Last week I travelled from Manchester (for St Emlyn’s Live and Teaching Manchester) to NYC for #FIX181. FIX – the FemInEM1 ideas exchange – is in its second year, and having been unable to attend the inaugural conference in 2017 I was determined to make it in 2018. I was lucky enough to be selected to speak (and ultimately spoke on a totally different topic from the one I originally pitched – more on that in due course!) but the conference was about so much more than speaking. From the opening party on Tues 16th October to the final talk on Thurs 18th October, FIX was about listening – to the people in healthcare; people of different gender identities, sexualities, occupations, experiences, cultures and nations, coming together to make things better. And let me tell you – it was every bit as vibrant, invigorating, emotional and inspiring as you might expect. Below and in the next three posts are my reflections and learning points. In addition, #FIX18 might have been the most quotable conference I’ve ever been to, so I’ve added some memorable soundbites and tweets to add to your #FOAMO.
FIX18 kicked off with co-editor-in-chief of FemInEM, Dara Kass2. Dara and her co-editor-in-chief Jenny Beck-Esmay3 have achieved incredible things in their vision of a project to address gender issues in Emergency Medicine (FemInEM). Dara’s opening address covered recent controversies in gender equity – but more importantly, how women have moved the conversation forward into addressing the causes. Attending conferences for women and networking events has positive effects for women’s careers4 – researchers have found increases in pay, greater proportion of promotion and more optimism and feelings of connectedness about their careers.
Dara also explained the meaning of her new book about otters. Esther Choo5 had advocated tweeting pics of otters and using the hashtag #ottertime to shut down disrespectful discourse on twitter, but the metaphor runs much deeper. Sea otters spend much of their time in single sex environments – female sea otters (called bitches) rest in the water holding each others’ paws so no-one drifts away6 – known as a raft. Dara reminds us that when we see sea otters together, we should remember that it is all about working together for collective good, preventing one another from drowning or drifting away – and that there is always room for another otter at the edge of the raft. Remember – you are not alone.
Jay Baruch took to the stage next to talk about why medicine needs more not-knowing. He reminds us that we don’t teach or train our juniors how to manage the uncertainty inherent in the practice of medicine. I loved his point that a medical history is not the same thing as the patient’s story – even the most comprehensive list of symptoms can miss the essence of what brings a person to interact with medical care. But not-knowing is not the same as ignorance – it is more like an openness, since overconfidence can lead to medical error. His message was ultimately a call for curiosity7 – something very familiar to anyone at St Emlyn’s Live or TTCManchester last week.
Arabia Mollette gave a spellbinding talk on the prejudices she faces as a doctor and a person of colour. “I do not have the luxury,” she says, “of being a woman first, as many of you do – because I am prejudged on the colour of my skin.” The narrative is absolutely hers, so all I am going to say here is keep an eye out for the podcast when it is released and listen – really, listen. She also referred to EM physicians as “Jills of all trades”, which really resonated with me!
There followed great lessons from Kathleen Meyers from her experiences with a business startup. Her seven lessons were transferable to general career advice (apologies for the typo in your surname!):
Nick Gorton talked about goodness of fit and gender bias in EM from the perspective of someone who has worked in EM identifying as both female and male. Our biases about what sort of people will fit particular job roles and our implicit biases act against diversity in our workplaces. A woman who has more agentic traits8 faces consequences of her non-normative behaviour, he tells us. Prescriptive biases describe the way that the same behaviours seen in different genders are interpreted differently; they include devaluation of performance, penalisation for performance and denial of credit for work. Entertainment media (TV and film) use this by emphasising cognitive distortion9 and usually resolve it at the end of an episode by reinforcing the biases that underpin the cognitive distortion. When men demonstrate “communal behaviour8” in the ED (like getting a patient a blanket), they are viewed much more favourably than women. If you haven’t undertaken the Harvard Implicit Association test10 yet, please do it – then practice thinking positively about people to traverse societal norms (Ed – you can read more about our implicit biases on the blog here11).
Nathalie Coeller spoke about the challenges of being an introvert in the ED – something I know many of us can relate to. One of her most tangible take home messages was that we should all pee more at work – not just because it’s good for your urinary tract, but also because taking five minutes off the shopfloor in the relative calmness of the toilet cubicle can be re-energising for those of us who have to work a little harder to thrive in the chaos.
Nii-Daako Darko brought a different perspective on podcasting from the one we have at St Emlyn’s – his podcast is aimed at a wider audience including patients and shares the stories of “ordinary doctors doing extraordinary things” while making him some money (Ed – definitely a different story from ours!). You can subscribe to his podcast Docs Outside the Box here12. What was familiar from his story was how much energy and enthusiasm engaging with the world through his podcast has brought him – I think I can speak for the whole of the St Emlyn’s team when I say we get similar rewards from blogging and podcasting.
“The imaginary line dividing those of us in white coats from those of us who are patients dissolved.” Shannon McNamara rounded off the first session with her talk about coming out as human. Her story of reconciling being a doctor, and its “impossible” expectations, with being accepted as a human was deeply moving and very powerful. Coming out was not just about Shannon’s identity as a queer woman but about every interaction that exposes us for who we truly are: the doctor who cries in Resus, the advocate, the parent… and coming out as human is a lifelong process. A beautiful story of compassion and acceptance. “Our humanity,” Shannon reminds us, “is our strength – not our weakness.” You can read Shannon’s blogpost version of her talk here13.
Eva Niyibizi, who was born in Rwanda and now works in Switzerland, spoke about her lifelong desire to fit in – and her continued role as an outsider, continuing to speak out against sexism and racism in her workplace. Her story of facing indifference in the face of challenging the status quo was inspiring, if stark in 2018. “There is power and bravery in uniqueness,” she reflected. Her manifesto for effecting organisational and cultural change? Identify the cracks, assess the need, build bridges. If you need something and it does not exist – create it.
Lynn Fiellin explored the endemic societal expectations around boys and girls growing up. I was particularly shocked to hear that at age 5, children associate brilliance with their own gender; by age 6 or 7, girls start to associate it with male gender. Associate Professor Fiellin is involved in a project designed to reframe the concept “as a girl”, often used as a derogatory comparator as if women are somehow naturally inferior and that being good at something is an exception (see this confronting video for examples of how this plays out in daily life14). The project (play2prevent.org15) involves role-modelling, mentorship, encouragement, fostering friendships and supportive relationships, and working together in teams to create games to have an impact on the wider world.
Gita Pensa and Tracy Sanson spoke jointly about a situation that challenges every physician I know, inside and outside the Emergency Department – coping with the palpable threat of litigation. This situation is much more prominent in the US – there were an unbelievable number of raised hands in response to the question “who has seen a lawsuit through to conclusion?” – but we definitely feel its emotional echoes further afield in the UK and Australia. We can be as careful as possible in the care we provide, but it’s likely bad things will happen anyway – aside from the obvious devastation to patients and their families, these incidences can have profound effects on the clinicians involved. Two questions hold us back: Am I worthy? Do I belong? The answer to both is YES, but when we are the subject of complaints, our frameworks to answer those questions come crashing down. Our reactions affect us both as physicians and as human beings. Simon spoke about coping with medical error at smaccGOLD16. Helpful take home advice was abundant:
- Get a GP. And see your GP!
- Have a hobby – engage with it regularly.
- Keep the positivity (the patient notes, the thanmk you messages – you need to have them so you can look back on them).
- Have that failure friend you can lean on (more on this from Sara Gary at #dasSMACC17).
- And in the midst of it all, engage with self-kindness. Start small, find the spiritual satisfaction in looking after patients again – and nurture that spark when it returns.
Gita’s story ended on a beautiful reflection – after twelve years (yes – TWELVE YEARS) under the shadow of litigation, she is not the same – but she is okay. “Our relationships are what will save us in the end.”
Elyse Portillo shared her story of her childhood diagnosis of retinoblastoma and her experiences of seeing medicine through her single remaining eye. “I am Elyse Portillo,” she began, “and I am a one-eyed doctor.” Her story of repeatedly being told she couldn’t do things in medicine – particular specialties, and by influential seniors and potential role models – resonated with many of us and made me wonder why we are so quick to see others’ limitations rather than their capabilities. “Like cheerleading, I just wanted a tryout,” she says of her frustrations. “I am not an effective clinician despite having one eye. Having one eye – something others see as my disability – is at the core of who I am as a clinician. And the same is true of our gender identity. We are not great doctors despite our gender identity; it is the foundation of our gender identity that makes us kick-ass clinicians. Don’t mistake different for deficient. Do not label as a shortcoming that which you do not possess.”
Valerie Dobiesz finished the morning session (yes, all this goodness in just half a day!) with some startling statistics on sexual violence, demonstrating her assertion that many cultures and places in our world do not value women. Particularly harrowing were the stats on female genital mutiliation, which usually occurs before age 5 (there’s statutory UK guidance about FGM here18), and the fact that 21% of women in Ghana have their first sexual experience as one of rape. It is important to remember that we as physicians, despite our privilege, are not immune to intimate partner violence and that as well as being alert to these situations in our patients we must also be alert to signs among our colleagues.
If that’s not enough for you to think about, there’s be more in Parts Two, Three and Four!
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References1.FemInEM Idea Exchange 2018 – FemInEM. FemInEM. https://feminem.org/events/fix2018/. Published 2018. Accessed October 25, 2018.2.Dara Kass. Twitter. https://twitter.com/darakass. Published 2018. Accessed October 25, 2018.3.Jenny Beck-Esmay. Twitter. https://twitter.com/jbeckesmay. Published 2018. Accessed October 25, 2018.4.Do Women’s Networking Events Move the Needle on Equality? Harvard Business Review. https://hbr.org/2018/02/do-womens-networking-events-move-the-needle-on-equality. Published February 13, 2018. Accessed October 25, 2018.5.Esther Choo. Twitter. https://twitter.com/choo_ek. Published 2018. Accessed October 25, 2018.6.Sea Otter Facts. Sea Otter Foundation & Trust. https://www.seaotterfoundationtrust.org/sea-otter-facts/. Published May 22, 2017. Accessed October 25, 2018.7.Helping Without Harming by Jenny Rudolph. Vimeo. https://vimeo.com/259658394. Published 2018. Accessed October 25, 2018.8.Agentic Traits vs. Communal Traits. Students exploring inequality in Canada. https://inequalitygaps.org/img_1668/. Published November 28, 2012. Accessed October 25, 2018.9.Psychology Tools: What are Cognitive Distortions? HealthyPsych.com. https://healthypsych.com/psychology-tools-what-are-cognitive-distortions/. Published 2018. Accessed October 25, 2018.10.Implicit Association Test. Harvard University. https://implicit.harvard.edu/implicit/australia/takeatest.html. Published 2018. Accessed October 25, 2018.11.Carley S. Do Emergency Physicians judge patients on race, sex, sexual orientation, weight, etc.? St. Emlyn’s • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/most-emergency-physicians-judge-patients-on-race-sex-sexual-orientation-weight-st-emlyns/. Published May 28, 2013. Accessed October 25, 2018.12.DOCS OUTSIDE THE BOX – Podcast By Dr. Nii Darko. DOCS OUTSIDE THE BOX. http://www.docsotb.com/. Published 2018. Accessed October 25, 2018.13.McNamara S. Coming Out As Human. Joy And Justice. https://www.joyandjustice.com/blog/coming-out-as-human. Published October 25, 2018. Accessed October 25, 2018.14.Always C. Always #LikeAGirl. YouTube. https://www.youtube.com/watch?v=XjJQBjWYDTs. Published June 26, 2014. Accessed October 25, 2018.15.Home – play2PREVENT. play2PREVENT. http://www.play2prevent.org/. Published 2018. Accessed October 25, 2018.16.Simon Carley – Medical error – SMACC Sydney. SMACC Sydney. https://www.smacc.net.au/2016/02/simon-carley-medical-error/. Published February 23, 2016. Accessed October 25, 2018.17.Voices in my Head by Sara Gray. Vimeo. https://vimeo.com/262918114. Published 2018. Accessed October 25, 2018.18.Multi-agency statutory guidance on female genital mutilation. GOV.UK. https://www.gov.uk/government/publications/multi-agency-statutory-guidance-on-female-genital-mutilation. Published 2018. Accessed October 25, 2018.