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Board-certified pediatrician and certified coach Jessie Mahoney discusses her article “The burden of the eldest daughter.” Jessie explores the unique psychological weight carried by firstborn women who are taught early on to hold everything together at the cost of their own well-being. She connects this childhood role to the high rates of burnout among women in health care where hyper-preparedness and self-sacrifice are rewarded until the body eventually breaks down. The conversation examines how the eldest daughter effect creates a cycle of over-responsibility that leads to resentment and even physical illness. Healing begins when we learn to release the need to be indispensable and start saying yes only when it aligns with our own needs.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Jessie Mahoney, pediatrician and certified coach. Today’s KevinMD article is “The burden of the eldest daughter.” Jessie, welcome back to the show.

Jessie Mahoney: Thanks so much for having me back.

Kevin Pho: All right. What is this latest article about?

Jessie Mahoney: Well, this article is about the burden of the eldest daughter. My podcast co-host and I did a podcast about the eldest daughter, and I had no idea that it was going to resonate so much. Then shortly thereafter, Taylor Swift was talking about the eldest daughter, and I was like: “What is going on?”

What I realized since then is I have been asking women physicians in my groups and at retreats, and I would say that 85 to 90 percent of women physicians are eldest daughters. Which is shocking, cool, interesting, and on the other hand, expected. I am an eldest daughter, and my podcast co-host is an eldest daughter. We didn’t even recognize that we are sort of expected or raised to be over-responsible, over-functioning, and over-performing from a super young age.

Because of that, many of us end up in medicine because it is a natural extension. We get praised for all the caregiving of either younger siblings or older grandparents or whatever it is. So we noticed this funnel, which looks different in medicine than it does just in the general population. I think because medicine is really set up to take advantage of that or to reward it.

We just had this really interesting exploration of it, and I had so many people reach out that I decided that I should share this idea more broadly because it is really the freedom and understanding that it has a lot to do with how you were raised and how you got here. So many of us blame ourselves about over-functioning and overwhelm and ask: “How come I don’t have boundaries?” It turns out that that was a huge part of how we ended up in medicine and how we were raised.

A super interesting thing about this, which came up in our own podcast and has come up many times since, is the recognition that we don’t really know where it came from. So sometimes we think: “Oh, it is just because you are the oldest daughter.” But were we then responsible and that was rewarded so we became more responsible, or were we expected to do that because it starts so young? There is just no clarity about it. When people start to explore it in-depth, we don’t know really what happened in our childhood. Part of us just wants to blame our parents or blame society or blame someone, and yet I think it is also an incredibly complex phenomenon. Just simply being aware of it and noticing it can really shift your whole experience of being it. You get then the agency to choose how you want to move forward.

Kevin Pho: When you talked about this on your own podcast where you and your co-host mentioned it, tell us the range of responses you get. You said it really resonated with your listeners.

Jessie Mahoney: The biggest thing was that most people were eldest daughters and hadn’t recognized that this role and these issues that they are trying to change now started when they were five or younger. So it was this real liberation, like: “Oh, well, this explains a lot.” It gave them permission to let go of the blame. I often talk about how medicine acculturates us, but for this group of women (which is huge as it turns out; I mean, literally now I ask in every group, and there is maybe one or two people who are not an eldest daughter) this resonates.

I am an eldest daughter, but I have an older brother. That doesn’t matter because you are still the eldest daughter. Or if you are an only daughter or an only child who happens to be a daughter, it also applies. It is this idea of understanding and recognition of where these patterns began: that they led to one thing, which led to the next thing, which led to the next thing. That is the piece that really resonates.

Then there is the idea that this was our role in our family, but it does not have to be. There are many women physicians who are now in their fifties who are carrying an older daughter responsibility to care for aging parents and caring for their entire department as a department chief. It bleeds into leadership roles tremendously. The phenomenon I think is that people feel this tremendous freedom. They feel seen, and then they get to choose. It doesn’t actually mean that they won’t take care of their elders, and it doesn’t actually mean that they are not going to be an amazing chief. But they are going to decide: “Who am I now, and what is the energy that I want to make these choices from?” Because eldest daughters aren’t making a choice; they are just sort of taking what is handed in most cases. So it is recognizing that this over-functioning began long ago and was a setup for where they are now.

Kevin Pho: Now you alluded to some of these characteristics earlier, like over-functioning. But let’s drill down a little bit. What are some specific traits that connect these eldest daughters together?

Jessie Mahoney: The more you do, the more you get rewarded. In our families, we are often the one. I have a younger brother who is 12 and a half years younger, and I just stepped into raising him. That is sort of what we are expected to do. So there is a lot of this hyper-responsibility caregiving at a very young age. Some of it is helpful and some not.

I would say also over-worrying. We tend to be the ones with whom a mother will share her worries or share concerns. So we actually will start to take on some of that responsibility. I grew up in a family where things were not super monetarily steady and my mom was always worried about it. So then my response to that was: “I need a steady job. I need a career where people don’t get fired. I need a career where you make enough money.” It is subtle. You are not really noticing that, but you are eliminating things along the way.

These are also people who don’t ask for help. They clean up on their own, they make dinner for the family. They are always sort of planning ahead and being hypervigilant. You might see people out in the world when their families are traveling; they are the ones who are making sure that things are getting taken care of. I have a niece who is an eldest daughter, and she is always making sure her little brother is organized and everyone in the family knows where they are going and when. That has become her role and she is not even eight. You can see it play out. I don’t know that she will go into medicine, but she might.

It is not that they are bad things because they are actually really helpful, and our society rewards them. But what ends up happening is that becomes the expectation. We get so much reward that we can’t see another pattern. Then when we show up in medicine, it is like: “Oh, well, they can do all these things. This is great. Let’s just keep rewarding it.” It becomes the expectation there. In fact, I think that the system is kind of relying on it. It is similar to the way everyone in medicine is trained, but when it is the root of something you have experienced since you were three or five, it is much harder to separate what is you and what is the system.

I think that is what really resonated with people and what I see people light up about: when they see how many other people are eldest daughters. They are like: “Oh my gosh. Like that explains a lot.” They feel very seen because I also think eldest daughters tend to not feel appreciated and seen. We very well might be, but for whatever reason, it is a real challenge to allow ourselves to be seen and appreciated and valued. That is another piece of it. When you are in a collective of others who feel that way, that is where you can start to peel things off and begin to change it from sort of “I am just going to have boundaries about everything and say no about everything.” You can have a little bit more agency and authenticity around what is you and what isn’t you, because we have sort of lost that perspective.

Kevin Pho: Now you mentioned earlier that these eldest daughters choose medicine because of some of their traits, but it’s a little bit symbiotic. Medicine chooses these traits as well, right?

Jessie Mahoney: Absolutely. I think that is really the challenge because it becomes so intertwined that we don’t really know: What is medicine? What is us? What is reasonable? What is not reasonable? I talk a lot about our expectations for women physicians in particular. But I also think in medicine: What is reasonable and unreasonable is very confusing. What we expect of ourselves is generally unreasonable, but we think it is totally reasonable. Then what we expect if we are a leader of all the people we work with is also generally unreasonable. And then we allow expectations of us to be unreasonable because we are so comfortable with it. Then it is like: “Why can’t I do all of these things well?” So it becomes hard to see what is reasonable for you to do as a physician.

Part of me wonders (and I almost don’t wonder; I know) that this way of being is adding into burnout and adding into just the exodus of women physicians in medicine. If women physicians are now over half of the physicians being trained, recognizing this pattern and helping people see: “Okay, I am an eldest daughter. What is mine? Maybe I can pass this off to my younger sister or my younger brother.” I have been working on gifting things back. I have two brothers. I am gifting some of the things back to them like: “I am complete. Maybe you can take this on for a while.” It is interesting because what I have also discovered is if you ask, people are willing to help. So a lot of it is on us because we have never asked.

Kevin Pho: You mentioned the process of setting boundaries and letting go, but like you said earlier, all their lives they haven’t done any of that. They haven’t set those boundaries, they haven’t delegated. But in order to reduce the incidents of burnout, that’s something that they probably have to learn to get started or learn to disassociate themselves from that particular identity. You mentioned the words peeling back, so what are some steps to go about doing that?

Jessie Mahoney: I think the first step is awareness: seeing that it is not your fault. So it is awareness and non-judgment, which are tenets of mindfulness: slowing down enough to notice where you aren’t boundaried or watching potentially other people where they are boundaried and where it works. We often look at them and are frustrated with them, but instead, what can we learn? Where are boundaries possible?

If most people want to stay in medicine and want to be able to keep practicing, then we really do want to figure out a way to make it sustainable. When you can step out of the judgment that “more is better” and “taking care of everyone is your responsibility,” you can look around for people who can help. What can you do that will allow you to stay practicing medicine healthily?

I think sometimes, especially in primary care, we want to address everything. I have a lot of physicians who come to work with me and they say: “No, my job is to answer all the questions and make sure that everything they want to take care of today is taken care of.” That is not realistic in a 15-minute visit. So part of it is actually owning your knowledge and your expertise and saying: “We are going to cover these three things today.” Or: “This is my agenda for someone who is here with cancer or here with a six-month-old. What are your questions?” We will make sure to touch on them at the end. But you can also then decide that those aren’t necessarily there for you.

I have seen some clients decide that they are going to focus on one or two things a visit. Even though I am a pediatrician—so the AAP standard is like “cover all 29,000 things,” which is not realistic—what they have discovered is their patients are actually healthier and they are enjoying their career and they are planning to stay. It is a trust in yourself that we actually have a lot of training to know what is important. So can we lean into that rather than: “I am not going to do that. I am not going to do that”?

I often talk about boundaries coming from a place of love, and that sounds very woo and fluff, but what that means is love for you so that if you want to stay in medicine, you can; love for your patients because our patients all need a doctor and it is so hard to find a doctor right now; and love for the system of medicine to actually be clear about what you can do and what you cannot do. I think assessing this idea of what is reasonable and unreasonable is extremely powerful to recognize: “What is actually doable in a 15-minute visit? What is actually doable in a day at work? What is actually doable in 24 hours as potentially a mom, daughter, sister, whatever else?”

If you struggle with the word reasonable or unreasonable, you could change it to human. That is a human expectation. When we have been made heroes, we are expected to have to do things that are not human. I think that the eldest daughter thing ties into the hero. We are the savior of the families. That is how we see ourselves. It is not even conscious at all. It is just that if we don’t do it, someone else won’t do it, for example. And so then what happens? We go into our default: “Terrible things happen and it will be our fault.” So I think this idea of recognizing reminds me of excellence. Excellence is actually other people doing their job. Excellence is letting your medical assistant do things. Excellence is letting colleagues do things. Yes, and recognizing that we don’t have to and can’t do it all ourselves.

Kevin Pho: So tell us a success story perhaps from your coaching experiences. Have you been able to successfully help someone with this eldest daughter syndrome and who is burnt out because that’s who their identity is tied to? What kind of things do you do in your coaching sessions and tell us a success story of what that would look like.

Jessie Mahoney: Really what it looks like is recognizing that you are an eldest daughter and what that means and where these traits came from. And then it is choosing how you want to move forward differently. I actually see a lot of people who might change roles. So sometimes people will be, for example, a full-spectrum OB/GYN, and then they will change to being a laborist or they will change to doing clinic only—not because they have to, but because they want to. Because they want to have more limits. They will start asking for help or some people in their specific practice will change how they interact with patients.

I mentioned this pediatrician who has changed her clinic visits, and she is someone who is going to retire early and is now staying because she likes her job. So it is recognizing that seeing this role and seeing how it impacts you gives you the ability to choose how much of it you want to carry forward.

We had a podcast a bit ago about caring for aging parents, and I will say that is actually where I see it being the most impactful: stepping back from that role. Not because you don’t care, but letting other siblings who may or may not be physicians (because they weren’t the eldest daughter also; I am sure the eldest son has a whole other thing about it as well) take over. That can give you this space so that you are not so compressed, so you can actually enjoy your practice or enjoy your relationship.

I think that the key wins in coaching around this is the recognition and critically non-judgment because what I see for many people who engage in coaching in health care is a lot of judgment about: “How come I don’t have boundaries?” and “How come I didn’t see this before?” I think if you can see that you were raised from childhood with it, of course you are not going to see it until you are made aware of it. Maya Angelou says that we can’t change things that we don’t see, but once we see them, we can change them.

So in coaching, it is really the recognition of where this pattern shows up in your life, in medicine, and in the rest of your life. Because a huge part of the struggle for women in medicine is that we have our work life and our home life, and both of them are full-time jobs. So how do we pare them down? How do we get help or drop some of the perfectionism? It is OK to make a mistake. It is OK to do things imperfectly. But this eldest daughter syndrome is actually not OK in that setting. It is interesting because (and this is where it gets fuzzy) it might have been OK. But we got so much praise for always doing it right that we aren’t willing to make a mistake.

So again, it feeds in. The shift out of it is pausing and slowing down and doing the exploration about where did it come from in your life and what parts of it are you holding and carrying, and which of those is helpful (because there is a fair bit of it that is helpful). What part of it are you ready to peel off? And so you can continue. I think we spend a lot of time blaming the system, but we also have to and want to have this clarity within ourselves because it is going to make us better advocates about what is reasonable and what is not.

Kevin Pho: We are talking to Jessie Mahoney, pediatrician and coach. Today’s KevinMD article is “The burden of the eldest daughter.” Jessie, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Jessie Mahoney: Well, number one, just awareness of how many of the women in health care are eldest daughters and what that looks like. And then an awareness of how it is impacting burnout. And that we can make change, not from a place of blaming ourselves or blaming those individuals, but from really focusing on what is human and what is reasonable. Just because it has been done that way or you have done it that way doesn’t make it the right way to move forward.

Kevin Pho: Jessie, as always, thank you so much for sharing your perspective and insight and thanks again for coming back on the show.

Jessie Mahoney: Thank you.