Today I am hit with a wave of sadness. It’s been six years since I graduated from residency at Oregon Health & Science University, and in those six short years, four of us are dead. Among the internal medicine-psychiatry-neurology cohort that I completed residency with, four people are no longer with us. At least two of these deaths were by their own hand. In what should have been the prime of their lives, they departed, leaving behind the grief of their loved ones.
When I first arrived as a new student at Harvard Medical School, I was surprised to find there was a metal detector at the entrance of the library. It seemed odd that there would be a metal detector here but nowhere else on campus. Then I learned that in the year above me, a woman had brought a gun with her into the library and shot herself after finding out that she had failed her anatomy course. The metal detector was to protect us from ourselves.
For my MPH thesis, I researched mental health disparities among Asian Americans. One of the things I learned was that there often were no warning signs before Asian American teens took their lives. When analyzing suicides among adolescents of other ethnic groups, there were often classic signs preceding the suicide, such as worsening grades or dropping out of activities. In contrast, Asian Americans teens continued aceing their classes, continued showing up to soccer practice - until the day they died.
The culture of being a healthcare professional has a lot in common with Asian American culture. In the indoctrination of each medical student into the culture of medicine, we hear the implicit message that it does not matter how a person feels on the inside, only how they perform and appear on the outside. Or put in other words: Just keep your head down and keep going. Keep plowing through. But what happens when the day comes when you can no longer keep plowing through?
The implicit message that how you feel is not as important as what you achieve is one which has been fed to Asian Americans since we were children. Perhaps this is why Asians make up only 5% of the US population but comprise 20% of the healthcare workforce. When we encounter the culture of healthcare, we already feel at home with the overwhelming burden of perfectionism and never being good enough.
The suicide rate among doctors in the US is around 35 per 100,000, or approximately double that of the general US population. Why would a profession that is well respected and well paid have people killing themselves at twice the normal rate? I believe it lies in the implicit messages within healthcare that we need to be perfect, that it’s not okay to make mistakes. Perfectionism and a judgmental environment create the perfect storm to fuel shame and secrecy, leading people to feel alone and unreachable.
I truly wish that I could go back in time. I wish that I could speak to that woman who had killed herself. I would tell her that she is so much more than a medical student or a doctor. That whatever she was troubled by, whether it’s failing a class, making an error, losing one’s job, or even one’s license - none of this is worth losing your life or your mental health. Each of us has an intrinsic value that goes beyond our work or our academics. Each of us has a value that is intrinsic to being human.
I have been lucky in that I was able to break out of the cycle of secrecy and self shame. I still struggle with anxiety, and the task of becoming “worthy” is one that I constantly wrestle with. But I am lucky that I started doing therapy when I was 24. I have also been blessed to discover meditation and yoga at a young age, which has helped me to find solid ground in an intense and competitive environment.
If you are struggling as well, please know that your worth goes so much beyond your work or academics. And there are resources to help. The Medical Society of Metro Portland offers free confidential counseling to physicians, which is not billed to insurance or documented in a person's health record. For those of you who live in other states, please check your state medical board. Most states offer a similar program, as does Kaiser Permanente for all employed physicians.
Your wellbeing does matter.
Another 138 years?
As I was nearing the end of my four years at Harvard Medical School in 2009, I was faced with the crucial decision of every medical student. What specialty would I go into? I was very interested in orthopedic surgery and even did two sub-internships in this specialty. I love the musculoskeletal system and being able to fix things with my hands. So what turned me away?
During my rotation, I met twice with my clerkship director, who happened to be a white male surgeon. As we were chatting in his office, I glanced at his roster of the different classes of residents. I couldn't help but remark, "I don't see any women in the intern class!" Dr. Hale (name changed) simply replied, "We would have loved to match a woman, but we didn't have any qualified candidates."
He then went on to point out that in the second and third year classes, there was one woman in each class of 12 residents. He indicated a petite young woman who was in the fifth year class. "The problem is, some people don't look like doctors. Like Sarah, she's so small that when she puts on her white coat, she practically disappears. She looks like a kid playing dress up. One time we were doing a hip replacement on a bigger patient, and she was really struggling to hold his leg up."
At the conclusion of my meeting with Dr. Hale, I asked if he would be willing to write me a letter of recommendation for my application in orthopedics. For a competitive specialty such as ortho, it is imperative to get a letter from your clerkship director. Not having such a letter would have been an absolute no in being able to match for residency. In essence, he was the gatekeeper.
Dr. Hale paused for a moment before answering. "Why don't you do one more rotation in ortho. And if you still really like it, then come back to me and ask me again." I felt confused and conflicted, not understanding why he had said no. I had worked hard during my rotation and had earned solid Step Exam scores. But I listened to Dr. Hale and did a second rotation in orthopedics where I was dismayed by the amount of sexist banter in the operating room. I wanted to be tough, but I knew there was no way I could handle training in this type of environment for five years. I never went back to ask Dr. Hale if he would write me that letter after all.
Was my experience an outlier? It would seem not.
According to this new study on The Gender Gap in Surgical Residencies by Bennett, et al, 138 years is how it will take until the number of women in orthopedic residencies equals the number of men, if things continue at the current rate of change. At a time when there are now more female than male medical students, this study points to there being a strong and active discriminating factor against women going into orthopedics and other exclusive specialties, such as neurosurgery and urology. Is it surprising that these are the same specialties with the highest compensation in the field of medicine?
No one explicitly told me, "Don't apply in orthopedics." I never heard an attending say, "Women shouldn't be surgeons." But I do wonder - if I had been a man, would Dr. Hale have questioned my sincerity in wanting to become an orthopedic surgeon? Or denied my request for a letter of recommendation? I've wondered about which implicit messages are told to women and people of color in medicine. How many of these messages are old scripts handed down generation through generation by those who held all the power and wished to keep it that way?
As I was nearing the end of this blog, I expected to finish it on a somber note. Instead, I am surprised and thrilled! Out of curiosity of how things are now, I checked out the Harvard Combined Orthopedic Residency website. The third through fifth year resident classes are exactly like I remembered with 0-1 women per class of 12. But the first and second year classes tell a dramatically different story with one class even having a majority of women. It's incredible that the number of women has risen from 0% to 58% in the last few years. The number of POC residents has also surged.
While the majority of this country's surgical residency programs are lagging in accepting women, this one has turned things around 180 degrees. This shows that change is not easy, but it is possible. I can't be certain if this is related, but the residency director is now Dr. George Dyer, who is a Black orthopedic surgeon. Being a minority in a white dominated field, I would suspect, makes Dr. Dyer a less biased gatekeeper in the evaluation of residency applicants. I'm doubtful that it was a dearth of qualified candidates that kept prior years' numbers of women low rather than the barriers in applying and being chosen in a field that is overwhelmingly run by men.
Progress is intentional. It does not happen by accident. But with having intentional goals and being aware of each person's biases, we can change the landscape of medicine. It does not need to take another 138 years.
Time that it will take for women to equal men in surgical residencies, by specialty:
Plastics: 7 years
ENT: 19 years
Neurosurgery: 47 years
Urology: 71 years
Orthopedic surgery: 138 years
Paper cited: https://jamanetwork.com/journals/jamasurgery/article-abstract/2768489
And if you wondering whether women surgeons measure up in the quality of care they provide for patients post residency - it turns out they actually do better.
When I was a third year medical student on my surgery rotation, I wanted to observe a particular surgery, so I asked the attending physician if I might be able to scrub in with him. There was a pause during which I felt increasingly uncomfortable. And then, "Of course, a beautiful Asian woman is always welcome to join me." Even now 12 years later, hearing that line in my mind makes me cringe. But what could I do? The power differential was such that I was a student, and my grade was dependent on this man's subjective evaluation of me. I knew that much of what I would be judged on was not my knowledge but rather be based on the unconscious biases of my attending physician. But there was little I could do about it. I sat through an uncomfortable two hours of surgery, attempting to be as inconspicuous as possible while laughing nervously at moments when I knew I was being tested and expected to laugh - the same moments when misogynistic banter was being tossed around me. I was the only woman standing at the operating table. During that time, and for much of my life, my policy toward racist or sexist acts was to look away and pretend it didn't happen, for fear of making things worse for myself.
Now as a hospital medicine doctor working on the front lines of fighting the Coronavirus pandemic, I find it deeply disheartening that in our country and other nations around the world, we have seen a rise in hate crimes against Asians and a surge in racist media coverage of the pandemic. In my younger days, I would have simply looked away, but now I'm reminded of the slogan popularized after the tragedy of 9/11: See something, Say something.
I'm saying something now. I recently sent the letter below to the editor of the Wall Street Journal urging them to recant a biased, xenophobic article. During this time of pandemic, we are seeing the effects of institutional and interpersonal racism manifest in many ways, including the differentially higher rates of infection among African Americans and Latinos in this country. Now is a crucial time for all of us to fight racism in the media by confronting it and speaking out against it.
Letter to the Editor of the Wall Street Journal
Dear Mr. Lemmer,
Tonight I find myself awake at 230 AM. It is not only because of the night shift I had done the day prior or the high anxiety I’ve felt since the Coronavirus pandemic began. I hold an MD and Masters in Public Health and work as a hospital medicine physician in the front lines of defending our population against infection. I couldn’t fall asleep because of an article I had read in the Wall Street Journal from March 23 titled "China is not a Coronavirus Role Model" by John P. Walters. In this article, he calls Covid-19 a "communist virus" and blames the emergence of this pandemic on the Chinese government.
It's been known for decades that a novel virus, toward which we have no immunity, could arise and cause a new pandemic. This could happen at any time and anywhere. It is through no fault of the Chinese people that Covid-19 happened to emerge from Wuhan. Instead of bolstering compassion and solidarity toward the Chinese, Walters urges us to fall back on xenophobic and racist sentiment, to isolate ourselves and point the finger of blame solely at the Chinese.
Yes, the Chinese government was at fault in attempting to hush the emergence of the novel Coronavirus in the beginning, but after it became clear that Covid-19 was a true threat, they have taken drastic measures to contain the virus from spreading across China and the globe. Most of the data we have, which we are now using in the US to prevent and treat Covid-19, have come from the work of scientists and physicians in China.
Furthermore, it’s come to light that US health officials also delayed our ability to prepare effectively for the pandemic. For example, infectious disease specialist Dr. Helen Chu already had the means to test for Covid-19 through her lab, but she was forbidden to do so by health officials. When she went against their advice and tested anyway, her lab immediately discovered a case of community spread of the virus in Seattle, which implied it had actually been circulating for several weeks already. Another botch in the American response was the CDC’s initial requirement that all Covid testing be run only at the CDC or state health authorities, which led to a huge bottleneck in getting widespread testing available.
Governments across the world, including our own, have all made mistakes in fighting this pandemic. But this is not the time to allow political rhetoric and xenophobia to block our vision. We need to place the highest emphasis on science and make every decision based on that. We need more than ever to come together (virtually) and to acknowledge our shared humanity. At no time in our living history has the global wellness of our species been so threatened.
As a physician working on the front lines of fighting this pandemic, I find it deeply disheartening that in our country and other nations around the world, such as Italy, we have allowed racism and xenophobia to rear its ugly head again in this new permutation. The number of harassment and assault cases toward Asians in the US has increased dramatically in the past weeks. Many Asian Americans now fear for their own safety and the safety of their children. Everyday there are more cases of Asians in the US being cursed at, spit on, and even physically assaulted as racism surges alongside the number of new infectious cases.
This situation is only made worse by bigoted articles in the media that encourage xenophobia toward China. Walters called Covid-19 a “communist virus,” which is absurd considering that the virus itself is nonpartisan and does not discriminate against race or political leaning in who it infects and kills. This type of microaggression is further highlighted by our own President calling the novel Coronavirus “the Chinese virus.”
Please do your part in fighting this pandemic by reporting in a scientifically sound way that is free from xenophobic and racist content. I would like to request that the Wall Street Journal recant the aforementioned article as an expression of apology to all Americans who stand against racism
In our society, women are often given the message, “Well, your baby is healthy, so you should just be grateful instead of dwelling on your own pain or birth trauma.”
Yes, I am grateful. When I look upon my daughter’s face, I see such purity there. At just three months' of age, she has a complete absence of guile or even the ability to understand what that might mean. I see in my daughter the original perfection of a human soul.
I am grateful beyond words to have her in my life. At the same time, her birth and the pregnancy have left deep marks on my body and soul that I am struggling to recover from. It would be unfair not to validate and fully acknowledge this.
After my c-section, I sat, walked, and slept curled up, with my chest drawing toward my thighs. The pain at my incision site was so intense that I was constantly scared of aggravating it. Over time, I became hunched in my posture, which only heightened all my fears.
One day as I tried standing up straight, I realized that my belly felt timid and vulnerable, but there was no pain. I wondered how long I had been stuck folded forward after the pain had gone away. I felt a sense of panic that my body was no longer my own, that I had lost touch with the sensations of my own body, despite being a student of yoga for the past 15 years.
I made a resolution that I would get back in touch with myself and strengthen my core from the inside out. I began taking physical therapist Sarah Duvall’s course on postpartum exercise. I also completed training in Wendy Foster’s postnatal Pilates course.
Today I did my first postpartum handstand. It thrilled me to be able to get upside down, even for an instant. Until this moment, the thought of kicking my feet above my head had seemed painfully impossible. I am still far away from feeling at home in my body, but I know I have begun the journey.
This fall, I’ll begin teaching yoga again for the first time since pregnancy. I invite you to join me on a journey together as we fumble, with grace, toward becoming whole and strong.
Ranger Eric told me that if I turned left at the ridge line, I would find numerous memorials built by family members of those whose ashes had been scattered over the ridge. The first one I encountered belonged to a woman who, I was startled to realize, had died at age 31, three years younger than I am today. I walked farther along the ridge and found wooden plaques, stone cairns, a spray painted boot...the belongings of those who have passed on, placed here by those who remain, in an attempt to make sense of their departure.
I sat at the edge of the sheer drop, the memorials at my back. I felt oddly at home. For the first time in my life, I felt at home as a citizen of this earth. At home in my smallness before the hugeness of the world.
I imagine their relatives had placed these memorials here because they felt this was where their loved ones belonged. I've wandered a lot in my life. I can't say that I've been searching for a "home" because a home cannot be defined by a place. But, in the back of my mind, I've been subtly searching for a sense of "placeness."
Whenever I visited my relatives in China, I was known as the American. Yet growing up in Arizona in the 1990s, I was constantly asked where I was from. If I replied, "Here," it was followed by, "But where are you really from?" I've never had a place that I could name, "That's where I'm from. That is the place that has shaped who I am." Perhaps one day I will wake up and find myself long enough in a place that I will claim it as my own. I will be surprised that my children have grown up there.
For now I sit quietly and watch the way that shadows and light dance across an expansive valley. If I were from this area, I would want my ashes scattered here. Let my ashes spread to the far corners of the John Day Valley until it becomes dust immemorial and retains no part of who I used to be. Build me a stone cairn that receives the last caress of warmth as the sun dips below the mountains on the opposite bank.
I loved what Kristin Neff, PhD, psychologist and compassion researcher, had to say about perfectionism. She really nailed it regarding this complex concept that I've been mulling over for years:
"Perfectionism is defined as the compulsive need to achieve and accomplish one's goals, with no allowance for falling short of one's ideals. Perfectionists experience enormous stress and anxiety about getting things exactly right, and they feel devastated when they don't. The unrealistically high expectations of perfectionists mean that they will inevitably be disappointed. By seeing things in black-and-white terms--either I'm perfect or I'm worthless--perfectionists are continually dissatisfied with themselves."
This simple explanation illuminates for me why I have been unhappy for such large chunks of my life. Now that I'm in my 30's, I'm beginning to understand that so many things in life are out of my control. And these factors ultimately determine "success" or "failure" just as much as my personal effort or talents.
Changing thought patterns or habits is hard. It takes time, practice, and conscientiousness. It's like carving a new route for water to flow down when it has been meandering down the same canyon path for the last thousand years. When something goes wrong, the same barrage of negative thoughts flood my mind, but now I can choose to slowly step away from perfectionism and closer toward self compassion. I can look at a difficult situation and place my hands on my own shoulders and say, "That was really hard. Honey, you did the best that you could in that moment."
Today I mailed off a card to the wife of one of my patients. The card was a print of a watercolor of vibrant red flowers. This card was painted by a woman whose home I visited three years as she was dying of end stage breast cancer.
The cancer had spread to her lungs, causing fluid to build up in the lining around her lungs. She had a tube placed in her chest that constantly drained a pale yellow fluid in an attempt to give her lungs room to expand and her the ability to breathe. She knew she was dying. She was determined to do it on her own terms, in her home, surrounded by the flowers that she loved.
She had a marvelous garden. As we sat in her living room, her flowers outside were erupting with brilliance. Each day as she grew weaker and the time that she could paint grew shorter, she began to paint with even more fervor. Recently finished works were scattered about her house, capturing the defiance of life even as the shadows grew longer with the coming night.
As my preceptor and I walked toward the door, she handed each of us a packet of cards with her paintings on them. Doctors are not supposed to accept gifts from their patients, and I had never accepted anything before. But in that moment, it felt right. She had an adoring circle of friends and relatives but no children. Her paintings were an important piece of her legacy. With her offering of this gift and our acceptance, we created an unerasable, tangible trace of her in the world that would remain after she was gone.
* * * * *
It's taken me two months to write to my patient's wife. I had wanted to write to her many times before today, but when I thought about what had happened, my guts twisted up inside and my breath caught in my throat. He had passed away suddenly, unexpectedly, leaving in the wake of his death, a bewildered wife and his strong daughter, who was now holding everything together. She reminded me of my father's daughter. I think about the these two women now, mother and daughter. They remind me that for those of us who remain, there is only one thing left to do.
T O L I V E.