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Will The REAL Dr. Slater Please Stand Up? Thoughts on Imposter Syndrome

“Without effort, your talent is nothing more than unmet potential. Without effort, your skill is nothing more than what you could have done but didn’t.”
― Angela Duckworth, Grit


I have been hearing a lot about imposter syndrome lately namely from the New York Times, but also by normal everyday physicians who have been vulnerable enough to share their experiences.

The definition of imposter syndrome is, ‘an internal experience of intellectual phoniness in people who believe they are not intelligent, capable or creative despite evidence of high achievement.’

In reading about it, I have also been thinking about how this topic relates to me, and how I have manifested it throughout my life. All of the articles I have come across make me feel as though I have been an imposter forever! In my experience, and the best way I can think of to describe it, it’s like always feeling as though someone is going to come around and ask me, “Where is the REAL Dr. Slater, because surely it can’t be you?!”

To be honest, I am not even sure where I developed it. If I think broadly–medical school, residency and fellowship were all very intense experiences. There was constant testing, evaluation, teaching, and judgment. Then came reprimanding, subsequent shaming for not doing something correctly, and fear. So much fear of being wrong, of getting the backlash for not catching on as quickly as my peers and fear of failing. When I look back, I can pinpoint specific instances that are burned in my mind, and probably together they helped to create the imposter syndrome I felt.

For me, it started once I entered medical school and was surrounded by hundreds of incredibly smart and motivated people. I began to question whether I belonged. I attended a rare 6-year medical school, where students graduate from high school and immediately enter an undergraduate/medical school combined program—this rigorous schedule at such a young age probably added to the pervasiveness of my imposter syndrome.

My first anatomy test is something I will never forget. I had to study really hard as I had not yet mastered the skill of memorizing. I remember studying while (it felt like) everyone else was goofing off and having fun. I distinctly recall those same peers getting A’s, while I performed average. At that moment I decided I am not as good. It was like I imprinted on my brain… ‘I am going to have to work extremely hard to be successful.’

In my second year, we had a no-nonsense physiology teacher who was known to have impossible tests and little sympathy for his medical students. On one of the major exams (that could define your grade in the class), I received a failing grade. The caveat, almost everyone was failing, because the average on the test was 60%.

It didn’t matter that the test was hard, I was still failing a class. At that moment I realized I was going to have to apply myself and work harder than I had ever worked in my life. I desperately did not want to fail. If you fail a class in the 6-year program you have to extend to 7 years. If you fail two classes you are removed from the program.

Quickly I learned how to study, sacrificed my free time and never failed a test again. I made it through the program not excelling, but completing. Justifiably, I continued to feel as though I was ‘less than,’ because of the level of effort I needed to put in to be successful.

Residency was the next step, and my feelings of inadequacy grew. I think I entered with the general thought that I wasn’t smart enough, and that I would continue to have to work harder than everyone else to be in-line with my peers. I felt like I had to fake it, fake that I was supposed to be there, fake that knew I what I was doing, tempered with being truly honest when I needed help.

I struggled during this time due to my imposter syndrome, but also because I struggled with the hours, I struggled with being away from home and without a family support system close by. My schedule was insane, I worked 80 hours a week, got one weekend off a month and two weeks off a year. Not only was it challenging to merely survive, I was also thousands of miles away from my family and my only friends were those in my residency.

In addition to a rigorous schedule, there was also endless feedback and conversations about what I needed to do to get better. These are all attempts to make us better doctors, but I think without a true support system, and with what feels like lots of negativity, it seemed like I wasn’t doing anything right. The natural conclusion is that I am not good enough and that I am not sure I am supposed to be here.

Despite these feelings, I found a true passion and niche in Pediatric Emergency Medicine. I matched into one of my top fellowship programs, and thus entered the final phase of my training. I was fully embodying my imposter syndrome at this point. I couldn’t really believe I deserved my fellowship spot and I just hoped that no one would notice that maybe I was chosen accidently.

When I became an attending, my imposter syndrome really came alive. I moved across the country for my first job, and found the hierarchy of medicine to be different on the west coast. On my first day, I had an intern (a recent medical school graduate) who openly questioned my medical decision-making. I was unprepared and unfamiliar with this level of challenging of authority and I was deeply unsettled by it. I felt like I had to prove myself, but I wasn’t sure if I could.

Then there were little instances that made my feelings worse. I was working a shift one day, and a much older and senior attending called me from home, asking me if I knew that one of my patients had a fracture. She was monitoring the ER board from home, looking at Xrays. My thought immediately was ‘am I that terrible of a physician that my colleagues are being entrusted to watch me work from afar and make sure I don’t screw up?’

There was a simulation I attended, where the person running the code was blindfolded. As a new attending, that person was me. The combination of trying to perform without a basic sense (eyesight) while being new, and concerned that everyone thought I was a fraud was disastrous. I was paralyzed. I couldn’t think, much less figure out a complicated patient case, all in front of about a third of my new colleagues.

All of these incidents happened within my first year of being an attending. I think together they would have shaken the confidence of the best, but mine was already questionable.

Fortunately, the colleague working from home apologized later, she was doing some study on fractures, and was abnormally stalking the ER board. The simulation folks realized their error when I was incapable of working through the simulation without my eyesight—as far as I know, they have never done a blind-folded sim again. I however, was destined to be an imposter for the next six years or so.

I lived with my imposter syndrome for a long time–and it always involved comparing myself to others, worrying about what everyone else was thinking, and fear that I would be discovered as being inadequate. 

I feel fortunate to be on the other side, to be able to say that these feelings eventually faded, and now they have all but disappeared. I think this is due to a combination of things, all happening as I gained experience and confidence.

I started volunteering at Camp. My worth as a physician was no longer just in the hospital. My passion for camp led to me becoming the Medical Director. In this role, I attended many meetings where I was the only physician in the room and my opinion and expertise were relied upon to make important camp-wide decisions. This experience helped me become more confident in my skills and knowledge.

The other thing that has made a difference is time on the job. I have been working full-time since I graduated from fellowship and I am now entering my 10th year of post-training life! Time builds confidence—I feel as though I have seen almost everything, but I have also seen enough to know that I don’t know everything.

Life experiences including loss, grief and becoming a mom have helped me to perceive my failings in a different light, to have more grace for myself, and to tame the judgment demons I used to suffer from so intensely.

I no longer focus on what everyone else thinks I do or do not know. I recognize now that I know a lot, and I have been through a lot. I also realize now that I am no longer an imposter. I no longer identify with those feeling I used to have.

A recent book I read, Grit, by Angela Duckworth, has also helped me to process through those former feelings of being an imposter. She talks about how talent is nothing without hard work, passion and drive. Now that I am 22 years into my career, I am realizing that it doesn’t matter that I didn’t ace my first anatomy test. I am still here, having worked extremely hard through training and continued to work hard post-training to be good at my job. It’s time to relax and give myself a break.

So, for all of you who are in the ‘imposter syndrome’ days, I understand. It is hard, and it can feel like you aren’t good enough on a daily basis. Just know that you are not alone, and it will get better. You can always watch Amy Cuddy’s TEDtalk on body language for some tips on “faking it.” Or read Grit. It will help you to get over feelings of inadequacy, as I can’t think of anyone grittier than those going through medical school and training.

What about you? Have you had challenges with imposter syndrome? How did you manage it? Do you have any good advice for our readers?

The Art of Appreciation–Why Saying ‘Thank You’ Matters

“Showing gratitude is one of the simplest yet most powerful things humans can do for one another.”
–Randy Pausch


I recently had my last ‘official’ day at Camp. It was bitter-sweet, leaving me feeling blessed to have participated, but also sad that it is ending. On my departure, I received a little notebook. In it was more than 20 entries, all from staff that I had worked with throughout the years, thanking me for my leadership, my kindness, and my service. Each entry is about a paragraph, describing how my presence changed Camp for the better.

I was deeply moved, and become emotional just thinking about what a gift it was for me. It is also an indication of how my dedication affected those around me. I am struck by the number of people that felt compelled to contribute, but also how good it feels to be affirmed for the work I put in. I always felt buoyed by the job itself, not thinking I needed any acknowledgement to feel as though I had done an excellent job.

In reflection on my experience, I realize that sometimes it is important to receive acknowledgement for the work we do, even if the work itself is a source of deep gratification. Appreciation can act as a signal to keep us going, it gives us strength when times are tough. It reminds us of our value.

This experience, and how profound the appreciation felt, has me thinking about my other job. In the hospital setting, (unlike Camp) people don’t make or receive ‘warm fuzzies’ on a daily basis and it is a lot harder to feel appreciated and encouraged that the job you are doing is a good one.

Often we do receive feedback in ‘real time,’ but the majority is focused on what we have done wrong or informing us if a family was dissatisfied with their visit. While necessary and helpful, it can have the opposite effect of appreciation, making us feel inadequate or ‘not good enough,’ and likely adds to our feelings of burnout.

There is rarely spontaneous and unsolicited positive feedback or anything resembling what I received from Camp. I receive about one complaint every 3 months or so, and about one compliment a year.

I try to continue to have a good attitude and I think I do my job with joy, but I now wonder if the lack of appreciation taints how I operate when I get there.

If the complaint/compliment situation is applied to everyone that works in the ED, every one of my colleagues is lacking good positive appreciation. Could it affect how they walk into work every day? Is it possible that a feeling of being unappreciated could alter how one treats others while at work?

Now knowing what it feels like to be appreciated, I think we all need more of it to survive in the healthcare field. To help pull us from a place of negativity and bring us back to remembering why we care so much, why we do the jobs that we do. I don’t think it matters who the appreciation comes from, just that someone else notices our efforts.

What would happen if we all showed a little more gratitude to our co-workers? What would that look like?

I believe it is possible to make this happen, but it would necessitate a little culture change, more awareness of how our environment effects each of us, and a daily conscious effort to be a part of the solution. Moving in this direction could impact the way we view our jobs collectively, and also make it an easier place to be. If each person was feeling more appreciated and that the job they did individually mattered, would our busy and stressful times feel less awful?

It is extra challenging because the environment we work in is a breeding ground for frustration. When we are frustrated, it is very hard to think about thanking someone. In reality, this is the time it is MOST important that we learn to do so.

I find it is often easier to get frustrated by the delay in a patient going to the floor than it is to thank a resident for spending time to explain a test to a parent or telling my charge nurse that I appreciate her for navigating the disposition of a psych patient.

When frustration instead of gratitude becomes the go-to emotion, the entire department can feel the ripple of this. Have you ever noticed how it feels to sit next to someone who is angry or allowing their frustration to consume them? It is as though their whole being is vibrating with negativity. This negative energy can be suffocating and repulsive, and it can make others feel negative as well.

On the other hand, do you know what it feels like to sit next to someone who is emanating gratitude? The calm energy exuded can be a welcome reprieve from the chaos of the environment. I actively seek these people out and try to emulate them.

In an effort to be in a place of gratitude prior to every shift, I have developed a habit of slowing down, breathing deep, and entering a mental state of compassion. I want to make sure that my frustration about traffic or my irritation over my messy house doesn’t cloud my interaction with my patients or colleagues.

It is important to me that I practice in this way, but I am also very aware that when the pressure is on (busy ED, high acuity, and stressed out colleagues) even I can get pulled out of my appreciative state fairly easily. Couple that with an email about a patient complaint and I am totally in a downward spiral, trying desperately not to allow frustration to overwhelm me.

I realize that the way out is to consciously choose to respond differently. If instead of feeling frustrated by the volume of patients, the angry parent or the know-it-all resident, I re-channel my energy to focus on what is going well, I feel better. The volumes stay the same, and the parent does not miraculously become happy with the care, but I change. Changing our perspective can subsequently change the lens through which we look at life. The chaos then feels less chaotic, and the areas of frustration feel less frustrating.

Which means, become appreciative! Focus on the team. Don’t let the negativity bring you down. Who can you thank? Who is doing an excellent job? Can you be the one who provides your co-worker’s daily dose of appreciation?

I am working on this in my own life, trying to call out my physician colleagues when I truly feel as though I am being supported, thanking my nursing staff when they go extra lengths to calm a family, or my residents when they work  hard to keep the ED flow moving. By taking an active role in giving others a ‘thank you,’ or taking time to genuinely appreciate their work, we might actually be able to change the way our workplace feels, especially in the stressful moments.

Recognizing the importance of appreciation and saying ‘thank you,’ is a good reminder for me on how I need to lead and model behavior. Knowing how good it feels to be appreciated, I can then make sure I shower people with it when I think they do a good job. Or if I am grateful for something they have done for me. If warranted, I will send an email to my co-worker’s supervisor, and make sure my colleague is also included in the email.

Can you imagine what it would feel like if we all did this? The ripple effect is real, so if you participate just a little, change will occur.

How do you like to be appreciated? How do you like to appreciate others?

Saying Goodbye To Camp

“I’ve heard it said that you can leave camp, but camp never really leaves you.”
–Paul Newman

Camp Korey’s summer season ended just last week. With it also ended my tenure leading their medical program. It has been a truly bittersweet ending, as I will miss the long hard days of making kids laugh into the evening, while also ensuring they receive the safe medical care they need. But having small children and running a time and emotionally-intensive summer medical program is untenable for me at this moment in my life.

My time at camp will forever have a very special place in my heart, as will all of the friends I have made along the way. I am a better doctor and a more compassionate human being for spending my summers there. I also learned a few things that I will never forget.

1. Put away your ‘cool’ card
You know, that thing in your back pocket that tells you not to be silly? I know, we all want to ‘not look stupid,’ and make sure that we are ‘mature’ with our doctor title, but camp is the place to let it go. To not worry what other people think. There is too much judgement in society.

The kids at camp are suffocating from judgment, they are the kids who are different, and all they want is to be themselves and be accepted. It is not surprising that children model how adults behave. So at camp, it is vitally important for us to wear funny hats, cheer as loud as we can, and dance as if no one is watching. At camp, no one cares whether you can dance… what matters is that you are dancing, having fun, singing and throwing spaghetti during Silly-O (a massive food fight).

2. Everyone needs a place that feels like home
Remember the theme song to Cheers, “You wanna be where everybody knows your name…?”
Most of the kids that come to camp don’t have places that feel safe to them. As I mentioned earlier, there is a lot of judgement in the world. If you are a child that looks different, needs frequent medications, or spends a lot of time in the hospital, life can be extremely challenging.

For these kids, it is very hard to have friends, to have “play dates,’ to go to birthday parties or sleep-overs. At camp, the medical team makes sure ALL the camper’s medical needs are taken care of, and taken care of in the background. So there is no anxiety about ‘how will I get my medicine?’ Or, ‘what if someone sees my scar?’ Every child at camp has something that brought them to camp, so it becomes this harmonious place where children feel accepted in a way they haven’t outside of their home. It is often life changing for them.

3. People desire to be in community with one another
The word community can mean different things for different people, but I feel as though it is being a member of a group that really appreciates my presence, and one that I choose to go back to. It is a group of people who I care deeply about, that cares about me as well.

Every camp season required the recruitment of 50-80 volunteer nurses and 15-20 volunteer physicians. Our volunteers came from all different aspects of medicine, I had NICU nurses and adult critical care nurses, I had orthopedic surgeons and dermatologists.

Once at camp, our identities and our white coats or our scrub tops get stripped away and replaced with camp T-shirts and funny hats. It felt almost like college, where we lived together, worked, and shared all of our meals together. In this environment, we developed relationships that were impossible within the confines of the hospital walls.

We were a family, pouring hundreds of medications each Monday, working late into the evening each day and becoming friends. These awesome professionals donated their time and usually would take vacation to come to camp. Every single year. These people chose this community, and they also choose to return. I know these individuals better than I know my colleagues, because you learn a lot about someone when you spend a week with them. I consider these friends to be life-long because we shared such wonderful, challenging and inspiring times, and I also believe they are the gems of the medical profession. I adore each and every one of these people.

There was always so much hard work and integrity demonstrated by the medical teams. I knew that I could promise families we would take the best care of their children during each session because I always had fantastic volunteers who were the ultimate compassionate professionals. With silly hats.

4. The counselors that spend their summer creating camp experiences for ill children are the best people
This is the genuine truth. At Camp Korey, there are actually college students that do this and they get paid very little doing so. Our counselors would work about 80 hrs/week, only getting Saturdays off, for 8 weeks.

Their jobs not only involve being big siblings to our campers, but making sure everyone is having fun and no one is being bullied. They are responsible for ensuring our campers get showers and have assistance toileting (if they need help) and have sunscreen applied EVERY DAY.

They learn about all of the medical conditions prior to each session, so they understand what to expect. We have campers with massive food allergies, and our counselors were responsible for ensuring all of the kids with special diets only got “their” food. Which is really hard when everyone else eats ‘family style!’ They carry epi pens and inhalers in their backpacks for the kids that might need it during the daily activities. They plan “sneak-outs’ for the older campers, so they get to experience a little bit of delinquency.

Every night, they have “cabin chat” to talk to their campers, process the days’ events and teach the campers about lifting one another up and giving each-other warm fuzzies. I don’t think I could have been a counselor when I was their age. But, I feel lucky to have been able to witness such unadulterated compassion by such young souls. Watching the counselors be such admirable human beings makes one have faith in society.

They are heroes, and some of the nicest people you have ever met

5. We all do better when mealtimes take priority
I lived forever in the field of medicine, where you are lucky if you eat. I currently work in an emergency department, where I am still lucky if I get a moment to shove something into my face. At camp—everything stops for mealtimes, three times a day! Our entire schedule is based around our meals. Even if there is a sick camper, someone on the medical team brings food to the medical center to ensure those on duty get fed.

We all need to eat, and we especially need to prioritize eating during an active summer camp with kids who are medically fragile. I learned that I need to eat, too. I learned that my ability to take care of others is way better when I am taking care of myself first. I also learned that it helps to have a bunch of your friends standing by, caring about you and making sure you get fed.

6. If you spend your time giving away warm fuzzies, you will feel the warmest in return
A big part of camp is giving away warm fuzzies to our friends at camp. Each camper, volunteer, and staff member has a paper bag with their name on it. Throughout the week, we write little notes to each other, congratulating a camper for being brave by climbing the rock wall or thanking a volunteer for calling a parent or trouble-shooting a g-tube.

This translates to living in a space of gratitude and the act of constantly trying to find something to thank someone for. It is a very rich way to live. I found that my perspective changed, and instead of being concerned about what was not going well for me, I was constantly celebrating our wins as a team. We should all be giving each other warm fuzzies on the daily.

7. Taking care of a bunch of children doing things they never have done before is incredibly inspiring
I loved seeing these super courageous children take risks. Just attending camp is scary. Then these kids get here and make friends and climb really tall walls and dance and eat strange food. It must be terrifying for them. At the end of the week they would then get on a stage and show off their talents. It was always beautiful and always inspiring. I learned a lot about courage watching campers overcome their fears.

I was lucky to spend 6 summers at camp. Some of those were as a volunteer, most were as the Medical Director.

I am so sad to be stepping away, but I know that camp will always be in the background, as will the memory of my time there. I will always believe in the mission and I will always support the cause. I hope that if you are interested, you would get involved as well.
Thank you SO much to all of my camp buddies. You are the best, and I will always cherish our time together.



An Open Letter to My Consultant in the ER

“If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” —Dalai Lama


The emergency department is quite possibly the most exciting place in the hospital, but it can also be the most challenging and chaotic. Patients arrive at all hours of the day, families are scared and frustrated to be there and sometimes we can’t work fast enough to take care of everyone in a timely manner. We are also constantly taking phone calls from other institutions to help decide whether a patient from another hospital needs to come to us, and how (helicopter, fixed wing, or ambulance).

Needless to say, it is a stressful environment. Sometimes stress can make us (any one of us, from a resident, nurse, attending) anxious. Sometimes this anxiety manifests by treating members of our team poorly. When I discussed our shame culture, I talked about this a bit.

I used to get really anxious when the ED got busy, especially if I was fielding lots of phone calls, and felt as though I was being spread too thin.

There is nothing scarier than to think I might miss a diagnosis or not see a physical exam finding because I am too busy. I used to translate that anxiety into barking orders and being impatient with my team, which unfortunately, only increased anxiety!

I have since learned how to improve my interactions and communications with my patients and colleagues. But I know all too well how easy it is to project these feelings onto others, and sometimes it is also hard to recognize we are doing it.

Recently I had a patient that was sent to us for subspecialty care. My senior resident tried to discuss the patient with the consulting physician. Unfortunately, this particular consultant treated the resident with irritation and general nastiness, asking some slightly irrelevant questions she didn’t know the answers to, then shaming her for her lack of knowledge.

He also told her it was ‘inappropriate’ to call him when she was ‘unprepared.’  This kind of interaction (consultants being exasperated with patient consults) is quite common in our field and brings me back to my shame post (which describes in better detail how this manifests). I don’t always have the opportunity to give feedback to the perpetrators of this behavior, partly because I am not always aware it happens, or I get busy with my day, and it gets forgotten.


This blog post is for my angry consultant.

I see you.

For what it’s worth, please know that I recognize we both have really hard jobs.

I know that deep down, under the years of clinical practice, you and I really are the same person, bright-eyed and big hearted, who entered into this magnificent career of medicine with a desire to help others and possibly change the world.

Our jobs turned out to be a lot harder than we pictured they would be in those days. We sacrificed time and relationships, and life moved quicker than we anticipated. The cost to continue in this career has interest, and the rate routinely increases, with no one asking if we have the ability or stamina to pay.

I see you. We are the same.

But for some reason, you have found joy in making others around you squirm. Your ego feeds off of the power this gives you, and it makes you feel entitled to treat others as ‘less than.’ You get frustrated that no one understands the pressure, that every minute of your day is spoken for, and you act on that frustration by being mean.

I promise when you enter my world, there is no judgment. I know you are doing the best you can, and behind the delayed response to your page is a list of patients, a scared parent, and your own family at home. Everyone is asking for a piece of you, but no one is really appreciating the place you are in, the struggles you have.

I promise to see you with the same compassion I see my patients. I promise to thank you for coming by, that I truly appreciate your expertise. I hope that maybe someday you can see me, too. Know that like you, I really try to do the best for my patients every day. I try to only call you when I am worried about a patient, or concerned about the family’s ability to get answers and navigate our difficult health care system.

I see you. I care about you too. Maybe next time you can show me a picture of your dog, or your vacation, or your children, and we can talk about how hard it is to be a doctor, a parent, a friend and how it never feels like enough. How sometimes we give our best self to our job, and how it always feels like someone is getting short-changed.

We can’t forget those people we once were, the bright-eyed ones, that jumped into this crazy field. We are all in this water together, sometimes it actually feels good to help one another swim.

I see you.




Your Friendly ER Doctor



Let’s Talk About Gender Bias

“Is it gender bias, or do I just suck?” –Esther Choo, MD MPH, Twitter

We all have biases. Each one of us has our own experiences, backgrounds and stereotypes that we learned which cause our everyday decisions to be influenced. Most of the time, we don’t even realize it. However, our unconscious or implicit bias allow our brains to make quick judgments and assessments without thinking much. For the point of this blog post, we will be talking about implicit gender bias, for example, a common bias (that is fading I hope) is that doctors are men, nurses are women.

The problem is that these implicit biases we harbor impact the way we view the world, and is the basis for the gender inequality we are seeing not only in medicine, but in almost every industry.

When I started medical school I had no idea that I could potentially suffer any setbacks due to my gender. The home I was raised in told me that I could do anything or be anything. Gender discrimination was not in my vocabulary, and I was blind to its presence. However, I was also being molded by societal bias.

My grandmother was a nurse (not a doctor), and when I was eight, and was asked what I wanted to be, I said a nurse. My mom later told me, ‘well, you can be a doctor, you know.’ I actually didn’t know. But that little encouragement was exactly what I needed to open my mind to the larger possibilities for my future, and actually alter the bias I had already developed in my young age.

During medical school, I was developing my own implicit gender bias. One I am now aware of is when I am about to talk to an orthopedic surgeon on the phone, I immediately assume I am going to talk to a man. In medical school I learned that there are areas of medicine that tended to have gender predilections, like more men go into orthopedic surgery, more women go into pediatrics. At the time, I didn’t question or think about these gender issues much. I also didn’t consider there was a possibility that my gender could play a role in my career decisions or options.

In my pediatrics residency I felt equal to my male colleagues (which is probably a very different experience than a female orthopedics resident), and I am sure I developed many biases that I am not aware of.  But, I do recognize I developed a bias around women having children during training.

There was little to no compassion or empathy around child-rearing. Women had children, and had issues with childcare. The general consensus was, ‘that is your choice, deal with it, and make as few waves as possible for the program and your colleagues.’ Oh and, ‘we aren’t here to help you figure it out.’ I unfortunately modeled the behavior exhibited by leadership and did not develop much empathy for the women who ended up having children during residency.

I am completely ashamed of this now, but am more disappointed that the behavior has been allowed to proliferate.

Early on in my job as an attending, I was still pretty unaware of unconscious bias or the gender gaps that exist, and I did not recognize that my gender could hinder my future job trajectory or my opportunities.

But, I was starting to wake up. The instances I noticed started small, but the more aware I became, the bigger the issues seemed.

The little things I experienced were parents complaining that they never saw a doctor, when I knew I introduced myself as the supervising physician. I would be working with a male resident, student or fellow and there would often be an immediate assumption that he was the one with decision-making power.

It was embarrassing to correct and unsettling to experience.

I heard rumors that some of my female colleagues were told they needed to delay their promotion when they had a baby. I am sure that the intent behind this thought was to benefit the woman, ie giving her more time to prepare. But it feeds the bias that women are less capable when we have children.

There were reports on the gender wage gap, in my field and across the country. It was no longer a theory. Unfortunately, the most recent reports show it is not only real, it is getting worse. I initially was in disbelief. I said in my head, ‘There is no way I am getting paid less than my male counterparts.’ But, how did I know? I didn’t.

One of my friends described an incident where she asked for more responsibility outside of her clinical time, and what was offered was so egregiously time intensive she felt essentially blown off. She said ‘no one should work that much, but I have small children at home, so they knew I wouldn’t be able to do it.’ I wondered if her gender had anything to do with the way she was treated.

I started recognizing that there weren’t a lot of women at the top to discuss these issues with. This is an example of the ‘leaky pipeline’ phenomenon—in Pediatrics, in particular, it has been reported that 70% of the residents are female, which becomes approximately 50% of academic faculty. But only 30% of Division Chiefs, Vice Chairs, and only 25% of Chairs are women.

How does this happen?

Unfortunately, we don’t have a ton of answers. There are some new studies being published that are looking at this. I think we will see problems we didn’t know existed, and become more aware of the gaps that do exist. I also think the lessons we are learning will prove to be just the tip of the iceberg, and true examples of how our implicit bias has been raging unchecked. I also think we will be able to recognize how we as a culture have been complicit in its proliferation, as I have stated earlier with my own biases.

In March of 2017, JAMA published an article describing evaluations for Emergency Medicine residents. In the study, it was found that female residents reached the same milestones as men in the first year of training, however after that year, the men achieved milestones at a rate that was 12.5% higher than the women. There were 30,000 evaluations they looked at, and it was clear the issue was gender. This is where the gender gap started for these particular residents in this training program, likely buoyed by implicit bias.

Is it possible that regardless of gender, we are ALL rating our female trainees with a harsher scale? The evaluations were controlled for gender of the evaluator, so women are doing this too.

These findings blew me away at first, and I found them to be incredibly discouraging. But also familiar. How many of you women have felt like you are climbing Mt. Everest while your male colleagues sail past you? How many of you have judged your female colleagues more harshly than your male colleagues?

Dr. Julie Silver, a physician in the department of Physical Medicine and Rehabilitation at Harvard, is at the forefront of studying bias and how it affects us, and she has two very interesting studies that came out recently. One of these reports discusses the disparities in the number of awards given to women by the American Academy of Neurology. Despite an increase in female representation in the field, where they are comprised of upwards of 30% of all neurologists, the number of awards given to women has stayed stagnant at about 18%. That is less than one in four.

Dr. Silver also recently studied the number of women being represented as first authors in pediatric journals. Although women make up 62% of all pediatricians, and around 50% of full-time faculty, women are only first authors 42% of the time when looking at a cross-section of the 4 highest –impact general pediatric journals.

To summarize briefly and harshly—women receive worse evaluations, we receive less awards, and we are less likely to be chosen for a journal publication. So, maybe it IS harder to get promoted. Maybe then we think that it isn’t worth it, that either it’s unattainable or that we actually don’t have the bandwidth to try so hard to overcome the bias. So we quit. And there is our leaky pipeline

The problem with implicit bias is that it hides under the radar, sneaky and hard to pinpoint. When gender bias is left unchecked, women are made to feel increasingly ‘less worthy,’ as opportunities go to male colleagues, and questions about advancement or leadership roles are dismissed.

I think we start by admitting bias exists, and then be willing to commit ourselves to changing the way we think. Can you think of biases you have? Can you think of a time you judged a female colleague in a way that was possibly unfounded?

For all the women out there…. We have to learn to promote one another, and to be able to use each other on the ladder to the top. We have to celebrate each other’s victories and stop operating from the place that we should be competing against one another. We are a part of the problem. We also need to stop acting like we don’t deserve a spot at the table, and start calling out gender bias when we see it. If we don’t, we are being complicit.