A Surgeon Grieves the Loss of a Friend… Quietly

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.

Coming of Age as a Woman in Surgery

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.


Don’t Blame the Canary… The Coal Mine is Toxic

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.



I Stand with My Sisters in Surgery

We will not stand to be judged

This morning I posted the following on my social media accounts.  

So 3 male surgeons published an article about vascular surgeons and social media. They have the audacity to decide that it is inappropriate for women surgeons to post photos of ourselves in bikinis on social media. No mention of men in swimwear as inappropriate. 

So it is ok for me to be a woman and a surgeon and a mom and to fix people at all hours of the day and night… but these men have declared that it is inappropriate for women surgeons to be pictured in bikinis. And thus the birth of the #medbikini stories. 

As a woman in orthopaedics I stand with the women of vascular surgery.

The support from family and friends, acquaintances and strangers, women, men, surgeons, aspiring surgeons, has poured in.  So I’m inspired to write for the first time in months.  

I wish this article were fiction, or a poor joke.  It was not.  It was published in a peer reviewed journal, The Journal of Vascular Surgery.    Peer reviewed means that other vascular surgeons read it and deemed it true, useful, and appropriate.  And before this, it was presented at the Forty-seventh Annual Symposium of the Society for Clinical Vascular Surgery, Boca Raton, Fla, March 16-20, 2019.  This means that a program committee, vascular surgeons chosen as educational leaders in their field, thought that the research was valid and useful for the surgeons that are members of their organization.  The paper is entitled, “Prevalence of unprofessional social media content among young vascular surgeons.”  The authors set up “neutral” (fake) social media accounts to do their “work.”  One of the “unprofessional” behaviors included in the study was “Inappropriate attire included pictures in underwear, provocative Halloween costumes, and provocative posing in bikinis/swimwear.”  

This morning I saw a post from a vascular surgeon (@lady-surgeon) on instagram using the hashtag #medbikini. She posted photos of herself dressed as a surgeon side by side with photos of her in swimwear.  She wrote, “These are all me… regardless of what I wear, regardless of what I speak out about, regardless of my personal life and what I choose to post on MY social media pages, I am ALL OF THESE WOMEN.  I am a goddamn great surgeon who’s been saving lives for 22 years as a board certified vascular surgeon and for 29 years as a practicing physician/MD.  How dare the (formerly?) esteemed Journal of Vascular Surgery publish a trash article that perpetuates these misogynistic ideas about what qualifies as acceptable, professions or unprofessional behavior, attire and social media content…  She ends by saying “I stand with my sisters in Vascular Surgery” and asks for us to email the editor of the journal.  My story was in answer to her.  And in turn women physicians on facebook, instagram and twitter have rallied.  

I have heard (but cannot yet verify) that the article has been redacted.  But the damage is done.  I have heard from 2 women today who were unwitting “subjects” in this “research,” young vascular surgeons whose accounts were followed by the “researchers.”  They are angry.  I feel violated and judged on their behalf.  

The silver lining of this experience for me is the #heforshe thread on twitter.  Men in orthopaedics have posted photos of themselves in swimwear expressing support for the women in our male dominated field.  

As a woman in orthopaedic surgery, where we make up only 6% of our profession, I stand with the women of vascular surgery.  I stand with all women surgeons.  And all women physicians.  All women in healthcare.  And all women.  We get to be full people, and we get to share that however we choose.  We do not deserve to be trolled and judged in the name of “research.”  We didn’t stand for it today and we won’t in the future.

update: the article has been redacted. Such power in social media and women standing together.

Masks: Your Doctors Don’t Have Enough

I have an N-95 mask.  Because one of my partners had the foresight to buy a pack on amazon a few weeks ago.  

The shortage of protection for doctors and nurses and people taking care of patients is real.  The DMHC maintains that patients may be offered virtual visits, but if they request to be seen in person they must be accommodated.  #flattenthecurve except for us.  And them.  There are reasons that patients need to continue to be seen by an orthopaedic surgeon in person: new fractures, infections, tendon injuries are a few examples.  But knee arthritis and trigger fingers can wait until the other side of this pandemic crisis.  We can guide effectively over the phone.  

My office is full of people making phone calls and fielding video visits, answering emails and messages.  We are trying to keep orthopaedic patients out of the emergency room and urgent care.  We are doctors and nurses working to serve our patients while we help #flattenthecurve.  

The medical field is short on supplies.  Specifically, gear that protects us as we take care of patients is running low and even being rationed.  We have learned from China and Italy that doctors and clinicians who are not protected get sick.  And then we can’t safely take care of patients anymore.  

The construction industry has begun to voluntarily donate their N-95 masks.  My husband just received an email on behalf of a local Children’s Hospital asking for mask donations (he is on an email list for builders).  Nail salons are being asked for their masks.  Yes.  Nail salons.  

Times are scary and unprecedented.  We were down to ONE roll of toilet paper in my home.  I did a back alley trade for wipes with one of my partners, and we now have enough for the week in my house.  The world is upside down.  Gloves and our short supply of sani-wipes were swiped from our patient exam rooms, and are now under lock and key.  

Like any team that works hard in close quarters, our team of doctors, nurses, orthopaedic techs, medical assistants, and others usually bicker and quarrel a bit.  But not this week.  This week we stand together, have each other’s backs.  We check in on each other.  True colors are coming through vibrantly.  But know this.  The front lines are scared.  We want to trust that we are taking whatever means possible to keep ourselves and our families as safe as possible in unsafe times.  And with the shortage of protective gear we know this is not possible.  

The evidence changes on us every day.  Is the virus airborn?  Do we follow workflows and safety procedures for “droplet precautions?”  This means that the virus spreads through droplets from our noses and mouths, and spreads with coughing and sneezing in addition to  touching. For example, MRSA usually spreads by touch, so hand washing is very effective.  The CDC tells us that Covid-19 spreads “through respiratory droplets produced when an infected person coughs or sneezes.”  (cdc.org)  This mainly happens when patients show symptoms, but the virus is also thought to be transmissible before people have symptoms.  The World Health Organization is considering results from a new study showing that the virus can stay suspended in the air in some states of humidity and temperature.  (cnbc.com)  This would increase precaution recommendations to “airborn”.  

Most front line physicians and nurses and clinicians cannot get an N-95 mask, the kind that protects pretty well (95% of the time), unless we are doing a procedure around an airway or secretions.  Right now the evidence is NOT clear.  We do not know if Covid-19 can live in the air.  If it turns out that it does, we are not equipped to protect ourselves.  

We function with a lot of “just in case” precautions in the hospital.  We wear masks and caps and gowns to protect patients from us and us from patients.  The data is not clear that the lengths that we take on a routine basis are necessary.  But an abundance of precaution is our culture, and we are proud of that.  Today we just don’t know.  The evidence is not clear.  But I do know this, we do not have the supplies to support us in an abundance of precaution.  Just like in China and Italy and Seattle, doctors and nurses and front line medical professionals will get sick.  And if we go down, there won’t be enough people to take care of everyone else.  We are here.  We are working.  We are following our moral and ethical obligation and sworn oaths.  We know that we are not protected.  We want you to know too.  So that you can help us by social distancing, supporting our efforts to obtain protective gear, and flattening that dang curve.  

Let it be said that we tried to do what is right

Physicians are on the front line of this pandemic crisis.  I am in a unique role as an orthopaedic surgeon. One of my friends said last week, “if anyone thinks that orthopaedic surgeons are going to be caring for patients with Corona virus, they are sadly mistaken.”  As correct as he is, our duty to lead from where we stand is immense.  

The CDC and the Surgeon General have recommended that we postpone elective surgery.  We do not want to expose our patients to Covid 19.  We do not want to use materials that are in short supply, like masks and protective gowns.  We must understand that the children of doctors and nurses and physician assistants and medical assistants and x-ray technicians and orthopaedic technicians are home and in need of care.  Our resources are short.  We must be ready to use these resources for the waves of sick patients who are likely to come.  Our elective surgeries are cancelled for now. Like joint replacements, and ACL reconstructions, and shoulder arthroscopy and carpel tunnel releases.

What about elective care?  Last week we made the decision to review all charts of patients waiting to see us in my orthopaedic clinic to convert to virtual visits whenever safe and possible.  Social distancing is meant to flatten the curve of spread.  We must avoid patients and healthcare professionals coming into mass contact to address issues that are neither urgent or emergent.  Most patients have received this information with grace and gratitude.  People want to stay safe and to keep those on the front lines safe.  

Some true colors are shining through in the past days.  Support.  Working after hours and on the weekend to do the right thing.  Keeping public health and the greater good in mind, many are rising up, leaning in, and supporting one another.  

And some are not.  This has not landed for some of us.  I had a patient’s mother yell at me last week for the 2 day wait to see her child with a non emergent problem.  I received this without the compassion and empathy that I usually conjure.  I am sure this woman was scared and frustrated, perhaps short on toilet paper, and daunted by the lines around the block at the grocery stores.  She was likely overwhelmed with the mixed messaging coming from the press and our government.  She was absolutely trying to advocate for her child.  And she was certainly not able to see that we are far from business as usual in the orthopaedic clinic.  I cannot blame her.  But I did not have the ability to offer her what she needed, patience and understanding.  

Last night my 13 year old had a sleepover planned with a new friend.  I do not know the friend’s parents.  I should have cancelled.  But I felt bad for the girls, and wanted to let them have one last hurrah before lockdown.  In the middle of the night my 10 year old daughter woke up with a fever.  I did not call the friend’s mother.  I made the call to keep my sick daughter in our room away from the friend.  This was not the right call.  The friend’s family was correctly upset.  All I could do was apologize, and this was received with much appreciated forgiveness.  

Today I went to my favorite Sunday yoga class, usually filled to the brim.  There were 5 students.  And a teacher dealing out everything I needed.  Hard work, deep breath, sweat, and focus.  I am sure even this outlet will shut down within the week.  

We are all so raw.  As parents.  As doctors.  As people.  Our leaders cannot get it right when there is no precedent in contemporary times.  A partner texted me, “our leaders are waiting for word from other leaders, and it all feels like trying to do a U turn in a big rig on a cul-de-sac.”  I have shifted to asking for forgiveness instead of permission.  I must do what seems right.  This is not the time for rule following, as there are no rules.  I am going back to my Hippocratic Oath.  Just trying to do no harm.  

To all of my tribe in medicine, let’s be patient with ourselves.  Let’s support one another.  And let’s remember that we have exited a world of patient led care and “customer” service in medicine.  As we do what we believe is right, we may not have consensus.  The moral and ethical barometer that comes with the art and practice of medicine cannot be dictated or scripted in these times.  Let it be said that we tried to do what was right with courage and even ferocity.  

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