The clock ticked past 4AM in the emergency room. It was eerily quiet for the ER as I sat next to the chief resident on my service with a 78-year-old patient who had presented with severe abdominal pain, deranged vitals, and pneumoperitoneum on his CT scan. After talking with him for 15 minutes, I provided my recommendations for treatment–an emergent exploratory laparotomy. As I finished explaining the operation, he laughed, and said “find me someone who’s actually seen a scalpel before – you look too young to be my surgeon!”
Competent, capacitated patients refuse medical treatment for many reasons, but refusing a life-saving operation when I’m the only surgeon in the hospital–a board-certified general surgeon and surgical intensivist, in fact–based on my appearance? That felt novel. I was frustrated, unsure how to convince the patient I was competent and capable. Then came the self-doubt–was I equipped to do this? Should I call one of my more experienced partners in from home? Lastly, and most importantly, I felt concern for the patient, sensing precious time slipping away as his condition continued to deteriorate, and not wanting to encroach on his autonomous decision-making. In my first year as junior faculty I would go on to hear this sentiment about my age numerous times, and realized I would need strategies to effectively and efficiently approach these conversations to ensure my patients received the care they needed while safeguarding my own wellbeing.
I am “young,” relatively speaking, having graduated from my fellowship only three months prior to this patient interaction. My experience here isn’t unique; comments like this are rooted in a societal perception of what a surgeon should look like—weathered, grey-haired, perhaps a little world-weary. Biases also equate youth with inexperience, age with authority. With the high-stakes nature of my work, coupled with scrutiny about my age and experience from patients, I found myself reining in feelings of inadequacy during those first few months on faculty–the dreaded imposter syndrome. Maybe my patients would be better served by my more senior and successful partners, many of whom are male. Studies have shown that female surgeons are more likely to experience imposter syndrome1 and face more scrutiny regarding their age and appearance than their male counterparts. One study demonstrated that patients perceive female surgeons as having higher “warmth” ratings but score inferior to male surgeons on “competence” ratings.2 Patients often compliment me on my bedside manner–commenting that I make them feel genuinely cared for and heard. Those compliments, however kind, do not negate the assumptions that my age makes me a less competent surgeon.
How, then, does one go about responding to a patient’s concerns about age? I am sure many readers will have their own approaches, and I do not qualify myself as an expert on the topic. All I’ve learned in the past year is that navigating patient’s concerns about age requires a delicate balance of confidence, empathy, and patience. Not every interaction is as intense as the patient I described above. I’ve received these comments in clinic, when a patient is deciding whether to proceed with an elective operation, or with me as their surgeon. Patients and families have told me I look “too young” after I’ve performed their surgery, perhaps reflecting how a few hours of sleep can rejuvenate my appearance.
My strategies are certainly not one-size-fits-all, and tailoring my response to the individual patient and the clinical situation is necessary. Though I’m still refining my own approach, here are some of the things I keep in mind.
- Calmly acknowledge and validate their concerns. Getting visibly angry or frustrated won’t help anyone. Acknowledgement can be as simple as naming what you sense is their predominant emotion, “I can tell you’re nervous about the operation, that this is all very overwhelming…etc.” Validating their concerns confirms that you know they want the operation to go well, they want to get back to some semblance of their normal life, and they want their surgeon to be competent and skilled.
- Connect on a personal level. I try to do this the second I walk in the room for every patient, not just the ones who think I’m “too young.” Knowing anything about your patients – what they do for a living, if they have children, that they like to walk three miles with their dog – will help you connect with them, build trust, and make them feel cared for and heard. This has the potential to alleviate so many surgeon-patient conflicts, not just those described here.
- Humbly cite your credentials. As much as patients want their surgeon to be competent and skilled, we want to be competent and skilled, and we’ve spent years honing our skills, mastering techniques, and staying up to date with the latest research and advances in surgical technology. When I tell my patients I’m board certified in general surgery and surgical critical care, and that I have an elective robotic surgery practice, and that a large portion of my practice involves taking care of patients who are critically ill or in extremis, I sometimes see them breathe a sigh of relief that screams “ok, maybe she is competent.” Maybe I shouldn’t have to do this to garner their respect, but it also helps keep my imposter syndrome in check. Telling them what I’m capable of often reminds me what I’m capable of, too.
- Never lose sight of the fact that the patient’s well-being is of utmost importance. There is no ego in this game. We have a duty as physicians to care for our patients and help protect them from harm, even if they’re anxious and stubborn. If they’re anxious or stubborn enough to get in their own way, ask for help. I’ve told a patient, “I’m going to call my senior partner, we’ll go over your imaging, and if he/she agrees we should move forward with the operation, can I book it and get you taken care of?” Another time, I actually did call in my very lovely, grey-haired senior partner from home. I added his name to the consent, the patient agreed to the operation, and 45 minutes later, we were making incision. Despite your best efforts, the patient still might not agree to let you be their surgeon. As awful as that feels, that is their right as a capacitated, competent patient. Do your best to transfer them to another surgeon or institution, hope they get the care they need, and try to move on to another patient who needs you.
For many patients, they believe “youth” brings new perspectives and innovative techniques. I agree with this wholeheartedly. While navigating age perceptions may be an ongoing challenge for me and others, I do believe it’s a testament to the evolving landscape of our profession. I see many young, female faculty in the surgeon’s lounge, at local and national conferences, and in the futures of my chief residents and fellows. Let us embrace our age, our knowledge, and our experiences. Our skills and credentials speak louder than any perceived notion of what a surgeon should look like. We’ve earned our place in the operating room.
(1) Narayanamoorthy, S.; McLaren, R.; Pendam, R.; Minkoff, H. Are women residents of surgical specialties at a higher risk of developing imposter syndrome? Am J Surg 2024, 227, 48-51. DOI: 10.1016/j.amjsurg.2023.09.025.
(2) Ashton-James, C. E.; Tybur, J. M.; Grießer, V.; Costa, D. Stereotypes about surgeon warmth and competence: The role of surgeon gender. PLoS One 2019, 14 (2), e0211890. DOI: 10.1371/journal.pone.0211890.
Nicole Meredyth