My navigation told me the drive to my first medical school interview would take seven hours. It took twelve. Twelve hours driving across Texas with my 3-month-old daughter in the back seat. Screaming. And my mother in the back with her, singing and making faces and trying to keep her happy. She hated her car seat. I made frequent stops to hold her and nurse her and change her diapers. And she was so happy. The minute she went back into her car seat, the screaming began again. But we had to get there. I prayed she would be worn out from all the screaming and she might sleep well overnight. Nope. The morning of my interview, I was excited—and tired. But tired was my life now. I must have kissed her a hundred times before I left the hotel for the health science center. And on the way, I probably prayed a hundred times that I left my mom with enough breast milk.
Our group of interviewees spent the morning on a walking tour. A walking tour. Of the largest medical center IN THE WORLD. I, of course, was in heels and a heavy black pant suit. And it was hot. My suit didn’t fit well, because who knows how to dress a post-baby body? I was uncomfortable and insecure, but this was my calling. Well, not sweating in a hot suit, but the profession of medicine. Alleviating suffering. My first interview of the day started with formal questions about items on my application. My interviewer was an attending dermatologist. I don’t remember much except how incredibly nervous I was. And how I felt like a fraud. Like I didn’t belong or deserve to be here. But the end of the interview is the reason I’m writing about it many years later. This physician told me, “You will probably get through the rigorous training, but you will never be as good of a physician as I am, because you have a family.”
Y’all. These words were spoken. Like, out loud. Today, I would never sit in silence after a comment like that. But at the time, that statement was my exact insecurity. Could I be an outstanding physician and mother? I don’t have any family members in medicine, so I didn’t really know what the training was like. (People can tell you, but unless you live it . . . .) Even my family members had facial expressions of sympathy when I informed them I was pregnant, assuming I would never become a physician. I was getting warmer by the second, and emotions started to well up. The entire surface area of my skin was sticky with sweat. We cordially finished the interview, and I walked quickly to the nearest restroom. Taking off my suit jacket was instant relief, until I realized about two seconds later that my breast pads were saturated and my shirt was covered with milk. I went into a stall and stripped down to my pantyhose. I couldn’t take them off because I had a blister from that walking tour and the tights were tamponading the bleeding. And I cried. A lot. What the hell was I doing here? Even if I became a physician, I wouldn’t be a good one. I was pitiful. I missed my daughter. And my PJ’s. And I was literally covered in blood, sweat, and tears . . . and breastmilk.
In private medical school offices all over the country, interviewees silently withstand statements of bias in hopes of the opportunity to pursue their goals. One would think that these biases would be absent in the highest, most respected, most humanitarian of the professions. Unfortunately, biases are omnipresent and often delivered with cringe-worthy arrogance, and the women of (the brilliantly named) Systemic Disease.com are bringing it to light. Inspired by private conversations between medical school friends, Yale medical students Jes Minor and Tehreem Rehman have launched the site, aiming to expand the conversation by providing a platform to share. A quick read of the posted stories demonstrates that biases pervade the system of medical education, affecting aspiring and current medical students, residents, attendings, and department chairs, and extend beyond gender to race, culture, age, and lifestyle choices. (I even think the attending in my story likely had to defend her choice to NOT have a family so often that her statement was more about herself than me.)
Raising awareness is just the beginning of the mission of Systemic Disease. The pair hopes to inspire others to evaluate the systems and structures that lead to bias within their own institutions, as well as inform curricula to combat and eradicate bias in medical training and beyond. Medical education lends itself to bias. We study “buzz words” and “high yield” facts to score well on exams and match into our first choice, competitive residencies. We learn that a disease is more prevalent in a certain culture, age group, or gender, and exam questions will, by rule, reflect such. Imagine if this were balanced with a formal curriculum on biases to reach impressionable medical students before they become overworked and jaded.
We in emergency medicine are particularly prone to biases which affect our patients, our colleagues, and ourselves. We work in the most fast-paced of the medical environments. We have higher patient loads with ever-increasing emergency department visits. We have the sickest patients who require snapshot judgments without all the data in order to initiate life-saving treatment. We are trained to use pattern recognition and heuristics (“Sick or not sick?”) to meet the demands. We make errors and patients suffer. And sometimes they die. Then we guard our hearts from the tragedies we encounter every day by separating ourselves from patients, often in the form of bias. Another addict overdose, another obese STEMI, another non-compliant diabetic presenting in severe DKA. If we were anything like our patients who were dead or near death in our resus bays, how could we sleep at night? Then we pass on our biases to our junior colleagues and rotating medical students. We sign out the “status hispanicus in room 2,” the “drug seeker in hall 4,” and in my shop, the “Long Island Boy Syndrome in bed 3,” referring to young men who come to the emergency department accompanied by their mothers. And we laugh. Because that isn’t an acceptable thing to do. It’s effeminate, and that is an undesirable trait. And the students who laugh with us? We recruit them to our specialty, because personality and temperament are so important in our high-stress environment. Perhaps the perceived need for this crude, locker-room sense of humor is why male physicians dominate our field. And the cycle continues . . . another active smoker with a COPD exacerbation, another uptight hospitalist pushing back on an admission, another uninsured patient using the ED as their primary care, another arrogant surgeon. With these endless biases, no wonder we have the highest rates of burnout.
And our biases are at the very least just mean, at the very worst wrong, and they are always degrading to our profession. I do not know yet if I am an outstanding physician, but my experiences make me a unique clinician. I hesitate to tell this story, because it is deeply personal, but I feel it is important. This year, a young mother rolled into my trauma bay on death’s door. The image of her exposed, lifeless body lactating is one that will haunt me forever. Our team worked swiftly to assess her injuries, get stable access, and start massive transfusion— but not even a childless physician could have saved her from her non-survivable injuries. When we stopped resuscitative efforts, once again covered in blood, sweat, tears, and breastmilk, I cried with her partner, and then I held their exclusively breastfed infant for hours while he said goodbye. And when I said “I’m sorry” in his native Spanish (“Lo siento” – literally, “I feel it”), I really meant it.
So let’s stop the cycle. Let’s join in the conversation. Let’s share our stories. Let’s evaluate our own institutional systems, admissions process, department banter, and weekly conference curricula. Let’s join Tehreem and Jes to cure the systemic disease of bias in medicine. We may not reach that goal (there will always be an arrogant jackass), but y’all, we could do so much better. Let’s not sit silently. Let’s get offended and indignant and impassioned. Let’s give whatever it takes: blood, sweat, and tears . . . plus or minus breastmilk.