On women in medicine

(To a female physician friend)

XXXX- You may or may not be aware that the accident of your birth date determined your career choices. Whatever ceilings women perceive now are a spit in the ocean compared to back when. When my dad was in medical school in 1943, they grudgingly admitted whopping two females, both homely as mud fences. Warts on both their formidable noses. It was considered that women would eventually get married, have children and waste the education when they quit. Of course, all that happened but they didn’t waste the education 😉

When I was in college in 1966, my then girlfriend was Carol (wholesome) Holcomb, my roommate “Friendly Fred” Horning referred to as the “most wholesome broad in the whole world”. Blond, beautiful, great student, very smart. Committed to a career as a lawyer. We were joined at the hip. We did EVERYTHING together and shared a unitary consciousness even though at the time I made Sid Vicious look like an amateur and Charlie Manson a punk. She was a double honors major in history and political science at the University of Georgia. Straight A’s. Maxed out the LSAT. When she interviewed at the UGa School of Law, they told her she was a stellar candidate and ordinarily she would be quickly accepted. Too bad she has two X chromosomes. Today she’s not a lawyer. By rights I should be doing five to ten the hard way, but I was male. The over-equalizer.

When I was a surgical resident at NYU, there were a few female surgical residents. Without exception they shared one characteristic; they overcompensated to become meaner than snakes. It’s quite possible that they had to as an effective survival mechanism. The term “Dragon Lady” was used liberally, and they earned it. They were not only mean, but with a flavor only females can do well. They were taught well by their equally vicious attendings, of which Joe Ransohoff, chair of neurosurgery was a prime example. Joe was the acknowledged inspiration for “Ben Casey”, (first neurosurgical resident on TV dramas in the early 60s). Joe wasn’t a sociopath (as were some recent players we both know); Joe was just plain mean, and he routinely got away with behavior what would embarrass the Marquis de Sade. He would literally turn red and jump up and down screaming. Everyone in the room would run for the exit. He would literally pick up residents by the scruff of the neck and seat of the pants and throw them bodily out of the operating room.

This kind of behavior was tolerated in the 60s and 70s because surgery was pretty much an exclusively male endeavor, and those bearing the brunt of these displays were invariably female. Nursing at that time was as exclusively female as surgery was male. Women of that era were considered to be nurturers, and absorbers of punishment. At the University of Georgia in 1966, women were not allowed to be seen on campus unless they were wearing a dress. No jeans, no slacks. If they were on their way to gym class, they wore a raincoat. The pedestal was absolute.

Things started changing for females in the early 70s, interestingly as a side effect of the SDS (Students for Democratic Society) which eventually morphed into the Weather Faction. Bill Ayres himself was quite surprised to see the transition of uppity females not putting up with that shit anymore, and with the juice to push it, if for no other reason than their ability (and propensity) to withhold essential services to males. 😉

Then females started slowly but progressively infiltrating previously male domains. Truly, I never thought I’d ever see the day women would have any particular interest in neurological surgery. In the early 70s, before CAT scans, they were giving away neurosurgical residencies. The average neurosurg. resident has a ten word English vocabulary. This was because all their patients died. There was no real way to know what was going on behind the bone. CAT and MRI revolutionized NS like TPA revolutionized neurology, a specialty accurately characterized by the maxim of the Textbook of Neurology in 1970. 1000 pages of diagnosis and one page of treatment. Now neurosurg. residents must be anointed at birth.

Now here you are, trying to maintain in a busy program, physically and emotionally exhausting, and buck the built in biases against double X chromosomes that have not changed all that much for generations.

I have some fatherly advice (was your mother even in any bars on Tu Do street in Saigon in the 60s?) Resist the temptation to fight fire with fire. Part of your ability to survive depends on your ability to be front and center when good stuff is happening and to insure someone else is pointed out to be responsible when things are going badly. There are effective ways to facilitate that, and ways to make it worse.

And now, a parable: My father was a general surgeon in a small town in Georgia/South Carolina for his entire life. Recently died at age 90 after an astonishingly full life. He took care of patients for 60 years.

From the time I started medical school till the present he only gave me two bits of advice on being a good doctor. Just two. For what it’s worth, here are those sage bits of advice:

1) “You’ll probably like women but you’ll definitely hate doing pelvic exams. It loses the mystery at eye level under the hot lights”

2) “Don’t ever abuse the nurses. Everything immediately goes from bad to worse”.

I have found both of these tidbits to be true in spades. Of particular note is the admonition about yelling at nurses. In that regard, I have learned over the last 20 years that three laws hold irrevocably true:

1) The short-term consequences of abusing nurses are that you can be sure that anything going bad will instantly and irrevocably get worse. If they couldn’t or wouldn’t do what you wanted before you blew up, the real chances of it happening afterward simply evaporate. They either completely decompensate or run around at a quicker pace trying to look like they’re being more efficient with nothing effective being done. You can take this to the bank.

2) The longer term consequences of nurse abuse virtually guarantee that your name will sucked into the pipeline of “problems that need to be addressed” and you will then die the death of 1000 meetings, a painful and debilitating fate.

3) Surgeons who develop a reputation for yelling at people slowly lose repute among their colleagues. The old chestnut of “Lord, Master and Captain of the Ship” has pretty much been replaced by “Lord, Master and Team Player”. Like it or not, there is a lot more team effort involved in patient care than there was in the 50s, and not only are nurses part of that team, they don’t grow on trees anymore. Picture what your life would be like with out trained and experienced NICU nurses.

It has been my experience that these irrevocable laws simply make hassling nurses a lose-lose proposition, not matter how ego satisfying it might be at the time to establish who’s boss. I would suggest that the maximum efficiency possible occurs when you guide events with an even temper, simply emphasizing the importance by tone, and assuming everyone is doing the best they can under the circumstances. Perceived lapses are best handled after the fact.

>>>1. I thought I would be treated the same as my male colleagues.

You probably should have known better in an endeavor that is mainly male. But hope springs eternal. Women have never in recorded history been treated as their male colleagues. Part of it is just the nature of the beasts. To be fair, much of it is because many women aggressively work any gender advantage they might have which may not necessarily fair either. Ask any divorced father who finds out rudely where the legal advantage lies. Heather Mills McCartney. Women learn quickly that a frontal assault isn’t effective for them, so they quickly apply the art of feminine wiles, which works well in some circumstances and less well in others. Not so well in a male dominated arena, where most of the males have seen it all before.

>>>2. I thought if I was nice to people, they would be nice to me.

Works in a perfect world. Still works in our world but with a caveat. There is more involved than just being nice. There is diplomacy, the art of being nice to people and engineering them being nice back, not expecting it as a given.

>>>1. Many many women are heartless snakes.

This is the nature of the beasts. The reality is that most women are friends with other women only insofar as there is no competition involved. Once anoher woman becomes a competitor in any realm at all, any semblance of camaraderie submerges below a facade of superficial civility. And “pretty” women get the brunt of it because almost without exception they have learned to mercilessly work that advantage, climbing over the bodies of their sisters. You can’t fix this. No one has ever fixed this.

>>>2. Have one hurried, busy moment and answer shortly (without even yelling,
>>swearing, or insulting) to a question asked of me, and I will never be forgiven by
>>that person, and that person will make it her life’s mission to spread an
>>embellished tale of my indiscretion toward her.

Sad but probably true as far as it goes, and more so for women than men. Wen men are short and obnoxious, it’s because they are being assertive. When women do it, it’s because they’re nasty bitches. Ask Hillary Clinton. (even though she is a nasty bitch).

>>>Having said that, I do love my job. I like people in general.
>>> I do believe that if most people knew the insanely bitchy bullshit
>>>I put up with from certain females in the workplace, they would
>>> question how I manage to smile at all.

I know you do and here is more cheap advice.

1. Always be who you are. Who you are will have to be good enough.

2. Choose your battles carefully, with an eye as to whether there is a better chance of losing and what the unintended consequence of winning might be. If you suffer injustice, think intuitively about the relative value of fighting it versus just blowing it off and moving on. Sometimes it’s best to let things go. they’re forgotten more quickly.

I grew up in South Texas for a while, in the county where Lyndon Johnson ascended to power as a US Senator. Duvall County. There is an old story of LBJ’s strategy that is absolutely true. Lyndon instructed his aides to spread the rumor that his opponent had carnal knowledge of barnyard animals. The aide balked. “Lyndon, you can’t say that, it isn’t true”, to which Lyndon smirked: “I know it isn’t true, I just want the son of a bitch to deny it”. Accordngly, the more an adverse event remains in the public eye, the longer it’s remembered, and the longer it can be embellished. Sometimes it’s better to let it die quietly to get rid of it rather tan let if fester. A favorite quip in tough situations of a very successful friend who could buy and sell any of us is: “Next”.

3. Always be irritatingly honest with your colleagues. The slightest hint of dishonesty on any level will be met with more detriment than the sum of the parts. Lie to your boyfriend, your mother, me…but never those that you depend on and depend on you. Even if it hurts.

4. This is important. If you come to an adverse event with someone, wait for a while, then take them aside and tell them you want to find a way to make it right. Without exception, all the personality problems I have seen could have been diverted in a quiet room after the fact. Sometimes you might have to give up more than you get back, and sometimes you might have to accept some responsibility for the event, even if it was minimal. Adverse events rarely involve one completely guilty party. This is a skill that will pay you big dividends.

5. The era of the career woman wasn’t intended by the genome. You wil never, repeat never, stand on the same level ground as your male colleagues in many regards. You are a woman, and you really are different, and many of those differences cannot be resolved just by wishing it. You must to survive, and in order to do so you must learn to gracefully change the things you can, accept the things you cant and know the difference.

You’ll be fine. Just go forth and fight the good battle consistently.

David Crippen, MD, FCCM

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