Leadership I

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.

New Call for Submissions ­to NEJM Catalyst

Connect

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

Learn More »

More From Leadership I

Reading List: Leemore Dafny and Stephen Swensen

NEJM Catalyst New Marketplace Theme Leader Leemore Dafny and Leadership Theme Leader Stephen Swensen weigh in on the most influential and inspiring readings of their careers.

Top-Down Implementation Process for Rapid Data Governance Adoption

Good data governance — a set of agreed-upon standards for gathering, formatting, and using data — is essential for health care organizations that want to tap into the power of their information.

Data Graphic: Cost and Coverage Impacts of the Better Care Reconciliation Act of 2017

Our breakdown of the Congressional Budget Office cost estimate of the U.S. Senate bill to replace the Affordable Care Act, compared to the U.S. House bill, the Affordable Health Care Act (AHCA)

Why Trump’s NIH Funding Cuts Would Be a Disaster

Undermining research funding will deplete medicine and science of the best and brightest minds and lead to a global destabilization with far-reaching impact.

Data Graphic: Health Care Drives Nearly One Million in Job Losses Under the AHCA

A recent study by the Commonwealth Fund on the economic and employment impact of the American Health Care Act (May 2017 version) shows almost one million job losses over the next 9 years, mostly in health care.

Reading List: Rushika Fernandopulle

NEJM Catalyst Thought Leader Rushika Fernandopulle weighs in on the most influential and inspiring texts of his career.

Treating Low-Income Individuals Is Our Obligation

The CEO of NewYork-Presbyterian discusses the policies, interventions, and perspectives required for making sure low-income individuals receive high-quality care.

Board Review and the Middle-Aged Doctor

Taking the boards as a middle-aged doctor offers a renewed perspective on one’s practice.

Reading List: Aaron Martin and Scott Weingarten

NEJM Catalyst Thought Leaders Aaron Martin and Scott Weingarten weigh in on the most influential and inspiring texts of their careers.

Reading List: Amy Compton-Phillips

NEJM Catalyst Care Redesign Theme Leader Amy Compton-Phillips weighs in on the most influential and inspiring texts of her career.

Connect

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

Learn More »

Topics

Leading Teams

114 Articles

Wanted: Talented, Energetic, Creative People to…

Let’s admit the inconvenient, boring truth.

Team Care

78 Articles

Physician Coaching: Clinicians Helping Clinicians on…

A physician coach reflects on who gets better, what works, and how to create a…

Health Care Leaders: Bill or No…

Members of the IHI Leadership Alliance on the enduring significance of the Triple Aim.

Insights Council

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

Apply Now