Jul 26, 2010

It's a Man's, Man's World

My pants fell down today.

I was listening to the lungs of a patient, and she had a toddler, about waist high, who tugged on the drawstring of my scrub pants to tell me something. They puddled on the floor, leaving me to examine my patient in my pink polka-dot panties.

How professional.

Nobody wants to be caught with their pants down. Particularly not in an audition rotation where you are trying to prove competence and professionalism to possible future colleagues. Given that I look young to begin with, a look exacerbated by no makeup and a daily ponytail, I try to make sure that I give a professional presentation in both a tailored dress and manner. Pink polka-dots were not the look I was going for.

I dropped my stethescope and snatched up my pants, silently cursing the bastard that invented "unisex" scrubs. They are the suggested uniform of the wards, and required to enter any surgical procedure. They are an ugly green two-piece set freely dispensed from the ScrubX machine in the hall. They say "unisex" but are clearly designed by a man for a man. First of all, no woman would pick that atomic booger color. Secondly, they don't fit.

I have the option of scanning my badge and pressing "10" for a size small uniform, and "12" for a medium. I can press "10" and get pants that are huge on the waist, yet hug my hips so tight that it brings the rise and hem of the pants four inches above my socks. I can press "10" and recieve a shirt that is so big that when I bend over, you can see my belly button through the v-neck. Or, I can press "12" and get a pair of pants that easily slides over my hips but has twenty extra inches around the drawstring waist and a rise halfway down to my knees. You can see my toes through the v-neck in that shirt. Usually I opt for the "12" since I don't like things tight on my hips nor unintended capri pants, but this choice leaves me vulnerable to rogue toddler pantsings.

Men do not have these problems. They walk around confident, broad-shouldered and tall, scrubs draped gently over their physician physiques. They look like doctors, not girls wearing their father's scrubs.

I do have some scrubs that fit me. I spent about $100 a pair, and they were worth it. Designed for a female doctor, they look like clinician scrubs, not nursing scrubs, and fit every curve and height. I look like a well-polished version of myself; the tailored female equivalent to the uniforms my male colleagues wear so easily and for free.

But I can't wear them in outside of ambulatory care. Any procedure requires a hospital-issued uniform where its sterility can be verified. With almost half of new doctors being female, this "unisex" policy is dysfunctional for nearly a majority of physicians. In ob/gyn, there were only 7% female physicians in 1970; today females make up 80% of incoming obstetricians. Yet most women look like I do, uncomfortably sandwiched or swimming in an ill-fitting professional uniform.

Medicine is still a man's world. Scrubs designed for a man's form are issued to women. I've sat in many doctors lounges filled with only males, making women driver/shopper/insert your stereotype here jokes over lunch, seemingly oblivious to the fact that I was there. Ugly, fat men that I have done hernia assessments on pull down the underwear and tell me to be careful, don't get turned on during your exam down there. Surgical instruments fit in a man's hand, not my small fingers. If a toddler pulled on a man's drawstring, their pants would stay up.

Aside from offensive jokes and patients with too much self-esteem, I genuinely think that our male counterparts are oblivious to the day-to-day difficulties that face a female physician. I'm sure they don't think how uncomfortable it is for pants to pull around your widest part all day, or for a male patient to leer down a gaping top. The tide of medicine is still changing; since older physicians are still in practice, females make up only 30% of doctors despite nearly equivalent numbers of males to females in medical school. And perhaps some of these challenges will change when the gender of the work force evens out. In the meantime, I think of James Brown's 1966 song...

This is a man's world
This is a man's world
But it wouldn't be nothing, nothing
Without a woman or a girl

Jul 23, 2010


I don't know what day it is. Hell, I don't even know what time it is. I was driving around at 7 today, genuinely wondering if it was 7 am or pm. The sky is a mellow blue at both instances of seven o'clock and either way the moon is up, so I just wasn't sure. Even though I have been driving to this hospital for two weeks now, I still turn my GPS on to get there from my motel. Normally I'm good with directions, but this rotation has turned my head around.

I get there before it is light. Sometimes I leave after dark. Sometimes I sleep during the day and go in at night. I am so beyond tired that I don't even feel tired; instead it manifests in a mild nausea and progressive confusion. This experience reminds me of training for deep diving, to prepare for the nitrogen narcosis that occurs at depth. With many extra atmospheres of external pressure, nitrogen solubilizes in the blood and decreases oxygen supply to the brain, and tasks that you could do at surface in 9 seconds now takes 14 at depth. A divemaster will show you this deficit and prepare you that even though you feel completely normal, your capabilities are affected by the external pressures.

Even though I feel okay, I am aware by objective measures that my cognition is not sound. My GPS tells me to turn right, and I turn left, and then am surprised when it says "recalculating" because I think I've gone the correct way. I do a patient's history and physical in Spanish, and then come out and write parts of the note in Spanish, because the conversation is in my head that way. I don't seem to realize that the English-speaking chief resident isn't going to know what I mean when I write "no tiene sangrado" on the intake form. My dad thinks he's been disconnected from me on the phone when he asks a simple question, because it takes awhile for me to formulate an answer. I'm making up words that make sense, such as the neologism of being "disorientated."

A lot of these skills are tested in what's called a Mini Mental Status Exam, or MMSE. We give to patients who are elderly, confused, psychotic, or otherwise just not making sense. It's a baseline measure of basic orientation and cognitive skills.

I'm sure I have a much better chance of failing it than whomever I am giving it to.

These external pressures are real, and even if I don't feel them consciously, I am narcosed by the environment, just like diving. I'm sure this is not the best idea for patient care. Would you want someone operating on you that had been working the last 84 hours with irregular sleep? Probably not. But it's an hazing of doctors into the fraternity of medicine, a tradition of each generation of doctors initiating the next. It's traditionally thought that this creates a stronger doctor that is capable of practicing good medicine despite all circumstances, but I have to doubt that. And I question the role of the older physician in this process. A divemaster demonstrates human deficit in the face of uncontrollable external pressure and teaches each student to recognize it and compensate for it. The doctor-divemaster takes young physicians to depths to try to prove that skills can overcome human reality. My sense is that this is not good for the new doctor, and certainly not in the patient's best interest.

Que hora es?

Jul 11, 2010

(Not) Paging Dr. Nobody

I'm starting the first rotation of my fourth year tomorrow. The night before a new rotation, I always have jitters. It's like the first day of school rolls around every four weeks- new teacher (doctor), new classroom (office), new classmates (office staff, nurses, etc), new location. But this one is different. It's my first "audition" rotation, which means it is an out-of-town rotation at a place that I hope to do residency. There are only two for ob/gyn in Phoenix, where we'll be living because of my husband's doctoral program, so I really need it to go well. I always have "sunday-night" anxiety before a new rotation, but this time I am alone in an unfamiliar hotel room, white coat pressed and stethescope polished, counting down the hours until 8 am.

I wasn't sure why this one bothered me more than others. Obviously the stakes are high- I desperately want this program to like me, and for me to like them, since since there are only two residencies in Phoenix. But I think it's more than that. In this hospital, there are attendings, fellows, residents, interns, other students. It's associated with a large academic university. It's planned down to the last four page memo emailed to me last night, with a reminder to bring fifty bucks with me to pay for my badge so I can work. In my hospital- wait. I don't have a hospital. I have a collection of low-income clinics that serves high volumes of underserved patients. My school is a thousand miles away. Planning is scant, since I am part of the school's first class and the rotations are arranged the month, week, day before they start. And I'm intimidated that I am finally going to a "real" medical school hospital, where I perceive other students to be better trained than me. I'm nervous about being in a place where there are tiers of doctors to be hard on me, and to prove myself to.

For most students, this is a standard experience. And every time I wish my school was "regular", that I had gone somewhere else where I would be more used to a traditional, well-planned curriculum, I think about what I got to do in my second and third year. The feel of a warm, slippery baby that I eased out of a mother's body, instead of a handful of paperwork. The unique pressure to make a clean abdominal incision, instead of peering over some other student's head. I wrote prescriptions, chart notes, did patient visits and counseling on my own, made changes in meds. I put in IUDs and did pap smears and colposcopies, rather than just being responsible for cleaning the sticky mess at the end. I told a mother her baby had died. It was an underserved area with too much work, and I was given responsibility beyond my formal education level, with the expectation that I would grow exponentially in skills and knowledge.

My school says this is the benefit of their new, unique curriculum- that students will really be used to care for patients, and will learn more as a result. There weren't other students or residents- just me and the doctor- which is a much different relationship than the model I will be entering tomorrow. I worry that the doctors above me will see it as their right and duty to humiliate me, be hard on me, and overwork me with busy work that they don't want to do, but I more worry about opportunities that will pass me by as a senior student. I don't get to deliver the baby, because that's the privilege of the second-year resident. I get to scrub in on a surgery, but not touch. Now that I've had a taste of these things, I think it might be frustrating and boring to be sidelined. At this hospital, I'll be a nobody, a not-even doctor.

I'm hoping despite these probable outcomes that I will like the program and make a good impression. Despite the usual anxieties- I hope I find the place, can I bring a lunch? will I get to eat it? What time do I go home? Will they like me? Will they give me good patient opportunities? How can I be a good student for this rotation?- there are new ones, more permanent and worrying ones. Will they like me enough to offer me a position for four years of training? Can I compete in an MD residency as a DO student? What are they looking for in a potential resident? What if I don't like them?- a horrifying thought since that eliminates half of the local programs. How can I show them that I will be a good doctor, that in some situations I have already been a good doctor?

T- 12 hours and counting...