Divine Secrets of the Surgical Sisterhood

When you choose to go into medicine as a woman, one phrase that you hear a lot is "old boys' club".  It's a reference to the fact that medicine, for centuries, was one practiced by men alone, a fact that was sharpened during the 1950's when the advances made by women were repressed in favor of a return to old time values.  It also references the fact that men, for centuries, have always formed fraternities in one way or another, a way to bond and speak as equals on subjects of substance and importance, and to form friendships, connections and networks for the benefit of all members.  Nowadays, the phrase "old boys' club" infers, due to negative connotation, a professional or social group into which women could be belong based on credentials but cannot because they are not male and therefore not welcome in the fraternity order.

It is a sad fact that women don't seem to have the same natural propensity towards fraternity as men, especially in fields that men have historically dominated.  Of course, the concept of sorority and womens' groups is an old one, but they typically form naturally for the benefit of social friendship, not professional advancement.  Those that exist for professional advancement often have a forced feeling to them, and the ones that have persisted through time exist only in reaction to a negative situation (such as being shut out of male groups).  One would think that, as a minority in certain professional circles, women would band together, help each other out, and act as mentors for each other.  One would especially expect that of the kind of women who have acted as groundbreakers, plowing a path for the rest of us to follow.  But it is not so.  

Dr. Karen Sibert is an anesthesiologist practicing in West Hollywood, CA.  She wrote a well-publicized editorial to the NY Times bemoaning the groves of women training in medicine, only to leave to devote time to family and lifestyle balance.  She includes a number of factual flaws in her argument (ex: she claims that residents don't pay tuition and instead receive a salary, but neglects to mention that repayment of medical school tuition starts in residency while being paid less than minimum wage for a 90 hour work week), and criticizes a pre-med college student for wanting to know about anesthesia as a specialty with regards to work-life balance.  She essentially argues that to be a doctor, one must commit to it to the exclusion of all else, as all men do, or society at large suffers the consequence.  She argues that women are selfish to enter the field and expect such things as time off, end of shifts or part time work, because they suck the precious national resources going into training doctors.

The undercurrent of this editorial is that women must suck it up, not complain, and not ask for anything different in terms of equity.  I am sure that, as a women who graduated medical school 30 years ago and had no other women to band with, this method worked for her.  She has become hard core and old school.  And, truly, I admire her for it.  I've met (heck, we've all met) tough-as-nails female physicians who trained when they had no other companions mentors or encouragement and threw themselves in head first to learn medicine for a higher cause.  It's something I could never do, and have undying respect for.  But there's a broader issue of humanity in medicine - I myself have encountered more than a few older female surgeons who do fantastic work but are a nightmare to be around.  They are, nearly as a rule, nicer to boys than they are to girls.  I never wanted to believe it, but I have encountered more manipulation, lying, sexist and judgmental attitudes at the hands of female surgeons than I ever have at the hands of my male surgical attendings (why by and large have been nothing but encouraging, patient and kind).  

The reason I feel that it's a time-related issue is that, when I look at my senior surgical residents, I don't see any of these traits at all.  I belong to a residency which is at least 50% female, and most of the other programs I applied to were similarly stocked.  The girls I work with are tough and smart, but also look out for me.  I don't get treated any differently than the boys, which is how I know that I am being treated the best I can be.  When I go outside of my residency cradle, I am always shocked at the slightest hint of gender discrimination because it's simply not how I was raised.  At the risk of putting all older female attendings in a box, I argue that the act of training in an all-male world has created a certain type of creature.  Brilliant, tough, smart, but also unable to trust anybody but men.  I believe that the female attending throws younger female doctors under the bus because she forgets her obligation to them.  She is jealous that so many things she had to fight for, her residents can take for granted.  The ability to even consider part time work as a doctor to be with her children?  That was a pipe dream in her day.  Having to be a thousand times better just to be considered at all?  It's the exception rather than the rule now. When she works with men, she's back on familiar territory, she knows how they will behave and react.  On some level, it probably even makes her feel special inside, to be above so many men who were once above her.  But female residents, they throw a wrench in that calculation.  And she forgets her obligation to mentor, guide and protect because she never had those things herself.

Like gay marriage and outdoor smoking bans, changes in this behavior will only come with time.  The female attendings like Dr. Sibert won't change their attitudes, they'll just retire at some point soon and be replaced by many more females who trained under more balanced circumstances, with respect and concern for each other.  Our network will come because we all worked with each other, remember our seniors with fondness and respect, and bond over a common experience.  As much as Dr. Sibert wants to flap her arms about the change in priorities in medicine, the fact is that, very soon, she'll be under our care and not over our heads, and we'll all be able to form the sorority we deserve without her stopping us.

Life as you know it

Hooray for vacation!!  I'm back in the states, after a week off in London and a few days off here and there at home.  I won't go on too much about the trip itself, except to say that there was lots of shopping, drinking and laughs.

Oh, baby.

But here's something that struck me - in the course of meeting many of my sister and cousins' friends, I wound up talking about my job.  A lot.  Probably a certain amount of that was just desperation and gratefulness at having the chance to get away that it almost seemed unreal.  A significant proportion was also residual pain from the way that I had been professionally singed on my last rotation, by some people who I had underestimated in their ability to put personal gain above team duty.  But the thing that drove it the most was the fact that I work so many hours at this one job, and so many people that I met just couldn't comprehend it.

It's a fact of life in the UK that work hours are very severely limited.  It's a culture that is hardly hedonistic compared to the rest of Europe, but by American standards can seem outlandishly fun-oriented at times.  To have several drinks with colleagues, to travel, to spend time together, to shop during the lunch hour, these are all things that are assumed by many to be a regular part of life on a weekly or even daily basis.  Even for doctors, the work-hour limit is about 50 hours per week, just over half of what American residents are limited to (and often work over).  So while discussing my job with people, the shock and horror I experienced at describing a standard 85 hr work week was overwhelming.

I used to encounter this sort of attitude years ago, when I was in medical school and dating around.  People would ask what I did for fun on weekends or holidays, and the response of "I'm studying" used to baffle people.  Later, when I started rotations, I would gripe about having to get up so early when the rest of the world seemed asleep, or having to travel so much in such an unpredictable manner.  But eventually, I took solace in knowing that I wasn't the only one.  It enabled me to get off my high horse when I realized that investment bankers work 90 hour weeks too, and while they have bonuses larger than my entire salary, they also have to do it all in a suit and tie, and deal with way bigger assholes.  Embarrassingly, it took me 3 years to figure out that the guy at Dunkin Donuts serving me my latte had to get up at 4:30 in the morning, too.  And my dad chided me for complaining about the frequent travel - nearly all consultants do the same, and they have to do it on planes.  I gradually started to feel that my situation wasn't special, and that allowed me to tone down the pity party I was throwing for myself at working so long for so little.

It is easy to feel jealous that I do not belong to a culture, or a world, in which lifestyle and experience are the focal points.  I certainly turn green at the thought of my friends, who casually meet up with each other with little notice and maximal enjoyment.  But, the fact is, to make those lifestyles happen, these people all picked jobs where they more or less sit at desks, deal with vague concepts and handle a level of office politics that I am, paradoxically, protected from in many respects because the people I work with just don't have time for petty grudges.  I would never be happy in those circumstances, and the few rotations I went through resembling such work had me bored out of my mind.  I didn't pick it because it didn't suit me.  I feel healthier in some ways, doing a job that keeps me occupied for the majority of my time.  I feel healthier in a job where I walk a lot.  If given the option of living the London lifestyle or not, I probably wouldn't pick it if I had to stay with it the rest of my life.  And that's just the way it is.

LDN

Things I have learned in the past 36 hours:

1) The aisle seat is NOT preferable when you are sitting next to a woman who ate NYC street food before getting on the plane.

2) They have Ben and Jerry's vending machines dispensing little mini-pints of ice cream at the Heathrow airport.  I live on the Eastern seaboard, how come we don't have that???

3) Gherkin is a far better name for this.

4) I am truly addicted to my Android.  Last night, I realized I was going to have to go a whole week without TMZ and I nearly had a heart attack.

5) I did not drink enough on Memorial Day, otherwise I would not still be feeling all that wine I had last night :/

The Pressure Cooker

I had dinner the other night with my med school friend T the other night, and we got to talking about how residency changes you.   There's the usual stuff, like how you have to force yourself to stay in bed past 9:30 am because your body is just so used to getting up early, or how I suddenly wear much more formal and girly clothing when I have the opportunity to, to make up for lost time.

But there's a major thing that changes in everyone, perhaps some more than others, in a way that I wish I could avoid.  We all become meaner.  By this, I mean my patience is shorter, my expectations are unreasonably higher and my shoot-from-the-hip reflex is quite a lot sharper.  Things that I might have let slide years ago, like a friend flaking out on me for a scheduled hang-out suddenly become massive transgressions.  I get into fights with people whom I have barely even disagreed with in the past.  I hold everyone to a standard which, to me, is totally reasonable but everyone else seems to think is unachievable.  Looking at myself from the outside, I can see a thin fishing-reel line connecting me to the young obnoxious attending I will soon become.

The origins of this are obvious, of course.  All you have to do is take one 24 hour call in which the pager goes off non-stop, the ER gets mad because you haven't seen the new patient with a chronic leg wound while you are managing two life-and-death emergencies in the ICU, the medical resident calls you with five new consults (none of whom she has the name, medical record number, room number, original chief complaint or labs back) all while your student gives you attitude when you ask him to collect the vitals, and you will see what I mean.  Nobody can be that nice when all of this is happening.  It just isn't possible, and if it was, it would disadvantageous because it would allow everyone else to walk all over you.  Part of working in medicine means triaging the emergent from the urgent from the routine, and having to say "no" or "not now" sometimes to a person who doesn't want to hear it.  Soften your heart here, and you will pay for it in spades.  Being mean allows you to be efficient, and sometimes that is the only virtue that will save you during a bad call.

Unfortunately, the trade-off is that this behavior becomes so hard-wired in you that you can do it instantly at any time of the day or night, without thinking, and you become a nasty bitch to everyone else who drops the ball for a brief moment in everyday life.  Even while on vacation, feeling more relaxed than I have in several months and quite happy with my life, I took my mom to town for butting in where she didn't belong (nothing new, of course), I spanked my friend for re-engaging in a toxic relationship, and my sister for not having my travel information ready to go.  In my head, everything I've listed here can be thoroughly defended to a T.  I'm exceptionally sure that I was in the right, the other person was in the wrong, and a cold hard look at the facts means nobody else will disagree.

But they will, because I wasn't nice about it.  I didn't give anyone a break.  It's true others dropped the ball, but "Can't you just chill out?" is a phrase I hear a lot.  Not surprisingly, it isn't one you hear in surgery - the expectations are set for me in advance by my seniors, and the bar is high.  I meet it only because someone told me I had to, and that's how I learned to be good.  I can't chill out anymore.  Even when I think I'm being chill, I'm not.  It's like I've turned into a vicious deer, one always ready to jump and run when a car shines its headlights on me at 2 am, but not before I've bitten the front bumper and dented the passenger side.  And as a result, I lash out at people in response to their failures, regardless of whether that's the best way to affect change or not.

I can't tell you how much I hate this about myself.  It's like having an awful argument in my head all of the time.  I feel like if I relax, it means I'm dropping my guard.  Not just with other people, although that's certainly a consideration, but many times with myself.  If I get chill and relax, I won't be as good as I am, and I'm already not that good.  If I tighten it up more, I'll just lose more people in my life because I'm not fun to be around.  Whether I use a knife or cautery, I'm still making someone bleed.  Is it better to take the attitude of "as long as it isn't me"?  I'd like to say no.  But "as long as it isn't me" is how you survive in a residency.  You can see how the vicious cycle goes from here.

An attending once told me that perhaps it was all from lack of confidence.  I thought it a ridiculous idea at the time, because one of the major criticisms I get is that I am overly confident.  In surgery, confidence is a positive trait because it is better to be confident and wrong than to be indecisive, because surgery is about making a decision and committing to it.  But perhaps the attending was right.  When I stitch, I am a better stitcher if I can take a deep breath and relax my hands.  I am a better resident on call if I can take a deep breath and remember that everything always works out by the time the morning arrives.  One could argue that these are exercises in confidence, and the lack of confidence in me manifests itself as tension, which of course leads to anger.

If it's true, I don't feel so great about it, because confidence in the greater scheme of things comes with time and experience and knowledge, things that I can't wait for.  If I wait for those things to arrive, I may become so hardened that I can't go back, like an abscess you sat on and now has to get I&D'd in the operating room instead of the oral antibiotics you could have taken weeks before.

What I realize is that I need (and I can't believe I'm saying this) a medical solution, and not a surgical one.  I need a way to stop the stress before it gets so bad that someone has to cut me to keep me from cutting someone else.