Always On Guard: The ER Physician's Fertility Journey

You can run a code without your hands shaking. But nine days after a transfer, you're checking your phone in a supply closet between patients.

This week's episode is part of my series on the specialties that make fertility treatment uniquely hard, and emergency medicine is one of the hardest. Shift work, trauma exposure, a body that never fully is able to shed the hypervigilance. ER physicians are trained to handle chaos everywhere, but this becomes counterproductive in their own fertility journeys.

In this episode:

• How shift work disrupts your circadian rhythm, raises inflammation, and keeps your body locked in alert mode

• How the hypervigilance that makes you excellent at your job works against you here, bracing for five failed transfers before the current one has even started

• Why the ultrasound down the hall isn't there for you, and how to define that boundary for yourself ahead of time

• Practical sleep strategies for post-call recovery, including one I didn't expect to work: Yoga Nidra

• How I helped one ER physician use data on physician pregnancy outcomes to write a letter requesting a schedule modification

There is a way through this. I have watched it happen for ER physicians again and again, and I want that for you too. Progress, not perfection. 💜

With Love and Science,
💜 Dr. Erica

P.S. If you're an ER doctor bracing your way through this, you don't have to figure it out alone. Book a discovery call here and let's talk about what's actually possible for you. I'd love to connect.

Also, be sure to check out our website: loveandsciencefertility.com

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Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.

• Transcript:

  Erica Bove, MD (00:01.016)

  Hello, my loves, and welcome back to the Love and Science podcast. Today we're gonna talk about the first of our series of the different kinds of physicians and why certain specialties are really hard on the fertility process.

  And so, you know, most of us listening to this podcast are female physicians who have done at least at medical school and residency. but what I've seen after working with dozens of clients in the various specialties and also, I mean, hundreds of patients at this point, is that there's particular patterns of certain lines of work that make it especially different difficult to be on the journey.

  So the first one we're gonna start with today is emergency medicine physicians. So why is it particularly hard to be an ER doc on the fertility journey? Well, first of all, there is shift work, and the shift work is not at reliable intervals, usually speaking. There's usually some mix of days and nights, or maybe you get off of your shift at 11 o'clock at night and you're still like on this adrenaline rush from all the crazy things that have happened, and it takes some

  time to calm down the nervous system to be able to go to bed. And so there never really gets to be a true circadian rhythm. And the body is often confused as to like when it should be asleep, when it should be awake. And a lot of my ER doc patients and clients do find it really, really hard to get into a rhythm to have high-quality sleep. And it kind of feels like the body is always on alert.

  And so the shift work I think can be really hard, especially the combination of days and nights and then, you know, trying to recover in between and and all the effects that can have on the body. Now, I actually have other podcasts about this, but there's data that when we have altered circadian rhythms, it actually increases the stress in our bodies and it actually increases the inflammation. And so at the end of this podcast, we're gonna talk a little bit about strategies of how to like take we can't just all stop working entirely, right? Maybe it's where we get our insurance, maybe

  Erica Bove, MD (02:05.421)

  I mean our livelihoods depend on it. We don't want to co keep our skills up. You know, there's there's reasons that we stay working in our jobs. However, I wanna give some strategies to say, okay, if you are to keep working as an ER doc, what then do you do? And we move we move on from there. Okay.

  so the shift work and the altered sleep go hand in hand. The stress. Now, yes, of course, there's stress from the altered sleep, but let's talk about the nature of the work. I cannot imagine a much more stressful situation than to understand that anything could walk in the door at any point. my you know, my partner at the at this point in my life is an ER doc as well, so I hear from him, you know, again, not in great detail, but that he's just always ready and on guard for whatever might walk in the door, which can be anything from a terrible trauma.

  Trauma to you know something that is you know really unusual, and you kind of got to be on your A game so you don't miss a diagnosis, or you know, even some of the dynamics with with other staff and other specialties and navigating all of those sorts of things. And like I get it, it's a very stressful, high-intensity job. And there is probably some element of self-selection, you know, people who thrive in that environment, who thrive on that stress, that chaos, that sort of adrenaline, people often.

  Often will s self-select to ER. However, it also does mean that the nervous system is in this kind of like hypervigilant state. And a lot of the things that you all see as ER physicians are inherently stressful, right? Things that maybe will take some processing. Like my therapist, for example, she works with a lot of ER doctors and she does EMDR therapy with them because the things that they see on the regular basis in terms of all the different traumas, again, trauma surgeons as well, like very similar spectrum.

  It just is a lot for the human body. And I think too you know, I've talked with my clients who take care of kids where tragic things have happened. I mean, there's just so many different layers of it. And so I just wanted to acknowledge that it is a very stressful job inherently, and the nervous system has to stay on guard to be able to handle whatever comes in the door and also modulate that intensity from time to time.

  Erica Bove, MD (04:17.544)

  also, I think it's really stressful, and I remember this from my gynecology resident days, I think it's really stressful to see people with unplanned pregnancies, and it just is one of those salt in the wound things of why life is so incredibly unfair. And you know, when I was working in a busy ER in New York City, I could not believe how many people came into the ER and they didn't know that they were pregnant. So if you are a female physician wanting nothing more than a pregnancy yourself, and you come into the ER and you see somebody who

  Maybe they have vaginal bleeding, or maybe they come in with a completely different complaint, and you're wanting to get a CT scan on them, and you know, by some surprise, their pregnancy test comes positive. I think that that is a mind warp. I'm gonna use kind language, that is a mind warp to be like, okay, universe, like what unjust situation is this where this person wasn't even trying, and I'm the one who has to bear the news to them that they are in fact pregnant. It feels incredibly unjust and unfair. So there's that element. There's also the

  That there are ultrasounds around. And so I do a lot of coaching with my clients and my patients who work in the ER to say, like, just because there's an ultrasound in your setting, does that mean that it is there for your use or you know that it's gonna help your situation? And I understand, trust me, because I did this myself before I knew better. I understand what it's like to just desperately want to know what's going on under the surface, and then you know, maybe you even have an early pregnancy at this point and you want to sneak a peek and see what's going on, but I will say.

  Say as a trained OBGYN, you know, those trans those trans abdominal ultrasounds are not that great. And even with trained hands, it can be really hard to see something. And so what I like to help people avoid is a situation where they're completely unsupported, they are questioning what they see, they're not sure if something's wrong, maybe it isn't, but they start to wonder. And that in and of itself can be a very stressful situation. So, you know, maybe you're ER, maybe you're not. But if you work in an environment with ultrasounds, let's define your relationship with those ultrasounds ahead of time so that you're the boss of them.

  And not the reverse. Okay, let's talk about the emotional aspects of being an ER doctor in a little bit more detail.

  Erica Bove, MD (06:26.026)

  I will tell you the people I know in emergency medicine are the most prepared people I have ever met in my entire life. Like I will tell you hands down, if I had to be on a deserted island, if I was stranded and needed to survive this life, I would want my ER colleagues to be with me because they are resourceful. They can, you know, basically use things that you'd never know could be used for certain purposes and find a way to find some survival mechanism to use them. again, incredibly resourceful, sometimes in very low resource conditions.

  Very thoughtful, very good under stress, very good under pressure. also incredibly hyper-vigilant. Like, if I were to live inside the brain of somebody who's an ER doctor, I would say, like, they are thinking 20 steps ahead, right? I went on a yoga retreat one time with this ER doctor and she had driven there. And when we looked inside her car, I still laugh to think about it. We really gave her a lot of trouble for it. You know, we kind of joked with her because she had like an emergency blanket and like stuff to start a fire and like extra water and extra food.

  And a first aid kit, and like I'm just not even scratching the surface. Like the things she had in her car, like she could have you know survived an apocalypse, right? And I think that when you are always in this disaster management, like emergency prevention mode, you tend to kind of like expect the worst so you can prevent the worst, so you could be prepared for the worst case scenario. And that mentality in a fertility scenario is not always the most useful. So, what does it mean? It means that if you've had unsuccessful transfers, you are breaking.

  Yourself for not just this next transfer to be unsuccessful, but for the next five transfers after that to be unsuccessful. It means that you are, you know, questioning your doctor and wondering if they have, you know, truly left no stone unturned and have the complete evaluation. You are, you know, thinking five steps down the road if you might need a gestational carrier or this or that. And and and maybe you do, maybe you might. I'm not sure. Like I'd have to talk to you to understand your situation. However, I think that like constant hypervigilance, that constant survey

  Cerebral, like, am I thinking of everything? Am I prepared? I think that physiologically we can truly overprepare. And, you know, I have whole talks on balancing, trust, and advocacy. So what I like to help my ER doc patients and clients with specifically is to find the reasons for the authentic hope, right? To reground into the science, to reground into the present moment, to reconnect with the reasons why it makes sense for you to continue. So I can think about, you know, one client of mine who had a number of high quality

  Erica Bove, MD (08:55.546)

  Quality embryos, and even though she had losses herself, like she really did have a good prognosis. Her lining was good. she, you know, had I had no reason to think it wouldn't work for her eventually. She did end up needing to switch to a different to a different physician, a different health system, and ultimately she was successful. But again, you know, I had reasons, I helped her connect with the reasons for authentic hope, which I think was really, really important for her. I can think of another person in my world who had secondary infertility and

  And you know, she was a little bit older, she had male factor. But we said, you know what? Like, your body has done this before. you know, your AMH is reasonable, even though you're on the older side. Like, I really do believe that we just got to get to a good embryo, and if we can get to the right protocol, it's gonna take. And then lo and behold, that's what happened for her. We, you know, her first IVF cycle before meeting me was terrible, but then the next cycle after she worked with me, she generated a euploid embryo. Her first FET cycle is canceled because it wasn't the right protocol for her, but then ultimately she.

  She had a transfer of a euploid embryo into the right FET protocol for her, and she stayed pregnant and now has a beautiful son and her family's complete. And so, you know, what I would say is that sometimes, and and that was really only over five months. It wasn't even like it took a long time, but during the course of that time, she reduced her shifts, she regrounded in her body, she started processing her feelings, she started just out of cura gentle curiosity, you know, asking herself, okay, isn't that interesting that your body already thinks it's not gonna work and it hasn't

  The cycle hasn't even started yet, you know, and just really trying to stay in the present moment and remembering, objectively speaking, it's actually more likely to work than not to work at this point. And so even though that isn't the remote chance of possibilities, your team is responsible for that. So focus on the present moment and like reduce the hypervigilance because it is not serving you physiologically. It activates the AP HPA axis. When that happens, it increases the cortisol, it increases the stress hormones, it increases the inflammation in the body. It feels terrible. And

  In my experience, the the, you know, the transfer outcomes are actually much worse. And so helping people find that sweet spot of staying in the moment, trusting the process for good reason, for authentic hope reasons, you know, really having confidence in the treatment plan, knowing that there are backup plans, but we're gonna hold those in reserve. We're not gonna put them in the consciousness, they're there, they're waiting, but we're gonna really focus on the present moment. I find that really, really helpful, especially for my ER physicians who oftentimes are thinking 20 steps ahead. I think 20 steps ahead. That's just what I do.

  Erica Bove, MD (11:25.072)

  But again, I'm REI and I say, let me take that burden from you so that you can be the patient, you can stay in the present moment, you can optimize your physiology and maximize the chance of success. I think that in a correlative way, the other emotional processing aspect that is really important of being an ER doctor is having a mechanism for processing the trauma.

  ER doctors are abused by patients more than anybody in ever in any other specialty. People come high, the people come you know, drunk, there's a lot of abuse. The data show it, right? There's a lot of abuse by patients to physicians and nurses really as well. Like in an ER medicine in an ER. I have an aunt who worked her whole life in crisis. You know, I I know from her stories as well. Like it is a really tough environment. And I think, gosh, it's so hard because we are master compartmentalizers. Like it is so

  Much easier to just like stuff it away somewhere. I do this in my work too sometimes. Like well, especially when I did obstetrics and I saw some really horrible things there as well. Like, you know, it takes some energy, it takes some time, it takes some feelings to process some of the really awful things that you can have to deal with on a day-to-day basis. But if we if we if we stuff it somewhere and we don't deal with it, it lives in us. It lives in our cells, it lives in our body, it creates blockages, it gives us PTSD, right? When we and and and

  And that's why I alluded to my therapist before. Like, I think that we all need time and space to process the things that we are seeing, that we are experiencing at work and beyond. And so, you know, maybe it's that you have a trusted colleague and you can talk about these things with each other. I do that, you know, with my colleagues too, when I have patients where there's a cluster of bad news or, you know, clients, like we all need, as people who are caregivers and giving to the world, we all need a mechanism for processing the trauma. But sometimes we think, it's just easier.

  I've dealt with this my whole life, you just gotta brush it off, you just gotta brush it aside. I'm telling you, it's not good for us. It's not good. You are a human being, we can process emotions, we can process the trauma. It is not that we have to like relive it and reactivate it every single moment every day, but to say in this job where there's a lot of things that many people never even see in their lifetime, a lot of bad news you have to give, a lot of you know things that are really, really stressful and traumatizing, it is really important to have a mechanism for processing.

  Erica Bove, MD (13:51.649)

  processing that and yes I believe in colleague support peer support absolutely but I also really think that having a trained professional who is a licensed therapist or a licensed psychiatrist, somebody who is really trained and good at trauma informed care that is especially important in the ER because we carry these things with us and you know we don't sleep well. They lodge in our bodies, they lodging our cells. And I really do think that sometimes they can prevent our best chance of success in this realm as well, right? They they affect our

  health, they affect our mental health, they affect our peace, and we have to have a way of processing those things.

  A bit on the sleepies of things. If you are an ER physician and you're listening to this, what I would say is try to anchor a postcall sleep schedule, just one sleep cycle post-call. Like whether it's say, okay, you know, you don't necessarily try to power through that. You go home, you go to bed, you put your fancy eye pillow on, you put your noise machine on, you try to sleep, right? I know it can feel very destabilizing, especially if you're on nights, but really, really trying to get some quality sleep in your post-call day.

  Day, that can be really important. And then also say it's more like you, you know, are working until 11 o'clock at night or midnight or 1 a.m. and like your brain is going. Have a bedtime routine. We talk about having a morning routine, right? Where we get up, we meditate, we drink our coffee, etc. The longer I live, the more and more I see the importance of having a bedtime routine. Super important to wind down. Maybe you take a bath, maybe you do a nighttime meditation. I've gotten obsessed with yoga nidras, N I D R A Yoga Nidra, where I truly feel like I'm

  Being hypnotized. It is the most beautiful thing. But I think those of us who, you know, have a motor, those of us who, you know, like really do run on adrenaline, it's really, really important that we have a way that we can soothe ourselves, that we can come home to ourselves, that we can calm the nervous system, and you know, ultimately fall into a rhythm of sleep. And so some for some people, like a couple of the clients I mentioned, some of them actually said, like, I have to go per DM during this time. This is too much. It's too stressful. Like, I really need to make my fertility the priority.

  Erica Bove, MD (15:57.217)

  here or maybe they didn't even explicitly say that, but just like I need to make some changes. I also have a client who, you know, when she was pregnant said, you know what, there's data that pregnant people have worse outcomes, especially with these altered sleep schedules. And so as a pregnant person, we're gonna have to rework the schedule such so that I'm not doing any, you know, nights. And I think it was for her it was like in the first and third trimester is what their policy said. But I think really looking at it and saying, okay, we're gonna need to make some changes because you know, just like we do for people on maternity leave, et cetera, like

  This is not good for my pregnancy. There's a reason why physicians have worse not just fertility outcomes, but pregnancy outcomes as well. And we have to make this a priority, just like we would somebody with diabetes or pancreatitis or something else. So again, giving yourself permission to be the patient, giving yourself permission to ask for more regular shifts, especially given that we know that there's data of worse outcomes. I even helped a client recently write a letter based on data, the data about the surgeons who, if they operate more than a certain amount in a week, they have worse pregnancy outcomes.

  outcomes. She was, you know, her job was having her work ungodly hours on call. And, you know, again, we have to ground these things in science, but you know, asking for a reduction in call related to data, data about pregnancy outcomes. I think it's really important that we look at these things and

  Do what we would do for our patients, right? We of course we'd write the letter on behalf of our patients when they make these requests, but we also have to believe that we're worthy of of similar treatment and similar similar similar accommodations and similar good outcomes, right? Like no more are we gonna have worse outcomes because we're just the martyrs and like everybody's always done it this way, it's not okay. And we have to start changing that, which starts with giving ourselves permission and sometimes even enlisting like an A an A team member to help you write a letter like I did for my client so that you can

  You know, figure out how to get what you need. Okay, so we talked a lot about why ER doctors have the problems that they do, the unique problems that they do, and also some of the emotional components which make it harder to process the trauma and to reduce the hypervigilance. But there are ways forward. I have so many successful patients and clients who have worked in an ER who have ultimately been successful. I think a lot of it is really calming the nervous system and figuring out that piece of it, and there are tools that are that exist. And so if you're in the ER, I see.

  Erica Bove, MD (18:14.913)

  See you. I love you. And if there's anything I can do to help your journey, let me know. Okay, until the next time. Bye.