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Avoiding #metoo in medicine

Let me say first that any woman who has ever been harassed or assaulted should NEVER be made to feel that it is her fault. It is always the perpetrator’s fault. Men can be boors, or worse, and testosterone can be toxic.

I went to Princeton University at a time when the ratio of men to women was 8:1, graduated from medical school in the 1980s, and raised two daughters. I’ve had ample reason and plenty of time to think about strategies to deal with harassment, parry a verbal thrust, and maneuver out of a potentially humiliating or harmful situation.

We’re lucky in medicine that we have intellectual qualifications — board scores, professional degrees — that are our primary entryway into medical school and residency programs. We’re not being judged PRIMARILY on our looks. Yet many social media comments recently have underscored the fact that some women in medicine have endured ridicule, harassment, and even assault in the course of their careers. It makes sense to explore any tactic that can help other women avoid similar painful encounters.

Here are some tips — learned through long experience. My hope is that they might help younger women in medicine feel less like potential victims, and more like strategists in a behavioral chess game.

Act like the person you want everyone to think you are

Don’t be fooled. The people who look most self-confident may be pretending. In fact, unless they have Trumpian egos, most people are less self-confident than you imagine. This is a game you can play too, to your advantage.

Stand up straight. Looking meek or unsure — whether you’re a little kid, a woman, or a man — invites bullying. Harassment is just another word for bullying. Don’t clutch your notebook or iPad to your chest. Learn to look people squarely in the eye. Nothing speaks confidence like a forthright look in the eye and a pleasant smile, no matter how much shorter you may be than the person you’re looking at. Social psychologist Ann Cuddy has given a fascinating TED talk on the importance of body language, and it’s well worth your time to watch.

Take a self-defense class for women. Many police departments offer them for free. The message they teach isn’t so much about learning to fight as learning how to avoid a fight. They show you how to adopt a stance that signals you’re not a vulnerable target.

Don’t wear a hairstyle that keeps you pushing bangs out of your eyes like a teenager, or trying to tuck a wayward strand behind your ears. Flipping your hair back could be misinterpreted as flirtatious, even if you mean nothing of the kind. If you wear contacts, think about wearing glasses at work. They protect your eyes against blood or fluid splashes, which is very important in every clinical setting, and they look professional.

Men have it easy in terms of what they wear. In professional, formal settings they wear a uniform:  suit, tie, light-colored shirt, and a narrow range of haircuts. The more conservative the setting, the more they lean toward white shirts and even more conservative ties. Think of this as protective coloration. They don’t want there to be anything to criticize about their wardrobe choices. They want people to listen to what they say, not focus on how they look.

Women have it harder, with too many choices, really. There’s nothing wrong with a conservative suit, or a dark-colored dress under a white coat. Hairstyles can get even more complicated. The prettier you are, the more important a professional-looking, even severe, hair style is to your being taken seriously. Look at photos of Gal Gadot in what was a silly, but actually very funny, movie called Keeping Up with the Joneses. In the role of an international secret agent, her hair is pulled tightly back away from her face and twisted in a braid. The message: don’t even think about messing with me.

Take sufficient care with your appearance that you look well dressed, well groomed, and competent, even if it doesn’t come naturally to you. Get a personal shopper if necessary. In every career and every setting, having people WANT to look at you and talk to you is an advantage in education, promotion, and success. This is reality, not frivolity, and it applies to men just as much as to women.

Yes, you have a right to wear whatever you like. But poor choices have consequences, whether it’s a very short skirt, too much cleavage, or not bothering to care if you look sloppy. As my late mother used to say, “Act like a lady, and people will treat you like a lady.” Dress for the respect you want to enjoy.

How to respond to harassment

Inevitably, nearly every woman will encounter an inappropriate remark. My usual response has been just to ignore it and let it fall flat. There’s no point whatever in responding. The speaker isn’t likely to repeat it. Pretend you didn’t hear it; pretend you’re busy writing a note or checking your phone. The worst possible response is to look embarrassed. That just encourages a repeat performance. Remember the classic Far Side cartoon about the giant squid:  Just don’t show any fear.

If the speaker won’t give up, and the comments are hostile, look him straight in the eye and don’t be the first to break eye contact. If the remarks are more cringeworthy than hostile, practice the faint sigh and eye roll, and look around as if you’re bored. Either way, then divert the conversation by asking a question about the case, or bringing the focus back to the next tasks to be done by the team. You look professional and the speaker looks foolish, but you’ve said nothing insulting and you’ve shown your ability to take control of the situation.

A psychiatrist friend, who was an intern with me, gave me excellent advice one day when I was complaining about an arrogant surgeon’s rude behavior. Don’t get angry or feel hurt, he said. Just think to yourself, “Is this what it takes to make your penis get hard?” I’ve thought of that advice often, and it always makes me laugh.

Don’t make the mistake of responding angrily, or making an equally insulting remark, especially to a person who is your superior in rank. This puts you on their level rather than on the moral high ground, and puts you at risk of career and reputation damage. However, if the speaker is at or below your level of seniority, you can say, “Seriously?” Or you may want to ask this simple question, “Where is your mother?” It underscores the juvenile nature of the behavior, and immediately defuses the sexual context.

When I was a resident in anesthesiology, there was a senior attending physician who seemed to be a very pleasant man. But he liked to teach the art of mask ventilation by standing directly behind me and putting his left arm all the way around me to hold the mask while he squeezed the bag with his right. This happened more than once, even after I had learned to mask-ventilate quite well. I compared notes with the other four female residents, and learned that we all had been “taught” in the same fashion.

We made an appointment — all five of us — to speak with the chairman. We explained that we liked Dr. X, we thought he was a fine anesthesiologist, and we didn’t want him fired, demoted, or shamed. We just wanted the behavior to stop. The chairman, who was a highly articulate man, opened and closed his mouth a couple of times. I had never seen him speechless before. Then he said it would stop. We said thank you, and left. The behavior stopped, we all went on with our training, and Dr. X continued to be perfectly nice to all of us.

Be gracious and make friends

People say men and women can’t be friends, but don’t believe it. The best way to avoid harassment is to be on cordial — but not overfamiliar — terms with everyone you work with, even if it’s just a short-term rotation. You want them to be happy to see you and to work with you. The art of good manners is making everyone around you feel good.

Once you’ve had coffee or lunch with someone, maybe shared family photos on your phone, or talked about the unique virtues of your cat, that person is very unlikely to behave badly toward you. With senior physicians, keeping the talk completely professional is best. Asking for career advice or how they would handle difficult cases is the way to learn from them and to get good evaluations. Most of those “old white men” are actually nice people, and they can help you.

Once, as a medical student on my surgery rotation, I had spent a long day in the operating room with a senior plastic surgeon, who then offered to buy me dinner. I accepted, which was a bad idea. In my defense, I was tired and hungry, and since he was married I didn’t think this was a date. He proceeded to tell me how his wife didn’t understand him. I was sympathetic, and said how lucky I was to have a wonderful boyfriend who was also a medical student and understood how hard the work is. I went on to ask his advice about my father, who was developing contractures in his hands from Dupuytren’s disease. The upshot:  I referred my father to the surgeon, who did an excellent repair on his hands, and the surgeon and I stayed on very good terms.

Friendly but not flirtatious behavior is even more important with a man who is aggressively coming on to you. You want to change the dynamic, and get him to relate to you the way he would relate to a sister or a cousin. Getting to know him personally, and making him feel friendly toward you if possible, is the best way to do that. If you’re scared or repulsed, and try to avoid him, the pursuit is much more likely to continue. Think of this strategy in terms of animal behavior; you’re much safer if you’re part of the pack, not prey.

There’s no insult in being asked out or asked for your phone number, though it’s certainly inappropriate if the person is your superior in rank. Use your words, smile, and say no, I’m sorry, I’m not available. If you’re really afraid of reprisal or of bruising his ego, say, “It’s so kind of you to ask. I’m so sorry; I’m in a relationship.” Then offer no further explanation, and divert the conversation to another topic. As the Dowager Countess of Downton Abbey says, “Never complain; never explain.” All of us are in relationships, after all, and there’s no need to specify whether it’s a romantic relationship or a special bond with your dog.

If you’re a resident or an attending, take pride in being a physician. Don’t encourage use of your first name. I always introduce myself to patients as Dr. Sibert, and I say “Dr. Sibert” every time I answer the phone or take part in a “time out” in the operating room. Residents are never rude to me. A thoracic surgery fellow joined the staff at my hospital, and after we had worked together for years, I finally said, “It’s fine to call me Karen.” He shook his head and said, “Dr. Sibert, I just can’t.”

The tactic of consistent friendliness and professionalism — not overfamiliarity — also works well with nursing staff. Many young women physicians encounter hostility from nurses, and have trouble even getting their orders followed. This too can be managed.

Smile, and learn the nurse’s name. Don’t get offended or bristle, even if a nurse is rude. Always explain the reason for an order, and treat the nurse as a colleague. If the nurse offers a good reason for doing something, as long as it isn’t outright dangerous, go along and say thank you for the suggestion. NEVER express irritation at being paged, and say “thank you for letting me know” at the end of the conversation. When appropriate, thank the nurse for a good catch or observation. When you’re in a new environment, if you need something, ask where it is and offer to go and get it yourself rather than asking the nurse for it. This engenders immediate good will, and shows that you’re neither lazy nor entitled. You’ll know you’ve won when the nurses invite you to their potluck lunches — well worth the effort.

Avoiding misery

Don’t make the mistake of allowing yourself to be caught alone with anyone you don’t already know and trust. If you’re invited to go into a private office and you’re not comfortable, just leave the door open. Claim a severe headache (accompanied by nausea) and a need for air if necessary. There’s no reason to share a call room; it’s better to doze in a chair, or nap on a stretcher.

Don’t take stairways at night; take the elevator. If you have to go to a deserted parking lot after dark, ask a security guard to walk you out. Any time you feel uncomfortable, even if it seems irrational, trust that sixth sense. Head for a public place, with good lighting, where other people are around.

Yes, it’s unfair that women have to think in self-protective ways while men don’t. It would be lovely if the world were a perfect place, but it isn’t and won’t be. It makes more sense to be smart and in control than to have the unreasonable expectation that life will change immediately just because Harvey Weinstein has been disgraced.

The potential risks of the #metoo movement were outlined well by former US Secretary of State Condoleeza Rice in a recent CNN interview. “Let’s not turn women into snowflakes. Let’s not infantilize women,” she urged. In the worst-case scenario, she pointed out, men in hiring positions could decide that it’s just too much trouble to have women around, and opportunities could paradoxically diminish.

That would be a shame. Women who make it all the way through medical school have worked hard, and we’re neither weak nor delicate. Let’s continue to prove it. The only behavior you can control is your own, but you always have the opportunity to influence the behavior of others. That, with negotiating skills, constitutes the art of leadership. Making absolute demands doesn’t work. If we want to keep the doors open for even more women to achieve leadership positions and political power as time goes on, we need to work hard and concentrate on turning the men we work with into our allies, supporters, and sponsors. Thinking of them as enemies is a path to nowhere.

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When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

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Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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