August 2004

Note: The following is based on a speech I gave at the ATS 2004 meeting in Orlando. Lynn Schnapp had just received the Elizabeth Rich award and I followed as the keynote speaker.

I have to admit that during most of my training, I didn't perceive being a woman as a problem in terms of professional development. Both Lynn Schnapp and I did our pulmonary fellowships at UCSF. At one time, there were 6 women fellows (out of about 18): Alice Boylan on faculty at MUSC, Lynn, Anne Weinacker on faculty at Stanford, Lisa Chen faculty member at UCSF/San Francisco General, Kim Kerr who transferred to UCSD and is a faculty member there and myself. There were only two fulltime female faculty members in the pulmonary division. But although we were a minority, there were enough women in the program to make me feel safe.

Not until a few years later did I begin to appreciate the subtle but very real obstacles faced by many women seeking to succeed in academic medicine. Discussions among faculty members on affirmative action were often challenged by remarks on how many women there were around. But, then as now, many women were in training or junior positions. Despite the fact that more than 10 years have gone by since that picture was taken, women remain a minority among medical school faculty. And of the women faculty members, many are in what have been traditionally considered to be "less prestigious" clinical or adjunct tracks.

In 1996, the ATS, under the leadership of Phil Hopewell, put together a task force to identify and examine the issues impeding the participation of women in the society. I was fortunate to be able to participate on this task force, chaired by Jeanine Wiener-Kronish. One problem that the task force identified was the lack of visibility of women members in the ATS power structure. In response, we recommended a group of qualified ATS women members to serve on the various committees. Lynn Schnapp was nominated to the membership committee, of which she eventually became chair, and in that role she played an integral role in establishing the mentoring program.

Two years ago, Lynn asked me to edit a column that would serve as an online resource addressing issues pertaining to professional development. It was clear from the very beginning that we were talking about more than "Women's Issues." Although meant to address the lack of available mentors and role models for women, these issues were relevant for any aspiring pulmonologist. And although the columns initially started out having a very practical focus, they have in many instances incorporated my philosophies about life and success. Career Talk was meant to give people the tools to proactively manage their careers. But, I discovered, all the tools cannot help you achieve success if you don't know what success means for you. The fundamental question is how does one succeed in a system whose definition of success may require personal or even moral and ethical compromises? And what does this have to do with the persistent lack of critical mass of women at upper levels in academic medicine? Even in the ATS, it has been more than 10 years since the last female ATS president.

Outright discrimination has largely, but not entirely, vanished, and there are a number of other reasons that conspire to subtly push women out of traditional academic tracks. In essence, the very lack of numbers itself leads to isolation and marginalization of women. There is often a subtle sense of exclusion, not knowing or being able to get to know the right people to get ahead. More importantly, though, is the fact that we live in a society and work in a system that clearly values market work over caregiving. Since women still function as primary caregivers, this disproportionately affects them.

There are other, more subtle obstacles that hinder women's access to traditional power structures. We tend to interact and communicate differently. We tend to think of ourselves as being part of a team. We are not given to self-promotion. The constant pressure to conform to male-defined standards of behavior/success often times leads to self-doubt and low self-esteem. Adding insult to injury, if women drop out, the tendency is to blame them, rather than the system. But does this need to be true and what can we do about it?

I entitled this talk "Power of Friendship" because I believe that the very characteristics that make us as a group different from men should be viewed as empowering, not dismissed as a "chick" thing. Our mechanisms may be different, but are equally adaptive and suited to our particular needs. Take, for instance, our ability to make friends. This is often dismissed as unimportant. Many men view the time and energy spent on the one-on-one contact so vital to sustaining friendships as better spent pursuing more obvious career goals.

But is it really a waste? Or does the ability to make friends give us a unique tool to survive the rigors of professional life? Women respond to stress differently. We tend to turn to our friends for support and reassurance in times of need. One critical reason for why I am here is because of the friends I have made. These friendships have nurtured me professionally and personally and enabled me to survive academics. Most men I know have well-established support systems at work and at home that permit them to focus on their jobs. Most women I know who work outside the home do not have the luxury of a spouse who works full- or part-time at maintaining a household. Most men I know are not concerned about finding good childcare or face the same guilt that women face dropping their children off at a caregiver's every morning.

So, the question that comes up is why bother? What price was I willing to pay and more importantly, what price would my family have to pay for me having a career in academics? I seriously considered leaving academic medicine after having my first child 7 years ago. I was sleep-deprived, hormonally imbalanced and just plain overwhelmed. It just didn't seem worth it to stay on at an institution that couldn't even understand its own childbearing leave policy. I had to think hard about what being a doctor meant to me. After 4 years of medical school, 3 years of residency, 4 years of fellowship and another few years in limbo and finally, a brand new faculty position, was I just a salaried plumber in a white coat, chasing an RO1?

That is the challenge, of course; how to make your way through a system and stay true to yourself. Eventually, I came to the conclusion that I would not leave -  not just yet. I loved and still love medicine and research. But I decided to stay on my own terms, meaning I consciously decided to limit my hours at work in order to spend time with my children. Yes, I would do what it takes - as long as I could make it home most nights to sit down and eat dinner as a family with my children, and as long as I could maintain the friendships that were and still are so vital to nourishing my own soul. No matter what, I was and am a doctor and a mother, and tenure cannot change that.

But many women do leave and it troubles me that the system still penalizes women, and not just women, but anyone who is "different." Women bring a unique blend of creativity and perspective to medicine and academics that can only enhance both professions. The tendency is to dismiss those who leave the system as "failures," not having what it takes to make it. But could it be that the system itself is flawed? That the loss of bright, dedicated and creative young physicians reflects a system failure and ultimately harms the system by draining it of needed talent and diversity?

It will take more than support, education of mentors and resources such as Career Talk to rectify the issues. It will take work on our part to establish new institutional paradigms that recognize the vastly increased amount of time needed to train academic physicians, especially in such a demanding field as pulmonary and critical care. To mid-level and senior women, I ask that you reach out to those coming up behind you. Too often, women compete among themselves or are unwilling to help a junior female colleague as if to say, "No one helped me, so why should I help you"? I would answer that it is part of your responsibility to promote the position of women. Regardless of how you achieved your position, you are a role model. By denigrating other women you are doing a disservice to yourself.

To junior women just starting out, you will be faced with making major life and career decisions, but whatever career choice you make, don't let the system make you feel like a failure. BELIEVE IN YOURSELF. You are making a choice. It is for yourself and the people important in your life. And whatever you do, stay involved. Be an advocate. It is naive to think that the system will change simply because it ought to. It is too easy to play victim and be bitter. The system can only change because of you and through you and your friends.

About 10 years ago, I was part of an ATS Task Force on Women in the ATS. The very fact that we are eating lunch together today is because of that group (initiated by a male president!). But, while much has been accomplished, much still needs to be done. As I mentioned before, many of the concerns and obstacles faced by women are not unique to women but apply to any young person considering the long career path of academic medicine or seeking to scale the power structure of the ATS. This is not about lack of ambition or dedication or talent. This is about life. This is about young people starting their lives and their families and feeling penalized professionally for doing so.

The ATS is about to embark on a strategic planning process that will define its goals and mission for the next 5 years. We - YOU - have a chance to participate in that process.
I mentioned earlier, that the loss of bright, dedicated and creative young physicians reflects a system failure and ultimately harms the system by draining it of needed talent and diversity. As the ATS begins to define and prepare for its future, what better time to re-affirm its commitment to its future, i.e., its future leaders and members by examining the difficulties faced by physicians and others seeking to navigate the long and sometimes arduous path of academic medicine.

I remember being at a meeting with Lynn and looking around at all these physically imposing groups of men standing together in tight circles and wondering how were we ever going to break in? But we looked at each other and said come on let's go, and together we politely elbowed our way into one of the circles. And so I would like to end this talk where I began, with my friends. To Alice, Lynn, Ann, Lisa and Kim - I would not be here without you. To Doug Conrad and Chuck Daley, who were also fellows with me at UCSF, you have given me the ability to believe in myself and the strength to follow my dreams. This poem is for you - (with apologies to Rudyard Kipling, the changes are in italics)

[IF]

If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you
But make allowance for their doubting too,
If you can wait and not be tired by waiting,
Or being lied about, don't deal in lies,
Or being hated, don't give way to hating,
And yet don't look too good, nor talk too wise:

If you can dream--and not make dreams your master,
If you can think--and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you've spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build 'em up with worn-out tools:

If you can make one heap of all your winnings
And risk it all on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breath a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on!"

If you can talk with crowds and keep your virtue,
Or walk with kings--nor lose the common touch,
If neither foes nor loving friends can hurt you;
If all men count with you, but none too much,
If you can fill the unforgiving minute
With sixty seconds' worth of distance run,
Yours is the Earth and everything that's in it,
And--which is more--you'll be a (hu)Man, my child!

--Rudyard Kipling