By Matthew Strickland
The Resiliency Blog’s first interview began in a basement simulation room surrounded by mannequins that lay under clean white sheets. Recording app switched on, an iPhone sat on the table in front of Dr. Jodi F. Abbott. Despite knowing that the next hour would be spent discussing her personal and professional challenges she was calm, smiling, and eager to get started. If you know Dr. Abbott-an obstetrician and gynecologist at Boston Medical Center (BMC)-this presentation does not surprise you. She brims with passion, energy, and conviction whether you are talking about maternal hypertension or the commute home. Most students, however, do not meet her until their third year Ob/Gyn clerkship for which she is the director. If they were present for this interview, they would notice her remarkably curly hair, warm smile, and formidable stare through thick glasses.
In addition to her roles as an Ob/Gyn attending and medical educator, she is Director of the Antenatal Testing Unit that oversees high-risk pregnancies at BMC. As a researcher, she has conducted nationally recognized quality improvement projects that focus on patient safety education. Her passion in teaching and medical education has led her to serve as mentor to many students and residents, through which she has witnessed much adversity and resilience.
“I’ve been interested for a while as an educator about how we can help people be more resilient. Resiliency is awareness of an internal capacity for overcoming obstacles. So that personal narrative-the way you tell it about yourself-becomes really important in how you manage crises.”
She believes that too often we get our personal narrative wrong attributing personal success to being “good at math and science, and not because of internal drive and determination.”
Dr. Abbott struggled in her first semester of medical school. One class in particular-biochemistry-would come to mean much more to her than simply surmounting a first year course. To illustrate the meaning of this experience, she contrasted herself with a college friend who was also on the pre-med track. He had focused his undergraduate coursework towards perfecting the art of taking a multiple choice exam. Rather, she prided herself on her ability to “talk and to write.”
In fact, she told us, “I was quite arrogant that I had gotten my money’s worth out of my education focused on the humanities. I felt I had a better quality education than he did, and that I was better prepared to become a doctor.”
She was in for a shock when they began medical school together.
“Suddenly no one wanted me to talk, or to write, and all I had to do was pass multiple choice tests. It was so easy for him because it was the way he thought; he had trained himself. It was so humiliating that I was struggling. I went through this little crisis like, I can’t let biochemistry define my career as a physician!”
She identified that her small group preceptor was part of her difficulty in grasping course material. Having grown up with a professor for a father, she had always been encouraged to reach out for academic help. Drawing on this habit, she met with the biochemistry course director and bluntly told him, “I won’t pass if you leave me with this preceptor.” Her course director responded in kind by taking her into his own small group. Not only did she begin to grasp course material more quickly, but a sense of autonomy had also sprouted.
“I advocated for myself and it completely changed everything for me. It left me feeling more empowered-that I could take action.”
Later, when she was again challenged by translating her understanding of course material into multiple choice exam points in neuroanatomy, she was able to meet the challenge head on with her newfound confidence.
“I understood it but struggled to get the questions right, I couldn’t even explain to you why. But it helped me to know that I had survived biochemistry. I put myself in a situation where I felt more confident when I struggled in neuroanatomy. I knew, okay, this is what I have to do.”
As she dealt fiercely with her challenges during her first year, she drew strength from her parents and friends as support systems. Looking back, she realized the benefit of focusing on a course she was good at:
“I was terrible at biochemistry but I was really good at anatomy. So being able to be a resource for someone who was struggling with something else, that helped my self-esteem. There was something good I could do; I wasn’t just failing.”
For Dr. Abbott, the importance of self-care emerged as a central theme during her second year as she prepared for the dreaded Step 1 national board exam. She fears that too many students go into a sort of “study-hibernation mode” for Step 1 and that it can become “really pathological not to interact with the outside world.”
“I don’t know a way to make it better. You’re reading stuff over and over again, and you’re not sure if you’re taking it in. I think there’s a point where everyone studying for Step 1 says this has to end! This is the most miserable experience of my life! But it does end! And that’s a good thing.”
Her coping strategy during Step 1 preparation revolved around a planned trip to Disneyworld with her future husband. “We literally had the car packed. We jumped in and drove to Florida in May. It was the best thing to have this plan of exactly what was going to happen-to have something to look forward to-to have this end date.”
Clinical Years and Internship
For anyone who has experienced the whirlwind of clinical clerkships, they happen at a break-neck pace slowing down only well into fourth year. Rarely, do students have time to ponder the greater design of such a system, and the rapid maturation that they undergo.
As Dr. Abbott describes it, “the best analogy for third year is it’s like the Tour de France for which each stage is different. This stage is about climbing, the next is about coasting…the one after that is the scenic route.”
She believes that what characterizes the majority of the medical school experience is lack of control. The beauty of fourth year is that you regain that control.
“Fourth year is like the sky opens up. It has sunshine and flowers; you can choose things and create something. Some people need to get their lives back, but others ask themselves what do I really want to learn before I start my next career? What will be fun? Where do I want to travel?”
Transitioning into internship, however, is a completely different story. She said, “internship is like going back to the first year except with higher stakes because you could actually hurt someone. You realize that you only thought you had no control over your life in school. But in internship, you really don’t.”
She explained that in first year, it’s still possible to skip class or even to sleep in. It is having a choice that makes the difference. This freedom to choose is taken away during intern year and “you’re at the bottom of the totem pole [again] except that people have expectations. You don’t realize until you’re out of third year that no one expects you to know anything-it’s kind of a bonus. But if the intern doesn’t know something, it is something that needs to be taken care of.”
She stressed how important it is for the trainee to remember that they do possess a good fund of knowledge even if it frequently does not feel like it. She shared an anecdote of her own self-doubt that occurred during the spring of fourth year:
“I realized I was going to graduate and not know anything. Where do splinters go and what are growing pains? I’ve never seen neurosurgery and I don’t actually understand what ophthalmologists see. As a kid, I really believed that I would know all of these things when I grew up to be a doctor. I had this very childlike view of what it would be like to be a doctor: omniscient knowledge-like when I get that M.D., I will know everything, which was stupid.”
Even years later as an accomplished attending, she was not immune to the same inner voice of self-doubt when trying something completely new.
“When I decided I wanted to go back to school, it was tremendously anxiety provoking. I took the Creole course they offered here at BU. I would sit there and just be sweating-not a panic attack-but physical discomfort from not being the most skilled person there. When you’ve finally mastered something, it’s really difficult to be the one with the least knowledge. It’s a really good reminder for me as a teacher, no matter how simple the task, you have to get past that intimidation if it’s foreign to you.”
Dr. Abbott’s Ob/Gyn clerkship can be a polarizing experience for students. It is an intense rotation that for many is a harsh introduction to surgical culture. She shared her perception of her role as the clerkship’s architect:
“This is who we are in Ob/Gyn and this is how we interact with the world. That’s how I will approach you coming to my clerkship. For 80% of my patients, I’m a really good doctor. For 10%, I’m the perfect doctor, and for 10%, I’m completely the wrong doctor. I would say that for students too. 80% of students appreciate the kind of energy that I’m trying to bring to teaching. 10% are like, I’m so glad, thank you for sharing. The last 10% are like when will this woman shut up?”
But why did she decide to focus on medical students-particularly when she had been involved with training residents before? The answer stems from having a brother who died of medical error-something she only found out as a third year medical student. Her initial reaction, when her mother told her, was disbelief.
“I was convinced that she had misunderstood. I completely over identified with the medical profession to such a degree that I didn’t allow room in my intellectual consciousness that my mother was right-that the medical profession had completely ravaged my family.”
After coming to accept what had occurred, she began to see teaching as a means to promote safety:
“I really wanted to help trainees not make mistakes. The evolution that I came to was that I could be a really good doctor-but who would help keep my patients safe when I’m not there? So I wanted to teach others to be safe.”
Dr. Abbott experienced a major period of adversity in her life before coming to Boston Medical Center (BMC). Previously, she was part of a practice with four men that adhered to a very specific compensation model where revenue depended directly on the socioeconomic status of patients coming in to a particular site. She recalls, “the site that I saw patients-which was for poor people compared to the rich people ultrasound site-made half as much. But I loved taking care of poor people.”
Pressure from her chair to generate more revenue began to mount and she gradually began to fit in more high-revenue kind of patients.
“My clinical practice evolved from seeing people with high risk pregnancies to people asking for me specifically-which was a great ego rush I have to admit. So I’d fit them in before work, I’d fit them in for lunch-I didn’t have lunch for like 8 years! But at the same time, I was taking care of very complicated and time consuming patients which meant less money.”
Her partners, on the other hand, were seeing more wealthy patients at lower volumes. To make up the growing difference, she was pressured into taking more call. This inequity culminated in Dr. Abbott making a staggering $250,000 less than her partners while still working more hours. A seemingly toxic relationship with the chair of her department worsened:
“I was told a number of times by my chair that my partners deserved to make more money than me because their wives didn’t work-that it wouldn’t be fair to them to move me to sites that were higher paying. I was told I had to stop teaching or see less complicated patients or cut my salary. I got paid the equivalent of two hours a week to be the residency program director.”
The downward spiral of taking on more and more call while balancing complicated patients with high risk pregnancies and teaching finally manifested itself physically as debilitating back pain from multiple herniated discs.
“What flipped me over the edge was I read this book about back pain that said your pain is a manifestation of anger, what is making you angry? I had this shocking revelation that I was really furiously angry at these guys that I was working with.”
Dr. Abbott’s malcontent led her to consider other career options such as getting involved with public policy or perhaps returning to school to study law.
“It totally messed with my head. I really believed I was unemployable and that my chair would block me if I tried going to another hospital. I was so vulnerable that while I would be sitting with him, I would believe all his comments about how worthless I was. I would leave the room and get furiously angry at how dare he ruin me when I knew in my core I was good at my job.”
“It really was this terrible, terrible point for me. I felt really ashamed that I let my job get so bad that I let myself get marginalized and persecuted. It’s that spiral you get into when you are really low.”
During this time she continued to see patients from all over New England whose high-risk pregnancies led to poor outcomes. The sadness and grief of seeing the parents whose baby had just passed away began to weigh heavily on her; especially since most of these outcomes were preventable.
“I remember reading about this cardiothoracic surgeon who committed suicide and thinking, “Yeah, I can understand how you could get there. Even though you know you’re helping these people, you feel like what you’re doing isn’t enough. And then I was like, Oh my God, this is a really bad sign! Am I really justifying this action as logical? Warning! Danger! Danger!”
Dr. Abbott’s newfound realization of how unhappy she was at her practice led to her decision to leave. But leaving was not a trivial matter as she was highly invested in her patients and residents. She drew on strength from her husband and kids during this time of transition.
She recalls a small epiphany from talking to her son about a new job offer, “I remember my son-who was eleven at the time-saying, so wait a minute, they will pay you more money to work less, and you won’t be with crazy people? What is the dilemma?” She admits that, in hindsight, she perhaps should have left her practice two years earlier than she did.
Boston Medical Center
After about a month off to focus on what would be her new direction, she decided to join BMC. “I was invited to apply the same standards of excellence I had developed at my old practice to poor underserved women and I was like, this is exactly what I need! I also decided to focus on medical students because I could impact a whole lot more people.”
Getting back to a healthy state did take time, however. She engaged with intensive physical therapy specifically for people with back problems. A muscular therapist taught her how to run, walk, and even sleep again. She practiced yoga frequently and took mindfulness training courses. All of these efforts were eventually successful.
“It was a classic story for physician burnout. You let things get so bad-there’s this cliff and you don’t see what a different life could look like. I’m lucky because I have my kids and family. I never had a situation with my family where I didn’t have their support and so I didn’t have to envision a whole life without it.”
With renewed energy and spirit, Dr. Abbott returned to her focus on high risk pregnancies. She seized the opportunity at BMC to run the antenatal testing unit (ATU) and improve outcomes. She attributes this opportunity to helping lift her out of the psychological hole that the “burden of people’s grief” had created many times in her past. “I fixed the ATU and stopped the problem of preventable deaths in this system. But that still isn’t enough, I want to do it on a national level.”
I asked her about coping mechanisms for these difficult conversations with patients whose babies had passed away. Surprisingly, she returned to the experience of her first-year biochemistry course:
“As bad as things got for me, they were never as bad as that first semester in med school, because I didn’t actually know I could be a doctor and help anybody [back then]. Everything that has happened to me since, I have always known inside that I could actually do it.”
She also discussed the ability to harness positive energy for sustenance through other more difficult interactions.
“You experience the patient’s grief, and then you go into the next room where a healthy baby was born and you actively take on that joy. You actively look that baby in the eye and can actually say this is the most beautiful baby in the world, what a miracle, you are so lucky. I can say that with complete truthfulness.”
Dr. Abbott hopes that The Resiliency Blog can help students develop their own self-confidence early and not be scared to reach out towards achieving their goals.
“At every stage, I think we struggle with developing our own personal and professional confidence. And so I hope that this project will be able to make the process more accessible students, maybe not just when they’re struggling. If you wait for them to be struggling to read it, then it might not be the right time.”
“I spent most of my years waiting to feel like a credible junior attending. I didn’t share anything personal with my residents or students at all. I felt that it wouldn’t be helpful to them-that they had this different story and that my story would not be of value in any way. So it took me to get a lot older to realize that this isn’t true.”