The following manuscript was submitted to the September 2019 Women in Medicine theme issue.
In the 1950s, my grandmother wanted to be a doctor. She asked her father for her dowry money, wanting to use it instead to get her medical degree to become the first female doctor in her hometown. She married another doctor and practiced from an office below her home, accepting vegetables and dry-cleaning services as pay.
In the 1980s, my mother was rejected by 7 suitors, all of whom said that she was too dark, that her skin had been charred by too many hours in the sun. It didn’t matter that her skin reflected hours working as a social worker in rural villages while working towards her master’s degree. My dad was the first man who didn’t seem to mind.
In the 2010s, I graduated from high school and started college. I finally grew out of my own timidity, an unexplainable trait given the legacy of the strong women I had been raised by. I learned that I had a voice and deserved to use it. I went to medical school, moving away from home for the first time, to become a psychiatrist — knowing that allowing people to be heard was the most meaningful thing to which I could dedicate myself.
In 2018, I started residency, carrying decades of accumulated strength, experience and hard work with me. However, I frequently felt as though I had gone back in time to an era that would have been foreign even to my grandmother. When I spoke up, I was considered over-confident or stepping on the toes of my seniors. If I shied away from answering a question, I was labeled as weak or unprepared. If I introduced myself to patients as “Arya,” I was told it was no way to inspire confidence in patients. If I introduced myself as “Dr. Shah,” I would get asked how old I was. I watched the men on the team get handshakes as the women got smiles. I watched male physicians interact with each other as equals, as female physicians were dropping “sorry” at the end of every other sentence out of habit. I scanned the room as I spoke with patients and their families, watching as every eye was on the tallest male physician in the room, even though the words were coming out of my mouth. No one else ever seemed to notice.
For years, I’ve seen women march, publish and fight against arbitrary divisions. However, for the first time in years, I found myself feeling a tickle of self-doubt. That same old timidity creeping in as I naïvely realized that I was finally experiencing what women have experienced for decades, what my own upbringing had shielded me from for so long. Moreover, it was happening in a field built on the principle of caring compassionately for all.
Nothing I am saying is being said for the first time.
In 2016, female physicians reached higher scores of self-reported emotional exhaustion and depression.
In 2017, women were significantly more likely to feel that their gender put them at a disadvantage in the workplace, and to note sexist behavior at work. Female residents were significantly more likely to have experienced discrimination from patients, attending physicians and other residents.
In 2018, quantitative studies using validated wellness questionnaires showed significantly worse scores for quality of life, psychological health, and daytime sleepiness among women, despite no significant differences in empathy or resilience scores between genders. Focus group analysis revealed common feelings among women of insecurity, guilt, and self-doubt as some of the most commonly identified contributors to these discrepancies.
In 2018, a quantitative study of general surgery residents revealed that fewer female general surgery residents self-identified as “surgeons” (11.1% versus 37.5%). Residents felt that patients and physicians more frequently disregarded female residents’ professional role.
In 2018, female students’ self-assessment scores were significantly lower compared to peer-assessment, whereas no significant difference was found between self- and peer-assessment scores for male examinees.
In 2018, female sex was independently associated with increased rates of burnout among residents.
In 2009, back when I was still swimming three hours a day, figuring out college plans, and able to eat as many hot Cheetos as I wanted without getting heart urn, the Royal College of Physicians published a report optimistically titled Women and Medicine: The Future. In it, a summary of data points to the fact that barriers to entry are no longer the principal issue facing women in medicine. Rather, given the growing proportion of women entering the medical field, it was noted to be imperative to establish structural changes and policies to ensure that this new demographic within medical practice be warmly welcomed and incorporated.
We have made progress: My grandmother spent her dowry money on her education, my mom learned to embrace the skin that came with her master’s degree, and women now make up most medical school applicants and matriculants. The physician workforce is increasing in its proportion of women, but this raises a whole new set of challenges for women in medicine, including the self-doubt, fear of discrimination, and anxiety prominently documented in the literature of the past decade.
For the first several months of my intern year, I felt like I was drowning in those very emotions — trying to claw to the surface of an ocean of electrolyte repletion, EKGs, blood thinners and diuretics. I would constantly look at those around me and wonder if it was a mistake for me to be there, as if I was an imposter who somehow snuck in, destined for failure. I’d go home, cook, go to yoga, call friends and family, try to live a normal life, and wake up the next morning to repeat the process. However, as days and months passed, I couldn’t seem to shake that feeling of not belonging.
Around six months into my intern year, I found myself in an all-too-familiar situation: I was speaking to a patient and his family members about the treatment plan. As usual, all eyes were fixed on the male physicians in the room. Deciding to follow suit, my eyes turned towards my senior and my attending. I noticed then, however, that my senior and my attending were looking at me. Anytime a question was addressed to them, their eyes met mine, expecting an answer from my lips. As minutes passed, I noticed a shift in energy and eye contact, as more individuals turned their gaze towards me as I spoke. I felt myself standing taller, even going in for the handshake at the end of the discussion before hands were offered to me. For once, I felt like others were seeing me as confident.
However, perhaps the most important realization that came with that experience was the realization that I deserved to feel that way. It was strange to think that I needed external validation to finally start to feel like I was doing what I was meant to do. I do know that eye contact and handshakes aren’t going to solve overnight the problems that women in medicine have been experiencing for years, but that day, handshakes shook my self-doubt, eye contact made me see my own worth, and a team standing up for me helped me to stand a little taller. It gave me what I needed to continue to push through the rest of my intern year.
The concept of faking it till we make it is something that many of us can relate to, women and men in medicine alike. All I can hope is that we all continue to validate each other, support each other, and value what each of us has to offer to our patients. Walking the walk and telling each other that we are good doctors may be just what we as interns need to sustain lifelong careers in medicine, to know that we are in the right place and to make medicine a field that embraces all of its professionals with the support they deserve.
Image credit: “Post-It Notes” by Dean Hochman is licensed under CC BY 2.0.