By Victoria S. Brown, MD, MS
Starting the first month of fellowship with my July newborn, I had a plan. I had recovered from my c-section and pre-eclampsia, my baby was sleeping 6 hours a night, and I needed to do something—anything, really—that didn’t involve diapers.
Time to pursue my 6-year-long dream of treating patients with complex cancer cases in a field exploding with new treatments. I dreamed of being compassionate and brilliant liked the oncologists I hoped to model.
I knew my hospital inside out and I loved it—the smell of cafeteria pastries and coffee in early morning, the mural of a hospital patient with caregivers, the hematology-oncology faculty and staff who had been so encouraging to me in my residency.
I was sleep deprived from the preceding months of q2h night nursing, but went all in, full time, complete responsibilities and duties, as is required of most trainees.
At first, I was indefatigable and accepted everything. I would print the NCCN guidelines for every patient with cancer and post them around my desk space. I read the referenced articles in UpToDate and How I Treat for hematology consults. I accepted that due to maternity leave and a shortened first year, I should have the least desirable seat with poor climate control. I accepted 3 fewer electives in my first year—I could make them up later by extending my training—and my service/consult months were largely uninterrupted. Days lasted until darkness and nights were yet longer.
For 6 months, I woke up between 4:30 AM and 5 AM, dried off soaking breast pump parts, unplugged the motor, picked up my cold pack and pumping bags and assembled everything in my tote. Missing a step meant risking breast pain, infection, diminishing milk supply, and worst of all, loss of precious breastmilk to nourish my baby.
Without recorded morning lectures, nursing the baby and making it out the door was challenging. I had the choice of abandoning my sobbing child and remaining engorged or showing up late to lecture. I questioned my commitment—to my child, to my work.
During the work day, handling breast milk was its own skill. Breastmilk needs to be near a cold pack or in a fridge. The pump needs to be wiped down. Some days, the pump would chafe my nipples to the point of tears. After finding a location and appropriate hygiene, pumping takes about as long as a longish bathroom break.
I surreptitiously found places to pump with and without covers—despite lactation being a biological norm, lactation rooms are not standard on every floor like restrooms are. Our hospital is big, so sometimes the nearest place to pump was not in the same building. In this, the oncology nurses ended up being my allies—they knew all the places to pump, were friends with nurse managers who might let me borrow a room. Favor after favor: “Would it bother you if I pump in front of you?” “Can I use this space for about 20 to 30 minutes to pump?” I lugged that 4-lb breast pump from hospital to hospital.
Some attendings weren’t sure what I meant when I said I needed to pump, which led to awkward moments. Almost everyone graciously assented when I asked for time to pump, however. Perhaps they thought “pumping” was some new cancer treatment delivery system.
In the evenings, I nursed my baby to sleep. Early on, I needed to be close to her to hear her cries in case she needed to nurse. I would open up charts sitting on the floor of my cold cramped bathroom near my baby’s crib so I could work and not wake her. Approximately half of my early overnight calls were answered with a child latched on my chest.
Over time I became anxious and disheartened as exhaustion took its toll. During home calls, I worried that I invalidated myself as a cancer physician with a crying baby in the background, so I would frequently isolate myself from my sweet daughter and the rest of my family. At work, I felt isolated from co-fellows and attendings who weren’t entirely sure what to make of my situation or how to help.
Advice as to how to handle my situation varied. One faculty member suggested I call a counseling program, perhaps thinking depression was the problem. Another suggested (after 5 weeks return to work) that I should just quit outright, as I was “too slow” and that breastfeeding was “not necessary.” Others advised me to ignore stinging criticisms, that the problem was me “taking it too seriously.” I was told that if I really loved oncology, I should be able to overlook the difficult times.
Slowly and with tremendous determination, I somehow survived the 40+ call nights that I returned to after my weeks of maternity leave. I became more active in tumor boards. I found ways of improving areas of weakness, and sought attendings willing to help me catch up. I found myself surprised to learn that the new first-year fellows even looked up to me sometimes. I made plans to go to ASH and started two research projects.
A year later, I look back at these memories as proof of my unflinching will and perseverance. Co-fellows and attendings in my program have seen me struggle and helped me through hard times. After days and nights of volunteering to cover last-minute calls, I have finally done others enough favors to be given grace and accrue coverage in an emergency—for my health or my child’s health.
The situation doesn’t have to be this hard. What could help?
- Clear upfront program expectations and accommodations disseminated to all faculty, staff, and trainees prior to delivery
- Part-time return to work
- Designated stocked lactation areas on every floor
- Employee health physicians who are well-versed in lactation health
- Adequate mental health resources
- Onsite childcare
- Recorded educational activities and web-conferenced tumor boards to individual computers
- Supervisor-to-supervisor notification of lactation requirements at all rotation sites
- Anticipating occasional sick coverage for postpartum women
- Not penalizing women for their absence with a high postpartum call density
- Frequently checking in to make sure that new barriers aren’t arising
- Departmental women’s support groups with power to enact policy change—that include trainees
There are so many ways to support new mothers, with the most critical being leadership validation of our struggles. There is absolutely no substitute for openly and verbally supporting our needs to physicians and staff who may not understand our challenges.
I am trying to love hematology and oncology and searching for my niche. Remembering my postpartum struggles brings a tinge of sadness to the endeavor, however.
My early naive optimism has been replaced with a degree of mature realism. Change will be slow to come, if it does. Even so, I still dream of a day when childbearing will be anticipated, welcomed and expected, and incorporated into our culture of medicine.
Maybe then there will be a space for me here, too.
Dedicated to the early passing of my second pregnancy.
The author thanks Dr. Julia Close, of the University of Florida, for her feedback and improvements to drafts of this work.
Dr. Brown is a second-year hematology-oncology fellow. Her professional interests include gender equality and quality improvement projects. She is grateful to her patients as they shape her career trajectory in hematology and oncology.