It’s implicit

I recently found myself involved in an interesting (and insightful) conversation with one of my residents and one of my practice partners about sexism and racism.  The short version of how we got there is that the resident noticed that a discussion of two trainees with identical professional development issues but of different (race/ethnicity/ I’m not going to tell you distinguishing characteristic so we’ll go with “blue” and “orange”) appeared to be VERY different in content and tone, particularly from one person.  Our discussion quickly moved from the particulars of this situation to the bigger picture- bias and prejudice, and the impact that they have on us and our trainees.  Specifically, our discussion moved to our perceptions that most prejudice that we experience, particularly as women, is no longer overt.  More importantly, most of the people we tend to identify as the biggest offenders don’t even realize their own bias.  In other words, the faculty member described apparently has no knowledge of that tendency to describe blue people and orange people in a dramatically different manner.

For those not familiar with this concept, it’s described widely in the social psychology literature as “implicit bias.”  Project Implicit, originally based at Harvard and now with an international infrastructure, is the most robust general research for information on implicit bias.  Housed within their website is the Implicit Association Test (IAT), which now addresses myriad potential angles of bias.  I first took a version of the IAT probably 8 years ago and I’ll admit- for someone who tends to think of themselves as a modern, liberal, open-minded, generally unprejudiced person it was eye-opening.  In spite of being a woman in a very male-dominated field, I found that I still had some biases about women and science (is THAT why I was a liberal arts major?!?), as well as women and command leadership.  Who knew?

What we know is that implicit bias is real.  We also know that it has a very real basis in both family and social experience imprinting; our biases are formed at a very early age. We know that those biases have a tremendous impact, and can certainly have an impact on women in academic medicine for a variety of reasons.  We know that even though those biases are imprinted early that they can be “managed”; simply being aware of our biases makes us more likely to be able to limit their influence on our behaviors and actions.  Many institutions now have in place implicit bias training as part of faculty recruitment as a starting place to address this issue.  I would be curious to hear from colleagues (yes, dear reader, that’s you) what, if anything, your institution is doing on this front.  And, of course, I would encourage you to take the IAT.  It’s eye-opening about those biases you might have about blue people versus orange people.

The great pretender

With all of the responses and comments I got about last week’s post on women and the confidence issue, it inspired me to take on a different facet of the same set of issues.

The impostor phenomenon or impostor syndrome.

First described in 1978 by Pauline Rose Clance, the fundamental premise is that despite tremendous professional accomplishment, those who are affected by the impostor phenomenon persist in sincere denial of their capability and believe that they have “fooled” others and the system to achieve their status.  Found disproportionately among high-achieving women, the impostor phenomenon is characterized by minimizing achievement, be it a promotion, a high test score, or a specific achievement that is meaningful in a woman’s professional world.  The fear that underlies this syndrome is that of being “found out”- for example, the anxiety harbored by many young women surgeons that when they take their certifying exam, their examiners will discover that they actually have little to no surgical knowledge.  Admit it, ladies:  at least a couple of you felt this way (and yes, gentlemen, I know that some of you did too).  The impostor phenomenon is likely to also disproportionately impact women in male-dominated fields, meaning that academic surgery…well, let’s just say it might be a set-up.

Several months ago, our WIMS office at the University of Utah hosted a terrific panel in which several very accomplished female faculty members discussed how the impostor syndrome impacted them and their career development.  If I were to use the model they used, my introduction would start something like this:

” It all started when I was admitted to college.  They were going to allow me to start at age 17, the end of my junior year?  My senior year as I applied to graduate school I somehow was mysteriously offered scholarships for my graduate work from all 3 of my top choices.  Then my course correction into medical school- I had the “wrong” academic background coming from the liberal arts, and had bailed on grad school shortly before comps.  Why would medical school want me with that pedigree?  Every day in basic sciences I was certain that a mistake had been made.  For the first time in my life, something academic felt hard to me.  Really hard.  Then I hit my clinical years where I felt insecure but not like a true impostor.  Until I hit internship, that is.

I matched at my first choice program in general surgery with a profile that my Dean had told me was unlikely to result in success in applying for a residency at an academic surgical program (note:  all of my surgical mentors counseled otherwise).  In Fall of my intern year, after participating in the application pre-review process, one of my co-interns and I looked at each other and commented that we both were certain we had been rank list errors; everyone whose applications we were looking at seemed so much more accomplished than we were!”

Here’s the thing:  Impostor syndrome likes dark, quiet places to hang out, where people don’t talk about their fears and insecurities.  It feeds on the shame of inadequacy.  That moment with my classmate was illuminating for me because it was the first time that I had “come clean” about wondering how I got to where I was with someone I really respected.  To find that she had the same fears was a BIG deal and the basis for a lot of sanity-preserving conversations over the next 5 years- with her and with another resident who started the year after us.  We learned from each other to take credit when good things came our way, and we were able to normalize one another’s anxieties as women surgeons.  Most importantly, when one of us needed guidance and constructive criticism, we had a safe community to provide that.

I’ll admit that I still have moments of stopping to look around and be awed by where I am professionally, and humbled by some of the opportunities I receive.  I’ve also learned how to simply say, “Thank you, I appreciate the honor,” rather than bumbling through why it was predicated on luck or timing or who I know.  I have a community with whom I can be honest when I’m feeling overwhelmed and mentors who both nurture and nudge.  I still keep looking for ways to grow, professionally and personally.  Are these things cures for the impostor syndrome?  I’m not sure, but they certainly help keep it at bay.



Women surgeons, leadership, and confidence

Did you happen to read this piece in The Atlantic on the Confidence Gap in April of this year?

If not, I’ll start by asking you to take a few minutes to read through it.  Yes, by definition I just violated my own “blog posts should be approximately 500 words” rule.   Then I want you to think about the last time you praised a successful man and a successful woman.  With rare exceptions, I strongly suspect that their responses differed.  Why?  A man will often respond in a way that shows they believe they deserve their success; sociologically, it’s simply how boys are programmed.  In stark contrast, a woman is more likely to tell you that she got lucky…that she happened to be in the right place at the right time…that she has succeeded because of exogenous factors that are in fact outside of her control.  The woman who publicly owns her success, who takes credit for it, is a rare thing.  With the number of highly successful women I know, particularly in surgery, I simply can’t believe that women are succeeding because of luck and men are succeeding because of talent.  To hear us talk, though, you would be left with that impression.

One of the critical impacts of women’s tendency to underestimate their talent is that they aren’t considered for or don’t ask for “stretch” positions.  While men are promoted or ask for leadership roles based upon their potential, women are promoted and ask for leadership roles based upon their accomplishments.  In fairness, the underpinnings of this phenomenon probably lie both with leadership and with those seeking advancement, but it’s something that is both anecdotally and scientifically true.  Anecdotally, I know that I personally have been guilty of asking for leadership roles only when I can demonstrate that I am more-than-qualified based upon my prior accomplishments.  Scientifically, the article from The Atlantic cites data showing that women apply for promotion only when they are 100% qualified, as opposed to men who apply when they are 50% qualified.

While as women we may be guilty of undervaluing ourselves and our potential, we’re also hamstrung by “cognitive shortcuts” that result in systematic undervaluation of our work.  While we want desperately to believe that we’re functioning in a meritocracy, self-promotion (and perhaps a bit of good-old-boy network?!?) seems to make a substantial difference in achievement of leadership roles and career advancement.

Obviously the generation of a “solution” to this issue is complicated by basic social mores, the acculturation of boys and girls, and the fundamentally different communication styles typically demonstrated by men and women.  I don’t have a simple fix for those things.  What we can do, however, is to move these issues from a place of unconscious bias to a place where we can discuss them openly and honestly.  To the men who mentor women surgeons (or who are in positions to sponsor women surgeons), please look at what we’re capable of, not just what we’ve already done.  Be a multiplier for us by putting us into those “stretch” roles and let us excel.  To my women surgeon colleagues, ASK for that role you aspire to, even if you think you’re not quite ready.  Don’t come to the table with excuses about why you’re not there yet and don’t point our your deficiencies.  Come to the table with faith in your ability to excel.  If our talents aren’t being fully used, it shouldn’t be because we’re not offering.

(With thanks to Justin Dimick for encouraging me to write something on this…even if that was about 6 weeks ago.)


A place of our own

Apparently there are a number of men who, upon hearing about a women surgeon’s activity will state, “We don’t get to have a men in surgery group!”

This statement is both true and untrue.

While it would probably be considered politically incorrect to have a formal “men in surgery organization”, it can easily be argued that academic surgery remains the “men in surgery” club.  Between 2001 and 2011, the number of women in surgery residencies increased from 24% to 37% of trainees, breaking that 33% number often associated with achieving “critical mass” for any non-majority group.  However, in the ranks of academic surgery in 2012, women constituted 21% of surgery faculty, and women are apparently stalled as 9% of full professors in surgery.  This paucity of women in academic surgery does matter, both in terms of availability of role models for our residents and students, and in terms of how women are seen and perceived in academic surgery.  If you were to ask most (if not all) of my male colleagues if they have walked into a room at a surgical meeting and felt out of place, the vast majority would tell you no, and many would look at you like you were crazy for asking.  In contrast, I know experientially from speaking to many of my female colleagues that we’ve walked into any number of surgical settings and felt fairly certain we didn’t belong there.  My first experience of this nature came during my fourth year of medical school while on the interview trail- I was one of 40 interviewees at a program that shall remain unnamed on a given date, and I was the only woman in the interview group.  While I knew I deserved the interview, I inferred that being a resident there had the potential for me to have to fight lots of battles that involved being judged not on my work, but on my gender.  I didn’t have an interest in that.  I still occasionally make jokes about it when I find myself seated in a room of surgeons in which I am the only woman- and yes, this does still happen in 2014.

My support for and involvement in organizations like the Association of Women Surgeons, is predicated on this idea that as women we do need a place where we are exclusively looked at for our body of work and where we aren’t judged for being any of the stereotypes associated with single/ married/ divorced/ childless/ childed women surgeons.  For me, and for many others, it’s been a “safe” environment to expand our leadership skills and to experiment with authentic engagement with colleagues.  My experience in a social sorority in college was similar, in terms of it being a place where my leadership skills were cultivated and I learned to collaborate with people who were very different from I.  While I recognize that many horror stories exist about the collegiate Greek system, I remain passionate about the benefits of sorority life when it’s done “right.”

Would I have the leadership and team skills that I have today without Alpha Delta Pi and without the Association of Women Surgeons?  Maybe.  Would I be where I am in my career without the support of some wonderful men who focused on who I was as a student, then as a surgeon?  Absolutely not.  Did opportunities in these women’s-only organizations change my life for the better?  No doubt, and I am absolutely certain that they helped make me into who I am today.  For me, and for many women leaders in varied professions (particularly historically male professions), this idea of having a “place of our own” is critical to our professional and personal development.

Sexism and Surgery: Starting off with a bang

Did you happen to see this great piece from Emily Graslie a couple of weeks ago?

I loved this video for a couple of reasons.  One is obvious if you are familiar with her work- Emily’s video series from The Brain Scoop is a terrific, user-friendly approach to science.  The other was that I honestly empathized with the comments that Emily included in her video, as I suspect many of us do, and I loved her approach to dealing with sexism and science.  She’s no-nonsense about it and addresses the issue head on.

I thought back to my first encounter with sexism in medicine, going back to high school.  Our family’s physician, upon being told that I was leaving for college at the end of my junior year under an early admission program with intent of going to medical school, simply commented, “Well, I guess it’s okay for women to be physicians these days.”  No, he wasn’t joking.  No, he never treated me again (nor my mother).  I’ll admit- this was almost 30 years ago, and with the entry of more women into medical school many things have changed.  Or have they?

Plenty of research shows that female medical students often experience gender discrimination, and that this occurs most commonly on their surgical clerkships.  Women medical students are more likely to experience gender discrimination during their surgical clerkship than are their male counterparts and are more likely to perceive sex discrimination, typically from male attendings and male residents.  My own recent work has shown that female surgeons and residents are more concerned about the presence of sex discrimination in the workplace than are their male colleagues, and that they perceive this discrimination as a barrier to advancement in academic surgery.  Clearly this problem isn’t just one of the 1980s; it persists in modern-day medicine.

Stories of incidents can be gathered easily enough from many sources; in one night on Twitter I was able to acquire stories ranging from colleagues or patients refusing to address a woman physician as “Doctor” to women being told they are “too nice” to be a surgeon, or being told that they are allowed to do more in the OR because of their looks.  While the overt sexism remains, many institutions are starting to consider the role of “implicit bias,” those subtle behaviors and actions that manage to undermine the leadership and credibility of any minority group.  Yes, women surgeons are still a minority group.

So back to where we started, with Emily Graslie’s video.  We have a problem still, and what we need is a solution.  We can start by speaking up when we hear sexist comments- particularly those of us who are a little more senior and are therefore more empowered because of where we are in our careers than our younger colleagues.  We need the buy-in of our “enlightened male” colleagues to support the career development of talented women.  We can also work within our institutions to increase awareness of implicit bias in hopes that this will have a durable impact.  And, as Emily Graslie stated, “We need to make sure we’re making it possible for people of all genders to feel acknowledged for their contributions and not feel held back by something as arbitrary as their genetics or appearance.”  That’s simply wise advice for life.