After so many years on this path, who was I?
Today is Father's Day, a day that for many is fraught with sadness.
Over the past week in clinic, I have heard from patients with estranged relationships with their fathers, abusive relationships, distant ones. People who have grown apart from their fathers and cannot explain why. People who have lost their fathers and who have unanswered questions. It has been easy to consider this day from a child's perspective. I don't have children of my own, and my own father is such a kind and generous man, so easily balancing unconditional love, tenderness, and steadfast consistency, that it has been hard for me to empathize with men that fail.
But I am lucky to have a job where my empathy is challenged every day. Failing at fatherhood is also the story of many of my patients, especially those suffering from addiction. One young man told me his kid will spend her first father's day without him as he struggles to get sober. The pain on his face almost cracked me open. Sometimes in my work I stumble on a kind of sadness I will never experience, one that pulls at the edges of my heart until my whole world opens up.
I have had fathers who have failed me: the professional fathers of medicine who were supposed to know what was right and apprentice me into their sacred trade. But they let me down. In my days as a student and resident, I was taught that opioids were a clear and easy way to treat nearly every kind of pain. My professional fathers were seduced by this promise, and did not spend enough time questioning its providence. Now my generation of doctors spends at least part of every day trying to correct this terrible mistake. It is difficult to understand how this happened, and even harder to empathize with those who made the mistake.
But I know these physicians. I know that they, like me, were trying to do the right thing for the patients that trusted them. If they were misled, I can be misled too. Understanding this means putting away childish things. It means living with the terrible knowledge that I will hurt someone, even when I think I'm doing the right thing.
Over the past few months, I have tried to understand how physicians could be responsible for the greatest public health threat of my time, and what it means for the future of medicine. I'm proud to share that reflection with you. I have received a lot of wonderful responses, but the one that meant the most to me was a note from a young woman. She told me that my article helped her process the anger she carries for the physician who started her mother on pain medication. To help someone else fill in the edges of their own story is the highest compliment I could be paid.
I hope an honest accounting of our mistakes can be a first step in moving forward. Thank you for reading.
Residency’s long hours, trauma, sleeplessness and social isolation inevitably erode our healthy coping mechanisms. At the same time, there is a powerful culture of fear, stigma and lack of self-care that prevents residents from seeking help. The resources that are in place in residency programs are simply not adequate.
Flu season is upon us, and with it a chance to test out my persuasion skills on a deeply skeptical public.
Consider this recent patient of mine, a young man in college who came in for an ankle sprain. “While you’re here, why not get a flu shot?” I asked.
He looked at me as if I were a car mechanic offering a few more add-ons to his maintenance exam.
“Oh, I don’t believe in that stuff,” he told me, waving his hand in front of his face.
“Well, even if you don’t believe in it, the vaccine works,” I responded.
“Yeah, well, you’re a doctor. You have to believe in vaccines,” he said.
Well, I’ve never felt that I “had to” believe in anything other than science, and I've annoyed most of my colleagues at some point with my skepticism about nearly every medical intervention.
But I've checked, and I can tell you the vaccine works. It's not perfect, but it's among the best forms of protection we have.
If you get the flu vaccine, you are between 50 and 70 percent less likely to get the flu, depending on how well the vaccine matches the current strains of the virus. You are slightly more likely to have soreness or a short fever with the flu shot, but you cannot get the flu from the shot, because it does not contain any live virus.
Serious complications may occur in one out of every 500,000 people. Compare that to the hundreds of thousands of Americans hospitalized for flu each year.
These numbers are great, but they don’t make for a very shareable headline. “You will be significantly less likely to get the flu if you get a vaccine, and complications are exceedingly rare!” is probably not going to light up your feed.
The sweet talk I learned about graphs and risk/benefit ratios in medical school seems frankly ineffective in the face of your friend’s Twitter rant. Appointment after appointment, I've had trouble conveying my enthusiasm to the unconverted.
So after looking into tried-and-true techniques, I no longer ask patients whether they want the flu shot, which could imply that the benefit is unproven or the risks are high.
Instead, I tell them they need it. I now simply say, "We have to do the flu shot before you go." And if they say no, I persist. Researchers find almost half of parents who are initially reluctant to vaccinate say yes when a doctor insists. If they have questions, I'm ready to answer them.
I also am more likely to push if patients are high risk for complications from the flu. When an older man with emphysema said no, I told him, "Your lungs aren't great. I really think you need this." He got the shot.
As for the young college student, where the benefit is smaller, I let it go. Though I did ask him to look at some trustworthy resources. Outside the clinic, we need to help patients navigate information, good and bad.
When it comes to shots, fake news is nothing new. I have been dealing with it for as long as I’ve been seeing patients.
One of my first interactions was with a young girl who was afraid of the HPV vaccine because of an article she had read on Wikipedia. Because I was a medical student and had all the time in the world, I spent 20 minutes convincing her that she should trust her doctor over a crowd-sourced internet article.
But as time goes on, I have less and less precious face time with patients, and more responsibilities in each visit.
The internet, meanwhile, doesn’t seem to be similarly constrained.
I would argue there is hope, however, that doctors can overcome some of these hurdles if we stop ignoring the fake news problem and start fighting it head on.
The most trusted articles on the internet are written by health care providers . And if the majority of our patients are going to spend more time on Facebook than in our office, it’s time to meet them there.
This is the reason I share studies on social media, and it’s the reason I write about my work.
And for those who want to follow doctors on social media, Dr. Wendy Swansongives great advice for parents and Vinny Arora curates medical content. For doctors and other science nerds, Kenny Lin brings a skeptical eye to family medicine studies on Twitter.
So here’s my attempt to invade your social media feed. Suggested tweet: “This doctor gave flu vaccines to her patients. You won’t believe what happened next: They were 50 to 70% less likely to get the flu!”
Dr. Elisabeth Poorman is a clinical instructor at Harvard Medical School and Primary Care doctor in Everett. You can follow her on Twitter @drpoorman.
Originally published on WBUR.
One of my dear doctor friends and (avid football fan) once described preventive medicine as the act of being a “cheerleader for people’s health.” If you’ve ever tried to lead a cheer, though, you know you have to have a clear message and the crowd on your side, or you’ll be shouting into the void.
Early in my time at Everett health center, a young man came to my clinic for a physical exam for college. He was 19, bright, and on the football team. His ankle had been broken twice, his ACL busted. Most disturbingly, he had had several concussions. I thought about what it meant that he would have to live another 70 years with those injuries, and the many more he would accumulate.
”Are you sure you want to keep playing football, given all you’ve been through?”
”Doctor, if I don’t play, I can’t pay for college.”
I signed the form.
To get an education, this young man was putting himself at risk of chronic pain and traumatic brain injury because it was the only path he saw open to him. I prayed he would be benched.
For those who are successful in college, a career in the NFL means the very real possibility of brain damage. One neuropathologist published an article in 2017 that put this in stark relief: of 111 brains of NFL players she examined, 110 had chronic traumatic encephalopathy.
There are some of us who can separate the things we see in clinic more easily from the rest of our lives. It’s never been easy for me, so I will not be watching the Super Bowl.
My friend who had encouraged me to be a cheerleader for medicine is still a huge college football fan, even though she insists her own son will never play the game. Increasingly, football is a game of young men trying to rise out of poverty, watched by people who would never let their own kids play.
This is a longstanding tradition in American life: using the poor, powerless, and racial minorities to do jobs considered too dangerous for the more well off children. It’s easier when we don’t have to see it, but we have been watching concussions in real time for years. We even have a video of all the concussions reported last year:
This kind of movie will become more difficult to make in the future as the league adopts tents for the “privacy of the players.” It will undoubtedly have the effect of sanitizing what we know is an unacceptable level of violence for a recreational game. At least for a time.
The makers of the concussion video stressed that they are not calling for the end of football, but I am. So say it with me: it’s time for America to play a different game.
When my friend was in her fourth year of medical school, she and her boyfriend sat down with their dean to discuss their residency applications. They were entering a “couples’ match” where partners rank programs together in order to end up in the same city.
The match is a nerve-racking and opaque process. Both have since gone on to have successful academic medicine careers, but on that day in the dean’s office, they were nervous. My friend asked the dean for reassurance.
“I’m sure it will all work out,” she recalled the dean saying. “After all, in 20 years your boyfriend will be running his department and someone has to take care of your kids.”
Medicine has long been a career path in the US for women in science, with women entering the field in nearly equal numbers to men for 20 years. But along the way, many women fail to advance and to earn the same recognition and salaries as their male counterparts.
These differences are often framed as “individual failures”, in spite of the robust evidence of gender discrimination. Women are told to advocate for themselves, to be better negotiators, and, in private, not have children if they are going to succeed.
The medical profession must confront this sexism if we are to address why women have double the rates of burnout as male colleagues, and among the highest levels of suicide in the country, at 2.5 to 4 times the rate of the general population.
As a culture and a profession, medicine continues to systematically disadvantage women physicians at every stage of their careers, causing many to leave. As a result, we are losing some of our most talented doctors.
When I decided as a young girl to become the first in my family to go to medical school, the road ahead was daunting, but no more intimidating because of my gender. Since 1992, women have made up at least 40% of medical school students, peaking this year at more than 50%. Back then, many ascribed to a theory of “critical mass” where women would transform a culture created by and for male physicians through numbers alone.
But the top leadership positions in medicine remain predominantly male. Only 15% of department chairs are women, and 16% of medical school deans are female. For the past 10 years, according to an Association of American Medical Colleges report, women in academic medicine have received only 30% of new tenured positions.
If female doctors were on even playing field with their male colleagues, we should have reached parity long ago. As Dr Julie Silver, associate professor at Harvard Medical School, told me: “Medicine should be leading the way” in gender equity. Instead, women are at a disadvantage beginning in medical school.
The most important part of our education involves interacting with patients and winning their trust. If patients do not wish to talk to us because they mistrust women or minorities, this has serious consequences for our education.
According to a survey by Stat News and Medscape, 41% of women in medicine reported a patient making an offensive remark about their gender, compared with 6% of men. About 1 in 5 physicians reported a patient making an offensive remark about their race.
As Dr Huma Farid, a South Asian obstetrician at Beth Israel Deaconess Hospital, explained: “When people look at a white woman, they think she’s a nurse. When they look at me, they think I’m there to collect their tray.” We are rarely given any forum to discuss that doubt or even open bias and discrimination.
Our medical educators are also affected by gender bias. Male medical students are more likely to be labeled as “quick learners” than women, and that gap actually grows through medical training
Dr Vineet Arora, associate professor at the University of Chicago, says that “because we don’t talk about gender bias openly, students may not believe that it exists.” They will therefore interpret their individual failures and successes as due to their hard work and merit alone, ignorant of the ways some students are at an inherent disadvantage because of who they are.
Evaluations in residency also favor men. One study found that at the beginning of the residency, women residents were rated as slightly better on average than their male peers, but by the end of training were on average 3 to 4 months behind their male counterparts.
Differences in residency evaluations have real consequences for physicians’ careers. They affect their selection in competitive fellowships, research awards, and even the licensing process. Nonetheless, I am aware of no systematic effort at any institution to address bias in these evaluations and help evaluators give trainees a fair shake.
Gender also plays into our ability to work with other professionals in the hospital. Dr Andrea Christopher, a physician at the Veterans Affairs Medical Center in Boise, Idaho, noted that in residency nurses were more likely to help her male colleagues, but did not know how to address the discrepancy.
“I would put in orders, and the male residents would put in orders, and theirs would be done and mine would not,” she said. “And a senior nurse came over to me and said: ‘You just have to do your own EKG, set up your own IV, and collect urine, and eventually they’ll notice.’ I was afraid to discuss this with my superiors because I thought if I complained, it would reflect poorly on me.”
Though we rarely address this prejudice head on, studies have found that in simulated cases, nurses were less likely to help women physicians with procedures, and more likely to view women physicians negatively than male physicians for the same mistakes.
Of course, nurses are dealing with their own issues of gender discrimination. Nurses report rates of sexual harassment of around 70%, comparable with rates reported by female physicians. Male nurses are also paid more than female nurses for comparable work, and are more likely to be promoted.
After residency, institutions continue to overlook women physicians’ accomplishments. From the portraits hanging on an institution’s walls to the names of medical societies to the number of women giving lectures, women are consistently under-represented.
Pay is the clearest indication of whom institutions value. One study of academic medical centers found women physicians earn $51,315 less, on average, than their male colleagues. With adjustments for factors such as faculty rank, years in practice and graduation from a top medical school, women still earned $19,878 less. This salary gap appears to be widening.
Many have asked women to become better negotiators to overcome this disparity in pay, but this discrimination is an institutional choice, and institutions have to be responsible for solving it.
Dr Jen Gunter, a San Francisco based obstetrician gynecologist, left academic medicine in part because of persistent gender discrimination that she faced in her career. After years working at a Midwestern institution, she found out that her male colleagues were “making more money for doing less work.” When she spoke with administrators, they told her that the men “had families to support and she didn’t.”
Later, at a different institution, she had a complicated triplet pregnancy with her children requiring medical care in the ICU. “I was the primary breadwinner,” she said in an interview, “but my children needed a mom and a doctor.” She found herself overwhelmed by her family responsibilities as she was applying for tenure, and under-supported by her institution.
Though she had spent her entire career in academics and had four different board certifications (when most physicians have one), when she asked for help she was told “maybe academics are just not for you.”
Reproductive choices weigh heavily on women physicians, who face opaque, inflexible and generally abysmal maternity leave policies. These policies range from 12 weeks of paid leave to only 6 weeks of federally mandated partial pay for new mothers, to no separate maternity leave for trainees. Nearly one in threephysician mothers reported experiencing discrimination because of pregnancy or breastfeeding. Many have trouble following the same recommendations they give to new mothers because of these policies.
More open forms of sexism and sexual harassment are rampant in this profession. Many were afraid to go on the record, but a few women did agree to speak about harassment they had experienced.
Dr Meredithe McNamara, a pediatrician at the University of Chicago, told me that in medical school, a surgical fellow told her to “get on your knees and suck my dick” during a surgical case when she couldn’t answer his question. She was asked to write up the incident when the rotation ended, but did not, in part because none of the other half dozen people in the room reported it.
Dr Sarah Candler, an assistant professor at Baylor College of Medicine, told me a prominent colleague groped her during a dinner at a leadership conference. She tried to get the help of a male peer who remained oblivious. He continued to touch her bottom until she got away, and apologized the next day “if he did anything wrong.” “I didn’t even know who to report it to,” she told me.
Gunter had a similar experience at a different national leadership meeting.” A few years ago, a very prominent person in academics, at a medical conference, I could not get his hands off of me,” she said. “Literally, I’m peeling his hands off of me. I asked two male colleagues for help, and they said, ‘What should we do? We can’t control him.’”
Sexism can be overcome, but it must happen at an institutional level. All of these issues of discrimination, from sexual harassment to paltry maternity leave policies to salary discrepancies are an institutional choice. Leaders who make a concerted effort to combat gender discrimination can advance women, and in the process, retain the widest pool of talent in their organization
Discrimination, from sexual harassment to paltry and penalising maternity leave policies to salary discrepancies are institutional decisions which institutions are responsible for changing.
Female medical leaders like Silver and Dr Lauren Thorndyke at the University of Massachusetts Medical School are tackling discrimination by promoting and mentoring women and minorities. Their efforts are more effective when they are explicitly supported by their institutions. At Massachusetts Medical School, for example, women now make up 26% of the faculty, compared to 17% at Harvard Medical School.
Like other professions, we need to address sexual harassment head on and not place the burden on victims to speak out. We need policies to promote and pay women and minorities so that we can continue to benefit from their talent and professional dedication.
Think of the patients that we could treat, the diseases we could cure, the innovations in our dysfunctional healthcare system women could innovate if institutions stopped thwarting our talents.
- Elisabeth Poorman is a primary care doctor in Everett, Massachusetts and a clinical instructor at Harvard Medical School.She is on twitter at @drpoorman
Originally published in the Guardian.
I started writing this article a few months ago with a simple question: why were there so few women in top positions of academic medicine when we have had near gender parity in medical school for decades? As I was asking this question, many of my female friends talked about being passed over for promotions, cutting back their hours because they needed more flexibility for their families, navigating gendered criticisms from trainees and peers, and facing pathetic maternity leave policies that are in direct contradiction to what we know about the medical facts of childbirth. The future of medicine was supposed to be female, but this is not the reality I see playing out.
At the same time, the #metoo movement caused me to question incidents of harassment I had dismissed or absorbed in school and residency that, in retrospect, were deeply unacceptable and sometimes wounding. I wonder how much these experiences shape our willingness to accept the de facto discrimination that shapes the trajectory of our careers.
I spoke first with Dr. Julie Silver, a leader at Harvard Medical School who has been a prominent advocate for women in medicine. She pointed me in the direction of clear scholarship on gender and race disparities in how we evaluate and promote or colleagues.
After speaking with her and many other leaders in medicine, as well as many peers, I realized that institutions can choose to actively promote women or minorities, or continue to lose their contributions. Unfortunately, many, like Harvard Medical School where I work, are generally choosing to do very little.
In the piece, Dr. Jen Gunter’s alleged aggressor is not named. I am not an investigative reporter, and unfortunately do not have the time or expertise to look into this incident. You can read her account on her blog. I contacted her alleged aggressor, Dr. Khan. He denied these claims in an email to me and directed me to a blog post titled "I was NOT groped by the editor of an OB/GYN medical journal. And I’m not the only one." It was, he told me, written by a woman he said "came forward spontaneously."
In spite of clear evidence of the role gender and racial discrimination plays in medical training and practice, I rarely hear it discussed with any real seriousness or actionable guidance. How should we evaluate our peers, students, and attendings knowing that we consistently rank the achievements of white men more highly and punish women and minorities more harshly for the same mistakes? We have failed to address this in spite of the fact that minority physicians are more likely to serve the underserved, and growing evidence that women have similar if not better clinical outcomes. We should be doing what we can to recruit, retain, and promote a diverse workforce for the sake of our patients, and our population, which needs diverse physicians to ask a wide breadth of questions about medicine and policy. But it seems our attempts are anemic at best, and lip service at worse.
Let’s hold our institutions accountable. Ask them to print salaries and examine them for disparities. Let's look at our evaluations of each other and help one another identify and combat our biases. Let's create real maternity leave which will allow women to heal and care for their children in the way that we, of all professions, know that they should have the opportunity to do. We can’t keep asking individuals to overcome this persistent discrimination by themselves. We have too much to lose.
There has been so much written and discussed about sexual discrimination in recent months, but here are some pieces that framed my thinking.
Lupita Nyongo‘s account of being targeted by Harvey Weinstein is an incredible account of not only what happened between them, but the hundreds of calculations women make when they are targeted by a man in a position of power, before, during, and after a violation takes place.
Who would believe a trainee?
”Who would believe a trainee over a tenured professor? Would he retaliate? How would this affect the rest of my training?“ Dr. Maria Yang describes the kind of harassment that many might dismiss as insignificant, but within the context of the intense hierarchy of medical training is deeply troubling, endangering her career and her ability to care for patients.
“Nytimes The Daily” podcast on harassment at the Ford Motor Company reminds us that we have been here before, and haven’t come that far. It’s heartbreaking in the best way.
Rebecca Traister writes that “This Moment Isn’t (Just) About Sex. It’s Really About Work.”
Gabrielle Union, who wrote about being raped by a stranger and how it continued to affect her life, interviewed on the podcast Death Sex and Money, speaks about how she moved forward with greater empathy and purpose.
Thank you again for reading my work. I’m incredibly proud of this article and the chance to share it with you.
Dr. Elisabeth Poorman is a physician in Everett, Massachusetts. She traveled to Puerto Rico in November to support Project HOPE’s emergency response to Hurricane Maria.
Over the past few months, I felt the worst kind of déjà vu: hearing reports about Puerto Rico and remembering the devastation to my father's home town, New Orleans, which was devastated 12 years ago by Hurricane Katrina, and still bears its own scars.
Tired of bad news, I found myself googling volunteer opportunities, and left for a ten day medical mission with Project HOPE in Puerto Rico.
Weeks after the hurricane, over 90 percent of the island did not have power. By the time I arrived, the situation had improved dramatically, but unevenly. In some places, it was like nothing had happened. The mall in Ponce was up and running, indistinguishable from any other mall in America with a large Christmas display. Then a block later all the lights would be out. Up in the mountains, many were still gathering water in buckets to drink.
Everywhere we went, there were humanitarian groups, civil servants, and ordinary Puerto Rican citizens keeping calm and carrying on. The physicians, nurses, and other health care workers were working valiantly, and family members were extending themselves to take care of the most vulnerable.
On my last day in Puerto Rico, I traveled with Orlinda, a nurse who has spent her retirement going on trips like these, to visit patients who were unable to leave their homes. We were accompanied by two men from a church down the road who had a list of the 120 neediest patients.
I knew I would only be able to see a few before it got dark, and I was already exhausted, having seen 90 people with another doctor at a health fair in a soccer stadium that morning.
When we first got out of the car, I thought it was a mistake. The house was beautiful. The hostess was well-dressed with every hair in place. She could be 80, but looked timeless thanks to her immaculate appearance, straight posture and easy smile. “Aquí está el paciente,” she said, as she wound her way through darkened rooms.
It was cool, even though they didn’t have power like the rest of the neighborhood. A storm earlier in the day had cut into the heat, but also made the roads harder to pass. I noticed mud on my shoes as we stepped across her scrupulously clean floors.
In one room there was an old man at the end of his life, lying flat in a hospital bed which did not have power to help lift him up. “My husband,” the woman said, “had cancer and is very sick.”
His limbs were contracted and covered with a fresh blanket. His cheeks were sunken and his eyes were far away. He seemed overwhelmed by the commotion but didn't say anything. He turned away and faced the wall.
His wife rattled off his accomplishments and ailments, weaving them together as if all episodes of his life were happening at once.
She showed me a picture of her husband, a veteran, from the days before he shipped to Korea. He was a handsome man. In the photo, he had a look of optimism that reminded me of my grandfather’s Navy photos when he was just a boy in a uniform, and didn’t know what awaited him on the other side of the world. My own grandfather had died peacefully, having served his country and his family, his pain eased tenderly by the most compassionate caregivers.
This man was in pain. He hadn’t moved his bowels in days. He was refusing most food. I asked if he had been out of bed recently. “The nurse is gone, we can’t get him out,” his wife said. “She left before the storm and she hasn’t been back. We’re waiting.”
She couldn’t lift him out, and her grandson who came to help had fractured his leg. Somehow she had managed to take care of her husband, but she was petite and elderly herself, sharp of mind, but incredibly vulnerable.
I got on my knees to try to talk to her husband. He responded very little. I took his hand.
“Are you in pain?” I asked. He shook his head no. “Can I examine you?” He nodded. I removed the blanket piece by piece, careful to keep him covered. He had been well-cared for in spite of everything, his skin clean and intact. His lungs were clear, his belly was flat and soft.
Finally, he met my eyes and I said, “Sir, it seems to me you are doing well, but being stuck in the bed, for an active man like you, is very hard. And you seem a little depressed?” He nodded, almost imperceptibly.
“Would you like to go outside more?”
As soon as I finished the question he grasped both my hands, pulled his shoulders off the bed, his face almost touching mine, and blew air hard to say “Sí!”
I turned to his wife and we tried to brainstorm. She only had a few family members near. Her church hadn’t visited. They are waiting for the nurse, but there was no telling if the nurse would ever come back. Outside I asked the men from the church to try to visit and help him get out of bed at least once a week.
When patients are at the end of their life, it is an opportunity to step back from the day-to-day accounting, to take stock of their lives, to try to let them know that they are loved, and attend to their most pressing needs. In disasters, too, we have a chance to step back, to think about what happened and how we can do better next time, to consider what would make an effective meaningful response to future tragedies.
I told the man's wife over and over how remarkable she was, what a beautiful job she had done taking care of her husband.
We looked at the bottles by the bed. I clarified which medicines she could give more of, and which she should cut back on. We also talked about how he could eat what he wanted and refuse what he didn’t at this stage.
I thanked her for her hospitality. I wrapped my hands around the patient again. I thanked him for his service. He mouths “gracias.” I’m grateful to have been let in.
Their resilience pushed me forward to the next house.
To donate or volunteer with Project Hope, check out Project Hope
At the heart of what is wrong in American health care is a failure of physicians to participate in the conversation about what medicine is really like.