Reading-Round Up, February 2017 edition

As promised, here’s the February reading round-up.  What’s caught my eye recently?

I was at SCCM two weeks ago, and would encourage anyone with an interest in critical care to read the Plenary Articles published in Critical Care Medicine.  These presentations at the meeting were all nothing short of amazing.

And… the Sepsis Guidelines have been updated (note: it’s mostly tweaks, little that’s entirely new).  If you’re not a critical care doctor, this is still important and relevant if you want to provide evidence-based best care when your patient has something go wrong.

In surgery we sometimes get to have conversations with patients and families when we don’t anticipate a completely smooth clinical course.  I’ve been playing with this framework since Gretchen Schwarze came and talked to us about it last year, and I find it helpful.  You might too.

Here’s some background work (with more great work coming) from my colleague Chris Pannucci on Anti-Xa level monitoring and perioperative use of enoxaparin.

Last year at the ASE meeting I was a little dismayed to find the frequency with which medical students use Wikipedia as a reference during the clerkship.  This article provides some justification for simply embracing it and makes me question if we should have a Wikipedia “hackathon” during 2018 Surgery Education Week.

I’ve preached about the importance of allies for women in male-dominated fields before in this blog.  Here’s another confirmatory article from HBR. Men, we really need your support, and if done right we can even benefit from your leadership.

Happy reading, all.

The need for enlightened men

Last week I was involved in an email exchange with two colleagues (we’re working on a subversive project together…more on that eventually) when one of them pointed out that a 2017 meeting of a major surgical organization has exactly zero women scheduled as a keynote speaker.  Yes, you read that right.  Zero.

This isn’t a a specialty organization I’m a member of because it doesn’t meet my clinical or professional development needs, but both of these colleagues are members. And while I know some of that organization’s higher echelon leadership fairly well from other organizations, I’m not really in a great position to point the issue out to them since I’m not a member.

Fortunately, our third colleague involved in the Subversion Project is a man. Most importantly, he’s a man who does not hesitate to speak up about failure of inclusion, and he also happens to be a member (and leader) of the organization in question. He’s asking lots of questions about diversity and inclusion, and I made it a point to thank him for doing that tonight.

This series of events was buttressed by an HBR piece last week on men who mentor women. While this particular instance is less about mentoring and more about “doing the right thing,” it’s behavior that tells me that this individual is also likely a remarkable mentor and sponsor to women surgeons. And he’s engaging in the first behavior identified in the HBR article, using his authority to change workplace culture.  While he’s not in one of the BIG leadership changes to force change about inclusivity in the organization in question, he is using his voice to ask important questions and make sure that the issue isn’t ignored. He’s being an ally, and that’s something that none of us can underestimate the value of, even as we’re about to enter 2017.

Patricia Numann has long used the phrase “enlightened man” to describe the allies who have helped to advance women in the surgical profession. In interviews I did in 2014-2015 about barriers to academic careers, the preponderance of the mid-career and senior women surgeons I interviewed described at least one male mentor who was instrumental in their career development. Until we achieve a critical mass of women in academic surgery, meaning we’re 1/3 or more of those at the table, this isn’t going to change much in the absence of spectacular help.

You know, the kind of help that raises its hand and says, “Hey, we can do better to represent our membership in general,” then gets to work making sure that actually happens.

(Additional reference for men who want to learn how to be better allies for women in male-dominated fields is the man-focused chapter in Feminist Fight Club.  When I read it, I thought immediately of several men I know who could have written it and definitely live it.  Thank you if you’re among them.)


Leadership and the ambition gap

The McKinsey 2016 Women in the Workplace report was recently released; it’s taken me a bit of time to process the information in it. It’s complicated, and in the throes of a Presidential campaign that is rife with misogyny, it might even be a bit discouraging. We know in professional America, and in academic surgery, that a significant fall-off occurs in the number of women as leadership roles become more powerful. In academic surgery, we see it with the drop from 16% of Associate Professors to 9% of full Professors; we see it with the paucity of women in leadership roles in major organizations; we see it with the number of women who are department chairs (recognizing this number has improved dramatically even in the last year).

We know that women often simply don’t seek promotion to the highest levels, perhaps because work-life integration is more acutely present for women in our society. Perhaps its because we have an unconscious bias against ourselves that only allows us to take a chance on that “big” job once we’re 100% qualified (or, perhaps, more than 100% qualified).

Or maybe, just maybe, it’s because we’re programmed to think of “power” and “ambition” as dirty concepts.  They’re not ladylike, and therefore we don’t want to be in that top role because that would require us to be ambitious and it would require us to use our power.

Gap in Leadership Ambition
Gap in Leadership Ambition

This week I saw an interesting complement to the idea of the the ambition gap, in which Anne-Marie Slaughter hypothesizes that women perceive ourselves as able to have a greater impact at the center of a “web” than at the top of a hierarchy. While her idea that women don’t understand the impact we can have at the top, it’s also plausible that we are so much more comfortable working collaboratively that the idea of having diffused impact through a network is what makes the most sense to us. What we may be overlooking is that we can use the same high-touch, collaborative skills when we’re in that “big” leader position, and use it to our advantage.

Maybe it’s time for us to change our thinking and stop being one of our obstacles (because heaven knows there are plenty without self-sabotage). Maybe we need to realize that it’s okay to dream big, and that it’s okay to start looking even when we don’t think we’re quite ready.  Maybe, ladies, it’s time to leap- and our nets really will appear.  It’s a win for each of us who is ready to do so, and it’s a bigger win for those coming after us as they see our courage, our commitment, and our strength.



Rule Number 5: Everyone’s an equal fighter

PSA: It’s Women in Medicine month.  I would be completely remiss if I didn’t have at least one feminist post this month.

And a warning: Have you heard of Feminist Fight Club (FFC)? No? I’ll warn you that there’s some salty language over there, so if you’re easily offended it may not be for you. That said, it’s a how to guide for fighting sexism with plenty of data.  It’s my current read, and I’m loving it. It’s also providing me with some inspiration.

Before you question if there’s a need in surgery and in medicine for something like FFC, I assure you that there still is. Although women have been half of all medical students for a decade or more, our gains in academia and leadership simply aren’t matching the numbers there- and it’s not simply a time decay phenomenon.  Women enter academics at a lower rate, and our attrition rates are higher.  Even with our equivalent levels of training, we are paid less. These are all simple facts. So, yes, while FFC isn’t written about careers in medicine, it’s no less applicable in our professional world.

Bennett divides her stories and facts into a few key areas:

  • Know the enemy (for the record, it’s patriarchy, not men in general)
  • Know yourself
  • Booby traps (a/k/a “office hospital politics”)
  • Get your speak on
  • F you, Pay me
  • WWJD- What would Josh (a really average white guy) do?

Interestingly, several of these concepts, particularly those around effective communications,  align with key features of Executive Presence, which were published in a more “formal”/ professional  manner.

One of the bits in Feminist Fight Club that resonated the most with me was one of the ground rules for Bennett’s group- no mean girls. We are all in this together, and if we’re busy fighting with you, we can’t get the work done.  You’re a distraction. If you’re a mean girl, we’re still fighting the patriarchy on your behalf.  We’re just not including you in our meetings about how we’re getting it done. Work this important requires a drama-free zone.

I’m going to borrow Bennett’s questions that she includes as discussion topics for a Feminist Fight Club meeting, and I’m going to encourage you (reader) to think about them, to develop your own set of responses.  Note: Men and Women both welcome to play!

  1. Where do you want to be in 5 years?
  2. What’s your biggest pet peeve at work?
  3. What career goals do you have, and who can help you to achieve them (include yourself on the list!)?
  4. When is the last time you were proud at work? Why?
  5. (For those who read the book) Try out a FFC ninja move, keep notes on how it worked, and report back to some like-minded friends.  Guys, you also have FFC ninja moves that start on Page 239. We’re all in this together.

You’re not crazy.  It is real. And being aware of it is the first step to solving the problem.

Apropos of nothing at all: The best piece of advice appears on page 103- Take the nap. 


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.


Mind the (author credit) gap?

HT to my Dad, who is a more reliable NPR listener than I am (it’s an advantage of retirement, I’m told). Yesterday he shared a short segment from All Things Considered that discusses the gap in women as first and senior authors in medical publishing.

I have two key concerns looking at the article they discuss and after digging a bit more deeply into the literature in this area.  One is the evidence of a plateau in women as first or senior authors in the last 7 years.  Is this because we’ve hit a glass ceiling in science? Is it because we’re not trying? Is it because of implicit bias? Or is it some combination of the three?  Those concept are all subtle enough that it’s almost impossible to determine the role that each plays without employing qualitative methods. Of course, the beauty of qualitative methods is that more reasons we aren’t even thinking of might be playing a role and this would help to identify them.

My second concern is the one alluded to in the conversation with the female cardiologist in the NPR piece. We know from many areas of the business and academic literature that as women we tend to advocate poorly for ourselves; most of us culturally can’t get comfortable with the probability of being viewed as pushy, which is a documented consequence of aggressive negotiation tactics. Is our absence as first or senior authors a result of us failing to negotiate and advocate effectively for ourselves in yet another realm? Is this another manifestation of “Women don’t ask” in a way that is perhaps even more insidious than failing to negotiate salary?

And, of course, I can’t help but wonder if this isn’t generally representative of our global shortcomings in attracting and retaining women into careers in academic medicine.  Until we have a system that provides the professional development opportunities, the hard resources, and the work-life integration capabilities that are expected in the modern world, there may be little additional room for change.

An accidental feminist

I have to start with a brief explanation of the framework I approach the world from.  I’m an only child.  I was raised by parents who never divided my world into girl things and not-girl things. I loved dresses, hated ballet, loved my motorcycle (yes, I had one), hated being told I couldn’t do anything. I took piano lessons for 10 years and was in choir from 1st grade on. I wore pink because I liked it, and I wore blue because I liked it too.  I did have a tutu and a tiara because in my mind those were power objects (fairy princess, FTW!). My career aspirations were to be a cowgirl princess surgeon President- at least I got three of the four right (with two only being part-time gigs, of course)!

The first time I encountered actual gender bias was at age 16.  I was in our family doctor’s office getting my requisite pre-College paperwork filled out, and when he asked I responded that I was headed to A&M with plans to go on to medical school. His response? “Well, I guess it’s okay for girls to be doctors these days.”

I walked out of his office, never to return.  Note: this was 1984.  It simply had never occurred to me that people might question my ambitions because of my gender.  Never.

The next episode of gender bias was during my career “detour” between college and medical school. What I didn’t realize when I started graduate studies in Political Science, and in International Relations in particular, was how much of a male-dominated world that was.  Women were definitely exceptional, though it truly wasn’t an issue in my day-to-day existence with my advisor and the rest of our group who worked for him.  Where it became an issue was when one of my classmates commented, “Well, you get all of the good assignments because you’re a girl.”

My response? “No, I get all of the good assignments because I’m good at what I do.” Please note that this classmate no longer was considered a friend after this episode and that I kept getting the good assignments until I left grad school.

And then I landed in academic surgery. I’m one of the 16% (women who are associate professors in surgery) and aspiring to move in the near future to the 9% (women who are professors in surgery). I finished my surgical residency with a class that was 60% women and in which everyone else took parental leave. I want to clearly state that my career has been fostered by many of those individuals whom Pat Numann calls “enlightened  men,” starting with my mentor in medical school and continuing into my decision to become a burn surgeon and my subsequent clinical career in burn surgery.  When I started as burn faculty in 2005, we had fewer than 10 women practicing in burns in the US.  Here’s the thing, though- when I decided to go into surgery, and when I decided to go into burns, I knew there weren’t many “like” me, but I also didn’t have anyone look at me and tell me it wasn’t a career for a woman.  I was fortunate to have been promoted and mentored and sponsored by people who simply wanted the best person for the job, and who (fortunately) thought I was that person.

My experiences have definitely colored who I am and how I perceive gender relations in our profession today. I believe that times are changing and that those who don’t believe that women can do the job, or who believe that women get special treatment, are fading quickly from our profession. I’m not delusional enough to say that it’s all sunshine, rainbows, and bunnies because I know the reality is different.  It’s not perfect everywhere…yet.

What do I want for all of us at this point? A level playing field, and one in which we don’t have to think about a woman surgeon or a surgeon’s race. I want us all to be surgeons, and to be great ones who reflect who our patients are.


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.



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.


Bias, interrupted

Earlier this year, many of the tech giants came clean about their remarkably low numbers of female employees, which are highlighted in the lack of female leadership in the tech industry.  While we are seeing dramatic improvements in the number of women training in surgery, we continue to struggle in academia, and particularly in areas of surgical leadership.  The October HBR includes an article discussing tech’s diversity problem, particularly with regard to gender diversity, and introduced me to the interesting concept of the bias interrupter.  To summarize, a bias interrupter is an intervention designed not just to demonstrate patterns of gender bias, but to break those patterns.

Williams includes a citation of this work published in 2013 as a bias interrupter for salary inequity at time of hire.  Apparently if women understand that there is an expectation to negotiate, we do so, and we might even do so better than our male colleagues.  Women may also derive equality (or non-inferiority) from negotiations that are not conducted face-to-face, something confirmed in Leibbrandt and List’s work and demonstrated previously in other venues.  To me, the most important feature of this work is that it took an area in which there is a known issue (women generally fail to negotiate starting salaries as well as men) and addressed it without explicitly bringing up culture or gender.  While I wrote in September about leadership perceptions and the gender gap, with an eye to performance evaluation and promotion of women in surgery, I will admit that I would prefer to address this challenge for our profession without having lengthy discussions on sociology.  I want data to clearly define the problem, I want a way to measure the problem, and then I want to start experimenting.

When Williams discusses the four basic patterns of bias, multiple opportunities jumped out at me. “Prove it again” comes up in evaluation for hiring and promotion, as well as in performance evaluations.  Reading about “Tightrope” made me wonder- are the women who leave academics leaving because they do more “housekeeping” tasks, as opposed to getting the glamour work, and are therefore dissatsified? Do glamour roles for women encourage their satisfaction and, in turn, encourage retention in academia?  What is the role of the “maternal wall” in hiring and promotion in academic surgery?  And last, but not least, why can’t we stop playing “tug of war” with each other- we really shouldn’t be our own worst enemies?

Obviously these are all just musings as I worked my way through Williams’ article, and all of her thoughts on tech diversity may not be perfectly applicable in academic surgery.  To my eye, performance evaluation of trainees seems an easy enough place to start, as does the promotion and tenure process; if we have clear objective metrics for these activities, and we spend time training people to improve their documentation and evaluation skills in a neutral manner, the accountability alone should mitigate bias and raise the playing field for everyone- not just women, and not just minorities.  I’ve found that driving change by showing how everyone benefits is far less scary for people than focusing on equity issues.