Wonder Woman Act I
The first time I recall exercising my personal power, and realizing it could have an impact – even on adults – was in 3rd grade.
Mrs. Akron, my 3rd grade teacher was a bit of a tart. Always pinched, always stern. But I was smart and one of her ‘pets’ nonetheless. She loved my artwork, and requested – or more accurately, insisted – that several paintings I’d done be displayed in the glass cases lining the halls of PS 201, my elementary school. Mrs. Akron had promised me that I could take my artwork home at the end of the school year. But on that fateful day in late June she flat out refused to give my paintings back, saying they belonged to the school, not me.
I was outraged. OUTRAGED. I planted my 3rd grader hands on my 3rd grader hips, feet hip width apart (my first ever, though unintentional, invocation of the Wonder Woman pose) in her classroom and refused to leave until she handed over my paintings. I mean I wouldn’t budge and was ultimately escorted, somewhat forcefully by the elbow, to the principal’s office down the hall. My single working mom had to leave work to fetch me from the principal’s office. When she arrived, nearly an hour later because of her commute, she asked the now very disgruntled Mrs. Akron, still at work because of me, if the artwork was, indeed, mine. “Yes, said Mrs. Akron, she painted those pictures.” “Did you tell her she could have her paintings back at the end of the school year?” my mom asked. When Mrs. Akron said yes to that, my mom said, matter of factly, “Well then, give them back to her.”
I was heard, validated, and justice prevailed. I left school that year both with my artwork and the value of being a badass when needed, as well as the importance of validating other girls and women.
Wonder Woman Act II
As a home birth midwife, my self-efficacy served me well. First of all, where I practiced, in Georgia, home birth midwifery was illegal. Yet where one births and with whom is a fundamental right, and to this day Georgia not only remains the state with the worst maternal and infant outcomes at birth, but has 78 counties with no OB/GYNS – none! So I chose to go where – well – no men were willing to go.
Further, the disenfranchisement of home birth from the medical system, especially pronounced in when there was a transfer from home to hospital, at times required me to protect my clients from unnecessary medical procedures or tough interfaces with an historically home birth averse medical community.
Tina was one such mom. Tina medically needed to have her baby in the hospital due to a serious condition called Rh-isoimmunization that had developed as the result of a previous fetal loss (that had occurred in the setting of conventional care and was largely unpreventable) and asked me to be with her for labor – and moral – support. Because of this complication, she'd required numerous tests and interventions throughout the pregnancy, which she graciously and gratefully underwent to protect this baby. But she didn’t want interventions she didn’t need – including an episiotomy – when she gave birth. At that time, episiotomies were done to 90% or more of women birthing in hospitals — and as midwives knew then, and the obstetric world now acknowledges, they are – and were then – almost never necessary.
When Tina was moments away from pushing her baby’s head out, after a peaceful 8-hour labor, the obstetrician, now sitting on a low stool at the foot of the bed, his 6'6″ frame taking up the entire space between her stirrups legs, picked up his episiotomy scissors from his instrument tray and prepared to cut her perineum. I quickly and gently reminded Dr. Green (when I'd previously asked the nurses his first name, one nurse curtly replied, “Doctor,” such is the protected medical hierarchy) that Tina had requested no episiotomy, at which time he looked me squarely in the eyes, scissors in hand right there at her perineum, and said “Miss, I’ll do one if I damn well please.”
My inner Wonder Woman spun into action faster than I could think.
Immediately, instinctively, and decisively, I put my hand, like a warrior shield, right over Tina’s perineum, blocking the path of the scissors, and looked Dr. Green resolutely back in the eyes, and said, “Well, then you’re going to have to cut through me to get to her.”
It was like a she-bear with threatened cubs possessed me. He visibly gulped, dropped his eyes, and put his scissors, neatly, back onto the tray. Tina birthed her beautiful, healthy 8 pound plus son moments later – over an intact perineum. I was told that weeks later Dr. Green was so impressed by my grit and protectiveness, that he was hiring midwives to join his practice.
Why I Won’t Stand Down: A Painful Lesson
As a medical student, things changed. At first. I hid my fierceness, tried to fit in, and not make waves. I was polite, at times even contrite – not my MO as a brassy New Yorker, and didn’t openly question my professors’ and attending doctors’ decisions. I simply watched, learned, and made mental notes on what I would – or wouldn't do – with my own patients. After all, I wasn't a fully-fledged doctor yet, and I was taking care of patients who were ultimately their legal responsibility. I was already different – the older, hippie midwife-herbalist in medical training. So I remained generally quietly respectful, as if I were a guest in someone's home.
But it was more than that, too.
Medical training – and medicine as a whole- is a culture in which fear is used as a tactic to get people to comply – medical students and patients amongst those people. In the scheme of fight-flight-freeze-fawn, the common range of stress response patterns, fawning is the expected response of medical students to the system. If you're a woman, and even more so a woman of color, the pressure to remain silent is great – we are still expected to be seen and not heard, and to never fulfill someone else's biases of women or Black women – being loud, shrill, difficult, or ‘a bitch.'
Een with all of my knowledge and experience as a midwife, I was unprepared for just how many medical errors really do happen in the hospital and doctor’s offices and just how many re overlooked because because nobody wants to be the one to point a finger, to make waves, to stand out, to be the messenger that gets blamed. It can be a toxic culture, and doctors in training, nurses, family members, and patients are discouraged from the “if you see it, say it” motto – even when one's patient's – or personal health – is in jeopardry.
For example, there was the time I went to round in the morning and found that my patient's note, hanging on the door of the room, and which I read before I entered, said my patient's chemotherapy IV had been started that morning. But here's the thing: My patient didn't have cancer and or any condition for which she was scheduled to receive chemotherapy. Much to my relief, the error was in the note, not in the actual delivery of the medication. My patient was comfortably tucked in bed, no IV, while her neighbor had the appropriate treatment running into her fragile veins from an IV bag hanging just above her on its silver metal pole. Someone had just entered the medication into the wrong chart, not given it to the wrong patient. I exhaled. Whew, crisis averted. I let the team know know. “Well, all's well that ends well,” I was told. That time.
In my last year of medical school, all of that compliance changed irrevocably for me. I learned, in the most painful way, that it doesn't always end well, and that we can never remain silent, can never place fear of repercussions over getting loud when needed, of putting on our Wonder Woman crowns and unleashing our lassos of truth, when someone else needs us to advocate for them.
Akiko was one of the loveliest women I’ve ever met. A gentle, soft-spoken but strong woman Japanese woman, in her 50s, she raised orchids, had 2 sons in their early 20s who adored her, and a tender relationship with her husband. Akiko had been in the hospital for weeks after a bone marrow transplant for the cancer that was being successfully treated. On strong immunosuppressive medications, she was weaning off and was to finally be going home at the end of the week.
But on Monday afternoon of her hospital discharge week, which the family was excitedly anticipating, Akiko spiked a high fever. Her oncologist, a world famous liquid tumor specialist who has more recently assumed a major government position in COVID-19 strategy and response (no, not Dr. Fauci), said it was from her treatment and that I just should't worry about. My instincts and clinical judgment told me otherwise. My gut was screaming, in fact.
On Tuesday morning Akiko again spiked a fever and was started on antibiotics, but they did nothing. She also began reporting upper right abdominal pain. I told my supervising resident and the oncologist that I’d like to order an ultrasound of her gallbladder, thinking she had a gallbladder obstruction or infection in the tubes that enter the gallbladder. They said no, and when I pushed it with the resident a few hours later, when Akiko's temperature was 104 degrees, the resident told me that if famous oncologist thinks nothing is wrong, then nothing is wrong and I should back down.
This scenario went into Wednesday, with fevers spiking and falling and the abdominal pain worsening. Akiko was now coughing and having difficulty breathing so I ordered a chest x-ray when neither my resident nor famous doctor were on the floor. I sat at her bedside, held her hand. She was no longer telling me about her orchids. She was listless, tired, waxing and waning in and out of consciousness.
The results came back: She had developed Acute Respiratory Distress Syndrome (ARDS), a severe, sudden injury to the lungs caused by a serious illness – the one we are now familiar with as a result of it also being common in COVID-19, and though this was nearly two decades, it was the same deadly complication. In her case it was caused by a necrotizing infection in her gallbladder that was also seen at the edge of that x-ray — and that was causing the abdominal pain and fevers. It wasn't her chemotherapy or anything else. She was now life-threateningly ill. Life support with mechanical ventilation was needed. I was patted on the back (literally) by famous oncologist, who said, “Good catch, Doctor” to me. Akiko was taken to the ICU. She never left the hospital. She died the next day.
Her family later sent me the most loving letter, thanking me for my loving support. I have it still, reread it every couple of years, and remember Akiko, and remember to never be silent. My inner Wise Woman, my Wonder Woman, became my inner guide as a result of Akiko's unnecessary death, and she's my most trusted personal advisor. when I need help speaking up, she's who I channel, my version of Beyonce's Sasha Fierce.
The “Bad Girl” and the Brain Hemorrhage
Just weeks later, on the same hospital rotation, and with that same attending oncologist, my patient – a put together even in the hospital, pixie cut- silver-haired English professor in her mid-60s, being treated for cancer – noticed that she'd been slurring her speech very slightly for the past hour or so, which she reported to me on my morning rounds, I did a routine neurologic exam at her bedside, noticing a subtle but definite deficit in what is called the rapid-alternating motion test on her left side. This can indicate a problem in the cerebellum of the brain.
I immediately notified her oncologist – my attending – and told him I felt she needed urgent imaging, and he said, “Oh, it’s just the chemotherapy probably causing her to have a little brain fog – we call it chemo-brain.”
“I don’t think so,” I said, “it’s a definite change – she and I both notice it.”
He said it was nothing and just looked at me as if I were an irritating child.
Wonder Woman took hold. Like I did in third grade, I stood there, hands on hips, feet firmly planted and said, “Look, just a few weeks ago a patient died here because her symptoms weren’t explored quickly enough. I’m sorry, but I am going to have to go on record that I think something serious is wrong and you’re refusing a test.”
As a medical student, I couldn’t authorize the test without his consent.
He looked at me shocked and barked, “Ok, get an MRI.”
I ordered one STAT and quickly received an emergency page from radiology – radiology calls only come back that quickly when something is really wrong. The radiology resident at the other end of the line said “Hey, I just want you to know that I’ve alerted the neurosurgery team about your patient – they will be on the floor in minutes to bring her to the OR – she has a hemorrhage in her cerebellum.”
My patient had a bleed the size of an orange in the back of her brain. Emergency surgery saved her life and her brain, and she recovered beautifully. Tears still spill from my eyes as I write this and can't help think how different it might have been for Akiko. And so many others, if they had someone to fight for them when they're most vulnerable, and how important it is to speak up for ourselves, even if we're perceived as being a squeaky wheel. Because it's not just these potentially life-threatening diagnoses that are missed, it's the everyday stuff that women are living with – Hashimoto's and other autoimmune conditions that can take years to get diagnosed, endometriosis which takes on average 7 to 9 years to receive a diagnosis for, and the list goes on, and it's mostly conditions that primarily affect women that are missed and for which women are dismissed.
Why It’s Good to Be A Bad Patient – and a “Bad Girl”
This article is not about how clever I am as a diagnostician. Or how fierce I am. It's about how not speaking up can cost someone their life – and less extremely – can leave us feeling victimized and incompetent.
From our earlier years we’re taught to be “good girls.” We’re told to be polite, to be nice, to not interrupt, to say thank you and fake appreciation even when we don’t like something, to be pleasant. We're taught that when boys bully us it's because they like us. We're told to give Uncle Charlie a kiss on the cheek even if we don't want to. We're directly and tactily taught to not make waves, to be seen and not heard, to not question authority, not stand up for our rights, not be bossy, not show our power, to dress down except when we're supposed to dress up, and to say yes to everything – including unwanted work advances from people in authority, to not take it too personally, too seriously, to smile…
The list of how we’re taught to “be good” is endless. I’m not saying we shouldn’t be decent citizens with good manners, but as I've taught my own daughters, there's a difference between nice and kind. Being kind is respect for humanity, bring nice is all the rest of it. I like how Brene Brown says, “Clear is kind.” Not speaking up and accepting what just feels wrong is also unkind to ourselves.
Our inner “good girl” usually starts at home, follows us through school, and stays with us for our whole lives until we free her.
She comes with us into the doctor’s office and the hospital.
She's with us in our jobs, in our workplaces and business dealings, and often even in our most intimate personal relationships. She keeps us from being fully clear and honest, and she keeps up playing small. And in healthcare, she can keep us from getting proper diagnoses and care.
And that’s what I’m talking about here today.
You see, the good girl trope translates into being a good patient. Good girls don’t question authority, don’t challenge the need for the test, the diagnosis, or the treatment, don’t say “No, I don’t want you to examine me.” Or “Thank you, I’ll just leave on my own clothing on top for the Pap smear and I’ll cover with a drape,” rather than wearing that insulting paper gown with my rear flapping in the wind. They don’t say “I think I’ll labor for a bit longer, thank you – we can revisit the epidural later. And while we’re at it, I’ll be walking around to help my labor move along” rather than being strapped into this bed by a fetal monitor and an IV. Or, “No, this symptom is definitely all ‘in my head,' it’s not ‘just' depression; I really am tired, losing hair, and am gaining weight for no reason.”
Many a good girl has suffered for months – even years – with symptoms of depression, weight gain, hair loss, low immunity, dry skin, constipation, and postpartum problems – because she didn’t know she could insist on further testing or another opinion or a different medication that might reveal or improve a thyroid problem.
Doctors and nurses, just like parents and teachers, favor the good girl patients and they dread those that are known in common medical parlance as “difficult patients.” “Compliant” is the word used to describe cooperative patients who do what the doctor tells them.
And I promise you, it comes out in how patients are treated. Eyes quite literally roll and groans are audible when a “difficult” patient comes into the office or hospital. Difficult translates as the mothers who question whether the antibiotic is really needed for the ear infection, the pregnant women who asks her doctor was his or her cesarean section rate is, or who comes into the hospital with a birth plan. Or any of us who even question the need for a test, medication, or surgery. How many of you have been bullied into a test or procedure you didn't want or feel was warranted by a doctor or a dentist? Made to feel you were silly, difficult, childish, stupid, irrational, overreacting?
These things happen every day in medicine. It’s bullying, and we get victimized because we’re afraid to speak our truth and hold our ground, which yes, is hard – but must be done if we're ever going to change the culture of healthcare of ourselves, our mothers, sisters, friends, daughters, and those most vulnerable to medical mistreatment – those who are gay, trans, overweight, Black, Brown, disabled? It can be done politely, but often needs to be done firmly and definitively. Nice and kind are different.
The Wonder Woman Pose and Other Power Tools for Girls and Women
Learning to say “No,” and doing so without apology or explanation, or insisting on something we really feel we need (thyroid tests, to eat during labor, to wait 24-hours with a common, unilateral ear infection in a toddler before starting an antibiotic)) isn’t easy. It takes practice. It’s uncomfortable. People might not like you. Your doctor might seem irritated. You might sweat or feel nauseated before you say no or have to insist on something the first few times you do it.
But remember, fear is a primal reaction that's meant to keep up safe, both as warning system and as a source of adrenaline that can fill us with energy, strength, and courage. It is a survival mode – and can save our lives. We sometimes learn to be good girls very young, before we even consciously know what we’re doing. In many family settings this default mode keeps us safe – which is common when there is an emotionally or mentally unwell parent, sometimes an alcoholic, or one with a personality disorder. Keeping the peace, being good, playing small, complying – all of these behaviors may have kept savage beasts calm or kept the peace, or may have been what gained praise or even love. It may have also been a way of self-differentiating in a family system with multiple siblings – often one takes the role of ‘the good child,’ of the good girl. It may also be a way we vicariously fill our parents dreams – we’re so good in school, at work, in every setting – and this becomes a means to success. Of a sort.
So when you feel fear rising, rather than feel, freeze, or fawn, try the following to transmute the fight energy into applied power:
- First, quickly notice the feelings in your body, and how they want to make you react (run, fight, etc.).
- Then, take several deep breaths. Breathe deeply into your belly, letting your belly rise and fall with the in and out breaths. Close your eyes if you need and can. Calm your racing heart by using your breath to get into parasympathetic mode. Yup, right then and there. You can do it subtly, but do it.
- Now, ease into Wonder Woman Pose: Amy Cuddy's groundbreaking research on power poses has shown that the Wonder Woman pose is associated with increased confidence and courage. Consciously feel your feet on the floor. Put your hands squarely on your hips. Feel the strength of the Earth and the power of all women on the Earth rising up in you while you simultaneously find your center and grounding. If you’re sitting you can stand up, or take the position in your mind if you’re in a chair or for example, on an exam table in the doctor’s office (as in you want to say no to something during a pap smear but can’t just jump into Wonder Woman pose). If Wonder Woman doesn't resonate with you, that's cool. Find what does. Beyonce has Sasha Fierce, her powerful, not so good girl alter ego. Find your inner badass and learn how to invoke her when you need her. This is great to practice anytime you have to speak up, before public speaking events, or applying for a job or asking for a raise – anytime you're about to have a difficult conversation. And the more you do it, the more the power association grows – what's wired together, fires together.
- Next, take a big deep breath and say what you need to say. Strongly, clearly, firmly. Easing into icy water is never as effective as just jumping in. so imagine you are taking the plunge – and just do it!
- Decompress from the intensity of using your power in this way by calming your heart rate with some slow, deep breathing and congratulate yourself for speaking your truth and having courage.
Practice with small stuff, for example, speaking up about overly salted food that you really want to send back in a restaurant, or honestly telling the person giving you the pedicure that you’d love a quiet moment rather than hearing about her love life, or saying no thank you the next time you’re invited to something that you really don’t want to go to rather than going and wishing you were anywhere else.
It takes practice telling the truth, speaking up for ourselves, to truly be in alignment with what we feel, what we say, what we accept. It means you have to let your inner good girl grow up into a badass woman- and that good girl has probably been with you for a long, long time. So it takes some relearning how to walk in big girl shoes. But doing so just might be transformative for you, and could be life saving for someone in your life. You’ll get there. We all will. It’s easier if we make the mutual commitment to all do it – together. In doing so, we will change the medical system, which is in bad need of a makeover. And we will change our culture. Clear is kind.