Finished Year, Unfinished Business

The jury's still out on reflective first year sentiments, but it's been gratifying to share my thoughts back from the very beginning of medical school.

I had the honor of reading my "Letter to a Young Doctor" on the medical documentary series White Coat, Black Art. The radio show ran on the Canadian Broadcasting Corporation (Canada’s national public radio and television broadcaster--similar to America's NPR or PBS).

Link to audio--my piece is at 22:00.

Link to June 10 show description.

Dissected

The anatomy article is running today.  I want to be a writer--not for my diary but for the public.  I know I've got to be open to scrutiny.

But damn if I don't feel entirely dissected right now.  On display, vulnerable.  The irony hasn't gone unappreciated.

Can Seven Comments Help Explain $17,000?

Update: Now on the Hastings Center Bioethics Forum.


A study this month in Health Affairs found that the gender pay gap for starting physicians had widened from $3600 to nearly $17,000 over the last ten years (after adjustments for specialty and hours worked).  The authors hypothesized that the main reason for this was that women are intentionally choosing lower-paying jobs because these jobs provide greater flexibility and family-friendly benefits.  Though they do not deny that gender discrimination may exist, they have doubts that it has gotten worse in the last decade.

"...it would be difficult to believe that discrimination, after a period of quiescence, has actually been on the rise in recent years," they write.

I do not know if gender discrimination is on the rise.  I do believe it is still a major problem in the medical community.  I have taken flak for this perspective, and I have elicited considerable backlash.  But, I present the content of these reactions as evidence of the problem. 

I am a student blogger for Medscape's The Differential, a community composed of medical students and residents around the world.  In other words, these are the people who will eventually be our colleagues and employers.

I wrote a post on Medscape linking to my analysis on this blog, as well as adding few anecdotes.

I received the lowest average rating I have ever gotten for a post.

I also received comments (36 total, discounting my own).  I have excerpted seven of them.  Six of them were within the first eight responses to my post.

Right off the bat (comment #1), a commenter argued that gender discrimination was logical.  Why?

"If a male and female both apply for an important position (suppose, a physician at a hospital, or CEO of a large company) and they have the exact same qualifications, and perform exactly as well as each other in the interview, (and seeking the same salary, if this is negotiable)...

As the employer, who would you hire?

For a female, the opportunity cost of childbearing (i.e. working for your hypothetical hospital / company) represents a huge loss of utility for you, the employer. She would be unable to work during the final 6 weeks of her 40 week gestation (and will most likely have maternity leave for much longer than that). Furthermore, the hormonal and mechanical factors of childbearing will greatly reduce her ability to perform at her best during weeks 28-34 of gestation (e.g. going to the toilet every 30 seconds)." 

 [Later on, this same poster added:

"- The employer has the right to decide his (or HER) own strategy for choosing the "BEST" candidate. This is what I believe a rational employer MIGHT do (for a position such as a physician or a CEO):

- If a male and female candidate had the SAME qualifications, SAME interview performance, and are negotiating for the SAME salary - and everything else is equal - then without further information (about future childbearing status), I would DEFINTELY choose the man. (Because they have equal likelihood of having a child, but if/when it happens the woman will require more time off work).

- If I knew the female had a Tubal ligation (but I am clueless about when/if the man intends to father a child) then I would DEFINTELY choose the female. (i.e. I am choosing the "sure thing" over a risk)

- If I knew that neither of them intended to start a family, then I would be INDIFFERENT."] 

Some commenters agreed with this biological rationale:

"I'm not saying sexism doesn't exist, but like the first commenter... intelligently said I believe this difference in pay check has more to do with pregnancy and the inevitable loss of money and utility for the company than anything else.... After all, if equality is what you are looking for, you can not work less than a man and expect the same pay check just because you are a woman. So, because of the biological diferences between men and women, I think job opportunities, salaries, roles, and available activities for both men and women will never be totally equal, and that has nothing to do with sexism but biology." [Comment #2]

"I think the only way a woman (or a man, for that matter, if the idea of paternal leave is a policy) could demand equal payment with the other sex is to prove that they are incapable of having children....which is fairly extreme. I'm very sensitive to the equality of women, but we must also be careful about 'overswinging' the pendulum." [Comment #8]

Other commenters questioned behaviors of women:

"There are dozens, literally, of other factors that congtribute to salaries in addition to simply hours worked. It is the misunderstanding of this issue, or the failure to recognize the true nature of this issue, then causes people to scream sexism... Of course there are those people who want to see sexism every where because it helps explain their own lesser position." [Comment #6]

"Here is my question for the self-titled "hyperfeminist", sexual organs aside, do you believe that men and women are different?  If not, I have no further comment. If so, do these characteristics differences translate to some sort of difference in their ability to perform work?"  [Comment #32]

Still other commenters argued that discrimination did not exist or that women were actually being favored:

"Men are judged solely on how much money they make and therefore work harder to make more money. Women are not judged solely by their salaries and numerous studies that are not ideologically biased have shown that women make different choices in where they study, what they study, how long they study, what extra work they do, etc that all explains the gender gap in salaries. Work done by Professor Stephen Cole at SUNY Stony Brook shows that there has not been gender bias in medicine since the 18th century... look at med school admission rates that far back and it has been proven."  [Comment #4]

"I completely agree, after reading this article I feel that these feminist views further support my belief that no matter how equal job opportunities, salaries, roles, etc becomes, certain women will never be satisfied. I feel "Hyperfeminists" are the reason why some men make sexist jokes or feel that women are treated unfairly well (i.e. admission into higher education is highly favorable for women at this time)." [Comment #3]

I am disturbed by the immediate responses for two reasons: 1) the community they come from, and 2) the fact that comments are fairly thought-out and presented as logical, non-sexist perspectives.

Commenters believe that it is legitimate to discuss average differences between two groups (males and females); I do not disagree.  

But when does a preference for particular individuals constitute an "ism" (which we have laws against)?  As the original poster pointed out:

"You want to hire a junior doctor at the local hospital. Two candidates - Andrew and Brett, are applying. They came from the same medical school, with the same marks, and perform equaly well on the interview. They desire the same, fixed salary. 

During the interview, you are impressed that Andrew is an extremely talented violinist in his spare time... and you are equally impressed that Brett is an extremely talented vert-ramp skater (i.e. "skateboarder").

However, Brett reveals "I am very passionate about my skating, and don't think I will stop any time soon. I'm always very careful, but there is a 50% chance that I'll have a fractured tibia in the next 10 years. It's a risk that I'm willing to take, and life is all about risk - however it means I might be out of action for 4 months".

Moral question: is it fair to choose Andrew over Brett for this reason alone? (All else equal)."

The obvious point the poster is trying to make is that yes, in this case, the discrimination is fair.  I would like to distinguish employer judgement in a hiring decision in a particular instance from an "ism," though.

In my opinion, an "ism" that should not exist occurs after a few criteria have been satisfied:

1) When group generalities become rules for individuals--e.g., in who to hire and how much to pay them.

2) When individuals have no control over the group to which they belong.

3) When one cannot (or reasonably be expected to) hide the group to which he or she belongs.

4) When it is nearly impossible to predict how an individual will do the job based on the group he or she belongs to.

Where it gets sticky, of course, is where to draw the line.  Gender, race, height, weight, religion, age, health.  The list goes on.  And what about certain professions with different standards?  At what point can employers choose their workforce without being accused of an "ism"?  

I don't pretend to have all answers for all situations, and so I am narrowing my scope to gender in medicine.  The aforementioned comments, I believe, constitute a form of sexism.

Commenters claim their views are grounded in the economic model we work within. That is fair, but--wrongly, I believe--there is nothing said of the normative, or "what ought to be."  Without this consideration, there is no impetus to address existing inequalities on a larger scale.

Later on, one commenter summed it up particularly well:

"Reading this thread I am impressed by the amount of tacit sexist comments and thoughts made by supposedly intelligent, 'progressive' students. I think it partly explains why we see this widening of the gap- just bringing up the idea of gender equality elicited such responses as, "we must also be careful about 'overswinging' the pendulum," (um, aren't we talking about how we're actually moving in the opposite direction?), and "there are those people who want to see sexism every where because it helps explain their own lesser position" (the entitlement of this comment makes me nauseous). Even more troubling is that these students seem to lack the awareness of how their comments come across, as if they wouldn't consider themselves sexist in the first place. I'm grateful to see some responders on here that seem as equally appalled as I, but the ratio of ignorant sexist comments to intelligent ones is disheartening."

Perhaps comments only select for the most vocal opponents.  But these are their attitudes, and one day they will be choosing our starting salaries.

Don't Rule Out Sexism So Quickly

The media is abuzz about a recent study that found that the gender pay gap for newly trained physicians is widening compared to ten years ago.  Adjusted for specialty and hours worked, new female physicians made an unexplained average of $16,819 dollars less per year than new male physicians in 2008.

These adjustments counter the claim that the pay gap exists because women go into low-paying specialties and that they tend to work fewer hours.  That's good.

However, what's not so good is that the authors favor some hypotheses over others when explaining the gap.  They speculate that women are intentionally choosing lower-paying jobs because these jobs provide greater flexibility and family-friendly benefits, such as not being on call after certain hours.  Women may negotiate these conditions of employment which come at the price of commensurately lower pay.  This is certainly a fair hypothesis.

This is also the hypothesis that the media is picking up on.  It's intentional and not imposed; it's unfortunate but not unjust is the subtext.

But there is perhaps too widespread of an acceptance of this theory.

Why do the authors prefer this explanation over others in the first place?

The authors state that they cannot rule out other theories, such as gender discrimination and women being worse negotiators than men.  The main reason they say these theories are not consistent with observed data hinges on a single, pivotal point: that, in 1999, using the same adjustments, starting salary differences between men and women were not statistically significant.

"...we are unwilling to accept the theory that women have become worse negotiators in recent years," the authors write.

"...it would be difficult to believe that discrimination, after a period of quiescence, has actually been on the rise in recent years," they also write.

"...by the late 1990s, women and men earned roughly equivalent salaries after observable factors were adjusted for," they add.

I think we need to look at 1999 more closely.

Time to get back to basic stats: what determines a significant difference?  The answer is usually a p-value of 0.05, which is arbitrary but accepted.  This means that if the study were conducted repeatedly, 5% of the time, the "significance" found would be a false positive, due purely to chance.

In 1999--without adjusting for specialty or work hours--new women physicians earned an average of $151,600 versus $173,400 for men (a 12.5% salary difference).  About 17% of this difference ($3,600) remained after adjustments.

In 2008, women earned $174,000 compared to men's $209,300 (a 17% difference).  Roughly half of this difference ($16,819) remained after adjustments.  Clearly, the unexplained adjusted starting gap widened.

But unexplained starting salary differences between men and women in 1999 were not found statistically significant.  Why?  The p-value was 0.08.  In other words, there was only an 8% chance that the difference in findings were due to chance.  But, in the world of statistical significance, 8% is simply not 5%.  (In contrast, p < 0.001 in 2008.)

So, if we repeated this study 100 times in 1999, 92 times we'd find a difference between starting male and female salaries.

Is it misleading to state that the pay gap in 1999 was not statistically significant?  No.

Is it misleading to state by the late 1990s, women and men earned roughly equivalent salaries after observable factors were adjusted for?  Only if you think that a $3,600 difference (~17% of the unadjusted salary figure) with a p-value of 0.08 is "roughly equivalent."

Onto the bigger questions: how does the 1999 data affect the author's conclusions for 2008?

The authors toss the sexism hypothesis mainly because they suggest that gender discrimination has been in a "period of quiescence" due to the 1999 data.  This is a far greater leap than what the 1999 data actually suggests.

The authors toss the women-are-worse-negotiators theory for the same reason.

All of this lies on the very large assumption that in 1999, things were fine and dandy.  They could have well been.  But there is only an 8% chance that they were.


(Update: additional thoughts here.)

Third Space Magazine Linked in Wall Street Journal

It's an honor to be listed alongside such established, prestigious magazines as the Bellevue Literary Revue and Pulse.  http://tinyurl.com/4zx7w74


We currently capture the voices of HMS students and physicians, but we are looking to expand to other medical communities.  As a free online journal, we are accessible--and we want to access more!  Featuring prose (nonfiction or fiction), poetry, artwork.


http://www.thirdspacemag.com/main.html


Submissions welcome at thirdspacemag@gmail.com.  

Dear The Atlantic, We Have Opinions

When I was applying to medical school, a big part of my spiel was on the importance of connecting the medical profession to the outside world by those inside the community (in my case, I wanted to do it via writing).  It's quite easy and tempting to speak candidly and frequently with colleagues, who by definition share our professional backgrounds: we are trained similarly, learn similar material, undergo similar challenges on the job, face similar frustrations, and basically just "understand" what it's like in fewer words.  It's more of a challenge to communicate to those without a similar professional currency.  It's time, it's effort, it's frankly patience that can sometimes be difficult to muster.

But the alternative is to have those outside the community describing to others outside the community what it's like from inside the community.  And sometimes it's misleading, or hits on precisely the wrong points... or both.  If we do not have the time to write, we should at least correct such misinterpretations:

In September 2009, The Atlantic published a piece on teaching ethics to medical students.

The premise was that medical students were getting a surprisingly inadequate foundation in ethics, buttressed by a study published in JAMA by Mayo researchers.  Used as major support for the article's premise was a startling statistic apparently found in the Mayo study:

Also surprising was the study's finding that only 14% of those students had an opinion about "appropriate interactions between physicians and pharmaceutical companies." How could 86% of medical students not even have an opinion on such a hot subject? 

The short answer is, they don't.  The study did not find that students did not have opinions on these issues; rather it found that students "frequently had opinions inconsistent with the AMA policy on conflicts of interest in relationship with [pharmaceutical] industry."  When researchers presented scenarios to students, "only 14%... of students' opinions on relationships with industry aligned with the AMA policy of all 6 scenarios."  Only about 5%--not 86%, as the journalist claims--did not answer at least one of the industry questions.  So, about 5% of students have at best "incomplete" opinions and at worst no opinions on industry.

We may not agree with the AMA, but we do have opinions.  Quite a difference.

Perhaps most disheartening is the fact that this result was in the abstract of the paper, right under Results.  It is accessible to all and is a mere 342 words long.  (This blog post is 417 words long.)

We're Not Taught to Do That in Medical School

Doctors vs. nurses (or doctors vs. nurse practitioners, or doctors vs. physician assistants, or what have you). The debate over superiority is old, tired, unimaginative, divisive, and wrong-headed--for reasons that are too obvious even to list. Does it get perpetuated because it garners comments?  

The New York Times recently ran a column by one of its editors, "In Praise of Nurses."  Nothing wrong with gratitude for nurses, who are certainly under-appreciated or mistreated, both in real life and in media portrayals of them.  Where it gets gnarly, apparently, is how to praise nurses in a vacuum, without comparing them to physicians, and without the snarky jabs.

To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder. (Maybe they’re taught to do that in medical school?)

The rhetorical question begs a response.  So... this is what we learn in medical school about how to interact with patients.  Keep in mind this highlights solely psychological factors.  How we learn to put together the relevant information to generate a differential is another story for another time.

-Consciously keep "patient as a person" in mind while we conduct our interviews. While starting, we even had a separate category entitled this, which would often include vocation, home life, and hobbies.

-Ask for a patient's explanation of his/her illness. "Why do you believe that?" is usually a good question and leads to better care.

-It's not an interrogation.  Seat ourselves during the interview at a slight angle to 180 degrees, so that we are not directly facing the patient.

-Body language, body language, body language.  It's like a first date.  Encourage conversation; it's information you need.  Make direct eye contact, nod, say "mmhmm" or "go on."

-Attend an AA meeting.  Watch alcoholics who have been sober for decades counsel alcoholics who have decided yesterday to quit.  "Today is a new day."

-Listen to victims share their domestic abuse stories. Ask questions. Listen some more. It happens at the most unexpected times to the most unexpected people.

-Learn how to take an appropriate and sensitive sexual history.  Don't assume anything--married or not, "straight" or not, "educated" or not.

-Make a home visit to a patient.  We see "disease"; he experiences "illness."  What is it like?

If something is going wrong with the author's doctors, unfortunately it is in spite of what our dedicated and caring preceptors teach us in medical school.

Dear Third Space

Third Space Magazine is a student-run literary magazine for Harvard medical students, residents, and faculty. It publishes fiction, prose, poetry, and art biannually.

I am currently involved in the Chief Complaints section, a mock advice column.  My first contribution:


Dear Third Space,

I dislike my anatomy lab partner, but I dislike confrontation even more.  Do you have any suggestions about how I can passive-aggressively voice my displeasure? 

Signed,

- Silent Rage Behind the Scalpel

Dear Silent,

The important thing to remember is, when donning the blue scrubs and gown, one must remain professional.  As we learned during Introduction to the Profession, being professional involves not raising your voice, not using your scalpel to nick your partner’s forearm, not burying fat in your partner’s hair, not naming your cadaver after your partner, not spraying formalin in your partner’s locker, not hiding your partner’s pants in the changing room, and not taking a hammer and chisel to your partner’s kneecaps.

It is also important to remember that every medical student in the anatomy lab is nervous and frightened to be there.  She may have had bad experiences in anatomy labs before.  Maybe she mistrusts the anatomy directors.  Maybe the anatomy labs here are not like the anatomy labs she is used to.  You must find out more about your partner as a person.  Instead of making assumptions about your partner’s expectations regarding anatomy lab, take the time to talk to her about them.

A good place to start would be to ask her what brings her into the anatomy lab today.  Try to obtain her explanatory model for why she thinks she is here.  It is also important to make empathic statements.  If she accidentally cuts the phrenic nerve, you may say, “This must be hard for you.”  Try to make your questions non-judgmental, and make the transitions natural but clear. Perhaps while she is dissecting the liver, ask her how many drinks she has each week.  While she is looking for the bulbospongiosus muscle, inquire “men, women, or both?"  While you both dig through fat, ask her if she is interested in exercising more.   Try offering advice about STD testing, AA meetings, or birth control in passing, just to let her know your door is open for additional questions.  Ask her how many children or grandchildren she has, and what she is most looking forward to doing when she leaves the anatomy lab.

No matter what, it is important to maintain an air of professionalism and understanding.  Remember, not all of this has to be accomplished in just one session.  Sometimes you may have to broach sensitive issues repeatedly on follow-up meetings until she eventually gives you satisfactory answers.  The partner-partner relationship is a unique, delicate, and long-standing one and should be treated as such.

Sincerely,

Always Professional

My Big Bird

"Which medical show on TV is the most realistic?" the oncologist I was shadowing today asked me.

No way could it be House, Grey's Anatomy, or Scrubs.  Boston Med?  (The show was filmed at one of the hospitals I was shadowing at--was he tooting the institution's horn?)

Surprisingly, Scrubs--with all its quirks and absurdities--was his answer.  "It deals with the insecurities and doubts that we all face," he said.  The character traits are dead on.  "Plus, it's hilarious."

His favorite episode involved a patient who died because of a medical error.  The show closes with a powerful scene: to remember their mistakes, the four main characters walk around the hospital with his ghost following each of them.  Apparently, oncologists feel the same way about some of their patients (regardless of whether they blame themselves).  They don't easily forget.

In fact, later that day, the oncologist was going to a patient's wake.  He said it wasn't a common thing he did--but it wasn't rare either.