The I’s of Women in Medicine

Intense, Insightful, Indefatigable

Irreverent, Indomitable, Irrepressible

Iridescent.

The I’s of women

who shine in

life.

An informal review of the numbers of men and women in higher level positions in Cardiology and recently published reviews on women in medicine, science, government, and business reveal that the percentages of women in positions of power remain low, in the 10-20^th percentile. With this editorial, we would like to encourage a wider and more open dialogue on the roles of women in higher academic positions and initiate interactions to allow for shared input of the ideas and talents of all genders and minorities in medicine and Cardiology. Rather than a standoff, we would like to see a cooperative approach, an understanding where we can work together and face challenges ‘eye to eye’. We will discuss here the problems women and minorities face in medicine and propose new approaches to deal with these challenges, in what we term the ‘I’ techniques.

The limits that women face in the professional world are real. In an informal online survey of current University Cardiology divisions throughout the United States, we found 32 male chiefs and 3 female chiefs. Similarly, in Canada, we found 10 males and 1 female as chiefs of Cardiology divisions. A recent editorial in the journal Circulation provides excellent commentary on the small percentage of women in Cardiology: 12% of general Cardiologists are women and for interventional or electrophysiology practitioners the numbers are lower than 10% (Saghavi M. “Women in Cardiology Introspection Into the Under-Representation.” Circ Cardiovasc Qual Outcomes, 2014; 7: 188-190).

This same underrepresentation is seen in the STEM (Science Technology Engineering and Medicine; https://twitter.com/4womeninscience/status/534705672009814016/photo/1) professions in general, with a marked decrease in the numbers of women in higher academic positions. In a prior commentary, we discussed an absence of women in senior editorial positions in the major Cardiology journals (Lucas et al., J Clin Exp Cardiolog 2014, 5:2). An apt article in The Washington Post recently discussed the more extreme example of the Catholic Church ruling that women are not allowed to become priests. Some view women as potential invaders who should be kept out of established systems of power (Petri A. http://www.washingtonpost.com/blogs/compost/wp/2015/01/13/cardinal-burke-is-right-women-are-terrifying). In a very elegant statement in a recent article in The Economist a similar disparity is reported for the numbers of women who work in Congress or as CEOs of major corporations (E.W. “Women and Work; What's Holding Women Back?” The Economist. Jan 23rd 2015, 16:36). This same article discusses both the current acceptance of women and also their success in leadership positions, which often contrasts with how they are perceived by their colleagues.

Thus, with this editorial, we are further discussing a chronic gender illness that pervades many scientific disciplines and medical fields, and more specifically Cardiology. Marginalized women in cardiovascular medicine represent one example of a suppressed population. Our intent is to use this discussion to illustrate the obstacles that prevent advancement to higher academic positions, to comment on suppressive techniques used by some to obtain and maintain upper level positions, and finally to discuss empowering approaches that women and other marginalized individuals can use to combat suppression. We wish to discuss a topic that is rarely acknowledged in medicine, despite the fact that we witness its effects on a daily basis.

To get to the heart of the matter, we see the limits visited on women in Cardiology as dysrhythmias, irregularities that produce dysfunction in the normal heartbeat of medical practice. These dysrhythmias not only damage women and minorities in training but also stand in the way of new and brilliant ideas, initiatives, and discoveries that remain locked within their bright minds. The continuous blockade and denial of potential medical talent is like the loss of blood flow and oxygen to the brain when a patient has a rapid, dangerous cardiac rhythm, causing damage due to anoxia when the arrhythmia is prolonged.

I often quote an older, classic psychology study when teaching. In this study, a grade school class was divided into two groups and each group was assigned for either 1) constant positive reinforcement or 2) constant negative critique. It was soon observed that those students with constant positive reinforcement began to excel, no matter their prior standing, while those who received constant criticism began to fail in their work, so much so that the study was terminated. Thus, if we continuously (and in some cases falsely) critique our colleagues, demeaning their ideas, work, and actions, then we are inducing a form of subjugation, or to continue the arrhythmia analogy, we are causing hypoxic damage. Too often in the field of Cardiology and procedure-based disciplines, women are and continue to be discouraged from pursuing powerful and lucrative positions. When they do pursue or achieve such positions, they become targets for suppression and marginalization. These same oppressive techniques are not unique to women and have been used to suppress many differing minorities, which is a topic we hope future editorials will discuss at length.

These techniques to gain power over others have been seen wherever one group has pursued dominance over another. We will now overview what we call the ‘I’ techniques, the ‘Suppressive I’s’ used to subjugate others, specifically women. These ‘I ‘techniques are drawn from personal observations and experiences over twenty years in Cardiology. A discussion will then follow on independent ‘I’ techniques that can be used to empower suppressed groups. We call these the ‘Empowering I’s’ techniques. These ‘Empowering I’s’ can be used to block or circumvent suppressive techniques, to rise above and beyond externally applied limitations.

We intend for ‘I’ to be a double entendre, as both the pronoun ‘I’ and the ego. On one hand, the ego can lead to an obsessive pursuit of power. On the other hand, an ego is fundamentally important for women to develop a sense of self-worth so that they can maintain their strength and courage to strive for higher positions and provide role models for other women.

We call the oppressive or marginalizing techniques the ‘Suppressive I’s’. These techniques are often seen in any pursuit of powerful positions or higher income. This discussion of this dysrhythmia is an analysis into the methods used to suppress women and other minorities, thus causing damage to the heart of our profession. Our intent is to discuss these ‘Suppressive I’s’ so that women can recognize the ways in which they are targeted and combat this suppression. The opposing ‘Empowering I’s’ are used to resist suppressive techniques.

The ‘Suppressive I’s’ incorporate the following techniques:

Insinuate- to imply that a colleague is inadequate, less capable

Insecurity- to engender a feeling of inadequacy

Irrelevant- to treat a colleague as if their opinions do not matter

Isolate- to effectively separate a colleague from the group

Interrogate- to openly question the ability and decisions of a colleague

Incarcerate- to place a colleague in a position of limited power

Imposter- to instill doubt in one’s capacity to perform or excel

All of these I’s represent an attack on the psyche, a form of hypoxia that can lead to what is termed the Imposter syndrome, wherein females feel inadequate or unworthy of their accomplishments, as if they have attained their higher positions by error or oversight, as if they are unworthy and are simply imposters in their own work and lives.

In the best of circumstances, a suppressed person will rise above and combat these oppressive techniques and regain self-worth. These remarkable women rise above the suppressive ‘I’s’ to establish their own ‘I’s,’ using innovative approaches that open new fields of study, new inventions, and new endeavours. As one of us and a colleague, Professor Marsha Bryant, often states, “If you can't outrank, outflank”.

The ‘Empowering I’s’ resist oppression, leading to new ideas and new paths:

Insight- to recognize new ideas and approaches

Initiate- to begin new endeavours

Invent- to create new approaches where none are as yet available

Irreplaceable- to produce unique work with infinite potential

Irreverent- to provide the power of humor and laughter

Involve- to include others in collaborative new initiatives

Irrepressible- to become an unstoppable force

Iridescent- to illuminate the infinite potential of brilliant colleagues, to shine

We suggest that one can combat suppression with the ‘Empowering I’s’ in order to pursue new ideas, initiatives, and infinite new possibilities. While our primary concern in this editorial is with gender inequality, members of any marginalized group can embrace these new ‘I’s’ in order to block dominating influences and initiate their own endeavours.

Some readers may suggest that women forego higher level positions in order to focus on family life, despite the fact that these women strived to obtain a doctoral degree (MD or PhD). Others may see women who balance a career with children as being too overworked and fatigued to be effective clinicians or researchers. There are also those who are insecure and feel threatened by the outstanding abilities and even brilliance of women who outperform them on the wards or in research. We suggest that women are still (too often) encouraged to stay in the home and to put their careers on the backburner.

One also sometimes sees women regrettably engaging in oppressive behaviour. Women are of course not immune to a desire to compete and excel. Some women may feel a sort of cultural pressure to embrace patriarchal values or may see this as a positive step to greater power. There is certainly room to improve our approach to attaining higher-level stations. Women continue to struggle to advance, and sometimes, unfortunately, see one another as competitors rather than as allies. We suggest that women can channel their impetus to excel into mutually supportive efforts. Women, or any subjugated minority, can gain more by aiding one another and by allying with members of other disenfranchised groups in order to change the structures of power in the work place.

This commentary is not meant as an invective against all males or all those in power, but rather to empower women and marginalized groups who are at risk of suppression to recognize suppressive techniques and to develop approaches to combat these techniques. Over these past 25 years in Cardiology we have seen some extraordinary and talented individuals, male and female, who have risen to the highest standards. One of our favorite professors is a Cardiologist (Dr. D. Humen, University of Western Ontario, London, Canada) who has always been equally supportive of people in medicine, whether male or female. I still quote him when I teach medical students, residents, and fellows. On ward rounds he would state, “My job is to make you a better physician than I am”. An understanding of the methods used to gain and keep power, whether unintentional or malevolent, may benefit the talented and brilliant women who have new and innovative ideas and who wish to share these with others and improve the practice of medicine and Cardiology.

In summary, we hope this commentary exposes suppressive techniques that have been used to marginalize women and minorities and to encourage new approaches that empower them to believe in their own abilities and to pursue their dreams. In other words, we want to lift the veil and open up this unspoken topic for discussion. Perhaps with some effort, this dysrhythmia, this heart block in medicine can be cured and a normal rhythm can be reinstated. We would like to propose that we work together to establish a new pace, a normal cardiac rhythm, and replace the ‘Suppressive I’s’ with ‘Empowering I’s’. The ‘Empowering I’s’ are intended to initiate a cure and provide a new pacemaker for this metaphorical dysrhythmia in medicine and other professions. We may then avoid standing ‘eye to eye’ in opposition and instead begin a new initiative to work together, ‘I’ to ‘I’.

This Editorial is dedicated to all the women in our next generation of Cardiologists and Internists, and to the women who came before and taught us the art of becoming empowered.