Abstract
On yet another chaotic day at the Accident and Emergency (A&E), as soon as I waved goodbye to the screaming toddler who was being ushered out of my clinic by his flustered parents, without missing a beat, my hand shot to the first file lying on top of a mountainous pile of unseen patient files. Like clockwork, my index finger was geared up to punch “Next Patient” but what I read in the triage information box made me halt my mouse clicking.
“Female rape victim, 1/7, Rain Lily.”
Where are my abdominal pains, chest pains, and loin pains?? I was a new Emergency Medicine (EM) trainee then, only a few weeks into the job. That day, I was almost proud because I was finally catching onto the rhythm and was able to “rush cases” like other older residents. But as if to put a stop to my gloat, I picked up this case of which I had absolutely no idea how to approach. With a “if you don’t know, ask” mentality, I grabbed the file and ran to one of the on-duty associate consultants. He said, “Uhh . . . the last sexual assault case I dealt with was at least 10 years ago. You know, the nurses always divert these cases to the female doctors . . .” I went through our staff list and asked, “. . . but all of you (associate consultants and consultants) are men! Who am I supposed to ask?” Fortunately, a female higher trainee rotating in from another hospital overheard our conversation and came to my rescue.
In April 2022, I had the pleasure to host one of the workshop sessions at the recent symposium held by the CUHK Accident and Emergency Medicine Academic Unit on Emergency Medicine Development in Asia: Future of Leadership and Education. Dr Clara Wu, president of our Hong Kong College of Emergency Medicine (HKCEM), shared her views on the topic of Female EM Leaders in Hong Kong, and put observation into statistics: the percentage of female registered doctors in Hong Kong has risen from 27% in 2006 to a mere 31% after 10 years. Within HKCEM—with rising female medical school intakes over the years and hence graduates, the percentage of female trainees has risen from 25% in 2010 to a whopping 63% in 2021. However, after a closer look at further statistics, one would find that the percentage of female EM fellows has remained disproportionately low over the years. In 2010, 14% of EM fellows were females. In 2021, 18% of EM fellows were females. 1 The loss of female emergency physicians has been staggering. Why are female doctors leaving, and why are they not rising to senior and leadership roles in EM in Hong Kong?
And is that the case in other countries?
I later had the privilege to converse with Dr Clara Wu again privately, as well as two other female EM leaders, namely Dr Eillyne Seow from Singapore, and Dr Rasha Buhumaid from the United Arab Emirates (UAE). The three inspiring ladies I spoke with are from three countries, three generations, and have three stories to tell.
(The below paragraphs have been paraphrased, edited, and/or translated from the original script.)
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After completion of her Bachelor of Medicine and Surgery (MBBS) in UAE University in 2007, since there was yet to be a proper local EM training program, Dr Rasha Buhumaid traveled to Washington, DC, and underwent her 4-year EM residency training in George Washington University. Afterwards, she completed a 1-year fellowship in Point of Care Ultrasound in the Massachusetts General Hospital with Harvard Medical School. Dr Rasha has since returned to the UAE and is the current President of the Emirates Society of Emergency Medicine, consultant emergency physician at Mediclinic Parkview Hospital, and Assistant Professor at Mohammed Bin Rashid University of Medicine and Health Sciences.
Dr Rasha Buhumaid ( R )
(With preconceived views about females in Muslim countries) Dr Rasha, what is it like being a female emergency physician in the UAE? And on top of that, being a leader in your field?
It’s great!
(Surprised) What is the percentage of female doctors in your emergency department?
R: 70% of us EM doctors are females! In fact, 70% of all university graduates in the UAE are females. Back in my days, females and males had separate university campuses. Our professors would need to give the same lecture twice! Not anymore though. The government has done a lot of work in engaging females in all sectors of the society, promoting participation in education, politics, business etc. Half of our Federal National Council (FNC) members are females. In the UAE Cabinet, consisting of the Prime Minister (PM), two deputy PMs and other ministers, nine are women. And Shamma Al Mazrui was only 22 years old when she was appointed as the Minister of State for Youth Affairs!
I am so impressed and encouraged! Ok, now if you don’t mind me asking something more personal: are you married? Do you have kids?
What a timely question! Yes, I am married, and I just had a pair of twins less than a year ago!
Wow congratulations!! What was it like balancing work and family?
It was ok! We received a lot of family support in childcare, especially from the children’s grandparents. By law, we all have 3 months of paid maternity leave, and 1 year of “nursing hours.” “Nursing hours” refer to an entire year of one-hour-fewer-per-week until the child is 1 year old. And normally, private work hours are capped at 45 hours per week, and 40 hours per week in public sectors. In Emergency Medicine, that would be one fewer shift in a month. And during the COVID pandemic, there was even a mandate for pregnant women and mothers with children younger than 2 years old to work from home—pregnant women and mothers can be as equally productive as other members of the workforce.
That is amazing. In Hong Kong, it is also a cultural norm for grandparents to participate heavily in childcare. But what if that wasn’t a feasible option or it wasn’t a common practice? What was it like for your counterparts in the United States?
During my years as a resident, there was a fair share of other female EM residents who got married and had kids during residency. A friend of mine continued her training and career, and her husband decided to be a stay-at-home-husband; whereas another friend of mine made the choice of working part-time, and her husband continued to work full time. It really came down to the couple’s joint decision.
Makes sense. Are stay-at-home-husbands an acceptable concept in the UAE?
(Laughs) Not at all! But fortunately, my husband used to work in tech and is now working on a coffee business, so he can spend quite a lot of time at home since his work nature is pretty flexible.
Awesome. Wait a second . . . I just recalled you saying that 70% of your department’s doctors are females. What happens when the ladies start taking maternity leaves one by one? Who’s left?!
Yes! Given our relatively young history as a country and as a medical system, we are mostly young doctors. The older ones are at most 10-15 years into the workforce. Them being in their early thirties, a good number of our ladies did get married and have children during their residency. All residents take the usual paid maternity leave offered by their institution and return to complete their training. However, with support from each other within the department, it works out and we continue to provide a high standard of training and service. And you know what, us females are good at this. We are used to chaos, unpredictability, and multi-tasking. It is our inherent advantage. Running a home, running an Emergency Department shopfloor—same thing!
Truer words have never been spoken!
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Afterwards, I spoke with Dr Clara Wu. Dr Clara Wu belonged to the University of Hong Kong MBBS Class of 1997, and later completed her EM training in Queen Mary Hospital. After taking a brief hiatus, Dr Clara joined the Union Hospital A&E, and slowly grew it from being just a small out-patient clinic to what it is today. The Emergency Medicine Center at Union Hospital was the first Hong Kong private emergency medicine center to be accredited by both the Department of Health and HKCEM. Dr Clara Wu later became the Director of the Union Hospital Emergency Medicine Center, the Deputy Medical Director of Union Hospital, and Chief Medical Officer of Hong Kong Jockey Club. In 2020, Dr Clara Wu became the first female president of HKCEM.
Dr Clara Wu ( C )
Hello Dr Clara! EM in Hong Kong is a relatively young specialty, and HKCEM was not established until 1996. So, what drew you to join such a new specialty?
You heard of the show ER?
Yea of course! George Clooney!
(Gleefully) My friends and I loved watching ER. I love the energy working in an A&E, and I also enjoy seeing outpatients. Back in 1997, the government changed the mode of doctors’ employment from permanent to contract. A lot of us were on edge and felt a constant pressure to need to equip ourselves, because you never know when a particular skill set would become useful. In turn, I think it made me proactive and driven, and I learned how to turn adversities into opportunities.
Right, that makes a lot of sense. So what was it like being a female EM leader?
(Laughs) You know the usual—being called “Ah Jeh (阿姐)” or “Goo Neung (姑娘)” -
I KNOW RIGHT.
—and when you’re in a boardroom, the assumption is that the male next to you is the president. Back then when I was a junior, when I found elective, training, or exchange opportunities and brought them up to my supervisor, he would ask me to hand those opportunities to other fellow male residents, excuses being “your colleague here is more senior than you; he needs it more,” or “he is a man and is the breadwinner of his family, why don’t you let him take this first and it will be your turn later.” I also remembered there was a time when I rotated from A&E to another department, and I soon heard that the Chief of Service (COS) of that department was asking around whether I was pregnant! Turns out, his logic was he could not understand why a female EM trainee would possibly want to rotate to his department, other than using his department’s man-hours to take maternity leaves.
(Flabbergasted) How did you manage to survive, let alone thrive in such a hostile environment?
I worked harder and showed them results. Whenever I was faced with obstacles in life, I tried not to allow my negative emotions to dictate me. Instead, I would focus on what can be done, and where to find help. That is a difference between male and female leadership as well. You know how when we are traveling and when we get lost, my husband would insist he is not lost, and try to figure his way out from the map. Whereas I would simply ask a local for the way!
For sure! One final question—how do you want to see things changed in the coming 10 years?
A fundamental shift in mindset, and to promote female mentorship opportunities. To be honest, I myself did not have much personal female mentorship in my own life, but I hope it will be different for the coming generation. And in terms of our workforce diversity e.g. gender, ethnicity, people need to understand that the above is crucial to providing quality and holistic healthcare.
G: I completely agree. I think no amount of leadership advice can match the power of witnessing our mentors in real life walking the talk. Thank you, Dr Clara, for being one of those real-life people!
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Finally, I spoke with Dr Eillyne Seow. Dr Eillyne Seow graduated from the National University of Singapore with an MBBS in 1985. She then went to further persue her postgraduate EM training in the Royal Infirmary of Edinburgh, Scotland, and Hope Hospital in Salford, England. She then returned to Tan Tock Seng Hospital and served there for 24 years, becoming the Department Head of Emergency Medicine from 2001 to 2010, and later the Chairman of the Division of Ambulatory and Diagnostic Medicine from 2005 to 2015. Since 2015, Dr Eillyne has been serving as a Senior Consultant at the Acute and Emergency Care Department at Khoo Teck Puat Hospital. Since 2005, Dr Eillyne has been a Clinical Associate Professor at the Yong Loo Lin School of Medicine at National University of Singapore, and since 2020, the President of the College of Emergency Medicine in the Singapore Academy of Medicine.
Dr Eillyne Seow ( E )
Good morning, Dr Seow! You have written an entire book—The Newspaper That Lines the Bottom of a Bird Cage and Other Stories from the Emergency Department—and I look forward to reading the entire collection of your stories one day. I could only imagine how hectic the Tan Tock Seng Emergency Department is . . . to be called the newspaper that lines the bottom of a bird cage. So. You have been there since the beginning, and you have seen it all. How have things changed over the years?
In the 1940s, A&E was just called the “Casualty and Outpatient Department” with a signboard—Emergency Outpatient. The first department in Singapore was in 1948 in Singapore General Hospital (SGH). Doctors working there were various young medical officers assigned from different in-hospital departments. Later on, it became the “Emergency Unit,” and finally the “Accident and Emergency Department,” reflecting our growth of function and independence. SGH was the first to be named as such in 1971. Other emergency departments in Singapore have changed their names to ED (Emergency Department), Emergency Medicine Department (EMD), etc. Whatever their names, all have similar work structures.
The Society for Emergency Medicine in Singapore was formed in 1993. One of our proudest moments was to have been instrumental in the formation and launch of the Asian Society of Emergency Medicine. It was also when the Society for Emergency Medicine in Singapore organized the inaugural Asian Conference in Emergency Medicine. In 2007, the Chapter of Emergency Physicians in the Academy of Medicine, Singapore was formed, and in 2014, became the College of Emergency Physicians. This meant that Emergency Medicine has been recognized in the medical fraternity as an independent discipline. It has been a long journey from the time we were looked down on by the big in-patient departments, considered second class till today’s independent discipline. Today in our hospitals, the most senior doctor on-site at night would be the senior doctor in our emergency departments.
Woah . . . I have never thought about it in that way. So, what was it like being a female pioneer?
I had a senior, Dr Ng Yuen Yen who I did not have the chance to work with. Dr Ng was the first official trainee in Emergency Medicine in Singapore. It just so happened that both Dr Ng Yuen Yen and I are females. We fortunately faced no bias because of our gender. Currently, there are 23 EM physicians in the department I am working in; half of us are females.
That is great. I love how you are not a “female pioneer.” You are a pioneer, who happens to be female. Gender has no grip on what you are capable of doing. Where do you think the future of EM is heading?
Geriatric EM. Our government is placing a lot of emphasis on community preventive medicine in the context of an aging population. EM also needs to find a way to stay relevant. Our geriatric EM training started 10 years ago. We have had geriatricians spending regular hours training our EM doctors and nurses in geriatric medicine, helping us understand that an older person has different physiology and requires more holistic care. For example, if an elderly attending A&E with a Colles fracture was simply treated with fracture reduction-stabilization and sent home, the unaddressed problem of fall will lead to subsequent attendances for head injuries, hip fractures, and eventually the elderly being bedridden. If we could properly identify these cases, and intervene with a multidisciplinary approach, we could better serve this aging community we’re in. Another area that our emergency physicians are concern with is how do we integrate palliative care into EM in Singapore, as well as be more proactive in end-of-life (EOL) care.
I am so encouraged to hear that. I think we could be cynical at times and tend to scoff at newer branches e.g. palliative, EOL etc. that arise within EM, thinking they are mere projects carried out to amass funding and attract attention. However, the reality is that the needs of people are changing, and EM must change—to stay relevant, like you said. There is nothing wrong with being flexible and being innovative with the care we provide. Let me discuss these ideas with our consultants and see what they think!
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After three inspiring and enjoyable hours of conversation, I am grateful. I am grateful for being born in a different time and being raised in a culture with way less gender discrimination than before. Although EM in Hong Kong is still male-dominant, us juniors are supported and cared for equally regardless of our gender or backgrounds. I am encouraged. I am encouraged by the phenomenal progress women have made in the UAE, with them showing the world that it has been and can be done. I am inspired. I am inspired by these three women who are not just great female EM physicians, but great EM physicians and leaders who also happen to be females, and have beaten a few extra odds on the way.
At the same time, I realized that the sheer absence of external oppositional forces is inadequate in encouraging female doctors’ growth into leadership—because as long as there is a potent internal chatter that questions each move of proactiveness, each plan of doing something out of the ordinary, and each thought of ambition, our potential will be stifled. Our internal voices are shaped by observations. Years of observing how our mothers, sisters and other women in our lives behave. Did they face or shrink from adversities? Did they embrace or let go of opportunities? Were they docile or fierce when treated unjustly? And just like children, we learn from observation. The most influential mentors in my life who taught me the most are those women and men who are not necessarily verbally eloquent. However, they spoke with their actions and were loud with the integrity they exhibited throughout various facets in their lives. Therefore, my hope for the future of females in emergency medicine—and beyond—is that we will humbly learn from and actively seek to be mentored by the leaders around us, rewrite the age-old gender narrative that feeds into our self-doubt, and rise to become a generation of leaders who will pass on the legacy to the sisters and brothers who will come after us.
