by Joan Arakkal
BUS RIDE
On the flight back to Perth, I thought of the bus rides of my youth. The medical school was a forty-five-minute public bus ride from home: forty-five minutes in which to greet familiar faces, contemplate and dream. The previous day’s fatigue had been scrubbed away and we boarded the bus in neat, fresh clothes. The bus always arrived on time and as we climbed the high steps we looked to see who the driver was – the smiling one who came up with witty comments that kept us entertained, the churlish one who ignored us, or the man who snarled and snapped at us.
Boarding from the front of the bus we always hoped to be able to settle into our favourite seat. A seat by the open window ensured a happy ride. As the bus covered the kilometres, it picked up more people and became very crowded. We squeezed together in our comfortable two-seater to accommodate two more. Like sardines in a can, we packed our bodies neatly on the seats. The lucky ones at the window seats looked out and ignored the growing crowd around them.
As the wind hit our face and kept us cool, our minds wandered in silent contemplation. We revised anatomy lessons, picturing the dissections in our head. We recalled the mnemonics that helped us remember: Please Try Lovely Shoes, Too Tight, Can’t Help – pisiform, triquetrals, lunate, scaphoid, trapezium, trapezoid, capitates, hamate. The tiny bones in the wrist could be discovered in the neat order of the ditty. The branches of the internal carotid artery splayed out in A VIP’S COMMA. We were not yet concerned about the clots that could clog the middle cerebral or anterior cerebral arteries leading to hemiplegia – stroke – of which there were many varieties, depending on which area of the brain was deprived of its blood supply.
The years passed, and we journeyed on. Gray’s Anatomy gave way to Robbins Basic Pathology. We looked out of the window and visualised organs ravaged with disease – the lungs loaded with tuberculosis, the scabitic sores of the skin where tiny creatures crawled, the infected bone that intermittently threw pus out of a tiny hole, the kidneys that gave up and swollen hearts that tried to beat on. The bus stopped with a single ting rung by the conductor. Two tings and the Ashok Leyland jerked and moved on to the next stop. Women entered through the front, strings of jasmine interspersed with saffron kanakambaram flowers looped into some of their neatly oiled and braided hair. The scent of incense sticks and sandalwood paste that appeased the gods clung to them. Men used sudden braking as an excuse to lose their balance and press their bodies against one of the chiselled beauties. Amidst unconvincing indignation, disingenuous apologies, the crunching of gears and the blare of the air horn, the bus moved on. It was a microcosm of human aspirations and emotions.
The languor of the return afternoon trips replaced the buoyancy of the morning. Wilted flowers, smelly armpits, limp saris, frayed nerves and angry retorts were dropped off along the way. Our brains took a rest from medical rumination and wandered into the world of romance and dalliances. A glance here, a remark there, processed and categorised – flirtatious, lecherous, true love – men were sorted and classified for a closer examination at the appropriate moment. The bus rolled on, delivering people to homes where more stories were woven into their colourful tapestry – each one unique, yet the same.
A few decades earlier, and thousands of miles away from my hometown in India, a woman entered a bus through the front door and took a seat assigned to people of her colour. Blake, the driver was affronted with her front door entry. Many years later, the woman entered a bus driven by the same man and took a seat assigned to her people. Blake moved the ‘Whites only’ sign to the seat behind her and asked her to give up her seat. She refused to leave the seat she had paid for. Her ‘cup of endurance’ was overflowing so she risked arrest and a jail sentence for the crime of having been born black and, worse still, for choosing to sit on a seat that had turned white right under her gaze.
Rosa Parks rode that bus in 1955 – well before I was born. That bus took her through the pitstops of racial segregation, discrimination, incarcerations – values bereft of morality and humanity. The years rolled on. The mother of the civil rights movement saw the ‘No blacks’ and ‘Whites only’ signs removed from public spaces. The winds of change swept through her country, and other Christian nations that had previously considered their black citizens children of a lesser god. What Rosa Parks could not have seen was the darkness that lingered in many hearts well after the signs had gone.
It was almost the turn of the millennium when I boarded the orthopaedic bus in Australia. There were no ‘Whites only’ or ‘Men only’ signs to direct me. There was certainly no ‘Keep out’ sign. I sat amidst the crowd, ready to chisel and hammer away. But the other passengers had other plans. The drivers did not ask me to leave my seat, but they jostled, nudged and plotted until I was unseated. I held on. Foul operatives dressed in legal jargon strutted through the courts.
My journey continues. I am still jostling for a seat on the bus.
From ice-creams that were denied, girlhood crushes that went unreciprocated and the unfair denial of opportunities, to the diagnosis of breast cancer and its recurrence twelve years later, the cauldron of my dance has not been without its challenges.
I grew up in the East and lived in the West. I married my Christian faith with the philosophy of Hinduism. I ventured into the male-dominated world of orthopaedics and also embraced motherhood. My life has been one of paradoxes. These contradictions have placed me in a unique position that allows me to dance into spaces that usually remain shut and peek in, sometimes as an observer and sometimes as the observed.
THE DANCE OF LIFE
A Tandava, or dance of life, includes the sequential cycling of the five principal manifestations of eternal energy: Srishti (creation), Sthithi (preservation), Samhara (destruction), Tirobhava (illusion) and Anugraha (emancipation). All the abundance in my creation and preservation could not have led to emancipation without the intervening elements of destruction and illusion.
When I look at the Tandava of my life, it includes a treasure trove of happy memories: a childhood in the midst of a loving family and community; an arranged marriage that brought prosperity and progeny; the opportunity to travel and work in different parts of the world; the chance to infuse orthopaedics with a new way of thinking about fractures through my research; and, importantly, the chance to play in the sandpit of clinical orthopaedics for over three decades.
Mine is not a story without twists and turns but, even with the benefit of hindsight, I would never have traded the blood and gore of orthopaedics for an easier life. From the day I graduated in medicine, I have been smitten by orthopaedics. Anything else would only ever have been second best.
The two main destructive elements in my life were my illness and the professional difficulties of trying to overcome the cartel-like guild of the orthopaedic profession. The illusion was my belief that the legal system could counter the cartel.
However, my emancipation would not have eventuated without the confluence of these two destructive elements. Many people who struggle within systems wish to make peace with it and not challenge the status quo. For me, the desire to just make the best of the limited opportunities offered to women in orthopaedics was tempting – no matter how difficult the idea was to swallow. But my illness gave me the kind of perspective and release that allowed me to fight and speak without fear. The combination of my professional difficulties and my health issues offered me the chance for deliverance in a way that neither could have done alone. I came to realise that I could contribute more to the progress of orthopaedics by fighting the shackles that constrained me.
When I took the Hippocratic oath all those years ago, I pictured myself bringing health, hope and healing to the people I served. Every year, thousands of medical graduates take the same pledge. The desire to honour this ancient code is written all over their youthful faces. Hippocrates, the father of medicine, lived four centuries before Christ. His solemn promise, invoking the gods and goddesses of his time, pledged to impart knowledge of the art to ‘his own so
ns and those of his teacher’. The oath has since been rewritten many times to suit contemporary mores, and references to ‘sons’ have been erased. Wiping away entrenched attitudes to women in the world of surgery, however, remains a greater challenge.
Nowhere in medicine are these attitudes and disparity more pronouncedly manifest than in the world of orthopaedics, where the scalpels still remain in the tight grips of the male progenies of Hippocrates. Though there is no gender disparity in the graduates of Australian medical schools, more than ninety-six per cent of orthopaedic surgeons are male. But is this lack of women in orthopaedics a problem?
Results in clinical orthopaedics have improved dramatically over the centuries. In medieval times, death was the almost-certain outcome of many orthopaedic procedures. Today, we can guarantee much better results. To a casual onlooker, the case for the inclusion of women in orthopaedics may look like an issue of fairness or gender equity rather than a societal imperative.
Impressive as the improvements in orthopaedics have been over the last few centuries, they come largely from advances that have been made outside the field of orthopaedics. Joseph Lister showed us how infections could be kept at bay. Modern anaesthesia allows more complex and time-consuming surgical procedures to be performed. Material scientists gave us biocompatible prostheses.
From within, orthopaedics has done very little to significantly influence treatment outcomes. The core of orthopaedics has remained largely stuck in the mindset of the medieval bone-setter. We align the broken bones and wait for nature to provide healing. Very little has changed from within – not just in clinical terms, but also in the way the speciality is structured.
Modern notions of meritocracy, which encourage the inclusion of all genders and races and the embrace of science, distinguish modern medicine from its old associations with quackery and thievery. Yet in orthopaedics, as it is practised today, this transformation has not yet fully occurred – women and science both remain marginal.
Orthopaedics is still essentially a trade. It functions like a medieval guild (or perhaps a modern cartel). Guilds operate under a very different set of rules and mores to academic disciplines. Loyalty to older members and conformity to existing practices is a greater determinant of success than professionalism.
The problem with guilds is twofold. Because they are organised around well-honed traditional skills, over which the guild members hold a monopoly, science is seen as a threat. Scientific advances allow new approaches and players, which disrupt the traditional sources of advantage for the guild members. Protectionism also blunts the drive for practitioners to improve the quality of their services. Because guilds are able to restrict the number of people who practise their trade they don’t need to gain a competitive advantage, as there is already an excess of demand for their services.
For the consumer, this translates to high prices that verge on extortion. There is ample evidence of this occurring today. Patients pay a much higher price for orthopaedic services than they do for most other medical specialities. The excessive remuneration that orthopaedic surgeons receive for their trade has another negative effect. The opportunity cost of participating in activities that are not lucrative in the short term – like research and quality improvement – becomes greater.
In short, the system ensures that mediocrity thrives. And the ultimate losers are the patients.
Guilds and cartels operate best when like-minded people band together, so minorities are deliberately marginalised. The exclusion of women from orthopaedics is a symptom of a larger problem – the failure of orthopaedics to modernise into a scientific discipline.
The best way to remedy this situation would be to address the gender imbalance. Including more women would be a step towards modernising orthopaedics and making its services more accessible and affordable for the public.
But are women suited to orthopaedics?
It has long been asserted by the male practitioners of orthopaedics that it is not a speciality suited to women. The need for significant muscle power to reduce fractures or dislocations, particularly of large bones, and the use of tools like manual saws suggest that women are at a natural disadvantage. This is archaic thinking. Developments in anaesthetics and muscle relaxants, and the increasing use of power instruments, have levelled the playing field with respect to the need for strength. The focus today is on good technique. The increasing use of power tools makes the adept user of a kitchen whisk a greater asset in orthopaedic surgery than a clumsy lumberjack. In modern orthopaedics, women are no longer the second sex.
There have been huge changes in attitudes to gender in recent years. The Royal Australasian College of Surgeons even engaged an advisory group to look into sexism in the surgical specialities. The report was a damning indictment of the college and, at least on the surface, the college seems to have taken the findings seriously. An apology was made and there was a promise of remedial action. This is certainly a move in the right direction, but there are a number of problems with this approach.
The college is a fraternity, not a statutory body. Its primary purpose is to serve the interests of its members. To leave it in charge of a process that would undermine those interests is problematic. The college should certainly be part of the solution, but it cannot be the sole driver of change. Organisations can only provide solutions that exist within the world view they inhabit. The college plans to provide female orthopaedic trainees with mentors – not dissimilar to teachers’ aides providing assistance for children with special needs. But women are not men with special needs. Similar thinking also results in strategies like quotas and affirmative advocacy. Paternalistic attitudes like these are the inevitable product of a male-centred style of thinking that believes that the natural deficiencies of femininity can be ameliorated through male-fostered mentoring and masculinisation. Approaches that ‘empower’ women to succeed ‘like men’ defeat the greater purpose of introducing women into orthopaedics.
Women do not need a hand up, they just need the foot that is holding them down taken off.
The solution to gender inequity needs to be sought in the wider context within which the problem exists. The problem exists because our society condones the operation of guilds whose ultimate motivation is financial. By changing the setting within which they operate, bodies like the AOA can be induced to change and modernise.
Universities can be a part of this change. In the West, universities first appeared in the eleventh century in Bologna, followed by Paris and Oxford in the next century. Universities have now taken over the majority of the educational activities that used to be controlled by ecclesiastical bodies and trade guilds. Today, the people who manufacture aeroplanes, dye our clothes or knit our wool are likely to be products of universities. This is also the case for undergraduate medicine but, strangely, the world of specialist medicine still seems to work in the medieval apprenticeship model, with fellowships conferred by guilds like the specialist colleges. These fellowships have become a requirement for practitioners who wish to ply their trade. Empowering universities to provide postgraduate medical training alongside specialist colleges could help increase the proportion of women in orthopaedics.
Such a move would not only help alleviate the gender imbalance in orthopaedics, but would also increase the supply of orthopaedic surgeons, reduce costs and drive up quality through competition.
We cannot allow institutions to operate above the state. While it may seem counterintuitive that we would allow this, we in fact do so indirectly, by allowing some bodies to self-regulate. The previous findings of the advisory group of rampant sexism and discrimination are being left to the colleges to redress and self-regulate. This would not be dissimilar to the situation of asking the Catholic Church to deal with the issue of paedophilia. When gross breaches of societal standards occur, civil society has an obligation to step in and investigate.
To the women who are drawn to this branch of medicine, I wholeheartedly encourage you to walk this path. Women h
ave explored space, discovered the double helix and governed nations. Why should we hesitate to enter a deeply satisfying branch of medicine?
It may well be the case that orthopaedics may have a larger proportion of male surgeons, or maybe not. Women should find their own equilibrium – driven by a passion for orthopaedics and competing on their own merit. Even if the number of women practising orthopaedics does not reach the level of male orthopaedic surgeons, equity in the ability of women to participate in orthopaedics should be the foremost goal. In many areas, women may exceed men and in others the reverse will be the case. As the fifteenth-century surgical maxim goes, ‘A surgeon should have the eye of an eagle, the heart of a lion and the hand of a woman’. Gentleness is the cardinal virtue of surgery. We need to bring our feminine skills to the surgical tables. When our numbers begin increasing, we will bring about real change.
When I see developments around the world, especially in India, I am hopeful that things will change. The vanguards of movements that set out to break down barriers are often crushed, but sometimes a trickle gains in strength until it eventually becomes a force that topples the barriers. It takes time. It took fifty-seven years for a black president to be photographed sitting on the bus from which Rosa Parks was ejected in 1955. Hopefully it will not take that long for a major orthopaedic body to be headed by a woman.