If hospital administrators and board members are future oriented, it is plain that they will have to take into account - in planning for the construction of new facilities - that within the next four years at least one-fourth of their interns and residents will be female. In seven to eight years, these women will be joining hospital staffs, and they will be demanding convenient and usable structural accommodations.
This represents a major change for our medical schools. Today women medical school students are beginning to have the freedom to choose from a fairly wide range of medical specialties, including even surgery - until now virtually not a choice for the female physician.
Ten years ago the woman medical student was most likely destined to become either a pediatrician or a psychiatrist. Her choice was narrowly determined by the handful of specialties to which she was most often admitted.
The new opportunities that are opening for women are beginning to be manifested in the specialties they are choosing. This was hinted at in a recent study of all women medical students at the University of Colorado and the University of California at San Diego. The women students' first choice was clearly family practice (44 per cent). Pediatrics was second (25 per cent), followed by internal medicine (20 per cent). Psychiatry, once one of the most "popular" choices, ranked low at 7 per cent. Surgery was beginning to become visible, with 4 per cent. '
So a discussion of "women, psychiatry, and surgery" is no longer an idle gesture, for surgery is becoming a viable choice for many women medical students.
At the University of Minnesota the trend is already evident: 7.3 per cent of the 82-member house staff of surgical interns and residents are women. However, representation of women at senior levels in surgery is all but nonexistent. Of the surgical faculty of 126 (clinical and academic), there are only two women: the author (a psychiatrist) and a surgeon at the rank of clinical instructor.
Comparable men-to-women faculty ratios are found in medical schools throughout the country. Of 4,498 senior positions in American medical schools surveyed last year, only 33 (0.7 per cent) were filled by women. Women, incidentally, were best represented in psychiatry, where they filled 101 of a total of 1,856 positions (5.4 per cent). 2
Looking at the situation objectively, one has to conclude that the process by which women have gained entry into medical schools on an equal basis has been extremely retarded. In 1928, nearly 50 years ago, women constituted 4.5 per cent of the first-year enrollees in medical schools. In 1968, 40 years later, the percentage had only doubled - 9 per cent.3 Starting in 1970, the percentage of women medical students began to rise more rapidly, and within four years it had doubled again. The percentage of women to total medical first-year students for the 1975-76 medical school year (the last year for which statistics are available) was 22.5 per cent. 4
A number of things had to happen before women could gain more of an equal footing in medical schools. Pressure was brought to bear on the male-established profession. Women slowly began to emerge from the role they had traditionally held, that of an ineffective minority in the profession, to become respected colleagues who could be seen and heard. The former aided the latter. Support came from both the sociocultural and the legal areas. As far back as 1964, the Equal Pay Act was passed. The following year, the Equal Employment Opportunity Act, which prohibits discrimination in employment on the basis of sex among other grounds, went into effect.
Policies of schools and colleges were affected by Title IX of the Educational Amendments Act, which requires affirmative action in employment and admissions.3 The diligent efforts by women's groups began to bear fruit in evidence of cultural and attitudinal changes. There was a growing awareness that many of the personality characteristics traditionally ascribed to women were simply invalid.
VISIBILITY IN MEDICAL SCHOOLS
As the number of women students in medical schools grew from a scattered few to a substantial number (sometimes as many as 40 or 50 in a class), the women instigated a mechanism that has proved effective in meeting their needs: they banded together to form support groups. These groups met regularly, beginning in the women students' freshman year.
In the women's group at Minnesota, which is similar to women's medical student groups at other schools, the students discuss the problem of defining themselves as females in a maleoriented atmosphere. The anxieties and pressures of medical school, student-faculty relationships, interstudent relationships and dependencies, and patient and staff attitudes and resistance all come up for discussion.
The success of these women's groups seems to bear out Lionel Tiger's contention that women have evolved a distinctive and efficient method for problem solving in developing such cooperative-action groups. Tiger believes that men usually turn to the model of dominant individual decisions following competitive action.5 Women, on the other hand, have acted in a group process - a method that has frequently been utilized by the national women's rights movement.
By banding together, the women medical students have effected cooperative action and are now beginning to exert effective political pressure in medical schools. For example, following a degrading episode directed toward women by a male faculty member at the University of Minnesota, a complaint to the dean of the Medical School brought effective corrective action. Subsequently, other offending faculty members began to receive official reprimands from the dean. The faculty members retracted their comments, and apologies followed.*
Since then, when offensive incidents have occurred at the university, other letters of protest have been sent to the dean. Recently, increasing numbers of male medical students have been joining the women students in signing the protests. On occasion, the male students have even instigated the complaints.
Today overt incidents by faculty members - either directed at women medical students or ignoring their presence - are more likely to occur at outlying hospitals where students are sent for clerkship than at the medical school itself.
Examples of this sometimes border on the ludicrous. Not too long ago a woman student was sent for her clerkship to a new community hospital supposedly utilizing the most advanced architectural design for a medical institution. The student entered the physicians' lounge and walked to the door labeled "Coat Room," only to find a cloak room complete with men's toilets and so occupied. The only place for women's coats was the employees' dressing room far down the hall. That is why I mentioned at the beginning of this article that if hospital administrations are seriously contemplating building new facilities in the future, they will ignore the growing number of women physicians at their peril.
PSYCHIATRY AND SURGERY
With the new options now open to women in the medical specialties, more and more women medical students are moving into areas previously closed to them. During the past eight years I have had a unique experience working as a psychiatrist in a liaison capacity in a department of surgery, specifically in the new subspecialty of renal transplant surgery. In the next few paragraphs I would like to discuss how this "union" of psychiatry and surgery has developed at the University of Minnesota.
In 1967 a new chairman of the Department of Surgery came to the university, and the then embryonic Organ Transplant Service began to grow. Kidney transplantation expanded beyond the experimental stage and became an established method of treatment. Mortality decreased as surgical technology and immunosuppressive methods both improved.
Today 80 per cent of the patients who receive allografts from living related donors have functioning transplanted kidneys at the end of six months; 75 per cent have them at one year and 60 per cent at five years. Sixty-one per cent of the transplants from cadaver sources are viable at six months, 56 per cent at one year, and 36 per cent at five years.6 Second transplants are performed when necessary. As many as four renal transplants have been received by some patients at the University of Minnesota.
Before 1967, few patients with end-stage renal disease under 16 years of age or over 50 were considered for kidney transplantation at any transplant service. But at the University of Minnesota the age boundaries were expanded upward and downward so that suitable patients in both older and pediatric age groups could be treated. Most recently, some diabetic patients with renal failure have received transplants.
The surgeons continue to assume the responsibility for the medical management of these patients because of the complexity of the immunosuppressive therapies and other complications related to renal transplants. This healthcare system is, of course, contrary to the usual surgical practice, in which the surgeon treats the patient for his acute problem and then refers him to his family physician for chronic-care management. As a result, the transplant service has developed a substantial population of patients whom it expects to monitor regularly for the rest of their lives.
Over the years, as more and more patients have been treated, the range of psychiatric problems encountered has increased until by now it covers the gamut of psychopathology that can be found in any varied population. Among these patients are those with neuroses, situational reactions, character disorder disturbances, and psychoses.
In addition to the problems facing the patients, unusual problems began to surface for the surgeons. There were ethical problems - for instance, whom to select when the organ available for transplantation was a scarce commodity. There were complex family problems when donor selection involved another family member. There were body-image problems when adolescents were treated with steroids.
In addition, there were problems related to long-lasting therapy. There is an elevated suicide rate among the patients on dialysis, and the seriousness of the psychologic effects of the treatment has been noted by many psychiatrists.*
The incidence of significant psychiatric disorders following organ transplantation has been reported as high as 32 per cent by some authors.7 In studying the effects of kidney transplants on recipients, Kempf has found depressive reactions, phobic reactions, and massive denial during the postoperative period.8 Castelnuovo-Tedesco reports that patients encounter significant problems in coping with an altered body image after transplantation.9 Another complication is caused by the steroids that must be given in large doses for long periods and that induce psychosis in some transplant patients. I0
Obviously, these kinds of problems interfere with the patient's ability to care for himself and jeopardize the survival of the kidney transplant - a fact that was recognized by the surgeons at the University of Minnesota. They realized that some patients' behavior was life-threatening. There were instances, for example, of adolescents with well-functioning transplanted kidneys who tested their adolescent identity by stopping their immunosuppressive medication, unknown to their physicians - thus initiating the rejection reaction themselves. In several such patients the results were fatal. Others lived to receive a second transplant.
After these episodes the surgeons sent out a tentative call to the Department of Psychiatry. Two of us responded - a male psychiatrist and myself. I remained, joining the surgeons as a consultant, researcher, and team member.
This union of psychiatry and surgery, as it has evolved and become firm over the years, has come to depend on five factors: visibility, availability, validity, viability, and productivity.
Visibility was effected by my joining the surgical staff on ward rounds. This made it evident that the psychiatrist was a member of the transplant team. It was a role validation that was necessary for both the surgical house staff and the senior staff, as well as for the patients.
During these rounds the house staff and senior staff members both brought up emotional problems in the patients as they occurred. The patients were thus able to see more easily the relationship that existed between their emotional adjustment to the kidney transplant and the whole procedure of organ transplantation. The procedure enabled everyone to see that the patient's reactions were more or less normal for his situation and that he was not a deviant expressing unique psychopathology.
Availability meant that the psychiatrist member of the team responded to a psychiatric problem with the same rapidity and definitive action that surgeons expect of themselves for their patients. The psychiatrist may need more time to define all aspects of an emotional problem and to investigate them. But the psychiatrist's ability to offer an immediate preliminary assessment of an emotional problem in a patient was necessary to demonstrate psychiatric validity. This immediate preassessment could allay the surgeon's anxieties about that problem and allow him to maintain his continued involvement with his patient.
Productivity meant that the psychiatrist clarified the patient's emotional problems to the surgeon in a way that was meaningful to the surgeon. Esoteric concepts and terminology had to be avoided. Written consultations and progress notes by the psychiatrist defined the problem - first subjectively, as it was presented, and then objectively. The latter included an assessment of the problem and presented a plan of treatment. A pretransplant psychiatric workup of patients included an evaluation of the patient's adaptive and coping strengths. Interns and residents were encouraged to assess these attributes in their patients along with blood and tissue typing, kidney function testing, and other physical evaluations.
Viability meant an element of endurance shown by the continued presence of the psychiatrist on the transplant service and in the PostTransplant Clinic to follow patients as new problems arose. Also, the psychiatrist was looking for new facets in a new field. An ongoing example is the recent trend of the University of Minnesota surgeons to offer transplantation to the diabetic patient with end-stage renal disease. Two hundred such patients have received transplants. I was aware of studies that found that such patients have a suicide rate that is higher than might be expected and numerous problems in readaptation after transplantation. Because of this interest, I am currently formulating a research project that will clarify factors contributing to this tragic outcome. The goal of the research is to seek methods to diminish the problems.
The union of psychiatry and surgery has depended on the psychiatrist's bringing to transplant surgery, which is symbolic of the technology of medicine, the concern for the whole person that psychiatry embodies. Transplant surgery may produce the mechanical human being of the future. Psychiatry must keep pace to preserve the patient's humanity. The psychiatrist focuses on the quality of life to come.
WOMEN IN SURGERY: THE FUTURE
For women, surgery has been a field traditionally bypassed. The previously cited surveys of medical students at the University of Colorado and the University of California at San Diego found that men still consider surgery to have the highest status. Female students choose internal medicine.
Surgery residency selection committees assert that, in the past, few women were represented on internship or residency staffs because they did not apply. On the other hand, women experienced poor reception in surgical clerkships as medical students long before they made a decision whether or not to apply for residency training. Even in the subspecialty of otolaryngology, where the issue of strength does not apply, there are still few women.
Today women are feeling freer to apply for surgical training in an atmosphere of improved acceptance, and the number of women in surgery is slowly accelerating. At the University of Minnesota, of the present group of 82 interns and residents, three of the 18 interns are women, one of the 17 first-year residents is a woman, one of the nine second-year residents is a woman, and one of the 10 third-year residents is a woman. Of this group, one woman plans to become a neurosurgeon and two women are considering transplant surgery. Finally, the first woman ever to have staff surgical privileges at the University of Minnesota Hospital has just been appointed in the Obstetrics/Gynecology Department.
I interviewed the six women surgical interns and residents. They perceive themselves in the dual position of being vulnerable yet elated. They are vulnerable because they are at the forefront and closely scrutinized by everyone. However, they are clearly elated to be in a field new to women. Their pioneer spirit clearly comes through. They all say that what women need for surgery is energy, compulsiveness, persistence, and endurance rather than brute strength. They point to women who are longdistance runners, where endurance is important. They feel less inhibited than the woman of even five years ago and assert themselves accordingly. They are exultant to be providing new role models for other women because they have had no female role models. They find that the male faculty has responded well. They exemplify the point that the qualities of a surgeon need not be determined by sex. In the words of the 16th-century description, there is "in a good surgeon - a hawk's eye, a lion's heart, and a lady's hand."11
ATTENDING THE BIRTH PROCESS
The present-day female medical student is attending her own birth process. The current social and legal climate is supportive of the woman opening new doors, but she faces the task of consolidating her own growth and development. Few identification models of senior women physicians surround and support her. The medical student brings with her to medical school a plethora of misconceptions about herself. She carries old labels of "passivity/' "masochism," and "narcissism." Few such qualities have been validated by scientific methods as being either male or female. Nor have these attributes been compared in a systematic fashion to determine their relative prevalence among males and females. She enters a profession where there are cultural stereotypes that require re-examination and re-evaluation. In Ericksonian concepts, she has to achieve a wholeness that includes both "inner identity" and expected roles. I2 Most women in medicine are unaware of the history of women physicians and, therefore, have little understanding of a continuity on which to build and consolidate their identity. They can neither rebel nor obey in terms of what has gone before, since a group identity for women physicians has never been established.
Women physicians have many roles to fill as scientists, healers, caretakers, humanists, mothers, and decision makers, among others. In the past, society has given female physicians less support than males in their attempt to fulfill themselves in professional roles. However, changes are occurring. Young men are expanding the scope of their professional and personal expressions and relationships. They are sharing in flexible residency programs with women and engaging in creative expression in family life planning in a way never seen before in the profession. This change frees men and women alike from the binding effects of stereotyped sex roles. The men perceive a benefit for themselves in such changes.
Once before, women believed they were entering an enlightened age of medicine in which they would make continuous gains towards equal acceptance. During the mid-1800s, the feminist movement gave strong support to women attempting to enter medicine. Political action helped women gain entrance into medical schools. Scholarship funds were provided. Women's hospitals were opened, providing training and hospital appointments to women excluded elsewhere. The first woman surgeon was trained at the New York Infirmary for Women and Children in New York City. By 1894 women accounted for 19 per cent of the University of Michigan Medical School student population, 25 per cent of Tufts University Medical School, and 37 per cent of Boston University Medical School medical students.13 The year 1910 marked the high point for the number of women physicians in the country. Soon thereafter, however, the feminist movement turned its attention to suffrage, and other forces came into play. Retrenchment in the medical schools took place, and by the 1920s women's representation in medical school classes had dropped to the low cited previously. Although the social climate has changed, women students should be mindful of the past. Success in the future will, to some degree, depend on their actions.
As today's women medical students begin a rebirth process, they must establish clear role definitions that will allow them to grow and expand their responsibilities and take their place in medicine. They must extend themselves to other women in the community, both to lend and gain support, so that this time, like Banquo's ghost, they will not be banished.
The author wishes to express her appreciation to the following, who contributed to this article by their interviews: Jo Ellen Geisel, M.D., Virginia Lupo. M.D.. Melody O'Connor. M.D.. Yolanda Roth, M.D., Nancy Asher. M.D.. Caliann Lum. MD.. Justine Willmert. RN.. and Pearl Rosenberg, Ph.D.
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