The Sandwich Generation in Otolaryngology

On Christmas Eve 2024, my father was admitted to a community hospital in Los Angeles for acute cholecystitis. Luckily, I was already scheduled to start vacation and fly out on Dec 27th to visit family before Dave, Claire, and I went to Cabo. Arriving at LAX just before 9 a.m., I went straight to the hospital by Uber. I was sitting in my father’s hospital room when I realized how ordinary this moment had become.

The IV pump clicked softly behind him. Another patient shared this small hospital room, sleeping quietly and motionless, separated only by a curtain. I heard and saw nurses briskly walking in the halls through the open door, amidst bustling noises of hospital staff, intermittent crying, the utterances of a patient two doors down, and families arriving to visit their loved ones.

My then 79-year-old father was not his usual animated self. Instead, he seemed so fatigued, spoke very little, and barely opened his eyes to acknowledge my arrival from Ohio. I ached as a surgeon seeing him in the re-washable blue patient gown—they never seem to fit anyone—with snaps misaligned and falling over his shoulders. His exposed hands and arms were covered with bruises where, clearly, multiple IV sticks had either blown or been used up since ED and admission. I wished I had been there three days earlier instead of being on call.

I spent the next four days traveling from my sister’s house in Orange County to the hospital in Monterey Park (about an hour). During this time, between checking his labs, hovering over the nurses’ station—repeatedly asking when the hospitalist would be rounding, when the surgeon and GI consultants would arrive, and when a phlebotomist was coming—and insisting on telemetry, I was also on my laptop logged in to Outlook and EPIC reviewing the call schedule for the group, managing my inbox full of message and results from cases I had just finished, and responding to staff and parent messages.

While I was physically in a hospital room as a daughter, I was cognitively still very much a surgeon, a division director, a wife, and a mother, checking to make sure Dave and Claire were arriving from Orlando the next day and arranging the weekend logistics.

In that moment, I understood what the “sandwich generation” looks and feels like for all of us as a part of the shared human experience. Not in theory, not in a definition, but in the lived experience of being needed by two generations at the same time while still being needed at work.

The Panel

Recently, I was honored to be invited by Elise Graham, MD, to join her panel, “Beyond the Otoscope: Family Care for the Sandwich Generation,” which also included Jeffrey Simons, MD, and Kristen Echanique, MD, and was presented at the annual Triological Society Combined Section Meeting in Orlando. After months of prep, we shared our own journeys, key challenges, effective strategies, and lessons learned. While we are each at different life and career stages, remarkably similar themes emerged:

• Navigating work, caring for aging parents (whether you live in the same town or not), and raising children (even after they leave the nest), is difficult.
• Balancing senior career responsibilities while managing parental health issues and children transitioning into adulthood puts us at risk for both physical and emotional burnout.
• Managing early careers with young children means facing the daily collision of diapers, childcare, and pumping/nursing amidst operative cases, building one’s practice, and learning how to optimize each day through prioritization and identification of resources that make such integration possible.

What became clear is that while the challenges we experience in caring for both our children and parents are not rare, they’re simply rarely spoken about in our surgical culture.

Key Challenges We All Face

Regardless of where we are in our lives and career stages, these are the challenges we have faced and will face. While we are not facing them all at the same time, it’s a matter of when and which ones become a focal point:

• Time. It never feels like we have enough! Luckily, I learned years ago that despite how we feel, we ARE time! What and who we prioritize determines the amount of time and attention we give. Our life is the source of time.
• Childcare
• Eldercare
• Career Sacrifices
• Financial pressure
• Emotional and physical burnout. We are also aging and are at risk of physical and mental health problems at any stage, with additional risks that are inherent in a career in medicine and surgery.

The Illusion of Balance

We often speak about balance as though it is achievable with the right time management.

All three of us on the panel described something very different.

“Responsibilities don’t leave you, even when you’re on PTO.” I shared the reality of serving in leadership roles in addition to being on the frontline. Leaders are often excessively accessible, intended or not. Our input and guidance are needed from trainees, partners, APPs, nurses, clinic staff, surgery schedulers, colleagues, and, of course, patients and their families. Our own children still need our presence well into their adolescent years and young adulthood.

Dr. Simons described taking phone calls about his parents’ health between cases, then going home to help his own children navigate their next stage of independence during adolescence.

Dr. Echanique described mornings where daycare drop-off was followed immediately by a full operative day, only to return home to toddlers who do not care that you operated for eight hours but need their mom’s full attention and presence.

There is no balance! There is only continuous role-switching or serving dual, triple, or more roles simultaneously.

Dr. Simons shared a brilliant conceptual framework, in which, instead of the typical career versus family simple two-sided scale, he sees balance as a pentagon that represents our daily demands (Figure 1).

When It Is Hardest

The hardest moments for all of us were not logistical; they were the times when we didn’t have any reserve and experienced high demands both at work and at home.

For me, the most difficult times to balance were when I was not okay. Burnout. Physical exhaustion. Health consequences. When bandwidth disappears, caregiving in either direction becomes overwhelming and not sustainable.

Dr. Echanique spoke about the emotional fatigue of being a young surgeon trying to prove herself professionally while simultaneously being needed intensely at home by very small children. She acknowledged her husband, live-in nanny, and the two sets of grandparents, particularly her mother, for their support.

Seeing photos of her husband bringing her young infant daughter to see her while she was on call brought back a flood of memories of my own early career after having Claire. Given that neither my parents nor my in-laws ever lived in the same city as us, we relied on close family friends and our social network for support. Of course, full-time nannies during early childhood years, transitioning to part-time nannies during elementary school years, helped. Dr. Simons shared how lucky they were to have the same nanny for almost 17 years. She is truly a family member and still a big part of their lives.

He reflected on the emotional weight of watching parents age while still carrying full professional responsibility without pause. He acknowledged the emotional burnout of juggling countless leadership roles across professional societies, the Academy, and his job. As he shared photos of his beautiful wife, their twin daughters, and their travels, along with one showing him dancing with his mother at the girls’ bat mitzvah, I saw the joy, pride, and love reflected in his smile and voice.

The hardest moments will always be when we have nothing left in the tank. I have shared in prior articles how self-awareness is critical, so we can identify when we reach that point, focus on our own recovery, and continue to care for others.

I was so impressed by Dr. Echanique. She shared that she had her first daughter as a chief resident, operating a full day the day before induction at 39 weeks! She moved to Cleveland with a four-month-old infant to start her facial plastic and reconstructive surgery fellowship. Her parents moved in for weeks at a time during that fellowship year, which allowed her to be a fellow. She had her second daughter as a new attending, 11 months into her new job.

She articulated the challenges of missing her children’s milestones, being sleep-deprived, and carrying a significant mental load. No one knows or hears the immeasurable constant planning, anticipation, timing, and decision making amidst breastfeeding before leaving for work, then pumping at work.

“Maternity leave is NOT a break,” she shared. This is a profound, accurate, and necessary acknowledgement and validation for us all. Immense guilt about optics from taking time off, pressure for success, and duration of breastfeeding, along with constant worry about milk supply, transport, storage, and planning feeding for caregivers—I have never heard our reality so plainly and courageously spoken out loud.

Dr. Echanique shared the definition of “mental load”—the responsibility of remembering, planning, and worrying about what needs to happen—even when you’re not the one physically doing it. When she shared examples of text messages received at work from caretakers asking her about her status, questions about food, and decisions for feeding her infant, I am certain most of us could relate, particularly female surgeons.

Boundaries and Strategies That Work

While none of us on the panel described grand solutions, we did have some recommendations for small adaptations that help: switching call during true crises; planning early rounding on weekends to preserve family mornings and breakfasts; accepting that some days are simply about survival; letting go of guilt entirely—guilt serves no one; allowing partners to support us; setting boundaries; accepting family support; finding dependable childcare; receiving support from department/residency/ Fellowship; outsourcing; choosing texts over calls from our loved ones—family always comes first!

Redefining Success

Dr. Simons and I are in the senior phase of our careers and life stages, and our definitions of success have changed. For me, as I shared with the audience, productivity is a measure; it does not define success. For him, success shifted from academic output to being present for both generations without resentment. Success became quieter, more personal, less measurable.

For Dr. Echanique, success often meant getting through a day where her patients were cared for, and her children felt loved, regardless of how much charting remained. I learned so much from listening to her and wished I had her clarity and resolve when struggling through all the same issues years ago. My commitment to self-compassion reminded me gently not to question if I could have done better, but instead feel proud of how far we have come, so surgeons today can model far better work–life integration for medical students and fellow trainees.

Systems, Leadership, and Culture

One powerful theme emerged during this panel discussion—culture matters.

I shared with the audience that I worked very hard to become a leader, so I can ensure a supportive culture for all and create positive changes based on my own experience. Recently, our new junior faculty member, who is expecting her second child this summer, came into my office and asked if she could preemptively make up calls she will miss while out on maternity leave for three months. I reassured her that she will not be assigned the same number of calls nor penalized for taking leave. I recall my own feelings of guilt and perception of not pulling my weight back in 2021, when I doubled up my calls the six weeks before I took a six-week leave for my musculoskeletal injury. Regardless of the reason for leave, including maternity leave, we should not expect the person who needs care and time away from clinical care to endure the burden of work or make up for it, and do double before or after their time off. Published data show far higher risks during pregnancy, delivery, and postpartum for female surgeons already, without the unnecessary stress and added work brought on by guilt.

Creating environments where flexibility is not stigmatized is critical. Surgeon schedules are anything but flexible. Collectively, we can create cultures within our division and departments where colleagues all step up without judgment. Where well-being is valued ahead of productivity metrics, especially considering so many of our contributions are not measurable by hospital or institutional metrics.

Dr. Simons emphasized how critical departmental understanding is when family needs temporarily eclipse professional output. Dr. Echanique spoke about how meaningful it is when senior colleagues acknowledge that this phase is real and normal.

Challenges for physicians and surgeons are not an individual’s problem—they are a cultural one.

Mentoring the Next Generation

I’m grateful to have learned so much from my fellow panelists and to once again contribute to an evolving culture where we can share and validate our challenges. Dr. Graham shared that what inspired her vision for this panel was the reality that many of us struggle while believing we are alone in the struggle. Feeling stretched is not failure; it’s evidence of how deeply you are needed.

There is a quiet privilege in being needed by two generations at once, and while it can be exhausting at times, it’s also profoundly meaningful.

Children grow. Parents age. Careers evolve.

In the end, I hope we all remember that it is enough that we showed up today. Note: This panel will be presented as a Beyond the Otoscope Webinar in the near future.

Dr. Wei is the Alfred J. Magoline Endowed Chair in otolaryngology – head neck surgery, division director of pediatric otolaryngology at Akron Children’s Hospital in Akron, Ohio, and professor of otolaryngology at the University of Cincinnati College of Medicine and Northeast Ohio College of Medicine in Cincinnati, Ohio.