Medicine's culture has something to learn from aviation's mistakes, and more insights from Dr. Jane van Dis

It's no surprise that Time's Up, the organization created in the wake of the #MeToo movement, is now turning its attention to medicine. Roughly 8% of the claims coming into the Time's Up Legal Defense Fund are health care workers, making this workforce the second largest to request legal assistance behind the entertainment business.

I sat down last week with Dr. Jane van Dis, medical director at Maven Clinic and a co-founder of Time's Up Healthcare.

"You have an industry that is very male-dominated," she said. "It's very hierarchical, and it's now populated with a lot of women. Women actually last year in 2018 matriculated more women medical students for the first time ever. And, of course, we know nursing is 91% women. So, you have a workforce with a lot of women, and yet you see pay gaps, inequity gaps, leadership gaps, as well as sexual harassment."

Read the entire, edited transcript of the video interview below.

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Jaimy Lee: You are an OB-GYN. You work in telemedicine. You co-founded a gender pay analysis app. And now you've co-founded Time’s Up Healthcare. Did you ever think your career would look like this?

Dr. Jane van Dis: That's such a good question, Jaimy. Actually, no, I didn't. I imagined I would have a straight trajectory going through residency and training in obstetrics and gynecology, and then practicing the full scope of obstetrics and gynecology, private practice, hospitals, delivering babies, performing surgery. It definitely has taken different turns, some of which were intended and some of which weren't. But I'm happy where I am. 

Lee: When did you realize that you could have a career in medicine that looks like this instead of the traditional route?

Van Dis: Well, it's interesting that you say that because I encountered some situations in the course of my career that caused me to think about how I might need to alter my career in terms of both revenue and where I would work. I actually got interested in telemedicine back in 2011, in part because of some situations that were happening in my work. I first got involved with HealthTap. And then when I saw in 2015 that there was a female-founded company designed to provide telemedicine services for women's health, I was absolutely thrilled with the chance to participate with Maven Clinic. I was on the platform for many years before I took a role within the company.

Lee: As a woman in medicine, how do you think that shaped what it is for you to be a doctor today?

Van Dis: That's a question that is so multifactorial. As a woman in medicine, I have encountered the challenges with work-life balance that I think any woman in any career encounters. Obviously, with overnight call at the hospital, those challenges are different in medicine than they would be in other sectors, just because childcare overnight can become an issue. I'm a single mom, so that's something that I obviously have to consider when thinking about my schedule as a physician versus my life as a mom.

And then there are also the challenges of wanting to seek out leadership roles, and sometimes finding roadblocks to those and trying to negotiate and figure out where I belong, and what my skills are, and where do I have a chance to give back to the profession and make it better for those who are coming behind. One golden lesson that I've learned about that is that I'm done necessarily asking others to acknowledge my abilities and talents and skill set and instead have embarked on situations where I create my own future.

And so that's what Dr. [Esther] Choo and I did with Equity Quotient, we created a company. I did not realize that creating a business was actually a creative enterprise. I thought it was just all numbers and corporate documents, and I didn't realize that, in fact, the business side of life is actually highly creative. When you're thinking about, what is the problem that you are trying to address? and how are you going to solve it? and what are the channels? What are the mechanisms? All of that thought process is creative. So I have a lot of respect for MBAs, in a way I didn't before I created a company.

But, again, it's a very creative enterprise so it's been very exciting, and I have to say I love working with female founders. I think that women approach business with a different perspective. I’m not going to say better. I'm not going to say worse, but I will say that the way that women seem to frame the problem and then how they think about solving the problem, to me, at least based on my experience, feels different. And the collaboration that I have found working with the female founders that I've worked with is very different, and I welcome it. I find that my imagination is the limit as opposed to more structurally imposed caps on creativity.

Lee: Interesting. And so with Time’s Up Healthcare, from a very practical level, why is there a need for this particular offshoot of Time’s Up?

Van Dis: There's a need for Time's Up Healthcare because women are 80% of workers within health care. We found from the National Academies of Sciences, Engineering, and Medicine report last summer that one out of every two medical students is experiencing sexual harassment during their training. We know that up to 70% of women physicians, depending on what stage of the career you're asking them, report sexual harassment during the course of their career. Similar numbers report gender discrimination.

You have an industry that is very male-dominated, it's very hierarchical, and it's now populated with a lot of women. Women actually last year in 2018 matriculated more women medical students for the first time ever. And, of course, we know nursing is 91% women. So, you have a workforce with a lot of women, and yet you see pay gaps, inequity gaps, leadership gaps, as well as sexual harassment.

The time is now to try and change our industry as much as we can to make it a safe, dignified and equitable work environment for our colleagues, for those coming behind us, for our daughters. My daughter is one of the main reasons that I do the work that I do. I have been her Girl Scout troop leader since she was in kindergarten, and she's in fifth grade now. And I found it very disingenuous to sell these girls on careers in STEM when we knew what they would be encountering once they got into the workforce. And it didn't seem fair to imagine or paint a picture for them of a meritocracy and that their ability to succeed, their grades, their papers, their publications, all of these things would elevate them up through their career only to find that they might be blocked by experiencing sexual harassment in the workplace or by experiencing gender discrimination and have the same types of disappointments in their career that so many of us have faced. 

Lee: We still see stories on a regular basis about hazing in health care, bullying, violence, harassment. What about the culture of medicine allows for these kinds of instances to persist? 

Van Dis: That is such a good question, Jaimy. But it is interesting to try and take the culture apart and try and understand why harassment and bullying finds a toehold in medicine. When we look, for instance, at say the operating room, which is a place that I'm familiar with being a GYN surgeon. What I have found is that there is a sense of hierarchy, right? With the surgeon being at the top, the circulating nurse, the tech, the orderly, in sort of a pyramid scheme. But the fact of the matter is that hierarchical design, it actually only works to a part.

And the reason is because we now recognize that health care is much safer and has better outcomes when it functions as a team. Recognizing, of course, that the physician has a unique set of skills. I as a surgeon am uniquely trained to take out a baby via Caesarean, and the nurse is uniquely trained to do what she or he does. And similarly the anesthesiologist and the surgical tech and the nurse that is there to take care of the baby. And that patient safety happens when we all work in coordination with one another.

Medicine luckily has taken some very great lessons from aviation in understanding that everyone who is on the airplane, in the cockpit, has the ability to use all of their senses — their eyes, their ears, touch — to know if something potentially is wrong or is going wrong. We saw that with the 1977 crash in Tenerife. The co-pilot wanted to say something, or tried to say something, about averting the worst air disaster in history, and the captain ignored his pleas.

I think the operating room is the same. I appreciate it. I love it, actually, when someone points something out to me that I didn't see because that tells me that they have the confidence and the ability to not feel that I will be threatening or respond in a defensive way, that their suggestion will be warmly accepted, especially if it's in service to patient safety. When you look at where we came from in medicine, when you have a hierarchical culture, it relies on human behaviors and traits that aren't always the best. Because the surgeon can make a mistake. The surgeon can fail to see something. And thank goodness if others in the operating room feel safe to say so. But I think that when you come to a stressful environment, like the operating room or the emergency room, you sometimes rely on base instincts. And so if culturally you have some misogynistic tendencies, those can come out and they're not really a good idea to have in health care. They can harm patients and hurt the staff.

Lee: We've heard a lot of talk lately about burnout with nurses. Some are choosing to leave the profession. And in instances like that, what's the answer to that? Is it leadership needs to step in? Do nurses and doctors need to be trained to be better leaders? What's the disconnect between what's happening and what's happening at a leadership level? 

Van Dis: In terms of addressing burnout, obviously I know the physician components and statistics better than I know nursing. I will say that having good patient safety ratios, the number of patients assigned to each nurse can affect their sense of being able to do their job and feeling safe in the parameters of doing so. California is the only state on record that has required nursing-patient ratios. Leadership should care first about patient safety. That's why patients come to us. They hope that we will heal them or help them through whatever disease or process they're going through. Their safety should always be our first concern. In terms of getting input from nurses as to what that feels like, whether it's how many patients they're in charge of, or is the nursing charge leadership: are they effective? Are they treating their nurses underneath them with kindness and respect? 

I have been amazed since I started this journey into how cultures are assembled, how they're put together. I work clinically as an OB hospitalist, so I solely work now in the hospital. Looking at the culture of labor and delivery is something I feel like I do now as a profession. It’s part of what I think about when I go to work and I'm really amazed at the variety of cultures that I've seen. I've seen effective ones and I've seen ineffective ones. If you were to ask me what an ineffective culture is, I would tell you that it's again one where nurses feel that they cannot speak up or if they speak up, they are disciplined for doing so.

I worked at a hospital that I absolutely loved. Unfortunately, it was a two-hour commute from my home, but I went there for close to five years. I did that commute, and one of the reasons that I loved working there was that the nurses were great at what they did, but more importantly, they felt like they had a voice. They felt like they were supported by administration. They felt like if they saw something, whether it was an elevated blood pressure, a patient's report of pain during labor, they felt like they had the opportunity to speak what they thought was the best possible course of action for the patient. They also felt supported that if they got pushback or they got yelled at by the physician for that patient, that they had other opportunities to use their voice. That might be through their nursing leadership or it might be through the chain of command in the physician leadership as well. 

When everyone on a unit has the ability to speak and feels that their voice will be heard, those are the best places to work. When people are scared, they might be scared to tell the physician that something's going wrong, and that is absolutely not where we want to be in health care.

Lee: You’ve talked about the need to tie compensation of hospital and academic leadership to gender equity metrics. Why this? Why do you see this as the solution?

Van Dis: That is a great question, and it's one that I am happy to speak about. Again thinking about culture and how it is that we change some-of-the-less-than-helpful deleterious cultures in health care. The problem, that is to say the harassment or the discrimination, is like an abscess, and obviously leadership wishes there were none of that in their institution. There's fear of litigation. So lawyers and HR are part of keeping that abscess confined. But what I have said is that I think it would be really good if health care would treat sexual harassment and gender discrimination like we treat an abscess in medicine, which is it needs to be lanced and it needs to be drained. And the very first time that you do that, there will be a lot of pus everywhere, and it will be smelly, and you actually won’t want to look at what has happened in your culture. But here's what I imagine. If you are able to be honest about what is in that abscess — so for me, those numbers are the number of sexual harassment claims that were filed in your institution, the number of gender discrimination claims that were filed, the number of these claims that are investigated, and then the outcome of those investigations, in addition to metrics.

The University of Michigan did this last summer. They surveyed everyone working in their hospital, and that included physicians and included nurses and that included all the employees and it included the trainees, as well. If you include everyone in that ecosystem, ask them: what does it feel like to work here? What does it feel like on the ground? What's happening behind closed doors? What's happening in the operating room? What's happening that leadership might not be aware of? And if you can collect that information in a de-identified and anonymous way, it can help you to understand where your baseline is.

So imagine if you are that CEO or that dean, you basically put together a dashboard and the dashboard includes all the metrics that I identified previously, plus the culture survey. And then that's your baseline. From there, what you do is you hire good people who are going to help you move the needle on that culture. That could be someone from diversity and inclusion that provides unconscious bias training. It could mean promoting women and underrepresented minorities to positions of leadership. Because we know that when women and underrepresented minorities are in leadership, the organizations tend to have diminished numbers of complaints of gender inequity and sexual harassment. There are some very key identifiable solutions.

What I'd love to see is leaders say, “You know what? I'm going to tie my compensation to my ability to move that metric and change my culture.” And that way the abscess is lanced. And the process is transparent, and, hopefully, we start to see some of these numbers turning around. So 

Lee: Do you think hospital leaders want to do this? Is it going to take board intervention to get changes like this?

Van Dis: We know that they want to have an institution that's free of gender discrimination, sexual harassment. How to get there is the more difficult road. Having said that, I do think it's going to take some bravery and some courage and honesty, and these are traits that they teach in MBA and MHA programs. So I know that these leaders have these skills. As a culture, as a society, we haven't valued the rule of women and how women feel in the work environment enough to make these changes and to be honest with ourselves. But I think luckily we are at a tipping point and hopefully we are going to see some of these brave and courageous leaders coming forward. That's my hope.

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