When I taught English, my students and I read Anne Bradstreet (1612-1672). A Puritan and a mother, she was also America's first published poet. Her syntax and use of unfamiliar allusions sound old-fashioned to our modern ears, and her reliance on Christian faith can prove difficult for secular readers to understand. But I loved teaching Bradstreet. Her poems always proved to be more than they appeared.

In "Before the Birth of One of Her Children," Bradstreet addresses her husband about an upcoming birth: "How soon, my Dear, death may my steps attend/How soon't may be thy lot to lose thy friend" (7-8).¹ She counsels him that if she dies in childbirth, he should marry again, but "if thou love thyself, or loved’st me, . . . protect [our children] from step dame's injury" (23-24).

At first reading, this fear of death-by-childbirth seems overwrought, but read in context of 17th-century realities, Bradstreet's entreaty to her husband is moving: the notion that pregnancy does not also foreshadow death is a 20th-century idea, and even now a luxury only the developed world can afford. Maternal and infant mortality in Bradstreet's day was high, and enough to make delivery of even the most wanted baby an occasion filled with dread. In this context, Bradstreet's pleas to her husband are not melodramatic: they are a frank assessment of what the couple faced when pregnancy represented not just beginning a new life, but the possibility of death.

Once my students understood this connection between pregnancy and death, we unpacked other particulars of Bradstreet's life. We learned that because she had eight children—and a heart weakened by rheumatic fever as a child—she faced death eight times. We calculated that eight births meant eight pregnancies and that eight pregnancies meant she spent 72 months, or six years, of her life pregnant. Eight births also correlates with nursing eight babies, and in a time when women breastfed for about 18 months or until the birth of their next infant, this means Bradstreet spent 154 months or almost 13 years of her life lactating. Moreover, these numbers only reflect babies she carried to term. Bradstreet likely lost additional pregnancies to miscarriage. But even if we only count births we know about, these numbers mean that America's first published poet composed while dedicating 19 years of her life—some concurrently—to work surrounding childbearing.

Having sorted through these details, my students and I read Bradstreet again, and even to our 20th-century ears, she made more sense. As poet and critic Adrienne Rich argues, "to have written . . . the first good poems in America, while rearing eight children, frequently lying sick, keeping house on the edge of the wilderness, was to have managed a poet's range and extension within confines as severe as any American poet has confronted."¹ No kidding.

I have been thinking about Bradstreet a lot lately, not because I am a mother or a Puritan, but because she understands something about the commingling of birth and death, and because doing the mathematics of her life is helping me make sense of my own. Two and a half weeks ago, or about 18 days ago, I finished a residency in emergency medicine and started a new life as an ED doctor. This reality is as complicated for me as the fact that Bradstreet bore eight children. As I have concluded the process that turned me into a physician, I am struggling to comprehend the math of my own life, and to understand what I have lost—and gained—along the way.

When I finished residency on 30 June 2007, I had been working at becoming a physician for nine years. This includes two years of pre-med, four of medical school, and three of residency. Medical training has taken up my 30s and consumed almost a decade.

In addition to time spent, there have been other costs. The most obvious of these are financial. I emptied my savings of $35 000 to pay for pre-med, and then the real spending began: I owe lenders about $150 000 in student loan debt. After consolidating my loans at an interest rate of 4.375%, I will owe $813.40 a month for the next 30 years, or until I am 71 years old. My loan money went for tuition but also bought groceries and paid rent. What loans did not cover went on credit cards, leaving me with balances too embarrassing to reveal in print.

Other losses hurt more than money. Deciding to go to medical school meant leaving a beloved teaching job at Bentley College in Waltham, Massachusetts, so I could return to college and accumulate prerequisites. It also meant leaving friends. On the Saturday morning I moved, neighbors gathered at my Cambridge apartment and helped me pack. My mother and I then drove to my office, where I loaded books into a moving van and began the process of trading one life and career for another.

But the process of accumulating losses had just begun, and over time, the list of important and mundane things lost grew longer. I missed weddings, Christmases, and too many dinner parties to count. Church services, time to exercise or to hear a favorite band play, all went by the wayside in the name of medicine. So did weekends, meals eaten with a fork, all my size eight—and then size ten—clothes, and sleep. Yes, lots of sleep. By my conservative reckoning, I have lost more than 200 nights of sleep in the last nine years, a number that includes only time spent in the hospital taking care of patients, not all-nighters pulled studying for exams. Of these 200 sleepless nights, more than 50 were spent on 30-hour in-hospital shifts, where going to work on Monday meant not going home and not going to sleep until Tuesday afternoon—only to do it over again every fourth day until the end of the month. Nights away from home also represent time lost for family and personal relationships.

Not surprisingly, when I think too long about these losses, I feel bitter and self-pitying—feelings that make me wonder if the last nine years were a mistake. This is when I start doing math in the other direction, to remind myself there are also things I have gained. I have gotten a medical education, I say, and start counting what that means: at 15 to 25 patients per emergency department shift, I have seen about 7500 patients. This represents 7500 opportunities to learn from another human being, and to try to provide some help. These numbers also represent opportunities to do procedures. According to my procedure log, I have placed 24 chest tubes, reduced 13 dislocated shoulders, performed 25 spinal taps, and intubated 109 patients. I have performed 45 trauma and more than 139 medical resuscitations. This, in turn, has given me the sad responsibility of telling two families a month that someone they love just died—and giving at least as many people the news that a family member has been resuscitated and is now in ICU. At the same time, I have looked at more sore throats, done more vaginal examinations, and sutured more limbs than I can count.

I recognize that these numbers mean I have gotten the "medical education" I call to mind in dark moments, so I add the numbers up regularly to remind myself it is a blessing that for the rest of my life I get to do a job that I love and be paid well enough to make a living. But because I have experienced loss, when doing this math, I still wonder if I come out ahead. I say this not because I am ungrateful for my education, but because I did not go to medical school to have a good income, or even to become a doctor with a capital D. Whatever money or prestige comes with my job means little to me: however sexy placing a chest tube or intubating someone looks on television, these skills alone do not make up for missing my nieces' birthday parties and having to calendar, months ahead, chances to make love with my husband.

These realities lead me to look for other ways to make sense of the last nine years, and answers come in a list of experiences that are less quantifiable, but still real. Often they have to do with patients: the Native American woman who called the spirit of her dead daughter into the ED to heal an ailing loved one (and ended up healing me); the drunk trauma patient who at the top of his lungs forbade us to cut off his pants because "I’ve got a really small penis and don't want anyone to know"; and the parents of a dead baby we had not been able to resuscitate who allowed me to cradle their infant daughter while we all grieved.

Other gains have nothing to do with medicine but are equally important. When I started medical school, I thought there was light and dark, day and night. I knew something about the way shadows fell in the evening and how that was different from the way light looked at dawn, but I had not yet had enough sleepless nights, or worked enough days in a row without seeing the sun, to know that indoor, fluorescent light looks different in the day than at night and that a peek at outside, ambient light on even the cloudiest February day can be something beautiful to behold. I did not know the difference between not sleeping at all and getting 20 minutes of sleep or that what I called "insomnia" prior to medical school meant I had not slept well—not that I actually had not slept at all. I did not know how precious an afternoon off could be after a night on-call or how dear it could feel to climb into bed at the end of a shift with a loved one—or even a dog.

To be honest, until medical school, I did not know what life and death and suffering really meant. Until I paid my $150 000, I had not known that dead bodies are genuinely cold or that the fluids that come from living bodies—blood, vomit, feces, urine—are always warm. I had not yet had the humbling experience of telling someone that a family member had just died or felt the impotence of knowing there was nothing I could do to help the patient or spare the family its grief. In short, until I was a good long way into all that debt and sleep deprivation, I had not understood very well what it meant to be human. Maybe not even what it meant to be alive.

Anne Bradstreet opens "Before the Birth of One of Her Children" with these lines:

 All things within this fading world hath end,

 Adversity doth still our joys attend;

 No ties so strong, no friends so dear and sweet,

 But with death's parting blow is sure to meet.

 The sentence past is most irrevocable,

 A common thing, yet oh, inevitable.

As I look at the last nine years and ponder the "inevitably" of death and the "irrevocab[ility]" of "adversity" attending "joys," I realize I have been miscalculating the math of Bradstreet's life—and my own. Thousands of dollars poorer and many sleepless nights more tired, I wonder if the important calculation in Bradstreet's life is not how she managed to write "the first good poems in America" while "keeping house on the edge of the wilderness," but how carrying, bearing, and nursing eight children enabled her to do so. Rather than being a heroic figure scratching out time from child-rearing activities to write, I am coming to believe that Bradstreet simply lived. I also suspect that the gains and losses of her life—"confines as severe as any American poet has confronted"—are the very things that generated her "range and extension" and left us with poetry still good enough to be read today.

When I think about Bradstreet now, I try to stop counting the months she spent lactating and hours she spent delivering babies and look at the big picture. I see her at a hearth with a ladle bent into a pot and her foot rocking a baby in a cradle. She may be pregnant or maybe not, but there is always a pen, nearby. For this Anne Bradstreet, to live was not to account but simply to experience and, when she had time, to set it down. This woman understood something in 17th-century America that I am just beginning to comprehend today: that life is not a zero-sum game. A gain in one column does not necessitate a loss in another, and winning does not correlate with being debt-free or having the fewest losses in the final tally at the end of life. Rather, all losses are gains. All gains have corresponding losses. This is not harsh or bleak or cruel. This is being human. This is life. Sometimes you are talented enough to write it down.

And sometimes you are lucky enough to read what a wiser writer had to say about it 329 years ago.

Acknowledgment: This essay is dedicated, with gratitude, to everyone in the emergency department at the Nebraska Medical Center.