Leadership

Letter to a Young Female Physician

Article · June 9, 2017

This past June, I participated in an orientation session during which new interns were asked to write self-addressed letters expressing their hopes and anxieties. The sealed envelopes were collected and then returned 6 months later, when I’m sure the interns felt encouraged to see how far they’d come.

This exercise, in which the intern serves as both letter writer and recipient, both novice and veteran, offers a new twist on an old tradition. In 1855, James Jackson published Letters to a Young Physician Just Entering Upon Practice. More recent additions to this epistolary canon include Richard Selzer’s Letters to a Young Doctor, which appeared in 1982, and Treatment Kind and Fair: Letters to a Young Doctor, which Perri Klass published in 2007 on the occasion of her son’s entry into medical school.

When I started my internship 30 years ago, I wasn’t invited to share my hopes and anxieties in a letter — or anywhere else, for that matter. In fact, I recall no orientation at all, other than lining up to receive a stack of ill-fitting white uniforms, a tuberculin skin test, and a hasty and not particularly reassuring review of CPR.

Perhaps the memory of my own abrupt initiation explains my response as I sat at the conference table watching the new interns hunched earnestly over their letters: I was filled with longing. I wanted so much to tell them, particularly the women — more than half the group, I was pleased to note — what I wished I’d known. Even more, I yearned to tell my younger self what I wished I’d known. As the interns wrote, I composed a letter of my own.

Dear Young Female Physician:

I know you are excited and also apprehensive. These feelings are not unwarranted. The hours you will work, the body of knowledge you must master, and the responsibility you will bear for people’s lives and well-being are daunting. I’d be worried if you weren’t at least a little worried.

As a woman, you face an additional set of challenges, but you know that already. On your urology rotation in medical school, you were informed that your presence was pointless since “no self-respecting man would go to a lady urologist.”

There will be more sexism, some infuriating, some merely annoying. As a pregnant resident, I inquired about my hospital’s maternity-leave policy for house officers and was told that it was a great idea and I should draft one. Decades into practice, when I call in a prescription, some pharmacists still ask for the name of the doctor I’m calling for.

And there will be more serious and damaging discrimination as well. It pains me to tell you that in 2017, as I’m nearing the end of my career, female physicians earn on average $20,000 less than our male counterparts (even allowing for factors such as numbers of publications and hours worked)1; are still underrepresented in leadership positions, even in specialties such as OB–GYN in which we are a majority2; and are subjected to sexual harassment ranging from unwelcome “bro” humor in operating rooms and on hospital rounds to abuse so severe it causes some women to leave medicine altogether.3

But there’s also a more insidious obstacle that you’ll have to contend with — one that resides in your own head. In fact, one of the greatest hurdles you confront may be one largely of your own making. At least that has been the case for me. You see, I’ve been haunted at every step of my career by the fear that I am a fraud.

This fear, sometimes called “imposter syndrome,” is not unique to women. Your male colleagues also have many moments of insecurity, when they’re convinced that they alone among their peers are incapable of understanding the coagulation pathway, tying the perfect surgical knot, or detecting a subtle heart murmur.

I believe that women’s fear of fraudulence is similar to men’s, but with an added feature: not only do we tend to perseverate over our inadequacies, we also often denigrate our strengths.

Letter to a Young Female Physician

  Click To Enlarge.

A 2016 study suggested that patients of female physicians have superior outcomes.4 The publication of that finding prompted much speculation about why it might be so: perhaps women are more intuitive, more empathic, more attentive to detail, better listeners, or even kinder? I don’t know whether any of those generalizations are true, but my personal experience and observations make me sure of this: when women do possess these positive traits, we tend to discount their significance and may even consider them liabilities. We assume that anyone can be a good listener, be empathic — that these abilities are nothing special and are the least of what we have to offer our patients.

I have wasted much time and energy in my career looking for reassurance that I was not a fraud and, specifically, that I had more to offer my patients than the qualities they seemed to value most.

Early on, I believed that displaying medical knowledge — the more obscure the better — would make me worthy. That belief was a useful spur to learning, but ultimately provided only superficial comfort. During my second-year clinical skills course, an oncologist asked me to identify a rash. “Mycosis fungoides!” I blurted out, since it was one of the few rashes whose name I knew and the only one associated with cancer. My answer turned out to be correct, causing three jaws to drop at once — the oncologist’s, the patient’s, and my own — but the glow of validation lasted barely the rest of the day.

A little further on in training, I thought that competence meant knowing how to do things. I eagerly performed lumbar punctures and inserted central lines, and I applied for specialty training in gastroenterology — a field in which I had little interest — thinking that I could endoscope my way to self-confidence.

My first few years in practice, I was sure that being a good doctor meant curing people. I felt buoyed by every cleared chest x-ray, every normalized blood pressure. Unfortunately, the converse was also true: I took cancer recurrences personally. When the emergency department paged to alert me that one of my patients had arrived unexpectedly, I assumed that some error on my part must have precipitated the crisis.

Now, late in my clinical career, I understand that I’ve been neither so weak nor so powerful. Sometimes even after I studied my hardest and tried my best, people got sick and died anyway. How I wish I could spare you years of self-flagellation and transport you directly to this state of humility!

I now understand that I should have spent less time worrying about being a fraud and more time appreciating about myself some of the things my patients appreciate most about me: my large inventory of jokes, my knack for knowing when to butt in and when to shut up, my hugs. Every clinician has her or his own personal armamentarium, as therapeutic as any drug.

My dear young colleague, you are not a fraud. You are a flawed and unique human being, with excellent training and an admirable sense of purpose. Your training and sense of purpose will serve you well. Your humanity will serve your patients even better.

Sincerely,

Suzanne Koven, MD

Harvard Medical School

Massachusetts General Hospital

Boston, MA


SOURCE INFORMATION

From Harvard Medical School and Massachusetts General Hospital, Boston.

1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salaries in U.S. public medical schools. JAMA Intern Med 2016;176:1294-1304. CrossRef | Web of Science | Medline
2. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA 2015;314:1149-1158. CrossRef | Web of Science | Medline
3. Lowes R. Most female physicians report sexual harassment at job. Medscape (http://www.medscape.com/viewarticle/866853).
4. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med 2017;177:206-213. CrossRef | Web of Science | Medline

This Perspective article originally appeared in The New England Journal of Medicine.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
The Largest Share of Organizations Do Not Have a Formal Strategy for Clinician Engagement

Leadership Survey: Why Clinicians Are Not Engaged, and What Leaders Must Do About It

Clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet nearly half of health care organizations are not very effective or not at all effective at clinician engagement.

Rowe01_pullquote - clinician well-being - fighting clinician burnout and creating culture of wellness takes all stakeholders

Defending the Term “Burnout”: A Useful Tool in the Quest to Ease Clinician Suffering

Health care leaders must take a preemptive approach to clinician well-being that is supported by all stakeholders and prioritized on an equal footing with essential clinical and financial measures.

Screenshot from the NewYork Quality Care Chronic Condition Dashboard

Success in a Hospital-Integrated Accountable Care Organization

How NewYork Quality Care achieved shared savings — by strengthening collaboration, enhancing care management with telehealth, and transparently sharing performance data.

Miller03_pullquote social determinants whole-person

How a State Advances Whole-Person Health Care

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations to expand access to vital resources.

Abigail Geisinger Scholars Program for Medical Students -Ryu02_pullquote

Why a Teaching Hospital Offers an Employment-Based Tuition Waiver Program

Geisinger Commonwealth School of Medicine subsidizes medical students’ education in exchange for their willingness to practice at Geisinger Health System.

Michael Dowling and Charles Kenney headshots

Rebooting Health Care: An Optimistic Outlook

The U.S. health care system may seem broken, but it’s on its way to greatness, according to the authors of Health Care Reboot. They discuss their optimism for U.S. health care reform, particularly on the social determinants of health, payment, consumerism, and technology.

Action Steps for Risk-Share Contracts for Medical Devices

Challenges and Best Practices for Health Systems to Consider When Implementing Risk-Share Contracts for Medical Devices

When done right, value-based contracting for medical devices can ameliorate shrinking margins at health systems, leading to a virtuous circle.

Health Care Organizational Culture Emphasizes Patient Care Only Slightly More Than the Bottom Line

Survey Snapshot: Who Should Lead Culture Change?

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in the right direction, but differ on who it should come from, and reveal too much balance between emphasis on bottom line and emphasis on patient care.

Culture Change Within Health Care Organizations Is Changing for the Better

Leadership Survey: Organizational Culture Is the Key to Better Health Care

Although three-quarters of Insights Council survey respondents say culture change is a high or moderate priority at their organizations, survey results show a lot of work on organizational culture remains to be done.

Metraux01_pullquote - dinners to combat burnout in the health care community

“Breaking Bread” to Combat Burnout

Can a simple dinner create community among health care providers?

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Leading Teams

170 Articles

Survey Snapshot: How Do You Know…

The NEJM Catalyst Insights Council discusses strategies for clinical engagement.

Team Care

110 Articles

Survey Snapshot: How Do You Know…

The NEJM Catalyst Insights Council discusses strategies for clinical engagement.

Rating the Raters: An Evaluation of…

Some promising innovation is taking place among organizations that rate hospital performance, but major systemic…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now