I am delighted to be joining other authors in this issue of Academic Medicine as we reflect on the state of women in academic medicine today. When Dr. Roberts invited me to write this commentary, I began to look back at the many adventures I have had trying to succeed in what was very much a man’s world. Many of the challenges I experienced as a trainee, faculty member, administrator, and editor-in-chief of the Journal of the American Medical Association (JAMA) seem unbelievable now considering how far women have come. Still, though, so much remains to be accomplished to achieve equity between women and men in academic medicine. So, I hope some of my experiences will help women who are navigating the challenges of a career in medicine today.
One way for me to tell you about key experiences in my medical career is to discuss, with examples, some of my life’s lessons learned. To prevent my being accused of self-plagiarism (heaven forbid for a JAMA editor-in-chief emerita!), I will disclose that much of what I write here is contained in greater detail in my 13th published book, Pursuing Equity in Medicine: One Woman’s Journey.1 I wrote that memoir at the request of many individuals (mostly women) whom I have mentored over the years. (Please note that all the royalties from that book go to the Johns Hopkins Child Life Program.)
To put my experiences in perspective, you need to know a bit about me. I was born in 1940 (the dark ages of wonderful brightness) to a family in which my 4 grandparents and father had been born in Italy. We were financially poor (something I learned in a college sociology course) but in all other ways very rich. I knew I wanted to be a doctor when I was 4 or 5 years old, but first I had to become a diploma-trained nurse to conform to expectations for women in the health care field. That learning experience in nursing made me a much better doctor, and I would never give up the joy of those years. When I finally graduated from medical school, 9 years after completing my nursing training, there were 7 women in my graduating class. How wonderful that I have lived to see that there are now more women than men enrolled in U.S. medical schools.
Life’s Lessons Learned
Good leaders share 4 characteristics, each of which begins with the letter “T”
This essential characteristic of a good leader encompasses determination or persistence in spite of failures. By example, the first 3 abstracts I submitted for presentation at a national conference were rejected, but I kept at it and all 3 were eventually published.
As another example, in this issue, Helzer et al2 examine components of gender bias among anesthesiologists when treatment advice was provided by an inexperienced doctor; not only did participants rely significantly more on the advice of a man over a woman, but their reliance on advice from female doctors was also based on their experience whereas reliance on advice from male doctors was not. Under circumstances like these, tenacity (determination and persistence) is key for female doctors to reach success.
Tough-mindedness (not toughness).
When you know something is valuable, hold on to it no matter how tough it might be to do so. I wanted to start a new Division of General Academic Pediatrics at Johns Hopkins, but it took me 5 years and required me to refuse to accept a position I wanted very badly until I negotiated the assurance and resources to start that programs as part of my acceptance to the position.
In this issue, Marshall et al3 showed that gender differences in burnout are related to practice setting and to other differences in physicians’ personal and professional lives. The tough-mindedness of these female physicians is what will keep them practicing through the burnout and finding ways to alleviate at least some of the related stress.
Having a thick skin seems to be the most difficult “T” characteristic for women, probably because we are generally more sensitive by nature or nurture than men. One time, when I was vice dean of academic affairs and faculty at Johns Hopkins, I was working with 7 men to try and solve a problem. At one point, I made a suggestion and was completely ignored. So, I made it again minutes later with the same result. A few minutes later, one of the men made the same suggestion and all the men congratulated him for having a great solution. When I asked why they had ignored my identical suggestion, all of them said I had not made such a suggestion. I then replayed that section of the tape I was using to document the meeting notes. They were shocked, so I jokingly said that I was going to make appointments for each of them with our hearing department, and we all laughed. There was nothing accusatory in my comment; a sense of humor comes in very handy sometimes.
Unlike having a thick skin, having a tender heart seems to be easy for most women and is essential to forgive all the reasons you need the first 3 characteristics. Also, it is important to know that the higher you go up the ladder, the more you become a target (another “T”!). If you have never been a target, you have probably never accomplished much and are therefore probably not a good leader.
Never underestimate your ability to change things
In 2004, I attended a meeting of the International Committee of Medical Journals as editor-in-chief of JAMA. We discussed the problem we were having with authors not paying attention to the U.S. law requiring that all clinical trials must be registered at clinicaltrials.gov when the first patient is enrolled. Despite our having no legal jurisdiction and representing only 11 journals (JAMA, New England Journal of Medicine, The New Zealand Medical Journal, Norwegian Medical Journal, Canadian Medical Association Journal, The Lancet, Annals of Internal Medicine, Croatian Medical Journal, Dutch Journal of Medicine, Journal of the Danish Medical Association, and The Medical Journal of Australia) and the National Library of Medicine, we decided that we would not even review, never mind publish, any clinical trial that had not been registered. Each of us published a simultaneous editorial in our journals announcing this rule, allowing the investigators a year to register studies already underway.4
There continued to be only a trickle of registrations until a few days before the deadline, when it became clear that we were serious. At that point, so many trials were submitted to clinicaltrials.gov that several part-time registrars had to be employed to manage the onslaught. That’s how a few individuals with no legal jurisdiction were able to enforce a law.
The study by Stack et al5 in this issue highlights another opportunity for individuals to drive change. The authors surveyed female residents from 25 specialties and found that 61% of participants were delaying childbearing. These respondents were more likely to be younger, not already a parent, working in a large program, and in a specialty with an uncontrolled lifestyle. Only 38% were satisfied with their decision. Without knowing the specifics of the dissatisfied residents, I might only suggest that these residents work with their programs to drive change. For some it might be possible to make an arrangement such as sharing a residency with another woman who also wants to have a child, discussing her options with another resident who already has a child or with the program director who might have a solution, or taking a year off from the residency if possible.
Always keep a paper trail
Women are frequently asked to serve on committees, such as medical student education or advising, that might be enjoyable but contribute little or nothing toward promotion. These roles also take a great deal of time. I have advised these women to accept the assignment only on the condition that they are also promised another assignment to a more academically rewarding committee, such as those dealing with the budget or with the promotion or selection of leaders. Too often, the supervisor agrees to that arrangement but forgets about it when assignments to those academically rewarding committees are made. When you are invited to serve on the first committee, send an email message stating the agreement “just to be sure I remember it accurately” and ask for a response to confirm. Then, do not serve on the first committee until your supervisor responds that you are correct about the opportunity to serve on the second committee. That written response makes it very hard for the supervisor to forget the agreement.
People will not remember what you said, but they will never forget how you made them feel
Although people might not always remember what you say, there are certainly exceptions to this rule. When I wanted to teach residents and medical students that they should not order tests unless they had a good reason, I taught what became known as the DeAngelis rule: “Ordering a diagnostic test is like picking your nose in public. You must first consider what you will do if you find something.” I still have former residents repeat that statement to me at meetings with big grins on their faces.
Words are important, but actions are even more likely to leave lasting impressions. One of our JAMA staff was diagnosed with colon cancer and required chemotherapy. Of course, I tried to console her with words, but I also suggested that she buy a roll of toilet paper and number the sheets counting backward from the last day scheduled for her chemotherapy. She did that, and we put the roll on a wire tacked to the general bulletin board near my office. Each day she would tear one sheet from the roll, and it soon became a ritual shared by many of our JAMA family. On the last day, we had a party. Fortunately, she did very well and these many years later, she and others remember the feelings of community and support we created through that simple daily ritual during an otherwise difficult time.
Support that comes only from the top is actually a hanging
Twice during my 11 and a half years at JAMA I almost died—the first time after I fell into a coma while at a publishers’ meeting in Istanbul, and the second after being hit by a Chicago Transit Authority bus. I had always supported my team with all the knowledge and power I had. But on those 2 occasions, I needed and received support from my wonderful staff.
While my husband and I were in Istanbul, my staff provided us with personal acts of kindness and assistance in getting me home after spending 4 days in a coma in a Turkish intensive care unit. My coma was the result of a bowel obstruction, which led to severe dehydration. Further, because I had a mesocaval shunt resulting from a congenital malformation of my portal system, my ammonia level increased to 10 times the normal level. With the help of Johns Hopkins physicians working via phone, through my husband, with the Turkish physicians, it took 4 days to get my ammonia level back to normal. It was an amazing experience of support and teamwork I do not advise you try to replicate.
After the bus accident in which I sustained a subdural hematoma and a fractured pelvis, my staff provided daily transportation so I could get to work every day. Throughout it all, their senses of humor were heartwarming. They told everyone who asked that “Dr. De hit a bus.”
Losing your vision might be worse than losing your sight
I knew from early childhood that I wanted to be a physician at Johns Hopkins. I would walk past the window of the corner drugstore, which featured a group of large pictures representing the history of Johns Hopkins Medicine, and I was hooked. But when I applied there for medical school, I was not accepted. I wish I had kept that kindly written rejection letter because many years later when I received a letter from the dean certifying that I had become a Johns Hopkins Medicine professor (only the 12th woman in the then-94-year history of the school) I would have framed it next to the rejection letter. I have never hung diplomas or other documents of merit on my walls, but I would have hung those.
In this issue, Barnes et al6 assess gender bias experiences of female surgeons at one institution, showing that trainee status was the most notable risk for gender bias. Surely, when these trainees stick with their vision, they will experience a successful career in surgery.
Some things can only be seen through eyes that have cried
I am not someone who cries easily, except when I am present when a baby is born, and after I am sure the newborn is healthy. I truly believe that every time a baby is born, it is a sign that God has not given up on the human race. There are a number of occasions when sharing a sadness with someone, when crying with her or him is a natural component of empathy. My last meeting with the JAMA staff was a very tearful time for all of us, women and men. The love in that room was palpable and enriching. To borrow an observation attributed to Archbishop Oscar Romero, there are many things that can only be seen through eyes that have cried.
Final Words of Advice
For women negotiating a first or a new position, it is vital that you negotiate from the best position possible. Men seem to know this by some special sense. First make a list of what you’ll need to be successful, including space, clinical responsibilities (including call time), salary, etc. For example, find out the salaries of others in that position, even if you can only find national data. But be realistic of what you should expect according to your training, experience, and accomplishments. In negotiating, it is usually wise to ask for something that you are willing to give up.
Finally, whatever position you take, remember that you are a member of the most wonderful profession in the world. What other profession allows you to be paid for the honor and joy of taking care of sick people, either clinically or performing research to help in that care?
1. DeAngelis C. Pursuing Equity in Medicine: One Woman’s Journey2016North Charleston, SC: CreateSpace Independent Platform;
2. Helzer EG, Myers CG, Fahim C, Sutcliffe KM, Abernathy JH. Gender bias in collaborative medical decision making: Emergent evidence. Acad Med. 2020; 95: 1524–1528.
3. Marshall AL, Dyrbye LN, Shanafelt TD, et al. Disparities in burnout and satisfaction with work–life integration in U.S. physicians by gender and practice setting. Acad Med. 2020; 95: 1435–1443
4. DeAngelis CD, Drazen JM, Frizelle FA, et al.; International Committee of Medical Journal Editors. Clinical trial registration: A statement from the International Committee of Medical Journal Editors. JAMA. 2004; 292: 1363–1364
5. Stack SW, Jagsi R, Biermann JS, et al. Childbearing decisions in residency: A multicenter survey of female residents. Acad Med. 2020; 95: 1550–1557
6. Barnes KL, Dunivan G, Sussman AL, McGuire L, McKee R. Behind the mask: An exploratory assessment of female surgeons’ experiences of gender bias. Acad Med. 2020; 95: 1529–1538