I take orthopaedic call 2 to 3 times per month. We work a full day, then we are available all night, then we work a full day the following day. In my 20s this was tiring but invigorating. In my 30s this was doable, and balancing babies and a pager in the middle of the night was just normal in my world. In my 40s I got tired. Tired and sometimes grouchy. Now that I am in my 50s I am struck with a new word to describe the interactions the physician community encounter on call, and it is reverberating in my mind recently… INDIGNITIES.
Recently, a gentleman broke his hip in the middle of the night. This is a painful injury. And most patients are downright scared. After reviewing his x-rays, learning his medical history, arranging his surgery with the operating room, and coordinating with the team in my clinic, I went to do the part of my job that means the very most to me. I went to talk to my patient. I pulled a chair up by his bedside. His tired eyes and my tired eyes met. I showed him his x-ray and told him about the surgery that would fix his painful broken bone. He had a lot of questions. And I was answering them. He was in the middle of a question when a nurse came into the room and somehow stood between me and my patient, with her back to me, and began speaking to him about his medication schedule.
He stopped her. He asked her to let us finish our conversation, and asked her to return later. And here is the kicker… He Apologized To Me.
Mortified does not begin to describe how i felt. There were a few ways this could have played out for my patient. He could have lost trust in me as his surgeon. He could have made up that I was not a respectable or capable physician, given that another member of his team of clinicians disregarded me in this way. Alternatively, he could have made up that the physician patient relationship is not important to our team in my hospital. I did not ask him how the interruption made him feel. I did not have it in me to acknowledge the unprofessional interaction. I did not want to risk coming off as divisive or critical. So I walked away and avoided a conflict. I did the surgery well. I took good care of my patient. He did well.
But this indignity has been weighing on me. Because it is not an isolated incident. The climate of healthcare has taken a direction that has angered me for years. But anger is really often unexpressed sadness. And I have found it more honest and healthy recently to just let myself be sad. I am mourning the culture that allowed doctors to have time with our patients. When I started my career as a surgeon the era of respect for the space for surgeon and patient to connect was still supported and dare I say sacred. The relationship began before surgery and went on well after surgery. Holiday cards and personal connections were still the norm. At that time, I cannot imagine a nurse interrupting a conversation about surgery between a scared patient and his surgeon.
I actually do not blame the nurse. I have been thinking about her perspective. She has so many metrics to answer to, so many computerized checkboxes to fill, so many patients and so little time. Our organization is so large that she does not know me and I do not know her. She has been trained in an environment that is quite foreign to me. She and so many others like her are doing their very best to get through the day.
As I continue to grieve the loss of respect in my profession, I will not abandon hope. I will try my best to make my patients feel respected. As I teach the next generation of physicians I will instill in them the old school approach to patient care that I cling to. In this way, I vow to do my part to stave off the extinction of dignity in medicine.
I have become a keeper of stories. And as I navigate the murky waters of the culture of Orthopaedic Surgery, I have become conflicted. I sit between generations of women and I am experiencing a crisis of my identity in terms of my volume. My burning question these days is, “Do I let myself be drawn into conflict by anyone other than my teenage daughters?”
My mother and her mother
My mother turned 80 this week. She is a force of nature. I was brought up with accountability to the nth degree. There was no shirking a chore or a task. There was no avoiding conflict. Disagreement meant conversation. Cooler heads prevailing was not a thing in my family. We called each other out, had intellectual showdowns, did not hold back, and then moved on with mostly love and a ton of humor. Shying away from a challenge was just not instilled in me.
The next generation of women and underrepresented minorities coming behind me in Orthopaedic Surgery do not yet have a paved way to follow. The way has been eased. But only slightly. And I worry that the culture of collaborative cool headed veneer may not be preparing them to be heard. Or perhaps I am dead wrong. Maybe this shift will arm them to be far more effective than I can imagine.
My daughters generation is skilled in reconciliation. They hold things in that I think are better out. In some ways their strengths harken back to my grandmother. Kill them with kindness. Catch more bees with honey. I know they believe that revenge is a dish best served cold. But once in a while they let their fight out. And when they do I can’t keep up.
Me and the next generation
It took me many years to learn that fiery behavior from women is both revered and repellant. Sometimes the only way to be heard is by raising my voice, And sometimes the best way to be ignored is by raising my voice. Either way, I have come to accept my own inability to accept the status quo in the culture of surgical culture. I am seeking to understand the most effective way to communicate the need I feel for change. Although my upbringing is with high volume, I can shape shift into many forms. At the end of the day, I am a pragmatist. And my cause is alienating to many, no matter which volume I choose to use.
I do not pretend to have answers. In 2023, conflict is afoot but change has not arrived. There are well known men who serve as faculty who continue to sexually harass their trainees in plain sight. Retaliation is alive and well, even among the leaders seeking change, and the hypocrisy is astounding. Orthopaedic societies have improved diversity on the Boards of Directors but the percent of women and underrepresented minorities in our Presidential Lines is not at all reflective of the membership. And most sickening are the stories of young physicians hired as Orthopaedic Surgeons by hospitals and organizations who create and allow for toxicity that detracts from morale, access to care, quality of care, and patient safety. Our newest graduates are at the mercy of some systems that can only be challenged by our senior leaders. New surgeons are gaslit and taken advantage of in new and creative ways, and they are grossly underprepared to stick up for themselves and their patients.
This crisis of culture is real. Surgeons cannot perform with compassion and excellence when we are distracted by bad behavior that has become normalized. And our community is divided, often over semantics. I do not know whether to be soft or loud, veneered or fiery, confrontational or cool headed. But one thing is clear. If we all disengage, the quagmire that is healthcare in 2023 will divide us and disable us from all that we need to give good care to our patients.
So I implore you, my community of women and underrepresented minorities in Orthopaedics (and our allies). Can we please stick together. There are too few of us to survive factions. There is too much at stake. If we continue to divide we will move backward. The next generation deserves a trail that is blazed.
I am almost divorced. I thought about staying private about this. And I mostly have over the last 9 months. But here’s the thing… this decision is one of the best ones in my entire life. I have not been at all immune to the roller coaster of emotions. The last few months have brought me peace and happiness. And as I have shared my story with more friends, I am recognizing that sharing our stories and normalizing the experience with transparency has become important to me.
I recorded a podcast with Jeff Smith, MD this morning. He and I have worked in the space of physician well being for the past decade. We have different approaches. Jeff emphasizes the path we can take as an individual, such as resilience, health, breath, and yoga. I emphasize the role that practice efficiency and operations play in supporting the physician to optimize our relationships with our patients and enhance medical care. We both agree that all of these things are important, but we choose to come at our work from different directions.
When Jeff and I come together in podcasts or speak alongside one another from the podium, we sometimes respectfully spar about our opinions. In fact, just 2 days ago, we did this from the podium of an instructional course lecture at the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in Chicago. So when Jeff asked me to join him for a podcast recording, I assumed we spend our time in that space that we have grown used to together.
But we went in a different direction. Jeff asked me what I wanted to talk about as we got set up with our microphones. I started rambling, and quickly realized how much I needed to share the story of my last 9 months. The floodgates opened, and I decided to “come out” about my divorce. My marriage ended last summer, and this morning I recognized that holding this private has been hurting my soul a little bit.
A few weeks ago a dear friend and partner in my orthopaedic practice admitted to me me that I have not seemed like myself. Although no-one spoke to me directly using the word “angry,” I heard through the grapevine that this descriptor was being applied to me for the first time in my life. I had 2 choices. I could get angry at being called angry. Or I could absorb, reflect, and try to grow. I was tempted to do more of the angry thing. But somehow I gathered myself to do the reflecting thing.
At baseline, I am consistent in criticism of the daily operations of my practice. I send emails expressing concerns about lack of support for physicians in our care of our patients. From scheduling to message management, call responsibilities to sleep deprivation, I am vocal when I see room for improvement. And I usually speak or write with a voice that is mostly level headed. Except recently I have not.
And there is a short explanation. Nine months ago my husband of 17 years and I decided to divorce.
The emotions that go along with divorce and the dismantling of a family of 3 children and 2 dogs are tremendous. For some reason I became subconsciously determined to avoid the cliche of the experience. I wanted to separate my home life from my work life for the first time in my career. I have spent the last 20 years advocating for work life integration. I have modeled with transparency the influence my personal life and family have on my work life and career, and vice versa. Well, it turns out that this is not so hard to do when life at home is stable and traditional. Yet the stressors of the massive change that divorce brought to my home became so real and sad for me that I could not open the smallest window to my work life for fear of a flood of crazy.
As I spoke to Jeff, I thought about my work partners. It turns out they have been noticing. And really, how could they not notice. I have been afraid of being judged as a woman who could not handle it all and keep it all going. I was worried I would be seen as disingenuous for my persona as @mymomthesurgeon. But I had it all wrong. These men who work alongside me have risen to a level of caring that has blown me away. Some of them have been through divorce. And they have been giving me grace without me even noticing. I have been grouchy and tired, complaining and short with people. And they have given me understanding without me even realizing.
A few weeks ago, when I realized that I have been an angry person recently, I asked my middle daughter for some feedback. My 12 year old daughter, Coco, is a fierce, honest and fiery redhead. She also prefers to be in a handstand as much as possible these days. So when I asked her she happened to be upside down. She looked at me sidelong from her inverted position and said, “yeah, mom, I’ve been walking on eggshells with you.” My 15 year old daughter, Lila, convinced me to get her not 1 but 2 one eyed cats to help her with her anxiety. She has told me without words what she thinks I need by bringing these cats to me over and over wherever I am in our home. My 10 year old son now opens doors for me, holds my hand, and pulls out my chair for me when we go out to dinner. Clearly he is stepping into the space of taking care of me.
I’ve gained a little bit of weight from the stress and change. I brought my girls shopping last week, and when I no longer fit into my preferred size Coco offered to go look at shoes with me, pointing out “at least your feet didn’t get fat.” She did try to back-pedal, and quickly shifted to calling me “thick,” which she assures me is a complement among her peers. Lila softened the exchange by saying, “Mom, it’s ok. I mean, you’ve never been through a divorce before and you’re just figuring it all out.”
My sister has been a rock during this time. Sometimes she is so irreverently funny about all of this. But sometimes she is serious and pulls out her professional best… and she reminds me to reground myself in purpose and intention. When I got on the plane to come to Chicago last Monday, I followed her suggestion and did exactly that. I set an intention to spend my week away at the AAOS doing 2 things. 1: re-grounding myself in my gratitude for my career in orthopaedic surgery at Kaiser Permanente. And 2: allowing myself to be uncomfortable in the work I am doing nationally to move my profession forward in culture, to call out and battle against harassment, bullying, racism, homophobia, and bad behavior in our realm.
When I met with Jeff this morning, I realized that I stayed on script this week. As I fly home, I am proud. I spoke from a podium alongside our AAOS president and dear friend, Dr. Danny Guy, with a resolution to tell the story of the behavior that has marred our field for too long. In co-founding #SpeakUpOrtho, I have stood up and spoken out.
I received an honor from the women in my field this week as well. I have been welcomed into presidential line of the Ruth Jackson Orthopaedic Society, whose mission it is to further the work of women in the field of Orthopaedics, I feel seen and supported. My malcontent is not easy to sit with. I have written about moving away from people pleasing and toward activism. This space is uncomfortable. But it is real. And perhaps it is one of the reasons that my marriage has ended.
And I guess it’s ok to have anger. I am going back to the model I created with my social media handle @mymomthesurgeon. I am not an Orthopaedic Surgeon in a vacuum. I am still a mom. And now I am a divorced mom. This persona is now the new one to weave into the work life integration I have touted for 20 years. I am proud of the happiness I am finding in this. And I am now proud to accept the condolences and kindnesses bestowed upon me as go public with my new place in life.
Still my family, but in 2 homes and with different lives.
We are coming up for air after a year that defies description. Life as we know it has shifted forever for our generation. As a physician and orthopaedic surgeon, there are things that are ironically easy for me right now. Things like handling crises and emergencies, broken bones and torn tissues feel purposeful. On the other hand, there is a whole other bucket of things that I tolerated pre covid that I am struggling to find ok now. And I hear myself becoming a complainer.
Surgeons are trained to be tough as nails. Our skin is thick. We can stay up all night and keep operating and conquering the world. But in 2021 I have found the weak spot in my armor. I can no longer react gracefully to requests of my time and energy that lack distinct purpose. Professionally, this includes asks that detract from my time and energy that should be focused on problems and tasks that require the expertise that took 10 years of training to develop after college.
People are getting back into the world physically and emotionally. We have forgotten how to act and how to move our bodies in contact sports and recreational activities Accidents and injuries abound, because we are all out doing things that our bodies can’t quite keep up with after a year in our houses. And in my experience, the level of anxiety surrounding injuries has skyrocketed. My patients in 2021 need their physicians to be whole and present. And my community of physicians need an incredible amount of support from other clinicians and staff. We are all exhausted. Thus the complaining. And I am not alone.
Physicians and clinicians have caught ourselves in our cries for help. We have been asked to take care of ourselves and our teams. We know the dangers of moral injury. Physician and nurse suicide continues to rear its head all around us. It is underreported for a variety of reasons. When it happens close to us, we often cannot heal properly, because we are asked to keep confidentiality. And when we take time to take care of ourselves, the guilt is tremendous. Keeping healthy boundaries has never been so difficult for me. Delaying an answer to a text or an email or a phone call even when I am on vacation takes more energy and generates more stress than being available. Last week I found myself crying in my office between patients. You see, I lost someone and cannot share who or how. I came to my senses and asked to cancel an afternoon clinic. I was not a good version of myself. I immediately received multiple phone calls from multiple people asking me to stay to see patients that needed me. I caved. I stayed. And I was in distress. I put on a brave face, and my patients were none the wiser. The staff was sweet and appreciative and brought me food to soothe me. I went home and had nothing left for my children, my husband, or even myself. And this was when I caught myself doing something that nauseates me… I was acting like a martyr.
What do I mean by martyr? There are at least 2 definitions of the word martyr. ”Historically, a martyr is someone who chooses to sacrifice their life or face pain and suffering instead of giving up something they hold sacred. Sadly, this does not describe my current state of affairs. Rather, definition number 2 is more accurate to me: “Today, the term is sometimes used to describe someone who seems to always be suffering in one way or another.” https://www.healthline.com/health/martyr-complex I am the less dramatic and non heroic kind of martyr, better known as a whiner. Step one for me is recognizing the space in which I sit, between a rock and a hard place. I know that I am suffering. And I know that my boundaries are inconsistent. People reach out to me for help because of the expectations that I have set over the last 20 years of my career. When people call, I answer. When people text, I answer. And when people email and message, I answer. It is up to me to sail out from this spot I have inhabited between scylla and charybdis. I am writing this to hold myself accountable, because I do not want to complain, I do not want to wine, and I do not want to suffer. I want to use my professional expertise to help my patients, and my people. But to do this with health and kindness I must establish the support and boundaries to keep me recharged, to save something for my family and for myself. My family also deserves a good version of me. So I invite you to stay tuned as I update you on my journey out of grief, and out of martyrdom.
I am a surgeon. A woman surgeon. And I’m pushing 50. To pile on, I am an Orthopaedic Surgeon, and only 6% of us are women. The vast majority (94%) of my field is made up of white (and some Asian) men.
I grew up as a pleaser. That is actually a personality type. It means that I was intent on avoiding disappointing others. It means that I wasn’t asking for too much. This is literally the description of my former style of collaborating, learning, working, socializing, and leading. I smiled pretty. I deferred to my leaders. I was polite. Socially adept. Always eager to learn. Moderate when expressing myself. Hesitant to contradict. Curious. Accepted feedback as doctrine without question or pushback. Oh, sure, I got edgy and even rude in the middle of the night on call. The nurses in Houston, Texas in the 1990s were not familiar with women as orthopaedic residents. Although some became close friends, many were not good to me, especially after hours. And the shame I felt about conflict and behavior the next morning would break me. Likeability trumped almost everything.
And then I hit middle age. Slowly but surely I (mostly) stopped caring about pleasing. I wanted more out of my relationships, career, medicine, and patient care. It was more than just about ME. I recognized that my profession as a whole was losing respect, that doctors were faring poorly emotionally, and that patient care was getting affected by this. It was and is a macro issue in healthcare for more than the last decade. And I no longer could afford the luxury of hanging back, being moderate, and pleasing people for a living.
During my younger years, I was elevated on a national stage in my profession of Orthopaedic Surgery. I served on the Board of Directors of a small but influential society as a member at large and then as the Communications Council Chair. Next, I served on the Board of Directors of a large and mightier organization. My story was that of an up and comer. The ascent was expected and clear.
Once I reached my mid 40s, I shed my compliance. My interest in drawing women and underrepresented minorities to my male dominated field became a drive and a passion. I launched my social media persona, @mymomthesurgeon, to document my ability to be a mother and a surgeon all at once. I listened when Sheryl Sandberg told me not to pull the ladder up behind me, when Madeleine Albright told us that “there is a special place in hell for women who don’t help other women.” There were conflicts, not everyone was in agreement about accepting all that goes along with women as truly represented in our field. I ruffled feathers. I spoke louder. I took up more space. A dear friend and mentor gave me the highest compliment, she told me that every woman leader in our field faces a time of shedding the persona of a “Darling.” She welcomed me to the Big Girl’s Club. She looked at me with respect and empathy, as I left the easier path behind.
Things came to a head for me in late 2019. I was on a trajectory to be considered for the big job of leading a little society. In the months leading up to this, I made a move that I believe took me out of the running.
One of my greatest accomplishments during my “Darling” phase was being included as faculty for a coveted course. There were few women at that time, and I could count us on 1 hand in those days. I worked incredibly hard on my lectures, I gave my true all to this prestigious commitment. I was warned by the 2 male surgeons in charge that women were rated poorly as faculty. They offered to coach me on my lectures, and of course I took them up on it. They were the elite, the masters. And I was grateful for their time and attention. I was asked back year after year. The sailing was smooth.
Medical societies have an incredible reliance on industry sponsorship. The regulation of this relationship has become appropriately strict over the last decade. I never took the opportunity to consult and accept income for industry relationships. It has always been a conscious decision for me. However, there is gender disparity when it comes to physician consultants to both pharmaceutical and medical and surgical device companies. Industry is learning to accept and welcome women into the leadership ranks of our field. I have received education, attended courses, even lectured at industry sponsored and funded courses. But that has been my line in the sand, I have not accepted money for my consultantship.
The incident that outed me as a driver, and not a pleaser, was one that was simple. A representative of a sponsoring surgical device company was dismissive and unresponsive to me. The details do not matter. What does matter is that she was deferential, responsive, incredibly friendly, and full of respect for the men who preceded me in this role. The tone was set before we even met in person. She left my emails unanswered and cancelled a phone meeting with little notice (I had inconvenienced patients to prioritize this meeting). In person things did not improve.
Upon meeting in person, my younger “Darling” self would have made friends, complimented her on her hair or shoes, and charmed my way into a friendship. But I made a decision. I had a direct and honest conversation that was not sugarcoated. I was not kind. But I was not unkind. I asked for accountability.
My peers and leaders, almost all men, were stunned. How could they navigate this? They had a choice to make. Industry funding or support me as a woman who was no longer playing the role of the pleaser. I’m not sure I understood then or understand now which choice they made. I’m not sure they understand which choice they made. I am not even sure who “they” are. What I do know is that the rumors continue, and that the story about me and my decision to stand up and not shrink away that day has been amplified and described as “she lost it.” I also know that if I were a man, this disrespect, lack of responsiveness, and lack of preparation would not have occurred. Furthermore, a male surgeon who stands up for himself when treated poorly, the map is drawn differently. Men are viewed as powerful, charismatic, and strong when they stand up to conflict. I was painted as emotional, a criticism largely reserved for women.
I also know that if I had chosen to back away, to stay hushed, to smile pretty, this behavior would continue to fester and be directed at the women coming up behind me. And I think I would be in line to lead this society, although I cannot be sure of this. So if I had a time machine I would not go back to change anything about this incident.
I am getting used to my new voice. I have come out of a black and white muted filter into full color. I am no longer a Darling. And now my biggest challenge is in mentoring and advising those coming up behind me. I hesitate to guide them to ditch the “Darling” phase. It was so comfortable there. But I just don’t think we can accomplish enough, or much at all, from this place. We can continue to catch bees with honey. But that cannot be the only arrow in the quiver. If this means I have invited a glass ceiling to appear over my head, so be it.
This week has been rough. Orthopaedic surgeons lost another great one to suicide. As we virtually support each other through our loss, we compare notes.
Our profession is brutal. We all love what we signed up to do, take care of people who break bones and injure arms and legs and knees and shoulders and hands. We help people with and without doing surgery. And sometimes the part about not recommending surgery can be the hardest.
Most physician specialties have gravitated toward a shift model that creates availability for patients that need urgent and emergent care any time of day or night. The medical and pediatric specialties have specialists called “hospitalists” who are perched to care for anyone who needs care in the hospital. Emergency room physicians and anesthesiologists and radiologists work in shifts to cover all hours of the day and night, relieving one another with predictability.
There are few fields that continue to to function in the antiquated way that orthopaedists function. We work long “business” hours. Then we cover “call” after hours. When we are awake all night, most of us continue to work the next day. We do not get relieved by the next shift. We protect our residents and students from this absurd way of life, but not ourselves.
The administrative burden of patient care in 2020 for surgeons is tremendous. We signed up to work hard: to meet patients where they need to be met. To diagnose, to treat, to operate. But the work surrounding that care that we love grows each year. Administrators have been added to the healthcare workforce to meet these requests, and they now oftentimes outnumber physicians.
As healthcare in 2020 looks to emulate the service industry, administrators often expect physicians to function like employees at Amazon and Marriott and Starbucks. When patients lead their care with the expectation that they are a “customer who is always right” their care can suffer. Sometimes the correct thing to do is not to order an expensive test or do an unnecessary surgery.
Physicians find themselves caught in a web of pathological altruism. The system functions on the back of the professionalism of the doctors, and this professionalism is taken advantage of. Physicians are expected to “please their customer” or make the patient happy at all costs. And giving too much can cause harm.
Ultimately, the responsibility for medical errors lies with the physician, who is at the helm of the team. The policies and procedures and systems are often not physician led. Thus another conundrum for the surgeon.
Pressure to work quickly in the operating room and in clinic amps up more each year. More documentation is expected from the regulators. As reimbursement for each patient visit and surgery decreases, doctors need to see more patients to make ends meet. Resources to support care in the operating room, such as equipment and staff, are dwindling.
Then there is Covid. Covid reintroduced gratitude and respect for physicians and clinicians. But it has made our jobs more dangerous. And many orthopaedists have not been able to do elective surgery. As income has dwindled, some have even had to close their practices.
This is not about lack of resilience in the orthopaedist we lost. This is about a system that has failed our patients and our doctors. I continue to call us to action. The coal mine is toxic, and it is not the canary’s fault.
