Women currently make up a greater percentage of medical students, residents, fellows, and physicians in the United States than ever before. As a result, balancing family and career has become imperative for an increasing number of women physicians. This issue, however, receives little attention in traditional medical forums. Ideally, the art of balancing family and career is equally important to men and women, but as long as women are the traditional caregivers, this balance is more of an issue for them. This is particularly the case in academic medicine; because the academic clock and biological clock tick in synchrony, efforts to build a family and a career typically converge for a woman in her twenties and thirties.

Obviously, all families are different, as are everyone's needs and wants. What works for me might not work for others. Nevertheless, it is the prerogative of middle age to become reflective. In so doing, it has become clear to me that certain things have been helpful, even essential, in having a family and a productive career and enjoying both on a full-time basis. Although my own experience is as a woman in academic medicine, my advice may be useful to physicians of both sexes in other settings as well.

I am currently an associate professor in the Department of Medicine at a major academic institution. I was the first woman with children to receive tenure in this department. I am active in research, administration, education, and clinical care. I have two children, 14 and 10 years of age, and a partner of 22 years who is also a physician. I offer this information as evidence that my suggestions are drawn from experience and have resulted, at least to date, in successful outcomes.

To start, set personal and professional goals and plot a course toward achieving those goals. Look in the mirror and ask yourself, "Who am I, and what do I want to be? Do I want to be a department chairman? Do I want to have a national reputation? Do I want to be a parent? Do I want to work full- or part-time? Do I want to do research? Do I want to live in a rural or urban area?" and so on. There is no right or wrong answer to any of these questions; they are personal decisions. I periodically ask myself, "If something catastrophic happened to me today, would I have any overriding regrets about the way I have lived my life?" If you ask yourself this question and the answer is "yes," I encourage you to change something soon.

Once you have established your goals, be sure to choose a partner who shares these goals. Although I did not realize it at the time, this was the single most important decision enabling me to achieve both personal and professional success. During a recent conversation with several other women on the faculty, we surmised that women and men pursuing a career in academic medicine often view the ideal spouse differently. The average man in academic medicine is likely to seek a wife who will take care of everything on the home front—house, kids, shopping, laundry—so that he can spend long hours at work and feel nurtured at home. Women in this field, however, usually want a spouse who is willing to share responsibilities, negotiate tasks, and exist on a more equal professional footing. Thus, I would caution a woman to be wary of choosing a life partner who was raised to think that the worst form of humiliation was to be "beaten by a girl." I also advise women to avoid selecting partners who think that housework falls under the purview of the female sex. If a woman's goal is to be a tenured professor and her spouse's goal is to marry a domestic goddess, the relationship is doomed to fail. In my case, hiring someone to help with housework and laundry was the best thing for my marriage and my mood. For all the men reading this, I am here to tell you that dirty socks, underwear, and dishes are no more appealing to the x chromosome than to the y chromosome. The time you save is time you can spend with the kids, your spouse, or getting extra work done.

Strive for geographic proximity—that is, have all your activities close together. This is something I did not actively seek to do, but it turned out to be crucial in balancing everything, especially when the kids were small. I live close to work and can park right outside the building in which my laboratory, my office, and most of my clinical work are located. In addition, I have chosen to live in a moderately sized city where such things as day care, schools, grocery stores, and the pediatrician are readily accessible. In our city, there is a juggler who performs a trick in which, one at a time, he starts spinning 10 plates on tall sticks until all of them are spinning simultaneously. Once the plates are spinning, it takes only an occasional push to keep them going. If a plate is too far away for a push, it falls and shatters. The life of a woman or man with a full-time family and academic career is analogous to the spinning plates: Keeping all your activities spinning successfully is simpler when the distance between them is not too great.

To achieve balance among the various responsibilities of family and career, it is essential to have competent and trustworthy support people, such as secretaries, technicians, and child care providers, to whom you can delegate responsibility. You can then decide which tasks you wish to delegate and which ones you prefer to do yourself. For example, at work I like to do much of my own word processing on grants and manuscripts, so I do not delegate this to the secretaries. I do, however, dictate all correspondence, memos, and less important documents. At home, I tuck the children in at night, read to them, and help them with their homework. My husband and I share such responsibilities, but I would not relinquish these joys to anyone else. In the same vein, you must always have a contingency plan. The school nurse will invariably call to tell you that your child has just vomited and has a temperature of 103 °F when your spouse is out of town, your grant is due, you have eight patients in clinic, and you are out of Tylenol. I was able to enlist the help of an older woman who was always available on a moment's notice and, in the occasional crisis, could come to the house at 7:00 a.m. and stay until 6:00 p.m. You can work out your own system, but a back-up plan is essential for the well-being of your family and career.

You must establish priorities in your life. My husband and I make every attempt to attend our children's school performances or sports events and to ensure that we have some family time every weekend and almost every weeknight. I have never heard one of my terminally ill patients say they wished they had attended that meeting, served on that committee, or made that grant deadline. I have, however, heard many of them express regrets about the amount of time they spent with their children and family. After all, very few of us will be remembered for our professional accomplishments. It is far more likely that we will be remembered as someone's daughter, son, mother, spouse, or brother.

Get up 1 to 2 hours earlier than you have to each morning. My mother gave me this advice. She worked full-time, went to school, and ran the household. That extra time in the morning, when the house is quiet and your mind is fresh, allows you to complete tasks and arrive at work feeling like you have already accomplished something. Don't fritter this time away on routine items; use it to attack some significant project. In addition, use technology as much as possible to blend work and home life; have a computer at home so you can work while the kids are sleeping and a cellular phone so you can take calls in the car or grocery store.

While the demands of career and family may occasionally feel overwhelming, it is critical that you take care of yourself. If your health fails, it is a stress on the entire family. I look at myself as being in training all the time for the tasks I must accomplish as a mother, wife, physician, researcher, educator. As such, I try hard to eat right, exercise (but not enough to strain anything) and get almost enough sleep (at least enough not to get sick). Family vacations are also essential and can be very healing.

Maintain a sense of humor. I have observed that the most frustrating or irritating situations at work or home, when reframed, can also be the funniest.

One of the best aspects of "having it all" is having two potential spheres of support. Sometimes, at home, the kids or my husband are grouchy and whiny, and no one listens to anything I say. At these moments, it is heartening to go to work, where I get a little respect, I have some control over things, and I write orders and someone follows them. Sometimes things don't go well at work. Perhaps I get a nasty manuscript review, one of my patients is not doing well, or a colleague is driving me crazy. At these times, it is gratifying to go home and cuddle with the kids, bake cookies, read together, and be a mom. There are also those special times when it all comes together; things are going great at work and at home. These are peak moments to be savored.

I also derive satisfaction from feeling that I am serving as a role model for my children. My husband and I have shown them from an early age that the success and happiness of our family depends on working together as a team to accomplish tasks and solve problems. I am proud that my 14-year-old son has a very gender-neutral view of the world. I tell him that if he ever gets married his wife will really thank me. My 10-year-old daughter has no clue (yet) that her sex bestows her with any potential obstacles. When my children were younger, I limited my travel to one or two meetings per year, but now I am gone about seven times per year for two to three days at a time. These brief absences provide my children the opportunity to enhance their sense of independence. When I return, I discover that they are doing things for themselves that they were not doing when I left, such as making their own lunches and helping with additional chores. They enjoy bragging to me about their achievements. They also seem to have a renewed appreciation for me when I return, which I find very rewarding.

At this point in my life, I am enjoying some of the perks of a career in academic medicine that I believe can only be fully appreciated by a woman with a family. As you move up the career ladder, you are invited places to speak about your research or various other topics. When you accept these invitations, your hosts put you up at nice hotels with room service. Room service delivers a meal right to you; after you have eaten, you can simply put the dirty dishes outside the door. This is a truly delightful experience. In addition, in your own hotel room, you have complete control over the channel changer. This experience, it seems, is a novel one for many wives.

Another perk is the opportunity to be a mentor to others. I derive as much professional satisfaction from the accomplishments of former fellows and junior faculty members whom I have mentioned as I do from my own. As one of the few tenured female faculty members in our department, I enjoy being in a position to give junior female faculty members advice that they simply cannot get from their male colleagues.

As with anything, there is a down side to "having it all." Balancing a full-time career in academic medicine and a family means that you serve many "bosses." The clinicians want you to see more patients, the educators want you to do more teaching and curriculum development, the researchers want you to write more grants and papers, and, of course, your children want you to be at their beck and call 24 hours a day. To prevent yourself from burning out by trying to please everyone, you need to set personal and professional limits. Decide what you want to do and what you are willing to do. Compromises and negotiations can be made, but try to emerge with your self-respect intact.

Another down side is meal preparation. When both parents work full time, it is impossible to provide a home-cooked dinner every night. If this is something valued by you or your spouse, my advice is to hire a cook. Our solution has been to have home-cooked meals on the weekends and, with good planning, as many as 3 nights per week. Thursdays are pizza, and Fridays are fast food. We all take a Flintstone vitamin daily. It works for us.

As women climb the academic ladder, there are fewer and fewer female colleagues or role models. I view myself as being just at the bottom side of the glass ceiling looking through, and, frankly, there are few persons on the other side whom I aspire to be like. This makes it a little lonely at times, and I get tired of sports discussions. Nevertheless, I am pleased to be guiding other female faculty members up the ladder and look forward to the day when one or two male colleagues will have to listen politely to an enthusiastic discussion of a sale at Marshall Field's.