As an immigrant woman physician (I came to America from a small town in India at the age of 28), an introvert who preferred flying under the radar, a mom with young kids who felt that every moment not spent at the hospital should be spent with my family, leadership was not on my radar.
Until it all changed.
The treasurer and VP of our anesthesia group had just announced that he was leaving the practice. Of the three remaining partners, of which I was one, none of us had any idea about the group’s finances. I had been a partner for less than a year, and during that time, none of the financial information had been openly shared, and I didn’t know enough to ask.
Unable to sleep one night, I wondered who would take over the responsibility. How would we run this practice? Billing companies, insurance companies, contracts, payroll, etc. Who would manage that? Who would make sure our nine physicians and 27 CRNA employees would get paid? I knew I would have to do something.
At that point I did not consider myself a leader. I was happy being a new partner in name only, happy providing the best anesthesia care I could. As soon as my car left the parking lot, I was content to put everything work-related out of my mind and focus on being a good mom to my two young kids. As an introvert, I had never spoken up for myself in my career.
When the three remaining partners met the following day, I found myself volunteering to be treasurer. My other two partners had no interest in the role. The minute I raised my hand, I felt sick. How could I do this? I knew absolutely nothing about finances. I had never balanced a checkbook or managed an account. I had gone from my parents’ house, a sheltered young woman living at home during medical school, straight into marriage right after graduating, to a husband who managed all our finances.
But I’d raised my hand and now I would have to live with the decision.
Looking back, it was the first time I realized that when you are offered an opportunity and don’t know how, say yes and figure it out later.
The first six months were among the toughest of my life. I began learning all aspects of practice management, from billing, to contract negotiation, to payroll, and even HR. Because this was before online searches, my best resources turned out to be our vendors. Long meetings with our billing specialist and our CPA became routine as I grappled with the new terminology.
I had to let go of my reluctance to talk to people and learn to reach out. I started attending conferences and learned to ask questions, even when I felt foolish, assuming everyone would think me stupid for not knowing the basics. I did all of this while still carrying a full clinical load.
Two years in, just as I was feeling comfortable, starting to enjoy the challenges, the rug was pulled out from under me. The CEO asked for a meeting with the three partners. We’d been in negotiations to renew our contract with the hospital and had several meetings with the CFO. In preparation, we’d hired an expensive outside contractor to assess the fair market value of our practice. He met with the C-suite and came up with a proposal on how many ORs we could staff and the budget required.
So when the CEO’s administrative assistant asked for a meeting for the following day, we assumed it was the follow-up to our previous meeting. Instead, we were informed that the hospital had decided to award the contract to a large national group. No discussion about an RFP (Request for Proposal) being put out, no opportunity for our group to put in a bid. This was a done deal. He gave us our 90-days’ notice. Our only options were for everyone to be employed by this group or leave.
After getting over the shock, we entered into discussions with the incoming group. The three of us decided, naively in retrospect, that we’d do our best to make it fair for all our employees. Long story short, the partners were offered a better deal which would severely undercut the other employees. After several weeks of negotiations, the three of us decided to gracefully bow out, allowing our employees to stay or leave and not enforce the non-competes we had in place. Several employees benefited from the temporary large increase they saw in their salaries.
Looking back, with 20-20 hindsight, I see so many mistakes we made as three good clinicians with little leadership and management skills. Still, I take comfort in the fact that I did my best and could sleep better at night with a clear conscience. We helped the employees, even if it wasn’t the best for us personally.
Lessons learned from this experience:
Raise your hand and volunteer even if you feel unprepared. When opportunity knocks, open the door. You never know how your life will change for the better until you do.
The business of medicine — billing, coding, HR, contracts — are all skills that can be learned by physicians. Be open to asking for help. My biggest learning came from sitting down one on one with our CPA, billing company, and attorney rather than from the practice management courses I took during this time.
If you are in a leadership position, or if you want to be in one, build relationships and network within the hospital — with the C-suite and with fellow physicians. If I had done this, I might have been better prepared. Instead, I left it to my partners, believing they were better suited to the task, not recognizing that it wasn’t their strength either. I had let my own insecurities and impostor thoughts get in my way.
Being Open to Change
The next phase in my journey started when I took up a position as a staff anesthesiologist. At first, after the trauma of the previous months, it was a relief to focus on just being an anesthesiologist and taking care of my patients, not having to worry about payroll and HR and everything else I had been immersed in for the past three years.
However, I soon recognized that some of the processes were not working efficiently. Although I knew I could make them better, now I didn’t have the power of a title. I went to my boss, but his priorities were different. I realized that for all the stress and anxiety of my previous three years, I did enjoy the power of being able to make decisions and improve processes. I enjoyed being a leader. It was challenging, stimulating, and rewarding.
Recognizing how little choice or say I had as to where and how I wanted to work, I began looking for a new opportunity. I found an ad for a chief of anesthesia position on a hospital job posting site for an employee of a large national anesthesia management company. Never having been chief or had that level of responsibility, I hesitated. How could I dare to apply? No way would I be considered. Yet, what did I have to lose? I sent in my application, secure in the assumption that I would never hear back.
I was shocked when asked to set up a phone interview within a few days. I was completely honest about my management experience as treasurer. The regional director interviewing me asked how I would handle conflict; would I step up or step away? I responded, “If you’d asked me this three years ago, I’d have said I hate conflict and I avoid it as much as I can. But the last three years have taught me how to handle it, how to challenge when necessary and how to negotiate when I can.” I believe that that may have clinched the deal. After several more interviews, I was offered the position.
Lessons learned:
Leadership and being in control of certain aspects of your career are addictive.
Sometimes, being stuck in a situation is worse than the pain of stepping out of your comfort zone. If an opportunity is presented, take a leap of faith even though you may think you would fail.
Being Chief
The next five years were a roller coaster of highs and lows — one moment believing I was a good chief, the next, that I was terrible.
I walked into a practice where the outgoing chief planned to step down after eight years in that role. The staff physicians had all been there for more than 10 years. For most, this had been their first and only job out of residency. Everyone was used to a certain way of doing things. There was a hierarchy with the OR manager the center of the power dynamic.
And here I was — a brown woman, a newly minted chief, a reticent introvert who disliked conflict, and yet who looked at the way things were being done and recognized opportunities for change. The set-up was perfect for me to be met with resistance, even for small changes I wanted to make.
In my previous job, I was used to having, if not full support, most certainly friendly co-operation from the OR staff. My first day in this hospital showed me how different things were going to be. Unbeknownst to me, my credentialing process was not complete. The final rubber stamp was still required.
My director suggested I could still start my first official day. Although I wouldn’t be providing anesthesia care for a couple more days, I could get oriented. While I was in the OR, one of my new colleagues had difficulty placing an IV. I asked if he wanted help. “Sure” was the response. No one in the OR said anything as I placed the IV, but a few hours later, I received a phone call that the CEO wanted to see me. I assumed he wanted to welcome me on my first official day. He did, but then asked if I was aware that I shouldn’t have touched the patient since I hadn’t yet been “officially signed off on.” I was mortified. In the moment, in that OR, I hadn’t stopped to think. I was trying to be helpful. I should have known better.
What really upset me was that the OR nurse who saw what was happening never said anything. Instead, he took the issue to the OR manager, who didn’t confront me either, but chose instead to pass it on to the CEO. I learned a harsh lesson that day. Up to that point, I’d been fortunate to work with people who worked well with me.
Even though this new staff and manager didn’t know me, I expected the same sort of teamwork.
Being an inherent people-pleaser, I found it a hard lesson to learn that not everyone would automatically like me just because I was nice to them. I didn’t realize that my failure might be something some people might look forward to.
The next day at work I took a deep breath, quietly determined. I would be a good chief, I would be fair to everyone working with me, I would give everyone the benefit of the doubt. I understood that I would likely make decisions that might be unpopular, but I told myself that I was not in this job to have people like me. My director had taken a chance on me, giving me this opportunity, and I would do my best to be the kind of chief I would like to work for.
I remained in that position for five years. There were many hard lessons and bitter realizations, but equally, many learning opportunities and personal triumphs.
Eventually I felt vindicated when fellow physicians, OR nurses, and even the notoriously hard-to-please OR manager told me I had positively changed the culture by bringing in open dialogue. Previously, rumor, innuendo, and miscommunication or deliberate miscommunication had created a sense of distrust and antagonism between the OR staff and the anesthesia department. The fact that they knew I was open to criticism without getting defensive, that I would listen, that I was not interested in attaching blame but in finding solutions, all helped to build trust and professional collegial relationships.
Lessons Learned:
Say “yes” to opportunity even if you don’t feel ready.
Don’t assume everyone has your best interests at heart BUT always go in with the intent to do your best, be open and willing to take feedback that hurts without getting defensive.
Treat everyone fairly, have an open door policy, be willing to assume responsibility for the mistakes you make (and you will make many).
Do not try to fit a square peg in a round hole. In other words, do not try to change your personality to fit your or other people’s assumptions of how a leader should look or act. Work with your strengths and you will be more effective.
The Winds of Change
The specialty of anesthesia has been undergoing a slow but inexorable change for decades. I saw this when my company lost our contract to a large management company. Up until then, once you finished residency, you either took an academic position or went into private practice.
After a three-year stint in academic anesthesia as part of the Johns Hopkins system in Baltimore, I moved to Florida and joined a private practice group that contracted our services with the hospital. The promise of a partnership was alluring even though it meant a lower salary for the initial years with no guarantee of being offered a partnership at the end of the three years.
The first year I took up the treasurer position, I learned that our group, as with most private practice groups in the area, could only function with financial assistance from the hospital. The economics of working in an area where most of our patients did not have private commercial insurance, with Medicare payment rates for anesthesia only 33% of commercial payers, meant that reimbursement for anesthesia services was not adequate to pay salaries to anesthesia staff. Most private practice groups survived on stipends given by the hospital.
Although I didn’t realize it at the time, when my small private group lost our contract to a large management company, this was the beginning of a wave that today has taken over the practice of anesthesia not only in South Florida where I live, but is slowly spreading across the country.
Although management groups had been around for a while, it’s only in the last dozen years that they have either taken over, merged with, or acquired most private practices. By employing many physicians and nurses, these groups’ economics of scale allow them to offer more attractive contracts to hospitals. For physicians, that means private practice opportunities are almost non-existent in South Florida.
No longer are there partnership track positions with the promise of being in control of some of the financial aspects of your career. There are several large management companies that employ physicians and nurses and contract anesthesia services to the hospitals. When I applied for the chief of anesthesia position, it was as an employee of another large physician management company. This entity is now the largest employer of physicians and allied nursing staff in the country.
What Next?
Early in my tenure as chief, I attended the annual weekend retreat that the large anesthesia management company I work for had for chiefs and vice-chiefs from all over the country. I remember how hard those two days were, not knowing anyone. Being an introvert, I couldn’t force myself to introduce myself to anyone. There were so few women attending. We would pass each other in the halls, smiling sheepishly as we hurried from session to session. It was a very lonely experience.
When the time came for the retreat the following year, I wanted to make this a better experience. I asked the organizers for a list of female attendees. I sent emails, asking the women if anyone wanted to meet up for coffee. The response was astounding. Everyone wanted to. We set a time and met outside a coffee shop. We actually had to make more room for the number who showed up.
We compared notes, vented to each other about the hurdles we faced, many of which stemmed from being female and the perceptions of being a female leader. As the conversations ebbed and flowed, I realized that each of us was desperate for this camaraderie. As a female leader, I had certainly felt very lonely. But I assumed that was just me — every other female leader I met seemed so put-together and confident. Now I realized we shared so many common experiences and challenges. We came away from that meeting energized and promising to keep in touch. Realizing the power in a community, I was determined to continue to create this not just for me, but everyone present that day.
Unfortunately, the following year, the organizers refused to release an email list and I couldn’t set up a formal meeting. However, as it turned out, that meeting was another turning point. Every physician and allied clinical staff being recognized with awards in different departments and clinical specialties that year was male. So were all the speakers for the conference. Some of the female chiefs and vice chiefs I had met the previous year were outraged. Several of us took up the baton to ensure there would be more gender parity going forward. As a result, a movement was created for diversity, equity and inclusion.
Lessons Learned:
You are not alone. There are other women who are experiencing some of the same challenges you are. Reach out and form a support community.
The ripple effects of something you create can go far and wide beyond your wildest dreams.
And Then the Next Steps: What If I Could?
During the time I was making forays into community building for women in leadership in the large management company I worked for, I realized that we lacked the resources to find help. Each of us lived in a silo in our own hospitals, without a network. We didn’t play golf like our male colleagues or have the unique male bonding rituals. Most of us were raising young kids. At that time social media like Facebook was still not as prevalent as today.
I had so many questions myself: How do I tackle a particular management situation? How do I find information about this position I am interested in? How do I learn what to say in certain organization meetings?
I thought, if I have all these questions, I’m sure many of my female colleagues must as well. So I decided to start a blog. I contacted women physicians who were in leadership positions in different parts of the country, none of whom I knew personally, and interviewed them by phone. They shared their journey, including the challenges they had faced, how they worked through and overcame them. As I talked to them, I built relationship and a network of strong supportive women. I now have a podcast along with the blog.
Lessons Learned:
If you want to learn something, never hesitate to ask. One of my early interviews was with Dr. Mary Dale Peterson, who at the time was the treasurer of the American Society of Anesthesiologists (an organization of more than 60,000 anesthesiologists). She went on to become the president of the organization in the most challenging time of COVID. Her warmth and willingness to help is something I will never forget, nor is her advice to “get to know your organization’s finances. If you can figure out the money, you will succeed.”
When Status Quo Is not Enough
While I was busy with my blog and podcast, work as chief of my department settled into a routine. While things on the surface seemed fine, I was restless. I felt I needed something more. I had attended our state anesthesia society meetings for several years and noticed the lack of women physicians on the board.
Not ready to do anything about it, I still faithfully attended the meetings, learning the language of governance and lobbying. It was an eye-opener. Sheltered as I was in my clinical practice with a distaste for all things political, I was shocked to find out how much state and national healthcare policy was intertwined with political parties. Slowly, I got more involved in committees, realizing that few physicians actively worked with legislators.
As I became more involved with the FSA (Florida Society of Anesthesiologists), I saw how few women there were on the board. At the next annual conference, I organized a panel for women physicians, inviting them to learn from other women physicians who were in leadership. The response from the attendees was tremendous. This became an annual feature at our subsequent meetings, bringing more and more women physicians together. I was building a community again.
Simultaneously, somewhat jaded from medicine and wanting an interest outside of my profession, I decided to start a business with a direct sales skincare company. Why, as a physician who hated the word “sales,” had no social media presence or skills, and no social network outside of medicine, would I consider this? At that time, I needed to be more than “just a doctor.” And I wanted an income stream outside of medicine. An online business that I could fit alongside my full-time medical career and commitments and my family seemed something worth exploring.
That “little” skincare business ended up teaching me more about myself, about entrepreneurship, and about having a supportive community than anything else in my life so far. Apart from business skills and entrepreneurial skills, it taught me more leadership skills and team building than some of the courses I have taken. It taught me to work on my personal development. And it brought some of my joy back in practicing medicine.
Lessons Learned:
Some of the lessons you need to learn to become a better person will come from the most unexpected places.
Keep an open mind. Don’t let other people’s judgments and expectations of you steal opportunities that could change your life.
Being True to Yourself
A few years into my involvement with the FSA, I decided to run for an elected office on the board. The first year I ran, I had no idea what was involved. When it came time to present my candidate speech, I was unprepared. I mentioned my few committee involvements and how I would like the opportunity to serve. Of course I didn’t win.
I decided to run the following year. I had a better idea why this position was so coveted: it was a lead up to becoming president of the entire organization, a seven-year step-up journey. The older White males still intimidated me there, and I hadn’t yet built many relationships. I lost.
By the third year, I felt I had a real chance. I’d put in enough time in the trenches, had a stronger voice, and knew the difference I could make. I lost by a narrow margin. Several people encouraged me to try again.
The next year, a month before the elections, I asked an older and wiser colleague if he had any advice that would help me win. He said: “Asha, you need to be one of the boys. Go out with us for drinks, let people get to know you.”
While I recognized the importance of letting people get to know me, I felt that there had to be ways other than “going out for drinks.” Did I even want a position that may or may not depend on my acting like “one of the boys”? Maybe this wasn’t for me.
I called a female physician friend who was one of my strongest supporters and told her I planned to drop out of the race. I was truly conflicted. I thought I was letting my female colleagues down. If I didn’t run, there would not be another opportunity for a woman on that all male board for several more years.
I decided to run, but on my terms. I wouldn’t try to change myself into becoming “one of the guys.” For the first time, I asked several colleagues to support me. Previously, I’d been too embarrassed to request help. This time my speech was prepared and was based on my strengths, on how good I was at building community and consensus, which was what our society needs. I won despite having a strong opponent!
Lessons Learned:
Be true to yourself. Step outside your comfort zone when necessary but do it for the right reasons in the right way.
Don’t be embarrassed to ask for help. In the past, I assumed I should be elected simply by being seen and recognized for my efforts.
The Journey Continues: Getting To Know Myself
Five years after taking up the chief position, circumstances outside of my control led to a parting of ways from that hospital. I accepted another position as medical director at a different facility. Compared to my previous job, this was as different as night from day. The manager and director as well as the staff were more cooperative and willing to work as a team.
Still, the baggage I carried from the circumstances of leaving my previous job was painful. I had lost my sense of self-worth as well as my confidence in myself as a leader. Outwardly, I was content. I couldn’t have asked for a better job and better people to work with. Yet I knew something wasn’t quite right. It came to a head when I felt a situation at work was unfair. I felt that I couldn’t negotiate for myself despite having taken several of these courses in negotiation skills. I felt like an impostor again.
I decided to consult a coach, hoping to learn how to negotiate for myself. Within three sessions I underwent a personal transformation. I started recognizing my thought patterns, learning why I act and behave the way I do. I learned to recognize my strengths and work with them.
Coaching helped me bridge the gap between who I was and who I wanted to be by taking all the techniques I’d learned over the years in the abstract and showing me how to apply them. What had earlier been “book learning” that I’d tried to emulate, I could now apply specifically to me.
As I grew personally, I saw this as the missing piece to my desire to be a mentor to other women physicians. I decided to learn to be a coach myself. I took a course that offered a certification. Now I coach early- and mid-career women physicians in leadership development so that they can step confidently into administrative and leadership roles.
Lessons Learned:
Every physician is a leader.
The key to becoming a better leader is to manage your mindset.
Self-confidence comes from knowing yourself, from becoming aware of your thinking process and being able to manage in the moment.
Coaching is something every woman physician (and every physician) should consider to reach their full potential.
New Realities
As Dr. Selma Calmes, one of the pioneers for women in leadership positions in anesthesia has said, there were very few women in management and leadership positions when she became one. Sad to say, today, even though there are many more women in the field, our numbers in leadership roles still fall far short of what they should be.
In the last several years, more than 50% of anesthesia residents are women. Yet, there are fewer than 20% of female professors in academic institutions or chiefs of departments. Women chiefs of anesthesia in private practice or in large national groups, like the one I work for, are still few and far between.
Added to the difficulty of rising in leadership are the changes in practice models. Certified Registered Nurse Anesthetists, who for decades have worked as part of the anesthesia care team, have been fighting to provide anesthesia care without physician oversight and supervision. In a few states, they have succeeded. In several others, the physician supervision requirement has been taken over by any physician (surgeon or gastroenterologist, usually). Imagine a surgeon performing surgery and simultaneously supervising the CRNA providing the anesthesia care.
Part of my duties as a physician leader within the community and within the Florida Society of Anesthesiologists is advocating for my patients and for preservation of physician-led anesthesia care. I spend a significant amount of time working to educate politicians about how removing the physician from the anesthesia team would be detrimental to patient care.
A few years ago, the Florida legislature passed a law granting independent practice to Advanced Practice Registered Nurses (APRNs) in several specialties, including Family Practice. CRNAs were excluded. However, this is a yearly struggle that our specialty faces every legislative cycle. The role of physician extenders taking over the practice of medicine is expanding rapidly.
I worry where this is leading. When I chose to become an anesthesiologist, I never envisioned the need to explain why having a medical doctor (rather than a nurse with far less comprehensive medical training) in charge of someone’s anesthesia care is so important. Yet that is what I find myself having to do, over and over. Is it a losing battle? I hope not. My hope is that the young physician leaders coming up will join the fight to keep anesthesia care under the direct supervision of anesthesiologists.
Bottom line: I would not trade in my years of enjoying my clinical practice, my leadership journey, and my personal growth in that journey for anything else. I’m a better human being and a better leader, a better mother and wife, for having faced these challenges.
Excerpted from Lessons Learned: Stories from Women Physician Leaders (American Association for Physician Leadership, 2022).