“The Change” is a phenomenon that has been present since the start of the residency program. It didn’t have a name back then. The physician assistants noticed it first. It wasn’t subtle. Bets were placed on who may avoid this metamorphosis, if it was even possible to avoid.

It wasn’t caterpillars turning into beautiful butterflies, that’s for sure. “The Change” was when a bright-eyed, optimistic female junior resident turned into an angry, and sometimes mean, senior resident with very little patience for anyone. In our five-year head and neck surgery residency, the title “senior resident” was bestowed at some point in the fourth year. 

“Why is she so mean?” Female junior residents would say nearly in tears, or sometimes in full-blown waterworks. Maybe she forgot one of 12 supplies for a procedure and was met with a fiery death stare before she ran to the clinic downstairs to grab it. Maybe she asked the same question twice for clarification and received a snappy response without an answer. “I will never ever do that to my juniors!” She would tell anyone who would listen. “I will never be mean!”

Two to three years later, she would grow into a confident fearless surgeon who flew super-woman-style into the hospital to save a patient from an airway emergency or a life-threatening bleed. At about that time, “The Change” would hit. Her blood would start to boil at the drop of a hat, steam would come out of her ears and fire or laser beams would shoot out of her mouth. She wouldn’t even notice it happening, or at least she never acknowledged it. But why? Why did this happen? And why, with some exceptions, were her male counterparts able to avoid changing?

I asked these questions over and over during my junior years as I watched or heard about previous female residents going through it. I spoke with Leslie, a resident in the year above me. She was the one who finally gave “The Change” its name.

“Don’t let me change,” I told her. I promised to bring it to her attention if it ever happened to her, too.

It was during my fourth year when I finally understood it. Of course, it took skirting along the edge of “The Change” to figure it out. It took a series of events to notice a pattern emerging. Allow me to give you some examples from just one of the many weeks where I was the senior resident on call:

The First Event

I was on call with one of my junior residents. We had taken call together before and we usually had fun teaching, learning and tag-teaming patient care and consults. This night, however, had been rough. Every time we turned toward the door to get some sleep, knowing full well we had to be alert at work the next morning, we got hit with ER consult after ER consult.

In one of these middle-of-the-night consults, we got a call. “You have a patient in the step-down ICU that has been transferred from another hospital. We don’t know anything about her, but she can’t breathe.”

Upon evaluating this lady’s airway with a laryngoscope (a spaghetti-noodle appearing camera with an eye piece at the end that passes through a patient’s nose and back into the throat), her airway looked bad but she was stable. She could make it until morning when our operating room staff came in. Heliox would help get her through the night.

Heliox is exactly what it sounds like, helium mixed with oxygen. The helium decreases the density of the oxygen allowing the oxygen molecules to bypass the obstruction and make it to the lungs. The respiratory therapist said this cannot be done in the step-down unit the patient was in.

Weird, I thought. I’ve ordered it here before with my male senior resident. I told her that.

She went to ask her supervisor, who joined her and the charge nurse of the floor to tell me it cannot be ordered outside of the ICU. Again, weird because the point of Heliox is to keep patients stable and out of the ICU. ICUs can be dangerous places and sending a patient there put her at risk of infections, a risk that wasn’t worth taking if the patient didn’t absolutely need to be there.

I explained my point, but finally I said, “Don’t worry about it — we will just take the patient to the operating room so she can return safely to your floor.”

They made me rush an otherwise stable patient to the operating room in the middle of the night. Frustrating, but I didn’t think too much of it until my junior resident that witnessed the conversation said, “They ganged up on you. I don’t think they would have done that if you were a man.”

Interesting, I thought.

The Second Event

I was on call again that weekend and taking care of our head and neck cancer patients along with one of our star physician assistant fellows training to become specialized specifically in head and neck cancer. Since some of our patients cannot eat due to resections or reconstructions in their mouths, we place feeding tubes as they heal.

We were taking care of one such patient and had placed him on a specific product for his safety. As usual, we started him on continuous trickle feeding using a tube feeding pump until we were able to get him to his goal calories. At this point, we transition patients over to bolus tube feeding, or give them cartons of tube feeding solution which they can put into their feeding tube from the comfort of home.

We got a call from the nutritionist saying that this couldn’t be done, since the hospital didn’t have any of the cartons of the product we needed. She then went on about how expensive this product was. I thought, Why did it matter? The cost if it was what was best for the patient and would keep him from getting complications. We suggested splitting the bag on the tube feeding pump into separate syringes so the patient could learn to feed himself as an alternative to cartons. This was the only thing keeping him in the hospital and the man wanted to go home. I told the nutritionist we order this product all the time for our patients and have never had an issue. I realized again — last time I had ordered it with a male senior resident.

I received push back again and again that weekend. For everything I would normally do for my patients, I had to discuss, advocate, coax and argue, which meant every task took much longer.

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As junior residents, we are used to being told what can and cannot be done. We learn from the nursing staff, respiratory therapists and nutritionists, as well as our senior residents and faculty who are experts in their respective fields. You learn that all of these people are a team with a common goal of taking care of patients. You learn that once you become a senior resident and finally know what to do, you lead the team and are responsible for the well-being of your patients.

What I had not learned was that confidence and knowledge were not enough to lead this team. I learned that apparently you also have to be male. If you’re not a male, your coworkers don’t trust you. As a female, you have to do a lot of convincing to prove to them that you know what you’re talking about — that you can be trusted. I didn’t learn this early on because all of my seniors had been male. They were trusted implicitly and assumed to be competent until proven otherwise. I also noticed that the push back I had received was only when working with staff that were not familiar with me. The staff that I work with often, the ones who watched me grow from an intern to a senior resident, respected and supported me at every turn.

I was exhausted and frustrated as the end of that nightmarish week rolled around. Everything I normally did had taken twice as much work. First, I had to make decisions in the interest of the patient and then I had to try to convince everyone on the team that a woman could make competent decisions for patient care. My blood began to boil, steam started coming out of my ears, and I was definitely starting to breathe fire…

It hit me. I looked at Leslie and mouthed, “I’m going through The Change.”

At that point, I went home and tried to have a relaxing evening. I tried to reset. I was not going to change. I was determined. The change finally made sense though. Wow, was it rough being a female surgeon. Of course, I’d been through all the normal gender disparities. I thought I had seen it all when it was assumed I was a nurse and not a doctor. Or after reading article after article about how female surgeons continue to be paid and promoted less, independent of if they have children or decide to take maternity leave. Or by being scolded by senior male faculty as if you were a child while our male counterparts got fist bumps. This pushback was different in that it compromised patient care. It made an already exhausting day longer and more frustrating. It made you angry, but I wasn’t about to take it out on other people. My predecessors had made it through and so would I, only I was going to be nice. I wasn’t going to let residency change who I am.

That said, I am at the beginning of my fourth year and still have two to go. There’s a fine line between losing your temper and being strong, persistent and firm. I don’t know if I will succeed in resisting “The Change,” but I have an advantage my predecessors didn’t. I am aware of its existence, and this awareness empowers me. I will continue to look for opportunities, support and resources — hopefully I will change into a beautiful butterfly instead of a dragon monster with poisonous fangs. Wish me luck.

Image courtesy of Dr. Abdel-Aty. Photo taken by Nathan Pallace.