What if it’s not our fault?

“If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so weave a less arbitrary social fabric, one in which each diverse human gift will find a fitting place.” – Margaret Mead

In the last week I have found myself in the midst of two interesting Twitter conversations, both with a similar underlying theme regarding the impact of culture and how we seem to underestimate its impact on the individual.

Here’s conversation #1 (remember to start reading at the bottom):

I particularly loved the empathy behind the idea that the term burnout implies that it’s a personal choice. While we’re getting smarter about identifying organizational factors that drive burnout (ahem…my group’s call schedule), there still seems to be this idea that if you’re struggling with burnout, you’re simply not resilient enough. Reality check: I’ve witnessed some people who are remarkably resilient struggle with burnout, and without exception they have been in a work environment in which they had little to no control. Yes, I understand that individual characteristics may predispose people to burnout or may limit the impact of a dysfunctional system upon the individual…but at the end of the day, victim blaming and pretending it’s ALL about resilience?  That’s simply feeding the dragon.  It’s not helpful.

On to Twitter conversation #2:

(The link that you can’t see from here is this recent piece in the Atlantic.)

So, maybe it’s not about biological clocks or because we’re not ambitious enough.  Maybe, just maybe that ambition is situational…and that if we’re in an environment where we see other women hitting their heads repeatedly against the glass ceiling,  or we experience that ourselves, we adjust our expectations accordingly. Or we leave when we realize that we shouldn’t have to adjust those expectations because there isn’t anything wrong with them.

It’s time to stop telling us to try harder, or telling us that we can’t be mothers and academic surgeons, or telling us that we don’t measure up because we don’t know the 100 extra double-secret and unwritten criteria that you’re using to evaluate us. Most importantly, it’s time to create a culture in which we feel valued and supported, not because you tell us that we should, but because we actually are.

What if it’s really not our fault?

Starting them young

How many of you saw this study about emergence of gender stereotypes and intellectual capacity that came out on Thursday?

Actually, let’s roll back to two years ago when the same group published this study on expectations of brilliance and their relationship with the number of women in scientific fields.  The summary is that fields perceived as requiring brilliance or genius tend to be male-dominated, while fields requiring hard work and empathy have better representation of women.

I’m grateful that the authors went back in to try to figure out when this happens; apparently, it’s somewhere between kindergarten and first grade, give or take.  Girls start picking up social encoding that boys are the ones who are “really, really smart” and the logical side effect of that is that girls stop pushing themselves to do those things that they think require being “really, really smart.”  I suspect this happens in a variety of ways- through the media, through acculturation, through implicit bias.  While I didn’t get messages at home that girls couldn’t be “really, really smart” (in fact, quite the opposite as I took everything in the house apart and climbed trees while wearing dresses and wasn’t told that girls weren’t PresidentSurgeonCowgirls), I definitely suffered bias at school in math.  Every time we would move- which was frequent as evidenced by 6 elementary schools in 5 years- I would get put back to grade level in spite of documentation that I was usually 2-3 grade levels above.  In hindsight, I have to ask, “Would that have happened if I were a boy?”   The reality is that the answer is, “Probably not.”

The bigger thing (since y’all know I try to be solution focused around here!) is to think about ways to (1) inoculate our girls against this and (2) “rescue” those who are already older than age 6.

The BBC published this helpful guide the day after the Science study dropped last week.  There’s a reference in there to A Mighty Girl, which you can also follow on Facebook.  I’ve followed them for a while, and even being a few years older than 6 routinely find their posts to be inspirational. We need to focus on the importance of doing hard work that we’re passionate about, regardless of gender. We need to remind each other when we’re doing hard things well and having brilliant ideas.

Now, let’s all go out there and bust some assumptions, shall we?

Words, words, mere words

This link describing the difference in language in performance reviews of men and women came across my Facebook and Twitter feeds.  To summarize the HBR piece it draws from in one sentence, men are more likely to get specific information about what they are doing well and what they need to do to get to the next level than are women.

Men get feedback on technical aspects of their performance. Women get feedback on their communication style (when is the last time you heard of a man being described as “aggressive” in an evaluation?). Men get constructive suggestions.  Women get constructive suggestions and are counseled in effect to sit still and look pretty. Men are acknowledged for their individual results.  Women are described for their team accomplishments. Men are expected to be independent and self-confident.  Women are criticized if they aren’t collaborative and supportive.

The real issue with the implicit bias that appears to pervade evaluation in so many areas of business and tech is the impact it has on women’s professional development. Although little work has been done to date, I suspect that the same phenomena are at work for medical students, residents, and women in academic medicine.

And, of course, since I always try to bring solutions for the problems I share, I’m particularly fond of solutions modeled on those recommended in the HBR article. For those of us in roles of evaluating our learners and our peers, how can we best do this to mitigate the unconscious bias?

  • Use specific criteria (or anchors) to evaluate individuals. What does competence look like for a specific skill or activity? What does mastery look like?
  • Set three measurable outcomes to review for each individual.  These may vary from one to another (no two individuals are alike); the key is that they should be measurable.
  • Relate feedback to goals or outcomes. Instead of saying, “Great job during that OR case!” perhaps we should mention to the resident, “The time you spent getting good exposure of the trachea made the actual placement of the tracheostomy safer for the patient and technically easier for you.” Or instead of saying, “The whole room thought you were panicky during that trauma activation on a patient who was clinically stable,” we could say, “We should work together on you maintaining command of the room during low-level trauma activations so that you can do the same when we have unstable patients. When you seem anxious, the team picks up on that and it impacts their care of the patient.”
  • Written reviews should all be of similar length- which also means similar level of detail.

I know that I’m discussing these issues largely in broad strokes. I’m also not finger-pointing at anyone in particular, especially because it appears that women bosses and men bosses are equally guilty in the business world. I’m also curious to look at evaluations I’ve written over the last couple of years on students and residents to see if I’m guilty. If I manage to pause and adapt a comment I might make tomorrow morning during our residency review meeting, it’s a victory for me and for that learner.

Most importantly, I want to put this in front of you, my readers, because the best way to beat unconscious bias is to realize that it exists.


Many pathways, similar goals?

Yesterday I received the monthly newsletter from our Women in Medicine and Science (WiMS) Office.  It has 10 bullet items in it, 5 of which relate to the Mom community, parental leave, child care, etc. This was notable to me primarily because I can’t say that I have a positive history with our WiMS group.  About 3 years ago our Dean hosted a series of dinners for women faculty with the leadership from WiMS and Academic Affairs serving as the co-hosts; I found myself at a table that spent the entire evening discussing marriage and children.  I have nothing against people being married and having children (more power to you, particularly in dual career families!).  What I do have an issue with is having a conversation in a place with people who are your professional peers that entirely excludes others at the table; there was one other unmarried woman without children at our table, and unfortunately she and I were seated directly across from one another, preventing us from being able to start our own conversation.  After the dinner I told my friend who is the Associate Dean for Academic Affairs what happened, and also told her the probability of me attending another WiMS event is near zero.  Yesterday’s newsletter heavy focus on issues relevant to that same subgroup who excluded me reinforces my belief that at our institution we probably should rename the WiMS office for what it really is- a Families in Medicine Office.

I want to be clear that I acknowledge the tension present for those who have the competing pressures of a young family- or aging parents- and a vibrant academic career.  I hope that my friends who are dual career with children and making their way in academic medicine understand how much I respect them; it’s all I can do to keep my own house running and I have a dog and two cats (and a wonderful mother who lives 1.5 miles away from me).  However, based upon conversations with male colleagues of my own generation, this family-work tension (or work-life integration as I also refer to it) is no longer the exclusive domain of women.  And based upon my own research about barriers to careers in academic surgery, while women surgeons do perceive that tension as a barrier, it was one of MANY barriers- and it wasn’t the first thing that came up in most of my interviews.  Resources, mentorship, having your work valued- all of these things were raised as much or more in terms of things that are critical to success in academic surgery.  More to come on all of that, I promise, as the stories crystallize into their themes.

I’m always happy to hear my friends’ tales of trying to juggle two careers, soccer practice, dance lessons, and getting dinner on the table.  I’m also happy to hear these friends’ tales of their latest research idea or commiserate over a terrible clinical story.  I need both of those things as a peer and a colleague- I need to know that they are multidimensional, that they are passionate about all of the things in their lives.  I want them to love their kids and spouses.  I want them to love their profession.  And I want them to strive for better in both of those spaces.

I still believe there is a need in medicine, and surgery in particular, for us to have organizations responsible for helping women to break down the structural barriers to our success in academia and in leadership roles. I do believe some of those barriers are still real and relevant.  I also believe that we must be thoughtful and non-exclusionary in our approach to these things because we are each traveling our own challenging path.  And more importantly, we need to include those who are different, be it in gender or family model, who are willing to embrace the concerns and to help us find ways to make all of these challenges just a bit easier.  Our loved ones and our profession- both at the individual and the collective level- deserve that.


The times, they are a-changin’

With an announcement about Sandra Wong becoming the Surgery Chair at Dartmouth (congratulations, my friend!), we’ve reached a milestone for women surgical chairs:  She makes #10 currently. Ladies, we’ve hit double digits!

I started this post last week and needed to let the ideas percolate a bit, and now the time is perfect.  I wanted to talk a little bit about #ILookLikeaSurgeon and its impact, but what I really wanted to address is the commitment that we all need to make for the groundswell from #ILookLikeaSurgeon to make a real difference for our profession.

And here, I believe is the secret:  We need to learn to actively engage, even embrace,  those who are somehow different from us in our profession.  When I say different, that can mean almost anything- scholarly focus, age, hair color, gender, socioeconomic background, football allegiance, ethnicity, sexual identity, cat-owning status, the list is infinite.  You’ll notice I threw some less “serious” ones in there, and I did that quite deliberately- not to make you laugh, but to make you realize that when we commit acts of bias, they may or may not be well founded.  We should treat the fact that Joel is obsessed with sandwiches no differently than we treat my obsession with shoes.

Anyone who has worked with me knows that I’m a believer in “manageable” interventions.  While the outcome of what we do may result in something absolutely amazing, I will always ask my team for an incremental intervention (or two or five).  What are some incremental interventions to increase inclusion in surgery?  Here are a few, and none of them are that complicated.

  • Actively encourage women and minorities to apply for leadership roles and awards; it’s been documented in many fora that accomplished women and minorities simply don’t put their own name forward.  Leaders can directly lobby and promote high-quality candidates for various roles.  In addition, those leaders’ mediation of the process helps mitigate concerns that applicants may have about the perception that they are “pushy” or “bossy.”
  • Creating programs to support the career development of all surgeons.  Making sure that everyone has access to the same “rule book” about how to succeed in training and in academia or private practice, depending upon their choices.  What sort of specific activities would this include?
    • Transitions Q&A at various meetings for individuals moving from one career phase to the next
    • Topical and timely career issues fora
    • Networking venues, especially for mid-career folks (this can be a tough transition!)
    • Travel awards to get underrepresented groups to meetings and to the table
  • Holding meeting planners/ program committees accountable for insuring diversity in speakers.  There is no reason in this day and age for any surgical meeting to have a panel of only white males.  None.  For those on program committees, please commit to looking at your speaker lists and making sure that it is inclusive.  For those who are not on program committees and who notice at a meeting a lack of inclusion, say something (nicely, of course).
  • Education and advocacy on diversity and inclusion, something that #ILookLikeaSurgeon has started for us.  In particular, education about unconscious bias needs to be front and center. If you haven’t done any reading on this topic, I strongly encourage you to do so.  While we can’t get rid of bias, if we are cognizant of our biases, we can at least manage them.


I’m proud of the fact that when I look at my list of mentees it is incredibly diverse, and I want to believe that those numbers actually count (thus my emphasis on inclusion rather than diversity).  Part of that has been accidental and is truly based on who I am and how I was raised, and I’m grateful to my parents for that.  Part of that is because I love being challenged by people who hold different ideas and perspectives than I do because they make me better at what I do and how I do it.  And I’ll admit, part of it has been absolutely intentional.  I’ve looked for people who I believe are talented and taken them under my wing- and they have almost invariably proven to me that with the right support they can excel.

My challenge to you is to make a commitment to choose one small thing that you can do to help promote inclusion in surgery.  If you’re a resident, it may mean looking for a medical student to mentor.  If you are junior faculty, look for a resident to bring along and to sponsor.  If you’re mid career and above, we’ve got to be the BIG part of the solution- and that means creating and sustaining programs to make us all better.




Don’t need a membership to validate the hard work I’ve put in and the dues I’ve paid

I realized last week that I generally spend more time thinking that the “gender thing” in surgery is getting better, that we’re making some slow but steady progress.  As of last month, we have 8 women chairs of surgery in the US (admittedly, I’m still eager for double-digits to happen).  As of 2013-2014, 38% of surgery residents are women (critical mass!).  Surgery is now #5 in terms of proportion of women in academic departments.  In my own department, more than 1/2 of our new hires in the last two years have been women, which has changed the composition of both the division and the department substantially.  I’m proud of that because the women who have joined us are all forces of nature (in a good way) and provide wonderful role models for students and residents who want to see how to “do” academic surgery and life gracefully.

And then…I have a week like last week, a week that I understand is a direct result of being a woman surgeon who has been in practice for a decade and who now has multiple leadership roles.  At one early-morning meeting, I was the only woman at the table.  During a PI meeting for a multicenter trial, the two women surgeons present were the PI (a dear friend from the burn sisterhood) and me.  Then there was the email that went out to a leadership group I’m part of for the American College of Surgeons- and because my antenna were up from these meetings, I realized I was the only woman on the email who wasn’t staff.

Surgery still has the 2nd lowest number of full-time women faculty of any specialty documented by the AAMC at 22%.  Our orthopedic colleagues continue in the cellar with 16%.  And while I revel in those 8 women chairs of surgery I mentioned before, if you look at the number of surgery departments out there that’s not a large proportion of departmental leadership.  I want to be completely clear about the fact that I am happy and honored to be “the” woman surgeon in the room/ on the email because I do not believe I am there as a token placeholder.  I just am still sometimes surprised that in 2015 it can still be a pretty lonely place to be a woman leader in academic surgery, and I’m reminded how much I rely on the women and the men who are ahead of me on this journey to make sure that I am (1) treated equitably and (2) given the opportunities that I earn.

Surgery is less of a man’s world than it was when I started my training 18 years ago, and I am delighted at the deserved recognition that my female and minority- and minority female!- colleagues are receiving.  It’s clear to me, though, that we still have miles to go before we sleep to reach that place when my junior colleagues aren’t faced with being the “only” of a group in the room.  And when we are still faced with those situations, it remains imperative that we carry ourselves with confidence and credibility.  Most importantly, none of us can do this alone.  Hard work and helping each other- that’s how we change the world, isn’t it?

Now listening:  Kacey Musgraves “Good ol’ boys club”



In the heels of last week’s admonishment to not be afraid to say no, there’s really only one logical follow-up (especially for the women out there):

Reminding you that you do not have to apologize when you say no; it is, in fact, a complete sentence.

We know that women apologize more than men do, for a variety of reasons (many of which are socially/ culturally encoded).

Our tendency to over-apologize may be attributable to a confidence gap exhibited by women, even amazing powerful women.  The overuse of “sorry” can- and often is- seen as a sign of weakness.  We need to hold each other accountable for the abuse of this poor little word, giving each other a friendly nudge when we catch each other (or ourselves!) apologizing for those things we can’t control, and apologizing for things that really don’t merit it.

This piece from Medium captures the author’s quest to decrease her inappropriate apologies over the coming month.  I particularly like her friend’s comment about only apologizing if he acts in a way that is inconsistent with his values.

I’m obviously not advocating for complete abandonment of common courtesy; I was raised south of I-40 and my Daddy was in the Marines, meaning manners are paramount in my world.  What I am challenging each of you and myself to do is to be authentic, to state our intention rather than taking the easy, “I’m sorry” route, and to only apologize when we really mean it.

I’ll count my abuse of the word “sorry” tomorrow and report back.  I hope you’ll do the same.

And do NOT apologize for saying no.  Ever.


The clothes make the…woman?

It’s consistently true that how we dress gives people a certain impression of us; it’s a way that we communicate nonverbally.  For many, there’s that idea of the professional “uniform” that gives them the proper identity.  Some of us target a look that is “professional but fashion forward” (my usual self-description).  Much like you wouldn’t expect an artist to show up in a skirt suit with a very traditional blouse, we don’t expect someone interviewing for a surgery residency to show up in a skirt and blouse reminiscent of Stevie Nicks in the 1970s..  Quite simply, there are fashion norms for all professions, and in order to have professional credibility, you find that you need to stay within them.

While the above is simply a reality, the one catch lies in the fact that women are often held to a somewhat more exacting standard than the men who are their colleagues.  Example, compliments of my own experience:  I was at a professional meeting in a pair of nice wool pants with a complementary jacket.  I was wearing brown suede Dansko Mary Janes that color coordinated with the rest of my outfit.  I was critiqued about my “shoe fashion sense” by a senior male colleague.  Now, those who know my lifelong shoe addiction well are assuming there’s a bit more to this story, which there is- I was nursing a broken metatarsal and simply couldn’t wear any other shoes except for running shoes (which seemed a  bigger faux pas at the time, but perhaps not).

Dear male readers, be honest:  How many of you have been publicly chastised for your shoe choice at a professional event by someone trying to mentor you?  I suspect it won’t be more than a handful, if that many.  But, somewhat ironically, the bandwidth of shoes that are considered “professional” for men is far, far more narrow than it is for women.

Lest you think I’m turning anecdote into data, think again.  Obese women suffer in terms of roles available to them and how much they are paid, but their male counterparts don’t.  Then there is the message in academia that “unless women dress modestly and conservatively, they look out of place in academia…they don’t have the right bodies to be academic authorities.”  This image preference for masculine styling for women to be credible isn’t a uniquely academic phenomenon, either.

So, what’s a girl to do if she wants to be taken seriously but doesn’t want to be a cookie-cutter of everyone else around her?

Personally, I have a stylist who knows that I’m a bit bound by a Very Traditional Career, but who also recognizes that I have no qualms about labeling things, “Boring!”  She does an amazing job finding things I consider smart- both in terms of their fashionability and because they navigate that narrow space I’ve got to work in.  That enables me to put together things like this, which are within the “rules” but quite the opposite of boring:

Mixed designers- Akris Punto (jacket) + St. John (skirt)
Mixed designers- Akris Punto (jacket) + St. John (skirt)

And, not surprisingly, I have a shoe “dealer.”  So that I can find functional but fun things like this:

Red Thierry Rabotins
Red Thierry Rabotins

As Don Henley said, I will not go quietly.

Mean girls: Our own worst enemy?

“There is a special place in Hell for women who don’t help other women.”  Madeleine Albright

I have participated in a number of leadership training seminars targeted for women in academic medicine.  These seminars spend lots of time helping us career plan, helping us communicate more effectively, helping us run meetings effectively.  What they don’t teach us is the sociology of organizations and leadership and one of the lingering barriers to women’s success: the role that relational aggression can play in women’s career development.

What is relational aggression? Quite simply, it’s manipulation of someone in a way intended to damage their relationships with others.  While it’s behavior that may be displayed by men or women, in American culture it’s a predominantly female behavior.  It consists of isolating someone socially through whisper campaigns.  It preys on the desire for connection and belonging.  It compounds workplace stress, something little needed in some of the environments where it is best described (nursing, I’m looking at your sisterhood on that one– stop eating your young!).  It’s often insidious, smoldering…and incredibly hurtful.  The most damaging piece of relational aggression is that those who see it for what it is often stand on the sidelines, afraid of becoming the next target.

Ladies, admit it:  You’ve either experienced it or witnessed it.  Gentlemen, I suspect you’ve had the opportunity to see these things occur as well.  This isn’t unfamiliar territory, but it is dangerous territory.

The reasons for relational aggression are likely complex, myriad, and something I will dig into when/ if I am reincarnated as a sociologist whose work focuses on power dynamics (because really, it is ALL about power).  What is perhaps more important is to be cognizant that it exists, and to figure out how we nip this phenomenon.

Organizational interventions can certainly help if it’s a pervasive part of culture.  In academic surgery we don’t have enough powerful women (yet!) for relational aggression to be a real danger in most settings.  Where we can have an impact in places where women are still a minority is to be individually accountable for our behavior and to hold our friends and colleagues accountable as well.

What is my commitment to help halt relational aggression?

  • As a leader, to insure that those who need access to me have that access
  • As a peer, to insure awareness of opportunities for participation and leadership
  • As a human, to not get sucked into smear campaigns and dirty gossip.
  • As a friend, to continue the work that a couple of colleagues and I have begun of nominating one another- or other Worthy Women whom we identify- for awards and opportunities.

It’s all about valuing people and their contributions, really.  I’ve never aspired to be a Mean Girl, and there is no time when that’s been more important than now for me.


Leadership perceptions and feedback: The Gender Gap

Last week this recent Fortune piece started circulating via email amongst a group of women surgeon colleagues of mine.  Included in the email chain was one friend asking, “Do you think this would be abrasive if I sent it to my Chair?”  and another lamenting about comments during resident evaluations with similar descriptors sneaking in.

For the Fortune article, the author acquired a convenience sample of performance review of men and women in tech; she found that the men were more likely to only receive constructive feedback, and the men were less likely to receive critical feedback.  The key differentiator?  Feedback based upon personality rather than behaviors.  While only 2 men received personality-based feedback, 71 (of 94) women did.  While I’ll blog soon about providing behaviorally oriented feedback, my discussion today is predicated on the previously identified “Double-Bind” dilemma that is faced by women in positions of leadership.

The 2007 Catalyst report that described the Double-Bind identified three main themes about women in leadership roles.    First, women struggle to navigate a narrow middle space between being too soft or too tough.  The bandwidth of “acceptable” behaviors for powerful women is indeed quite narrow.  Second, women leaders face higher demands for competence than their male colleagues.  I’ve said more than once that to truly succeed as a woman in surgery you have to be able to run faster, jump higher, and achieve more; being “average” is not an option for women in surgical training, nor for women in leadership roles.  Finally, women leaders are often perceived as either likable or competent.  We struggle mightily to reconcile these two descriptions, and in many ways it relates directly to being too soft or too tough as a boss.

How do we improve the perception of women as leaders?  The “Ban Bossy” campaign is probably a start, simply because it raises the issue to a level of awareness.  We mandate that evaluation is behaviorally anchored, not personality-based, unless personality issues at hand truly impair someone’s effectiveness in an irretrievable manner (e.g. a personality flaw that results in them yelling and throwing instruments in the OR- ironically, behavior that is disproportionately male). The recognition that cultures, particularly in male-dominated professions, remain conflicted about “whether, when, and how” women should exercise authority is important, but it’s ultimately only half of the battle.  We all need to speak up when we hear those subtle slights being made, and being conscious of them is the first step to generating change.

The truth is that many women ascend into leadership positions because they perceive that they have a responsibility to effect change.  To be an effective change agent, relationships play a tremendous role.  As women leaders, it’s our responsibility to remain purposive in our roles, using those leadership roles as a bully pulpit.  If we’re being placed into roles where we get an audience, we should- and must- use those roles to educate about the need for change.  That’s really the crux of leading, regardless of gender.


(Note:  I would LOVE to figure out a way to study women academic surgeon’s retention/ promotion/ tenure letter content to see if this holds in my own profession.  Anyone want to collaborate?)