{Mandatory preamble: As with all of my blog posts, the views espoused herein are mine alone and should be construed as neither shared nor endorsed by any organization with which I have an affiliation.}
{Trigger warning: white male privilege, heated exchange, gender-based harassment}
As a woman in academic medicine, I felt compelled to write because of four intersecting developments in recent years:
- The posting of a powerful video featuring male healthcare workers condemning gender- and sex-based discrimination and harassment in the healthcare setting;
- The book I’m currently reading, entitled “The Beauty in Breaking” by Emergency Medicine physician Dr. Michele Harper, which describes shocking incidents of gender-based violence against healthcare workers and inconceivable statistics on the commonality of such occurrences;
- An unsolicited email received at my personal address in which a man, using his actual name and actual University of Western Ontario email address, stated the following: “All doctors are wannabe academics who, truly believe, wearing a lab coat makes them a scientist. It would be hilarious if I wasn’t so sick. FUCK YOU ANDREA. DUMB FUCKING CUNT. 🖕🏾” and,
- The in-flight medical emergency to which I attended for essentially the entirety of a pre-pandemic transatlantic flight, which I describe below.
In the wise words of Mme. Gisele Pelicot, “the shame must change sides”. All the shame. And so, I speak.
While the flight began uneventfully, it was not long after takeoff that I was approached by a flight attendant to, a. verify that I was a physician, and b. request that I attend to a passenger requiring medical assistance. Naturally, I agreed, requesting that she procure the medical kit, whilst I shuttered my laptop, kissing goodbye the seven uninterrupted hours I had planned on working in a non-clinical capacity. In order to protect the privacy of the patient, I will spare the readership the details, but suffice it to say that this passenger was ill enough to require vital sign assessment and interventions of some kind frequently, with each assessment – as with any such patient encounter – followed by written documentation.
Please entertain a small digression around the organization of the medical kit, in case any aviation decision-makers happen to be reading this and care. Beyond the A-B-Cs, codes are not run in alphabetical order. The process of hunting around for all the pieces I required to acquire vital signs was the exact opposite of ‘lean’. Notably absent from the kit was alcohol-based hand gel with which to clean my hands. Biohazard bags and small surgical towels would have been especially handy. I found no plausible mechanism for delivering intramuscular meds, despite their availability, with the only parenteral option being starting a line. One thought might be to have the kit organized by task and syndrome, understanding that in-flight emergencies may have common manifestations and the ultimate goal is to keep an ill passenger alive. Separate, labelled sections for drugs to manage blood pressure, cardiac-origin chest pain, nausea, allergy, and analgesia seem logical. Overall the kits are reasonably comprehensive, but organization by system, syndrome, and task (e.g., vital signs) might be more intuitive for professionals accustomed to a non-alphanumeric approach to patient care. Of course this is all in the eye of the beholder, but just a thought!
Now, back to Time’s Up……Delivering medical care in a densely populated fishbowl at 35,000-ft is obviously not ideal. Most other passengers are respectful of the process and the inherent challenges of delivering such care effectively. The beeping of the sat probe will occasionally garner more attention than justified, but overall, when I’ve performed in a medical capacity in airport lounges and in the air, my work has never been impeded by another passenger. Until this particular flight, in an exchange that went something like this:
Patient to Me: {near the end of assessment #5 that trip} “How much longer until landing?”
Me: {glancing at the electronic map} “About two-and-a-half hours”
Him: {and by him, I mean a completely unrelated, seated-6-rows-back, Xennial-ish, possibly inebriated, definitely nosy white guy be-bopping back-and-forth to the galley, with zero business loitering around stage left of my performance) “Actually it’s two-hours-and-nine minutes”
Me: “Okay, sure, I don’t know, I just checked the map” {turning back to my patient to reiterate the plan that I had just communicated moments ago, and to advise that I’d be back soon, having fulfilled the tasks that I had come to complete}
Him: “Ha, ha, you’re right – it is two-and-a-half hours!” {continuing to stand in the aisle, 9-inches from my patient’s head}
Me: {delivery of a mute sideways glare whilst leaning over, bidding my patient farewell for the moment}
Him: {still loitering} “How’s the patient doing?”
Me: {Really? Has this gentleman never heard of the Hippocratic Oath? It literally contains a line, which states: “I will never divulge, holding such things to be holy secrets”. At this point, I straightened myself erect – all 5-ft-3-and-3/4-inches of me, having lost a quarter-inch during pregnancy; thanks son! – to wordlessly meet his gaze}
Him: {without awaiting verbalization of what I hoped to be a facial expression clearly communicating my thoughts} “Are you a nurse?”
Me: “Actually no, I’m a medical…” {about to say “doctor”}
Him: {interrupting, with an obnoxious smirk} “Pardon? I can’t hear you!”
Me: {turning on my heel to head back to my own seat} “Actually, it doesn’t matter. You really don’t need to hear me.” {as I walked away}
Him: {beyond incredulous, demanding loudly} “Are you walking away from me??”
Me: {walking away from him} “Yes, that’s exactly what I am doing. I am walking back to my seat.” {noting the absence of any airline staff within my sight-line}
Him: {enraged, now shouting while following me} “I can’t believe you’re just walking away from me!! Why are you walking away from me?!”
Me: {reaching my seat, turning to face him} “I am under no obligation to engage you in conversation.”
Him: {devolving into a full-out code-white explosive mantrum, gesticulating wildly and petulantly screaming at me about how rude and horrible I was to be walking away from him because he’s a “human being” [quite possibly the same kind of “human being” who would call a complete stranger a “dumb fucking cunt” using his actual email address?]
Me: {locking eyes with another female passenger in the cabin who appeared nanoseconds away from entering the exchange} “My objective for this flight is to return home and get my patient into the care of medical staff on the ground. Alive.” {beginning to take my seat, thinking that this could go all ways of bad if it continued off the aircraft}
Him: {more crazed lunatic shouting}
Me: “I don’t owe you anything.”
At that point, as I was seated and a flight attendant had appeared, shouting morphed to bleating as he began to de-escalate and ultimately let it go. He was “spoken to” by the service director, who additionally severed his alcohol pipeline, neither intervention of which did anything to prevent him from loitering inappropriately on a subsequent patient assessment and audibly decrying my maltreatment of him to yet another unrelated passenger.
Reflecting on the entire incident and on a scale of harms, of course it was not that bad. The words used were tame, the duration was brief, and no one was hurt. All told, it was pretty minor. We’ve all been trained to deal with the difficult, belligerent person, and, within the confines of a system equipped with security and other safety controls, including equally trained colleagues, we become inured to this type of hostile interaction. It occurs stereotypically – flapping arms, blazing eyes, bellowing maw – and with regularity. I defy anyone to locate a female healthcare worker with whom this type of interaction does not resonate. Print and social media are awash in stories just like this and much, much worse. As with many things in life, though, it is delivery rather than content that makes an impact. Trust me on this, their rage is the same, whether they touch you or they don’t.
As I returned to my seat, my hands still shook; I was still tachycardic. Composing that assessment note was challenging, while the others had been easy. This is because having someone screaming in your face triggers the fight-or-flight response, which in turn channels all of one’s energies into survival, regardless of the actual threat. The cerebral cortices are effectively shut down, limiting one’s ability to perform any kind of cognitive task, such as provision of medical care. Eloquence becomes elusive, logic and precision, a fantasy.
How does this all relate to Time’s Up Healthcare? The stakes of this type of behaviour are high. In the operating room, emergency department, on the ward, in the clinic. Women healthcare workers cannot afford the temporary cognitive impairment that stems from a galactic meltdown happening in their face, nor can their patients. Had this person insinuated himself into my orbit in this manner at a bar, for example – an experience owned by women from adolescence onward – I would have been annoyed, but the stakes would have been inconsequential; only I would suffer any fallout. This happened while I was embroiled in a mid-air medical emergency where it was presumably my ability to think that was of value to the situation. A patient was at stake. Maybe femininity and gender had nothing to do with it. Perhaps the incident would have unfolded exactly how it did had I been a male physician providing the care, but I don’t believe that to be the case. Male physicians also aren’t waking up on a random Saturday morning to emails from perfectly entitled strangers calling them obscene gendered slurs. Reported rates of harassment and discrimination are three-times as high among women physicians as men.
My other reflection on the in-air incident, which has equally motivated this posting, stems from hindsight. In the heat of the moment we never say what we’d like to say, or do what we’d like to do. This is why fire drills save lives. This person felt entitled to me. Simply by virtue of our shared environment, I owed him my time, conversation, and genial acquiescence. My disagreement with his supposition caused him to lose his mind. I wish I had simply said “No means no”. “No I don’t want you following me, no I don’t want you in my personal space, and no I don’t want to have a conversation with you”. I didn’t know him, and he should have been aware of the social contract that precluded what I was doing from being any of his business. The safety cultural practice of zero tolerance for explosive, aggressive, hostile behaviour towards any healthcare professional should be extended to the friendly skies (a place, I will add, where said healthcare professionals are least likely to expect it). “No means no”. It is a refrain that most women have practised. Twenty-five years ago, at the start of medical school, I naively never imagined having to use it in a professional capacity. Well, let me tell you, that wore off quick. I could choose from any one of dozens of incidents to write about, as could most women, but this minor one is particularly memorable. Still, at 35,000-ft in front of 300 passengers, one is out of their professional comfort zone and the usual context of “No means no”. Reflecting back, I am surprised that I was surprised by the incident at all.
I write this as a white, cisgender female physician, and all the privileges those sociodemographics entail. Strip away those privileges and the experience and interpretation will differ. Countless Black women physicians have been humiliatingly denied the opportunity to provide medical care at altitude simply because their credentials have been disbelieved. Although I am also on a learning curve in this arena, an intersectional approach to addressing all forms of discrimination in healthcare is clearly a very good idea, one that has been espoused repeatedly in the literature, and is supported by robust evidence. Male healthcare workers are subject to hostile belligerent interactions as well, of course, and they may be equally lobotomized by them in the moment, and affected by them over time. As a woman, that is not my narrative to write, but it should continue to be written. When it comes to gender-based harassment in any setting in which you are called upon to perform in a professional capacity, my advice is to expect the unexpected, have your refrain and exit plan at the ready, and remember, practice makes perfect.
