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.

Medicine Simply Author

My Winter Skincare Routine

Is winter starting to make your skin dry and your lips chapped? Below is my winter skincare regimen as well as tips for keeping your skin glowing all year long.

The first tool I find extremely versatile is Aquaphor. It is an ointment made of 41% petrolatum that serves as a semi-occlusive barrier on the skin. This keeps water and oxygen from being pulled from the skin by the elements, which helps with wound healing and creates a protective moist environment. It does not contain fragrances, preservatives, or dyes so it is good for even the most sensitive skin. It is non-comedogenic so it won’t clog up your pores. I use it on my face, my lips, my hands, and any other dry areas in the evening.

Vaseline is also made of petrolatum but it is 100% petrolatum, so it forms an occlusive barrier and is a lot thicker and stickier.

Some people prefer moisturizing with a cream or lotion rather than an ointment. The difference is that an ointment contains around 80-100% oil and up to 20% water, so an ointment feels oily on your skin and doesn’t “rub in.” A cream, on the other hand, is about 50% oil and 50% water so you will still have an oily layer that doesn’t fully rub in but it is less greasy. Make note, however, that creams often contain emulsifiers and preservatives which can be irritating to the skin. A lotion is similar to a cream but it is an even lighter or less thick formulation and can sometimes contain alcohols for faster drying. Gels and foams are the lightest, so to speak, and they also dry faster the the aid of alcohols. One cream that I find to be non-irritating to my skin and a great moisturizer is Cetaphil Cream. Some providers recommend CeraVe Moisturizing Cream but when I have tried it myself a felt a stinging sensation on my skin, body and face.

Another part of my skincare regimen that I use at night is Differin Adapalene Gel 0.1%. I had mild acne in college and used adapalene (Differin) gel, which at that time required a prescription (now it is over-the-counter!), along with an antibiotic cream called clindamycin. Differin is a topical retinoid that increases skin turnover and wards away acne including blackheads and whiteheads. Retinoids are also anti-aging (you may have heard of prescription Retin-A). I still use a pea-size amount of Differin gel about once every 3-4 nights to maintain clear skin. However, retinoids can be very drying so be sure to moisturize aggressively. Also, wait at least 30 minutes after applying Differin to apply moisturizer as you want to avoid getting retinoid on the sensitive skin around the eyes.

In the morning, I use a tinted CC cream that contains SPF 50. I am currently using IT cosmetics’ Your Skin but Better CC Cream with SPF 50 Plus (Medium) – 1.08 Ounces. I really like the way it gives me a smooth, even skin tone without feeling heavy at all. I use this in the morning with some Aquaphor on my lips. I even use it at night as my foundation and then use a contour stick over it plus mascara, lipstick, and bronzer or blush. I love the fact that it includes SPF for daytime. Protecting my skin from UVA and UVB rays is a priority in order to prevent skin cancer as well as aging and discoloration (and yes, you do need SPF in the winter time too! You can get your Vitamin D from food or a supplement). I will admit, on rotations where I have to wake up at the crack of dawn, I often roll out of bed, brush my teeth, throw on scrubs, and go to work bare-faced, as evidenced in this photo from my intern year.

However, lately I have been making an effort to effort to wear SPF, and to look a little more polished. Also to floss my teeth nightly, but that’s a story for another day.

Lastly, I am a lifelong user of Dove soap. It is the only soap that does not dry out my skin. Because I use Dove I do not have to regularly moisturize my body skin.

And that sums it up. I like to keep my skincare regimen simple and effective. Moisturize at night, preferably with ointment or a non-irritating cream, and wear SPF in the morning.

Welcome back!

Welcome to the revamped version of Medicine Simply! I am currently a third year resident physician in internal medicine. I graduated medical school and obtained my MD in 2015. I currently see patients every day, either in the hospital or in the clinic, under the guidance and supervision of attending physicians. This summer I will complete my residency, apply for a full, independent medical license (I currently operate on a training license), and sit for the boards in order to become “board certified” in Internal Medicine. I will also begin specialty fellowship in July 2018.

In the next series of posts I will be providing you with affiliate links through Amazon Associates. For example, in my last post, I provided a link to Afrin No Drip Extra Moisturizing Pump Mist 15 ml, a brand name version of the nasal decongestant oxymetazoline, as I have used oxymetazoline in practice. If purchases on Amazon are made by readers who click on the links, I will make a small commission. I am not partial to any particular brands and will aim to present multiple options when available. I will only highlight products and over-the-counter medications that are evidence-based and/or widely recommended in practice. I have already turned down offers to review herbal supplements because I do not believe in those products, for example.

Future posts will include further medical lifehacks such as how to avoid cold and flu, recommendations on my personal favorite skincare products, and information on your burning questions such as, what does “gluten-free” really mean? I will always continue to incorporate my experiences as a resident physicians. Stay tuned!