The Valley of the Shadow

I never expected residency to be a cakewalk. I knew it would be hard, especially as a woman. Growing up in the deep South, I understood the concept of the "good ole boys' club." Believe me, it's still alive and well.

In the dark ages, when I started residency, there was no 80-hour work week. We were expected to stay until the work was done, which admittedly prepared me well for the real world. As a new intern, I thought that if I just put my head down, did all the work, and never complained, that everything would be fine. More than one woman had already graduated from my training program, so I figured the ground had been broken. I was optimistic as I rolled up my sleeves and dug in.

In my PGY-2 year, my fellow residents and I calculated that we were working about 120 hours a week on average, and that came to about 33 cents/hour. We tried not to think of that too often!

In my PGY-3 year, I became pregnant (amazingly, nature cooperated with our plans). I spent my third trimester as the junior neurotrauma resident at the second busiest trauma center in the country. It was known to be the hardest rotation in the program. I caught the expected grief from my (male) fellow residents, but I never missed a day of duties or call. I worked up to 38 weeks as planned. I took maternity leave (after a C-section) during my neurology elective, during which one did not take neurosurgery call; my fellow residents were therefore inconvenienced not one whit.

Things went fairly smoothly after my return 6 wks postpartum, to my mind. Fast forward through lots of backbreaking work to PGY-6, my last year. I had just completed a complex spine fellowship and was looking forward to a happy ending in about 6 more months. It was fun teaching the junior residents basic neurosurgical skills. I had a happy, healthy 3-year-old son and a loving husband. I could see the light at the end of the tunnel.

One afternoon, I went to one of the ICU's to deliver the articles each resident had to present at journal club the next morning. I approached a group of about 5 younger residents and greeted them as usual. One of our attendings was doing paperwork nearby. I held out an article to a PGY-5 I'd worked with for years.

He glared at me and said flatly, "I'm not taking this. I have plans this evening, and I don't have time to prepare. You'll have to do it!"

I stared at him, taken aback, as he stood there oozing belligerence. Then the other residents chimed in. In the middle of the busy ICU, they took me apart, my colleagues who I'd worked beside, covered for, praised and supported.

"You are so lazy." "You have a terrible attitude." "You never seem to be there to help with anything." "We're tired of working with someone so lazy." "This is all your fault."

"Lazy." "Lazy." "Lazy." It echoed, etched itself in burning letters in the air. I don't remember much else of what they said; mostly I remember the looks on their faces, the silence of the one resident I thought I had known the best.

I hadn't known them at all. And they didn't know me at all, these men who all had stay-at-home wives who took care of everything for them, had their children, made them dinner. They could carelessly condemn me without ever having been to my home, met my family, asked me anything about my life. They could never know the phone calls I'd taken for them, the things I'd done with patients in the afternoon so the call guy wouldn't be bothered. So much they didn't ever know, and didn't really care to know. So much hard work I'd done that had made no difference.

I remember leaving the ICU, articles in hand, without seeing anything around me. I paused in the parking lot just outside the door; turning, I saw the attending just behind me, and I knew he'd seen the whole thing. I asked, "Dr. X, could I talk to you for just a minute?"

To my complete astonishment and dismay, he stammered, "Have to be at, ah, a meeting, ah..." and actually *ran* to his car, leaving me standing there. So much for expecting any support from on high.

I went straight home and sobbed on the sofa for an hour, unable even to tell my husband what was wrong. Then, as a good neurosurgical resident should do, I prepared all the articles myself. I walked into journal club at 6:00 am and presented them all. I explained to the chairman that it was all my fault they didn't get distributed. And then I went to the OR.

For the next 6 months, those residents made my life miserable. Every day, I dreaded walking into the hospital. I dreamed about the word "lazy." I never, never asked for help, because you don't do that in neurosurgery. I blamed myself, because that's what you do as a surgical resident, even though I knew better. But I faced them all down, every day. It was the hardest thing I had ever done.

To this day, I still don't know why they did this. I'll probably never know, since I avoid the residency reunions held every year at the national meeting.

I was so relieved to get in the moving van at the end. Shortly before we left, the chairman held the annual dinner honoring graduating residents (there were two of us). My fellow residents had prepared the slide show, including a section spoofing the "Priceless!" commercials on the air at the time. It intimated that getting gcs15 to come in to help with a case was "priceless." My husband and my co-senior resident's wife got the same "spouse's gift" - a dried flower arrangement.

My neurosurgical training was excellent, and it has stood me in good stead over the 10 years since finishing. I have enormous respect and gratitude for many of my professors. I can say that I am a good surgeon with confidence. I love my profession, and I still can't imagine doing anything else.

What I have come to realize, however, is the destructive effect residency had on me. I'm sure I'm not the only one. I love neurosurgery, but I hate its culture. The primary tenets are: don't ever complain and always accept responsibility, even if it's not your fault. Most importantly, don't EVER, EVER, ask for help. If you do, it's a sign of weakness. If you do, you are not worthy of Neurosurgery. Call me if you need me... but don't call me, because you will be vilified. This is true in training, and it's just as true in practice. And if you don't fit the neurosurgical stereotype, you don't "belong."

I have never really gotten through the Valley of the Shadow. I have worked harder and longer than I should have worked to prove to everyone, especially myself, that I am not "lazy" after all, even though I know I never was. I swore that no one would ever speak to me again like those residents did, and I found myself unleashing a tirade on an anesthesiologist once because of that. He started off, "The problem with you is..." and I just snapped. It was visceral. The shadows still darken the valley.

Running a neurosurgical practice is hard, complicated work, but I have made it harder than it should be. Because of this, my family has suffered. I have tried very hard to strike a balance, but it has not been enough to avoid inevitable crisis. Wisdom is only gained through hard experience; I hope I have enough now to finally get past the demons. With this, much of the fault is truly mine. I should have forced myself to exorcise them long ago; I underestimated their menace.

To those who would tread the path of surgical subspecialty, I say it can be done. I know what I must do to correct my mistakes and make things better for my family. You will make your own mistakes and face your own Apollyon, but you too can overcome. One day, the culture will change. We must make it so.

"Now morning being come, he looked back, not out of desire to return, but to see, by the light of the day, what hazards he had gone through in the dark. So he saw more perfectly the ditch that was on the one hand, and the mire that was on the other; also how narrow the way was which led betwixt them both; also now he saw the hobgoblins, and satyrs, and dragons of the pit, but all afar off, (for after break of day, they came not nigh;) yet they were discovered to him, according to that which is written, 'He discovereth deep things out of darkness, and bringeth out to light the shadow...' " - Pilgrim's Progress, by John Bunyan