Why women in surgery need other women in surgery - #thisiswhatwelooklike and #ilooklikeasurgeon

I recently spoke at another university 'Women in Medicine' night. I find these events both enjoyable and educational. It's a great opportunity to meet colleagues and other young women who are studying to become doctors and try and inspire and instruct some students (both male and female) into what I hope will be fulfilling and productive careers.

But every time I get ready for one of these talks, two things go through my head. The first being that I have no idea what they really want to hear. I had some very good advice that they just want to see that we women surgeons are real and that it can be done. (Turns out that is true) The other thought I have is how relevant is this anymore? After all, over half of medical students in a number of universities now are female. And then...

Whilst waiting to talk to a patient on the phone "Hang on, the nurse is here to see me" (after seeing them every day for a week and doing the surgery)

From a male physician "Women should just work harder to make up the pay gap. And because they have time off for children."

From a colleague involved in conflict resolution, man (and recent) cases of women in distress due to discrimination in the workplace, resulting in illness or leaving the profession.

Let's be honest. In my country, I won't be injured or killed for walking down the street with a man who is not my husband. I can drive, I can vote, I can be educated and I can be gainfully employed. When you look at things that way, I am very fortunate. However, this does not mean that we don't have some problems with the way our society views and sometimes treats professional women. Whether it be medicine, corporations, politics, law, trades or engineering, women are by and large, a minority group. Which means that for younger women wanting to join the ranks of the patriarchy, finding someone to identify with is pretty difficult. And we know that gender plays an important role in mentoring in medicine.

As a junior doctor, my mentors were male doctors. They were and still are, excellent mentors and I am very appreciative of their guidance. In fact, on several occasions, they were insightful and sensitive enough to make sure that I was aware that some unique challenges may face me in my career and made sure that I was equipped to think them through as part of my career and life planning. Sometimes though, I really wanted to know how that actually played out for someone like me. I was very resolved to the fact that I was to some extent going to have to carve out my own path in life. And I have been okay with that.

There is some research around that by and large supports the availability of women mentors for young women doctors and medical students. Gender matching can have a very positive influence on a mentor-mentee relationship with the 'mentee' being more comfortable to seek out advice from a mentor of the same gender without worrying that gender will colour the perception of the question or the advice itself. What it may boil down to is as simple as my talks for women in medicine nights. We just want to see that it can be done and learn from a mentor's journey.

Finding a female mentor, in surgery especially, can be tricky. Finding any mentor can be tricky. It is a relationship like any other, where both party needs to be satisfied with in order to work. When we have a lack of women on a a sheer numbers basis, finding a gender equal you identify with can be really hard!

Social media has been awash in the last few months with campaigns and hashtags such as #thisiswhatwelook like, a campaign created by an anaethetist and a philosopher to challenge societal and professional ideals of what professional people look like. It's extended to virtually every profession and skill you can think of; CEO, drummer, programmer, lawyer and surgeons. I got on board pretty early with my 'This is what a surgeon looks like' t-shirt and it's been great fun to be a part of. Recently, engineers joined in with a hashtag #ilooklikeanengineer when a young woman apparently was not considered to be what we would consider 'looking like an engineer' and has crossed professional lines to surgeons with #ilooklikeasurgeon now trending. And I love it. Being a part of this feel inclusive, inspiring and just fun. In the last few months, I've chatted with women surgeons around the world about surgery and not about surgery. But by and large, it's been about positive change and positive role models. It's about changing perceptions and expectations and encouraging young women into a profession that we all love.

   Every time I talk about being a woman in surgery, I want to achieve a few things. Firstly, I want to show people that I have a cool job and inspire others to maybe try it out. I love when a junior doctor (male or female) tells me they've loved cardiac surgery and now they want to do it. Secondly, I want to share that you absolutely do not have to be a certain race, gender, personality, sports fan or other group to be a surgeon. In fact, diversifying our specialty to involve women, for example, is a fantastic thing. Every different person has something unique to bring to the table and we should encourage that enrichment. And finally, I want to show the world that I don't have to be a stereotype to be a surgeon. Because I am a surgeon and this is what I look like.

 

Mentors can certainly mentor across gender and racial boundaries. But let's be real, in a world where people can still discriminate or belittle or neglect you like my two short (and very recent) examples, a ground swell against stereotypes can only be a good thing. If I encourage one young woman to be a surgeon just by being one myself, that's wonderful. If together, we can all make positive changes in a society and a system that is imperfect, then that is amazing and is truly an achievement to behold.

#ThisIsWhatWeLookLike

    #ILookLikeASurgeon

  

P plate surgeons - teaching, learning and ethics

The New England Journal of Medicine has published a fantastic article on trainee participation in surgery. The story is told by an ophthalmology resident (registrar equivalent) with a patient, none the wiser that a training surgeon, fully supervised, has just performed successful cataract surgery. The author talks about striking the right balance between teaching and training and what the patient would wish to have happen. Hospitals, especially teaching hospitals, are home to doctors of vastly different experiences. There is the professor, with thirty years of experience on one side of the table. On the other side of the table, there may be a doctor with weeks, months or only a few years experience. It is through this vast experience that an exchange of knowledge and learning of skills takes place. And at the centre of this is the patient.

I have always found that patients, by and large, do not have an understanding of the medical hierarchy. Which is understandable. There are so many words, terms, faces. Interns, residents, registrars, fellows, consultants. Age, or rather a perception of the doctor's age, is one thing I think patients use to try and work out who is in charge or experienced. They may perceive the person they have had the most contact with as the leader or the person who spoke to them for the longest. While I'm sure the patients appreciate that a hierarchy exists, I'm not sure that they always appreciate that there can be a chasm of experience, skill and knowledge between two people.

But whether they appreciate that difference or not, the patient has a most vital and important role in closing that knowledge gap. It is through their illness that junior doctors learn. I actually loathe to use the word practice. To me, that sounds akin to shooting hoops from the free throw line, over and over, hoping you get one in. Refinement. Advancement. Training. That is what it is actually like. A process rather than a crack at the goal. And with an experienced person standing there. I'm not sure during training that we say often enough that we are thankful for the trust our patients place in us. Without them, we simply could not learn.

But we don't say it. Very often, we don't specifically inform a patient that a surgeon in training may perform some or all of their surgery. A number of consent forms have a standard provision that reads something along the lines of 'a doctor other than the admitting doctor may perform the procedure'. As the New England article mentions, the patient may well not consent to a trainee performing their procedure. Which leaves us in somewhat of a pickle. Like so many situations, we have an obligation to more than one person. We have a very important responsibility to protect our patients and their health and well being. And we also have an obligation to train surgeons, for without them future generations would not benefit from medical care.

A number of things are leading to concerns with training young surgeons. Sicker patients requiring true expert intervention, changes to surgical training program execution, excessive working hour restrictions and oversubscription of doctors at certain levels of training. The use of simulation in both high and low fidelity models has been used to teach, develop and refine skills prior to getting to the operating theatre. I had the opportunity to practice on some fantastic models during my training. Paul Ramphal, an American surgeon who works in the Bahamas, has a fantastic simulator that uses a pig heart in a model chest cavity and has engineered in a way that it 'beats'. I had the opportunity to practice coronary bypass grafting on this model several years ago. And it was great fun. There is nothing quite like the real deal, but I think we will move towards simulation more and more as a way of teaching and training. Aviation and sport have made use of such technology for years and medicine is now catching up.

But what about for the now? Well, for starters, in cardiothoracic surgery, the literature seems to support that a patient's operation will not be compromised by having it performed by a junior surgeon. For coronary artery bypass grafting and valve surgery, there have been a number of publications that suggest that the outcomes are similar between a training surgeon and an experienced operator. In my field therefore, I can tell a patient that having a trainee operate should not adversely impact on their outcome. Their grafts will still flow and their valves will still open and close.

But we do need to be more open. And we need to do it such a way that the patient is not only reassured but also happy to be part of a very important process. The New England article makes mention of another ophthalmology publication whereby the authors got 95% of patients to consent to trainee participation by honest and open discussion in the informed consent process. And honesty and openness is so important to not only the consent process but the respect for the patient's autonomy and as a fellow human.

Personally, I think that moving towards transparency is the correct move. I think if I can reassure a patient that their outcome is unlikely to be unchanged, that they will participate in a very important process and of course, that trainee surgeons have appropriate supervision, then that is a process that it is ethically sound. However, I would be lying if I thought that a proportion of patients would decline a trainee surgeon or that all of their anxieties would be put to rest by any open and honest discussion. Going for surgery is scary at the best of times, adding another possibly worry into the mix may not be helpful for some people.

During my training, a small proportion of patients have asked who will actually be doing the surgery. Most of the time, I answered that it will be the consultant they were admitted under. If I knew that I was going to be do that patient's operation, I told them that too. I am very, very grateful for the patients who taught me. Who taught me simple things like placing an IV cannula. To the ones who showed me where their good veins were for taking blood. I am grateful for donor families who trusted me to use their loved one's organs for transplant and to the patient on whom I learnt how to perform joins in arteries with a suture the thickness of your hair. I am grateful for the learning because my future patient's will reap those rewards. But most of all I am grateful that you trusted us, all of us, to look after you when we were still learning the nitty gritty of just how to do that.

The 'B' Word

Bitches get stuff done. - Tina Fey My team had developed a little habit of being late to work. I hate being late, it's just something I really try to avoid doing. For the first four months, I let it slide. But then, I told them all that they need to be on time. I did not name call or swear or shout. But I saw it all on their faces, the raised eyebrows, the downcast gaze. And then, as predictable as death and taxes came the 'B' word. Bitch. How original.

I have been called a bitch for as long as I can remember. And some of the time, it really makes me mad. That ambition, assertiveness, requesting a standard, standing of myself or taking no rubbish from people equates aggressiveness, dominance or is in some other way threatening is the way female behaviour is often skewed. The rest of the time, I wonder what fool would call a woman a bitch if he really thinks she is aggressive, domineering and won't take his BS? Talk about poking a bear!

It's not so much the choice of the word bitch that annoys me, it's what it implies. If a male boss asked his juniors to perform to a certain standard, he may be called firm but fair. If he wanted to advance his career and expressed desire to lead or win or achieve, he would be called ambitious. A woman in those same positions gets called a nasty bitch or a bossy bitch. Why should a woman boss not demand a certain standard? Why should a woman not express ambition to rise through the corporate ranks? What is that is so wrong with this? Why do women get name-called for it?

I'm a bitch, I'm a lover, I'm a child, I'm a mother. - Meredith Brooks 'Bitch'

When you call me a bitch, you turn me into a one dimensional nasty, scheming, domineering and unstable woman. I could be a sweet as pie, laughing and joking, even inspiring for 95% of the time. The 5% of the time I get cross or demand a standard or assert myself and get called a name colours everything else I do. Nobody will seem to remember that 95% of the time. Nobody will ever remember that their actions necessitated repercussions. My team for example, very swiftly forgot that they had mostly been 5-10 minutes late the entire year and that asking for everyone to be on time is courteous to everyone who is.

Once you are called a bitch once, that is all you are. Everyone is waiting through the fun times and laughter to see what I will next identify as unfavourable and 'turn into a bitch' about. A woman who is a bitch is incapable of expressing a range of emotions, of which anger or frustration are normal human emotions. She can only be that one thing from there on out. She has been painted with the bitch brush and that is hard to erase.

Bitch, like a number of other derogatory feminine nouns, is thrown around so commonly these days. It's no surprise that even as children, we use the word bitch and pretty indiscriminately too. Rap songs have been infamous for their use of words such as bitch, hoe or slut. Snoop Dogg, a pretty masculine kind of guy, recently came out and said that with his daughter and mother in mind, he would never refer to women as 'bitches' again. He would be horrified for someone to use those terms to describe his daughter so he should lead by example. And how true is that? We call each other names that if they were used for the women in our life that we care for, we would be furious. But with terms like bitch firmly engrained in our vernacular, is it any wonder that we so freely use the term in a derogatory fashion?

She didn't care that people called her a bitch. 'It's just another word for feminist,' she told me with pride.

By all accounts, Steve Jobs was a hard task master. He demanded excellence from his employees and from himself. When he sadly died from cancer, the world mourned the loss of this brilliant mind and business man. People called him a visionary and a genius. Will we do the same if the world were to lose a bitch? Probably not.

If being a bitch means voicing an opinion or demanding a high standard, then I am a bitch. If it means that you don't take someone's BS and will fight back when insulted, then I'm guilty on those counts too. If you think that I am confident and not afraid to challenge the status quo, then again, I am sorry to say that I am a bitch. And you'd better watch out. Because the bitches of the world are coming. Beyonce, Sheryl Sandberg, Michelle Obama, Hilary Clinton, Oprah Winfrey, Julia Gillard, Julie Bishop, Taylor Swift and Melissa Mayer. The woman executive at the bank, the lawyers, the doctors, the politicians. The small business owner and the athletes. If you are threatened by the bitches of the world, you had better get over that quick smart.

I am not going to say that I am 'proud to be a bitch'. I do my best to be a good leader and although I am not perfect and have plenty of learning to do, I actually think I do an okay job of it most of the time. I am proud to be opinionated and dedicated. I am proud to believe in high standards and I will never apologise for wanting to be good at my job, for wanting the best for my patients from myself and from those around me. I will not let go of my ambition because I am proud of my drive and dedication. I will not admit to being consistently even tempered or sugar, spice and all things nice. I am human and I express anger, sadness, happiness, despair, jealousy, fear and hope, all normal and healthy human emotions. If you want to call me a bitch, that's fine. I won't stop you. But don't be surprised when I use all of my 'bitchy' qualities to succeed while you call the next ambitious woman names behind her back.

As much as I say that sometimes being called a bitch upsets me, I know who I am and I am proud of who I am. If those qualities that I am proud of also get me called a bitch, then so be it. I have broad, bitchy shoulders that should have no trouble bearing the load. I can't wait to be in a workplace with more 'bitchy' women. We're going to do a great job!

'We don't do that at home' 

I am away at the moment in Fiji with Open Heart International. The organization has been traveling overseas to many countries providing services including cardiac surgery, burns and women's health. This is my first trip with the team and it has been a really incredible time. One of the things I've found myself saying a lot is 'we don't do that at home!'. We don't have mice and geckos on the ward, we don't reuse items that are meant to be disposable (like oxygen masks and nasal prongs and plastic gowns). Our parents sleep on a rollout bed with linen next to their kids in hospital at home. Here, they sleep on a hard wooden bench about 4ft long. There's been a lot of things that we do not do nor do we see at home.

And that is just the tip of the iceberg.

The local villagers did an ask around and came to visit the children and their families I the ward after their open heart surgery. They gave each family $250 (Fijian) to help while their child is sick. We don't do that at home.

The local blood bank has a bus that is run by an ex-pat volunteer. When the locals donate blood, they test them for a wide range of things including kidney function and HIV for free. People here can't afford the blood tests so they get it for free for donating blood. We don't do that at home.

 When doctors train here, they earn a very low wage. Partly because they have to pay back the government for their studies. But when they have finally paid that back, the doctors send the bulk of their earnings back to their whole villages. Most of us don't do that.

We operated on a six year old girl today and her mother left the anesthetic room in tears, worried for her little girl. But her operation went smoothly and she was awake in ICU not long after. Her mother, with tears in her eyes, hugged me so tight. It was all I could do not to cry myself! Some people say thank you at home but that soulful, deep and genuine gratitude. We barely acknowledge each other sometimes. Little or big, thankfulness is something we struggle with at home.

This trip was about changing lives. Operating on men, women and children who will now hopefully go on to lead productive lives in their community, who will grow up big and strong, or who will see their own kids grow up. But really, they change us too. They make us feel the warmth of the local welcoming and gratitude and we will take that back home. Maybe it will be some small thing that we will show gratitude to somebody else for, like the guy who makes your morning coffee. Or maybe something big like your surgeon. But no doubt about it, there's a lot of things I've seen in this little country that we don't do at home. But boy do I wish we did.