Changing the paradigm

by Robert Swendiman

Whether I am at Grand Rounds, a department meeting, or the American College of Surgeons Clinical Congress, it is often like looking into a mirror. I cannot help noticing the abundance of white men – especially at “the top.” While I meet numerous female and minority surgical residents and junior faculty, most of the chairs, program directors, and full professors are men.

Outside of the medical profession, surgery has an “old boys club” reputation. But I come from a school of leadership where difference and diversity are more than just opportunities for social progress – they are requirements. So I was disappointed when I perceived the stereotype affirmed. The more I look around, the more men I see.

Constant inquiry (or “quality assessment and quality improvement” in medical terminology) is an important component of leadership. Without it, we fail to analyze, understand, and improve the systems in which we are a part. Thus, I began my investigation, and what I found was shocking. Despite the increasing number of women entering general surgery residency programs – from 10% in 1980 to 36% in 2011 – as of last year, women only represent 9% of all full professors, 17% of associate professors, and 25% of assistant professors in surgery. 1, 2 While these numbers are obviously disproportionate, what is perhaps more concerning is that they also remain stagnate. In the last 15 years, these percentages have not changed. 3

Despite the fact that men and women enter academic medicine at equal rates, the rate promotion is uneven. 4-6 Though men and women start at similar ages, the mean age of attaining “Professor” status in approximately five years younger for men. 4 “Even after adjusting for number of publications, amount of grant support, tenure versus other career track, number of hours worked, and specialty, women [remain] substantially less likely than men to be promoted.” 4

Thus, female surgeons remain impressively underrepresented in the ranks of surgical faculty at 21% of the workforce (the average across all medical departments is 37%). 2 Of all academic departments in the basic and clinical sciences, surgery ranks second to last in percentage of total female faculty members (orthopedics, 15%). 2 However, in other specialties, women hold more than half of all faculty positions (obstetrics and gynecology, pediatrics, and public health and preventive medicine). 2

The famous surgeon, Dr. William Halsted, once quipped that the issue with surgeons taking call every other night was that residents would miss half of the cases. In the same manner, when we exclude 51% of the population from top leadership positions, we are missing out on half of the talent. If fewer than 10% of professors of surgery are women – and that figure has not changed in more than a decade – I wonder, “Is our academic community really moving surgery forward?”

Fellow colleague, Sophia McKinley, wrote about her own early lessons in leadership. She states, “Individuals at every position in a hierarchy can exhibit leadership.” I agree, and I see this lack of diversity as an urgent opportunity for real-time leadership at every level. As a white male, I think it is my job to participate in changing this paradigm – chipping away at the explicit and implicit barriers that male surgeons still espouse in surgery, advocating for and leveraging diversity, and staying curious about surgery’s present and future challenges. As an inspiring academic surgeon, this also meant research, which is why I joined a multi-institutional team from UNC, Harvard, and Stanford to better understand how we can change the status quo. I know it’s not enough, and change will not happen overnight, but doing nothing is not a viable option.

I was often asked on the interview trail, “Can an intern or a medical student really be a leader?”

This is the answer I give them.

~~~

References

1. Cochran A, Freischlag JA, Numann P. Women, surgery, and leadership: where we have been, where we are, where we are going. JAMA Surg 2013;148(4):312-3.

2. Association of American Medical Colleges. “Women in Academic Medicine and Science: Statistics and Benchmarking Report 2011-2012.” Table 3: Distribution of full-time faculty by department, rank, and gender, 2012. < https://members.aamc.org/eweb/upload/Women%20in%20U%20S%20%20Academic%20Medicine%20Statistics%20and%20Benchmarking%20Report%202011-20123.pdf>. Accessed November 6, 2013.

3. Sexton KW, Hocking KM, Wise E, et al. Women in academic surgery: the pipeline is busted. J Surg Educ 2012;69(1):84-90.

4. Zhuge Y, Kaufman J, Simeone DM et al. Is there still a glass ceiling for women in academic surgery? Ann Surg 2011;253:637–643.

5. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310

6. Buckley LM, Sanders K, Shih M, et al. Obstacles to promotion? Values of women faculty about career success and recognition. Acad Med 2000;75:283-8.

~~~

Robert Swendiman is a dual-degree M.D./M.P.P student at UNC School of Medicine and the Harvard Kennedy School of Government. He spent his time at Harvard as a Dubin Fellow for Emerging Leaders at the Center for Public Leadership, researching how leadership principles can be applied to medical education. Robert is participating in the 2014 Match cycle, and is interested in pediatric surgery.

Finding Strength in Setbacks

by Jane Zhao

Two months ago, I read a great book, and I’ve been raving about it ever since to whoever will listen. David and Goliath: Underdogs, Misfits, and the Art of Battling Giants by Malcolm Gladwell is a book that stays true to form to Gladwell’s other works. In it, Gladwell challenges readers to look beyond conventional wisdom to reevaluate the way we look at setbacks.

The nonfiction book begins with a vignette from the biblical passage of David and Goliath. Historically, David has always been painted as the underdog and Goliath the giant. But based on what criterion? The fact that David is of significantly smaller stature? Pfft. According to Gladwell, David wasn’t such a weakling. In fact, he had numerous other qualities that made him just as formidable (if not more so) than Goliath.

Gladwell writes early on in the book:

“There is a set of advantages that have to do with material resources, and there is a set that have to do with the absence of material resources—and the reason underdogs win as often as they do is that the latter is sometimes every bit the equal of the former.

“For some reason, this is a very difficult lesson for us to learn. We have, I think, a very rigid and limited definition of what an advantage is. We think of things as helpful that actually aren’t and think of other things as unhelpful that in reality leave us stronger and wiser.”

As I read, I thought bemusedly how his words could be applied to setbacks faced by women in surgery. How often have I heard of the challenges faced by my predecessors described as blessings in disguise? Based on his writing, Gladwell probably wouldn't think of that analogy as far-fetched at all.

So I came up with some examples of surgeons whose pasts as underdogs and misfits shaped them into amazing role models.

• In the 1970s, women were discriminated against from receiving credit in their own name at banks, and if these women were married, they were told to use their husband’s name on the checking account. Finally, in response to the refusal of service, a number of women banded together and formed the first ever women’s bank. Dr. Anita Figueredo was one of them. During the creation of the bank, these women received derision and dismissal from many of their peers. But after the bank’s successful launch, banks all around (even the ones that had previously refused them service) began to open up "women’s departments" and "women's divisions." Lessons learned: when these women didn’t feel welcome, they decided that instead of trying to fit in, they’d start from scratch elsewhere. As a result, they each became successful entrepreneurs with leverage of their own right in the banking community.
• Dr. Frances Conley never really considered herself the victim of sexual harassment. Anytime an off-color joke was directed her way, she’d fire off a snappy retort, and that’d be the end of that. She built an incredibly successful career as a neurosurgeon at one of the most prominent academic institutions in the country. She kept her head down and didn't rock the boat. But then came an incident of misogyny that she simply couldn’t ignore, and she publicly resigned from her tenured position in protest. Her office and lab were ransacked; she was vilified by the media and many of her peers. Thanks to her efforts, numerous medical schools, universities, hospitals, and research labs created or updated their policies regarding sexual harassment. When she finally performed the unsavory deed of “rocking the boat” that she’d spent so long trying to avoid, she became recognized and respected as a leader brave enough to speak the unspeakable.
• Dr. Linda Brodsky serendipitously discovered in 1997 during a residency program review that a recently hired male faculty member in her department with lesser qualifications, responsibilities, and seniority was being compensated by her university at twice her state salary. Upon further investigation, she discovered that this was not an isolated incident. After more than two years of trying to resolve her gender and pay concerns internally, she resorted to filing charges of discrimination by her two employers. As a consequence, she lost her job. She’s since spoken publicly about the innumerable times she became wracked with guilt over putting her family through the tortuous process. Often, she’d lose sight of the light at the end of the tunnel and question whether she’d made the right choice by filing a lawsuit. After ten long years, the lawsuits were finally settled. Because of that grueling period in her life, she is significantly wiser about the laws regarding fair gender compensation, and she has become a fearless leader in the global community by advocating for others who are now in similar situations. 
• And lastly, an orthopedic surgeon I know was teased and called “Token” by her co-residents all throughout residency because she was the token woman their program had taken in that year to meet its quota for diversity and inclusion. Being called by a nickname she hated irked her to no end, but that experience made her aware of just how damaging and alienating such taunts, however slight, can be over time. As a result, she is an infinitely more sensitive caretaker and teacher than she would have been otherwise.

The incidents suffered by these women were awful. They faced difficulties because they were different. The silver lining to all of this is that we wouldn’t know about any of these women and their heroic contributions to society if they hadn’t been pushed to the brink and been forced by their situations to find the inner courage to implement change when change was needed.

Globally, women and underrepresented minorities still have a ways to go before full equality is met. It’s a new year though, and with that as reason enough to celebrate, I’d like to raise a toast to the tremendous progress we’ve made as a society, all thanks to the efforts of underdogs and misfits who saw setbacks not as obstacles that blocked their paths but as walls to be climbed over.

Happy 2014.

Oh, and make sure to read David and Goliath: Underdogs, Misfits, and the Art of Battling Giants by Malcolm Gladwell. It’s a good book.

Do you have an experience where being an outsider made you a stronger individual? Share your story with us in the comments below.

~~~

Jane Zhao is a fourth year medical student at the University of Texas Medical School at Houston. She completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award. Her interests include healthcare social media, quality improvement, and public health from a surgical perspective. She chairs the AWS blog subcommittee and can be followed on Twitter. She is in the process of interviewing for General Surgery residency for the 2014 Match.

Sexism & Surgery

by Amalia Cochran, MD, MA, FACS, FCCM

How many of you saw this great piece from Emily Graslie a couple of weeks ago? 

 

I loved this video for a couple of reasons. One is obvious if you are familiar with her work- Emily’s video series from The Brain Scoop is a terrific, user-friendly approach to science. The other was that I honestly empathized with the comments that Emily included in her video, as I suspect many of us do, and I loved her approach to dealing with sexism and science. She’s no-nonsense about it and addresses the issue head on.

I thought back to my first encounter with sexism in medicine, going back to high school. Our family’s physician, upon being told that I was leaving for college at the end of my junior year under an early admission program with intent of going to medical school, simply commented, “Well, I guess it’s okay for women to be physicians these days.” No, he wasn’t joking. No, he never treated me again (nor my mother). I’ll admit- this was almost 30 years ago, and with the entry of more women into medical school many things have changed. Or have they?

Plenty of research shows that female medical students often experience gender discrimination, and that this occurs most commonly on their surgical clerkships. Women medical students are more likely to experience gender discrimination during their surgical clerkship than are their male counterparts and are more likely to perceive sex discrimination, typically from male attendings and male residents. My own recent work has shown that female surgeons and residents are more concerned about the presence of sex discrimination in the workplace than are their male colleagues, and that they perceive this discrimination as a barrier to advancement in academic surgery. Clearly this problem isn’t just one of the 1980s; it persists in modern-day medicine.

Stories of incidents can be gathered easily enough from many sources; in one night on Twitter I was able to acquire stories ranging from colleagues or patients refusing to address a woman physician as “Doctor” to women being told they are “too nice” to be a surgeon, or being told that they are allowed to do more in the OR because of their looks. While the overt sexism remains, many institutions are starting to consider the role of “implicit bias,” those subtle behaviors and actions that manage to undermine the leadership and credibility of any minority group. Yes, women surgeons are still a minority group.

So back to where we started, with Emily Graslie’s video. We have a problem still, and what we need is a solution. We can start by speaking up when we hear sexist comments- particularly those of us who are a little more senior and have less to lose than our younger colleagues. We can also work within our institutions to increase awareness of implicit bias in hopes that this will have a durable impact. And, as Emily Graslie stated, “We need to make sure we’re making it possible for people of all genders to feel acknowledged for their contributions and not feel held back by something as arbitrary as their genetics or appearance.”

How have you experienced sexism? And, perhaps more importantly, how have you dealt with it when you have either experienced it or witnessed it?

This post was originally published on Dr. Cochran's blog, Life in the Wild West.

 

~~~

Dr. Amalia Cochran is Associate Professor of Surgery at the University of Utah. She is heavily involved in undergraduate medical education, serving as the Surgery Clerkship Director and the Director for the Applied Anatomy track for 4th year medical students at the University of Utah. Her research interests lie in surgical education and in clinical outcomes in burns. She is Vice President of the Association of Women Surgeons. Follow her on Twitter. Visit her blog. 

There’s Something In the Water

by AWS writer, Denise Harrigan

Often-invisible but highly influential, second-generation gender bias often impedes women’s ascent to top levels of leadership. The Harvard Business Review intends to expose it.

Fifty years after women were first admitted into Harvard’s MBA program, the September 2013 issue of The Harvard Business Review (HBR) examines the status of women in the business world. The cover alone – with a silhouetted female profile and the words “Emotional – Bossy - Too Nice ” -- reveals that women are floundering, not flourishing.

The bottom line is that only four percent of Fortune 500 companies have female CEOs, and 50 of those companies have no female board members. According to Adi Ignatius, editor-in-chief of HBR, women remain “distressingly underrepresented at the top levels of institutions.”

The HBR focus is not on the numbers -- those numbers, in recent years, have been documented to death. The goal, according to Ignatius, is “finding practical new solutions to a seemingly intractable situation. Closing the leadership gap is a formidable challenge. But there’s no excuse for accepting the status quo.”

The issue, part of the Harvard Business School’s global effort to accelerate the advancement of women leaders, features major articles on persistent gender bias and inclusiveness as a mission and moral imperative.

Unfortunate Legacy

The article “Women Rising: The Unseen Barriers,” by Herminia Ibarra, Robin Ely and Deborah Kolb, examines undercurrents that impede women’s progress and identifies second-generation gender bias as a major but rarely acknowledged impediment.

Where first-generation gender bias involved the deliberate exclusion of women, the second generation “erects powerful but often subtle and invisible barriers for women that… inadvertently benefit men while putting women at a disadvantage.”

Insidious

As a result of second-generation gender bias, unspoken cultural perceptions about women often carry more weight than job performance. Perhaps the most insidious belief is that men are natural leaders, and women are followers.

“In most cultures, masculinity and leadership are closely linked,” the authors report. “The ideal leader, like the ideal man, is decisive, assertive and independent. In contrast, women are expected to be nice, caretaking and unselfish.”

Linking leadership with common male behaviors suggests that women are not cut out to be leaders. It can also create a double standard. Assertive men, for example, are admired – and promoted. Assertive women are advised to “soften their sharp elbows.”

As a result, many women waste professional energy trying to project the perfect image -- not too pushy, not too nice. According to the authors, some employ voice coaches, image consultants, and branding experts “to manage the competence-likability trade-off— the seeming choice between being respected and being liked.”

“But the time and energy spent on managing these perceptions can ultimately be self-defeating. Overinvestment in one’s image diminishes the emotional and motivational resources available for larger purposes. People who focus on how others perceive them are less clear about their goals, less open to learning from failure, and less capable of self-regulation.”

Leaders Are Made, Not Born

Leadership is not an innate gift – it’s a skill that requires practice. More often than not, men are given opportunities to practice this skill. The workplace, still predominantly led by men, instinctively grooms men for leadership positions, creating stepping stones where men can practice leadership skills.

According to the authors, “Women have fewer opportunities to develop leadership skills and seem less inclined to create these opportunities for themselves.” By nature or nurture, women often gravitate to behind-the-scenes positions, and their efforts fade into the blur of teamwork.

Internalizing Leadership

“People become leaders by internalizing a leadership identity and developing a sense of purpose,” the authors observe. “Internalizing a sense of oneself as a leader is an iterative process. A person asserts leadership by taking purposeful action—such as convening a meeting to revive a dormant project. Others affirm or resist the action, thus encouraging or discouraging subsequent assertions. These interactions inform the person’s sense of self as a leader.”

In the wake of positive affirmation, “a person’s leadership capabilities grow. Opportunities to demonstrate them expand. High-profile, challenging assignments …. become more likely. Such affirmation gives the person the fortitude to step out-side a comfort zone and experiment with unfamiliar behaviors and new ways of exercising leadership.”

Well-Meaning but Off Center

The authors of “Women Rising” acknowledge that many companies attempt to level the playing field for women. “Many CEOs make gender diversity a priority, set aspirational goals for the proportion of women in leadership roles”…. and invest in building “a more robust pipeline of upwardly mobile women.

“But then, not much happens,” according to the authors. “The solutions to the pipeline problem are very different from what companies currently employ. Mentoring and leadership education programs are necessary but not sufficient.”

Deeply Conflicted Culture

“These approaches don’t address the often fragile process of coming to see oneself, and to be seen by others, as a leader. Integrating leadership into one’s core identity is particularly challenging for women, who must establish credibility in a culture that is deeply conflicted about whether, when, and how they should exercise authority.”

Call It by Name

Since second-generation gender bias “can be subtle, subconscious, assumed but not articulated by both men and women,” the authors recommend that employers begin to address it by simply naming it.

“Second-generation bias does not require an intent to exclude; nor does it necessarily produce direct, immediate harm to any individual. Rather, it creates a context—akin to ‘something in the water’—in which women fail to thrive or reach their full potential.

“Without an understanding of second-generation bias, people are left with stereotypes to explain why women as a group have failed to achieve parity with men: If they can’t reach the top, it’s their own fault for failing to be sufficiently aggressive or committed to the job.”

Alternative Reality

By identifying and addressing second-generation bias, however, companies can finally move toward gender equity – and an executive suite that “doesn’t look or behave like the current generation of senior executives.”

“When women recognize the subtle and pervasive effects of second-generation bias, they feel empowered, not victimized, because they can take action to counter those effects,” the authors promise. “They can put themselves forward for leadership roles when they are qualified but have been overlooked. They can seek out sponsors and others to support and develop them in those roles. They can negotiate for work arrangements that fit both their lives and their organizations’ performance requirements.

“Such understanding,” the authors conclude, “makes it easier for women to ‘lean in.’”

Disparities

by Marie Crandall, MD, MPH, FACS

Poverty

Living in Detroit as a child, I learned that if your water got turned off, you just went down to the city Water Board, paid $10, and got your water turned back on. When I started high school in the early 1980s, our family moved to Northern Michigan. It was there I met folks who didn’t have running water. I have countless memories of stumbling out past snow-covered woodpiles to drafty outhouses, then pumping ice cold water over my hands before returning to not terribly public health-focused high school parties. Seeing both urban and rural poverty and the ensuing late-diagnoses of cancer, alcohol-induced car crashes, and gunshot wounds that ruined lives absolutely influenced the course of my life and my career.

The crushing effects of poverty are pervasive and have a tremendous impact on health disparities, as income and race have been found to predict outcomes in nearly every kind of illness, from trauma to appendicitis to cancer, though we are only just beginning to understand the mechanisms. However, programs that improve housing stability and access to healthcare and healthy food choices have been shown to improve ALL health outcomes for children, underscoring the principles of the social determinants of health. If we can address some of the nutrition, education, and health issues of children living in poverty, we may be able to narrow the gap of subsequent health outcomes disparities. Likewise, if issues of homelessness and substance abuse could be more comprehensively addressed, there is evidence to suggest that Emergency Room visits and healthcare expenditures can be reduced.

Trauma

Injury is the leading cause of death of all Americans ages one through 45. Gunshot wounds take the lives of 30,000 Americans every year. There is an epidemic of violence and endemic acceptability of violence in our communities with African American and Latino youth suffering a disproportionate amount of gun violence in the United States. Simply providing excellent trauma care is not enough. Programs like CeaseFire/CureViolence in Chicago and Safe Streets in Baltimore are necessary adjuncts to address the underlying root causes of handgun violence. Ensuring safe access to schools, improving educational and earning potential for underprivileged youth, and teaching conflict resolution skills as alternatives to violence are essential to preventing the loss of life that takes such a heavy toll on our disadvantaged communities.

Fear of flying is one of the most common phobias in America, affecting nearly 40 million people. Yet if you ask any group of people if they know someone who has been killed in a commercial aviation crash, almost no one will raise their hand. However, most people have no fear at all of getting behind the wheel of a car, even when intoxicated, though nearly 30% of Americans have lost someone in a motor vehicle crash. However, there are things you can do to make your ride safer, like wearing a seatbelt, which reduces the risk of death for a similar velocity crash by up to 80%. Many researchers have found that people of color are less likely to use a seatbelt; this disparity is completely eliminated in states with primary seatbelt laws. These data suggest that primary prevention can be effective in some cases to decrease racial disparities in health outcomes.

Upshot

So, what does all this mean? I believe that by recognizing the disparities around you, affecting your families, friends, and communities, and by striving consistently to acknowledge and eliminate them, you will be a better clinician and global citizen. Your role may include public health work, competent clinical care, health policy, and/or advocacy. But a holistic worldview, with an understanding of the social determinants of health that affect all of us, is essential to the comprehensive care of your patients.

What health disparities have you witnessed in your community or during your travels? What efforts have you made (or wish to make) to transform the world into a better, healthier place? Leave your comments below!

~~~

Marie Crandall, MD, MPH, FACS is an Associate Professor of Surgery and Preventive Medicine in the Division of Trauma and Critical Care at Northwestern University Feinberg School of Medicine. She is originally from Detroit, MI, a product of Head Start and local public schools. Dr. Crandall obtained a Bachelor’s Degree in Neurobiology from U.C. Berkeley in 1991, and completed her M.D. in 1996 at the Charles R. Drew/U.C.L.A program in Los Angeles. She finished her General Surgery residency at Rush University & Cook County Hospital in 2001, and in 2003, completed a Trauma & Surgical Critical Care Fellowship at Harborview Medical Center in Seattle, WA. During her fellowship, she obtained a Masters in Public Health from the University of Washington. Dr. Crandall performs emergency general and trauma surgery, staffs the SICU, and is an active health services researcher. Dr. Crandall loves travel, triathlons, hiking, and is a passionate animal rights activist; you can follow her on Twitter @vegansurgeon.