS) to Jordan to provide eye care for refugees and other underserved populations.  I traveled with a large team of healthcare providers spanning all specialities, including a team of 6 ophthalmologists from all over the US.  Most of the people we treated were refugees who fled the war in Syria. I saw patients in the infamous Zaatari refugee camp, in a make-shift clinic in a small border town, and in a modern eye hospital in the capital, Amman.  I performed some laser and cataract surgeries, but primarily, I did exams for medical conditions of the eyes and glasses prescriptions. We worked for 6 days straight. In one day alone, I saw over 50 patients in the refugee camp.

I walked away in awe of the strength and resilience of these people.  Empowered by their will to not give in to desperation, to not curl up and cry about injustice, to push on and build a life for themselves under these awful new circumstances.  They were kind, appreciative, funny and sometimes very clearly depressed.  The children still had a sparkle in their eye and hope for the future.  One little boy (featured above in the picture at the slit lamp) was accompanying his grandfather who was one of our cataract surgery patients.  When I asked him what he wanted to do when he grew up, he said he wanted to be an ophthalmologist like me.

Much of what I did was listen to people’s concerns about their eyes, do a quick examination, and give them a bottle of artificial tears, after they had been lined up outside for hours waiting for their turn to be seen.  But their gratitude that someone took the time to fly across the world, leaving their own family and job, and peek into a slice of their life, made those moments more meaningful.  I believe that the impact we make on people in these situations (just as in my everyday medical practice) surpasses the actual medical care that we provide.  I believe that we can convey a sense of worthiness and value to each individual, a feeling of collective humanity, and a ray of hope for brighter times.

I was overcome with my own sense of gratitude.  Gratitude for my overly comfortable life, for my excellent education and training, and for having a skill to offer those in need.  The ability to help others is a privilege. It was my honor to serve in this capacity, and I hope to have similar opportunities in the future.