Monkey See Monkey Do

“It’s like monkey see, monkey do.” This observation was made by one of the chief residents in reference to his experiences learning surgery. We were scrubbed in a robotics case at the time. He was alluding to an aspect of residency training that senior level residents were learning mostly by imitation and not necessarily through understanding why something is done a certain way. At the time, the chiefs had complained repeatedly to faculty because they were concerned about their lack of access to surgical training due to the priority given to large amounts of administrative tasks.

Hear no evil, see no evil and speak no evil

Surgical experience was seen as gold with very little to go around. This created pressure for upper levels to offload any clerical tasks they could onto the lower levels. As a female intern it was even worse.  It got to the point where even the chairman noticed. He told me “I hope that you do not offload onto your interns the way your upper levels have offloaded work onto you.” My response to him at the time was “will do”. In hindsight my answer should have been “sure, as long as everyone is being held to the same standard. I feel like I am constantly being held to a higher one and being set up to fail.”

I always seemed to be within ear shot of male co-residents giving a fellow female resident praise for being so efficient with all her documentation and having such a nice personality. No discussion among the male residents, at least around me, took place about her surgical or clinical skills. That part did not seem to matter to them. One of the chiefs pointed out to me how much he admired how “forgiving” she was. The implied message I got was that because she had endured being offloaded onto and treated to a double standard and that she still kept a smile on her face, I was expected to be the same as her. We were low on the hierarchical totem pole not just because of both having been interns, but because we were women.

Ironically having less power in a patriarchal hierarchy comes with many valuable learning experiences. These valuable experiences are not just seen in humans but other social animals. Such observations were made very clear in the research done by primatologists studying the strict hierarchical society of rhesus macaques. One such researcher’s work was on National Geographic. Her study involved food being placed in a box that required advanced skills to open the box to get to the food. None of the alpha males were able to do it, nor were other males lower on the hierarchy or females higher in the hierarchy. It was only one of the ostracized lone females at the bottom of the totem pole that figured out how to open the box. Throughout her life, under the observation of the researcher, the macaque was denied access to food by the society she lived in. As a result, she learned how to find food for herself in much more difficult places. The monkey’s more challenging life experiences, caused by social alienation and the withholding of necessary resources for survival, trained her to become a better problem solver through her own self-reliance. A similar dynamic is also seen in medicine, so much so even patients notice. One of my patients told me specifically that she wanted to see only female doctors because she believed they would have been held to a double but higher standard.

 Power dynamics in medicine continue to be very hierarchical, even beyond training. It behooves faculty, as well as hospital administration who profit significantly from the extremely cheap skilled labor of residents, to look at how the hierarchy itself contributes to gender inequity in medical education. The limited resource in residency programs is, unfortunately, medical education. This is due to large overheads, clinically complex high-risk patients and a litigious society. Knowledge and time are the meals that are scarcely fed to lower levels. Many star residents bully others in order to obtain a hold on the resources they need to thrive in a fiercely competitive hierarchical arena.

http://www.bbc.com/earth/story/20160822-why-bullying-is-such-a-successful-evolutionary-strategy

Studies in human sociology have shown that male networks are wealthier and more influential than those of women and that men have access to more mentoring than women in hierarchical work settings. While the need for increased resourcefulness amongst women in a competitive workplace may end up making women physicians better doctors in the long run, it also makes them more vulnerable to missing out on leadership opportunities due to the increased time expenditure. The decreased need for resourcefulness required of men prevents male physicians from developing into their full potential.

While my chief’s experience of learning surgery in the OR might have been “monkey see, monkey do”, my experience was quite a bit different. Mentoring was even more sparse of an interaction yet I was still expected to perform. In turn, it was more like “monkey not able to see, monkey expected to do anyway.” I could not trust my upper levels as they had thrown me under the bus before and deliberately misdirected me. The people who were supposed to be in a position to be empowered and lead those behind them saw those below them in rank as a liability or competition. The hospital’s bottom line and reputation was a strong driving force behind people’s behavior in the patriarchal hierarchy. It was a crazy making situation for those with the least amount of social influence at the bottom of the totem pole. Much of this same behavior is seen in America’s history in its development as a corporate capitalist economy founded on servitude.

In the documentary “The Minds of Men”, the history of Psychosurgery is discussed in detailed events. America was concerned about social violence, predicting it and controlling it with the objective of socially engineering a diverse population that would be obedient and not disrupt the powers that be which were essentially sustained in their positions of power through an exploitative labor model. Rather than looking at the economic systems that were driving social inequality and creating frustration in people as a result of the injustices and stressors they were facing, the oppressed were termed as violent and seen as having an organic neurological source for their volatile behavior.

Social violence requires a mass exertion of energy to make it happen. People do not just wake up one day and decide to be angry or emotionally volatile. There are events, interactions and circumstances that occur repeatedly prior to such emotional responses in people. But it is easier to categorize all such emotional responses in a population as a mental disorder, something that requires a medical intervention, a psychiatric intervention.

I vividly remember sitting across the table from the chair of Psychiatry at the time, in front of 5 other faculty members. This was the resident wellness committee. I remember feeling exhausted because I did not have a set of vocabulary to articulate clearly my experiences. I only gave the emails I had received from senior residents that were “over the top” as the HR coach I was assigned to described them. But showing them did not seem to make any difference. No one cared and why would they? They went through worse right? Each of those faculty members got to their positions with no mentoring, no help, completely under their own steam with stones thrown at them along the way?

The chair of psychiatry told me that the real reason I wanted to become a surgeon was because “oh everyone likes having something handed to them on command.” Even though, I had been bullied and harassed for several months, he turned it around with his language making me the perpetrator. He then said that he was going to perform some “psychosurgery” on me. That was the first time I had ever heard that word. At the time, I did not know what it meant. I assumed incorrectly that it was like a more intense metaphor for Cognitive Behavioral Therapy.

It would not be until 5 years after the fact that I watched the documentary on what exactly psychosurgery was to fully grasp what the Chair of Psychiatry was referring to. It meant literally doing neurosurgery on a person, placing electrodes in their brains, administering electrical currents to those areas of the brain to change mood and motor function remotely and then burn those areas of the brain that were causing problem behaviors. The Chair of Psychiatry was of an age group that he would have known what the term really meant. I clearly had no idea at the time what he was exactly referring to with psychosurgery. I realized that they wanted me to “toe the line”, but I did not understand what behavior they wanted me to show them to get them to back off. In order to “toe the line” one has to know what the rules are. It was becoming apparent that those above me in rank had another set of hidden rules just for me that kept changing behind my back. It was like shifting quick sand.

The Minds of Men documentary did not come out until 2018, years after I left residency. Since psychosurgery is not the standard of care by any means it was not taught in medical school even in our bioethics course. Essentially it was the politicization of medicine and science as a method to subdue and control a diverse population experiencing increasing economic disparities. These social inequalities understandably cause emotional stress in even the most resilient of people; people with no psychiatric or neurological conditions.

Not only was psychosurgery used as a method to control oppressed communities emotionally reacting to injustices, but was also used to subdue and destroy individuals seen as stronger threats to the powers that be. One of whom was an engineer, Leonard Kyle, who had several patents including with the CIA. He started out functional and productive. After psychosurgery was performed and holes were burned into his brain, he ended up hiding under bed covers with seizures and psychotic fits.

Psychosurgery obviously was never a medical treatment but a surgically invasive experiment with dire side effects. Fortunately, the “psychosurgery” that the chair of psychiatry was able to carry out with me was not taken to its true definition. Instead getting me to “toe the line” was taken to the level of psychological manipulation where I agreed to take SSRIs. I actually began to believe I was the one with the problem, not the system I was subjected to. I never had a history of anxiety or depression prior to entering residency. Once I left residency, I came off them and have not needed them since. I was being harassed. The program was not going to change its social power structure, so I had to be labeled as medically abnormal in some way and be given treatment. The use of medicine to get me, a medical doctor, to internalize and fear the social power structure was disturbingly similar to the social engineering function of psychosurgery in the 1960s.

My mind had been so manipulated to  that point that I could not tell which way was up. All I knew is that I wanted to get out. I remember the day I walked out of the chairman’s clinic to resign. It was me, the chairman and an elderly patient in the room. While sitting on a chair, I was presenting a patient’s history and about to give my interpretation and plan. That’s when the chairman interrupted me, gave me specific instructions on how I needed to sit all the way down to nonverbal minutiae such as the expression on my face I needed to have, how I needed to position my head and where exactly I needed to place my hands. All of this occurring in front of the patient.

Outside observers would not have been able to appreciate why I began to cry in response to being critiqued about my posture because they would not have known the history of the social dynamics I had been subjected to previously. There are different kinds of violence, including even cunning, clandestine, invisible kinds. I cried in front of the patient and told the chairman “I can’t take this anymore”. The patient responded “it’s OK doc, it’s OK this is just a learning experience.” The patient probably was not able to see nor fully understand why emotionally I would have that response. The patient was in his 80’s, part of the Greatest Generation, who had lived through hefty wars. I doubt he would have thought being told how to sit in a chair would seem that offensive. The patient may have even deducted that I had a big ego and was just overly sensitive to constructive feedback. This is where the true power of systemic social oppression, psychological manipulation and psychological warfare is revealed. It is invisible. No one sees it from the outside looking in because they do not know the complete context and no one sees it from the inside because they think that is the objective norm and therefore they cannot see outside. Monkeys think they see x, monkeys do x but from a more objective view point it was really y not x.

Subconsciously there was a more specific deduction that was causing my emotional response to cry not due to sadness or self-pity, but anger towards something horribly sinister. “Toeing the line” was really nothing more than being reduced to something less deserving of decency than a cockroach. It was like Kafka’s Metamorphosis occurring within seconds without any written language required. The deduction was that the chairman, program director, attendings, senior residents, all those who played “the game” wanted more than just me following orders, covering their behinds, making sure tasks got done efficiently and effectively, they wanted something in me destroyed. They wanted my sense of self-worth, my personal integrity, and my spirit decimated.

The only person who did notice and comment on the concerning dynamic from the chairman towards me, was a faculty member in the department of Sociology. Interestingly his specialized area of academic research was Criminology. He ended up telling the chairman that he had to cut the conversation short. Once the chairman left, the Sociologist asked me “does he always treat you this way?”  I told him yes. He then said “if you ever feel you need help, feel free to contact me.” I never did while I was in residency. The reason was because I had internalized being low on the totem pole, and that I deserved to be treated badly because I was not a good enough resident. I did not believe there was much he could do.

It would have been extremely wise to watch primatology documentaries which evaluated the hierarchical behaviors of chimpanzees and macaques before entering medical training. Unfortunately, I grossly overestimated how evolved humans socially interact within hierarchies in the medical profession. Macaque documentaries that evaluate social systems are insightful and reveal just how similar the power plays and dynamics are to those in residency training, the medical profession and other hierarchical workplaces. Watching these documentaries would have provided a context to human social behavior in hierarchies and allowed me to emotionally compartmentalize a lot faster. I would have understood the mechanism behind the behavior, lowered my expectations accordingly and used language that would send the appropriate message. Instead at the time, I thought the behavior I was experiencing was because there was something wrong with me and no one would tell me what that was. I recall one of the RNs telling me “it’s about knowing what someone wants without them having to tell you.”

The thing with human intelligence is that it obviously has much more creative and ingenious ways to show its sinister side. Monkeys assault, withhold resources, ostracize and many times even kill their own to send a message to “toe the line” to groups or individuals that are seen as a threat due to difference in heritage. With people, power plays and messages to “toe the line” to the social power structure can be taken to a whole new level of ingenuity through psychosocial manipulation with verbal language, subtle behaviors, and even medical and scientific technologies.

A young female faculty member in the department of Psychiatry was assigned to me for my well-being during my administrative leave. During one of the therapy sessions she told me “you are a very attractive woman; I think that is why your co-residents treat you this way.” Yet I was the one being psychiatrically examined, evaluated and recommended to take SSRIs. Macaques do not have the intelligence or technology to give medications to lower ranking females to keep those females functional, feel happier and not rebel against abuse of power; against being attacked because the higher ups see them as a threat. Instead macaques physically assault each other in the open and that also happens in medical training.

Maybe the reason why the powers that be in my residency training program instinctively took such insidious, invisible methods to get me to comply was that they did not want to lose face in front of me. Here they were in a healing profession, with the responsibility of human lives, going to be pillars of their communities with respect and prestige. More overt methods would have held up a mirror to their self-image and the mirror would have shattered that image. More overt methods of repression would have allowed me to see what they really were and what the game they played was really about. In turn, I would have had no problem playing them at their game with their social rules and with their use of language; “monkey see, monkey do.”