Dr. Suzanne Koven, primary care physician and writer-in-residence at Massachusetts General Hospital
In this column, Charlotte Lawrence spoke to Dr. Suzanne Koven, primary care physician and writer-in-residence at Massachusetts General Hospital about her book, “Letter to a Young Female Physician: Notes from a Medical Life”. Dr. Koven shared why her strong interest in Humanities made her a natural fit for medicine, how caring for aging parents can cause intense feelings of guilt, and her hope that more women in medical school will change the healthcare landscape for the better.
Dr. Koven: Yes, I’ve been a primary care doctor for over 30 years at Mass General Hospital. However, I was an extremely reluctant premed [student]. I actually majored in English. My conflict about medicine was -- on the one hand -- I liked it because I had grown up around it. My father had been an orthopedic surgeon, and I used to love going to his office with him. I think I had an intuitive sense as a kid that it would be a fit for me. But I had two roadblocks: one, all the doctors I knew in that era were men. And the other was that I just did not love math and science. I loved the humanities much more, and I had more of a talent for them.
I graduated from college with an English degree, but then I thought, "what would happen if I took organic chemistry and the other pre-med prerequisite courses?” So, I did. I didn't love the courses, nor did I particularly love the first two, very science-based years of medical school. But once I started seeing patients, I realized that I was a fit for medicine. My humanities background began to be useful and in fact, it served me better in many ways than the science that I had crammed in.
Mid-career, I decided to revisit my earlier passion for English which I could never seem to put on the back burner. I went back to graduate school in my early 50s while continuing to work, and I started writing professionally. I had a monthly column in the Boston Globe about what it's like to be in medical practice. And now I’m Mass General's writer-in-residence, which lets me coach healthcare workers interested in writing.
Dr. Koven: No. I don't think so. I should say that there are certain subspecialties of medicine that are more science-oriented than mine. However, I think medicine more than anything is just as Gavin Francis, a Scottish physician writer, explained when he said that "Medicine is an alliance of science and kindness". Of course, you need the vocabulary of science, and knowledge of human anatomy and physiology. I believe that a doctor needs communication skills, compassion, and empathy just as much as medical competency and the necessary bank of scientific knowledge.
Dr. Koven: Well, there's good news and bad news. The good news is that there are more women than men in medicine at younger ages, and there are more women than men entering medical school, and in medical school. And if you look at physicians under [age] 35 in this country, there are more women than men. The bad news is there's still a lot of sexism, there's pay inequity between men and women. There's sexual harassment. And sadly residency programs are not doing a great job helping people who are pregnant navigate medical training with pregnancy. And this is a prominent issue because they occur at the same time of life, and are likely to coincide.
A big revelation for me is that I thought those stories of sexism would be mostly of historical interest to younger readers. Sadly, It turns out it's not a historical interest; it's not too different from the way things are today. But there are more women and as those women rise to leadership positions, it will force things to improve.
Dr. Koven: We know that across the board, women's pain tends to be underestimated and undertreated, particularly women of color. And we also know that in heart disease women often don't come into the emergency room with the set of classic symptoms that everybody's heard of. Their story looks a little bit different from the common narrative: "I was shoveling snow. I had pressure in the middle of my chest. It went down my left arm." Sometimes women have pain that isn't entirely in the chest, maybe it is in the abdomen or the jaw. They may have fatigue or nausea. Now having said that most women, including my mother who has had a heart attack, have chest pain, left arm pain, fatigue, shortness of breath, and other typical symptoms.
However, these are less likely to be taken seriously because women are more likely to be thought of as having psychosomatic symptoms than men are. Something called the confirmation bias is also at play here. For example, if you have a belief that women with chest pain are less likely to have heart disease than men with chest pain, you will act on that belief when you see a woman with chest pain.
Dr. Koven: [Fen-Phen] was the first popular medication for weight loss. It medicalized obesity in a way that most doctors had been resisting. I mean, if you think about it as I put it in the book, there is no other medical issue I can think of other than maybe addiction that doctors absolve themselves of responsibility for. Before these clinics popped up, the general recommendation from physicians was commercial programs like Weight Watchers. I think part of the reason obesity medicine changed so much as a result of these Phen-Fen clinics was that for the first time doctors could prescribe a drug for it. This made physicians view obesity as more of a medical problem. This led to a more medical interest in obesity. Then of course, the whole thing blew up. The drugs caused heart defects and deaths and went off the market. But I think that the cultural change that occurred within the medical community around obesity at that time has persisted. We still don't use weight loss drugs widely, weight loss surgery more so. But I think what we’ve seen in the last 20 years or so is a willingness of physicians to engage people's issues around weight more than they used to.
Dr. Koven: That’s a tricky question and I remember asking my mom when she was getting older, "What can I do for you? "And she said, "Bring me back my health, bring me back my husband, bring me back my career." And of course, I could do none of that and she knew that. She was joking in a sense. And what I came to realize -- and something I've certainly told my patients and friends -- is that when somebody you love suffers, you inevitably feel that you have failed to prevent that suffering, and in the broadest sense, you have failed. I mean, not really but you didn't prevent their suffering. And so you feel guilty, and it's of course very easy to feel guilty about not being able to prevent the suffering of someone who cared for you for so many years.
Even if you and your parents did not have a great relationship, if your parents were not nurturing, then the guilt is perhaps of a different type. It may be the guilt of not wanting to provide the care, but it's guilt nonetheless. So, what I came to realize and what I tell my patients and my friends, and I guess what I'll tell my kids one day, is to realize that if you could somehow physically attach yourself to your parents, if you could duct tape yourself to them, you would still feel that you weren't giving them enough. And so, I think you just have to recognize that this thing that you perceive as a failure, this thing you feel guilty about is just part of the human condition and you're in very good company.
Dr. Koven: Oh, that's a great question. I think men and women in medicine now are more compassionate, more politically aware, and more interested in issues of social justice as they relate to medicine than we were. Back in the day, we were just working very hard, as they are now, and we thought it was enough to simply be doctors. We didn't have to be advocates, we didn't have to be political, and we didn't have to worry about the patients' poverty or the racism that they faced. My perception is that young physicians now have a much broader sense of their role as physicians, and I think young women particularly are very aware, especially now, of the threats to women's bodily autonomy, and many of them are going into practice to challenge them.
