Random Thoughts from a Restless Mind

My life is centered around, and centered by, the myriad women with whom I share airspace. There are certainly men there, too, and I am certainly fortunate in that my immediate world does not include anything like what other folks would consider a boss. While most of the women in my daily professional life are either employed by me directly, or employed by someone who has in some way contracted to assist me, the reality of my daily existence is that I have a symbiotic relationship with teammates who happen to be women, and we depend on one another every waking moment.

Because of this I have become alert to all kinds of slights leveled at women in general, and women who work in healthcare in particular. Frankly my worldview is really pretty restricted when it comes to the workplace, especially since the family Box closed a couple of years ago. In healthcare the hierarchy/patriarchy has historical sheltered bad behavior directed at women from both view and recourse. Is it changing in this volatile world that has emerged these last few weeks? That’s not really for me to say, of course; all I can do is whatever is in my means to provide an environment that respects a gender-neutral environment and chain of command whenever I have the privilege of setting the tone.

What is very interesting to me, and what I find to be a very positive (if tardy) side effect of the recent “outing” of men in power who have abused that power, is the celebration of thoughtful women whose thoughtfulness might not have been quite as well-known before. Again, it goes without saying that this should not be something that is remarkable in the least, but for the sake of this particular musing perhaps we can simply acknowledge and agree upon that, and spend our time thinking about what it is that these women are saying.

Reese Witherspoon comes instantly to mind, of course. Ms. Witherspoon has forcefully said that SOP in Hollywood is no longer even a little bit OK when it comes to opportunity to control the spoils of the industry. Not content to simply raise the issue she has literally put her money on the line along with that of like-minded individuals and begun to create those opportunities. Ms. Witherspoon has much to say that is worth hearing. One could do worse than the recent WSJ Magazine cover article as a jumping off point to begin your listen.

It’s highly unlikely that there is any woman in the world about whom more electrons have been circulating of late than the actress Meghan Markle. There’s not a rock big enough for you to have crawled under in the developed world for you to be unaware that she has recently been betrothed to an heir to the British throne. While Ms. Markle and her beau are, indeed, impossibly cute together, it’s more than a bit of a shame that it has taken her very public romance for the non-People reading public to discover her, her story, and her intellect. This is a person of substance.

Hopefully Ms. Markle will forgive me for I will certainly get some of details wrong (as usual I am writing without notes). She is the daughter of a caucasian father and an African-American mother, and she has been on the receiving end of various forms of discrimination from a very young age because of that. She tells a story of being forced to declare in school that she is one or the other, Black or White. To check a box because, well, that’s what is done. She declined. Maybe she was 12. She opted not to opt. I don’t know how long it’s been since you’ve been in school, or had a child in school, but that’s a rather gutsy move.

She went home and asked her Dad why. Why should she have to choose? His response informs her message today: draw your own box. Man or woman, if the choices that are presented to you do not include the right choice, draw your own box to check. Ms. Markle tells the story so much better than I, but I am happy to pass it on with a further encouragement that you should go look for her telling this story, and while you are at it there is a wonderful clip of her accepting an award for her advocacy on behalf of empowering women. She is universally described by anyone who has listened to her as a woman of substance.

My hope, and my goal in writing this today, is that the term “woman of substance” will one day be replaced (as I did above) for both men and women with “person of substance”. Substantive ideas matter, and they ought to matter irrespective of whatever labeling might be applied to the holder of those ideas. While they may not have the name recognition of Ms. Witherspoon or Ms. Markle, I am surrounded by women of substance whose ideas bear our listening. My wife and my daughter, my sisters and my mother, my daughters- and sisters-in-law, as well as the extraordinary women with whom I’ve worked in healthcare and met through CrossFit, give me confidence that this can be.

Not today, not yet, not soon enough but soon, for the benefit and betterment of all.

The endless debates about the “Pay Gap” between men and women in the United States drones on. Today is “Equal Pay Day”, kinda like “Tax Day”, the day when you stop paying the government and instead start paying yourself, only it’s the day when the “average” woman supposedly has to wait for before she starts to make what a man makes. It all makes for great spectacle and epic barstool arguments for the same reason that people argue about who’s greater, Michael or Elgin, Kareem or Russell, The Babe or Barry: there is no proper, standard way to measure the issue at hand. On a barstool arguing “greatest ever” you never agree on either the definition of “greatest”, nor can you account for the vast differences in historical eras.

So it is with the pay gap. No one agrees on what constitutes work, let alone equal work.

This creates the maddening situation in which we find ourselves now whenever this comes up for discussion. Absent a meaningful definition of either “work” or “equal” we are left with folks on all possible sides of the issue simply choosing whatever statistic will support their deeply held beliefs about the issue. It’s crazy, actually. I read a dozen citations today and each one was so deeply flawed that it couldn’t stand the scrutiny of the middle if you velcroed it to the  50 yard line. Work is invariably conflated with “hours worked” with no discernible effort made to investigate something like intensity, or the measurable work performed per unit of time. “Equal” work is just a quagmire of competing opinions with, again, no effort whatsoever at objective measurement. How can you have a discussion that is meant to conclude with some sort of actionable agreement when all you do is pull numbers out of the ether and throw them at each other?

While engaging in a sorta, kinda conversation about this on Twitter it struck me that I actually live and work in the perfect laboratory to investigate the issue of the Pay Gap between men and women. You see, we have reams of objective data that can be evaluated. We all, men and women, do exactly the same things if we have the same jobs. Not only that but we have a unit of measurement for that work, the RVU. If Dr. Darrell does a cataract surgery and Dr. Dora does a cataract surgery, we have both done the same job. We can even determine the “intensity” of our work, our output if you will. A simple survey of hours worked per day can generate the metric: RVU/hour. Better yet, don’t take my word for it in a survey, just look at that heretofore meaningless and useless EMR and look at the measured time Darrell and Dora took to do their work. The OR record is a precise measurement of how much work we did per unit of time.

This is powerful stuff. Work is defined. An appendectomy is an appendectomy. A Level 4 New Patient Office Encounter is a Level 4…you get the idea. You get to compare apples to apples, heck, you get to compare Honeycrisp apples to Honeycrisp apples. It doesn’t matter if you are a man or woman or transgender. White, Black, Brown, Yellow, Red (did I miss anyone?), Millennial, Boomer and everything in between, work is work and an RVU is an RVU. Heck, you could gather all of the information about the work without anyone knowing who did it until after it’s all together. We could have a big unveiling when we lift the blinders and see who did what and how much they did. Seriously, how cool is this? It would almost be like science.

Let’s do be a bit serious for a moment. Imagine what kind of information we could acquire and what kinds of questions we could ask and answer. For sure there will be very reasonable concerns about how much we will be able to extrapolate from medicine to other areas of employment (advertising, investment banking, etc.), but it’s a great place to start. The question of the Gender Gap is primary, but how about looking at work across the generations. There is a “feeling” in medicine, certainly among crusty old folks in my generation, that younger physicians of both genders work fewer hours and do less work per hour when they do work. Is that true? It sure looks like it would be easy to answer that one, too.

There are actually a number of other issues in medicine that would be clarified if we had this kind of data, at least insofar as the work done is concerned. For example, how do private practitioners stack up against salaried physicians in large groups? Is there a correlation between how those salaries are determined and the intensity of work done? We can also look at value, work done per dollar paid (again, assuming equal outcomes). Where are we getting the best bang for our buck? For that matter, with the EMR’s that never sleep we can actually look at the responsiveness of doctors to their patients in urgent or emergent circumstances. Is there one group (men vs. women, private practice vs. employed) who are more responsive?

Having a discussion that is based on hard definitions of terms and data-driven rather than belief-driven opens up a whole world of meaningful inquiry.

Once upon a time I was among the highest paid physicians in the U.S. I worked insane hours, and the intensity of my hourly output was off the charts. In a word, I earned every penny I made, and the fact that I made more than another ophthalmologist had nothing to do with the fact that I was a man. Funny thing though–I now make a fraction of what I once made because I don’t work as much as I once did. The intensity of my work is similar; I still do as much work per unit of time, and my ability to perform at this high level of intensity is still greater than 95% of my peers, I just work fewer hours. What are we to say about women who do what I do, work more hours than I do, and yet do less work? Is there a gender gap in pay if I make more money than they do? What are we to say about my ambitious female colleagues who work more hours than I and work at the same intensity? I’m firmly stating that they should make more than I do. Is that the reality on the ground?

In medicine we have the ability to answer this question in a very objective, non-ideological way. I don’t know if what we find will be something we can extrapolate to other jobs, especially if we find that pay is directly related to actual work done in a domain where work can be both defined and measured. But hey, it’s a start. And it’s way better than just playing emotional whack-a-mole with how we value what we all do.