ASN President's Update: From Mother to Daughter: Four Decades of Evolution in Medicine

Michelle A. Josephson Michelle A. Josephson, MD, FASN, is Professor of Medicine and Surgery, University of Chicago, IL, and is ASN President.

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This month, I'm attending my 40th medical school reunion. Besides looking forward to catching up with old friends and accepting the reality that so much time has passed, I've used this milestone to think about how much medicine has changed since I graduated. This reflection has also been intensified by the many emotions and memories that have accompanied the happy news of my daughter Maya's recent acceptance to medical school. The profession she has chosen to pursue is not the same one I entered. Please don't misunderstand me: I am not saying that is a bad thing, just that it is very different.

Of course, health care, medicine, and science have evolved since I started medical school. HIV and AIDS were yet to be, cyclosporine had not even been introduced, PCR did not exist, donor nephrectomies were all open, bacterium Helicobacter pylori was not recognized, CAPD was mostly used because CCPD was in its infancy, RVUs were not a thing, scalpels were still flying in ORs and barely missing medical students, and duty hour limits for residents and fellows resulting from the Libby Zion case did not exist. But the greatest difference since my time in medical school has been the fundamental change in the culture of medicine. It is easy to be nostalgic (as I will be at my reunion) and think upon the “good old days.” Truth be told, much was not so good.

In the 5th Edition of On the Origin of Species, Charles Darwin wrote: “This preservation of favourable variations and the destruction of injurious variations, I call Natural Selection” (1), or the survival of the fittest. This concept has been paraphrased as: “In the struggle for survival, the fittest win out at the expense of their rivals because they succeed in adapting themselves best to their environment” (2). With these concepts of adaptability and resilience in the face of change in mind, let's consider how things have changed, what my Generation Z daughter will encounter that her Baby Boomer mom did not, and how we “more-seasoned” physicians might consider our roles as we adapt to new realities.

The year that I started medical school, 27.9% of first-year medical students were women (Table 1) (3, 4). By contrast, for 2022–2023, women made up 56% of matriculants (5). To put the year I started medical school in context, Jimmy Carter was the U.S. president, Margaret Thatcher was elected Prime Minister of the United Kingdom, China instituted the “one child per family” rule, the Three Mile Island nuclear accident occurred in Pennsylvania, Sony introduced the Walkman, and “60 Minutes” was the most-watched television show (followed closely by “Three's Company”).

Table 1.

A tale of two eras: Demographic shifts among medical school matriculants over 40 years

Table 1.

I entered medical school in the early phases of a major demographic shift. My female classmates and I recognized that more of us were in medical school than ever before, and we were happy about it. At the same time, however, we also felt that we were not the dominant culture. It is not that much was particularly overt; it was more below the surface. For example, after an exam, the men would get together and play video games and drink beers. Whether any of the women wanted to join them is not the point. I don't think we were actively excluded, but we were not actively included.

After I graduated, my intern class had more women in it than ever before. This new reality was accompanied by some surprising reactions. Our residency program director, for example, was concerned that having so many women in the class would inevitably result in several of us needing maternity leave. He could not fathom how this could be managed. We laughed when we learned that, but we should have been very angry. We were young adults whose biological clocks were not based on the prevailing medical training paradigm. Why shouldn't there have been a plan in place for pregnancies during training, as there is now? It was too early in the demographic shift, and the idea of adapting training to the needs of the trainees (be they reproduction or sleep) was not in vogue, and that was just not the way it had been done in the past.

Fortunately, many things have changed for the better, such as duty hours and greater respect for work-life balance. And yet, some things have not changed for the better. Women are still woefully underrepresented in leadership positions. On average, only 19% of department chairs at the most research-intensive institutions are female (6). Other leadership positions in academic medicine have been slow to change too. Based on the trends in positions of permanent, acting, or interim department chairs and medical school deans since 1992, it will take another 50 years to reach gender parity (7). A study that assessed the gender pay gap for female academic physicians found that when comparing male and female physicians in their own racial or ethnic group, Black women earned 79 cents on the dollar, White women earned 77 cents on the dollar, and Asian women earned 75 cents on the dollar (8).

At last year's Kidney Week, I was honored to give the Annual Nancy E. Gary Memorial Lecture, which Women in Nephrology (WIN) has hosted at the ASN Annual Meeting since 2005. Having joined WIN in the 1990s, I've seen firsthand how Kidney Week and other international meetings have intentionally attempted to include as speakers more women and other faculty who identify as underrepresented in medicine. Former National Institutes of Health Director Francis S. Collins, MD, PhD—another former Gary lecturer whose daughter is a nephrologist—used his unparalleled platform to publicly call out all-male panels, or “manels,” at medical meetings.

From 1966 through 2009, ASN had 43 successive presidents who were male. Sharon Anderson, MD, FASN, started her tenure as the first female ASN president at Renal Week (now Kidney Week) 2009. Since Sharon's historic tenure, 4 of the 12 ASN presidents have been female (five if you add Barbara T. Murphy, MD, MB, BAO, BCh, FRCPI, who was elected to serve as president but died before her term), including ASN Past President Susan E. Quaggin, MD, FASN, and me. Next year, Deidra C. Crews, MD, MS, FASN, will become the first Black, female ASN president. She is also our first Generation X president, bringing us one step closer to Maya and her Generation Z classmates.

In the class of 2022–2023, the race and ethnicity of a combined 23% of the total matriculating students are Black or African American; Hispanic, Latino, or of Span-ish descent; American Indian or Alaska Native; Native Hawaiian or Other Pacific Islander; and “other” than Asian or White (5). By contrast, during my first year of medical school, 9% of the class nationally was comprised of matriculants who were Black, Mexican American, mainland Puerto Rican, and American Indian (3). This change is not accidental. It is a consequence of policy goals of the Association of American Medical Colleges (AAMC) and medical school efforts to increase the number of applicants and matriculants with individuals who identify as underrepresented in medicine.

During his tenure as AAMC president from 1994 to 2006, Jordan J. Cohen, MD—a nephrologist and former teacher of mine—recognized that greater physician diversity will lead to improved patient-doctor relationships, stronger physician teams (across the tripartite mission), and ultimately to improved public health. The impact of increased diversity in medical schools is already having a positive impact. After all, it was medical students who led the charge to remove race from clinical algorithms, compelling us to remove race from the eGFR.

One of my closest friends from medical school is a gay man, who was closeted for much of medical school. At the time, there were medical students who were open about their sexual orientation and identity, but my friend was far from being alone in his concerns about encountering homophobia. We matriculated only 6 years after the American Psychiatric Association removed the diagnosis of homosexuality from the Diagnostic and Statistical Man-ual of Mental Disorders (DSM), which had equated homosexuality with a pathologic state. By including homosexuality in the DSM, medicine played a significant role in the social stigmatization of LGBTQ+ communities (9). Not surprisingly, LGBTQ+-related medical topics were not routinely taught. By the time my friend was training as a resident, he was living openly. He was also the person in his residency to educate others about caring for LGBTQ+ individuals, because there was no such curriculum in medical school.

Although considerable room for improvement still exists, the situation is better. Medical schools are encouraging applications from LGBTQ+ individuals (10). In 2014, the AAMC released the first guidelines (11) to support medical schools in training students to care for LGBTQ+ and gender-nonconforming patients, as well as for those born with differences in sexual development (12). For the past decade, the ASN Diversity, Equity, and Inclusion Committee has supported LGBTQ+ communities within ASN and the broader kidney community. For example, ASN hosts an annual reception at Kidney Week for LGBTQ+ participants and their allies. Last year in Orlando, FL, ASN supported the onePULSE Foundation—which was established in response to the 2016 massacre at the Pulse nightclub—and the foundation's executive director spoke at the reception.

During the past four decades, I have welcomed the changes described above. I would be disingenuous, how-ever, if I give the impression that I welcome all change. I don't. Change is often hard and sometimes not good. Holding onto the past can feel comfortable and safe, and many good reasons exist for precedent. That is part of the draw of events like reunions. So, yes, I am guilty of nostalgia. But change is inevitable, and to be fair, it is often a good thing. I, for one, am not trading my computer for an electric typewriter. As we age, we all must figure out how to adapt to novel technology, approaches, and perspectives.

Social scientist Arthur Brooks observed that as we age, our strengths evolve, and we shift from fluid intelligence (that which allows us to solve problems or innovate faster) to crystallized intelligence (that which is built on wisdom or enables us to form teams better) (13). Our gained wisdom can help those with less experience. Even if there is not a term limit on a position, transitioning after a period makes sense, not only because our strengths may no longer be as good a fit for the job but also because we must allow the next generation to have its turn.

Nevertheless, giving up a position can feel difficult for many reasons, including that we may fear losing our value or relevance and becoming invisible. And, in the current medical culture, which is based on a business model that values productivity, teaching or sharing one's experience is not billable and does not generate RVUs. Career opportunities are not as abundant for maturing physicians. In other words, leaving a position is not often followed by a new opportunity. Career development workshops are usually directed at those in the early career stages and sometimes those who are midcareer. Providing resources for career and life decisions to those who are past these phases is rare. Although some physicians may be ready to retire or back off, others may continue to want to contribute.

Taken together, these forces lead to marginalization or ageism across society, from those of us who've dedicated our careers to medicine to those in the entertainment business to everyone, everywhere in between. As we embrace diversity, equity, and inclusion in medicine, we must continue to harness the irreplaceable wisdom of those who entered the profession before us.

Last month, I stepped down as Medical Director of Kidney Transplantation at The University of Chicago, giving a talented Generation X nephrologist an opportunity. This transition has not come easily for me, especially since I founded and developed the transplant nephrology program. However, it is time, and I am taking on a new, ded-icated, educational position in the transplant program. After all, someday, in the not-too-distant future, Maya deserves to have opportunities to advance in her career. That won't be possible unless we all adapt, evolve, and support the next generations.