Subliminal Sexism in Medicine

For the most part, the sexism in medicine is not subliminal at all.  It’s quite overt.  However, unless you’re a female physician, you probably are unaware that it’s still an ever-present reality for us.  I do want to note that there are very good men out there who are trying their best to be advocates for equality in our field even though they can not fully appreciate the female physician plight.  My father is one.  My husband, an Anesthesiologist, is one.  The male physician-entrepreneur I met with last week to discuss a partnership in my new solo practice with his clinic system is one.  These men are the “He’s for She’s” of medicine.  And yet, the hurdles are massive even once we women have finally made it to attending status.

Examples of overt sexism abound.  As this article notes, the pay discrepancy for the exact same job and hours worked is blatant (>$100,000 difference).  Physicians in specialties such as ER and Anesthesia may not appreciate this, as their shifts might be salaried per hour.  However in fields that require a lot of non face-to-face patient care and fields which weigh “productivity” aka patient face-to-face volume and turnover heavily in the pay, women are often paid significantly less.  I’d contend it’s because in many non-procedural fields females more often take the time necessary for patients despite the sacrifice to their productivity earnings.  We women, frankly, tend to care more about the patient than our paycheck.  And yes, there is evidence to back this up.  A Harvard study released in JAMA this year showed conclusively that elderly patients admitted to the hospital had lower death rates and readmission rates when treated by female internists compared to their male counterparts.  While the numbers are overt, the subliminal sexism is written into the RVU methods of physician reimbursement.  Those who care enough to take the time to do the job well inevitably get punished financially.

Let’s forget about numbers.  There is overt sexism we women experience daily in how we are addressed and spoken to.  Frankly, a man would never tolerate without a complete fit the words and tones I have had to take from coworkers, bosses, and patients alike.  Last week I had a meeting with a hospital system in my town who has been trying to get me to agree to work for them for months without retainer.  We finally met and I told them about starting my own solo-practice instead of employment, but also to discuss how I’d be happy to assist with medical directorship for their SNFist program and inpatient Geriatric care improvements.  The female care manager told me how she didn’t think what I could offer was necessary from a physician and the male physician said,”I just don’t think you’re going to get anyone to pay for your care out of pocket when it’s something medicare covers” (I’m opting out of medicare).  I don’t think they’re aware of how this came off.  What they were trying to communicate is that they aren’t looking for a medical director at this time and they are concerned for my financial viability solo.  That’s what they would have said to me if I were a man.  Never would they have insinuated that my expertise as a physician and Geriatrician, something unique to this community, were not wanted or needed (it actually very much is), or that my care was comparable to the the care provided by the non-physician providers who go to the nursing homes and assisted living facilities here (it’s not comparable, my care is better because I am trained at a much higher level to care for this vulnerable population).  No, Medicare doesn’t actually cover the quality of care I provide.  So this is blatant.  This kind of thing also happens routinely to female physicians of every specialty.

Let’s get to the truly subliminal content.

My husband opened my American Academy of Family Physicians CME advertisement in the mail and brought to my attention the fascinating pictures.  Here are 6 of the 8 pictures, including all of the pictures featuring women.

I guess I don’t know if these truly are subliminal because it was my husband who pointed out to me how sexist this seemed.  He’s not one to catch subtlety.  The pamphlet has a ratio of men to women pics of 6:2.  So the numbers already don’t reflect the reality of family medicine.  However, in the entire pamphlet, there are only pictures showing men as smiling, engaging physicians/leaders/teachers.  The women pictured are either facing away or with an expression that says, “I am a passive recipient, incapable of worthwhile thoughts of my own or engaging discussion.”  Then there is the woman staring at the painful computer CME module with the pen in her mouth.  Is she a secretary enthralled by data entry?  Why is there not a single picture that depicts a woman physician smiling, engaged, like someone you would want to talk with, or care for you, or capable of teaching you?  And this is not a testosterone driven surgical specialty.  This is family medicine people!  Where women are actually more prevalent in the field!  Also, it’s not like the pictures are showcasing the keynote speakers (although that is something that is also far too male-dominated).  It’s advertising how the AAFP envisions its audience.  Even the AAFP does not view women as equally capable of being physicians, leaders, and teachers.  Their marketing tells us so.

Still today in medicine, even in the fields full of women, the message sent is that men lead in education, discussion, and patient care.  But truly, it’s the women making the most impact in time-based fields and giving our heart and souls to do so.  We are just as capable, just as engaging, and it’s time to demand that our fields recognize this before we continue to break our backs in the trenches.

 

 

“Sorry, I Ain’t Sorry”

At first listen, Beyonce’s Lemonade album seems to purely be about her, and her relationship with herself and her husband.  However, as I’ve had it literally on replay for the last week in the midst of facing a major Professional decision, I can’t help but feel it’s so much more for women.  For me, it can help me find the confidence, self-love and inner strength to know that I really don’t need a man, or an organization run by men, to be successful and to do what only I can do.

I am still in the midst of the decision.  Do I accept an employed job as the only Geriatrician in an entire hospital system run  on a fundamentally corrupt physician payment model and subsequently poor patient care model just for the salary?  Or, do I do what I know will make me most happy and opt-out of Medicare and start my own practice doing medicine my way (the right way……where I spend time with patients and families, listen, counsel, diagnose, and walk with) despite the likely low financial return?  If anyone’s reading this, they’re probably thinking, “This seems obvious…….do what will make you happy, go for option number 2.”  I wish it were that simple.

I am a female caregiver through and through.  I became a wife and mother right as I became a physician.  I am terrible at putting myself first, even when it’s essential.  Part of taking care of oneself is knowing how to and when to avoid abusive relationships.  It’s from learning from our past mistakes.  Whether it’s with spouses, friends, employers, businesses, or any type of relationship, knowing one’s strengths and failings is crucial.  Often it takes making the mistakes first to learn our own strengths and weaknesses.

My strengths are these.  I’m smart, and also extremely caring.  I empathize truly and deeply.  I do feel the pain of my patients and their families, and the joys too.  I’ve been a patient also, so I don’t have to work too hard to put myself in the shoes of my patients.  I’m honest and transparent.  Authentic perhaps?  I can’t lie, nor can I fake things.  This leads me to my weaknesses:  I am incapable of being “political”.  If I see something that isn’t right, I can’t keep my mouth shut to save-face for someone else.  When I try, I become testy.  I don’t suffer foolishness among colleagues well at all.  I will fight for my patients and doing what is right for them at all costs…….usually at the cost of reimbursements from Medicare.  I am intensely bothered by the difference in how female physicians (myself included) and male physicians are treated by those we care for, work with and among, and are employed by.  And I am unlikely to get over that.

Where is this exercise going and why is Beyonce’s “Sorry” the current song-de-jour on repeat?  Despite the above, I still have this nagging voice telling me I should take the job with the hospital system.  It’s the voice of fear, of feeling bad for saying no to them, of repeated patterns of delving into a relationship for security and not for what is right for me, and of the problematic thinking on my part that constant self-sacrifice is a good thing.  Here is what I know.  The job will not make me happy.  It would allow me to stay in Medicare, but in a very toxic practice environment.  It won’t afford me the flexibility I want to be the best mom and doctor I can be.  I know I’m unlikely to last in that environment as I can’t keep my mouth shut about things that are wrong but I also don’t like pissing off all my colleagues.  I don’t like that kind of competition.  For a geriatrician, opting out of medicare is such a huge deal.  Telling my future patients that I won’t take their free insurance (because Medicare is a narcissistic regulator of physicians) is scary, even when it allows me to give them better quality of care.

So, I have been gearing myself up for the moment when I finally make the right choice for me.  This hospital system has been literally leading me on for months now.  They are apparently finally going to show me the proposed contract and letter of intent soon.  And I want to be ready to do what is right for me.  I don’t want to close any doors prematurely, so I’m waiting to see the contract before I do anything definitive.  However, based on their behavior thus far (poor communication, asking me to wait on them without any guarantees or retainers, clear resistance from other physicians I’d be working with), I have no reason to believe that this is a group or organization I want to be part of, particularly when I’d be one of the only female physicians doing what they’re asking me to do.  Just like people, organizations don’t change unless they see the need for it and seek it out themselves.  Medicare and many of the businesses of healthcare are indeed narcissistic.  While many good people work for and within them, the overall company culture is one that is incapable of empathizing with those who work for it while simultaneously being hyper-sensitive and reactionary due to a fragile sense of self (or lack of any true mission beyond money making).  These are the kind of relationships that are so trying.

I don’t know if I’m ready yet.  However, it’s not a matter of if, just when.  And when I finally am ready, I will serenade Medicare with Beyonce’s words, “Sorry, I ain’t sorry…….middle fingers up, put em hands hi.  Wave em in his face, tell him boy bye……I don’t feel bad about it, it’s exactly what you get, stop interrupting my grinding.”  Instead of a boy, it’s Medicare in my mind, and the health systems.  And my “grinding” is my doctoring.  Because I am one bad-ass physician, and just about every patient I’ve ever had will tell you that.  Medicare, regulators, politics and those who just care more about the Benjamins have been interrupting my doctoring…..and I’m sick of it.  And I ain’t sorry when I finally leave them.

 

An Open Letter to my “Pro-Choice” Friends

To my pro-choice friends, and anyone willing to read, Post-March day 3,

I am one of the women who considers herself a feminist, maybe not in the typical sense, but a feminist nonetheless who was made to feel like I didn’t have a place at the Women’s march.  Admittedly, I am super sensitive to exclusive behavior.  I don’t know if it’s because I was bullied as a kid or what, but nothing irks me more than when a group that I feel connected with (like the group that purports to speak on behalf of my ENTIRE gender) excludes me or anyone really.  Maybe that’s why I’m an Independent and don’t subscribe to labels such as liberal or conservative or parties such as Democrat or Republican (it’s super inconvenient and lonely in our bipartisan system).  I confess, I didn’t actually go to the DC March or the one in my hometown (more due to logistics of my son’s over-packed Saturday schedule than hurt feelings).  But had I felt welcome, I would have prioritized the march over consecutive 7 year old birthday parties on Sat Jan 21, 2017 because I am an ardent supporter of human-rights, better treatment of all women everywhere, immigration, equality for the LGBT community under the law, separation of church and state, basic healthcare (including contraception) for everyone who needs it, Black Lives Matter, opposing dictatorial leaders such as Trump from gaining unbridled power and really all social justice issues.  The Women’s March official website, under their “Unity Principles” tab, states, “We do not accept any federal, state or local rollbacks, cuts or restrictions on our ability to access quality reproductive healthcare services, birth control, HIV/AIDS care and prevention, or medically accurate sexuality education. This means open access to safe, legal, affordable abortion and birth control for all people, regardless of income, location or education.”  Frankly though, I am big enough to let that slide because with the exception of the abortion bit, I am on board with all of it, including access to reproductive healthcare services and prevention such as birth control.  I’m a devout Catholic family physician who has never used contraception personally.  But that’s a personal choice enlightened by my faith and allowable due to my privilege of being white and having an extremely supportive and intact family and high education status (I’m a medical doctor).  What really tipped me over into feeling unwelcome was when a Pro-Life secular group called New Wave Feminists were taken down from the Partner’s page of the website with this message from the organizers: “The Women’s March’s platform is pro-choice and that has been our stance from day one. We want to assure all of our partners, as well as participants, that we are pro-choice as clearly stated in our Unity Principles. We look forward to marching on behalf of individuals who share the view that women deserve the right to make their own reproductive decisions. The anti-choice organization in question is not a partner of the Women’s March on Washington. We apologize for this error.

Here’s the thing.  I have so many amazing friends who are inclusive, amazing people, pro-choice and despite knowing my views on abortion would have made me feel so darn welcome because they know damn well what I stand for and that it’s for them and all women and humanity and essentially relieving suffering wherever I can in my imperfect but genuine way.  On the other side, I am an avid reader who believes in going to primary sources, thinking critically and accepting facts that are indeed facts (and not alternative facts).  The facts are this.  The primary page for the Women’s March and organizers made it VERY clear in the above statement to all of their partners and participants that they are only “marching on behalf of individuals who share the view that women deserve the right to make their own reproductive decisions  [which they clearly define abortion as a reproductive decision]”   There is another kicker in all of this, one that actually hurt me more than the exclusionary statements from the official organizers.  On the Mission Statement page, they say “In the spirit of democracy and honoring the champions of human rights, dignity, and justice who have come before us, we join in diversity to show our presence in numbers too great to ignore.”  It’s beautiful and I thought it was speaking to me.  They also have a quote from Audre Lorde stating “It is not our differences that divide us. It is our inability to recognize, accept, and celebrate those differences.”  Silly me. I thought after reading those beautiful quotes that the March was about all women everywhere who work to bring women up, not just the ones who believe that access to abortion an essential part of that.  And yes, it was far more than the organizers that finally led to this “open letter”.  After the march, I saw some very encouraging Facebook posts from the day that were focused on all the other issues other than abortion that people were about at the March, and I was happy and grateful.  Sadly, it took a turn for the worse.  I saw the few like-minded to me people hint at their frustration with feeling excluded and the barrage of exclusionary comments that essentially reduce all things women down to being for or against access to abortion.  Women stating, “If you aren’t for women having the right to chose what to do with their bodies, then you shouldn’t be at a women’s rights march.”  There was the friend who asked if I was going to the March, and when I confided that I didn’t feel totally comfortable because it seemed more about being pro-access to abortion than all the other social justice issues I fight for, her response was, “If you don’t like abortion, don’t have one.”  I could go on, there were many many more posts and comments clearly making it about abortion.

While I am so grateful to my friends and those who were inclusionary, the overall message from the group’s organizers and the many comments suggesting that if I wasn’t gung-ho for more access to abortion that I really didn’t have a place hurt.  It lacked love, compassion and an open-mindedness to a diversity of thought.  I saw an awesome interview from VP Joe Biden in which he noted a lesson he learned that to not attack motives, but to attack judgement.  Well, I feel like my motives have been attacked.  I’ve been straight up told that if I’m not pro-access to abortion that I am somehow not for women’s rights and even better choices for women.  And it’s just not true.  Moreover, it was even more heart-wrenching because I have already received enough flack from my faith community for voting for Hilary (due to her pro-access to abortion stance).  My old Parish Priest and I thought personal friend replied to an article I posted on Facebook entitled “Thanks to Trump, We Can Better Understand How Hitler was Possible” stating, “…..We are called to be a  faithful Catholic citizen and vote with our church, not against her.”  My response was this, “First and foremost our Church urges me to form my conscience and vote based on what I know is right. There is a separation of Church and Sate in this country (or at least there was) that is in our constitution and equally important as the 2nd Amendment. I didn’t know the Church took sides in American Politics………if it did where is Pope Francis’ comment?”  Needless to say we are suddenly no longer facebook friends (not my doing) and I am lonely and tired of being made to feel like I don’t have a place within my Church, a political party, a social group, my entire Gender’s cause, my profession, etc because my views don’t consistently align with “liberal” or “conservative” labeling and exclusionary rhetoric.

So, now that I’ve expressed why I’m hurt, here’s who I am and what I’m about.  I’ll let you decide if you think I should be made to feel welcome at a Women’s Rights March.  I’m first and foremost a woman.  I am Pro All-Life.  I am imperfect.  I am Catholic because I believe the teachings of my Church to be the best way for me to find God and be the best I can be. I also realize my Catholic faith is made up of many imperfect humans just like me and it takes a lot out of me to not let the hurt that people have caused in the name of the Catholic Church to shadow the actual message of my Faith.  I recognize my privilege in being lucky enough to be born to an amazing supportive white family with a strong emphasis on education and knowing my own self worth.  I also am a Family physician/Geriatrician, and I became a mother at the most inconvenient time relative to my profession in 4th year of medical school while married to another 4th year medical student.   Despite having an awesome family, they didn’t always have money and I had to rely on medicaid to have access to essential prenatal, maternity and childcare.  I can’t imagine what I would have done had I not qualified for medicaid but also couldn’t afford healthcare.  Personally and professionally I know how crucial access to basic healthcare and education are for true freedom and opportunity.  In practicing family medicine, I have listened, felt the pain of, suffered with and felt the injustices of our society of hundreds of women of all socioeconomic backgrounds, races, religions, ages and creeds.  I have felt powerless when I hear my female patients or even friends tell me stories of how they define their worth based on what a man thinks, or they were made to feel objectified or less than, or when they told me they had an abortion because they couldn’t support a child on their own.  It breaks my heart because after what I have done, worked for and been through, I know that in our society women can’t have it all, but we certainly can do it all, and we do so while creating life with our own bodies.  I also know that this is a very threatening prospect to men with big egos and many insecurities.  As a mother, I know the miracle that I created.  I also have been infertile since my one and only and know the pain that comes with not being able to create life as I once did and the frustration with how difficult and costly adoption is.  As a physician, I know the difference between disease processes, natural physiology, and when the two play a dangerous dance.  I know well what it’s like to be stereotyped based on my looks, gender, or religion or to have very un-me things assumed falsely about me.  As a scholar, I know that semantics and definitions matter and should only be narrow if highly specific.  I know that the term “pro-choice” tries to paint a broad stroke where it shouldn’t.  Technically, reproductive health care is a misnomer if it includes abortion.  If one is already pregnant, then they have technically already reproduced, and abortion should not be clumped in with reproductive health care as abortion has nothing to do with reproduction (as it already took place).  It’s reasonable semantically to include both contraception and fertility treatments in the term reproductive health care, and also preventative care.  Also, when a “choice” is made out of fear, or desperation, or any negative unloving constructs that our society has forced upon women than it is not really a choice at all.  Lastly I am a Geriatrician.  I am the most needed and yet most taken for granted type of doctor there is in America.  Despite this, I never stop fighting for my patients, loving them, caring for them, taking the time despite not getting paid for it to do the right thing.  I’m not only a Geriatrician because the type of medicine suits me.  It’s also because I know that every patient that I help through old age is a patient that likely died or will die with dignity towards the inevitable end of their natural life (while simultaneously not costing our tax payers millions that could be otherwise spent on younger future generations in non-curative and futile medical treatments).   I do not fit into a stereotype.  But I thought I fit into the category of a woman fighting for Women’s Rights in the best way I can with the tools and gifts I was born with……until the organizers of the Women’s March told me I didn’t and many women reinforced that.

So, now that you know me, what do you think?  Did I belong at the March for Women, possibly the only gathering of its size ever without any violent incidents (probably because it was organized for and by women)?  If you think its purpose was inclusive of women like me, then please let the organizers know.  I appreciate the apologies for having my feelings hurt by being excluded, but that’s not enough.  If we (women) really want to bring all women up, we need to be open to anyone willing to fight that cause in whatever form and we must make it clear we’re open.  We can’t state our mission as inclusion and diversity but then explicitly exclude anyone who has a diverse thought other than our own as to the means to achieving the shared mission of the cause.  It’s by making women with loving motives and good intentions feel like we aren’t pro-woman that we fragment ourselves.  Every pro-life, anti-abortion woman I have ever met not only takes the stance at the defense of the unborn life (or other body we don’t seem to want to acknowledge) but also because she truly and at her loving core believes that abortion is not good for women and overall hurts women everywhere.  And we have to be honest with ourselves.  It’s an amazing and powerful thing to be able to grow a human life inside you.  When society is constructed in a way that makes women believe their greatest physiologic power (and essential for the future of our human race) is an inconvenience, then it’s a tragedy committed towards women and our future children and the society that must change.  There are many women fighting for those necessary changes while still being pro-life.   When we fragment ourselves, we hurt our unity and we hurt ourselves, and then people like Donald Trump get elected.  Not every pro-life woman with good intentions is as experienced with diversity, as objective in their news and fact sources, and as knowledgeable about our Constitution and politics as I am.  If we are honest with ourselves, this election result was as much about the disenfranchised white rural person as it was about the pro-life religious right feeling the wrath of liberal intolerance and having no other way of getting their voice heard than to vote for an objectively anti most life other than rich white men and persons who can give him power based on the single issue of abortion.  I had this inkling on November 10th, along with an awful sinking in my stomach of the horrific reality of what was to (and now has) come.  I had so desperately hoped the Women’s March would help heal and prove me wrong.  Instead, the Organizer’s went out of their way to exclude pro-life women, and thus proved me right.  I won’t pretend, I like being right, but not always.  It was not even bittersweet.  It just made the hurt more, like my faith in women and people was crushed even further than it already was this year.  It was just a bitter and awful kind of right.

My hope now is that my pro-choice friends, all of them, will be open-minded enough to read this open letter.  After that, I hope and pray that we, women and men for women, will not make this mistake again.  If we are about all women and diversity and inclusion, don’t allow those who speak on behalf and for the entire cause to alienate a not insignificant number of women who are fighting for women’s rights too.  There’s a multitude of issues, for better or worse, that all contribute to equality, dignity, justice, and women’s rights.  Do you really need to constantly talk about your stance on more access to abortion as a means to find common ground with me?  Cuz right now that’s what it feels and sounds like……and it certainly is not building any bridges where we can meet in the middle.

Inspiration for this post came from www.Icantkeepquiet.org/thesong/ and I hope they’ll have me despite my pro-life stance.  Also, if you prefer more scholarly and eloquent writing, here’s another “open letter” https://www.firstthings.com/web-exclusives/2017/01/an-open-letter-to-my-liberal-friends.