Tag Archives: Culture

How Strange to Be Unable to Name a Daffodil

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“We saw daffodils!” I said. My voice sang with an enthusiasm that only such a definitive sign of spring could coax from me on such a rainy, gray afternoon in February. My co-resident looked at me blankly. The importance of a daffodil passing through their genius brain just as the medical terminology doctors like to use pass through patients’ ears – jargon without meaning, hardly in and definitely right out. “You know, it’s one of the first flowers of spring. I saw it in the park.  They’re yellow…” I gave up and the conversation moved on to other topics.

Doctors are more diverse than we once were, but our makeup doesn’t come close to mirroring the population we serve. My visible profile is common in the medical world – white (always very common) and female (slightly more females are entering medicine than males these days). Yet my unseen profile, my story before medicine and path to medical school, is unusual for a doctor.

Sometimes I’m reminded of my different background when it’s easier for me to relate to patients than my colleagues who come from medical families and have never known what it is like to not know what “coronary artery disease” and “hypercoagulability” mean. Other times I’m reminded of my different background when it’s easier for me to understand the social determinants of health such as why someone might not have transportation to appointments and why medications might not be worth the monthly bill to a specific individual. Where I grew up if you didn’t have a car you went nowhere; further, I solely used public transportation for most of my 20s. I’ve also run a tight budget most of my life which has given me a lot of practice deciding where my money will and won’t go.

It’s not just my economic background that makes me different from many of my co-residents (though I’ve come to realize more with each passing year that economic background is a mountain that dominates world view). The nuances of my difference from many of my colleagues present themselves at unexpected times such as on slow days when making small talk with co-residents and supervising physicians.

I grew up in a world where medicine was minimally understood, mysterious, and (perhaps) feared. The distance of medicine was partially possible because my family was healthy and required minimal medical care; it was also who we were. Our lack of medical knowledge did not mean, however, a lack of knowledge. For my colleagues who have known the medicine way of life since childhood as they watched their parents (many doctors and some nurses) come and go from work, the hospital system is familiar and almost second nature. I didn’t grow up knowing the hospital. Yet, I know other things that are part of who I was, am, and will be.

For example, I know the birds, trees, and plants of my childhood and I’m learning the ones of my new home in Virginia. I know how to grow plants indoors or in a garden because I grew up in a culture where we all knew how to tend plants. In a similar way, I don’t believe cows are cute because I’ve been almost late to school chasing them after they got out of the fence. I know how to stack 6 cords of wood in a day, use power tools and wood tools, and change my car tires because these are skills that were necessary in the world where I grew up. I notice architectural details, complementary colors, and other design elements because these were some of the themes of my childhood.

Being an older resident with a different background and careers prior to medicine is isolating at times. A small portion of my co-residents can relate or are interested in where I’ve been before medical school. I’ve become accustomed to this. My life extends beyond the hospital. I have family and friends who understand the nonmedical aspects of my life just as my co-residents understand the Doctorhood Quest in a way non-physicians can’t.

I have so much to learn about medicine from my co-residents and supervising physicians regardless of whether they understand any aspect of my life outside of residency. But, on days such as when I find a resident who can’t name a daffodil, I’m torn between amusement and sadness. In my world it’s ridiculous to be unable to name one of the most common spring flowers in the US. The realization that there may be many doctors who can’t name a daffodil reminds me just how different we all are. It also reassures me that there is much I can teach my co-residents too. And, perhaps more importantly, it reminds me how much physicians can learn from our patients and non-doctor colleagues if we find time to listen.

My Hero List Grew by One That Night

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It was early during residency. I was still adjusting to primary care clinic which included learning how the computer system worked. I still didn’t have home access to the electronic medical records so I couldn’t review my patients ahead of their appointments. I also couldn’t write my patient notes at home. All my patients were new to me. Between the challenge of learning new patients and the computer system, I fell behind in clinic one day.

My patient appointments stacked up like logs against a dam before it bursts. And, with my appointments running behind and my slowness with the computer system, the notes I had to write for each patient appointment were pushed to the end of the day.  My last appointment ended an hour late because it started an hour late.

There I was, already after closing time and just starting to fight the computer system to write my notes as fast as I could. Everyone else in the clinic had left an hour or so earlier. I was hungry because I hadn’t thought I’d need to bring dinner.  I’d already eaten breakfast and lunch at the clinic. I was startled when I heard someone in the hall. The janitor walked by my office, “Late night?” he asked pausing outside my open office door.

“Yeah. I’m new here and I’m still slow with the computer,” I said.

“And they just left you?” he asked.

“It’s okay. Hopefully my notes will be done soon,” I said.

“Well, thanks for your work,” he said.

Hours passed. One note at a time, like small footsteps, my pile of remaining work dwindled. The janitor stopped by my door again. “I got you these. It’s not much but it’s all I could find,” he said. He handed me a bag of BBQ potato chips and a mini-Fanta orange soda.

“Thank you so much! You’re so kind,” I said. I was too tired to be giddy but in better circumstances I would have been gleeful for the snacks.

“Have a good night. Hope you can leave soon,” he said and walked away, back to his own work.  

I don’t think he’ll ever know how much he saved me that night. When I was finally done with my work and as I walked through the empty clinic and then the empty parking lot to my car, I thought about how much I appreciated the janitor. I’ve often thought it odd that society focuses so much on big names and money. In my experience, heroes are always humble strangers acting out of kindness and with no motive or expectation of recognition.  

That night I was reminded that all it takes is pausing to offer a little help to transform a person’s night. The janitor clearly had already ingrained that knowledge into his existence. And like the heroes who came before him, I added the janitor to my life’s hall of fame as I walked to my car to drive home. My hall of fame isn’t a hall of fame like those for baseball players but, to me, it’s a lot more important. And, in case you’re wondering, I’ve never had a more delicious bag of chips and can of soda.

This Is How I Started Residency

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Starting residency was like a flash flood. Beginning from the first day, I was overtaken with more work than I knew what to do with. As a new doctor in a new healthcare system, I found myself equally challenged by creating care plans for my patients (like deciding which medications to prescribe them) and implementing the plans my supervising doctors and I devised (like ordering medications in the computer system). I completed tasks more slowly than I imagined possible. My patients were well cared for because I was part of a team, but my work hours lengthened in a way that the saying “burn the candle on both ends” was created to describe.

All of us headed to residency (regardless of specialty) are warned that it will be challenging. Each person experiences different challenges and different low points. Residency is hard for everyone because the hours are long and there’s a lot to learn. So, when my work hours exploded like water through a broken dam, I wasn’t surprised. I was surprised by how my program responded.

As my hours lengthened to a point where I was exhausted and just barely surviving, my chief residents stepped in to help me develop ways to become more efficient. Senior residents observed me throughout a shift and offered advice on how I could streamline my workflow. People on my team and other teams helped take some tasks off my plate so I could focus on learning the computer system better and on writing patient care notes quicker. I was given a little extra time off to catch up on sleep because I was on track to work far more hours than permitted by the national governing body that oversees US residency programs.

At first the extra help and attention made me feel like a failure. I tried to keep my spirits up because I’ve struggled to overcome big obstacles before; I always learned more from those experiences than I did from experiences where I didn’t struggle. Similarly, past experiences have shown me that it’s okay to accept help. Still, I wondered if I was going to learn enough or as quickly as I should if people helped me more than some of my peers. I wondered if I’d get better at being a doctor.

On my extra time off I reviewed my senior residents’ feedback. I reorganized my view of the electronic health record system to make it easier to access all the information I knew was important. I took time to recharge. When I returned to work, I was still a new doctor. I hadn’t changed much from the days prior. Yet, I found myself checking things off my to-do list without the help I’d required before my recharge day. With a little more sleep behind me, I was able to see how much I’d learned in my previous days of working – something I hadn’t noticed when I was exhausted.

As I reflect on my first two weeks of residency, I don’t look at them fondly. I do think that I’m a tiny bit better at being a doctor now than I was two weeks ago. I appreciate my past self for prioritizing a work culture of support and collaboration when applying to residency. I know that there are many hard days to come before residency is over. However, my experience during these first weeks made me confident that I will be able to overcome future hard patches when they come – not completely alone, instead, with a program supporting me as I find my path forward. Feeling like my residency program genuinely wants to help me become the best physician I can be gives me confidence in the residency training process and makes me excited for who I’ll become by the end of it.

This is how I started residency. The future will tell how I end residency.

Maintaining the Body/Mind

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In zooming around healthcare settings, I’ve noticed that many people approach illness as a weakness or a betrayal of their body and mind. I’ve even noticed myself having a similar feeling occasionally when I must visit my own doctor. This way of thinking is like how I think about my car: I expect my car to get me from A to B every time I ask it to, with minimal effort on my part, and no upkeep.

To further outline the analogy between bodies/minds and cars:

  • The hospital is to the body/mind as the auto shop is to a car after a crash. If something gets damaged, we usually must fix it to run again.
  • The primary care setting is to the body/mind as an oil change, tire change, and alignment are to a car. For optimal performance, we must continuously do some upkeep and occasionally get a tune up.

As we examine the analogy between cars and bodies/minds there is an essential difference. If we have the money, we can buy a new car periodically to avoid all the upkeep that inevitably comes with the wear and tear of use. However, we each only get one body/mind and, therefore, not even money can spare us the required upkeep that comes with the wear and tear of life.

Considering that we each only get one body/mind and life is hard, I’d like to propose the viewpoint that going to a primary care provider isn’t a visit with the enemy. It’s not intended to be a place of judgement or punishment. Instead, think of primary care appointments as tune ups that include chatting with an expert on the human body/mind. In this chat, we can uncover what aspects of our body/mind are optimized, what aspects aren’t optimal, and how we each can make our body/mind run better. By optimizing our body/mind, we may prevent many diseases from occurring (prevention is better than treatment, why get sick if there’s a way to avoid it completely?). 

In a similar fashion, no one wants to stay in the hospital, but needing the hospital isn’t unique; it’s part of the human experience in places where hospitals exist. Hospitals can save lives and fix big health problems. They might not be the most pleasant places, but without them we might not get the care we need to recover when things in our bodies/minds break. If we can think of our hospital care team as a bunch of people on our side who are looking out for our bodies/minds, it might make the whole experience a little better.

 Just as we know our cars require a certain amount of upkeep, I challenge all of us to remember that the body and mind also require a certain amount of upkeep without considering a need for that upkeep a shortcoming.

Did the Jones Cheat?

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I strode along one of my most frequented paths which combines my town’s main street and a side street that parallels it. I like the route because it represents two separate worlds despite their proximity. The main street is scattered with restaurants reflecting the many Central and South American cultures that comprise a large portion of my town’s heritage, hair salons, family-owned gift shops and clothing boutiques with their signs as much in Portuguese and Spanish as English, churches, places to learn English and send money orders, and empty store fronts. The side street is lined with one-family homes so large that if I lived in them, I’d need a map to navigate them and an intercom to find my family members in the far reaches of rooms and floors away from me.

As I crossed a four-way intersection, navigating the streetlights (including their left turn arrows) as I always do because I don’t think the walk signal ever turns on, I came upon the first house in the row of mansions. I slowed my pace. There was a landscaping crew. This was a common sight on this street and in many places in Connecticut – people spend lots of money on their lawns here. You always know a landscaping crew because they have big beaten-up trucks with letters painted on the side and a big trailer behind. What made this crew different was that they didn’t have mowing equipment, pruners, or leaf blowers from what I could tell. They weren’t even looking at the plants in the yard. THE LANDSCAPE CREW WAS HANGING CHRISTMAS LIGHTS AND CHRISTMAS WREATHS FOR A PRIVATE HOME.

I thought of that scene in The Grinch where one neighbor is using the Christmas light gun to decorate her house and the other neighbor is blowing electrical fuses to try to get her Christmas light display to just turn on. It never occurred to me that people might pay someone to hang their Christmas decorations at their home. Businesses obviously do that, but a private home having someone else decorate for Christmas?

On a later night, I passed the house of the family who had paid a crew to decorate for Christmas. Their house looked fantastic but in my heart of hearts the decorations were empty. I found myself wondering:

  • Is decorating for Christmas more about the quality of the decorations or is it more about the combination of annoyance and joy of putting them up and then criticizing and loving your own work until you must go through the added chore of taking the decorations down again?
  • Is decorating for Christmas about the quality of your house decorations or the conversations that go into convincing various family members or friends to help you hang decorations or the determination required to hang them all by yourself?

I found myself leaning toward the belief that decorating for Christmas was a lot about the journey and less about the end. Having decorated many a Christmas tree I cut down in the middle of my dad’s woods as a child, which is to say that we had untrimmed trees in all their asymmetrical glory, I find myself solidly believing that what makes home Christmas decorations special is that they were done by amateurs in the spirit of holiday cheer, family fun, and acceptance of an imperfect final product. It’s not that I faulted this family who paid to have their house decorated for Christmas, it’s just that their approached seemed business-like. Much like the Christmas displays on 5th Avenue in NYC, the house with decorations hung by a hired crew was beautiful.

I found myself chuckling about the concept of “keeping up with the Jones.” I found myself glad I grew up in a space and time where lawns were sometimes mowed by teenagers, often not mowed recently, and sometimes mowed by livestock. I’m not sure why the imperfection of unprofessionally maintained homes warms my soul, but it does. And as the holiday season unfolds, I find myself thinking about what exactly is most important in creating holiday spirit.

Finding Purpose and Meaning

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The patient was nicely dressed and collected. They sat with elegance as I chatted with them during their checkup. By most accounts they were doing well. They didn’t have many aching joints or the other common issues of people their age. But, as we finished going through all the normal appointment questions and checklist items for a primary care visit, the conversation turned to the main issue at hand: meaningful existence. 

The patient had recently moved from the south to the north to be close to their adult children. In moving, they had left behind the hair salon where they’d worked for many years and where they continued to work until moving. Nobody in their new, northern community would hire them as a hairdresser because of their age. This disappointed them. They were very energetic. They were involved in many clubs and had many social engagements weekly, yet, they found themselves depressed, tired, and empty. Nothing they were doing gave them the sense of purpose that working had.

We brainstormed together. If not work, could the patient volunteer? Where might they like to volunteer? Our town had many opportunities for volunteering. The patient jotted down a few nonprofit ideas and smiled. They said they’d consider it; it seemed better that sitting around doing pointless things.

Depression is common in the elderly. Among other things, it’s postulated that feelings of isolation and loss of purpose can contribute to depression. On an anecdotal level, I’ve heard many elderly patients describe feeling alone, especially when they’ve moved to be close to adult children and left behind an existing community their age or that they had been part of for a long time. Even children who visit frequently aren’t the same as having a whole community – especially a community that has also lived through the same decades and seen the same changes in the world. What’s more, many elderly people are retired or decrease their activity in work and volunteering. It’s easy to say that retirement and less work is good and that these wise people have worked their whole lives and deserve a rest. This is true; however, what I’ve also noticed anecdotally among the hundreds of patients I’ve met as a medical student, is that the happiest people are the people who have meaningful projects regardless of age.

This elderly patient is an example of someone who was driven to work well after they reached retirement age. Their case showed me that perhaps encouraging and supporting our elders to be active participants in their community would be helpful for their wellbeing. This seems especially important in a place like the US where many families are scattered all over the country and generations tend to live separately. There are many elderly folks who find meaning in caring for grandchildren as I’ve seen in other places like when I lived in Paraguay. However, we must remember that there are many elderly people who didn’t have children or who don’t wish to spend their days caring for their kids’ kids and that their need for meaningful activities is also valid. As we forge forward as a society, it seems prudent to keep this in mind and continue to support and develop programs that help an aging population remain active in their communities’ productivity and progress if they would like to be. Be it work, volunteering, or other projects in and out of the home.

Learning to See

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Before I moved to me latest city, the people I talked to about the city during my travels through medical school rotations didn’t have anything good to say about it. One person said there weren’t any good food. Others said there wasn’t much to do. When I moved here, someone went as far as to tell me it was dangerous. And, while I listened carefully because I knew little about the city myself, I had a suspicion they were wrong.

When I was a child, I learned to see the trees and birds around me. I learned to name them. I could tell a white pine from a red pine or a sugar maple from a red maple. I could tell you the sound of the chickadee and the hermit thrush. I knew the difference between a red wing blackbird and an oriole or a bluebird and an indigo bunting. This type of seeing was the outcome of growing up in the middle of nowhere while surrounded by women who knew these things and shared them with me.

Early on, I learned to tell the difference between real wood and fake wood. I could identify sloppy joints and beautifully joined boards. I judged furniture and house finishings based on their joints. I could tell you how sheetrock differed from plaster. I understood these things because my father had taught me to notice them. My mom taught me to see colors and how they might be paired. I still notice boldly paired colors and they bring me joy regardless of if I find them in a painting or on someone’s clothes.

As a I grew, I learned to name the flowers in people’s gardens because I worked in a greenhouse. I was trained to tell the difference between a rose and a lily, for example. My parents taught me to notice architecture. What makes a classic New England home look as such and how that differs from an adobe house. I came to understand what a well-built house is.

When I moved to DC, I learned how to see a street for what it was. A pathway to somewhere. I learned how to chart my course and tell if I was safe on a particular path within moments. I learned to see the places, like underpasses, I should avoid at night and the places that were filled with architecture, trees, and flowers. I learned this out of necessity and because I have a savage passion for walking and walking and walking.

When I moved to Paraguay, I learned to see what someone was trying to say because I couldn’t always understand their words. I learned to see if they were lying, or friendly, or joking. I learned to see why some people might follow God. I started to understand why life in Paraguay is different from life in the United States. And I learned to see that difference as both beautiful and challenging.

In medical school I’ve spent years learning to see exactly what a normal breath is and how stretchy skin should be. I’ve learned to see how the heart and abdomen are when all is well and what an infection looks like. I’ve learned to understand almost every part of the body and to see when it is healthy.

All this learning about how to see I carry with me always. And, when I moved to my latest home, I applied my seeing to understand what this city was. I learned that there is a lot to say about Danbury. I found the trails (there are numerous) where I can run and walk among the trees, birds, and flowers. I’ve noted the buildings with outstanding architecture. I found half a dozen murals with beautifully blended colors. I’m mapping out the good eateries—so far, I have a recommendation for every meal of the day plus elevenses and snacks. Much like Paraguay, Danbury is filled with people who don’t look or speak like me. But, when I took the time to observe my neighbors; it became apparent that they are a bunch of people trying to carve out a little space to work, eat, and be merry. I came to understand they were just like me in many ways. And, noticing our similarities, I understood that this city suits me. Seeing is something that takes practice. But once you learn to see you can begin to understand.

Burnt

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Her hands had become so numb she could no longer administer the eyedrops that kept the pressure in her eyes from getting too high. If her eye pressure got too high, she’d go blind. So, her eye doctor said she needed surgery if she couldn’t use the eye drops. There were two surgical options. One surgery would take an hour and she’d leave the operating room able to see. One would take 3 hours and she’d leave the operating room blind, requiring 4-6 weeks of recovery before her vision would return. She was lucky because she had family who already helped her a ton because her other health conditions had made independent living hard for her. For some reason, the insurance would only cover the 3-hour surgery that would leave her blind for over a month. The holidays were coming up. The family members that took care of her had kids. She refused to make them care for her while she was blind over the holidays. She postponed the surgery. Would she go blind before she could get her surgery? Is this the healthcare system we want?

~

The patient wasn’t COVID vaccinated. “What will you do to treat me if I get COVID?” she asked. I thought about the patient a resident had told me about. That patient had been dependent on family for care. His family didn’t vaccinate him. He got COVID. He came to the emergency room with trouble breathing and then went to the intensive care unit. He lived on the intensive care unit for a year. Eventually, his healthcare team cut a hole in his neck to put a breathing tube in because he needed it. They did everything they could to keep him alive. The resident said when the patient first came to the emergency room, he was a happy, funny soul. The patient lost his happiness slowly during the year he fought to breath. After a year of an entire hospital trying keep him alive, he died. When exactly did avoiding sickness fall out of favor? Do you ask what firefighters will do if you set fire to your house or do you make a concerted effort to not catch your house on fire knowing that firefighters will do their best to stop a fire if it occurs but are limited because fires are destructive and destroy houses and the people who try to stop them?

~

The patient asked, “Why are so many doctors retiring?” I wondered how he didn’t know the answer to that question already. It seems so obvious. Then, I realized he was not a medical student. Being a medical student is to have a front row seat for observing the current state of healthcare. What had I seen? Why did it seem perfectly logical to me that so many people were retiring from healthcare even as I was striving to make it my career?

Not just doctors and nurses, but everyone in healthcare seems to be retiring…

We report our COVID cases. Our COVID test rates. Our COVID survival rates after hospital admission. Our COVID deaths. Who was there to perform those tests, to care for those people when they came to the hospital, and to close the curtain when the ventilator wasn’t needed anymore? Healthcare workers. But, they were also there for all the other things too. The heart attacks. The stomach pain. The broken bones. The cancer. The normal healthcare screenings. They were there when people looked for help with their depression and their anxiety. Healthcare workers’ hours increased. They worked the job of two, three, four, and five people because the hospital was short-staffed before the pandemic hit. Again, healthcare workers were already working long hours and doing the work of several workers before COVID came. Then healthcare workers got sick. And the ones left standing worked for their sick colleagues, worked for themselves, and worked for the staff who were missing before the pandemic came. Wages stayed the same.

Housing and food got expensive for everyone, including healthcare workers. Healthcare workers missed the same performances, social events, and restaurants that everyone else was missing. Life got more expensive because everything including industry was disrupted by COVID. Healthcare wages stayed the same. Healthcare workers got sick. Sick leave was used up. Shifts were harder because healthcare was short staffed and there were more patients than before. And the patients were dying. And insurance didn’t want to pay for the treatments that patients needed, not that that was new, but it remained disheartening. And there was the need to wear masks at work. And to put on goggles and gowns and for healthcare workers to take extra time to protect themselves from infection. There was the risk of bringing COVID home after working in healthcare. Wages stayed the same.

People got sick. And healthcare workers got tired. Wages stayed the same. Hours were long. Vacations couldn’t be taken like they used to be taken. And just like their patients, healthcare workers got sick, tired, depressed, and anxious. Staff shortages increased in the hospitals and clinics.

People denied that COVID was real. People invented vaccines that helped prevent COVID infection. People refused to get vaccinated. People complained about wearing masks. People got tired of social distancing. People got sick. The intensive care unit was full. The psychiatric ward was full. The cardiac ward was full. Alcohol use disorder, diabetes, high blood pressure, and all the other medical conditions that always exist marched on because they don’t stop during a pandemic. Healthcare workers shouldered the workload of several workers each because some of their colleagues had left, some had died, and some were sick. Wages stayed the same.

In such an avalanche, how long would you have waited to change careers? For many, the answer was between 1 and 2 years.

~

There is always hope and healthcare has been grounded in hope since the beginning. But as a student so excited to become a physician I know that change must happen if hope is to materialize into lives saved. And for my sake and all the people who might need the hospital or a clinic in the coming years, let’s not make it take a healthcare collapse before we seriously consider how we might improve and restructure our healthcare system. I’d very much like some seasoned healthcare workers who are not completed burnt at my side when I start practicing as an independent physician because experience is gold in medicine. I’d also really like to have enough staff to care for patients without having to burn myself and burn my colleagues with the weight of too many lives in each of our two hands.

One Example of Sexism in the Operating Room

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Often enough to be considered a pattern, the men in the operating room chose to discuss the annoyance of the hospital’s anti-harassment yearly training videos and anti-harassment policies when I was the only female in the operating room with them or when it was just an older female nurse, them, and me. And while I also find the hospital’s anti-harassment training videos frustrating (for entirely different reasons than my male counterparts), I did not appreciate when a surgeon said he could get tips from the scenarios in the video. I did not appreciate his comment (despite his humorous tone) because the truth is that harassment doesn’t just occur in training videos. It occurs all the time and in all settings of women’s lives.

And I found it interesting that these men were complaining when most of them are fathers of daughters, and many are fathers of young daughters. And if the risks weren’t so high for me, I would have asked them the questions I pose now, “How old do you think your daughter will be when she first gets cat-called so badly she feels unsafe? How long riding public transportation will it take before she has a set of rules she follows because of the physical and verbal harassment she experienced from male passengers?” The use of “when” and not “if” is intentional.

You see, women close to me have been strangled and shoved into walls. I’ve sat by as a younger woman asked for advice from an older woman about what to do because her husband raped her every night. I’ve been called by friends in tears because they were cat-called so badly they were shaken. I’ve sat with women as they hid behind dark glasses waiting to get photos of their bruises to use in court. On my first day of one of my first jobs, my preceptor told me how to use the printer and warned me to be careful of our male boss. He left the company before I had to worry about exactly how careful I had to be. By the time I’d worked in healthcare two years, two of my female friends had been groped by male patients. I’ve only been training in the hospital as a medical student for six months and already two female physicians have taken time out of their busy schedules to have lengthy conversations about how to keep my head up and build my career despite disrespect from male colleagues and male patients.

And the reason I would ask the fathers of young daughters the questions above is because I know they love their daughters. And I know they can’t fathom that they are being exactly the type of men who will get in their daughters’ way as they reach for their dreams. And I would ask the fathers of young daughters these questions to remind them that they cannot protect their daughters from the future. And, truth be told, they will likely never know the harassment episodes of their daughters’ life. And I would ask these questions to recommend that they learn how to respect women so that they can set an example for their daughters of what it’s like to be respected. That way, when their daughters do experience disrespect, they know it is not their shortcomings but the shortcomings of the disrespectful one. In other words, it’s worse to be a daughter of a father who doesn’t know how to respect women because he sets a poor example of the male gender. And the behavior of these men in the operating room made it clear that they still had much to learn about respect despite surgeons being among the most highly educated people around. What an unsettling reality to have so many years of education and still lack competency in a basic principle like respecting all humans.

You can look up the statistics in the US for harassment and rape of women (and other demographics) if you’re curious. It’s an easy Google and the numbers are almost as bad as the news that makes the front page of the newspaper. If you want to get really dark, look up statistics related to intimate partner violence. The numbers are horrific. And the numbers always surprise me because all women are daughters and perhaps sisters, mothers, and partners. Fathers and mothers see the statistics and are inclined to tell their daughters to be careful. To not drink too much. To not wear too revealing clothing. To never set down their drink. To not walk alone at night. To not live on the first floor. To lock their windows and doors. To always go out with friends….the list goes on. But the question I always wonder when I hear these statements of warning is why don’t parents just tell and teach their sons that “no” means “no,” “stop” means “stop,” respect applies to all people regardless of genitalia, and that drunk or not you are responsible for your actions? Because all men are sons, and many are brothers, fathers, and partners. It would seem more helpful to prevent the problem of people harassing others, than react to the problem by telling the victims to avoid harassment.

I also find parents’ lectures of caution stifling because they do not address so many of the manifestations of sexism their daughters will experiences. Yes, there is the risk of rape and physical abuse. But for those women going into competitive or historically male professions many of the troubles we face as women are more subtle and persistent than acts of violence. The times we’re told we’re mean or bossy when a male counterpart with the same behavior is considered strong. The times we’re ignored, spoken over, interrupted, and discredited despite consistently being correct. The times (like in the operating room when men decided to complain about harassment protection for women) when we’re othered and made to feel like demanding respect isn’t a right, but a burden we place on our male counterparts. The times we’re underpromoted, underpaid, and passed over simply because we are women. The times we must dig deeper than our male counterparts not because of shortcomings but because our parents taught their daughter to be cautious and taught their sons to be bold.

And as these fathers of daughters discussed sexual harassment policies as an annoying restraint placed on them, I thought about their daughters. I knew when they’d be cat-called. I knew how long it would take on public transportation before they developed their safety rules. And I hoped for those daughters’ sake that they would have men that set an example of what it’s like to be mutually respected. It had made such a difference for me to coexist with many men who looked at me as a person and not some different creature. You see, it’s helpful to know respect is possible because at times it seems like a fictional concept. I thought about those young daughters one day standing where I was. I sent them strength. As much as I hoped the world would change in the years between us, I wasn’t sure it would because these men I stood with in the operating room would still be here. And their sons who had them as role models would be here too.

And I was once again weary, not so much because of the long hours I was spending studying or the fact that I was scoring equal or better to many of my male counterparts in medical school while also getting cat-called and navigating colleague and patient sexism, but I was weary because these men in the operating room, like so many others, stood in the way of my father’s daughter. They stood in my way because they made things more difficult for me than my brothers simply because of my genitalia. None of this was new or surprising, but it did make the hours in the operating room seem especially long. And if the operating room had been a safer place for me, I would have told these fathers the reason I didn’t like the hospital’s anti-harassment videos was because they were triggering for those of us who have been sexually harassed and spoke of a justice system that I have not found anywhere I’ve worked. And I’ve worked in many places.

Autonomy In Medicine

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Set Up

I’ve been thinking of patient autonomy and the humanness of physicians a lot recently. In my short time training to be a doctor, I’ve had many experiences that have brought these topics to light. Here are a few examples:

  • An attending physician told me he usually first recommends pills to women seeking birth control because he believes that women find it reassuring to have their period every month. Odd perspective as my experience as a woman is that some women find periods reassuring and many find them annoying. Odd perspective as my short time in his clinic showed implant and injectable birth control methods as the most common forms of birth control requested and used by patients. Odd perspective as research has shown LARC (which include implants and IUDs and NOT birth control pills) have greatly decreased unwanted pregnancies because they’ve removed the mishaps of having to remember to take a pill every day. Medicine is complex. It requires both keeping up with research and checking your personal beliefs at the door. The approach I’ve seen most physician take when discussing birth control is to outline the different available birth control options so patients can decide themselves which is best for them.  
  • I overheard an attending physician talking to a resident physician about a D&C they did recently. A D&C is a procedure that can either be used to end a pregnancy early on or clear a miscarriage that occurred early in pregnancy. The patient these physicians were discussing had the procedure to end pregnancy. The resident physician stated that she thought the patient was looking for validation from the attending physician for choosing to have the procedure. The attending physician shrugged. I (medical student) asked what the attending physician had told the patient. The attending physician said, “She doesn’t need to give me a reason for the D&C. I told her she doesn’t need to give me a reason to terminate the pregnancy.” I found this statement to be a powerful example of approaching medicine without imposing personal beliefs on a patient.
  • An attending physician walked out of a patient room and told me the patient’s problem was that she was naïve. This was his reaction to the patient (a pregnant woman) planning to visit friends/family in another city while in the third trimester of her pregnancy. The patient had gained too much weight during pregnancy. She also had high blood pressure at this appointment. When asked the patient described improving her diet. The physician laughed at her when she described eating salad. In self-defense, the patient then described eating very healthy-sounding salads. The patient’s trip would delay the follow up blood pressure reading the physician wanted by two days. The physician did not explain why he was concerned about hypertension specifically in the last weeks of pregnancy. I wondered why he didn’t recommend that the patient monitor her blood pressures with a home blood pressure cuff and bring in a log of her blood pressures when she was able to schedule her next appointment. It seemed the risk of delaying a blood pressure reading in the clinic by two days might be outweighed by the benefit of social support during the final weeks of pregnancy. I questioned the choice of “naïve” as his diagnosis. Why should she know about preeclampsia if he didn’t tell her? Naïve is a loaded term and isn’t one I’d be quick to use to describe a pregnant and uninsured woman with friends/family in multiple cities. Medicine is a team sport. Patients are the captains and physicians are the coaches. It’s important to remember that the patient is part of the team and that while they don’t bring medical knowledge, they do bring life knowledge.
  • The patient told the attending physician that they stopped their antipsychotic medications. The physician recommended that the patient continue taking their medications. The patient refused. The attending and the patient came up with a plan to watch for warning signs that the patient’s psychosis was returning. The patient continued to attend group therapy even though they stopped their medications. This allowed the group therapist to send a community crew out to the patient’s home to check on the patient when that patient showed psychotic behavior at the online group therapy session. The patient did not self-identify that their psychosis was returning. However, because they continued to attend group sessions they were still connected to care and were brought to the emergency room before their psychosis led to self-harm. I found this case an excellent example of a physician respecting autonomy while also trying to prevent serious health outcomes for her patient.

Reflection

Medical school, residency, and being a physician teach us to solve complex problems. They teach us the complexities of the human body and how to cure diseases and treat symptoms. They teach us to think critically and sift through data efficiently. They provide us with guidelines and treatment recommendations. But, medical school, residency, and practicing medicine don’t and can’t teach us the complexity of each patient. They can’t give us the ability to foresee the future or understand patients’ life goals better than patients do themselves. And, despite our great knowledge as physicians, we can’t (and will never) have all the answers. Despite extensive training, medical research, and detailed guidelines medicine is still decided by humans (yes, physicians are just humans) and is (therefore) based partly on intuition, experience, and practiced guessing.

In medicine we are fixated on being right. Our goal is to reduce suffering, cure disease, and help patients navigate illness. And while as doctors we strive to cure, as humans we know that life can be more complex than curing. As humans we know life is paired with death. As humans we know not all questions have an answer and not all problems have a solution (at least yet). And as humans we know that health, sickness, healing, recovery, pain, and death are individual experiences that share commonalities across individuals but (ultimately) are unique experiences that each person endures differently.

In my short time in the hospital, I’ve already observed patients losing their autonomy. I’ve seen patients’ wishes ignored and explanations of why skipped or glossed over. I’ve seen us (medical experts) angered when patients don’t follow all our recommendations, insulted when we’re asked why, and forceful that our way is the only right way. And I’ve seen patients suffer. I’ve seen patients suffer taking our recommendations and I’ve seen them suffer when they refused our recommendations. And while suffering seems to be a part of some points in all lives, it also seems that sometimes in addition to our patients suffering we (physicians) push our patients to accept a treatment plan that is discordant with their values and life goals. It seems sometimes that we add to suffering by piling on shame or judgement.

In medical school, in residency, and as physicians we are taught to find the truth and to be right and to be directive. We are taught to recommend the best medicine has to offer. Yet, the best options based on evidence are not always the best option for an individual patient. And even if they seem right, the best options are not foolproof. The best options are based on probabilities, percentages of effectiveness and likelihood of reducing disease or preventing further harm. Probabilities are helpful, but they are not certainties.   

I’ve been thinking of medical recommendations and patient autonomy and the humanness of doctors because medicine can be hierarchical. It can be rigid with the attending physician setting the law; a mix of other players like nurses, medical students, and resident physicians in the middle; and the patient disempowered.

There are more cases than I presented above that I’ve experience which illustrated the complexities of patient autonomy and the humanness of doctors. Medical school is a whirlwind of learning. What I’ve come to discover, however, is that all the learning isn’t strictly medical. I’m also learning how I’d like to conduct myself when I’m an independently practicing physician, the ethics of medicine, and the challenges of working in a field where the outcome is dependent on the efforts of all team members.

As I reflect on the hierarchy and the complexity of medicine, if I could hold one piece of advice for myself as my training continues it would be to ensure my understanding of medicine is excellent while also remembering that patients are autonomous individuals. This advice reminds me that my job is ultimately to help people navigate the complexities of health and illness. This advice acknowledges that patients can say “no” and that the “why” is just as important as the “right answer.” This advice helps me to remember that my patients and I are a team. And just as I can decline or refer a patient to another physician if I am not comfortable with a patient’s request, my patient can also decline my recommendations or seek the medical expertise of another.