From Both Ends of the Speculum: Reflections on Women's Health Care in America
The following speech was given by Dr. Alice Rothchild at the American Medical Women's Association National Conference in Chicago, Nov. 5-9, 1997.
When I finished medical school in 1974, my fantasy of providing healthcare without society, sexism, and economics battering at the door was long gone. And while many of my male colleagues and friends were joining the medical establishment and developing a sense of loyalty and belonging, I was becoming a feminist and a permanent outsider, thanks to my medical school training. I wanted to change society rather than help women adjust to the existing oppression in their lives. Medicine, it appeared, would be my battleground.
This was a time of protest on many fronts. The Vietnam War was front page, the women's movement and other self-help movements were growing, the civil rights movement was being fought in the workplace, schools, and streets. I lived in a commune and struggled with the issues of sexism, relationships, and community in many a consciousness raising group where women could learn, listen and try to imagine a different kind of future. Even the medical students in my class underwent radicalizing changes: our class proudly sent our free stethoscopes from Eli Lilly to the North Vietnamese. We refused to sign our bimonthly exams and created a defacto pass/fail system at the medical school.
Meanwhile, the Playboy bunny pictures intermixed with the microbiology slides, the surgeons who discussed their cases in the (male) Doctors’ Change Room and expected me to sit patiently outside, and the constant barrage of low level hostility took their toll. The first year psychiatry course was based on a textbook entitled The Person, which spent an entire chapter on the importance of work in the life of men, mentioning women in a short paragraph at the end. One psychiatrist lectured us that the women were in medical school only because of our "unresolved penis envy." Our gynecology text advised women that their role in sexual intercourse was primarily to satisfy the husband. One edition of our obstetrics text had an entry in the index listing "male chauvinism" and cited the entire book—I have always wondered what brave and subversive secretary slipped that in!
Although I had wanted to be a psychiatrist since the age of six, I found my first obstetrics and gynecology course profoundly important. The esteemed department chairman gave a famous lecture entitled something like, "What is a woman?" The hand- out consisted of a useful list of answers: "a woman is a man's wife, a man's competitor, a man's mistress...." This provoked protest signs and a vigil during the lecture which ultimately brought an end to this yearly offense. Nonetheless, women were always referred to as "girls"; one frequent comment by the chairman was, "The only good uterus is a uterus on the table!"; middle-aged women were referred to as "the three F's" (forty, fat and fertile). These things, and watching inadequately supervised City Hospital residents struggle through their surgical education, practicing on the poor and powerless, left me with an intense sense of outrage and a need to respond.
My exposure to obstetrics and gynecology, in particular, revealed a field so politically backward and oppressive to women that I felt that I could have my greatest impact as a physician in just this specialty. At a hospital in Brooklyn, I watched in horror while a woman strapped to her gurney screamed, smeared feces, and labored under the influence of twilight sleep. I turned to her doctor and asked, "Why do you do this?" He replied that this is what women want and that if you don't give them heavy sedation, you can't get patients. At that moment I was reborn as an avid believer in natural childbirth. I went into the field to change it—not because I identified with my mentors, or was intellectually interested in research or the technical challenges of surgery. Contrary to the usual process of identification, I joined the Fellows as a permanent and often angry outsider.
I did my internship at a city hospital in New York. There, the issue of sexism paled beside the obvious impact of poverty, drug abuse, alcoholism, and homelessness. I got to live the two-class health care system in action—walking down the open wards with beds lined up in every corner, bagging (manually breathing for) comatose patients when the electricity failed, running out of essential items like IV tubing and penicillin. While there was intense community involvement in the hospital, it was clear that major changes in society were needed if the lives of these people were to improve. My ob-gyn residency, in a well-run, well-funded hospital, was a striking institutional contrast. Records arrived with the patient, women planned their surgery, and once again the impact of economics on how well health care could be provided was apparent. As I became more independent, it was also a very positive experience to support women through pregnancy and childbirth in a more empowering environment.
Nonetheless, the culture of the specialty did little to change my perception that this was still a battlefield. Few women physicians had gone before me, and I always felt I had to prove myself, particularly in the OR. The attitudes of the attendings towards both their patients and the small but ever increasing number of female residents, who did unheard-of things, from changing in the "Doctors’ Lounge" to getting pregnant, left much to be desired.
Later I participated in establishing a nonprofit group practice in the inner city, with another woman obgyn, a midwife, and a pediatrician. Ideologically, our practice was what I wanted, but despite our immense popularity, we constantly came up against the status quo. The midwife couldn't get hospital privileges; health centers went bankrupt, leaving large debts; our former attendings were unwilling to share coverage.
We were the only private physicians who accepted Medicaid, who worked with midwives, and later a nurse practitioner, and saw ourselves as having a feminist mission regarding the care of women and their families. We worked in the office, in neighborhood health centers, a woman's health center, and at the hospital where we trained. We were on the "fringe" in this mostly male and often quietly hostile environment. Our allies were the nurses, midwives, nurse-practitioners, and women patients who were both the users of health care and prime negotiators for their children and their elderly parents. For these people, being a woman doctor was finally an asset.
Our practice consciously set out to do things differently. Besides the warmed speculums, potholders over the stirrups, and endless supplies of mirrors and Our Bodies, Ourselves, we emphasized education, making health care a joint venture with the woman, her family and her support system. We tried to be attuned to the fact that there is no such thing as a "routine pelvic," since approximately one in four women has experienced sexual assault. We welcomed lesbians and people with disabilities; we supported home births and alternative approaches. In short, we saw the patients no other private MD wanted, and we learned exactly what it means to be outside the "old boy network." Our hospital colleagues were friendly, but finding coverage during our maternity leaves was almost impossible. They told me, "I'm too stressed." "Your patients are too difficult." "Your patients expect too much from their doctors." The translation was that whether we took care of pushy educated feminists or poor, non-English speaking Medicaid patients, we were on our own. What kept us going was our popularity in the communities we worked, our passion about our work, and our political commitment to provide feminist health care. After eight and a half years, having had two babies each, while being on call almost every other night, with little financial success (Medicaid paid $5 per office visit) or cooperation from other hospital staff, we gave up.
Since then all of my old partners and I are working in a pre-paid nonprofit HMO. The struggles are obviously different because of the massive chaos and constant restructuring of health care. I am lucky that I work in a group with many women, and men who treat me as an equal, although sometimes different, colleague. I am lucky that there are now many women in this specialty, who are beginning to be in positions of power. Much of the current challenge comes from the economics of medicine—the previously unimagined power and control of insurance companies, the squeeze on resources and staff, and intense pressure to shorten hospital stays, while learning new gynecological procedures and technologies and the desire to use them for the benefit of the patients and not only the bottom line.
My challenge in this "system" is to save the ideals that have evolved in me over the last quarter century: to treat each woman with respect; to make no assumptions about sexual preference or safety; to provide surveillance, guidance, expert advice, emotional support; and to honor each woman as the ultimate judge of her own body. I try to pay attention to the whole context of a woman's life—is she 45 and pregnant, or menopausal? I see every exam as an opportunity to educate and empower a woman about her body and her healthcare, and to give her a sense of validation about her perceptions. Also, I focus on menopause, PMS, and sexual dysfunction, areas in which women have been classically dismissed. During pregnancy, despite the availability of technology and women's unquestioning belief in it, I see my role as to support and educate, to "love someone through their pregnancy." I see women increasingly tending not to trust their bodies, and my role is to remind women of their immense power and strength, and of the normalcy of childbirth.
In the OR my personal struggle has been to learn to be decisive, aggressive, and calm. When the OR is no longer a man-surgeon’s fiefdom and the usual yelling and temper tantrums of the past are unacceptable, what are the rules? I am constantly learning how to deal with the enormous stress, anxiety, and insecurity (which surgeons rarely admit to), while needing to be the leader of the team and to command respect.
The other struggle is the physician-wife-mother balancing act. There are days when I feel like I am the woman who has everything and I'm doing all of it badly, and on those days it is critical to redefine the meaning of a successful career in medicine. My medical training told me that a good doctor is an academic, with few limits on work hours, and a magical ability to read every pertinent journal. In 1997, a good doctor can be a clinician, can limit hours and still be a "serious player," can take off all school vacations, and be respected for her devotion to her work. The more difficult redefinition for me is the good mother. I wanted to really parent my daughters and not feel like a visiting dignitary between the yearly au pairs. I used to rush home in between office and surgery to breast feed because I had a child who would not take a bottle. I now rush from office to school, lugging canvas bags of paperwork to be done after bedtime. How many other surgeons get paged during a case because their child has a fever at school and needs to be picked up immediately, or the kid forgot her trumpet or can't find her socks? Being a good wife is also an ongoing, constantly-being-invented state of affairs. My husband is a cabinetmaker—I work more hours than he does, I have a more inflexible schedule, make more money, have more social status. These are all loaded and complicated issues. Our relationship is anchored on a respectful kind of equality of value as individuals who are sharing the tasks of life in nontraditional ways. We really have to make up the rules as we go along.
In the world of work, managed care has always existed. Before, care was secretly managed by a patient's socioeconomics, power, and ability to speak English. Now the battles are clearer and more vicious and more dangerous to everyone. This is a battle we did not foresee. As a clinician, I work at the lowest level of the medical food chain. As a feminist physician, I see the future as fighting the battles on the ground while keeping a close eye on defending reproductive rights and options, working for national health insurance, respecting family diversity, defending preventive services. I worry that with all the corporate maneuvering and the complete absence of responsible national leadership and vision, that the changes that are happening will have very little to do with healthcare.
I feel that like-minded people must remain agitators, both from the inside and the outside of the systems in which we work. Just the fact that there are more of us women is a reason for great expectation and possibility. Clearly the innocence of the past is lost forever.
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