MAY 4, 2021
SUZANNE KOVEN FACILITATES writing workshops with new medical interns as part of their orientation. On the faculty at Harvard Medical School, she is a primary care physician and writer in residence at Massachusetts General Hospital (MGH). One exercise she assigns her interns is to compose a letter to their future selves. The practice is not new; it can be traced to James Jackson, the first MGH physician, who in 1855 wrote “Letters to a Young Physician Just Entering Upon Practice.” The intentionality of this exercise, and how it diverged from her own perfunctory orientation, inspired Koven to compose such a letter to her younger self — hence this book, Letter to a Young Female Physician (LTAYFP). Her aim is to include the wisdom and nuance left out of textbooks. The nucleus of her book, the letter emphasizes the difficulty women face attaining legitimacy in a system built for men, including the risk they run of suffering from “Imposter Syndrome.” Koven writes that she herself, despite her obvious success, was “haunted at every step of my career by the fear that I am a fraud.”
In the book’s epilogue, she notes that this letter, originally published in the New England Journal of Medicine, elicited divergent responses. Though many identified with it, some readers pointed to systemic issues in medicine, with women of color noting that much of this “syndrome” could be better defined as institutionalized misogyny and racism. A singular critique came from an 80-year-old feminist scholar who questioned, “Imposter syndrome? I thought we were all over that decades ago!”
Her memoir, erected around the essay, is likely to elicit a similar range of responses. Featuring 24 roughly sequential essays, the final one, “They Call Us and We Go,” dated April 3, 2020, gives us an early glimpse of the pandemic. Conversations around structures of power, racial injustice, and inequality are accelerating in its context. But the act of noticing what has been allowed to go unnoticed is in fact a recurring theme throughout the book. In an earlier chapter, “We Have a Body,” Koven relates a story told to her by a retired pediatrician named Henry. Henry was “rounding” with the legendary female pediatric cardiologist Helen Taussig (pioneer of the Blalock-Taussig shunt, a life-saving procedure for “blue babies,” as they were called). As they walked past the blood bank at Johns Hopkins, she pointed out to Henry that the blood was segregated by race. This was intentional and ensured whites would never receive the blood of Blacks. Taussig asked Henry, “Doesn’t this strike you as very wrong?” Henry, having walked past the blood bank countless times, and aware of the policy and practice of segregating transfusions, had simply never questioned it.
In Koven’s retelling of the past, there are many such examples “hiding in plain sight.” Koven completed her residency training at Hopkins, during a time when the wards and by extension the patients were segregated much like blood was. When she reconnects with Black classmates, they remind her that they were often not allowed to provide care to white patients. In the aftermath of those conversations, Koven describes relating to Henry, recognizing that she herself allowed so much to go unquestioned.
I don’t recall ever speaking with my fellow-residents about the racism reflected in the way the hospital was organized, and in a way, white residents had no motivation to do so. The hospital’s segregation reinforced the reassuring message of the hidden curriculum, that we were fundamentally unlike our patients.
Refusing to cast herself in a heroic, prescient, or moral role, Koven’s faithful depiction of her acceptance of such practices allows us to consider our own blind spots, which is in effect what enables ongoing institutional cowardice and injustice to become more viscerally visible.
To be sure, some generational battles have been fought and ostensibly won — a majority of medical students in the United States are now women, for instance. Still, the sexism that was so ubiquitous during Koven’s training is worth considering. Koven writes of her youthful self, “I now ask myself why I was so unquestioning of a system that was fundamentally hostile to women and certainly to mothers.” She contextualizes without necessarily rationalizing her perspective by depicting her childhood home. Her father, an orthopedic surgeon, is doted upon by her mother. In their community, the male surgeon is likewise idolized. She is transparent, too, in her depiction of a Black housekeeper, Essie, who serves and clears an ornate dining room. “A sterling silver dinner bell meant to be used to summon Essie sits by my mother’s place.” Presented without judgment, this is simply how the author was raised.
Much of what drew Koven to medicine is entangled with her adoration of her father. She vividly describes how, from the youngest age, she wanted the “freedom of men.” She sought a career in medicine, not simply as a vocation but as an identity. When she tells us that she vomited in the bridal suite upon becoming someone’s wife, and did not feel “quite like a woman,” as she tells her therapist, we can deduce that she welcomed donning the identity of a doctor, which she identified as masculine. It offered a refuge:
Just as I had flexed my biceps and pretended to shave in front of the bathroom mirror when I was a child, when I was in medical school and my husband was an intern, sometimes when he wasn’t home I would try on his white uniform pants, Oxford shirt, and departmental tie, navy blue with a pattern of white shields emblazoned with Aequanimitas.
It somehow wasn’t enough to become a doctor; her early self-valuation was contingent upon not being a female doctor. In a telling passage, Koven notes, “I like to think I was respected by the men I supervised as if I weren’t a woman.” A young female physician may balk at the youthful Koven’s complicity with misogynist values. Yet there is value in knowing this history: clearly, the system was such that some women felt there was no other real choice available to them.
Elsewhere, Koven illustrates medicine’s tendency to exploit and shame certain of its students or practitioners, especially those identified as “weak,” and admits that she felt gratitude when the harsh lens of judgment was directed at someone other than herself. It elevated her by comparison. Her description of the pride she felt in being identified as a stronger member of a team will be familiar to readers who have trained in medicine. They may also find themselves uncomfortably familiar with the routine denigration of foreign-born physicians, or the overtly classist preference for “prestige” residencies. But as Koven explains, at the time it all “seemed normal then, at least to me.”
I do not fully agree with how much Koven blames the individual. Koven writes that “one of the greatest hurdles you [will] confront may be one largely of your own making.” Do our individual doubts truly account for our inability to thrive in medicine? Though Imposter Syndrome is well described, and many practitioners are like Koven in identifying with it despite their manifest success, it should be acknowledged that the system actively cultivates these doubts. Indeed, Koven herself observes that even in instances where women’s traditionally gendered attributes (good listener, empathetic) are outright assets, women are conditioned to devalue them, believing them to be unremarkable. Patients, however, never devalue these traits, deliberately seeking out physicians who demonstrate them. Koven cites her large catalog of jokes as part of her empathetic arsenal. Were “medicine” itself to more keenly value such traits, this would surely benefit patients.
For a field of practice drenched in story and emotion, medicine is famously stoic. The concept of Aequanimitas, emblazoned on Johns Hopkins men’s ties, mandates emotional equilibrium. Medicine acculturates trainees to police their own behavior with a masculine, heteronormative, Eurocentric ideal in mind. Clinical acumen should be governed by emotional self-regulation. One could argue, however, that denying one’s own emotions has consequences. In LTAYFP, Koven demonstrates how this conditioning affected her career. Throughout the book, there is a push and pull between her love of “story,” and medicine’s tendency to devalue it, despite its role in healing. Koven’s first tentative steps toward the study of literature occur in a virology seminar, where she convinces the instructor to let her present Susan Sontag’s Illness as Metaphor to the seminar. Exuberant when he agrees, she is so deeply engaged by the material that he accuses her of plagiarism: her work was “too good” to be her own. This experience provides external confirmation that anything that comes “naturally” to her and is also pleasurable isn’t worth doing. Having so completely internalized this message, when she presents the case of Albert Blake, a 54-year-old man with leukemia whose story she knows intimately, she literally throws his narrative away and focuses on only the medical aspects of the case, as dictated by medicine’s values.
As I read her book, I wondered if Koven’s resistance to exploring her true passions was really just about devaluing what was easily accessible and pleasurable to her. Could it also have been about discomfort with the vulnerability and intimacy of being known? There are hints of the latter in her uneasiness with the physical intimacy required to swab her microbiology lab partner’s nasal flora. But it becomes explicit when she does not invite her husband to her graduation from the Harvard Extension MFA Program. She writes, “I feared that I had finally, finally come closer to being fully myself and that the person who knew me best would tell me that no, I was mistaken: that this was just another fad, another phase, another fake.”
Koven was, of course, not mistaken. Far from being unprofessional, her literary endeavors enabled her to thrive. They emboldened her. Her true triumph comes as she lets go of her lifelong search to become something other than what she is, releasing the judgmental voice in her head that insists she be smaller, lighter, more feminine or less of a chameleon. The game of self-alteration itself is of course a trap, and she devotes an entire heartbreaking chapter to her weight.
Despite these candid disclosures, there is a measured, even clinical distance in Koven’s writing. It is clear that some truths and stories will not be shared. Privacy will be honored. Aside from an essay on her young son’s seizures, her children are mostly removed from the narrative, and we don’t walk away with a genuine sense of Koven’s marriage, only that there were ups and downs, interspersed with therapy and loneliness.
A large portion of the text is spent reconciling herself with her relationship with her mother. In Chapter 21, “Bury Me in Something Warm,” Koven revisits her mother’s death through the eyes of a writer,
I wish I had taken notes, recorded these small details. I would enroll in an MFA program in nonfiction writing a year later, but perhaps because my mother had been so sick for so long by this point, I had no sense just then that anything worth writing about was taking place.
As Koven leans on the “parental door” against which she “had spent a lifetime pushing” and it finally gives way, she is finally free to envision the book she has always been writing.
A search for a discernible identity in the confines of a stifling culture, LTAYFP is also, in many ways, a love story — initially of her father and medicine, then of “story,” but later of herself. And as is true in love, we treat each object differently. Her love of medicine was besotted and immersive. Her love of story, tentative and untrusting. Her love of herself, hard won, but ultimately enduring. Koven’s book reminds us that we sometimes accept unkind treatment from those we love. Choices can be rationalized and reframed through a nostalgic lens. And other times, when looking back, we have clarity. Koven ultimately makes no excuses, telling those young, female physicians: “Perhaps the reason I didn’t rebel against the culture of my medical training was that I loved it.”
Rana Awdish is a pulmonary and critical care physician in Detroit and a writer. Her essays have received a Sidney Award from The New York Times and have been nominated for a Pushcart Prize. Her critically acclaimed, best-selling memoir, In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, is based on her own critical illness.