For those who follow MommyDoc by Niran S. Al-Agba, MD, 

The new website where the blog has been moved: 

www.niranalagba.com  

When Even a Surgeon is Slighted

Why do real-life images of camouflage-clad women soldiers or female surgeons wearing scrubs make us more uncomfortable than the highly sexualized images of fictional women warriors, like Wonder Woman?  Are many of us more nervous boarding a plane that will be piloted by a woman than a man?  And why hasn’t a woman been elected to the highest office of the land?  Does society believe female physicians are less qualified than male physicians?

In the 1960’s, less than 10% of entering medical students were women.  Today, the percentage of women entering medical school each year has surpassed men.  As a result, medicine is undergoing rapid change, yet vestiges of an antiquated physician code valuing men over women is ever present. Gender bias, discrimination, and even harassment remain deeply embedded in the culture of medical training and practice. 

Women surgeons, in particular, who work in a stereotypical male environment, face unique obstacles.  Take Karin Muraszko, MD, for instance, who is the first woman to head a neurosurgical department at any medical school in the US.  Born with spina bifida, she was also the first neurosurgery resident with a physical disability.  I recently had the pleasure of hearing her speak at the inaugural Physicians Moms Group Medical Conference this past weekend.

As any surgeon will attest, having a physical disability can makes a surgical career challenging. However, Dr. Muraszko did not see her physical disability as her largest hurdle. “People often ask me which is harder—being a woman neurosurgeon or having a disability as a surgeon.  Being a woman was more difficult.” 

 

Dr Muraszko recounted an anecdote from her first few weeks as an intern that illustrates the experience of blatant gender bias. A supervising attending was teaching a new surgical approach to trainees in her intern class.  Wanting to capture their attention, he identified the anatomical landmarks on pictures of women naked from the waist up, an aspect of their bodies which was not essential.  About halfway through the lecture, he paused, looked directly at Dr. Muraszko, and said, “Oh I forgot, you guys took a woman at Columbia this year.”  As if that was a bad thing.

 

Dr. Muraszko is certainly not alone.

Research published in the New England Journal of Medicine last October explored the pervasiveness of sexual harassment, bullying and gender discrimination in the field of surgery, surveying more than 7,000 general surgery residents.  Researchers found 32% reported gender-based discrimination, 16% reported experiencing racial discrimination, 30% reported verbal or physical abuse, and 10% reported sexual harassment. 

And to be sure, discrimination comes in all shapes and sizes.  Patients and their families are the most frequent source of gender and racial discrimination.  Most retirement-age female surgeons can recount numerous experiences where patients preferred a male surgeon and asked them to leave the room.  It turns out we, as a society, are chewing up and spitting out the youngest and freshest among us. 

Ironically, statistics indicate that women make better surgeons than men.  A large study published in the British Medical Journal compared the effect of surgeon gender on postoperative patient outcomes and found that female surgeons had the edge.  Patients operated on by female surgeons had a 4% lower risk of complications and a 12% decrease in 30-day mortality rate.  In other research, mortality rates in patients treated by female internal medicine physicians were 4% lower than men.  While these differences are statistically significant, they may have less clinical importance.  At the very least, statistically, female and male surgeons are equally capable.

  

Attending surgeons—who supervise resident trainees—were the most frequent sources of sexual harassment and physical or verbal abuse.  The fact that medical training is hierarchical by design, leaves female surgeon trainees particularly vulnerable.  One anonymous female surgeon shared in the study that a supervising surgeon “can assault you and get away with it since your career is in their hands.”  One female surgeon practicing east of the Mississippi reported symptoms of depression to her hospital administration after being raped by a physician colleague and was ultimately forced to take a leave of absence due to developing a “mental health condition.”

 

Even once training is complete, female surgeons contend with discrimination and bullying and try to avoid receiving any unwanted attention associated with being a woman.   For instance, female surgeons often set ground rules, like “always wear a shirt under your scrubs or else male surgeons will look down at your chest.” How can female surgeons perform at their best when they are hampered by discrimination or abuse that negatively impacts the quality of their care? 

Medicine has been described as “one of the loneliest professions,” with good reason. For female surgeons, working in the field can lead to feeling isolated and marginalized on the basis of their gender alone.   Karin Muraszko said, “it is harder to be a woman because we have to deal with what’s going on between someone’s ears, how they perceive me, and it’s something I cannot change.  I can overcome a physical disability, but not make them respect me.”

I am reminded of the advertising slogan for Virginia Slims cigarettes: “You’ve Come a Long Way Baby!” Unfortunately, in our society, women physicians still have a long way to go.   

If you wish to learn more about gender bias in medicine, I will be writing more about it in my next column.   On the evening of Friday, March 20, I will be giving a lecture titled, “Goddesses, Whores and Women Physicians: Gender Bias and Why it Matters” as part of the Enlighten Series. The lecture is free to the public.

 

Dr. Susan La Flesche Picotte: A doctor who thrived against inequality

National Women Physicians day is celebrated on February 3^rd, coinciding with the birthday of Elizabeth Blackwell—the first female physician in the United States.  This year I would like to tell you about Dr. Susan La Flesche Picotte, the first Native American women to earn a medical degree in the United States. She was the quintessential family physician, serving in limitless capacity for her people, the Omaha. Throughout her life, she focused on public health issues, ardently fought for Omaha land rights, wrote for her local newspaper, and never gave up the fight for social justice.

La Flesche’s motivation to pursue medicine came from a haunting experience she had as a child, watching an elderly woman die in agony awaiting the arrival of a local doctor.  Despite being summoned four times, he never came.  In her opinion, the doctor’s absence made one thing painfully clear: It was only an Indian.  She wrote years later, “It has always been a desire of mine to study medicine ever since I was a small girl.”

Susan’s Father, Joseph LaFlesche, known as Iron Eye, served as the last Chief of the Omaha tribe. Iron Eye encouraged his children to become educated so they stayed true to their Omaha culture, yet understood both worlds.  At 14, Susan moved halfway across the country to attend the Hampton Institute, in Virginia, where she graduated as salutatorian. Hampton graduates were expected to return to their reservations to become wives and mothers.

Instead, LaFlesche applied and was accepted at the Woman's Medical College of Pennsylvania.

Medical school was expensive, so LaFlesche appealed to the Connecticut Indian Association, who sponsored her medical school expenses, housing, books and other supplies.  It should come as no surprise Dr. LaFlesche was valedictorian of her graduating class in 1889.  Thereafter, she accepted the position of government physician at the Omaha Agency Indian School, a boarding school run by the Office of Indian Affairs, which had a government salary of $500.00 per year.  While not obligated to care for the broader community, LaFlesche became the sole doctor for 1,244 patients spread across a massive 1,350 square mile area. Her office space in the corner of the schoolyard doubled as a community meeting place.  She was widely trusted in the community as a doctor, but also served as their lawyer, accountant, pastor and political liaison.

La Flesche routinely put in 20-hour workdays making house calls by navigating her horse drawn buggy through terrain blanketed with snow and biting subzero winds while wrapped in a buffalo robe.  When she returned home, “Dr. Sue” often found a line of wheezing and coughing patients awaiting her. At night, while sleeping, a lantern lit in her window served as a beacon for those sick with tuberculosis, influenza, cholera, dysentery, and diphtheria.

In 1894, LaFlesche married Henry Picotte and they had two sons: Caryl and Pierre.  Flouting convention, Picotte continued practicing medicine after the birth of her children and took them with her on house calls.  Her most important crusade was against tuberculosis, which killed hundreds of Omaha, including her husband in 1905. 

After being widowed, La Flesche’s role expanded to defender of Omaha land interests. She became outraged when the federal government reneged on the Omaha Allotment Act.  She wrote letters to the Office of Indian Affairs and harshly critical newspaper articles continuing to work on her community's behalf until the end of her life.

It was during a summer measles epidemic—during which the tribe lost 87 members, mostly children—that La Flesche began to dream about building a hospital on the Omaha reservation.  A fundraising campaign generated enough private donations to build the hospital and even furnish many of the rooms.  The Susan Picotte La Flesche Hospital in Walthill, Nebraska—completed in 1913—was the very first privately funded hospital built on a reservation in the United States.  In 1993, it was declared a National Historic Landmark.  In 2018, the hospital was named one of the top endangered places by the National Trust.  A fundraising effort is currently underway to pay for restoration of this historically significant building.

It is difficult to determine whether Dr. La Flesche faced greater discrimination as a Native American or as a woman.  La Flesche died in September 1915, four years before women were granted the right to vote and nine years before she could claim citizenship in the land where she was born and raised.  Omaha means “against the current.” In her lifetime, Dr. La Flesche broke many gender, racial, and economic barriers, but more importantly, she straddled two completely different worlds successfully:  Native and White, Omaha and Victorian, and motherhood and medicine.  She was born in a tipi on the Nebraska plains, attended summer buffalo hunts with her family, and rode bareback across the reservation, by the time she became a physician, she had also lived in the big city, attended symphonies, and ridden in horse-drawn carriages on cobblestone streets.  What I found most inspiring about Dr. Susan La Flesche was her tenacity. No matter the obstacle she faced, her spirit was never broken. May every one of us remain as resolute in our lifetime as Dr. La Flesche. 

To learn more about how Susan La Flesche overcame racial and gender inequality to become America’s first native physician, read “A Warrior of the People” by Joe Starita. 

Striking Nurses Should Be Supported

On April 3, 1968, Reverend Martin Luther King Jr. delivered his speech, “I’ve Been to the Mountaintop,” inside a jam-packed church in Memphis, Tennessee. Dr. King spoke of the injustice faced by the city's sanitation workers, who were on strike to protest low wages and unsafe working conditions. On February 1, 1968, two Memphis sanitation workers, Echol Cole and Robert Walker, were crushed to death—while taking shelter from the rain--in their defective garbage truck compactor.  Two men had died the same way four years earlier, but the city had refused to replace the dysfunctional equipment.  A previous strike attempt was unsuccessful, but this time, with support from their union, the middle class in Memphis, and Dr. King, the sanitation workers succeeded in winning concessions.

Lately, the oppressed are more apt to be healthcare workers, like the nurses of SEIU Healthcare 1199NW at Swedish Medical Center.  The bargaining agreement between the two parties expired in June and last week, union members voted to strike January 28-30 if proposals from Swedish do not address patient safety and staffing issues.  Swedish CEO Guy Hudson said that since the union has filed the strike notice, Swedish has taken their latest offer off the table and won't bargain until the strike is over.  Swedish plans to fly in thousands of contract nurses and caregivers from across the country to fill in during the strike. 

The priorities for SEIU Healthcare 1199NW are “safe staffing, workplace safety, recruitment and retention, racial equity and inclusion for all,” according to their press release.  Understaffing poses a threat to patient safety and care quality. Documents released by the hospital show Swedish offered to add 200 full-time employees while the union asked to add 2,000 full-time employees.  In regard to wages, Swedish offered an “11.25% wage increase over the four-year contract” while the SEIU Healthcare 1199NW asked for “23% over the four-year contract period and that Swedish management transfer authority over staffing decisions to the union.” Many members of SEIU Healthcare 1199NW cannot afford to live in Seattle and must commute due to wage stagnancy. 

Providence Health and Services affiliated with Swedish in 2012. And after taking over St. Joseph Health system in 2016, the big winners appear to be the top executives.  Between 2016 and 2017, Providence CEO Rod Hochman’s total compensation increased from $4.1 million to $10.5 million.  Taken altogether, Providence executive’s compensation jumped 64%--from $25.1 million to $41.1 million—following the merger.  Yet the following year, Swedish announced 550 layoffs as part of a reorganization effort that Swedish executive Guy Hudson dubbed a “more cost-effective model of care.”

If executive compensation can grow by 64%, why can’t front-line healthcare workers have an increase of 23%?  “Members of SEIU Healthcare 1199NW say they believe that providing the best quality care is no longer Swedish-Providence's top priority,” the union said. 

Do large hospital systems prioritize revenue generation over patient care?  Maybe.

Scientific research is just beginning to evaluate the impact mergers have on patient care.  A study published this month in the New England Medical Journal shows that acquisition by another hospital or hospital system is associated with worse patient experiences and no improvement in mortality rates. Of course, this is not altogether surprising. 

But, are unions any better for employees and patients?  Presumably, yes. 

According to a report released by the Economic Policy Institute, workers with a union contract earn 13.2 percent higher wages than non-union peers who have the same education and experience.  Unions raise the earnings of women, black, and Hispanic workers, three groups whose pay tends to lag behind that of their white, male counterparts.  Unionized workers tend to be healthier because employers are being held accountable for safe, non-abusive working conditions.  Unions have a track record of strengthening families by obtaining better leave policies, retirement benefits, and health insurance for their members, while at the same time, safeguarding that employees have due process in promotions, dismissals, or terminations.

Which side are you on? 

In my opinion, the nurses and other healthcare workers of SEIU Healthcare 1199NW need and deserve the support of their communities.  Nurses save countless lives every single day.  Our broken healthcare system cannot be fixed without a safe workplace, proper staffing ratios, equitable wages, and adequate resources to deliver the highest quality care to patients.   At some point, our lives will depend on skilled care of bedside nurses; these same nurses who are going on strike to fight for the patients they serve. 

Martin Luther King, Jr. said, “Let us keep the issues where they are. The issue is injustice. The issue is the refusal of Memphis to be fair and honest in its dealings with its public servants, who happen to be sanitation workers. Now, we've got to keep attention on that.”

Yes.  Let’s keep our attention on the members of SEIU Healthcare 1199NW and especially the nurses who are fighting for our very lives. 

The Privilege of Knowing Piper

The 2018-2019 flu season was the longest on record, lasting a total of 21 weeks.  The average season lasts between 7-15 weeks.  Only 143 children died from the flu last year, compared to 187 children during the 2017-2018 flu season, the deadliest on record for children.  Each year, half of the pediatric deaths occur in healthy children, the majority of which were unimmunized against influenza.  But this column is not about vaccines or statistics. 

This column is about the loss of one very special little girl, Piper Lowery, a healthy, vibrant 12-year old girl, who died from H1N1 Influenza in early 2016.  This week marks the fourth anniversary of her death and I want this community to know her better.

More than 15 years ago, I attended her delivery in an operating room at Harrison in Silverdale and I loved her from the moment she was placed in my arms by the delivering Obstetrician.  For 12 years, I had the privilege of watching her grow into a bright and self-assured young lady.  Whenever her name appeared on my schedule, it would put a smile on my face.  She always brought sunshine with her wherever she went.

Piper and I had an effortless rapport. She could always make me laugh.  I cherished her hugs and her quiet smile.  I often bribed her with chocolate from my personal stash to assuage my guilt after giving her shots.  These are some of the things I miss most of all. One crystal clear memory is a conversation she, her grandmother and I shared after I had become pregnant for the third time.  I assumed it would be yet another boy, having had two sons already.  At the age of eight, she was clairvoyant, assuring me it would be a girl this time.  And of course, she was right.

Piper was not technically my child but that is still how I thought of her. I heard her sing, listened to her jokes, eased her fears, and shared many other extraordinary moments with her.  I am so grateful to her parents for allowing me to be part of their lives.  I expected to take care of Piper’s children someday and knew she would make a wonderful mother herself after watching her care for her little brother, whom she adored.  I never imagined it would end.

The last time I saw her she did not feel well.  She was pale yet still had a twinkle in her eye.  I repeated her vitals myself and spent extra time with her to ensure nothing was missed.  I treasured our hug when she left, not knowing it would be our last. Her mom knew to take her to the local children’s hospital if she worsened over the weekend.  That Saturday morning, they headed off to Tacoma.  Upon arrival, Piper collapsed in the parking lot and had to be carried into the ER by strangers.  I wish I had been there, though the outcome would have been no different.  Not one day has gone by since her passing that I have not thought of Piper and longed to see her smiling face one more time. I know many of her friends and family members in this community echo the same sentiment.

Every year, I listen to the voicemail message her mom left that day telling me Piper died.  As both a physician and mother, I was overcome with grief.  I drove to their home without knowing what to say to her family.  We shared so many stories about Piper and her shenanigans that day.  We laughed and cried for what felt like hours.  I think her family might have been more of a comfort to me than I was to them. 

Piper was the first and the only patient in nearly 20 years of practice for whom I have signed the birth certificate and the death certificate.  100 years ago, country doctors did that sort of thing frequently, but today, it is rare.  It remains one of the hardest things I have ever done as a physician. 

I want those of you reading this column to know how thoughtful and considerate Piper was at the tender age of just 12.  On the drive to Tacoma, Piper asked her mother whether I would be in the ER to meet her. Piper had never been anywhere but my clinic and was disappointed that I would not be there. I requested that they let me know how Piper was doing that afternoon.  Despite her illness, Piper thought to tell her mom that she loved me.  Those final words are etched on my heart forever.   

At her funeral, I sat next to a mother of four whose children attended school with Piper.  She handed me countless numbers of tissues as tears were streaming down my face.  While taking in each picture of Piper over the years, I realized I had known her at every single stage of her all-too-brief lifetime.  Halfway through the service, this mother leaned over and said “I wish my children had a relationship with their pediatrician like Piper had with hers.” 

And that was the moment it dawned on me that I was actually the lucky one; to know Piper and to love her.  Being her pediatrician was my honor and privilege and I was lucky indeed. 

When Lawmakers Try to Play Doctor

State Representatives are elected officials who are tasked with drafting legislation.  Very few of them have been trained in medicine or practiced in a hospital or clinic, even in a part-time legislature like our state's. Unfortunately, looking across the country today it's too easy to find cases of these untrained legislators exceeding their mandate to advocate for unproven treatments, often setting dangerous precedents.

Take Ohio, for instance.  That’s where Representatives Candace Keller and Ron Hood introduced House Bill 413 to create a new felony called “abortion murder.” If passed, this measure will punish those who have or perform abortions with 15 years to life in prison and will be the most restrictive abortion law in the nation.  But that is just the beginning of a story that affects far more women than just those seeking an abortion.

Ohio sprinkled a little “fake” science into their anti-abortion legislation by allowing physicians to be charged with “abortion murder” if they provide the standard treatment to pregnant women with a life-threatening condition.  According to the bill, physicians must “take all possible steps to preserve the life of the unborn child… Such steps include, if applicable, attempting to reimplant an ectopic pregnancy into the woman’s uterus” or face criminal prosecution. 

The problem with that language is that reimplantation is pure science fiction, akin to mandating teleportation or time travel. Ohio lawmakers are not only trying to play doctors, they want to play God.

In a normal pregnancy, the fertilized egg must implant in the uterine wall, which has been specially prepared to support the growth and development of the embryo.  When the fertilized egg implants somewhere outside the uterus, such as the fallopian tubes, it is known as an ectopic pregnancy.  1-2% of all pregnancies are ectopic and account for 3-4% of pregnancy-related deaths.  In fact, ectopic pregnancies are “the leading cause of pregnancy-related death during the first trimester.” To save the life of the mother, the ectopic tissue must be removed.

 

An ectopic pregnancy cannot be relocated like a potted plant. 

In response to Ohio’s physician criminalization efforts, the American College of Obstetrics and Gynecology, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Psychiatric Association released a joint statement opposing “efforts in state legislatures across the United States that inappropriately interfere with the patient-physician relationship, unnecessarily regulate the evidence-based practice of medicine and in some cases, even criminalize physicians who deliver safe, legal and necessary medical care.”

Lawmakers got the hairbrained idea from a century-old case report published in the journal Surgery, Gynecology and Obstetrics, by C.J. Wallace. The author claimed to have successfully transplanted an ectopic pregnancy from a woman’s fallopian tube to her uterus in 1917.  A more recent case report was written by a British physician who was later fired for falsifying the data he used.  Case reports are not subject to the same rigorous scientific standards as most academic papers, but gullible Ohio lawmakers on their crusade aren’t looking for facts.

Instead, legislators are using propaganda—in the form of “fake” science—to remove protections for vulnerable pregnant women under the guise of saving unborn children who cannot be saved. It is reprehensible that these lawmakers are increasing barriers to life-saving care for women during a time in this country when maternal morbidity and mortality rates are skyrocketing.  Women facing an ectopic pregnancy need more than the involvement of their local elected official to save their lives.  Without intervention by a properly-trained physician, women could die.

Representative and bill co-sponsor John Becker, acknowledges that the law is more “wishful thinking for the future treatment,” than it is a reality.  He forgets the fact that many ectopic pregnancies happen to women who desired to be pregnant.  Circulating misinformation through this bill gives women false hope, which is cruel to those grieving a pregnancy loss.  In addition, women may feel guilty or their misinformed partners might blame them for not risking their lives in the quest for “reimplantation.” The premise of reimplantation is so farfetched that one has to wonder if Ohio lawmakers paid attention during human growth and development class in the 5^th grade at all. 

As strict anti-abortion laws sweep the country, I am afraid of a future where medical decision-making prioritizes the moral compass of the political party in power instead of evaluating the scientific evidence.  Representative Keller comments that “the time for regulating evil [abortion] and compromise is over,” but to me, this legislation is practically sanctioning manslaughter.  It is dangerous and irresponsible for lawmakers to enforce the use of a medical treatment that does not exist.  The ethical standards and practice of medicine should not be at the whim of politicians.  Ohio should be ashamed of the fact they are risking the lives of women everywhere.   

The Understated Impact of a Public Health Officer

The announcement that Dr. Susan Turner, the Kitsap Public Health District Health Officer, plans to retire next July was met with little fanfare.  It occurred to me that Kitsap County residents may be unaware of how much Dr. Turner has touched their lives.  In reality, we are losing a passionate health advocate who has worked tirelessly to improve the health and wellness of this community for more than five years.

 

Over the last 100 years, life expectancy at birth has increased from 45 to 75 years, in large part due to our public health services, such as improvements in sanitation, the provision of clean drinking water and safe food, and the elimination of occupational and worksite hazards.  Policy-guided public health interventions continue to address major health issues:  new environmental hazards, tobacco and opioid addiction, infectious disease, racial health disparities, injuries, gun violence, and worsening maternal mortality.

The potential impact on countless lives makes the medical health officer position the single most important physician in a community, yet, at the same time, the fruits of their labor are often largely unseen. Public health is an essential part of the healthcare system.  In fact, I believe the goal of universal healthcare cannot be achieved in the United States without incorporation of the already-existing public health infrastructure and collaboration with innovators like Dr. Turner. 

Having more than 25 years of experience in the public health sector, Dr. Turner dove right in when she first joined the Public Health District in 2014.  We collaborated serving patients at the Juvenile Detention Center where I learned firsthand, she was also a tremendous and compassionate clinician.  

Throughout her tenure, Dr. Turner championed many public health initiatives, including restricting smoking and vaping in public places, modernization of the Health District’s syringe exchange program, and narrowing the focus offered by the district to prioritize funding programs which encompassed “the greatest good for the greatest number.” Dr. Turner accomplished all of this while weathering significant challenges during a time when public health services were devalued and grossly underfunded.

My own professional career began at the Kitsap County Public Health District in 1995, when I accepted a job as the Assistant Health Educator after graduating from college.  I first learned that my childhood dream of becoming a doctor would come true while standing in the hallway of the old building on Austin Drive, when my acceptance to the University of Washington School of Medicine was announced by overhead page. 

Since that time, I have had the honor and privilege of collaborating with three Kitsap Health Officers, including Dr. Willa Fisher, Dr. Scott Lindquist, and Dr. Susan Turner.  After becoming a practicing physician, my reverence for the public health system has continually grown.  I literally cannot do my job without the support of the dedicated employees working there. 

My last call to Dr. Turner—which required about a half dozen conversations—was about measles.  A patient too young to be immunized had been inadvertently exposed to a case of measles at a hospital outside of Kitsap county and had been seen in my clinic before being informed they had been exposed to someone with the disease.

   

Measles is highly contagious; up to 9 out of 10 people with close contact to a measles patient will develop measles. A child can contract measles by being in a room where an infected person has been, even up to two hours after they leave.  Even worse, an infected person can spread measles to others before knowing they are infected themselves. 

After realizing more than a dozen children in my practice could be at-risk, I called Dr. Turner in a state of panic.  In usual fashion, Dr. Turner calmly talked me off the ledge, providing reassurance she would obtain more information before deciding our next steps.  Thankfully, proper precautions had been taken to prevent spread of infection for all involved.  The buck stops with Dr. Turner and for that, I am truly grateful.

I am going to miss Dr. Turner as my colleague, friend, and mentor.  The Health Board has started nationwide recruitment efforts for a new health officer to serve the Kitsap community and if the Health Board finds someone even half as good as Dr. Turner, then Kitsap County should consider themselves lucky.  I wish her many wonderful and quiet years in retirement, but hope she plans to keep her phone on just in case I need her calming presence and expert advice.