Time’s Up for Sexism in Medicine

I would venture to say that medicine is one of the fields with the most blatant, widespread sexism in the workplace. In watching women in Hollywood stand up to the injustices that women in their industry face, I feel empowered to share the struggles that female physicians face. I wrote about this several months ago but deleted my post in the setting of fellowship interviews as I was concerned that it would seem too controversial or that I would seem as if I were complaining.

I grew up believing that I could be anything and anyone I wanted to be. I excelled in many aspects of life including academics. However, once I entered medicine, I encountered on an almost daily basis people who wanted to strip me of my hard-earned title. Administrative assistants and operators from other institutions on the phone who ask me what my first name is after I introduce myself as “Dr. Villasante.” Not because they want to write my full name but because they want to only write and address me by my first name. Patients who cannot understand that I am a physician even when I introduce myself as such. Who confuse the male nurse as the doctor and me as the nurse.

Our society has such deeply ingrained assumptions that “doctors are male” and “doctors are authoritative” and “women are not authoritative” and “women cannot be doctors.”

Here are some examples.

-We were discharging a patient, Ms. A, on a specialty service. We were talking to Ms. A about setting up follow-up, and she stated “I would like to fellow up with that girl from yesterday. She’s not a doctor though, the therapist that was here.” In fact, she was referring to Dr. J. Our current (male) attending Dr. Y explained that Dr. J was one of his colleague attendings in that specialty and that she had, in fact, trained at this fine institution and was an excellent doctor.

-At a community hospital that we rotate at, I was rounding with Dr. H, a petite blonde female attending. She had laser-sharp precision and was very efficient. We were visiting one of our patients and had a whole conversation with her about her medical care. As we were about the leave the room, she asked, “so when’s the doctor coming to see me?”

-Patient who thought I was his interpreter rather than his doctor, despite the fact that I was the physician who was most involved in his care and made the most management decisions for him.

-It feels that patients and families are much more likely to ask me for directions, some ginger ale, or help to the bathroom than they are of my male colleagues.

-“Can you close the door on your way out, Miss?”

-“Thanks ladies!”

-“As I was telling the girls…”

“Sure, sweetheart.”

“Good morning Doctress”—one of my personal favorites. A well-intentioned but odd greeting a received daily from a maintenance employee at the Veteran’s Hospital my intern year. I just smiled and nodded back.

“Do you have a boyfriend?” – asked by an attending subspecialty surgeon in the middle of the OR during medical school. [A statement like this is not just sexisim but sexual harrassment.]

-“All of my clinic patients are crazy. That’s because I have 70% female patients,” said by a [female] resident physician, overheard a few years ago. “It is hard for me to hear them complain. Just put your big girl pants on already,” she added.

These are just a few examples. These occurrences have become so commonplace for me that I mostly forget them and keep going. I can recall some positive comments as well, like the 96yo woman who told me I was “wonderful” and that she felt so proud that there were so many young women in medicine. Better yet, often gender does not come up at all.

Thinking back to grade school, I remember people being stumped by the following riddle: “A father brings his son into the hospital after they both got into a car accident. The surgeon sees the boy and says, ‘I cannot operate on this boy, as he is my son.’ How is this possible?” The surgeon is the stepfather? The grandfather? The biological father while the other is adoptive? No, the surgeon is the boy’s mother.

Yet, as recently as the summer between college and medical school I was at a party when a young man my age asked with doubt, “but do you really think a woman could be as good of a surgeon as a man?”

Though I encounter wonderful humans who make the daily grind a little bit brighter, from my co-residents to attendings to nurses to patients, I also encounter at least one message every day that says “your status as a female is incompatible with your status as a physician.” I do not blame the individual messengers as, for the most part, they are sending it unintentionally, and not maliciously. They have just been programmed to operate under certain assumptions, and they have not learned to override those assumptions. I am more frustrated with the system that programmed them and continues to program us. And I am hoping to change it.

We can do it

Red snapper fish for dinner

A Day in the Life of an Intern

She blinked forcefully as she parked her car in the resident lot, fending off her tiredness. She stepped out into the 6am darkness. The morning dew had frozen over, leaving a carpet of frost between her car and the hospital doors. As the cold air crept under her scrubs, she held herself tightly as she briskly walked to the entrance. Once inside, she walked to 1 East, the general medicine floor, unzipping her jacket amid the smothering heat.

Gggguuuaaahhggg….

A guttural scream was heard as she walked through the automatic doors to 1 East. It was the patient in room 15, who had been in the hospital for over 300 days. He had frontotemporal dementia, a form of dementia that causes disinhibition, and he required an enclosed net bed to restrain him. No nursing facility in the area “had the capabilities to care for him,” and the hospital could not push him out. So he stayed. In his cage, in the hospital, for as long as he lived. And he screamed. Every day.

The nurses went on with their business without flinching at the sound of his jarring, spontaneous outbursts. Sienna still jumped every time. She was an intern, or a first-year resident physician, in internal medicine.  She was new to the hospital and to rural New England, having graduated from medical school in New York City six months prior.

Walking into the workroom, Sienna put her backpack under her usual seat and her jacket around her chair and opened up her laptop. She paged the night float intern who called her back to let her know she’d be there in five.

“Hey Sienna,” said Ali, as she walked into the small, windowless workroom.

“Hey Ali, how was your night?”

“Not bad, got a bunch of ridiculous pages throughout the night, but no one crumped, so it was a good night.”

“Awesome. How did my peeps treat you?”

“Not bad. Mr. Martin had some shortness of breath around 10pm that got better after he got his nebulizer…” Sienna received signout on the remainder of her 10 patients, learning about the events that had occurred the previous night. None of her patients were actively sick at the moment, so after she signed into the team pager, she skimmed through the electronic chart to follow up on studies she was waiting for, and glanced at the vitals and labs of her sickest patients. She donned her white coat, her badge, and her pager and placed her stethoscope around her neck.

Grabbing her laptop, she began her process of “pre-rounding,” or seeing all of her patients early in the morning before official team rounds, a ritual that interns everywhere perform daily. She had about two hours left to dedicate to her 10 patients before 8:30am. Taking into account the time needed to walk between rooms, this left her less than 10 minutes per patient, of which she spent about 7 minutes in the room and 2-3 minutes outside the room reading the chart. Within that time, she was supposed to not only gather information, but also formulate her assessment and plan for each patient, and prepare to defend her plan to her senior resident and attending.

Who should I start with? She thought. She decided to do gravity rounds, starting on the 4th floor and working her way down to the 1st. But I’ll leave Aaron for last, she thought. Aaron very medically stable. Interacting with him was also challenging. He was a transplant patient who was stuck on the medicine service for weeks because of an ileus, or slow moving bowels. He was about her age. She had to remind herself to be aware of transference and counter-transference, of the fact that he splits the healthcare staff, and that he often does not respond well to women. That no matter what he says to her, she cannot take it personally, but instead must let it roll off so that she can focus on his care.

No, maybe I’ll leave Betsy for last. She’s so cute and pleasant. She’ll brighten up my day. I’ll see Aaron 2nd to last. Betsy was a 90-year-old lady with cellulitis, a skin infection, on her leg. A typical encounter was as such:

“Good morning Betsy! How are you feeling?”

“Oh I’m fine, better than I’ve been all week! Now how are you doing, dear?”

“I’m doing well, Betsy, thanks for asking. How’s your leg feeling?”

“Oh the leg is doing okay, it looks like it’s getting better with these antibiotics they’re giving me.”

Sienna performed a review of systems and a physical exam. After examining her heart, lungs, abdomen, and legs and taking a peek in her mouth, she asked Betsy if there was anything I could do for her before the rest of the team comes by to see her.

“Oh no, I’m just fine, thank you so much. You all are doing such a fine job taking care of me. Now you go on and have a good day!”

Betsy was the only patient who asked Sienna how she was feeling, and who wished her a good day, and the kindness made Sienna smile.

As Sienna saw each of her patients, she asked them how they were feeling, asked them specific questions related to their conditions, examined them, and studied their charts.

Sunlight began to creep in through the window in the hallway as Sienna power-walked from the staircase to the patient rooms on the third floor. Her stomach grumbled loudly, as she had not had breakfast. For just a moment, she turned her head towards the window, inhaling and exhaling the dim sunlight, her feet never pausing.

By the end of her prerounding, her stethoscope weighed heavily on her shoulders. She placed it in her pocket as she entered the workroom again, sitting down as she waited for her senior resident to arrive from morning conference.  Her pager had begun to buzz incessantly, with nurses calling to ask questions or update her on patient information, and with case managers calling to coordinate patient discharges. She called the pages back, phone held up to her ear by her shoulder, all the while her fingers busy typing notes. She inserted the overnight events, the things her patients said to her, and her exam. She jotted down a couple of key phrases in the plan section of her note to jog her memory of what she wanted to discuss during the assessment and plan component of the presentation—the part she dreaded the most.

Giving presentations made Sienna feel like she was on display, and like everyone was judging her abilities. This was perhaps because she was her own harshest critic. More than carrying the pager, more than writing notes, perhaps even more than having to wake up at 5am, the task that she disliked the most required of her as an intern was giving daily presentations. Even though she had spent the last four years of her life in medical school and the four years prior to that as a premedical college student, she often felt like she knew nothing. Although she had always been one of the brightest kids in the room growing up—highest grade point average every year, valedictorian, magna cum laude at a top ten university, and winner of awards at the national level—in medicine she questioned her own intelligence daily. When pressed by a superior to answer a question about patient data, an academic fact, or her reasoning for proposing a plan, her mind often drew a total blank, no matter how much she knew. Subsequently, all she could think about were her evaluations, and what the program director would think, and how she would fare in the next step of her training. What she liked the most about medicine was talking to patients, and thinking about how their diseases worked and what to do about them. She wished she had more time to interact with and think about her patients. While the team rounded, Sienna presented and then stayed outside of the room to answer pages and enter orders while the attending, senior resident, and medical student spoke to and examined the patient.

By noon, Sienna’s team had finally finished rounding. By that point, all she could think about was lunch. Leaving her stethoscope at her desk, she walked over to the noon conference where a lecture was about to take place for the senior residents and free sandwiches were available. She grabbed a plate to bring back to her cave, as she had two patients to discharge and was likely to have a new admission coming soon. Not to mention all of her progress notes she had yet to finish.

She snuck into the nursing conference room off the floor to do her work and eat her lunch, as that room had a window and more space, and was more often than not empty. She checked her phone, and smiled at a message from her husband wishing her a nice day. Thank God for this man, she thought. She met him while she was doing research, and they fell instantly in love. He agreed to go on this adventure with her, uprooting his life so that they could start their new life together. I hope you have a great day too. I love you.

The rest of the afternoon was a blur. She had to coordinate discharges for two patients and write their discharge summaries, and she also got two new admissions. One was very sick, a man with liver cirrhosis and a gastrointestinal bleed, who would be on her team but staying in the step-down unit, where he would receive closer nursing monitoring and be in closer proximity to the intensive care unit.

By 5:30 pm Ali was back, but Sienna had not yet finished her work, having an admission note still to finish. Although it was not her late call day, it was her day where she could get new admissions between noon and 4pm, and she received two admissions in the last hour.

At 7:15 pm, she was finally heading to her car. As she stepped out into the darkness of the evening, she noticed that the frozen morning dew had melted and the sidewalk was wet but not icy. It was early November but winter had started early this year.

Aaaah. A sigh of relief as she sat in her car. She plugged in her phone and turned on her favorite playlist. She was looking forward to dinner with Jake, and was also thinking about her plan for tomorrow and what she had to follow-up on in the morning. She was calculating that by the time she was home, she had give or take an hour and a half to shower, eat, and spend time with Jake if she wanted to get 8 hours of sleep before the next day. Ha, she thought, slim chance of me being in bed by 9pm.

As Sienna entered the apartment, she could smell the delicious dinner Jake was cooking.

“Hey babe!” she called, as she walked into their apartment.

“Hey sweetheart. How was your day?”

“Eh, it was okay. How was your day?”

Jake loved to cook, which made Sienna’s life so much easier.

Sienna hung her jacket and placed her bag and shoes in the coat closet. She caught a glimpse of herself—dark hair pulled back, no makeup on her face, glasses on. Do I still look like me?

She threw her scrubs in the hamper and got in the shower. Ever since third year of medical school when her clinical rotations began, she developed a daily ritual of showering first thing when she got home. She let the stream of water wash away all of the events of the day. All of the sins of the hospital. In the shower, she had time to reflect, and time to forget, depending on what she needed that day.

Another day down. And it’s only Monday.

Red snapper fish for dinner

Written by Alexandra Villasante Fricke, MD in 2015.

Last night in the ICU

We brought his family into a separate room with plenty of chairs. Sitting to the right of his father and mother, our attending uttered the first words in the room.

“I think you know what I am about to say.”

His mother took in a deep sigh, her eyes already swollen from inconsolable tears.

“I think he is dead.”

The whole room sank. We were all punched in the gut by those words.

“Oh my God….” his mother cried out, sinking her face in her husband’s shoulder as she was being told that her worst nightmare was her current reality—her 29 year old son was dead.

His girlfriend stared blankly and silently at the wall with glassy eyes, kneading the hands of those next to her with her fingers, not moving or crying or saying a word. She had found him last night on the floor, blue, without a pulse. His parents said that “she kept him alive” for the past two years, “loving him unconditionally” as he struggled with addiction to narcotic pain pills (opioids).

His father was the first to try to address and tackle the death, asking about the logistics of where and when and what now. As we got up he buried his face in his hands and sobbed.

I stood against the wall next to my co-residents, on the 14th hour of a night shift in the intensive care unit, using all my inner strength to not cry.

Amidst a night of putting in central lines, diuresing patients to goal, and repleting patients’ electrolytes, the only moment I will likely remember vividly in 20 years is the moment my stomach sank when his mother learned that he was dead.

Earlier that night my intern and I met his parents and siblings as they sat around his hospital bed praying that he would return to them. Intubated and mechanically ventilated, his heart was still beating because it was receiving oxygen, and his body was still warm. His youthful skin and handsome face belied his morbid condition. His parents hugged and kissed his body and asked us what his chances were of recovery.

“His brain injury was very serious because his brain was without oxygen for a long time. In the morning we will do a test of whether he can breathe on his own, which will tell us if his brainstem is functioning.”

There was no mention of death. We left it at “we need to gather more information.” But all the while I felt that he was already gone.

“He’s a good boy” they said, “my protector,” said his sister. They described him as bright and caring. “But he had an unhappiness inside the past couple years” his mother said. “He got sick.” He had just gone to rehab and was looking forward to his 60 days sober milestone—which would have been today.

His parents found comfort in the idea that he would live on in others by donating his organs. Yet the only time his girlfriend spoke was to say, “I told him not to put that on his license.” “He would have loved to help someone else,” his brother replied.

There is no moral to this story. A man was alive yesterday and today he is dead, and I was there when his family heard the news. This happens somewhere in some way to someone every moment of every day.

The last time I wrote in this blog I wrote a long, dense post about what it means to be brain dead. I chose to play it safe by writing about what I know. About objective facts, things that are written somewhere, that are backed up by evidence. I have not written in a while because I have been busy being a medical resident; but also because I do not really want to write about objective facts. I want to write about my experiences in medicine, what I have seen and what has become ingrained in my mind and in my soul.

Every day in the hospital, I invariably walk through someone’s personal hell on earth. For the most part, nothing I do will pull them out of their inferno. At most I can crawl into that hole with them and, just for a moment, keep them company.

 

How Your “Natural” Supplements Could Kill You.

Today during our “morbidity and mortality” lecture, we discussed a case of a woman who suffered a devastating stroke because she was taking naturopathic dietary supplements. She had a list of 70 different homeopathic supplements that she was taking, one of which contained thyroid hormone from animal organs. She presented to the hospital with a heart arrhythmia called atrial fibrillation as a result of the off the charts thyroid hormone levels in her body. Soon after arriving to the hospital she suffered a major stroke which left her permanently disabled (new-onset atrial fibrillation can put patients at risk of forming clots in the heart which can travel to the brain and cause ischemia, or inadequate blood supply, leading to cerebral infarction–commonly known as stroke).

Earlier this month I took care of a patient who died of metastatic breast cancer because she refused conventional treatment. She was diagnosed with breast cancer in her 40s, 7 years prior to her death. At that time, she had a very good chance of being cured with surgery and local radiation alone. However, she was a firm believer in naturopathic medicine, which essentially teaches that the body can heal itself, and she refused conventional or allopathic treatment. She was an educated person, and she had received a doctorate in a branch of alternative medicine. Eventually, her cancer became metastatic, infiltrating her liver, her bones, a diffusely throughout her tissues (known as “carcinomatosis”). She did agree to some chemotherapy towards the end of her life, but by that point it was too late. When I met her, she was bed bound, in severe pain all over her body, with chest tubes in place draining up to 2 liters per day of pleural fluid (fluid from around her lungs). The morning I met her I assisted her husband in draining her chest tubes, a task he meticulously completed every day. They were a very loving couple, speaking gently and kindly to each other in the most frustrating of circumstances, and she was a very sweet lady. After she died, after I left her room, I went somewhere private to cry. I had bonded with her. After some time passed, I also felt ashamed that she had died a preventable death. Somehow, we as allopathic doctors had failed her by not doing a good enough job of convincing her to allow us to treat her with evidence-based medicine. Maybe we hadn’t pushed hard enough, because we thought it was a losing battle.

Last week I met a patient with gastroesophageal reflux disease (GERD) who did not believe in taking medications and refused to take her Nexium (omeprazole, a proton pump inhibitor which decreases the acid content of the stomach). She experienced an uncomfortable feeling in the back of her throat after eating, and she was convinced that she had food allergies. A naturopathic doctor had diagnosed her with a whole slew of food allergies. In clinic, skin testing to the common food allergies, including the ones diagnosed by the naturopath, were all negative. The one treatment that would make her feel better was the proton pump inhibitor; however, due to misinformation and her mistrust of conventional or allopathic medicine, she would continue to feel lousy.

In medical school I took care of a patient who went into liver failure because she was taking Herbalife. Here, a local police officer lost his job because he was taking a weight loss supplement that contained amphetamines.

There are countless stories like this. In the US, about half of the adult population uses dietary supplements. The US Food and Drug Administration (FDA) defines dietary supplements as “vitamins, minerals, herbs or other botanicals… amino acids, enzymes, organ tissues, glandulars, and metabolites… extracts or concentrates” and may be found in many forms such as “tablets, capsules, softgels, gelcaps, liquids, or powders.” Dietary supplements are a $34 billion per year industry. These supplements are marketed as “natural” and they are sold at “health food stores,” GNC, Whole Foods, etc.

The reality is that dietary supplements are not categorized by the FDA in the same way that drugs made by pharmaceutical companies are, and thus they are not held to the same rigid standards and regulations. Dietary supplements do not even need approval from the FDA before they are marketed to consumers. Under current law, the responsibility of monitoring safety and effectiveness falls not on the government, but on the manufacturer. In other words, I can bottle a concoction of sugar and rosehips and write on the label that my product cures cancer, diabetes, and heart disease, and the government will not stop me.

Though regulations were created in 2007 to “ensure the identity, purity, quality, strength and composition” of supplement products (in other words, to make it more likely that the bottle labeled as Vitamin C actually contains Vitamin C), the government does NOT enforce these regulations. Straight from FDA.gov: “Unlike drug products that must be proven safe and effective for their intended use before marketing, there are no provisions in the law for FDA to ‘approve’ dietary supplements for safety or effectiveness before they reach the consumer.” Under the DSHEA law signed in 1994 by President Clinton, dietary supplements are regulated retroactively; manufacturers are supposed to report adverse effects of their products to the FDA. In other words, the onus of regulating supplements falls on the manufacturers of these products, who have a vested interest in selling them and making money.

Furthermore, the dosing is completely unregulated. As mentioned on FDA.gov’s Q&A section, “Other than the manufacturer’s responsibility to ensure safety, there are no rules that limit a serving size or the amount of a nutrient in any form of dietary supplements. This decision is made by the manufacturer and does not require FDA review or approval.” A supplement may contain very high levels of a compound, or they can contain such a minimal amount that a person would have to take thousands of pills to have any kind of effect.

Many supplements are manufactured abroad, and often contain dangerous contaminants, including lead.

There is one reason alone to take vitamins or supplements: when your allopathic healthcare provider (board-certified MD or DO, or ARNP/PA working under the supervision of one) prescribes it. Notable examples include

  • When you have certain types of anemia that require supplementation with Vitamin B12, Folic acid, and/or iron.
  • When you have been diagnosed with Vitamin D insufficiency or deficiency
  • When you are trying to become pregnant, and prenatal vitamins are prescribed.
  • Or when studies have otherwise shown that taking that supplement is 1) safe and 2) effective in treating your problem.

Why is there a demand for dietary supplements? Now, this is just my personal conjecture… But perhaps we buy supplements because, in spite of the best evidence-based conventional medicine, people still get sick and die every day. The big bad pharmaceutical companies have big bad reputations, and conventional doctors make mistakes every day that hurt and kill people (“iatrogenic” events). We place unreasonably high expectations on medicine, and by proxy on doctors, to be perfect and Godly, Almighty Fathers and Mothers who keep us safe and take away our ailments. And conventional medicine very often fails to accomplish either. So, in rebellion, or perhaps with our last ounce of hope, we buy magical potions sold with impossible promises. Because we need to believe that something will fix us. Because illness is scary. Because death is scary.

My suggestions to the reader are:

  1. Know what you are ingesting.
  2. Do not waste money on products that are at best ineffective, and at worst dangerous.
  3. Put your faith in scientific evidence, not in false promises.

[PS This post is in no way implying that all alternative and complementary practices are harmful. The stipulation is that they be evidence-based–meditation and other stress-relieving techniques, for example, have some proven benefits. Otherwise, that they be low-risk and have subjective benefits–for example, massage therapy makes me feel great. In any case, alternative and complementary practices are not adequate substitutes for conventional medical therapy. The purpose of this post is to make the point that certain active compounds found in dietary supplements can be very harmful.]