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The Resident Parent

I started medical school just four years after the quota on female medical students at NUS had been lifted. I'm not sure if the millennial generation remembers this, but female medical students used to be capped at one-third of the cohort between 1979 to 2000, due to the higher rate of attrition of female doctors from the workforce. Singapore is run in a pragmatic way and MOH explains that this quota was lifted when the gap in attrition rates between males and females decreased and the medical student intake increased. At my medical school interview, I encountered the not-unexpected question, "What if you have children?" I had given this some thought and replied, "I'll probably continue working even if I have to go part-time". This seems to have been good enough for the interview panel because I passed. 

What my Residency journey looked like as a parent

As life turned out, I got married during my Cardiology rotation in R2 year, to a gracious and forbearing school teacher who accommodated my shift-work schedule as an emergency medicine resident. We had our two sons in 2014 and 2016, during my senior Residency. Each time I gave birth, I took a 10-month leave of absence, kindly granted by my Programme Director (four months 'Maternity Leave' followed by Five months 'No Pay Leave'). The 10-month leave of absence each time was to allow me to a) breastfeed for at least 10 months and b) figure things out (feeding, sleep, schedule) as a first-time parent and then as a parent of two so that I could have a sustainable arrangement in place before returning to shift work. This stretched out my two-year Senior Residency to four years without exceeding the maximum allowable period of leave, and I took the different components of my exit exam over a period of two and a half years with three different batches of my peers. During this time, I was referred to jokingly in my programme as "The Permanent Resident" - an apt title!

I am also possibly the first Resident in Singapore to whom permission was granted to work part-time for a spell of nine months, so that I could have greater home presence when my firstborn was going through a boundary-testing stage during the toddler period, at a time when my husband's work commitments had increased. I had to go back to full-time work after the birth of my second son, as one is not eligible to take the clinical exit exam when part-time. It was quite an unconventional route, but I count myself immensely privileged that I had an understanding programme director and faculty who supported me in my decision to prioritise family and gave me the time and space I needed to do so. This support was what enabled me to continue with my Residency journey. 

The pain of breastfeeding as a working mother

Motherhood is quite an adventure which would have been daunting without the allowance that I was given to take things slow. I don't think I can write an article about being a working mother without talking about breastfeeding. To begin with, as doctors, particularly if we have rotated through paediatric rotations or Children's Emergency, the mantra "breast is best" has been drummed into our heads. It's part of the accepted wisdom that we dispense ourselves. However, what I didn't realise till I became a parent was how closely breastfeeding is related to sleep. A breastfed baby, to whom the breast (and the attached mother) is the primary object of comfort, often relies on sucking to sleep, and sucking BACK to sleep at night. As first-time parents, my husband and I were very gung-ho about breastfeeding. As our son did not take well to the bottle, I did direct latch all the way the first 10 months, which was an overwhelmingly positive experience, except that by the time I went back to shift work, we had a baby who would wake up at night multiple times to latch. My husband was doing his MOE HQ rotation then, so he had office work rather than the "clinical work" of teaching classes the next day; when I was on night shift, he would wake up with the baby up to five times a night, explaining to the baby "Mama is not at home", and would sometimes have to bring our son through the house showing him the empty rooms to show that I was at work before our son consented to go back to sleep without the breast! 

The second time around, we could not afford to have my husband up all night if I was on shift because he was back to a very demanding work commitment and had to rest at night. So, for number two, we steeled our hearts and introduced the bottle very early on (amid much loud wailing and gnashing of gums). Only to find that in order to introduce the bottle very early on in infancy, one has to pump at very short intervals to resemble the frequency with which the baby would feed if it were latched directly. Since the pump is not as good at stimulating milk production as the baby latching directly, it invariably leads to supply problems. It's thus a trade-off between familiarity with the bottle (and interchangeability of caregivers, ability to place child in infant care, put baby to sleep without having to suck to sleep etc), and a good supply of breastmilk. I personally find pumping when I am at home very frustrating because a) instead of cuddling 20 minutes with my baby, which is what I really want to do, I find myself stuck to a machine for 20 minutes; and b) beyond sacrificing the direct latch with baby, I have to wash and sterilise the pump parts before and after. In addition, pumping on schedule while trying to take care of an infant at the same time can sometimes be impossible. 

Ultimately, I found pumping (while still on leave) so frustrating that in the end I started supplementing with formula at 6 months on the dot, and by 8 months baby was off the breast entirely and fully formula-fed. In my own experience, formula milk thus became something that one could buy for peace of mind and which enabled me to concentrate fully on my patients in the fast-paced emergency department. 

Back to work!

Adjusting back to work after each period of no-pay leave calls for understanding on the part of one's peers and seniors. While one is away, one's peers have been seeing clinical cases and growing in their practice every day, whereas one has been gaining experience in diaper-changing, baby-talk, breastfeeding, sleep-training, toddler discipline, De Quervain's tendinitis and trigger fingers from lifting a live weight all day. Once back to work, a period of adjustment is required - one's clinical skills are definitely rusty and there is a period of sharpening required for the blunted axe. Just like how one may have been running marathons of 42km, once one stops running for 10 months, it takes time to get back to the same level of skill and stamina - first one has to start with 2km, then 5km, then 10km. So you have to cut yourself some slack and you cannot be expected to be in just as good condition as you were right off the bat after a period of absence for motherhood.

It's great if people understand this, but it's a bonus if they do. Your absence may sometimes be "unseen". People may not understand that you've been away from clinical work, and think you've just come back from a different rotation. Worse still, your clinical abilities may still be "pegged" to those of your peers who have been working the last 10 months, and people may still be mentally putting you in the same bracket as your (now more senior) peers, when actually they should be comparing you with your old level at which you stopped working 10 months ago, but a bit rusty compared to even that! So one has to work extra hard to catch up, and be prepared to be unfavourably compared both to peers as well as to juniors. I was realistic about all this and anticipated a lot more criticism than I actually faced. Thankfully, any disapproval of my abilities when I returned from both my absences seems to have been mostly imagined. I did get a comment from a senior about how "your junior knows such-and-such better than you", but I think all of us doing emergency medicine are fairly resilient (with much worse things said to us by patients), so as long as I knew I was doing my best, it was ok. When I was on no-pay leave, I also felt it was my duty, whatever else I might forget, to be safe at least with regards to ECG reading, and spent some time mugging Amal Mattu ECG videos so that I wouldn't miss a dangerous ECG on my first day back at work. 

The joy of motherhood and medicine

Sometimes I ask myself if I am less of the doctor that I could have been because I am also a mother. I think about that quota on female doctors which was removed only four years before I entered medical school. Wasn't it there because people were afraid that female doctors might leave the profession or do less work after they had kids?  However, I always come to the same conclusion, which was that part-time or no-pay leave doesn't make one a bad doctor. A bad doctor is an angry doctor, or one who lacks compassion, or who forgets about treating people like humans. In that sense, motherhood has actually made me a resoundingly better doctor than I was before I had children, because what motherhood has done is to make me human.

I find that the main change in my life after having kids is twofold. Firstly, I have become more patient and more realistic. When I was young and kid-less, I had the invulnerability of youth and strength. I could do back to back night shifts without a sweat. I could work like a machine and was less forgiving of inefficiency. But kids have given me a doorway into a more human experience. I spend so much time every day doing things that are repetitive and mundane, and have been taught to value what is small and humble as I know that it will sow seeds of what is great. I am made inefficient by my children, which teaches me patience. I have been shown, to quote Victor Hugo, how closely kindness is akin to greatness, and this has made me more kind in my practice of medicine. 

Secondly, I have become more vulnerable to feelings and to fears.  In the past, before kids, I could shrug death off more easily. But with kids, who are wholly dependent on you and who teach you feelings again (both in the sense of having feelings for them and experiencing the world through their innocent eyes), it's as if some greater capacity for feeling has been unlocked; nowadays I cry much more easily, including at newspaper articles and thoughts about the state of the world we live in. As I raise my kids to be able to articulate their emotions, I am better able to articulate mine as well, which I find is a vital skill for any doctor as we need to be able to talk about the experiences which trouble us, to avoid burnout. In the past, paediatric deaths, or indeed anyone's death, struck less close to home; nowadays I find the sight of death and suffering more affecting. And indeed, I am thankful that I do; that after encountering so much death and suffering, I am still able to feel compassion for the patients.

One thing I've observed in emergency medicine Residency is that one may have plans to work in emergency medicine, but if shift-work turns out to be a deal-breaker for family, one will have to prioritise and change one's plans. Prioritising family is never wrong. I am glad my supportive family has allowed me to remain in this profession and that I have been given the experiences I have. Indeed, all of us, whether parents or not, are shaped by our human experiences, and can bring these lessons to our practice to help us improve the art of medicine.