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Staff in intensive care have found themselves right at the heart of the COVID-19 pandemic.
In this episode I speak to Dr Rosie Baruah, a consultant in critical care medicine and anesthesia at the Western General Hospital in Edinburgh, about the pressures faced by those working to look after the sickest patients.
We covered a range of subjects around working through the pandemic, including burnout and moral injury, as well as gender bias in medicine.
You can follow Rosie on Twitter @RosieICM.
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Transcript
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Dr. Paula Redmond: Hi, I’m Dr. Paula Redmond, a Clinical Psychologist. You are listening to the When Work Hurts Podcast. On this show, I want to explore the stories behind the statistics of the mental health crisis facing healthcare professionals today and to provide hope for a way out through compassion, connection, and creativity. Join me as I talk to inspiring clinicians and thought leaders in healthcare about their unique insights and learn how we can support ourselves and each other when work hurts.
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The COVID-19 pandemic has brought into sharp relief the physical and psychological pressures faced by those working to save the lives of our sickest patients. Staff in intensive care found themselves right at the heart of this crisis. I wanted to find out what this was like and how this experience evolved over the course of the pandemic and what the lasting impact might be. I spoke with Dr. Rosie Baruah, who is a consultant in critical care medicine and anesthesia at the Western General Hospital in Edinburgh. In this episode, we reflect on what it’s been like for the doctors and nurses in intensive care and the impact of moral injury, particularly in relation to end-of-life care. We also talk about gender bias in medicine and how this affects both men and women. I started by asking Rosie what the pandemic had been like for her.
Dr. Rosie Baruah: It’s been, I think for everybody, the most extraordinary time in our lives because especially for those working in healthcare, it’s not just been incredibly challenging at work, but it’s been incredibly challenging outside of work too. I think it’s the first time I’ve had that dual experience because normally you have perhaps challenging things going on at home and you can go into work and count on the certainty and the routine being a grounding thing, or you have challenging things going on at work and you can count on things at home being routine and grounding.
This was the first time I think we all felt that we were just on absolute shifting sands and lost all sense of certainty both in terms of how things were going to be at home, how things were going to be at work. I mean, I very much hope it will be the only time in my professional life that I was made to feel like this. When I look back to, from early March to probably end May of the first wave in 2020, that feeling of just being in some parallel universe when you’d be driving to work and the streets would be empty, like it was driving to work on Christmas Day or something.
The hospital would feel empty because there were no visitors and no patients coming in for our outpatient clinic. Then you’d get into the ICU and it would all be poly-properly in tunnels and everyone walking around dressed like spacemen and not knowing when you were ever going to see your extended family again. It just- absolutely extraordinary. That was the peak, certainly in terms of our clinical activity, but also in terms of that uncertainty. It’s now filtered into just this ongoing uncertainty that I think we’re all feeling, the inability to make plans, either professional or personal.
Just that feeling of you never know what the future brings, but before you could always at least think, “Oh, well, in two years you might do this, we might go there. I might try this, I might not.” That feeling that you can’t actually plan for anything really because if you do, COVID is going to throw up another new variant or something else is going to happen. Losing that certainty is something that I think I’m still coming to terms with. I sometimes think back to the before times and it feels like literally a different world. It’s been extraordinary and when you sit and think about it, I mean what time to be alive?
Dr. Paula: Yes, and I can relate to so much of that. I guess my experience is very different to yours, not being working in a hospital. That just, the weirdness of thinking the other day of how, because I was working for the NHS, I used to go and do the weekly shop because I could get to the front of the queue, which was around the block and our car died because we weren’t driving anywhere. I would have to go and do the weekly shop by myself. Walking around with masks, that experience of just not being able to really read people very well, and the weirdness of human interaction that there’s still so many awkward moments.
We’re still really navigating that, aren’t we, about what’s okay and what’s not okay and how to respect those things? I think there’s something about, as you said, we’re thinking about the before times. I like that phrase. There’s a sense of actually, I think for me, that we’re not going to be ever going back to that, that we’re going through something rather than being able to go back. The longer it goes on, the longer, the more changes in life, thinking back to- my life’s completely different two years ago than it is now. People have died, people have been born, so much has changed. It’s so strange to look back and reflect on how long it’s been.
Dr. Rosie: Because it’s exactly that, isn’t it? You’re mentioning going to the shops, that feeling of going to the shops and their pasta aisle would be completely empty and the fresh fruit and veg would be all gone, and never having experienced that kind of feeling of panic of how am I going to– How am I going to feed my child? It sounds, we’re still privileged in the West, aren’t we? That’s not generally something we have to think about. It was exactly that feeling of you were living through this time of crisis that I’ve had the great privilege of never having to have thought about before, that fact that our lives, my life is not particularly exciting. It was very, very pedestrian. I like it that way. Suddenly not having that certainty of being able to go to the shop and buy food enough to feed your family, it’s just–
Dr. Paula: What’s your sense then, Rosie, of the mental health impact of these last couple of years on the staff that you work with and your colleagues?
Dr. Rosie: Again, sort of take it in phases. The first wave, for me personally, that run-up was really challenging because it’s almost– It looks like you’re thinking about a movie or something that on the BBC website, seeing these stories of this virus emerging from Wuhan and then, “Oh, it’s in Europe.” Then seeing the photographs and the footage from North Italy of all of the ICUs just being full of these patients. Because North Italy is very similar to the UK in the way it delivers healthcare, seeing how it was completely overwhelmed and then it’s spreading through mainland Europe and [unintelligible 00:07:48], and just this sense of inevitability when we had never before had to deal with a pandemic in the same way, even in the swine flu pandemic of 2009, I think it was. Things were difficult for a winter, but the social impact of that was pretty minimal.
For us as a ICU, I work in a hospital that’s a major cancer center. We have this difficulty of not wanting to compromise the care of patients who needed their cancer treatment, but also knowing that we needed to get set up for this virus that was coming. Yet feeling the sense that maybe it won’t get here because it never has before. For our nursing staff, particularly, we knew that we had to increase the numbers of staff dramatically in a really short space of time. Lots of nurses came from theater, from theater recovery, from research, from specialist nurse roles, from having previously been critical care nurses being thrown into this environment that was physically austere.
You’re wearing this PPE, which impeded your communication. It was hot. It was loud because you have these masks and these thick plastic visors we had at that time, which meant you had to shout all the time. You were dealing with patients who were really sick because in the first wave we had no effective treatments for COVID other than supportive treatment. The patients that were with us were so, so sick. I think the biggest thing, obviously, for nurses who weren’t used to ICU, dealing with the unstable physiology of these patients and the equipment and the drugs was challenging.
Our nursing staff were having to support nursing staff beside them. That doubled their cognitive load. I guess the emotional burden of having people who are needing a lot of support, I mean, our nurses are fantastic. They would never withhold that support from people, but that is an additional burden for them. I think the biggest thing was a lot of people died. In ICU, we are used to one in five of our patients not surviving. I genuinely think that giving people a good death is one of the best things that we do as intensive care staff, that when patients survive, that’s obviously a great thing.
Acknowledging that somebody is dying, allowing them if they’re awake and their families to prepare for that and supporting them and their families through that death is such a rewarding thing to do. Also something that I think gives us huge amounts of emotional and psychological well-being, I guess, knowing that we’ve really supported that patient and that family. Instead, we were completely withholding families from their patients- from their loved ones, I should say. They were allowed one hour visit when we had acknowledged that this person was dying. They had to keep their gloves on, they had to keep their mask on so they couldn’t touch their loved one, they couldn’t kiss them goodbye.
After that hour was up, we had to tell them to leave, and then that person would have their life-sustaining treatment withdrawn, and they would die alone, surrounded by strangers.
That was, for me, having to film these families day after day saying, “I’m really sorry, nothing’s working, they’re getting sicker. I’m really sorry, they’re getting sicker. I’m really sorry, you need to come in, they’re dying”, was terrible and just one of the hardest things I think I’ve ever had to do. Remember in the first wave, these families were completely alone. Very often it was almost all of the patients who died in the first wave were men so their wives were at home.
There was no bubbles at that stage, they were completely isolated, just getting this phone call from the hospital every day, and then they would go home to being completely alone again. Our nursing staff could see that, and they could see just how distraught these people were when they were coming in. I think for them, that act of care around the process of dying in ICU was completely just absent because you just couldn’t do what you would want to do which is to really spend time with these families and allow them to spend time with their loved one.
I think that was incredibly, incredibly difficult. For our staff who were not ICU staff who’d maybe never looked after a dying patient anytime recently to have to be exposed to the process of dying in such an abnormal way, I can’t imagine how they processed that. It’s funny, sometimes I’ll be in theater recovery during my days in anesthetics and there’ll be a recovery nurse who I remember looking after a particular patient when he or she was sent down to ICU. We’ll talk about that patient, “Do you remember that night, that man, and we did this, and do you remember when the family came in?”
We’ve got that kind of collective memory, and I wonder if actually just sharing those together helps a little bit because I think those memories, particularly the first wave, it was a difficult time. Then we moved past the first wave onto that period of uncertainty of are we getting a second wave, what’s it going to look like, is everything going to shut down again? People whose partners weren’t working, financially, how are they going to manage? There was all that uncertainty. Then there was that, I’d like to think it’s a minority, but that tide of public opinion turning from the clapping every Thursday to rallies in Trafalgar Square calling for us to be hanged like the [inaudible 00:13:43] trials.
Our nursing staff found that really, really difficult, saying they’d go on Facebook and people saying that the NHS staff are just being lazy and all these people are dying of heart disease and cancer and they just don’t care. Again, that was the next, I think, really difficult thing because what we do, we do with, I like to think great sincerity and with the most effort we can give. I guess this is something that you would know a lot about is healthcare workers have professional identity and our personal identities and sense of achievement, and sense of being a good person are so closely enmeshed to be told that you are a bad person for doing what you felt was the right thing in circumstances where you felt you had very, very little choice in the face of huge uncertainty, that was really, really hard.
Dr. Paula: It’s hard to hear you describe these experiences. I can only imagine what it must be like for people. I guess part of what I’m hearing is the sense of how your work and your colleagues’ work is so values-driven. Really driven. All that commitment and hard work is driven by a real commitment to the care of your patients and to providing compassionate dignified death and a sense of duty and responsibility, and a public service. The sacrifices that you’ve made in your careers and your lives to deliver that and the sacrifices you’ve made during the pandemic especially.
For that to become a source of vilification and anger and hate is- must be so painful. Especially at a phase when you’re probably exhausted, there hasn’t been time to recover physically or emotionally. To then feel that you’re going against the tide of– You haven’t got that public support from a loud minority of society.
Dr. Rosie: It’s funny because there’s always people who like to criticize the NHS, but I don’t remember it being so organized before. When you hear incredibly experienced, incredibly kind, caring, lovely, funny, hardworking ICU nurses saying, “I just don’t think I can do this another time.” You just say, “Well, who is”, because ICU nurses don’t grow on trees. To have somebody with that unique combination of a skill and compassion and knowledge and sense of humor and commitment to teamwork, all that kind of thing. When I think about our team in ICU, we’ve talked about a lot of things that are quite challenging that we found really hard, but there was also a huge amount of personal reward, enjoyment and happiness from that camaraderie that we had.
I think back to team wave one and some of our doctors in training who came, who had been in specialties and been what we call redeployed, which sounds very military, but sent back to ICU to help. Some of whom are not anesthetists or intensive care trainees, one of whom was a GP in training, one of whom was taking some time out. They were just fantastic, they didn’t know what they were going into. At that point, we didn’t really know how deadly COVID really was. We’d heard of healthcare workers in Italy and China dying, would that be us as well? They just flung themselves into it with not just enthusiasm, but genuine, they put their best work faces on every day. I can remember some genuinely, incredibly happy times in our work environment, just getting on with it.
Although some of the times were the hardest I think I will ever face, I have so many incredible memories of our team in that first wave and going on from that, just in that sense of teamwork and camaraderie that we had.
Dr. Paula: Where are things now, Rosie, with–?
Dr. Rosie: We always know Winter’s a busy time, but there’s a sense now when you have COVID patients. The really strange thing about COVID, is if somebody’s coming in just with the, let’s just say ordinary pneumonia, they normally, they’re very distressed, they’re often very confused. They need to go to sleep and go in a ventilator right away. That is what we do for them, but COVID is a really strange disease. People can have the lowest oxygen readings you see, they can be on 100% oxygen through a mask or a nasal oxygen delivery device.
They will feel absolutely fine and they’ll be chatting away to you and watching TV programs on their iPad. That’s obviously very nice that they don’t feel distressed until they deteriorate to the point where they need to go in a ventilator. The difficult thing is you get to know them a bit. Often now, when people come to ICU, they know what that means and they’re so scared and they share with you how scared they are. Then, if they deteriorate and you say to them, “Look, I think things aren’t working here, we need to go to our next stage of treatment and get you on a ventilator.” They’re making those phone calls to their families to tell them that’s what’s happening.
Again, there’s that feeling of, “Here we go again, here’s another poor person who is going to suffer the discomfort and the harms ICU treatment can deliver to people.” When you think that some of that potentially is preventable and you know that, the political management of COVID is like a whole other podcast, but there’s that real sense of I guess, emotional exhaustion of why is another person having to go through this, why is another family having to go through this? Some people will always be susceptible to COVID, but other people you think maybe would not be here if things had been done differently and that’s quite hard.
Dr. Paula: How does it show up that, the things that people have experienced, the strains of these last couple of years, what do you see amongst your colleagues on a day-to-day basis?
Dr. Rosie: It’s funny, isn’t it? Because burnout, if somebody’s crying in the toilets, they’re having a terrible day, it’s almost quite an easy thing to respond to. If you can give them a hug and you can say, “Oh, I’m sorry you feel really terrible” and, “We’ll get through this. Do you want a cup of tea?” All those things, it’s a very straightforward situation to deal with in many ways because their distress is openly manifested in a way that is socially straightforward to provide a response to but burnout can often just be people, you ask them to do something and they’re just like, “No, I’m not going to do that” or cover is needed for another shift. “No, I’m not around to do that”, and maybe just being more short-tempered than usual and just that sense of disengagement.
I can’t say I’ve seen that in my team directly, but I know that there’s a lot of it around and I think that’s the difficulty, isn’t it, because it’s not so easy to comfort somebody who’s been very disagreeable and “unhelpful”. They’re not, they’re really struggling but you can’t really go and hug somebody when they’ve told you for the 25th time they’re not going to do something [laughs] that they really should be doing. I think that’s the difficulty, isn’t it? Because we’re all feeling really tired. Then if somebody’s symptoms of burnout are manifested as that disengagement, how do you meaningfully engage with that person?
Rather than just raise your eyebrows and go, “Oh, right, I’ll just do myself.” I think that’s the real challenge because I’m sure there are so many people that are manifesting their burnout in that way, in a way that you can’t put your arm around them and say, “Don’t worry, can I make you a cup of tea?” I do remember, I was clinical lead of my department during the first wave of COVID, and in that period, in early March to late March when we were still preparing, I’d be walking through the hospital and people from doctors from other specialties would come up and say, “Right, so you’re expanding the ICU and that means I can’t do this and I can’t do that.”
Oh [unintelligible 00:22:26] I have to get fitted for a mask and I just don’t have time in my schedule and offloading all this stuff and I know that it was their way of saying, “This is really horrible, I’m really scared about this. I don’t know what’s happening, I’m a kind of person who thrives on being in control and I’m losing all sense of control and this is really tough for me.” I don’t know that I’m always better at being the better person, but even though I knew that that was what they were really saying, I was still like, “Why do you not think I’ve got stuff I’m thinking about too?”
Do not think my plate’s pretty overrunning with COVID-related crap right now and do not think I’m worried about my family. It’s that kind of thing isn’t it that when people are manifesting their stress in a way that can seem quite abrupt and can seem quite confrontational, I sometimes find it really, really hard to dig deep enough to confront that not in kind, but with kindness because you just think, “Come on grow up.” That’s not helpful, but I think that was my internal response a lot of the time and I’ll be nodding and be like, “Yes, that must be really terrible for you, yes, I’m really sorry that’s–”
Dr. Paula: I guess there’s something about our own capacity for that, our own capacity to absorb and hear and contain other people’s distress when we are really full up, we haven’t got that, any spare to give other people. I’m wondering and particularly looking back over these years whether there have been spaces or you’ve been able to carve out ways to pause and think and talk together in order to process some of this stuff and create some of that capacity.
Dr. Rosie: In our hospital, as we’ve already talked about, there have been some good things that have come out of COVID and one thing has been in the first wave, we were given the opportunity to hold– They weren’t counseling sessions, they were I guess, if you were to call them anything, as listening circles or one of our liaison psychiatrists would take any members of staff that were free, from any discipline, six or seven people at a time and just talk about how we were feeling. What was really interesting is that one of our docs in training who is with us, who is an incredibly insightful person, who is now a GP and I think his patients will be just extremely lucky because he’s just so emotionally attuned in a really smart way.
He went to one of these listening circles, I think it was him, another adoption training, and about four or five nursing staff. He said a lot of the things they talked about were things that we actually talked about in our doctor’s room just when we were writing up notes or just doing the business of the day. I think for our nursing staff, the way that they work tend to be a little bit more isolated because they’re with their patient in the bed space. They don’t have those points in the day like we do where we are still in work mode, but we’re all sitting in a room and can discuss together because for them the time that they’re in a room and discussing things together, it’s the coffee room.
I think there is this implicit expectation that you’re not going to bring heavy conversations into the coffee room unless it’s maybe just you and one other or two other people. It’s there as a period of rest, literal refreshment, but maybe also mental and emotional refreshment and to come in and be like, “Oh, this has been terrible, I’m so upset.” maybe is just, again, the implied rules of the coffee room are you don’t take things in there because that is a break room. I thought that was really interesting because I’d never really thought of that before that we as the medical and the critical care practitioner staff, we do have that space, the physical space of our room that’s still a workplace, where- A workspace where we feel we can have those conversations.
I guess again some of that is just the culture of the ICU where I’m so pleased to work that there isn’t that, I guess you could call it machismo, that whole kind of, “Oh, yes, whatever, machines, I love machines and sick people, they’re just people to stick big lines in.” There is this feeling of, that was really horrible, I’ve had this conversation with the family, they were so upset, I found it really hard, I can see these patients are getting sicker, it’s really difficult for me to deal with that. I think that culture of openness is something we’ve always had and it bore fruit during COVID when it meant that we could have that space where we could talk about that stuff and not feel the need to have this veneer of invulnerability because some places I think that is the expectation that if you show emotion, that is construed as weakness rather than just another part of what makes you human. I don’t know how I would’ve managed if I worked in a place like that.
Dr. Paula: That’s really helpful insight as you said about how other professional groups might not have those opportunities or those carved-out spaces and times to have those conversations. Do you have a sense, again, we’re not sure where we are in the story, but of what the longer-term impact might be for ICU staff in particular in terms of mental health?
Dr. Rosie: I don’t know, but I suspect you do, the impact of long-term uncertainty on people in the workplace and I think that is a really big aspect of mental health and well-being. Although we, as NHS staff, we know and we are very grateful for the fact that we have had a consistent income throughout all of this. A lot of people in two-person domestic units have been facing economic uncertainty which may be ongoing. As I’ve already alluded to that sense of wariness when you’re looking after these patients who are awake and very conscious of the fact that they’re in ICU with COVID and that this could end in their death. The psychological distress that causes them and the psychological distress it then causes you is a carer seeing these people really suffer because of that. I guess that sense of there being no end in sight and just new variants coming out all the time.
I think if I were to say there’s one thing that’s potentially going to be the root cause of mental health issues, it’s going to be that uncertainty because for the first wave, we genuinely thought it was going to be over by summertime. It was just, “Right, all hands on deck let’s go, team, let’s do this”, because anyone can do that for three months. In terms of a major incident, if you had to deal with this major incident that lasted 12 weeks, you can do that, but it’s now been a major incident that’s lasted 21 months. That’s the difference that when’s this major incident going to stop and I think it’s the uncertainty and the emotional burden of looking after these people and cutting them off from their families. Again, doctors do something. That is a caring job, I think.
I haven’t trained in nursing, so I can’t speak directly from this perspective but the act of care seems to be so fundamental to the practice of nursing. I guess then it’s so fundamental to a nurse’s professional identity and self-identity to have those acts of care taken away or modified in such a potentially devastating way. Again, every death I think is just another little death for that nurse, for them personally.
Dr. Paula: I guess there’s two things there. One is about exhaustion in terms of just the emotional and physical exhaustion that not only comes with this extended period of intense work but also of managing that uncertainty. The cognitive load that carries both in the real– It’s hard now even to plan for the weekend because we don’t know what’s happening, never mind planning breaks or personal development or all those things that we’d be nurturing and nourishing and that might keep us going during normal times. We have a rhythm, don’t we, to our lives and- our professional and personal lives, and that’s just so disrupted now. We haven’t got that sense of rhythm. The second thing you mentioned there which sounds– I guess we might be talking about moral injury there.
That sense of being in a position where we find ourselves either acting or being complacent in acts that really contradict our moral code like denying families access to each other when someone’s dying. Really painful to not have a choice but to be enacting those policies is so hard.
Dr. Rosie: What I find really interesting again going back to the way that– This is huge generalizations obviously but that medical staff and nursing staff may view things. Back in the first wave, we didn’t have any specific effective treatments for COVID, now we have many. Speaking of uncertainty, I had to short notice cover a bit of a day on Sunday because one of our colleagues had to self-isolate. When I was handing over on the phone to another colleague, he was saying, “There’s a new drug, Ronapreve, which has just become available which a patient had received and they were now doing quite well.” Whether it was down to this or not, you never know 100% but just saying [inaudible 00:32:42] a great thing that we can give now. It’s almost like for us, now if a patient does not survive, at least we’ve given dexamethasone and we’ve given Tocilizumab and we’ve given [unintelligible 00:32:52] if they need it and we’ve done all these things.
We have that sense of, we gave all the treatment we could give but unfortunately they did not survive. For us as doctors, I wonder if actually that sense of heart, of feeling that I have all this training and I have all these machines and yet there’s nothing I feel that I can really do to make you better, that has moved on a little bit since the first wave. I wonder if that means that we will feel less moral injury but for the nursing staff, I think that separation, particularly of the deteriorating patient and looking after patients who are awake but absolutely terrified, that’s still there.
I don’t know that the advent of new treatment necessarily because of their slightly differing professional role, would have the same impact. Who knows? I think it’d be a fascinating piece of research to do but for us as doctors, I think feeling that we had nothing to give other than supportive care was really hard because that’s just anathema to us as people who are knowers and who are doers but now we feel that we do know and we can do. That’s taken a little bit of that away.
Dr. Paula: Stepping back a little bit away from the pandemic. I know that you have particular interest in gender disparity and gender bias in medicine. I wonder if you could just tell me a little bit about that, about your interest there. I’m particularly thinking about the impact that that can have on medics in the workplace.
Dr. Rosie: I’ve always had an awareness of the role of girls and women in society and how we’re conditioned from a very early age to expect to behave in a certain way. Like for instance, my brother and I were very close in age but I would always be the one called down from my homework to come and set the table for dinner. Not him because his work was somehow seen as slightly more important and slightly less interruptible. Again, at medical school at Edinburgh, which is where I trained we were the first year, I think, to be slightly majority female, something like 52%.
That trend has continued in the 27 years since I started at medical school and now overall in the UK, it’s about 55% to 57% female. It varied on year on year. Yet in certain specialties, for example, intensive care medicine, which is where I practice, we’re still only 20% female at consultant level. In medicine, we see these twin phenomena, horizontal segregation, which is where you see men and women as clustered into certain specialties. For example, surgery, intensive care medicine, still predominantly male, and things like GP are predominantly female.
Some of that, of course, is personal choice but a lot of that is that men and women are directed into certain specialties based purely on their gender rather than on their ability, on their preference, and a whole heap of reasons for that. Then we see vertical segregation where women are underrepresented in leadership positions. Again, of course, some of that might be personal choice. I would not want to go into higher hospital management, that’s not where my interests lie. I’m not complaining that I haven’t been given the opportunities, I haven’t sought them out.
A lot of that has to do with how we view women as leaders because leadership in Western and I think pretty much all societies is strongly coded with behaviors that we like to see in men, authoritativeness, dominance, confidence. When they’re absent in men, we view men very negatively for not being authoritative, not being dominant, not from being confident but if those are seen in women, then we are viewed very, very negatively. They just are completely incongruent to the female gender role. We don’t like authoritative women. We don’t like to see women in leadership positions and women in leadership positions find themselves generally being viewed quite negatively as a result, or they have to style themselves as being very benevolent and very caring. Wise Angela Merkel, who’s one of those powerful women in the world called Mutti, which I believe is German for mother.
I could be wrong, I’m not very good at languages but why does she have to be styled as mother? Because mother isn’t just female parent, mother is all about caring and being warm and making sure other people’s needs are met before your own and all those kinds of things. Gender bias in medicine can be seen in the numbers of women in certain specialties and in the numbers of women in leadership positions. Just in your everyday experiences, as well as the women in medicine, you will– I’m currently doing a research degree looking into this and my participants tell stories that you would expect to hear that they will be sitting in the doctor’s room or going with a more junior member staff to go and see a sick patient.
All of the comments and questions are directed to their more junior male colleague because how could she possibly be the more senior person because she’s a woman? Again, we all wear the same clothes. We all wear the same blue scrubs. Visiting teams coming into the ICU, they will assume that you’re the bedside nurse rather than a doctor. I’ve done that. This is something that is embedded into all of our brains by being given nurse Barbie toys when we were little. It’s not in any way to say that being a nurse is not an aspirational profession for women to be in but it’s that assumption that because you’re a female, you’re a nurse.
Being spoken over male doctors in giving accounts of members of nursing staff coming up to them and checking the prescriptions and the plans given to them by female doctors, “Is this okay?” Again, that kind of idea of female authority and knowledge not being thought of as being of similar quality to male authority and knowledge. I think again it just harks back to social norms of women not being seen as those who have knowledge, and those who are allowed to know and to actually talk about that knowledge with authority. What we see in medicine is nothing different from what we see in wider society. What we want, I think, a society is with the very best people to do the jobs that suit them best so that they can then do those jobs to the best of their ability.
If we continue to give female trainees advice that, “Oh, well you don’t want to do surgery because how will you mix that with your family? Or, “you don’t want to do surgery, it’s just not somewhere that women thrive.” To a man, “You want to take share potentially but isn’t your wife the one with a vagina?” We will never change these norms. As human beings, we will not flourish to the full spectrum of the human experience because men are not being given the opportunity to be the caring people that they can be and do things like take time off to look after their family. Women are not being given the ability to potentially demonstrate the full spectrum of their leadership abilities because that’s not how we like our women.
Dr. Paula: It makes me think a little bit about imposter syndrome because that’s something that I hear a lot, people really struggling to connect with a sense of confidence and often feeling like their achievements are by luck rather than by design. They’re just waiting to be caught out. Really interestingly, I was reading that impostor syndrome initially was called imposter phenomenon. The idea that it’s an experience that happens within a context. In the 1960s, some authors tweaked it to recoin as impostor syndrome, which has connotations of disease or disorder and something that’s very much located within an individual. A problem that the individual needs to fix and do something about.
Whereas, I guess we could see how these things like gender bias and I guess racial prejudice and other forms of bias would really create and reinforce that imposter phenomenon. If you are facing expectations that- or you know, coming up against expectations that you’re not going to be able to achieve what your colleagues are because of your gender or race or whatever and how that can just be so subtly and constantly and insidiously reinforced.
Dr. Rosie: I could not agree more and imposter syndrome, I think it’s great to talk about because it’s such a widely recognized feeling that people have but again, that syndrome, putting the locus of that phenomenon within the person, when we know that, for example, if we take this to gender. I know a lot of men feel that they suffer from imposter syndrome too. As a girl, you are less likely to be called upon than your boy classmates when answering questions in class. There was a study in a medical school in Cardiff, Cardiff Medical School, funnily enough.
When they looked at the experience of undergraduates on their surgical placement and male trainees were routinely given advice that, “Oh, I think you’re going into surgery, well, this is what you should do.” Female trainees, every single female trainee was given advice to think about their future family and what specialty they decided to go in. Men were given more opportunity to scrub in and help with procedures compared to women. Again, who is feeding the syndrome? It’s all of us by just making women frame their own ambitions as being ambitions that have to be tempered by the obligations they have to other people.
The fact that women are just intrinsically less suited to high-risk, high-stress specialties. It’s exactly, we condition women to develop imposter syndrome. Flipping it back to the actual woman as in, “Well, you need to cure yourself.” Well, how about, we put in some mitigating strategies to actually stop it being so contagious? I think we’d give it to people.
Dr. Paula: I think being able to name it and acknowledge and validate those experiences is a good first step maybe. How do you think the pandemic has played into this, the role of gender disparity within medicine? Have you seen any impact of the pandemic on that?
Dr. Rosie: There have been a couple of robust studies published in both scientific and medical publishing, looking at authorship of papers and COVID-19. The proportion of female authorship has fallen. The putative reasoning behind this is that women are having to shoulder the burden of domestic work in COVID with limited childcare and all that associated domestic tasks in a way that men are not. Again, we have these families that I’m sure both educated parents with very high-power careers, and yet there’s a disproportionate share of the domestic burden falling to the female partner. Assuming it’s a heteronormative setup. Certainly, there has been a reduction in female productivity.
I’m sure not because of desire to be less productive but because women still share the burden of domestic work. That will only have been amplified during the times of Coronavirus. Again, I haven’t read anything about this but you do wonder, just everything has had to take a step back from COVID so are women who previously had been benefiting from mentorship and sponsorship and all of those positive role modeling that could help move them forward, so much of what we do now is over a screen, like we are talking now. In-person relationships are becoming harder to form so are women perhaps getting less in the way of that mentorship and sponsorship that can move their careers forward?
I don’t think we know yet. I’d be really interested to see how people in maybe five years’ time looking back can think that those relationships flourished or did not flourish because of what we’re finding now. I’m sure there’s still a lot of work to be done on the impact of COVID and women. I’d be really interested to see what the gender pay gap in medicine looks like over the period of COVID, for instance, because if women just have less time, they’re going to be earning less money. I think that there are impacts many of which are related to the fact that childcare in the absence of schooling and domestic duties have had to come to the fore and the fact that they do disproportionately affect women.
Dr. Paula: That interesting research about the number of women publishing having fallen. I guess this has lots of ramifications, doesn’t it? My understanding in medicine is particularly that there’s a real constant striving to be producing in those ways in order to have career progression. Not being able to produce as much of research and project work can prevent career progression and that then becomes disproportionate, which further reinforces the disparities in leadership. Also that the science itself is being created without a women’s lens, a female lens. We’re losing out as a society on not only the skill of women scientists and women medics producing the work but also that lens through which the work is done.
Dr. Rosie: I’m glad you mentioned that because there’s just always this idea when we’re looking at quantitatives, sort of positivist research that it is completely objective and the research question is completely objective and the gathering and the analysis of data is completely objective. We know that’s not the case then. I mean, as a qualitative researcher, embedding yourself and your identity and your views and just positioning yourself with respect to your research question is so central to what we do in qualitative research. I think quantitative research prides itself in its objectivity, but that’s not the case.
Exactly like you said, a whole segment of the scientific community is not involved in setting priorities and setting research questions, and actually, the doing of the research, uou are missing out on that viewpoint. I think the problem with quantitative positivist research is that its objectivity allows it to continue in this very, very potentially biased way. It can always just sit up and be behind the objective.
Dr. Paula: Just as you’re talking, I’m thinking about the constant emotional labor that women need to do to function at work in terms of navigating this bias and as well as shouldering more of the domestic burden. I guess I have a sense of that feeding into exhaustion and potential disengagement. How do women continue with this work in this extremely, particularly in your field, where it’s a high, being able to have all your cognitive faculties to hand in really critical situations is so key. Potentially with little respite from that, if even the negotiations in the coffee room or back home.
Dr. Rosie: It’s something I observed particularly in our female senior nursing staff because, again, I think when you look at that relationship between doctors and nurses medicine being traditionally a masculine profession, in the sense, initially it was almost entirely men because women couldn’t get medical licenses. Then it was one that very much valorizes masculine personality traits and is associated with intervention and procedures. Whereas nursing being very associated with feminine traits of caring and the giving of love as a therapeutic intervention. Many of our more senior nurses are female and the way that they have to spend exactly, you say, that emotional labor applicating other people’s drops.
Somebody can walk into unit and be like, “Oh, I wanted that drain out in that patient last week and no one’s taking it out.” and “Yes, this has all been documented incorrectly and they can’t just turn around.” and be like, “Take Rashid elsewhere, boss.” Has to be, “Really sorry about that.” Don’t worry, I’ll have a word.” Just pouring oil in everybody else’s troubled waters and then having a newly qualified nurse who’s really struggling, come into their office and having to provide, which they do gladly and they see it as part of their role, but the emotional support for them.
Maybe doing phone conversations with people who are thinking about coming back to work after a period of ill health, who may be very upset and anxious, and having to provide the emotional support to them. Whilst also doing clinical work, which is very demanding. I think particularly for nursing staff, because I think nursing carries with it a huge amount of emotional labor just intrinsic to the role. If you’re in a senior leadership position, you have to, as a nurse demonstrate that leadership in a very communal way where you’re being really warm and you’re being really sympathetic and you’re being very kind in a way that I think must really take it out of you.
Dr. Paula: Coming to the end, I wanted to ask you, we’ve been thinking about the challenges of the pandemic and I guess life in the NHS was hard at times before we heard of COVID and what’s, you know, happened in the last couple of years and potentially what we face going forward. I wanted to ask you, what keeps you going in this work?
Dr. Rosie: I’ve alluded to it several times already, but I just have such an amazing team at work. I feel I’ve always got somebody that I can just have a two or three-minute-conversation with during the day about, oh my goodness. I like to feel that people can have the same kind of conversation with me, but having colleagues that you can really be yourself with. I’ve got probably two or three consultant colleagues who I feel that I can be really honestly authentically myself with. As one of them who is probably the person I speak to most. He says, “Did I sign up for that though, Rosie?”
It’s like, “You didn’t sign up for it. Sorry, you’re going to have to hear me moaning again.” It’s great because it’s a really negative thing to do about people, to just malignantly moan nonstop. To have a friend who is also a colleague who understands what you’re talking about, who knows that you are just sounding off. Who gives you the permission to do that. Then who tells you not just what you want to hear, but sometimes what you need to hear, which can be very, very helpful even though it’s not always easy. Also, you just know that they’ve got your back because I think it is one of these things that, again, you will know far more than me as a psychologist.
There’s something about that self-identity we have as healthcare workers that I think is really difficult for people who haven’t been in that profession to necessarily understand. Especially with COVID, it’s been such a unique experience to find somebody out with our immediate circle who really understands what it was like, I think could be really hard.
For me, having a group of medical and nursing colleagues who were there, who get it, who know me and all my flaws and weaknesses, but are happy to accept me despite that and are happy for me to unload my woes.
Hopefully, feel that they can do the same with me. As I say, if I worked in a workplace where I didn’t have that, I don’t know how I could continue because I really enjoy the practice of intensive care medicine, but it is hard and this last 21 months has been particularly hard for all the reasons that we’ve discussed. I think yesm you build a team in peace time and you rely on it in battle. I know that there’s a lot of controversy about using military metaphors in medicine, but I think in COVID it has felt like that, and to know that I’ve got my colleagues around me and that we’ve all got each other’s backs and we’ll support each other, is the one thing that I think yes, I can keep doing this for another 15 years until I retire.
Dr. Paula: That sense of really authentic connection and shared values and shared experience. You found your tribe and you’ve got it [unintelligible 00:55:08]. I also wondered whether a sense of humor is something that keeps you going and is something that forms part of that?
Dr. Rosie: Yes, and again, sense of humor is really interesting, isn’t it, because it can become sometimes too dark to the point where almost becomes cruel, but I think finding the absurd in the everyday is probably number one survival tactic for the NHS, isn’t it? I think if your sense of humor is finding the absurd in the everyday, then that is something that’s going to get you through.
Dr. Paula: I wanted to ask you on that note about something that’s made international headlines for you, when you showed an ophthalmologist a picture of an eye?
Dr. Rosie: It looked like an eye from a distance, it was not an eye, it was terrible, and it was one of our ophthalmologists who had been with us through COVID, as I was saying, we had doctors redeployed to us. We had two ophthalmologists come to ICU and it’s a very, very different environment, but they were fantastic and they just threw themselves in there and they were doing the daily reviews and they were great. They also did some quality improvement work, helping eye care health of patients on ventilators because they lose the ability to blink when they’re sedated and they can get terrible corneal problems that can be life-long visually limiting if they then go to survive ICU.
It’s a really important thing to do. Then he’d come to see another patient who’d come in with a condition which can also be sight-threatening and the guideline for treatment of that, if that was beside him. I just pointed that, is that the worst-case scenario for the eye? He just looked at me because it didn’t sound like I was joking because I wasn’t joking, but it wasn’t an eye, it was the tip of a penis and it was a black and white poor-quality photocopy. That’s my excuse, but one of the other doctor in training in the room just went, “Rosie, that is not an eye.”
[laughter]
Dr. Paula: I hunted Twitter for the picture.
Dr. Rosie: Right, a poor-quality photocopy in black and white. It could look like an extremely swollen eye, but in retrospect, I should have really looked closer. I’d done that thing, hadn’t I? Was it top-down association or something that ophthalmologist sitting beside a picture, “It’s got to be an eye, but no, it could also be genitals.” You shouldn’t always do that kind of association.
Dr. Paula: Thank you for listening. If you enjoyed this episode and you’d like to help support the podcast, please do share it with others, post about it on social media, or leave a rating and review. I’d love to connect with you. Do come and find me on LinkedIn or Twitter. You can also sign up to my mailing list to keep up to date with future episodes and get useful psychology advice and tips straight to your inbox. All the links are in the show notes. Thanks again. Until next time, take good care.
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