Women Rise up!

Alice A. Tolbert Coombs, MD, MPA, FCCP

Portions of this publication has been published in VSA Newsletter October 2020

A pivotal moment in the history of anesthesia is highlighted by a patient being anesthetized in the classic picture, “Under the Ether Dome” at Massachusetts General Hospital, on Oct. 16, 1846 (figure 1). While we are impressed with the historical significance of what happened under the Ether Dome, there exists another narrative. In a 19th century, male-dominated world, women understood the power of influence and basked in the appreciation of informal authority. While formal authority is expected in organizational structures, informal authority stems from relationships that are cultivated and which result in acquired influence. Informal authority or power is your brand and signature that ultimately impacts your organization and society. Female physicians are showcased in Figure 2, administering anesthesia in the operating amphitheater of the Woman’s Medical College of Pennsylvania in 1903. While women may be exhibiting formal authority, successful leadership development does evolve from informal authority. There are examples of positive and negative informal authority. As female physicians, we must understand the value of resourcefulness, empowerment, legitimacy and affinity as they relate to leadership development.

Black women in medicine introduced the issue of intersectionality. Columbia University and the University of California at Los Angeles law professor, Kimberlé Crenshaw first coined this term more than 30 years ago in which she described: “the way people’s social identities can overlap, creating various forms of inequality and experiences of discrimination” (1). Intersectionality highlights the fact that not all inequalities are equal. The percentage of female Black physicians has steadily increased over the past 20 years and currently represents 59.1% of all Black physicians while the absolute number of Black female physicians has only increased minimally (2). Minority women in medicine may aspire to advance in leadership positions both in private practice and academic environments. Establishing some informal authority may offer a stepping stone into formal leadership positions. It takes doing the extraordinary and disruptive innovation to break through the glass ceiling.

Dr. Elizabeth Blackwell was the first woman to receive a medical degree, doing so in 1849, and her role in mentoring and advocacy of the underserved was a constant theme in her life. She was a sponsor and mentor to her sister and other women. Dr. Blackwell demonstrated informal authority, but she had challenges that forced her to make career decisions based on an acquired physical disability (monocular blindness), infrastructure support, gender and her finances. At one point, she struggled to find work. She found strength in other women, who encouraged her. One of Dr. Blackwell’s closest friends insisted that if she were cared for by a female physician, she would have received better care. Dr. Blackwell’s empowerment allowed her to be decisive. Once she lost her vision, she could no longer be a surgeon, but she considered her next best alternative was to become a generalist. Her legitimizing body was her patients and other women. She recognized the reciprocal appreciation in this sector. Although she was forced to make decisions in the midst of uncertainty, she was empowered because a key element in her decision-making was her “connectiveness.”As female physicians, we must determine, “who is my legitimizing body?”In other words, who are not only my supporters but who shares a similar vision and therefore is a reciprocal relationship (3).

Dr. Rebecca Crumpler was the first Black female to graduate from a U.S. medical school , New England Female Medical College in 1864. Sometime after graduation she traveled to Richmond, Virginia, where she cared for freed enslaved persons. The Medical of Virginia had so many marks of discrimination against Black people during this period. There are stories of procedures performed on Black individuals for teaching purposes (Medical Apartheid, Harriet Washington). There was a separate hospital for Black people and white people. In this city, she received comparable patient support that would have been rendered for a white male physician in Boston. Despite this fact, she and other Black physicians in Richmond still experienced intense racism. She published a book, “Book on Medical Discourses.” She was empowered because she recognized her legitimizing body was made up of other Black individuals having to relocate to practice medicine. Her informal authority and greatest influence were in the Black community. Female physicians sacrificed professional advancement because of their limited resources and lack of social capital. The struggle for female physicians was complex. Three years following the graduation of Dr. Crumpler in 1967, Dr. Rebecca Cole, a Black woman, graduated with her medical degree from the Women’s Medical College of Pennsylvania.

These female physicians were resilient, focused and with dogged determination. But these qualities were only part of the solution (4). Firstly, it is affinity that opens the doors to success. I will define affinity as connectiveness. As a female physician, recognizing when we have affinity in an environment is essential to our success. Several questions are important. Affinity is influenced by personalities and tolerance. Can you increase affinity and, is there a secret sauce to making your colleagues be connected to you? For women, sometimes they recognize, when you first walk into a room, if you have a halo-effect. Other times your support from others, or lack thereof, may not be obvious. We must be creative in gaining access into the lock-out minds of decision makers. It will be an experience in understanding the value system of the environment. In some circumstances there will be obvious biases. I will caution physicians to hold steady and understand the perspectives of key players in your workplace prior to taking any stance or formulating conclusions. Once your homework is complete, seek not just mentorship but allyship – a person whose ideals resonate with yours although they may not agree with you on all issues. There is amazing value in divergent-thinking colleagues who are not paralyzed by terminal group think in the landscape. A strategy to gain affinity would be to engage in activities or work projects that result in the increase of connectiveness. Here are a few suggestions which are by no means complete. The role of mentorship cannot be underestimated. People who become your personal BOT are helpful for growth-propelling transparency. For example, for hospital-based physicians, seeking out the most visible and essential core committees and activities in a hospital may prove beneficial. Probably the best halo-getting action is to be a great physician. Lastly, it is important to engage in professional society activities: linking up with other like-minded individuals promotes connectiveness.

February is Black History Month. What are the lessons learned from these historic icons?At the turn of the century, we had only a handful of women and Black individuals graduating from medical school. Today, Association of American Medical Colleges data reveals that in 2019, 50.4% of the graduates from medical school, and less than 40% in practice, are women but Black physicians in the U.S. only represent 5% of all physicians while Black individuals represent 13.4% of the U.S. population (5).

How do female and minority physicians succeed in an evolving world? A complex question invites us to explore solutions that are multi-pronged. Being a GOOD DOCTOR is essential for advancement into leadership positions. No matter how much advocacy a physician engages in, her or his voice is strengthened by care for patients. Mentorship, allyship, sponsorship and understanding the importance of education and service are paramount for advancement.

Over my more than 30 years of private and academic practice, I am eternally grateful for the role that others have played in my development. This includes: Wilbur Jordan, MD; Marlene Myer, MD; Bart Cilento, MD; Estelle-Stez Marcus, MD; James Devin, MD; Linda Healy, Corrine Broderick, Alex Calcagno, Robin Allie, Steve Phalen, the Hammonds, Elba and Roosevelt Tolbert, and of course my husband Albert Coombs, MBA. Together we really are stronger. Physicians rise up and take a place in society! +

Figure 1. The Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine traces its roots back to the October 16, 1846 public demonstration of medical ether

Figure 2. Woman’s Medical College of Pennsylvania operating amphitheater, 1903. Legacy Center Archives, Drexel University College of Medicine

Alice A. Tolbert Coombs MD MPA FCCP Interim Chair, Department of Anesthesiology and Critical Care Medicine, Virginia Commonwealth University, Medical College of Virginia Richmond, Virginia