Wednesday, October 5, 2016

The Unacceptable Cost of Silence

By Dr. Cedrek McFadden

Nearly a month before our national presidential election, a video surfaced online capturing a conversation between Presidential candidate Donald Trump and reporter Billy Bush. During this 2005 “private” conversation between the two, Trump lewdly brags to Bush about kissing and groping women without their consent. He is even heard boasting he can “get away” with this behavior because of his celebrity status. Trump has been heavily criticized for his words and actions. Billy Bush, on the other hand, was criticized and fired from the “Today” show for what he did not say. There is no footage of Bush stopping and discouraging these comments by Trump. Instead he plays along and is heard saying “whoa” and “whatever you want.” He has since apologized and expressed feeling “embarrassed and ashamed” for his lack of immediate condemnation of Trump’s suggestive comments and for playing along.
The backlash that ensued reminded me of times in my own life when I played along or remained silent in the presence of language or actions I genuinely wanted to condemn. As I spend a great deal of my time at the hospital, many of these incidences have occurred there. Unfortunately, these incidents transpire more times than most of us in the medical community would want to admit. What is the cost of our silence? In the case of Billy Bush, his inaction cost him his job and perhaps his career. When we as surgeons, fail to speak up in the presence of inappropriate behavior, injustice, and bias, what are the stakes?
The operating room is one place where I have witnessed these types of incidents. The offending culprit was the attending surgeon. Generally, the attending surgeon controls the social climate and atmosphere. So, for example, if that surgeon wants classical music playing, there will likely be classical music playing. Aside from the care the patient requires, the surgeon is the next most looked after person in the OR. When the surgeon engaged in otherwise offensive conversation, no one on the surgical team spoke up. No one expressed concern that the language or tone was inappropriate. No one changed the subject to signal that the content or nature of the conversation was not ok. At worst, the joke was countered with a similarly vulgar example. "Sadly, several members of the team responded with either silence or laughter, but no one stopped or condemned the conversation."
Such derogatory, offensive, or discriminatory comments to or about another person or group are not confined to the OR. The subject of the comments have ranged from patients, nurses, hospital administration, or even other physicians with racist, sexist, or ageist undertones. My years in medical school and early years as a resident, when I was most vulnerable and the least powerful and influential in the medical hierarchy, coincide with the times I was most tolerant of this behavior.
So, regrettably, I acknowledge that I, too, have remained silent in the immediate presence of injustices, and because I did not speak up, I have continued to internally replay these moments, wishing I had responded differently. One specific example haunts me to this day. While I was on the interview trail for surgery residency, a department chairman made a racially insensitive comment to the group of interviewees, including me, an African-American, about not taking care of “tar babies” at their hospital. In the moment, I said nothing. I did nothing. In hindsight, I am ashamed of that fact.
In the ensuing years, I now understand I was unable to fully process what was happening in the moment.  Partly, I was in shock. After having time to think about his comments, I think this is likely true of others who may have been in very similar situations. Several questions come to mind. What should you say? When should you say it, and how?  Secondly, I believe there is a certain cost to speaking up against ethically unjust and offensive language. One could certainly not be accepted or in some cases could be detested for “stirring the pot.” It could lead to social isolation. Nevertheless, I question whether the cost of speaking up (social isolation and exclusion) may not compare to the ultimate cost of not speaking up (further discriminatory and defamatory practices, preventing forward societal progression). But regardless of the cost, I now hold myself accountable and will speak up and address, in a variety of ways, any offensive, derogatory, or discriminatory language.
The demographics of the world are changing, which is appropriately reflected in the surgical profession. Fifty years ago, blacks had great difficulty getting access to surgical residencies and women were considered primarily for degrees in nursing. Today, our surgical societies and residencies have had made progress in increasing diversity to more accurately reflect the patient population and create a culturally sensitive health care environment. This change should also be reflected in what we say and what we tolerate being said in our presence.
How would things have been different if instead of tolerating those words spoken by Trump and playing along, Billy Bush would have discouraged it or even just brought up a different topic? What if every man (and woman) who heard him relay stories of or bore witness to his behavior against women spoke up and declared it unacceptable? But Bush didn't, no one did, and we continue to have debate and even protest about this and other offensive and derogatory words and actions of not only Trump but also others. While these protest and arguments create a great dialogue in our society, real change occurs in the exact moment and space when inappropriate, discriminatory, and ethically debased language is spoken and a courageous person makes the decision to intentionally speak up against it.   
Dr. Cedrek McFadden

Dr. McFadden is a husband, father, colorectal surgeon, mentor, speaker, and believer in health and wellness.

#ILookLikeASurgeon: My Grandmother's Silent Lessons on Life and Wellness

“I come as one. I stand as ten thousand.”
        -Maya Angelou in her poem Our Grandmothers

I am a surgeon. I am proud of this fact partly because I am the first in my family to go to medical school. I am also proud of this fact because I recognize that me becoming a surgeon has been less about me and more of a collective and cumulative effort of my parents, grandparents, great-grandparents, and countless other hard working ancestors, many of whom remain nameless. More than any other, perhaps the one person that would influence my initial decision to become a physician was my grandmother. She would also later influence my decision to become a surgeon. Seeing her sprawled out on her kitchen floor after having a massive heart attack when I was 5 years old would, furthermore, influence my resolution to become that surgeon committed to wellness.
        My grandmother was the center of our family. Growing up in a very traditional and conservative African-American home, I was surrounded by a large, loving, and supportive family. Family gatherings at my grandmother’s home were frequent and sometimes without any specific cause. She was generally in charge of deciding the menu items during these gatherings, many of which she prepared herself. At the time, the food was delicious and filling. In hindsight, it was oftentimes, greasy, fried, and nutritionally sparse. The paradox presented in this is that at the same time, my grandmother had many chronic illnesses. I always knew her to be diabetic and was unfazed watching by her self-administering her insulin injections. I became well-versed in hearing about her “Coumadin levels” or her “heart pills.” I knew she was not well as she had difficulty walking short distances and went to the emergency room on a frequent basis, but at the end of the day, medication was the only lifestyle modification for her problems.
        Growing up in this setting, I wanted to know the “why” of her health problems. I was not satisfied with knowing generic glossed-over answers, but I constantly asked questions, which eventually led to me choosing medicine as a way to learn more and answer those questions. As most of her health problems were chronic, she was on many medications with oftentimes no immediate change. As a surgeon, I would have the ability to make almost a direct change in the patient’s health, which in addition to a love of anatomy and being in the OR, subsequently became a strong incentive to become a surgeon.
        I was fortunate to train at an institution where the hospital embraced the concept of wellness with “eat right” programs and even offered discounted gym memberships. So it was never odd to have a mind towards personal wellness in this setting. I had many attendings that were great examples to me because of their own commitments to eating well and physical fitness. They themselves took time to exercise, spend time with their own families, go to church, and encouraged me to do the same. One attending was known for making climbing the stairs mandatory during rounds! Regrettably, during the early years of my residency, I struggled to find the time and energy to squeeze in exercise and make good food choices. I was at the hospital at 5 and leaving later in the evening. I made poor dietary choices and skipped out of  going to the gym. This compromise resulted in weight gain and continued fatigue. Ultimately, towards the end of my training, I had to make my workouts a top priority. By doing so, I was able to foster the required discipline to train and to successfully complete my first marathon during my chief year.
        Now as an attending surgeon, my commitment to maintain a sense of personal wellness continues to be a longstanding, purposeful, and intentional journey. By this, I remain in a much better position to prevent burnout and not become detached and frustrated with my patients and the care they require. I am able to handle the increasing physical and mental stressors of being a surgeon much better as I continue to recognize the value of exercise and have kept it a part of my routine. I make time to go to church and spend time with my family. Dietary changes have been the most difficult to make and maintain partly because it has required creating a complete turnaround of what I understand about food. The culture in which I grew up was not particularly health conscious, but after seeing the health problems of those I loved, I recognize that pattern was not one to observe and continue.  I have gone through periods of being a vegetarian and even maintained a strict Paleo diet. Ultimately, while not 100% protective, my goal has been to make better dietary choices so that I reduce my risk of having health problems I observed as a child in my family.

        The night that I saw my grandmother in cardiac arrest on the floor of her kitchen was fortunately not the last time I saw her alive. She was able to recover and lived another 20 years. In the end, she was unable to recover after a surgical procedure. At the point of her death, I was no longer a confused 5 year old boy but now surgical resident with a better perspective and understanding on the various factors that contributed to her declining health. I now recognize my life as a surgeon is a composite of the invaluable and mainly unspoken lessons my grandmother taught me about health and wellness of my mind and body, and the personal responsibility to ensure I am continually taking care of them both.

Dr. Cedrek McFadden

Dr. McFadden is a husband, father, colorectal surgeon, mentor, speaker, and believer in health and wellness.