Exceptionalism is not as inspiring as it once was.  Talking about women who have scaled higher and a greater number of mountains than the usual woman physician does not help us face our own barriers and limitations.  These examples answer one question, “Can it be done?”  And the answer is, “Of course!  Look at these 12 women.”

Only 12 women were highlighted here when there are hundreds, maybe thousands who have pioneered and innovated for almost a century.  The definitions of pioneering and innovating need to be reconsidered.  How about the first woman to successfully have a child while still in medical school, in surgical training or while in practice?  Fifty years ago this was almost unheard of.

How about the 500th woman physician to have gained academic tenure?  Or the 40th to lead a major organization?  Or the 10,000th to have graduated medical school?  These are the women we ought to be celebrating because they have, despite ongoing challenges and bias, continued on the most difficult career path there is. 

Women do not need to have heroines to achieve great things.  There is nothing wrong with celebrating success, but as long as we insist on creating the category of gender as a factor in this success, we have failed to recognize (once again) the tremendous efforts it has taken every woman physician to get where she has gone.  We have devalued the worth of too many women physicians because they were not extraordinary by criteria that has little bearing to the “ordinary” physician among us, if she even exists.

We are all extraordinary.  We are all innovators and pioneers in our own lives.  We don’t need a Nobel prize or a title of Surgeon General to have made incredible differences in the lives of others.  Time to look for role models that can actually impact our daily lives as women physicians.

No thank you, CNN for another reminder that only 12 women were needed for “content” to create the illusion that “news” is actually being reported or should we say “made.”  We know it can be done; it’s now time to report on how often and well it is done, so these women are no longer “alone” in their exceptionalism. Exceptional women in medicine are the rule, not the exception.

woman looking at sea

More people are dying because they commit suicide than in motor vehicle accidents this year.  The number of suicides is rapidly approaching the number of deaths from breast cancer.  The trend upward has been noted for the past decade.

Physicians are the professional group with the highest rate of suicide. And studies have estimated that women physicians have as much as an eight fold rate of suicide compared to their male colleagues.  Is this a crisis?  I think so.

But what can we do? Recognize. Respond. Reconsider.

First we need to recognize that there is a problem–either with ourselves or in others.  None of us is immune from the small (or not so small) daily doses of devaluation that women physicians tend to experience more than their male colleagues.  Instead of pretending that we are not hurt by slights large and small (such as when we are mistaken for a nurse or the resident is addressed by the family as “the doctor” instead of us, as the attendings). And we all suffer from the rather large doses of increasing expectations from patients and a system is putting unprecedented burdens on physicians, the consequences of which are reflected in these startling statistics.

Next we need to respond. Most urgently is our need to be on the watch for our sisters in medicine who seem depressed, are giving up, are more negative than usual or have had a change in behavior. Any signs of burnout or overload should be cause for concern. Talk to them. Don’t be shy. Save a life. Be a friend, even if it is someone you don’t know very well.

Reconsider how we work. This is the long term plan. Under no circumstances should we belittle anyone who takes a different career path than the one we may have chosen. Schedule flexibility, getting off the track when needed, and taking time to reflect and refuel are all options that both women and men physicians need not just to survive but also to be happy.

Take a few minutes now to think about some of your colleagues and how they might be feeling. If you know anyone who is going through a tough time with a patient, a partner, a job change, health problems, or other family challenges, find a few moments to talk. Also, find out the resources in your community that are available for physicians in trouble. This doesn’t mean only addictions or anger management, where most of our efforts are focused. This means the mental health of the women physicians around us who we went to medical school with, trained with, and want to have a long collegial relationship with. Remember, it could be you one day.

The healthcare workplace is undergoing profound changes.  Where once a letter and a handshake were enough to create a life-long working relationship between colleagues, now the multiple work settings and relationships create many possibilities.  Understanding not only how to get into the relationship, but also what might happen when you need to leave or are forced out of a relationship is critical.

True Case Report:  A woman internist arrives at work one Monday morning and before she starts her schedule, one of her “partners” asks to speak to her.  The conversation begins: “Patty, we really have had a great relationship, but I am afraid we have to let you go.  We have rescheduled your patients today for Dr.  Burns.”  Stunned, she responds, “How can you do this to me?  I have been working here for 17 years.  I am really liked by my patients and I get along with everyone well.”  He says, “Well, I am sorry.  We are doing some re-organization and what with retirements coming up, we just don’t need you anymore.  Please remember that you have a non-compete clause for 18 months and a 5 mile radius.”

Unbelievable?  It happens more often than you would like to think.  Dr. Smith came to work for this group right out of residency.  She liked and trusted this group.  She felt really lucky that she had a job.  She felt even luckier that she was able to “negotiate” that she would work 4 days a week for a salary reduced by 25% but with no chance at becoming a “partner.”  She didn’t think she cared and didn’t want the hassles of “partnership.”

She just signed her contract.   She never even read her contract.  She didn’t know she was an employee “at will.”  She didn’t understand that all her hard work and investment in the practice could disappear in a moment.  She thought she would work with these physicians until she retired.

Physicians are notoriously naive and incredibly cavalier about contracts and negotiations…..until they are hit with a crisis that forces them to actually read their contract, that is if they even had one.  What’s a woman to do?

More women than ever are entering the medical profession during a time a physicians shortage is predicted.  Our knowledge, skills and training carries more value than ever before.  We have the opportunity to get the “benefit” of a bargain–one of the definitions of a contract.  But in order to do this, we have to understand the power and protection a contract gives us,  if properly negotiated.

Physician contracts are different because of the many regulations in healthcare law.  Stark Laws, anti-kickback regulations, non-compete clauses, non-solicitation clauses, buy-ins, buy-outs, sharing of alternative revenue streams, and limited liability are but a few of the many issues that find their way into physician contracts.  And then for physicians employed by hospitals, the important question, “Whose patient is this anyway?”

For women, we also think about flexible scheduling, maternity benefits, career trajectory consideration, resource allocation, pay equity, and much, much more.  These  issues that have to be discussed up front, before signing on the dotted line.

Not every doctor can diagnose a rash properly, not every attorney can decipher a contract properly or complete a complex negotiation successfully.  Physician contracts are special and it is important to get the right help.  Look for a contract attorney who has extensive experience in physician contracts.

After speaking with this doctor, she was emboldened to negotiate continuing her benefits for the next 4 months while she looked for another position.  She also got an excellent letter of reference.  She was able to stay in the same city, but traveled much further to work.  Some of her patients found her, but mostly she had to start over with new patients.  This time she negotiated a contract that suited her and created a long term career with her new group.  She now understood the value of a contract.

A few critical points:

1. Protect yourself for a separation no matter how much you like or are liked by the group.  Spell it out first.
2. Never accept the contract that is “non-negotiable” or “standard”–everything is negotiable and nothing is standard.
3. Understand your own value in the geographic location you are in–this will drive the negotiations.
4. Do your homework and think about everything that you want and need and then some.

So, if you have a contract, look at it and understand it.  If you don’t understand it (and they are convoluted), get someone qualified to help.  And when the time comes to renegotiate, think what it is you want and then go into it with a positive sense that you have value that can be leveraged.  Get the right help.  More often than not, you will come out ahead.  It’s worth the investment many times over!

Undoubtedly, those pursuing a career in academic medicine have a tough time line.  In most medical schools, somewhere between the 7th and 10th year, depending on whether the academic clock was stopped for pregnancy, the fate of the academic physician is decided.  During these years when women have the biologic clock ticking, they also have the “up or out” academic clock ticking.

This rush to create academic contributors is pure insanity, even for men who don’t physically “have” the children, but are increasingly interested in being with their young children.  When careers extend over 3-4 decades, it is time to think about changing the timing of academic productivity.

Let’s take the story of one woman physician who is in the “twilight” of her academic career. For more than 25 years she has worked as a surgeon in a top Children’s Hospital.  She became a full professor only 7 years ago.  She has recently acquired an NIH grant. She has assumed leadership roles in major specialty organizations in the last 5  years.  So how did she do it? 

In the first decade of her career, she had her children.  She build her practice, taught the residents, and established her expertise.  She did some research and acquired skills she didn’t know she lacked and needed.   She didn’t attend national meetings regularly, because that required travel.  She did not take on too many administrative responsibilities (i.e. committee work).

And most importantly she found her research focus from among the patients she had cared for during the first 10 years. She established relationships for meaningful inter-disciplinary collaboration.

The kids got older.  She had more time and more energy.  She turned more attention to her academic career. She wasn’t burned out.  Her flame was beginning to burn brighter and brighter and brighter.  The next 15 years have been incredibly productive.

This is a true but not a unique story or women in academia.  Unfortunately it is not as common story as it should be.  This is an “inverted” career trajectory–starts off slowly and accelerates and peaks much later.  But over a lifetime, it results in productive, contributing academic physicians.  Her department was smart enough to invest in her differently, and their investment has more than paid off.

So what needs to be done?  Get rid of the current model of promotion and tenure that place emphasis almost exclusively on the first decade of one’s career.  Instead, using self-evaluation and input from colleagues who understand motivating physicians over a long career, use continuous career building mini-milestones that build a foundation that will support more advanced work later on.  These are good years to help junior faculty find their focus, their passion and the best way they can contribute.

As the complexity of medical education increases, as the process of producing quality research becomes more difficult, and as the administrative demands of  academic institutions multiply–all in the face of decreasing revenues for academic departments–new models for academic advancement are critical to the success of the academic physician and our medical education system as a whole.  The way women physicians work best should become the way all academic physicians are made to pursue their careers.

superwoman ready for great things

The WMDR March Newsletter polled our readers, “Would you live away from your family for a year or more for the sake of your career?”  The response was astonishing!  43% said “Yes”, 43% said no and 17% were not sure.  Fourteen unique women answered this question.  Granted we know little about them.  Are they married or have a partner?  Do they have children? Where in their career cycle are they?

So what information can really be gleaned from such a broad question, with no qualifiers to characterize these women?  And how valid is the opinion of a mere 14 women?

But first, some background as to how this question came about.  More than one of our WMDR coaching clients have been faced with these types of decisions.  “I want more training to do exactly what I love in medicine, but I have to leave my young child and husband for a year.”   Or, “I want to change career directions and found a great job in another city and could commute on the weekends.  My kid is in school and I don’t want to disrupt his life.” Or, “I have to start a new career because I really don’t like what I am  doing.”  Or, even, “I lost my job and have to leave the area.”

Each one of these reasons gives rise to a different set of circumstances to consider.  But what they all have in common is that these women did not give up.  They faced hard choices and all of them made the decision to stick with it.  This is no easy choice.

Today, thousands of doctors are moving around and even leaving the profession.  The reasons are many, but most are around the basic themes of other job opportunities (to move) or physician burnout (to quit).  And the myth is that women are disproportionately abandoning all their education and training to take the path of hearth and home.  It is clear from our small survey that this may not really be the case.  Are we telling the wrong stories?  Asking the wrong questions?

It’s time to find out about the work habits and experiences of women physicians and how and why they make their decisions.  Assigning action and motive to this ever increasing demographic is demoralizing, unfair and a not too subtle form of gender bias.

We must help these women in their choices.  One young woman surgeon who is taking a fellowship and is leaving her new, small family for an extra year of training–create new work scenarios for her choice to live apart during that time.  Her new program was amazingly helpful–they really wanted her and all she had to do is ask.  Another woman, much later in her career fashioned a 2 year “sabbatical” from clinical work to pursue an extraordinary leadership role, which she has leveraged to an exciting “retirement” career in medicine.

With these “wins” come too many less favorable stories.  Too many women deal with leaving their “jobs” and starting over–early, middle and late career.  Harassment, discrimination, and just plain old, “You don’t fit in.”  “You are no longer needed in our new reorganization.”  “You are not a partner and we are not doing well.”  Each situation left them with no where to go in the short term.  Some found the strength to re-group.  Others did not.

Women in developing countries often leave their families for a better life.  We support them because it is out of necessity to live their dreams. Why not support women physicians with the same dreams (or nightmares)?  We all have difficult choices and women doctors make them often enough to indicate that we are committed to all of our roles–wives, mothers daughters, and as women physicians.

The lock-step 7-12 year program from white coat ceremony to farewell to residency dinner assiduously avoids models of participation in our healthcare system which don’t involve direct patient care.  And during this time, the call to serve directly is so strong, and the representation of “administrators” is negatively portrayed, most physicians don’t consider a career in “administration,” which is a form of medical leadership.

“Medical leadership” typically evokes the image of the president of the American Medical Association, the Dean of a Medical School or the chair of the department of medicine.   Women have  made few inroads into these rigidly controlled positions.  But we are entering uncertain and tumultuous times.  The best time to advance and make the most of new opportunities.

New, more accessible positions of medical leadership are emerging out of the necessities of running a rapidly morphing healthcare system.  New structures and new functions require unique skills and experiences.  These positions fall into the broad category of “medical management”–from hospital president to chief medical officer, from managed care coordinator to industry consultant.

With over 10,000 members, the American College of Physician Executives creates a forum for physicians to take on the leadership roles in medical management.  Their newly published book by consultant, author and entrepreneur Deborah M. Shlian, MD, MBA spotlights women physicians in medical management.  A must read for everyone:  Lessons Learned: Stories from Women in Medical Management

Through story telling of 26 women “managers”, the world of medical management for women physicians is nicely laid out.  The “how to rise” to positions  in government, hospitals, large provider groups, managed care organizations, industry, academia, and entrepreneurship.  Some have pursued additional degrees (MBA, MPH, PhD), although this is not a requirement for all.  But thinking out of the box is.

Why are women not just qualified, but uniquely qualified to lead our healthcare system?   We are taught from early childhood to get along with others, to create win-win situations, and to handle multiple people and their many problems all at once.  Creating “family” harmony without losing sight of the individual’s needs are well instilled in women starting from a very early age.  Time to make use of the things we were taught to do as little girls and instead of bemoaning the things that we weren’t taught because we weren’t little boys.  We can instead use these qualities and apply them to leadership in management positions.

Shlian’s book is an excellent way to familiarize yourself with an alternative career path for women physicians.  No matter the stage of your career, keep your options open, keep your mind open.  Pursue your interests.  Learn how other women have transitioned from bedside to board room.