EP. 50: THE UNDERSIDE OF MEDICINE

Feb 18

WITH ARGHAVAN SALLES, MD, PHD

A minimally invasive and bariatric surgeon describes the struggles she has faced as an immigrant, minority, and woman in medicine, and shares how we can create a more equitable and inclusive future for physicians.

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Episode Summary

While this podcast has largely featured clinicians sharing the joy they have found in medicine, in this episode—breaking with tradition—we speak with a physician left disenchanted by her experiences working in medicine. Our guest is Dr. Arghavan Salles, a minimally-invasive and bariatric surgeon who conducts research on gender equity and implicit bias in medicine. At Stanford Hospital, she advises initiatives to promote physician well-being and diversity. During the COVID-19 pandemic, her frontline experiences were featured in Newsweek, NBC, CBS, and other press outlets. Over the course of our conversation, Dr. Salles shares fiercely honest accounts about the difficulties she has faced as an immigrant, minority, and woman in medicine. Her stories are by turns saddening, shocking, and amusing, but ultimately invoke us to reflect on the part we can all play to create a more just and inclusive path for current and future physicians.

Dr. Salles is a minimally invasive and bariatric surgeon. She completed medical school and residency in general surgery at Stanford prior to completing her fellowship in minimally invasive surgery at Washington University in St. Louis. She stayed on faculty at Washington University for three years prior to moving back to Stanford. Dr. Salles obtained a PhD in education from Stanford University during her residency training, and her research focuses on gender equity, implicit bias, diversity, inclusion, and physician well-being. Dr. Salles became a COVID Frontliner in 2020 and served in ICUs in New York and Arizona. She has written and spoken about these experiences in popular press outlets such as Newsweek, NBC, and CBS. She is a sought-after speaker and has given over 80 national and international invited talks related to gender equity, physician well-being, and weight bias.
In this episode, you will hear about:
• Dr. Salles’ path to medicine and her regrets along the way - 2:11
• The social pressures within medicine to overlook the downsides and hardships of a medical career - 7:11
• Why Dr. Salles chose surgery as a specialty - 11:02
• How, upon accepting her first academic position , Dr. Salles found herself in an environment that did not adequately support her surgical practice and her research - 14:12
• The systemic and cultural factors that led to the lack of support Dr. Salles faced - 23:03
• Dr. Salles’ research on gender equity in medicine - 29:57
• A discussion of the challenges of life as an academic physician - 32:13
• How Dr. Salles made the decision to put herself over her career and leave her academic position - 36:47
• Why it can sometimes seem that hospitals are exploiting physicians - 41:12
• Advice on how institutions can better promote diversity, equity, and inclusion in their culture - 47:32
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor-patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives; those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Over the past year, we have spoken with more than 50 clinicians about what makes their work meaningful. But in this episode, we are changing things up and speaking with someone who has been disenchanted with their experiences working in medicine. Our guest is Dr. Arghavan Salles, a minimally-invasive and bariatric surgeon who conducts research on gender equity and implicit bias in medicine at Stanford Hospital. She advises initiatives to promote physician well-being and diversity during the COVID-19 pandemic. Her frontline experiences were featured in Newsweek, NBC, CBS and other press outlets. Over the course of our conversation, Dr. Salles shares fiercely honest accounts about the difficulties she has faced as an immigrant, minority and woman in medicine. Her stories are by turns saddening and amusing, but ultimately invoke us to reflect on the part we can all play to create a more just and inclusive path for current and future physicians. Arghavan, thank you so much for taking the time to join us and welcome to the show.
Arghavan Salles: [00:02:09] Thanks for having me.
Henry Bair: [00:02:11] To kick us off. Can you share with us what first drew you to a medical career?
Arghavan Salles: [00:02:18] Well, I do not have an inspirational story. I will tell you that I was an engineering major, biomedical engineering major in college and for various reasons decided I didn't want to do that as a career. And then it was a very rational process of like, okay, I have taken these courses. What career pathways are available to me with these courses, you know, without having to repeat or take extra long to complete my undergraduate studies and medicine was right there. You know, I had all the things. So I was like, Yeah, that seems good. Being a little glib about it, I mean, I did really love math and science and had done a ton of service work all through high school and college. So I thought this would be a good way to use my interest and passion for science and working with people to try to do something good. But but it's very shallow if you think about it, that that rationale and and sometimes I say like I'm probably one of those people who should have gotten screened out in the med school admission process like I had not shadowed literally anyone. I had no doctors in my family. Like I really had no clue what it was I was signing up for, but somehow I snuck through.
Henry Bair: [00:03:27] Well, I mean, at what point did you realize that, Yes, this is this was the right choice after all.
Arghavan Salles: [00:03:33] ...
Henry Bair: [00:03:36] Hopefully you're -
Tyler Johnson: [00:03:40] (laughter) That that qualifies as the top five most pregnant pauses we've ever had on the podcast. I'm not sure how you quite convey the full weight of that pause, but that was amazing. Rewind. What Henry meant to say was....
Arghavan Salles: [00:04:05] (laughs) No, I mean, I cannot say with certainty. Actually, I can probably say with certainty medicine is probably not the right place for me. But yeah, I would not say I ever had a moment when I was like, "Yes, this was the right choice. I am on the right path. Everything's great." Like I never had a moment like that. In fact, I'm a person who, for better or worse, my disposition is to always be questioning and doubting. It's not particularly healthy. But when I started medical school, I was like, "This is not what I was expecting or hoping for." You know, people who know about medical training know that the first two years of medical school are spent really memorizing a lot of things. And of course, those of us who get to medical school usually have quite a large capacity for memorization. So that's not the problem. It just felt like such a dumb thing to do. Like, why do I need to sit here and memorize things? I much prefer deriving formulas and understanding why and how things happen than memorizing like steps in a cycle that no one understands the rationale behind. Because like, we don't know why things happen. And so that was really frustrating to me. So I took the LSAT because I thought maybe I would couple law school. Maybe that would be a better fit for me.
Tyler Johnson: [00:05:20] (laughs) That was the moment, Henry, when she was studying for the LSAT. That's the moment she realized.
Arghavan Salles: [00:05:27] (laughs) Well, I talked to a lot of people to get advice and, and the general consensus was, you know, maybe do third year with the first full clinical year that we do in traditional med schools and and then decide and if you really don't like third year then maybe apply. So I took the LSAT, I did not apply. I went into third year and third year, to be honest, is like pretty fun. You learn a lot. You're constantly in a new environment and it's challenging and it's different. So, you know, a lot of it is acclimation. And I thought, yeah, okay, like maybe one of these things would work for me. And then I ended up choosing surgery, which we can talk about that decision if you want. But anyway, I chose surgery and then most surgical residency programs, especially at academic places in this country, require or incorporate a few years of doing something else. Traditionally, it's like a basic science experience, but in the last decade or 15 years or so, people have started doing like other degree programs like MBAs, MPH or whatever, just other professional development experiences. So anyway, during that time, that's when I actually got my PhD. But also during my PhD, I thought, I don't know if any of this is right for me. So I went and did an internship at a management consulting firm, ended up just doing that internship and not going on to a career in management consulting. But I share all that to say, like I'm constantly questioning whether I am on the so called right path for me. I know that there is no one right path, but am I doing what makes the most sense for me in my skills and my interest? And yeah, again, I'm not sure that's a good trait, but that's what I do.
Tyler Johnson: [00:07:11] Arghavan, I'm sorry. You must have missed in the mail the script we sent you, where you're supposed to be telling inspirational stories about how much you love medicine. Probably in your mailbox. If you want to go check, we can hold on a minute, and then you can just come back.
Arghavan Salles: [00:07:25] (laughs) You're right. I actually I do think about this a lot because I do not have the same "medicine as the best thing ever" script that most physicians share, at least in public spaces. And actually think about that a lot because there is definitely a social pressure within our profession to only say good things about the profession. There's also, you know, we have we certainly have privilege in a lot of ways with the education that we have, the training that we have, the role that we're able to play in people's lives. And there is some some financial security with knowing people will always be sick, they will always need doctors, etc.. So we have a lot of privileges. So it feels a little bit ...ick? Right? To say, Well, but this career is not great because of X, Y, Z. So I think that's part of it too. But I really think that we are misleading people. Now, to be fair, I don't think we would have that many people becoming doctors if they knew what it was they were getting into. Like, I think a lot of how this functions for our society is people's lack of understanding and awareness of what it really means.
Arghavan Salles: [00:08:37] Not to say that there's not good things about being a doctor for sure there are, but I think for many of us they end up outweighing a lot of the challenges, partially because our systems are so flawed and there's not enough support and all the burden that we carry for doing such really emotional work day after day, for week after week and month after month and year after year, which I don't think we've really got adequate support for. So anyway, I think for these reasons people don't often share their criticisms of the profession and there's just immense pressure to focus only on the things that we like or that we love and be that inspiring story that you're looking for. But I just can't do it in good conscience, to be honest. And I really struggle with that too, because obviously we need people to be doctors, like I'm only getting older and we'll only have more health problems. I need people. We all need people to care for us. But. I. I just can't look a person in the face and say, "Yes, you should be a doctor."
Tyler Johnson: [00:09:43] A couple of things in reaction to that. One is that it's interesting that I've started going- my alma mater doesn't have an affiliated medical school, and so people who are there who are thinking of going into medical school are don't really have anyone to talk to, write about what it's going to be like. And so as soon as I became an attending, basically, I started going there on my own expense. Once every semester they have like a a pre-med seminar class, as many colleges do. And basically I go there and give a lecture that is literally called "counting the cost." And I go through and do all of the nitty gritty stuff because like you, there are no doctors in my family. I had no exposure to what medicine- I mean, I had shadow doctors for a couple of days, but I had no- I didn't know what a residency was. I didn't know how long medical school was. I didn't know what a fellowship was. I mean, I just didn't know any of that stuff, right? So I go back there and just go through the nitty gritty of how many years is this going to be? How much debt are you going to have? When can you start paying it back? How much does an intern make like just all of that stuff? Because nobody tells you that, right? At least for me, I had no idea. And my point is not to persuade or dissuade. It's just to inform because I feel like you should be able to do. That's why it's "counting the cost." You should be able to count the cost when you're making that decision.
Tyler Johnson: [00:11:02] Let me go back though. So I want to because your training ended up being, I mean, as it is for everyone, but in your case, even more so in different and unusual ways, ended up impacting the rest of your life so much. Can you talk first about why did you decide to go into surgery?
Arghavan Salles: [00:11:16] So third year, as I as I mentioned earlier, like third year was actually mostly fun. I mean, obviously it's challenging and long hours and etc., but you're always performing right in your third year and that's exhausting. But I really did enjoy learning about how different specialties work and learning about different disease processes and in ways that you don't in your first two years. So literally in every rotation, I was like, "Maybe I could do this." You know, it was like neurology. Maybe I could be a neurologist. And then psychiatry, huh? Maybe I could be a psychiatrist. And then it was Pedes, and I was like, Huh, Kind of like the kids, you know, like, that's how it went for me in my third year. And by the end of the third year, the two things I like the most were radiology and surgery. And people think that's weird, but that's what I liked and for different reasons, obviously. And so I actually did sub I's in both of them. And in the end I chose surgery because of the people. You know, that's often I think that's a very cliched thing. That's often what people say. But specifically because of the women who I had worked with, both residents and faculty who I just thought were so smart and funny and cool and real, and they were people who I aspired to be like. And it felt like if I went into surgery, I'd be joining this like, cool club. So that was a big motivator. Obviously, like we talk about the specifics of surgery, it's very gratifying. You get to do things for people in a way that other physicians don't like.
Arghavan Salles: [00:12:46] Someone comes in with appendicitis, we can take out their appendix, their pain is gone. It's pretty amazing. And it's different from the work that a lot of other doctors do with prescribing medications or so on. And I'm not at all like looking down on that. I'm saying it's different. And so I really liked that immediate gratification of being able to use my hands and do something physically that was going to improve these patient's health. But really, like everything in medicine has cool aspects to it. So in the end, for me it was that I wanted to work with these people and I liked that surgery was like physically active, know you're not sedentary as a surgeon. So I thought that was a plus. But honestly, that was a miscalculation on my part because I thought that I would be healthier because, like I said, I was down to radiology and surgery. And radiology, I thought, Oh, I'll just be sitting at a desk. If I'm sitting at a desk, I will be eating. I just know myself. If I'm sitting at a desk, I will be eating through the day. I will have whatever unhealthy snacks, and then I will just gain weight and be a really unhealthy person. But the miscalculation is that radiologists do not work the same number of hours as surgeons. So while we may be sedentary for a certain number of hours in the day, they have all the other hours in the day to go do non sedentary things and to eat healthy food and and live a life which, you know, a lot of surgeons don't have in our lives. So.
Tyler Johnson: [00:14:12] Okay, So then I have to imagine that when you you're coming out of medical school, you're entering into your residency program, I imagine that you had a vision of what life was going to look like. You were going to go through and finish your training and become a, I don't know, world renowned something, something surgeon in some place you were dreaming about at the time. But what I'm trying to say is that what I gather from what I know of your story is that the life you are living now and what you spend a lot of your time doing now is not, let's say, necessarily the life, the picture that you would have painted back however many years ago when you were entering into residency. So what happened?
Arghavan Salles: [00:14:55] Yeah, well, that's definitely an accurate assessment. I mean, if I had a vision, it was definitely a vision of being a surgeon and being in the operating room and having patients in the hospital and doing the work that I trained for so long to do, and I did that for a few years after residency, I did a fellowship in bariatric and minimally-invasive surgery, then took a faculty job at an academic center doing that kind of surgery, and-.
Henry Bair: [00:15:24] I'm really sorry to interrupt you here, but I, for one, do not know what minimally invasive and bariatric surgery were until I was on my surgery rotation in my third year of medical school. So since we have a lot of medical trainees and even pre-medical students on the show, can you just give us like a one or two liner of like what that work entails?
Arghavan Salles: [00:15:43] For sure. You know, minimally-invasive surgery is an approach to doing procedures unlike, say, colorectal surgery or hepatobiliary surgery or even surgical oncology, where the focus is on a specific set of diseases or a specific organ. Minimally-invasive surgery is just a way of doing surgery, so you can have minimally-invasive approaches to any specialty, pretty much. All it means is that we're using smaller incisions and typically, at least for general surgery, when we talk about minimally-invasive surgery, we're talking about laparoscopic surgery for the most part. So that's small incisions made on the abdomen and then we put instruments and a camera through those small incisions to be able to do the surgery that we do on the inside and then be able to just have those small incisions instead of making the other option would be to make a big incision and then actually get our hands in to the abdomen and then do whatever it is we need to do. It's usually the exact same thing that we would be doing on the inside. It's just whether we're doing it with our hands in there or with these instruments through small holes. And you can I think it's intuitive to understand that it's it's better for the recovery of the patient if we're able to do something minimally-invasively, they have less pain, they spend less time in the hospital, they recover more quickly, etc.. And bariatric surgery is some people used to call it weight-loss surgery. Now it's often called metabolic and bariatric surgery because there are metabolic changes that occur. And the basic idea, there's multiple different specific procedures that people can do that's part of bariatric surgery. But the overall idea is to help people be able to treat their obesity so that their overall health is improved.
Henry Bair: [00:17:26] Thank you for that. And now back to your your story. You were talking about how you landed in an academic position after training.
Arghavan Salles: [00:17:33] Right. So I had this job, which, you know, it was some things that I wanted, like it was an academic job. I had a PhD and really wanted to do research. So it made sense for me to be at an academic center. But it also was some things I didn't want, like it was geographically in a place where I didn't have a lot of social support and was just there by myself. And so that wasn't ideal for me and it was far from friends and family. But, you know, your first job is- no job is perfect. So I took the job and unfortunately things unraveled pretty quickly within the first 12 to 18 months or so. That has to do with a lot of things which we probably don't have time to get into. But what I can say is that I, in that time did not feel that my clinical practice was supported, and I also did not feel that my research was supported. And that's because of specific things that were or were not done. For example, I can say on the clinical side that when I started the job, I use this example often because it's the easiest or it's a very easy one to understand. I was not given preference cards, and so here's what preference cards are. They're basically a recipe for how we do a procedure. So it tells everyone in the operating room, the various staff members, that if we're going to, for example, take out somebody's gallbladder, we need to have these instruments in the room.
Arghavan Salles: [00:18:59] We need to have the room set up this way. For example, they would know that we need the laparoscopic equipment, that we need, the monitors that go with the laparoscopic equipment, etc. Without those preference cards or without having that recipe, the staff has to kind of make it up. And that means they're not going to get it right because it would be impossible for them to. And then what that leads to is a lot of inefficiency and the frustration on the surgeon side of just constantly repeating over and over and over again what it is that we need. And and it's not, by the way, these preference cards. It's not like there's five things on the card. It's often 100, 150, 200 things on the card, depending on the complexity of the procedure. So it's really very taxing for every single procedure to have to go through that process. And I had to deal with that for four months. And that's not normal, you know. And that's frustrating not just for me, but again, for the staff as well, because they also want to be able to do their job well and they want their day to go smoothly. They want everyone's day to go smoothly. But when they don't have that information, there's very little they can do. And one workaround if someone else finds themselves in this situation, is if you at least have consistent staffing -so if you have the same people who are helping you, then of course they start to write notes for themselves, then they can use those.
Arghavan Salles: [00:20:24] But I wasn't given that either. And so it was just like Groundhog Day, every day. And as much as that's frustrating in any job, to not have the support for the work that you need to do. We have to remember that in this job, there are other people's lives at stake. And I'm the one who bears the responsibility for that. And I'm the one who's entered into a contract of sorts with that patient. And they've put their trust in me. Not understanding, I think, that I'm only one part of the equation. There's a circulator, there's a tech, there's an assistant, there's an anesthesiologist, and those people may be multiple people for any one case. And I don't have control in most of our academic centers this is true, I don't have control as a surgeon over who any of those people are for any given case, nor do I know in advance who those people are going to be. And so, again, that's just one of the easier to understand examples of how I did not feel my clinical practice was supported. Because it's very difficult to be starting out your first job as a physician, any kind of physician, no matter how long you've trained, it's the first time that really the buck stops with you. And that's a very different experience that I think is hard to understand until you go through the transition yourself and to do that and know that you have the responsibility and to care very much about your patients, to have very high standards, but then not be given the tools with which you would be able to deliver that quality of care is an extremely challenging position to be in.
Arghavan Salles: [00:21:57] And I'll just say very quickly, on the research side, like they literally would not write letters of support for me to apply for grants so I could not build my portfolio in terms of academics because I couldn't get you know, we all know the currency in research is these grants, and I was not allowed to apply for them because they decided that they didn't want to support me because they had made some judgment about what kind of person or what kind of surgeon or whatever I was. And, you know, within a year of being in my current department, I got an R-01, which is kind of like the big deal NIH grant within a year. Meaning the first time I tried, which is very unusual. And I got lucky and I have great support and there's all sorts of reasons for that. But I wasn't even given the opportunity to to apply for those types of grants, which is harmful, not just for that job that I had, but then it makes it harder for me to make a case when I apply for other jobs that I should be given time for research, because research is really important for me because they look at you and go like, okay, but like what money are you bringing in?
Tyler Johnson: [00:23:03] And just to be clear, the lack of support that you faced there was because...why?
Arghavan Salles: [00:23:11] This is a good question. I've obviously thought a lot about it, and I think it comes down to a number of different things. One is just negligence, like I think some of the people involved in leadership at that institution in that department are not capable of supporting someone. They just don't know what it takes. You know, I think what a lot of people don't realize is that in medicine, to kind of climb up and get promoted into like a chief level or a chair level position, in most places, you don't get promoted to those roles because you're an excellent mentor. It's usually because of either research productivity or service to the institution or maybe something else. But it's usually not anything to do with mentorship. In the same way that in universities, professors don't get promoted because of their teaching ability, right? They get promoted because of their research and their grants and that productivity, it's similar in medicine. And so you have people who are in a so-called leadership role who sometimes have literally zero leadership skills. And I found myself in a situation like that. So that's just negligence. On their part.
Arghavan Salles: [00:24:34] On top of that, though, I think that there is. A very strong current of me being a woman. Who speaks up when I feel things are not right. Who advocates for myself and who also advocates for other marginalized people. And all of those characteristics make me unlikable. In our society. So that was part of it.
Arghavan Salles: [00:25:03] And then the other part of it I think was the research that I wanted to do would expose problems in our culture and in medicine. But when you have people who are not real leaders, they see that as though you are trying to undermine them. Because their ego is so problematic that they can't see beyond themselves and understand that this is a societal problem that is holding all of us back. So rather than let you do that work and try to solve that problem, they just want to squash you. And I think those are at least some of the things that were going on there. And admittedly, I'm not sitting here saying I am perfect, like by no means. I certainly made mistakes in the time that I spent there, for sure. I do think, though, and this is based on conversations I've had with a lot of surgeons at a lot of different places, that it would have been very difficult for pretty much anyone to survive the circumstances that I was put in. So the other thing I think was definitely at play or at least cannot be underestimated, is that I am an immigrant from the Middle East and I was living and working in the Midwest, in the United States, where there is very little diversity. There is much less progressive thought. And a very strong current of xenophobia. So I do think that was another factor.
Henry Bair: [00:26:39] How did that manifest?
Arghavan Salles: [00:26:42] There is a very real challenge around intersectionality that we talk about a lot in diversity, equity and inclusion work. So the intersectionality, the idea is that oftentimes people carry more than one marginalized identity or there's more than one aspect of our identity that is marginalized. So it might be someone's race and their gender. For example, if you look at black women or Latino women, or it might be your gender and your socioeconomic class, or it might be multiples, it could be your sexual orientation and your gender and your socioeconomic class and your race. There's no limit to the number of marginalized identities we can have, sadly. So one of the challenges around intersectionality is when someone who holds more than one marginalized identity has a negative experience with a person or with a system, you often don't know why. Are they saying this to me because I'm a woman? Are they saying this to me because I'm an immigrant or are they saying this to me because they think I'm a terrorist? Are they saying this to me because they just don't like me? Like why? Why are they saying this to me? Why are they doing this to me? Very hard to disentangle on a practical like day to day basis.
Arghavan Salles: [00:27:58] But I will say that there are specific things that happen that honestly, I had never experienced in California. Not to say that California is perfect, but I just had not experienced these things here. So one is I was giving a talk for our hospital. At another, it was like an outreach, you know, going to an outline clinic to talk to them about bariatric surgery. And so they would know who to refer and what the process is and so on. And the person from my institution who had organized this trip for me says, "Oh, I see that you speak Farsi. How did you learn Farsi?" Like they don't. Understand that I could grow up, learning. I mean, like, I don't know, I just thought that was very confusing to me. Like, how do you think I learned Farsi? Or do you even know what Farsi is? Or like, what? Why are you asking this question? Like, it's very strange and this person is well intentioned, right? Like, I'm not at all blaming this person for, like, wanting to make conversation, but that's a weird question. Like, do you not know that people from Iran speak Farsi? But anyway, that's one example. I'll give another example that I observed, which was a medical student who actually is from California who was working with me, and let's just say her name was Sarah. This is not her real name, but let's say her name was Sarah. The circulating nurse says to her, and she's an important note, this student is Chinese of like her family is Chinese. She's born and raised in California. So the Circulator, again, a very nice person, says to this student, "Sarah, why didn't your parents give you an Oriental name?" I mean. Like, that's the type of stuff that would happen. So when you say how does that manifest? Those are the types of things where you're like, people have never seen people like us. I guess in those spaces, which is so hard to understand when you live in, especially like in the Bay Area where we have so much diversity and so many languages. People speak just on the street.
Henry Bair: [00:29:57] What was the research you were trying to do?
Arghavan Salles: [00:30:00] So my research was then and continues to be related a lot to women in medicine and our experiences. I was able to do some really good work there despite all of this because. There are amazing medical students and residents who I was honored to work with, and so we carried the work forward. Despite the lack of grant funding and the lack of institutional support. So some of the things that we published from my time there were about how we as physicians write our evaluations differently for men versus women in training and the types of words that we use that end up making the men sound better. Or another paper that we published from that time was looking at the level of implicit gender bias among health care workers and talking about how that. Sets up the situation where in a woman physician talks to a patient, explains all the ins and outs of their disease and the treatment plan, and then the patient says, When am I going to see the doctor? And the ways that. Our work is undermined because people don't see us as physicians. So that was some of the work. And then one of the things that I think has been. Really impactful from that time was an interview study that we did interviewing surgeons to try to understand challenges in how they set up their practice. So these were assistant professors all over the country, and we published this paper on one of the very clear themes that came out of that work, which was that they both men and women surgeons noticed an unequal expectation and asymmetrical expectation between men and women physicians, such that women physicians were expected to show up early and stay late, bake cookies, bring in brownies, do what we call 'performative niceness,' and do a lot of work building social capital with other members of the team just so they could get the care they needed for their patients, so they could get cooperation for the care plan. And this is all additional labor that the men don't have to do. So that's some of the work that I was trying to do.
Tyler Johnson: [00:32:13] You know, I think one thing that is a little bit counterintuitive to trainees is that it it feels like becoming an attending is the promised land, right? Like you're working and you're working and you're working and you're working and then one day you like cross the finish line at the end of residency or fellowship or whatever the of training is. And then now you've arrived, right? But as you say particularly- I think there may be some more to that, depending on sort of what your niche in medicine is and whether you're in academics or private practice and some other things, but certainly especially if you're trying to set up a research career, in some ways it's more like the beginning than the end, right? Because you're applying for grant funding and you're trying to like establish yourself at a new institution and all those kinds of things. So you're in that really determinative period where you're trying to set yourself up for how you're going to move forward as as an attending, and then you're being met with frustration left and right. You don't have the support that you need to succeed, all of that. So then what happens next?
Arghavan Salles: [00:33:19] Yeah, I think that we do our trainees a huge disservice in saying things like, "Just wait, it gets better." Because I heard that over and over again, you know, in medical school the first two years, right. They say, "Oh, just wait till clinical, then it'll get better." And then you do that and then you're like, But I can't do anything. I can't write any orders. I can't actually do anything to change the path of these patients. And they say, Oh, that's okay, it'll get better in residency because then you'll actually be able to do things. Even though we all acknowledge residency is very challenging for lots of reasons. Then in residency, because of all those challenges, people will dangle this carrot in front of you like it'll get better after this, whether it's a fellowship or you go straight into a job as an attending. But I mean, if I had probably even a nickel for every time I heard that, I think I'd have a lot of money. And that I don't think is necessarily true. I mean, there are some things that are better, undeniably, like the fact that most people will get a significant pay raise once they're an attending. Obviously huge cannot discount that. And the fact that you do start to have a little bit of control over your schedule. Now, how much varies A lot, depending on what kind of work you do and where you are.
Arghavan Salles: [00:34:33] But you can in most circumstances, for example, block off a day because you need to have surgery, for example, yourself, whereas as a resident you have to ask permission from all sorts of people to figure out coverage. And anyway, so I do think there are things like that that are the truly are better. But wow, there's so much that's worse in my estimation, you know, in terms of impact on the person's mental health and their ability to live a life. So I think the immense responsibility that comes with being the name on the chart, being the one who's making the decision...if you're a conscientious person who cares, that is a very heavy weight. Then there depending again on what specialty you go into. But for someone like me and surgery, there's the being on call every few days and getting woken up throughout the night and having to maybe go into to the hospital in the middle of the night to do surgery for somebody. The giving up every however many weekends to be able to be on call for from Friday morning to Monday morning and not be able to really do anything in that many hours and to repeat that week after week, month after month, year after year.
Arghavan Salles: [00:35:49] That kind of toll, I think, is very difficult to understand when you're more junior. So there are things like that that I think are obviously inherent in the system, and that's going to be true wherever you go. But make it really hard to live life as a as a human and to have time off and to get away from your inbox and to be able to have family and friends and go to birthday parties and weddings and funerals and so on. I think those challenges persist once you're in attending. It's just a little bit different in how you navigate them. You know, someone might say, well, what did you think was going to happen when you moved to the Midwest? And I was naive. To be honest, like, I knew it was going to be different for sure. But I did not realize how much of a step back in time it would be a really felt to me like I was stepping back 15 to 20 years in time.
Tyler Johnson: [00:36:41] So. Okay, So what did you do?
Arghavan Salles: [00:36:44] Oh, so then I left.
Tyler Johnson: [00:36:47] Okay, But. So. Okay, let me back up a little bit. Like, I can imagine that in the process leading up to deciding to leave, that position had to be pretty tortured. Right? Like you're grappling with, I would imagine questions about what is this going to do to my career and where am I going to go from here? And what does this mean about who I'm going to be as a surgeon and like all that kind of stuff? And so but then on the other hand, you have all of these feelings that you've been describing about not being supported and not, you know, all of that. So all of that is to say, like what was making that decision like and how did how was it that that ended up that leaving ended up being the decision that went out And then where did you go next?
Arghavan Salles: [00:37:30] The challenge is, especially when you have your first job. You feel like so much pressure to prove yourself. And this is another thing where people say it gets better. You think like, oh, as a third year student, I have to prove myself. Then I have to match. I have to prove myself. Then now I'm a resident. Oh, wait. Every single rotation I have to prove myself. And then, you know, whether you go on to fellowship or not, then you get your next your job as an attending, and all of a sudden you have to prove yourself, like every step, have to prove yourself, because there's so much mistrust in medicine and there's so much criticism. I would say it's a hypercritical environment, so you're constantly proving yourself so within the first year. Was when they started saying I couldn't apply for grants. And I remember there was a faculty member from where I trained as a resident who said, Oh, no, you cannot stay there. That's them telling you they don't support you, you need to leave. And I thought, But I've only been here a year. If I look for a job now, that'll be a red flag, right? Because you hear this. And so you're like you said, they're doing these calculations all the time. Like, how long do I have to stay here before I leave? So that doesn't look suspicious to people because people don't honestly have the bandwidth to engage with what's true.
Arghavan Salles: [00:38:43] They just have what does it look like? And that's really all. And they make judgments based on that. So if you leave somewhere too early or at least this is the concern, then people will tend to think that you are the problem. And I will say right now that that was flawed thinking. If I had just left right then, I might still be doing surgery. To be honest, I might not. But I might. Because what ended up happening was I did what I think many people do, which is I tried to contort myself, "What if I do this? What if I do that? What if I shift this? If I do this extra strategy, if I have these meetings, if I get a coach, if I see a therapist, if I try to do all these million things." In the meantime, my mental health is going in the toilet because I feel like I'm the worst thing that ever existed. And I've never felt that way in my life because, again, I'm privileged. And so at some point you realize that this is not sustainable, that you cannot live this way. And often, as was the case with me, the people there also send you signals - they do not want you there. So then you're like, You don't want me here and I don't want to be here, so let me just GTFO, bro.
Arghavan Salles: [00:39:57] And so you try and then that is hard to because why? Because then they undermine your efforts to get another job. Because all it takes to sabotage someone's efforts is to say things like, "Yeah, she's fine." That's it. And everyone knows what that means. I had looked at a number of academic surgery jobs that mostly felt like there was a high risk that they would be the same thing. But just in a new town where I also didn't know anyone and I was at such a low point mentally and emotionally that I couldn't. I couldn't go lower. Couldn't afford that risk. I ended up deciding, I mean, this was an intentional choice that I decided I was going to choose geography over career, choose myself over a career, and move back to California, where I had friends and family and accepted that that would mean not taking a surgery job because there was not one available to me. I did try to find one, but did not. And so I moved back for a low paying job that at least let me be home. And that was really critical in rebuilding my career from there.
Tyler Johnson: [00:41:12] One thing that I wanted to draw out there that you just mentioned in passing, but that I think is really fundamentally important for especially younger listeners is that you said that at the end of all of this mental and emotional back and forth that you made the decision that you were going to prioritize yourself over your career. And the reason that I want to draw that out is because I think that one of the most poisonous parts of the unwritten curriculum in medicine is that there is no such thing as a difference between yourself and your career, that your career is your self. Right? And because medicine is such a competitive and as you put it earlier, hypercritical environment, if you allow yourself to buy into the mindset where your career comes to constitute your self, that's so incredibly dangerous and toxic. Because what it effectively does is it effectively hands other people the ability to measure and modify and determine literally your self. Right. So when you don't get a job or you don't get a grant or you're attending says something bad about you or this or that or whatever it is, you are subject to self-determination by other people. And it's totally understandable, right? Because medicine requires such a wholesale self dedication that if you're in the middle of your fifth year of residency and you're working 90 hour weeks, it's pretty hard not to fall into that mindset, right? Because like, what else is your self? Other than that, I mean, that's how that's not true, but that's how it feels, right? And I think that's a fundamentally important point to hold on to. But hard.
Arghavan Salles: [00:43:15] It is really hard. And I would just like to point out that, as they say, I think this is a feature, not a bug. It's like this is what the system wants. And by the system, what I mean is health care systems and administrators and the people who are making money off of the life-saving work that physicians and nurses and other health care workers do. What they want is for us to think that we are this health care worker identity. So I am a doctor. That is who I am. That is what I am. That is all I am. Because if you have that singular identification, then of course you will work extra hours, you will come early, you will stay late, you will do all the things that they need for documentation so they get the money so that they can keep going on their vacations and whatever it is. And I'm being a little bit not nice to health care administrators and I don't mean it personally for any of them, but if you look at salaries and stuff and who's making decisions like I can't see how they come out looking good, but that's what they want and that's how we're trained. I mean, even if you look at a few years back, I don't know if you remember this, but the ACGME added a clause about wellbeing in their program requirements. And this was a big deal because they didn't have anything before about needing to support trainees wellbeing. And so they put some verbiage up on their website and ask for comment. And you know what they said in their in their section on clinician wellbeing, on trainee wellbeing, they said "patients always come first. But then after that you should think about yourself."
Tyler Johnson: [00:44:56] This. This reminds me of the fact that the ACGME, when I was a resident, added a requirement that all residences had to show their trainees a video every year about the importance of good sleep hygiene. And I would watch it and then I would get done and I would be like, literally the only point of me watching this video is so that I can click the bubble on the ACGME survey that says that I watched the video on sleep maintenance because I'm working 30 hour shifts every fourth day. Like what the?! So.
Arghavan Salles: [00:45:29] And I mean, I think we all or many of us have had the experience of being post call after a 24 hour shift and sitting in a lecture like a grand rounds type lecture on sleep and falling asleep during the lecture. Because what should be happening is I should be home. I should not be here listening to you lecture me about sleep. I should actually be getting sleep. Like what? It's so messed up.
Arghavan Salles: [00:45:51] I do want to say one more thing, which is that one of the reasons that everything continues on the way that it has for so long is that there's very little that we can share about what happens in the hospital because of HIPAA and because of malpractice issues. So a lot of the things that go on that are not good for patient care are never spoken of outside of our hospitals because we fear even I mean, I posted something I don't know if I'll leave it up, but I posted something about a day when I went to the operating room and the nurse, the circulating nurse came to me in pre-op and was crying because she had never helped on this procedure before and neither had the tech and they didn't know what they were doing. And she was so upset because she knew that they couldn't properly support me. And she wants to do a good job but knows that she cannot. And the position that that puts the patient in that that puts the surgeon in is horrific. And I haven't talked about it before because, you know, is someone out there going to be like, was that the day that I had my surgery? And then are they going to want to sue somebody? I mean, to be honest, my patients did really well. So I don't have like, oh, you know, 10,000 people out there looking to come after me. But but these are the reasons, I think, that a lot of people don't talk about it because there's too much risk.And so then it's just, oh, yeah, let's focus on the positives. And then that gives a really misleading picture to folks.
Henry Bair: [00:47:32] Arghavan, it's been so great talking to you. And we appreciate all of the searingly honest stories you've told us. As we near the end of our time here. I feel somewhat obligated to steer our conversation towards what we can do to fix the problems you've mentioned. I know you're currently involved in many diversity equity and inclusion initiatives, so what are some concrete things institutions should bear in mind when trying to make things better for their clinicians?
Arghavan Salles: [00:48:03] I think that the biggest work is changing the systems and the structures. The more we talk about what individuals should be doing differently, the less anything changes. And not to say that we don't all as individuals matter. Absolutely we do. And there are things we all should be doing, and I can mention some of those. But the biggest thing is going to be demanding better for ourselves and for our colleagues. Like I'm so inspired by all these residents who are unionizing. That's just amazing. That obviously could never have happened when I was in training. It didn't happen when I was in training. I mean, there was University of Michigan has had a long standing reason, but that's it. So those are the types of things that really need to happen, is we need to be rethinking what should it mean to be a trainee in medicine, what kind of hours make sense, what kind of salary makes sense, what kind of parental leave makes sense. Because I'll tell you, none of that right now makes sense in the current system that we have. In the meantime, since we're working in this very flawed system, I think it's really important to try to have grace with each other, and that's really challenging. And I definitely haven't always been able to do that.
Arghavan Salles: [00:49:19] But that means when a student or a resident needs to go to a doctor's appointment or be gone for a day or whatever it is, instead of the kind of knee-jerk traditional response, which is "this person doesn't care, this person's not invested, this person's not going to be a good doctor" or whatever nonsense people have been trained to think, because that's what people said to us when we were in training. What we should be thinking is "that is amazing. I am so glad that you are standing up for yourself and taking the space that you need." Like that's the reaction that we should have because that's better for all of us. And I think there's a lot of resentment. Like this is always the case that older generations are resentful of younger generations because things change and they're like, "Well, I walked uphill both ways and snow, etc. And so you should too," which is a really flawed thinking, because if it was awful for you, why should you want it to be awful for anyone else? I've really never understood that. Like, if it was awful for you, you should be motivated to change it. So it's not awful for anyone else. And for whatever reason, that doesn't seem to be what happens not just in medicine, but like anywhere. So individuals need to give each other grace. We need to prioritize our humanity above all else. I really believe that, like we are people who need to eat and sleep and go to the bathroom and take care of ourselves.
Arghavan Salles: [00:50:40] That is all fundamental. Before we can memorize the Krebs cycle and do whatever else, take a 24 hour shift or operate in the middle of the night or whatever. Like, we can't do any of that if we're not taking care of our own human needs. And so we have to not only do that for ourselves and role model it for other people, but then support other people when they do that too, so that we can change the culture. And I think another thing that we're really working on is creating a culture of feedback where it's not punitive to give people feedback on something. And this is in particular I'm talking about related to diversity, equity and inclusion. So things like, you know, if someone does make an inappropriate comment about gender or race or sexual orientation or anything like that, what we want is a culture wherein someone can say, "Hey, I'm not sure you meant it this way, but what you just said actually was transphobic." And then the reaction for that person should be, "Oh, thank you so much for letting me know." Like, that's the culture that we need, where we can give each other that kind of feedback and say, "Oh gosh, thank you so much. I appreciate it," because it's hard to give feedback. It is much easier to just let it all go. And then that's when the toxicity all continues because nobody ever intervenes. So that's, I think, a really crucial shift that we need to make.
Henry Bair: [00:51:57] Well, you have been so generous with your time and so honest with your experiences. We really, really appreciate it. So thank you so much for joining us.
Tyler Johnson: [00:52:06] Thanks so much, Arghavan.
Arghavan Salles: [00:52:07] Thank you for having me.
Henry Bair: [00:52:11] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:52:29] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:52:43] I'm Henry Bair.
Tyler Johnson: [00:52:44] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.