Settling into a rhythm that allows you to thrive, not just survive — that’s the real work.

Consultant/ Attending life is harder because the rules change — and no one explains how.

During residency, there is a curriculum. Explicit expectations. Defined milestones. Clear hierarchies. You are assessed constantly, but you’re also held.

Consultancy is different.

On paper, your days are structured by clinical work. You might take on roles in education, governance, research, and leadership. There are appraisals to complete, portfolios to maintain, and objectives to set.

But very quickly, you realise something unsettling:

• Your appraisal is as meaningful as you decide it will be.

• Your job plan is more negotiable than anyone tells you.

• Your career trajectory is no longer managed — it’s self-directed.

This is where the hidden curriculum of consultant life really begins.

The hidden curriculum is everything you are expected to know, navigate, and perform — without ever being formally taught.

• It determines who gets stretched and who gets sidelined.

• Who is protected and who is exposed.

• Who progresses with energy — and who quietly burns out.

We talk about the hidden curriculum in training, but it doesn’t disappear at consultancy. If anything, it becomes more powerful.

Because now the stakes are higher—and the safety nets are thinner.

The evidence is clear that the hidden curriculum underpins differential attainment in medicine: the unfair gaps in progression, pay, recognition, and retention that disproportionately affect those with protected characteristics — gender, race and ethnicity, disability, and socioeconomic background.

We see it in interviews.
In hiring decisions.
In who leaves medicine early, and who is referred to the GMC.

But I’ve come to believe it also shows up in places we talk about far less:
Job plans, discretionary points, pay scales, leadership opportunities, and long-term burnout.

Listen to my interview on the “The Obstetrician & Gynaecologist (TOG)” podcast about Differential Attainment >>>

Read my publication on the subject >>> HERE

This isn’t just about “getting through” the early consultant years. It’s about what kind of consultant you become — and whether you recognise yourself ten years later.

Early in my career, I watched senior consultants who were technically brilliant but visibly depleted. Disillusioned. Trapped in roles that no longer fit. People who had given everything to medicine — and quietly lost themselves along the way.

At some point, it dawned on me: this could be me.

Medicine trains us to conform.

To compress parts of ourselves to fit the system. To prioritise output over identity. To suppress vulnerability, defer to hierarchy, and show up as if we have it all together. During training, that conformity is rewarded- sometimes even necessary as it keeps teams functioning, patients safe, and the system running

But consultancy is the inflection point.

This is the stage where continued conformity stops being protective -and starts becoming corrosive.

Innovation, leadership, sustainability, and joy in medicine come from the opposite place: clarity of values, self-leadership, boundaries, and the courage to practise differently.

No one teaches this. So many make the paradigm shift too late.

Without that shift, the hidden curriculum doesn’t just make your work harder - it chips away at your identity. That’s how brilliant doctors burn out, drift from purpose, or feel depleted by a job they once loved. And yet, these early consultant years quietly shape the next twenty.

That is why I created The Next Step.

Launching in March 2026, The Next Step is a career series for doctors becoming consultants or attendings — senior residents, speciality grade doctors, and early-career consultants.

It is not another interview course.

It’s a masterclass in self-leadership in clinical careers — in spotting the hidden curriculum early, managing it intentionally, protecting yourself from burnout, erasure, and disillusionment, and building a career that sustains you

Consultant life is the stage where your identity as a clinician becomes an expression of yourself — not just a reflection of what the system expects.

If this resonates — if you feel the hidden curriculum tugging at your confidence, your energy, your sense of purpose — you’re not alone.

I write more about the hidden curriculum of medicine, career transitions, and leadership on my blog and in my newsletter.

If you haven’t already — Subscribe Here 👈🏾

And if you want to go deeper, The Next Step was designed with you in mind.

I’ve been asking myself this recently.

Lifestyle medicine asks individuals to eat better, move more, sleep well, manage stress, avoid harmful substances, and build connections. These pillars are evidence-based and powerful. In my clinic, I see their benefits daily. But when we present lifestyle change as the solution—without naming the conditions that constrain choice-we drift into a quiet moralisation of health.

Lifestyle medicine is necessary, but not sufficient.

When the structural determinants of well-being are not addressed, “choose better” only works if the choice is genuinely available.

A woman working two jobs on unpredictable shifts cannot optimise sleep.
A family living in overcrowded housing cannot “reduce stress.”
A neighbourhood without green space makes “move more” an abstraction.
Ultra-processed foods are cheap, accessible, and aggressively marketed; fresh foods often aren’t.

This is not a failure of motivation. It is a failure of systems.

Decades of public health evidence show that income, education, housing, transport, gender norms, racism, and environmental exposure shape health outcomes as powerfully (often more so)than individual behaviours. The World Health Organisation has been explicit about this for years: where you are born, grow, work, and age predicts your health trajectory long before your willpower enters the room.

There is also a risk we rarely name: when lifestyle medicine is over-emphasised, responsibility quietly shifts from institutions to individuals. Health becomes a personal project rather than a shared societal outcome. Those who cannot comply are labelled “non-adherent,” when in reality they are structurally constrained.

Lifestyle Medicine Omits the Impact of Inequity

As a clinician, I was trained to blame my patients for their 'bad choices'. I wonder if lifestyle medicine is doing the same thing to women?

The healthy choice is sometimes harder for women- especially women of colour. New research links discrimination, higher cumulative stress and inflammation to mortality gaps between Black and White individuals.

Lifestyle medicine often arrives wrapped in hope, scented candles, and quiet guilt- layered onto women already expected to parent like they don’t work and work like they don’t parent.

Intersectional disadvantages based on socio-economic status, race & ethnicity, disability and migration compound the inequity gap fostered in lifestyle medicine.
Then the pièce de résistance arrives in the form of perimenopause- brain fog, rage, exhaustion, weight gain, challenged by hormonal shifts- and still the message is: Try harder. Choose better.

So where does that leave lifestyle medicine?

It remains essential-but only when positioned within a broader frame:

1. As support, not substitution
   Lifestyle medicine should complement policy, not replace it. It works best when social protections- living wages, safe housing, parental leave, access to healthcare- are in place to make healthy choices feasible.

2. As a collective, not just individual effort
   Behaviour change scales when environments change: walkable cities, affordable nutritious food, clean air, psychologically safe workplaces. Health improves faster when the default is healthy.

3. As trauma-informed and context-aware
   Telling people to “manage stress” without acknowledging chronic precarity misses the point. Stress is often a rational response to unstable conditions.

4. As a lever for advocacy
   Clinicians and public health professionals can use lifestyle medicine’s evidence base to argue for upstream change (urban planning, labour policy, food systems), not merely downstream counselling.

If we are serious about wellbeing across the life course, across communities, then lifestyle medicine must be paired with structural medicine: policies that redistribute opportunity, reduce exposure to harm, and create conditions in which healthy lives are realistic, not aspirational.

Lifestyle medicine can change lives.
Social determinants decide whose lives are easiest to change. The real question, then, isn’t whether lifestyle medicine is enough.

It’s whether we’re brave enough to stop asking individuals to compensate for systems that fail them, and start fixing the systems instead.

They may seem unrelated. They’re not.

For the first time in history, there are more women in their forties having babies than there are teenage mothers. This shift has been building quietly over the past three decades, driven by education, careers, fertility treatment, and economic reality. But biology hasn’t moved with the same flexibility.

Perimenopause - the hormonal transition that can begin in the late thirties and early forties- is now increasingly overlapping with Matrescence: the profound biological, psychological, and social transformation triggered by becoming a mother.

Both are periods defined by hormonal flux. And both can turn a woman’s sense of self inside out.

Clinically, these phases can look remarkably similar. During pregnancy and early motherhood, hormones reshape the brain, metabolism, sleep, mood, and identity. During perimenopause, the gradual decline in oestrogen, progesterone and testosterone can bring brain fog, insomnia, anxiety, low mood, weight redistribution, and changes in libido. At work, women describe feeling less sharp, less confident, less themselves, just as their responsibilities are often peaking.

Into this already complex picture has entered a third ‘M’: Mounjaro

Studies estimate that 1 in 3 women are now using mounjaro and other GLP-1 weight loss medications - such as Ozempic and Wegovy.

GLP-1 receptor agonists are drugs that mimic the action of our naturally occurring hormone, Glucagon-like peptide-1 (GLP-1). This hormone is involved in regulating our appetite, blood sugar & insulin levels and gut movements.

As a consultant obstetrician-gynaecologist, I look after women across the life course. In the past two years, a growing number of my patients, particularly those who are peri- or post-menopausal, are using these medications for weight loss. Some estimates suggest that perimenopausal women make up the majority of users.

Ever since I realised how widespread their use had become, I changed my practice.

I now ask every woman I see a simple question: “Are you taking weight-loss medications?”

Not because I’m opposed to these drugs.

But because they interact with hormones that shape women’s health at every stage of life.

There is evidence that when GLP-1 drugs are used responsibly alongside nutritional, activity and psychological support, they have a positive long-term impact on heart health, diabetes, breast & womb cancer and inflammatory diseases, beyond mere weight loss.

All drugs come with risk, especially when used irresponsibly. GLP- 1s are no different

NB: GLP-1s are not ‘new drugs’; what’s new is the widespread use of them for weight loss amongst people without type 2 diabetes

• GLP-1s, as a class of drugs, were first discovered in the late 1980s.

• GLP-s1s have been approved for use in people with type 2 diabetes since 2005-2006 in North American & Europe

Weight loss, particularly when rapid, affects ovulation, fertility, menstrual bleeding, muscle mass, bone density, mental well-being, and cardiometabolic risk. GLP-1 medications can alter the absorption and effectiveness of oral medications, including oral contraception(birth control) and oral hormone replacement therapy (HRT).

Yet many women are prescribed these drugs with little discussion of how they intersect with reproductive or midlife care.

There is also Stigma. Shame. Silence.

Some women don’t disclose use because they fear judgment from clinicians, colleagues, or even family. That silence is risky. We must stop shaming people using weight loss medication and instead be curious about how to make access safer and equitable.

This matters not just clinically, but publicly. We are rolling out powerful metabolic drugs at scale, disproportionately to women in midlife, without fully accounting for how they interact with the female life course -from fertility to menopause to long-term bone and heart health.

So here’s the call to action.

• If you are a Woman using GLP-1 medications: tell your healthcare provider. Ask how these drugs might interact with every medication you take, especially hormonal contraception and HRT. If you’re on oral contraception or oral HRT, discuss non-oral options such as patches, implants, coils, gels or sprays. Make sure progesterone dosing is adequate to protect you from unopposed oestrogen.

• If you are a Clinician: ask the question — routinely and without judgement. Weight-loss medication use is now part of women’s hormonal history. Treat it as such.

• And if you are shaping policy or health systems: recognise that matrescence and menopause are not niche women’s issues. They are predictable, population-level transitions. Arguably, it is a window of opportunity to extend the healthy life span for women. The way we manage GLP-1 drugs within them will shape women’s health and health inequality for decades.

The three Ms are already colliding in women’s lives. It’s time our conversations and our care caught up.

Here’s a question I’d like to explore

• Is there a public health argument for weight loss medications?

• Comment below

REFERENCES

1. Matrescence to Menopause: a Second Window For Female Longevity

   https://www.drisiomaokolo.com/blog/female-longevity

2. British Medical Society Advice on Use of Incretin-Based Therapy in Women on HRT

   https://thebms.org.uk/wp-content/uploads/2025/05/23-BMS-TfC-Use-of-incretin-based-therapies-APRIL2025-E.pdf

3. McKinsey Health Institute – Closing the women’s health gap: A $1 trillion opportunity
   https://www.mckinsey.com/mhi/our-insights/closing-the-womens-health-gap-a-1-trillion-dollar-opportunity-to-improve-lives-and-economies

4. UK Women’s Health Strategy
   https://www.gov.uk/government/publications/womens-health-strategy-for-england/womens-health-strategy-for-england

5. Nature Medicine – Reviews on GLP-1 receptor agonists and metabolic health
   https://www.nature.com/articles/s41591-024-03412-w

6. NEJM – GLP-1 receptor agonists and cardiometabolic outcomes
   https://www.nejm.org/doi/full/10.1056/NEJMoa2307563

7. NHS MBRRACE-UK – Maternal mental health and postnatal outcomes reports
   https://www.npeu.ox.ac.uk/mbrrace-uk/reports

8. FDA – GLP-1 receptor agonists: prescribing information and drug interaction guidance
   https://www.ncbi.nlm.nih.gov/books/NBK551568/

9. European Medicines Agency (EMA) – GLP-1 receptor agonists safety information
   https://www.ema.europa.eu/en/medicines/human/referrals/glp-1-receptor-agonists

The goalposts keep moving.

We are living longer. Having our first children later. Working well into our sixties and beyond. Women still outlive men—but often with poorer physical and mental health in the years that matter most.

If the average woman now lives to around 80, and perimenopause typically begins in the early forties, that means many women will spend nearly half their lives navigating hormonal transition. Yet until very recently, this phase of life barely featured in mainstream health conversations. That silence has consequences.

Pregnancy offers an early clue to why this matters.

I’ve long thought of pregnancy as the ultimate stress test of a woman’s body -particularly her heart and metabolic system. Cardiac output surges. Blood volume expands. Insulin resistance rises. What we see externally is a growing bump; what’s happening internally is a demanding physiological recalibration.

Conditions such as pre-eclampsia or gestational diabetes are often treated as isolated complications- problems that begin and end with pregnancy. In reality, they are early warning signals - red flags that a woman may be on a trajectory toward high blood pressure, chronic metabolic disease, stroke, or type 2 diabetes later in life.

Pregnant women and pregnant people who had:

• Pre-eclampsia have a double risk of stroke in later life

• Gestational diabetes are 10 x more likely to get type 2 diabetes in later life

Pregnancy doesn’t cause these outcomes; it reveals underlying vulnerability earlier than we might otherwise detect.

And that revelation doesn’t stop at birth.

Matrescence-the physical, psychological, and emotional transition into motherhood-is a term finally entering public discourse. It describes something women have always known but rarely had language for: that pregnancy and early motherhood reshape the body, brain, identity, and sense of self. After birth, the shifts continue. The postnatal period brings another abrupt hormonal drop, sleep deprivation, identity change, and psychological vulnerability. In the UK, suicide remains the leading cause of maternal death in the first year after childbirth. We talk about baby blues and postnatal depression, but often without urgency. Everyone wants to hold the baby. Far fewer ask who is holding the mother.

Matrescence and Perimenopause: two sides of the same transition

Whilst matrescence is finally entering mainstream awareness, it rarely gets connected to the next transition in a woman’s life, perimenopause and menopause, which represents another massive shift.

As maternal age rises, this overlap between matrescence and perimenopause will become increasingly common. Yet our healthcare systems, workplaces, and cultural narratives still treat these stages as separate and often invisible.

The past five years have forced menopause into the spotlight. Public advocacy, regulatory changes around hormone therapy, economic analyses showing the cost of ignoring women’s health, and national women’s health strategies have all played a role. But the conversation often starts too late

The Real Opportunity Lies in the Years Between Matrescence and Menopause.

This is a critical window to shape women’s health span. Not just how long we live, but how well. It is the moment where prevention can meaningfully alter trajectories around:

1. Cardiovascular health,

2. Metabolic resilience,

3. Mental well-being,

4. Cancer risk and

5. Neurodegenerative disease

These 5 domains, sometimes referred to as the 5 horse wo(men) of death & disability, are significantly impacted by hormonal transitions in women.

Hormones impact AND are impacted by sleep, weight changes, activity levels, social connection, nutrition, stress/nervous system dysregulation- the pillars of lifestyle medicine.

For women, knowing how hormones interact with these five domains—and applying the basics of lifestyle medicine—is key to a healthy lifespan

How to Apply The Pillars of Lifestyle Medicine to Your Life

You Must Add Women’s Health Checks & Screening to Lifestyle Medicine

Screening helps people identify problems early on and take necessary steps to prevent them from progressing. It’s knowledge and well-being empowerment in action!

Is Lifestyle Medicine Enough?

Sometimes healthy choices are hard. Women are living longer in bodies that are more metabolically stressed, often under-resourced, and disproportionately burdened by caregiving.

Therefore, equity cannot be ignored. Lifestyle medicine at scale-nutrition, movement, sleep, stress management, and social connection matter here. Not as individual blame or responsibility, but as an expanded public-health strategy applied at the personal level, shaped by real social determinants of health.

Matrescence, matrescence, and GLP-1s are shaping women’s health right now.I

I’m noticing a trend: later motherhood, midlife hormonal change, and powerful new weight-loss drugs- all overlapping. A growing number of women, particularly those in perimenopause, are turning to GLP-1 medications. We need to talk about all three - together. These drugs may have a role, but we still lack clear answers about their long-term impact on women’s cardiometabolic health across this longevity window.

I explore this in another blog. The conversation is just beginning.

The Economic Dividend of Investing in Women’s Health

Whilst I dislike framing people in terms of economic value, this is where the argument can, and must, shift from the individual to the structural.

For years, investment in women’s health has been siloed, under-resourced, and under-studied. But the data now show that this is not just a women’s issue -it’s an economic one. According to analysis by the McKinsey Health Institute in collaboration with the World Economic Forum, closing the women’s health gap- including better care across the life course - could boost the global economy by at least $1 trillion annually by 2040.

Women spend about 25% more time in poor health compared to men.

Largely because so much of the spectrum of women’s health (beyond pregnancy) has been ignored. Closing that gap could add seven extra healthy days per year for each woman, more than 500 days of healthy life over a lifetime, with profound implications for individual flourishing and societal productivity.

Investing in perimenopause and menopause specifically is not niche or soft. Workforce health research suggests that better support for women through these transitions could meaningfully reduce absenteeism, lower healthcare costs, and improve engagement and retention. Employers that prioritise comprehensive health, including midlife hormonal health, often see measurable gains in productivity and lower turnover- real returns that resonate on the balance sheet

A Second Chance

So what am I really saying?

That the stretch between matrescence and menopause is not a blur to survive. It is a second chance.

• For Women themselves- it’s a call to awareness and action: understand your risks, prioritise prevention, advocate for care that ‘sees’ you.

• For Clinicians- it’s a call to bridge siloes, to recognise that reproductive events are not discrete episodes but predictors of later health outcomes.

• For Policymakers- it’s a call to align investment with evidence. Health equity is not just ethical - it’s economic: healthier women, stronger communities, more resilient societies.

Because when women live healthier for longer, everyone benefits: families, workplaces, economies, and societies built, often quietly, on women’s labour and care.

The window between matrescence and menopause matters. It’s time we treated it like it does.

Here’s a question I’d like to explore

• Has lifestyle medicine quietly shifted blame onto individuals around healthy choices?

• Comment below

In October 2025 stood in the lecture hall at the University of Dundee Medical School, honouring a pioneer whose story still ripples through time. Dr Jainti Dass Saggar arrived in Scotland from Punjab in 1919, became Hilltown’s beloved doctor, and in 1936 shattered barriers as Scotland’s first South Asian councillor. His life was a masterclass in global citizenship—bridging cultures, fighting for equity, and reminding us that justice is local work with global echoes.

This year’s Jainti Dass Saggar Lecture was my invitation to connect the dots. Six degrees of separation isn’t just a party game; it’s the thread linking a pregnant woman in Dundee to a midwife fleeing conflict in Sudan, a policymaker in Westminster to a girl facing FGM in a refugee camp. We are all connected. And in 2025, that truth is both our burden and our superpower.

The Weight We Carry in 2025

Let’s not sugar-coat it. The world is on fire—slowly, structurally, persistently.

• 123 million people displaced by war and persecution.

• Over 700 women dying every day from preventable pregnancy-related causes—90% in the Global South.

• 18 million health worker shortfall looming by 2030.

• Maternal mortality rising in the USA post-Roe, stalling in parts of Africa, reversing a decade of progress in sexual and reproductive health.

• Climate collapse, antimicrobial resistance, AI bias in healthcare algorithms, pandemics that hit the poorest hardest.

As clinicians, we don’t just read these stats—we live them. We hold hands, shaking from postpartum haemorrhage. We counsel the teenager coerced into an unsafe abortion. We watch moral injury erode our colleagues. We see Black mothers in Scotland fear childbirth because the system wasn’t built for them.

How are these all connected?

• Political decisions dictate funding for education, workforce staffing which impacts the quality and quantity of care mothers & babies get.

• The rise in far-right, racist, fascist rhetoric ripples across borders, popping up as brazen, dangerous displays of xenophobia and islamophobia.

• Disease epidemics and unequal responses to pandemic preparedness influence migration patterns and supply chains.

And through this chaos… we have front-row seats to human suffering—and with that comes the rare privilege of acting.

From Despair to Joyful Resistance

I didn’t coin “joyful resistance,” but I live it. It’s choosing to dance in the storm. It’s turning rage into policy submissions, grief into community co-design, and burnout into collective care.

In 2019, I joined KWISA (Women of African Heritage) for the free food. I stayed for the vision: African women-led communities, dismantling inequalities at the intersection of race, gender, and health.

Fast forward to NAUWU – Nothing About Us Without Us, the first partnership in Scotland between KWISA and NHS Lothian’s Maternity Voices Partnership. We held five community listening events. 120 voices—pregnant Black women, midwives, doulas, public health experts—spoke raw truths:

"They assumed I didn’t speak English because of my name." "I was left in pain because ‘African women tolerate more.’" "My baby’s heartbeat dropped, and no one believed me."

MBBRACE reports confirm it: Black women are 2x more likely to die in pregnancy or postpartum in the UK. In Scotland, severe maternal morbidity hits ethnic minorities hardest. This isn’t biology. It’s structural discrimination—the most shocking form of inequality, as Martin Luther King Jr said.

But NAUWU isn’t just lamenting. We’re co-producing solutions: cultural safety training, bidirectional learning, and community-led birth equity. From individual healing to collective transformation.

Maternal Health: The Canary in the Coal Mine

Every system shock lands hardest on mothers and newborns:

• Conflict: 61% of global maternal deaths in just 25% of births—Sudan, DRC, Palestine, Yemen.

• Climate: Floods destroy maternity units; heatwaves trigger preterm labour.

• Workforce crisis: The UK saves billions relying on International Medical Graduates (20% of NHS doctors), yet subjects them to differential attainment, racist GMC referrals, and unethical recruitment from the Global South.

• Pandemics: COVID killed healthcare workers at higher rates if they were POC.

Women are 70% of the global health workforce but lead <25% of it. We birth the world, then patch it up—often without PPE, fair pay, or respect.

Six Degrees in Action: Your Patient in Dundee, Linked to Punjab

That woman labouring in Ninewells? Her outcome is shaped by:

1. UK aid cuts to sexual health in fragile states.

2. Scottish maternity staffing reliant on Filipino nurses.

3. AI triage tools trained on datasets erasing Black skin tones.

4. Local racist microaggressions eroding trust in care.

5. Global supply chains for oxytocin delayed by Red Sea conflict.

6. Dr Saggar’s scholarship funding the medical student advocating for her.

Your scalpel in the operating room is a political act.

Hope is a Discipline

Mariame Kaba taught us: “Hope is a discipline.” It’s not passive. It’s showing up. It’s the multidisciplinary NAUWU collective— mothers, midwives, obstetricians, doulas, lawyers, nutritionists, TV researchers—building systems rooted in justice and joy.

It’s clinicians refusing to look away. It’s turning compassion into bold, purposeful change.

If Hope is the Cure to Moral Injury, then Joy is the Preventive Pill to Burnout.

Joy is not happiness despite suffering. In medicine and activism, joy isn’t escapism—it’s strategic resilience. It’s the difference between burning out and burning bright enough to light the way for others.

• It is resting; not every day has to be about organising and social justice

• It is celebrating small wins, like maternal grief and lived experience turned into evidence-based policies

• It is building chosen families, sharing our hearts, not just action plans

• It is clinicians choosing compassion over apathy for and with our patients

Your Call to Action

1. Donate toward KWISA’s good work: https://kwisa.org.uk/get-involved/

2. Read the NAUWU community report: https://kwisa.org.uk/nauwu-report/

3. Reflect: How does your daily practice connect to global systems?

4. Act: Mentor an international medical graduate (IMG). Challenge bias at work. Support community-led research.

5. Share this post. Tag a colleague who needs to hear that resistance can be joyful.

In the face of suffering, look closer, not away.

By acting boldly with curiosity, we find joy in resisting injustice—while healing.

Because, as Dr Saggar showed us, one life, well-lived in service, changes everything.

Grateful to the University of Dundee, the family of Dr Jainti Daas Saggar, KWISA, NAUWU collective, and every woman who trusted us with her story.

—————————————————————————————————————————————————-

Dr Isioma Okolo | Consultant Obstetrician & Gynaecologist | @dr_isi_obgyn | drisiomaokolo.com

• I’m Dr Isi, making women’s health, careers and social change easy.

• Follow me and sign up for my newsletter for more

This is not an isolated tragedy. Black women in Scotland are 4 times more likely to die in pregnancy or childbirth than white women; they are more likely to experience a ‘near miss’ adverse outcome and disrespectful, discriminatory care in pregnancy, birth and beyond—a statistic that hasn’t budged in over a decade.

But now, there’s a blueprint for change.

I’m proud to share the NAUWU Maternity Report—Nothing About Us Without Us—published by KWISA (Women of African Descent in Scotland) in partnership with NHS Lothian Maternity Voices Partnership. This isn’t just research.

It’s a movement—built on lived experiences, evidence, and unapologetic demands for equity.

What the NAUWU Report Reveals: Stories and Stats

The report doesn’t just describe the problem—it names it.

Black mothers we spoke with reported feeling ignored or dismissed during their pregnancy and birth. Cultural misunderstandings, racial bias, and lack of continuity of care were recurring themes. Women reported that staff were slow to respond to their pain; staff did not know how to recognise medical conditions in darker skin, e.g. anaemia and jaundice. Staff

Voices from Black Mothers

The Numbers Don’t Lie

Other reports and studies highlight:

• 4x higher maternal mortality risk for Black women vs. white women in the UK ( UK MBRRACE)

• 62% of African/Caribbean women felt their cultural needs were not met ( AMMA Birthing Companions Report)

• 3 in 5 reported microaggressions from healthcare staff ( FiveXMore Black Maternal Experience Report)

1. Exploring ethnic minority women's experiences of maternity care during the SARS-CoV-2 pandemic: a qualitative study

2. MBRRACE Report 2021- Comparing Maternal Mortality by ethnicity in the UK

These aren’t just numbers—they’re lives, families, futures.

The Road to Equity: Actionable Recommendations

The NAUWU Report doesn’t stop at diagnosis. It prescribes real, scalable solutions:

• Mandatory anti-bias training for all maternity staff, with annual refreshers

• Culturally responsive care plans co-designed with African and Caribbean community leaders

• Ethnicity data tracking in all NHS maternity units to monitor and eliminate disparities

• Dedicated Black maternity advocates in every health board

• Community birth companions trained in trauma-informed, culturally safe support

Policy Wins: Collaborating with NHS Lothian. As a consultant OBGYN and advocate, I’ve seen what happens when systems listen. NHS Lothian’s partnership with KWISA is already piloting ethnicity-coded feedback loops—a model that should go national.

Why This Matters: Celebrating Resilience and Calling for Change

This report isn’t just about survival—it’s about thriving.

It celebrates the resilience of Black mothers who birth, heal, and lead despite the odds. It’s also a reminder: Equity isn’t a privilege. It’s a right.

Too often, the voices of African and Caribbean women are overlooked in the broader maternity care narrative.

Through first-hand accounts, evidence-based analysis, and actionable recommendations, this report shines a spotlight on the systemic barriers and biases that perpetuate unequal care while celebrating the resilience and agency of Black mothers. The NAUWU Report doesn’t stop at diagnosis.

Join the Movement: Your Next Steps

📥 Download the full NAUWU Maternity Report → Get the Report (Free PDF)

Take action today:

• 🔗 Share this post with your network—tag a midwife, doctor, or policymaker

• 💬 Comment below: What’s one change you’d prioritize in maternity care?

• ✉️ Join my community for monthly updates on women’s health, careers, and equity

Quick Poll: What should NHS Scotland prioritize? 🗳️ Reply with: A) Anti-bias training B) Cultural care plans C) Data tracking

Follow @kwisa_women kwisa.org.uk to stay in the loop.

Together, we’re not just bridging evidence and impact—we’re building a maternity system that works for every woman.

References:

1. MBRRACE-UK Perinatal Mortality Surveillance Report (2023)

2. NAUWU Maternity Report, KWISA & NHS Lothian MVP (2025)

Dr. Isioma Okolo is a Consultant Obstetrician & Gynaecologist, Harvard MPH, and founder of initiatives amplifying women’s voices in healthcare.

I’ll never forget sitting with a patient in my Edinburgh clinic, her eyes brimming with tears as she described feeling dismissed during a previous appointment about her heavy, painful periods.

- she’d waited 9 years to be diagnosed with endometriosis, a common condition that affects 1 in 10 women.

The truth is, shared decision making doesn't happen in a vacuum.

It happens in a 15-minute appointment, in a department brimming with people, with a clinician who hasn't eaten since 6am and a patient who has waited months to be seen — and possibly years to be believed. The system is under strain in ways that are structural, not incidental. And yet, within that strain, something still matters: the quality of what happens in the room. That's what this blog is about.

Not being heard. Not being told. Not enough time.

Have you ever left a doctor’s visit feeling like your concerns were brushed aside? Maybe you mentioned pelvic pain, only to be told it’s “normal,” or felt overwhelmed by medical terms without clear answers? You’re not alone.

Evidence suggests that clinicians interrupt patients within 20 seconds of speaking and only spend 5% of the conversation answering questions.

It’s not uncommon for patients to leave clinics with either too little or too much information & jargon. Clinicians also report feeling frustrated about not meeting patients' needs.

This blog equips you—whether a patient or clinician—with tools to make shared decision-making a reality, particularly in women’s health.

To do this, I’d like you to imagine 2 things:

1. The patient and clinician are on the same team.

2. There are always two experts in the consultation room- you are one of them.

Shared Decision-Making: What Matters To You?

Shared decision-making (SDM) is about teamwork—you and your clinician deciding together what’s best for you. It’s not me dictating a treatment plan; it’s us talking through your options, like whether surgery or watchful waiting suits your fibroid symptoms, or what birth plan feels right for you. The 2022 Realistic Medicine report calls this personalised care, and I’ve seen it work wonders in my practice. When I ask, “What matters to you? or “What’s keeping you up at night?” or” What do you think might be going on?”—maybe over a cup of tea in my mind’s eye—I hear what’s really on your heart, and we get to the core of your needs faster.

SDM takes time, sure, but it also saves time. By focusing on what matters to you, we avoid going down rabbit holes of irrelevant tests or treatments. For example, one patient told me her biggest worry was balancing menopause treatment with her demanding job. Once I knew that, we crafted a plan that fit her life, no extra appointments needed.

What If the Response is ‘ You’re the Expert-You Tell Me’

I’ve had attempts at SDM slap me in the face. My fondest memory of this was when I attempted my routine approach with an African Auntie. Her response- ‘Didn’t you go to medical school? You should be the one telling me.’

Acknowledging the cultural contexts of roles and power dynamics between care providers and users is critical. As clinicians, verbally acknowledging how important a patient’s perspective is in their care plan can be empowering. It gives people permission to share, contradict and question.

After that encounter, I changed my approach.

Now, when I begin a consultation, I explain why I'm asking. Not just what, but why. I'll say something like: your perspective is as important as my clinical training — it helps me understand what you already know, what concerns you, and where the gaps are. That reframe matters, because walking into a room and asking someone what they think is going on can feel strange, even disrespectful, depending on who you are and where you come from. Language, age, cultural background, socioeconomic context — all of it shapes how comfortable someone feels questioning a person in a white coat. I can't assume that an open question lands as an invitation. Sometimes I have to build the door before I can ask someone to walk through it

To ensure that you make the most of your upcoming appointment with your gynaecologist or any other healthcare professional, it is crucial to communicate your concerns and priorities to your medical team effectively. What matters to you?

Remember, providers exist for patients, not the other way round.

There Are Always (at least) Two Experts in the Room

Whilst as a patient you cannot compare your Google search to my 2+ decades of experience, as a clinician I cannot compare my medical education to your 2+ decades of living with that condition.

Despite decades of medical education and specialist training, no clinician will ever know your body more than you will. As a patient, this is your lived expertise. Both lived experience and professional expertise are important in shared decision-making.

If you’re dealing with endometriosis, heavy periods, navigating fertility challenges or perimenopause symptoms, lean into your lived experience. Your insights are gold and shape the shared decision-making.

Knowing your normal is, therefore, the number one most important skill you should invest in.

Track Your Symptoms

Use Your B.R.A.I.N to Make Shared Decisions

Think B-R-A-I-N!

This is my favourite prompt to enable shared decision-making. Ask( and answer) these questions:

1. What are the Benefits of this option?

2. What are the Risks of this option?

3. What are the Alternatives?

4. What’s my Intuition( gut feeling)?

5. What is likely to happen if I did Nothing?

Your Toolkit for a Great Gynaecology Visit

Here’s how you can walk into your next appointment feeling confident, drawing from my practice and resources from FiveXmore:

1. Come Prepared: You don’t need to shave or have matching socks- but bring a diary tracking your symptoms over a 4-8weeks.

2. Share the impact: Talk about how your symptoms affect your daily activities, sleep & relationships

3. Speak up: Ask about all your options. Think B.R.A.I.N to get the full picture—risks, benefits, and alternatives.

4. Bring a buddy: A friend or family member can jot down notes or back you up if you’re nervous.

5. Get a second opinion: It’s your right if something doesn’t feel settled.

6. Trust your gut: If something’s off, say so. Your instincts matter.

7. Do your homework: Check trusted sites like NHS.uk or RCOG Patient Information.

8. Write it down: Keep a notebook for your questions and the answers we share.

The Bigger Picture: Fixing a Stressed System

I won’t sugarcoat it—healthcare providers are human too, and we’re up against a lot: packed schedules, outdated tech, and burnout that’s all too real. The Reimagining study found that low morale and a lack of communication training hold us back from listening as well as we’d like.

But there’s hope.

• Policymakers, imagine funding training that helps doctors like me better understand women’s unique needs, like addressing racial disparities in maternal care.

• Academic friends, let’s study care models that center lived experience.

• Corporations, let’s team up on tech that frees up time for real conversations.

Having worked across diverse settings—from clinics in Edinburgh to community health initiatives in Kyanzanga, Uganda—I’ve witnessed the power of partnership and shared decision making: when clinicians and patients collaborate as equals, outcomes improve, trust grows, and care becomes truly personalised.

Let’s Keep the Conversation Going

Drop a comment, share this post, or shoot me an email at contact@drisiomaokolo.com. Let’s make women’s healthcare a place where everyone feels heard.

👉🏽 Sign Up for My Women’s Newsletter

For more topics like this and a FREE roadmap of essential Female Health Checks

Resources to Explore

• FiveXmore: 6 Steps to Advocate for Yourself

• Shared Decision-Making in Realistic Medicine

• RCOG: Understanding Risk in Healthcare

• ACOG: Patient Education Materials

Too busy to read or prefer audio? Listen to the audio version of this blog above. Now available on my Spotify

As an obstetrician and gynaecologist, it’ll be no surprise that I relate many things to pregnancy. Like the beginning of most pregnancies, the beginning of my consultant(attending) journey has been full of learning and adjustment, excitement at navigating new territory and above all, growth and development.

Before jumping into my reflections on the consultant journey so far, I paused to recall things about the end of training(residency) and the beginning of consultancy that I wish someone had told me.

1. The end of training can feel both like a climax and anti-climax. You reach a huge milestone in your life, but your daily life is still full of the mundane. Also after such a high, the comedown and realisation that your journey up yet another mountain has only just begun can feel very sobering. It’s ok. The feeling will pass. It’s normal to feel like this.

2. Celebrate yourself! Resist the urge to move on to the next goal post without acknowledging the momentous journey. It took me eighteen years to become a consultant! Mark it in some special way.

3. Take time off between the end of training and the beginning of consultancy. This will allow you to transition effectively into your new role mentally and physically. Budget for this to give yourself financial breathing room to take a break.

4. You have to pay to CCT. If you are a UK-based clinician budget for the surprise bill(£420) you will get from the General Medical Council(GMC) just to be added to the specialist registrar. This is different from your annual GMC fees.

5. Life does get better when you become a consultant. This may seem obvious to many. However, I’m not convinced enough consultants are sharing this message with junior doctors and residents. Being a consultant is brilliant and something to look forward to. Yes, it’s full of challenges. Our patients are getting more complex, and we face much more scrutiny today than ever before. There will be complications, new anxieties, low staff morale, rota gaps you must sort out, interpersonal dynamics chess games, workplace politics, and a never-ending soul-draining stream of admin. These multiple truths are not mutually exclusive. But being a consultant is great. Look forward to it, don’t fear it.

 So, what has my first consultant trimester been like so far?

My first consultant trimester has been enjoyable. I’m one of those annoying ones who “didn’t have any morning sickness”. I’m working in a familiar and supportive unit where I have previously stepped up from being a junior to senior registrar( resident). They’ve seen me at my best and worst. So I’m lucky to be surrounded by people I trust and who care about me. I appreciate that’s not the case for many.

My first couple weeks were spent figuring out the logistics of IT, paperwork, computer systems, my schedule, regional clinical pathways, and re-acquainting myself with my team. I have had my share of challenges including surprising rejection and tough clinical cases.

I was intentional in giving myself grace and space to ease, stretch and expand into this new role. My only expectation was to settle in gently. So I created healthy buffers to support this. I’ve been paying particular attention to my physical, emotional and mental well-being during this important transition.

Thereafter it was a mental battle of overcoming the normal anxieties of encountering new consultant ‘firsts. Navigating my first on-call shift, my first theatre list, my first complex case and complication as a consultant were equal parts exciting, challenging, satisfying, and humbling. My last four months have been marked by highs and lows, huge successes, and some disappointments but most of all growth.

So What are My Top Tips for Thriving in Your 1st Consultant Trimester?

1.  Learn How to Say No

Don’t take on additional responsibilities in your first three to four months.

Focus on settling in, building your confidence, experimenting with leadership styles, and studying your new clinical environment and culture before taking on additional roles and responsibilities within the department. Take time to understand the department’s interpersonal dynamics, priorities, and resources in the first few months. Armed with this knowledge, then explore departmental opportunities and needs that align with your strengths, priorities and values. For example, clinical governance, medical education, research etc.

2.   Be assertive and set good boundaries early on

Healthy boundaries allow you to practice medicine safely and sustainably and protect you from burnout, poor mental health, and attrition.

Sadly, in medicine we have normalised unhealthy maladaptive work behaviours to the extent that healthy work balance behaviours (e.g. taking required breaks at work, using designated annual leave, timely handovers, not responding to e-mails 24/7 or outside normal work hours, resting following an on-call shift, etc.) may occasionally be perceived as deviant, lazy, not being a team player.  Becoming a consultant is a great opportunity to reaffirm and re-assert healthy boundaries.

I am choosing to break deeply ingrained intergenerational medical curses by modelling healthy work-life balance so that my registrars, residents, junior doctors, and medical students see my example and courageously aspire for more. As a recovering people pleaser, some days it’s easy to hold these boundaries; other days it’s hard. However, I remember this quote from Dr Kemi Doll as a mantra to keep my boundaries solid. Create boundaries. Stick to them. Do not expect applause.

3.   Celebrate all your firsts- your first theatre list, ward round, first complication, first complaint, first compliment, first argument with a colleague, first wrong call, first heroic save when you’re called in from home to fix things. It’s only been four months and I have had nearly all of these firsts.

Pause and mark them as an intentional way of learning from the experience(good/bad). Reflect on it and record it in your portfolio as evidence of your continuous professional development. This will come in handy for your annual appraisal. Express gratitude and move forward.

4.    Go on lunch dates with your senior colleagues.

Getting to know senior colleagues can be a great way to get to know your department. Senior consultants, managers, midwives, and nurses hold the institutional memory and many words of wisdom. It’s also a good idea to identify a senior consultant as your informal or formal work buddy- a senior colleague you trust who can be a sounding board and moral support because they are likely to have been in your shoes at some point. Also, you may be able to bag yourself a free coffee ;D

5.    Figure out an organizational system early!

The rumours are true. When you transition from trainee to consultant the admin goes from zero to 1000. In the time I have written this blog, I have probably received 10 additional work e-mails that need immediate attention. Sigh.

Get into the habit of reading, dealing with, filling emails into subfolders and deleting regularly. This will keep your colleagues, secretaries, and managers happy. Create a system to allow you to do this in a proactive rather than a reactive manner.

Multi-tasking is a fallacy( even for women).

A great tip a colleague once shared is to avoid doing admin in between patients during a clinic and I’ve stuck to this. If you are fortunate and have a lull in the middle of your clinic, grab tea, coffee or water or read through the latest publication from TOG, BJOG, ACOG, or listen to your favourite podcast etc. You’ll notice that in between patients you don’t truly have time to read a journal paper or listen to a podcast( semi-mindless tasks). So why are you busy rushing to do admin that requires your full attention at the same time?

6. As your pace slows down interrogate your “Why”

For most of us the pace of working changes. Our degree of autonomy increases. After decades of studying and training for the first time, you may find yourself at a loss for ‘what to do’ when you are no longer being told exactly how to structure your time. This is a great time to fine-tune your self-leadership skills. I wrote about this in a previous blog exactly a year ago. It was one of my most viewed blogs!

As physicians and surgeons our training prioritises technical skills. However, I believe that it is the non-technical executive-level functioning skills required to successfully manage and lead oneself and team that are ultimately what makes an excellent consultant. In honing these skills as a new consultant, I found it useful to ask myself two questions “How do I want to show up as a consultant?”” Why?” Beyond a list of desirable characteristics and abilities, understanding your “why” is a useful exercise in the emotional interrogation of one’s motivations, values and ultimately your ikigai. I believe that this is what you should focus on nurturing and cultivating during your career, as it is ultimately what will sustain you.

7.   Give yourself some grace (build in some rest)

Confidence comes with time. I believe confidence is the reward you get from being courageous in life. Be brave and consistent in exploring your new role. It’s taken me eighteen years (since starting medical school) to get to this point and yet, I’m only at the beginning of my journey of being a consultant. There’s no rush. Ask questions! Be open-minded. Take on constructive feedback with grace and interest. Remember to rest- it’s your number-one superpower.

8.   Finally, enjoy it!

One of the best things one of my mentors said to me was “Just enjoy it Isi. You made it and you deserve it!” Receiving that verbal affirmation and charge for joy from someone I deeply respect was liberating.

 So far in my first trimester of being a consultant I have had several highs and several lows and I’m sure that will continue all through my career. I continue to expand into the role. And I am choosing to enjoy it all, the good, the bad and the ugly.

Bring on the second trimester! Stay tuned for more.

NOW WHAT?

• Do you know a new or soon to be consultant(attending)?Share this with them.

• Make sure you sign up for my newsletter and podcast to receive updates on new blogs.

Are you a senior resident at the end of training or an early-stage consultant?

Access “The Next Step”- a course for doctors becoming consultants/attendings — about the things no one really explains.

What does Black Joy look like in maternal health?

The narrative around ethnic minority maternal health is often steeped in stories of perpetual struggle, pain, and systemic suffering. The media leans into this narrative of Black pain.

Whilst it is critical to bear witness to disparities as part of the advocacy to overcome them, what is the cost of glorifying Black maternal pain without telling the full story of our experiences which celebrate our success, knowledge, values and strengths when it comes to birthing?

There are Unintended Negative Consequences of Advocacy

I have been guilty of causing unintended negative consequences in my zealous advocacy.

Advocating for birth equity is essential, but sometimes, it inadvertently fosters fear, helplessness, hypervigilance, and avoidance among those it aims to help. While fear can mobilize people to take action, it rarely builds sustainable, dignified change. Fear can stigmatize communities and detract from the root causes of disparities: unjust systems, policies, and environments. Fear can also alienate allies eager to help but who are overwhelmed with moral injury and helplessness.

Our Bodies are not Broken

Media headlines, research articles, policies and activism that simply describe disparate statistics without context fuel this fear and paralysis.

These well-intentioned actions contribute towards the pathologising and reinforcing the image of broken Black and Brown bodies.

To counter fear and helplessness we must share stories of positive change, resilience, and joy alongside adversity.

I recently spoke at a National meeting about maternal and newborn health inequalities in Scotland. In the spirit of sharing positive stories, I’d love to highlight the progress happening in Scotland as we work to close the gap in maternal health outcomes.

Use the time stamps to explore:

00:00 The work of the Scottish Patient Safety Program (SPSP) in improving maternal care.

07:29 An overview of perinatal disparities in Scotland ( Consultant Obstetrician Dr Isioma Okolo)

45:04 Practical examples of initiatives driving positive change in Glasgow ( Midwife Nicola O’Brien)

Five Reminders as You Watch:

1. There is nothing inherently wrong with Black and Brown bodies.

2. Black and Brown women aspire to experience safe, affirming, and positive pregnancies.

3. A greater risk of poor outcomes doesn’t mean you are destined or doomed to experience them.

4. Pregnancy and birth in the UK are safe.

5. Positive change is happening, and it’s all around us.

I think it’s time we shift the focus and ask different questions

Shifting from damage-centred narratives means moving the focus from stories of survival to stories of thriving. Maternal health advocacy can and should be a space where joy and resilience are celebrated despite, and not just because of adversity.

How to Shift Away from Damage-Centred Narratives

• For healthcare providers: Instead of wondering, “What’s wrong with this person?” ask, “What matters to this person? What’s wrong with the environment I am providing care in? How are power imbalances and biases showing up here?” Creating a safe, supportive space is crucial for dignified equitable care.

• For minoritised pregnant individuals: Don’t let yourself believe that you’re bound to experience a negative outcome. Instead, ask, “What in my environment nurtures, serves, and supports me, and what doesn’t?”

Check out some wonderful examples of positive birthing stories from these organisations:

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• FiveXMore

• AMMA Birthing Companions

• Association of South Asian Midwives 

  ( ASAM)

• Maternity Engagement Action ( MEA)

I got this question frequently in my recent absence.

Where have I been? Right here. Exactly where I should have been. Taking care of life; working; resting; and transitioning to what feels like a new chapter in my life. Holding space for the transition- withholding my natural tendency to ‘begin’ another journey, set another goal post without first appreciating the beauty( and pain) of the last 100,000 miles.

I’m very good at ‘doing things’; and less practised at truly resting and pausing- rest is a superpower I continue to aspire to.

Since my last blog post, I have had so many firsts.

• My first half marathon- I ran the Glasgow half marathon in under 4 hours!

• My first oral presentation at an international conference on a  subject I genuinely care about.

• My first party to celebrate myself that I’ve thrown since my wedding in almost 10 years.

• My first consultant (attending) job, after completing 9 years of residency in obstetrics & gynaecology🍾#CCT

I’m sure there will be more firsts!

But I am marking time to celebrate my achievements and failures and express gratitude for the body, mind, experiences, and community that got me here.

I am learning how to speak without self-censoring. I am enjoying resting and just being. Normally I’m an active rester. Which is code for I just can’t sit still and my sense of self-worth is still wrapped around my productivity.

But increasingly I’m learning how to truly rest. I’ve had agenda-free, guilt-free rest- listened to so many books and podcasts; and read some new fiction- which is a big deal as I’m more of a non-fiction kinda gal. I’ve been experimenting with creative fictional writing and brainstorming on creative and communal ways to channel my passion for social justice. It’s been fun and I can’t wait to share some of this with you.

In this period, I have also been lucky to be able to see and spend time with those nearest and dearest to me. This is significant because my home and my heart are far and near across multiple time zones and continents. I am part of a global village that sustains me.

And now I’m writing this blog on a plane to Antalya- my first and not my last trip to Turkey. I’m excited about the prospect of a bit of sunshine and warmth to break up the harsh Scottish winter. But even more excited about trying authentic Turkish delight, which I’ve had a mild obsession with since reading Edmund’s account of indulging in the sugary cubes of temptation in the book The Lion the Witch and The Wardrobe by C.S Lewis.

For some time, my happiness felt rogue. I would even get intrusive thoughts warning me about ‘senseless’ impending doom. Perhaps don’t celebrate so openly in case you fail, or something unexpected happens. The undertones of this are that being authentically joyful would grant me the well-deserved karma of mishap ‘because you shouldn’t be so joyful and immodest in your truth and glee. I’ve also felt a pang of guilt about expressing joy in the face of the senseless humanitarian crises and genocide in Palestine.  I remember the ongoing instability in Sudan whilst caring for a pregnant woman who recently fled Sudan to seek asylum in Scotland. And am reminded about the daily trafficking of young women when I met a 16-year-old Vietnamese woman in the early pregnancy unit with an ectopic pregnancy.

We need a global cease-fire

Everywhere you look if you look hard enough there is a plethora of human suffering. Thinking specifically of innocent lives in Palestine, Sudan, Syria, Yemen, Ethiopia and the DRC.

I renounce the oppressive forces globally brought on by historical enduring legacies of colonialist, white supremacist, capitalist and oppressive systems that disregard the sanctity of human life.

I remember the lives of people gone too soon. I pray they rest in peace, power, and love. I pray for strength for those left behind.

And(not but), amidst this suffering there is also a plethora of joy. Right now joy feels like a privilege. I am grateful to have some.

Today I choose joy

 When I first launched this blog, my dad intrigued by the title quizzed me about my choice of title- Echi Di Ime. In my language, Igbo, Echi Di Ime means “tomorrow is pregnant”. Perhaps an apt title for an obstetrician and gynaecologist, we joked.  Echi Di Ime also means “no one knows what tomorrow will bring”. The title's significance to me is in my daily affirmation of hope. I continue to choose joy amidst the less joyful and uncertain parts of human existence.

 Whilst away I thought about you my readers of Echi Di Ime. Initially, I felt guilt- oh I’ve let it slip. What if I don’t know what else to write? What if I lose my readers? Perhaps I’m not cut out for this. That’s the recovering people pleaser with a tinge on imposter syndrome in me speaking.

 Nevertheless, It feels right to be back here. I have so much to write about. I’m taking my time, hopefully, you’ll stick around.  

Stay tuned for more( whenever it arrives).

I love to hate you,

Hate to love you yet need you,

Resilience, my dear.

- a haiku about resilience

If Resilience and I were a couple, our relationship status on Facebook would state, “It’s complicated!” It’s complicated because we are in a constant flux of breaking up and making up, but we also cannot seem to exist without each other. I have written this blog three times, and with every iteration, I felt an increasing confusion towards resilience. Like ‘The Persuaders’ said, it’s indeed a thin line between love and hate regarding my relationship with resilience.

Why I  Love Resilience

Because without it, I would not be who or where I am today.  The highlights of my life reveal someone successful in many areas; however, I’ve had my fair share of adversities (rejections, incivility, failures, epic mistakes, burnout, disappointments, etc) that have critically shaped my path today. Peaks and troughs, as my sister Nomis calls them. I would rather never have experienced any of these. I keep chasing the soft life, but it keeps running away from me.

Medicine is a marathon, not a sprint. I have previously compared medical training to elite athletic or military training- they differ physically, but the mental rigour required to survive and thrive is similar. The long shifts and decades of training are merely the tip of the iceberg. I sometimes marvel at what I do for a living and how most of the world will never experience or understand what it is like to witness the most vulnerable points of people’s lives daily; to resuscitate, excise, cauterise and triage to heal. Sometimes we heal by doing nothing. Sometimes we heal by holding our patients’ hands and supporting a dignified death. Our actions are based on occasionally difficult decisions at difficult times, frequently with limited resources.

Drawing on detective skills using anatomy, physiology, pharmacology and sociopsychology to put together a differential diagnosis and treatment plan: to prescribe medications with known side effects with the belief that they will do good and cause minimal( or no) harm; to pull out babies stuck at caesarean birth or an impacted shoulder with the awareness that every second of oxygen is precious; to control major bleeding following a ruptured ectopic pregnancy in a woman who has already experienced multiple pregnancy losses; to review fifty patients in emergency department without a toilet or lunch breaks because you know they have waited five hours to be seen; to hold a patient’s hand whilst they die alone with no family or friends; to utter the words “ it’s not cancer” and experience shared relief; to break the news “I’m sorry it’s cancer” and hold space for despair; to assist the birth of a baby conceived after multiple failed rounds of IVF; to look a family in the eye after conducting an ultrasound of their precious baby and say the words “ I’m sorry but I cannot see a heartbeat”; to care for patients who have physically tried to assault you two hours ago;  to apologise because we made a mistake we know may have been avoided if we had more time, training, staff or rest; to relish in the simple joy of delicious slice of NHS buttered toast at 3am on a night shift.*Sigh* #IYKYK

  We do all these things, then go back to our family, friends and lovers and talk about the latest episode of “ Black Mirror” and our plans to see Burna Boy’s concert over the weekend whilst chopping up tomatoes to make jollof rice. The degree to which health workers can(must) compartmentalise work, and life is incredibly weird. We do it because we love the profession( mostly). We do it because we must get through the shift. We do it because we are trained to. We do it because we are resilient.

 Why I Hate Resilience

I have often heard resilience being compared to being like a malleable rubber band. When placed under immense pressure, the band stretches, maybe never returning to its original shape but never breaking. Which material on earth can withstand indefinite stretch and strain? Is the aspiration for individual resilience in the face of chronic stress and strain realistic when we know that resilience, like willpower and self-control, are finite resources? Arguably there is a fine line between resilience and normalised maladaptive behaviours to chronic stress.  Resilience can very quickly evolve into or be masked as apathy, indifference, quiet quitting, burnout, incivility, and hypervigilance.

Resilience is occasionally weaponised in healthcare settings. I have heard of junior doctors, nurses and midwives being offered “resilience training” when they have struggled emotionally or physically following significant adverse outcomes, resitting professional exams or dealing with chronic rota gaps. Some colleagues refer to the younger generation of health workers as “snowflakes” because we do not cope with (or rather refuse to tolerate) the working conditions that our predecessors accepted and normalised.  This is a shame but not a surprise. In times of stress, empathy is often the first thing to disappear. We pay more attention to building resilient people rather than resilient systems and environments that do not run by burning the finite fuel of goodwill, willpower and resilience of hardworking but overworked individuals.

Endurance is the Near Enemy of Resilience

I recently learned of the Buddhist concept of ‘near enemies’- emotions or traits which masquerade as positive virtues or values but actually arise from a different and sabotaging space. For example, pity is the near enemy of compassion, and attachment is the near enemy of love. Is endurance the near enemy of resilience? Perhaps the problem is the definition of resilience I’ve been sold. The kind that requires you to be tough, thick-skinned, be able to endure indefinitely and have a camel’s bladder.  Perhaps like me, many of you have mistaken endurance for resilience when the truth is you can be an absolute ‘snowflake’ and still be resilient! The (un)fortunate truth is that we cannot survive or thrive without resilience. The ability to bounce back from setbacks and the strength to grow through adversity are vital components of a resilient mindset. Bouncing back requires self-awareness, softness and ease. By embracing the delicate balance between recovery and strength, we can practice healthy resilience as a way to face life's challenges head-on, adapt to change, find strength in vulnerability, and emerge from hardships stronger, wiser and softer.

Personally, I’m unlearning the lies I have been told about resilience and embracing a new definition that centres on growth, self-awareness, authenticity, healthy boundaries, and soft fluffy edges. To do this, I have had to learn the difficult but liberating concept of self-leadership and explore my ikigai, which I have written about in previous blogs. I’m still very much a work in progress.

My take-home message is to continue to moisturise your soft fluffy edges.

Writing this in the backdrop of the junior doctors’ strike and celebration of the NHS 75th birthday is apt. I support my colleagues on the picket lines and am proud of the NHS. I chose to study medicine in the UK because of the NHS. As a teenager growing up in Nigeria, I was blown away to learn of a healthcare system founded to provide free care to all at the point of need. Universal Health Coverage is a  human right that I will continue to fight to uphold.

I am proud of the NHS because it is propped up by amazing, talented, hardworking ( and resilient) people who show up. But I know we can and must do better. NHS workers deserve to be valued, nurtured, and adequately renumerated because we are worth it. Our patients and service users deserve to be cared for by the best.

Happy 75th birthday to the NHS!

Rose et al. found in their study that if you experience imposter syndrome, you are statistically more likely to be overqualified and extremely high-achieving.

Why, then, do you suffer despite your glowing CV and references?

The reason you may feel impostor syndrome is because the spaces you occupy were never designed to include you.  You have likely been implicitly or explicitly told that we do not belong. So today, I want to invite you to reimagine your definition of imposter syndrome by holding a mirror up to your personal and professional environments.

I, too, thought I was an imposter. 

S&%t! What have I done now? Is it too late to revoke my application? Maybe I can tell my residency training program director that I’d like to defer my entry into  OOPR (out-of-program research). I’m not actually going to Harvard, am I? What am I going to do there?

 These thoughts plagued me for weeks after receiving and initially celebrating my double acceptance to Harvard Medical School and Harvard TH Chan School of Public Health for a research fellowship and master’s degree. I’d never been to Harvard, but I knew it was hard to get in and full of bright people, exciting opportunities, and an even more impressive alumni list. And they let me in?

In my case, the imposter syndrome was worsened by the knowledge that my parents, in true African style, had probably told every person on their WhatsApp contact list of my admission. Now the whole of Nigeria knew I was going to Harvard. OMG.

 What Imposter Syndrome is Not

Imposter syndrome is not just self-doubt and ‘first’ anxieties. These are normal feelings that we all experience, not infrequently. They are a normal response to encountering a new situation for the first time. The anxiety from such scenarios can provide the healthy stress that encourages us to attack the hill with a good balance of humility and self-belief.

So initial self-doubt and anxieties were not new to me. I experience them frequently. What was new to me was this deeper intellectual questioning of my self-worth. Where had this come from? It didn’t make sense. Why would I have applied in the first place if I really did doubt myself?

What is imposter syndrome really is

Three years ago, I realised the true nature of imposter syndrome – a manifestation of internalised systemic bias and discrimination resulting from living and working in sexist, racist, xenophobic, classist, ableist, and homophobic societies.

 The reason you may feel impostor syndrome is because these spaces were never designed to include you.  We are implicitly or explicitly told that we do not belong.

Imposter syndrome is many steps beyond normal self-doubt. It is the inability to internalise one’s own successes and achievements instead of labelling external success as luck. Imposter syndrome is that little( loud) voice in your head that says, “You should not be here!” This is fuelled by fear of being discovered to be a fraud. In many ways, it is a tango of intellectual gaslighting that only leads to an erosion of self-worth and suffering.

Until three years ago, I’d been protected from ‘imposter’ syndrome’ thanks to what I fondly call my Nigerian privilege- the benefit of growing up surrounded by multiple examples of realities, including excellence. That and having a pushy mother who was always rhetorically asking whether “Ola has two heads?” to remind you   #NaijaNoDeyCarryLast

 I think imposter syndrome started to seep in the longer I had been away from Nigeria.  The longer I stayed in the UK, still surrounded excellence, but notably fewer examples of excellence that looked like me.

Did you know that imposter syndrome was originally thought only to affect High Achieving women?

Imposter syndrome was first described in a 1970 research study by Drs Pauline Clance and Suzanne Imes. They defined it as ‘an internal experience of intellectual phonies, which appears to be particularly prevalent and intense among a select sample of high achieving women.  Certain early family dynamics and later introjection of societal sex-role stereotyping appear to contribute significantly to the development of the impostor phenomenon.  Despite outstanding academic and professional accomplishments, women who experience the imposter phenomenon persist in believing that they are really not bright and have fooled anyone who thinks otherwise.’

This study took a very normal experience of anxiety and self-doubt and pathologised it for women without critiquing the systemic and structural biases in environments that enabled or hindered their progress. This study and the general concept of imposter syndrome is an example of ‘damage-centred’ work- anything that superficially appears to highlight and support the plight of a marginalised group but, in doing so, deems and defines the individuals and that group as deficient or damaged.

Confidence will not fix imposter syndrome, but courage might

In their famous Harvard Business Review article with over 1 million reads, Jodi-Ann Burey and Ruchika Tulshyan assert that the key to overcoming imposter syndrome is to change work cultures, not fixing individuals. The goal of overcoming imposter syndrome lies with people in leadership and privileged positions. The goal is to make workplaces as diverse, inclusive and equitable as possible. Recognise the difference between normal self-doubt and impostor syndrome fuelled by systemic biases. This work requires courage ( a bit of resilience), not confidence. Confidence is the reward you get for being courageous.

MY TOP TIPS FOR OVERCOMING IMPOSTER SYNDROME…

1. Find your tribe- a safe space to talk about your experience and, most importantly, triggers.

2. Let go of people-pleasing and perfectionism by celebrating your successes and achievements

3. Mentor people who are coming up behind you.

4.  Engage meaningfully in initiatives which aim to improve equality, diversity and inclusion in your workplace-but never   

         at the cost of your wellbeing.

5. Learn how to master self-leadership- which I have written about previously here.

6. Build capacity and exemplify compassionate, inclusive and diverse leadership.

7. Consider accessing career coaching and or therapy.

8. Rest- it is the fuel that keeps us going in. Rest is resistance and a superpower.

Imposter syndrome has a negative impact on all of us, not just those who experience it.

I believe that many companies and institutions are functioning below their potential because exceptional and often overqualified people continue to second guess their abilities whilst working in toxic and non-inclusive cultures. Imposter syndrome negatively impacts productivity, recruitment, and retention of staff. What a waste of talent!

 Equality, Diversity, and Inclusion( EDI or DEI) seeks to address this, which is important but insufficient. EDI/DEI initiatives are often top-down with little room for co-production ability to truly hold organisations accountable to their shiny ‘Commitment to Equality” statements visibly plastered all over websites but not replicated in their recruitment, promotion and retention policies and practice.

 This approach tends to garner suspicion from minoritised people ( is this another tick box exercise) or resentment from non-minoritised people ( mostly white male, cisgender heterosexual men) who feel like they are being forced to engage in yet another company ‘woke exercise’.

The ultimate result is non-engagement and little or no sustainable change. The cycle of imposter syndrome continues.

 Breaking the cycle involves building accountability into whatever  EDI/DEI initiatives. Leaders and team members must ask, how will we know we are having a positive impact? How will we measure and share change? How will we invite people in?

 Imposter syndrome is exhausting, so rest up before you rise up.

As individuals from minoritised backgrounds, we are socialised as ‘firsts’ and ‘only’- the first Black woman to blah blah, the only woman in a hijab on national TV, the first trans man in government etc. Being socialised as firsts is initially exciting, ego-stoking but eventually exhausting. It is a further reminder that the environments we exist in were not made for us. So existing and thriving requires quite the activation energy that, quite frankly, not all of us possess or desire to expend.

My message to you, my reader, this week is that you are enough. In the words of Toni Morrison, “ You are your own best thing”. To the person experiencing imposter syndrome ( to my possible future self), remember it is hard( not impossible) to become what you cannot see. So surround yourself with positive examples of who and what you aspire to become. When invited to the party, sometimes you’ll have to bring your own chair to the table. But when you get to the party, put your best foot forward and remember to hold that door open.

Must Read after this blog….

• Harvard Business Review: stop telling women they have imposter syndrome

• The Original 1970 Research Paper on Imposter Phenomenon in Women
  

Using race and ethnicity as risk factors for health conditions is “risky business” because it embeds and normalises damage and deficiencies in Black and Brown bodies whilst conveniently ignoring the environments, structures and systems that perpetuate poor and unequal health & wellbeing outcomes.

Essentially, racial risk assessment with good intentions may encourage negative racial profiling and the use of inappropriate or delayed interventions. You cannot change an individual’s race or ethnicity, but you can challenge and change the structures which uphold or withhold good health and well-being. But do you want to?

Good intentions alone are not enough when seeking to address health inequity.

In this week’s blog, I explore the risky business of racial risk assessment, risk factors, risk markers and structural determinants of health and wellbeing.

#ReimaginingBetter

CALL TO ACTION

Race is not a proxy for genetics.

1. If you do include race and ethnicity in clinical decision algorithms and risk assessments, be sure to acknowledge and educate people using these algorithms on the impact of systemic racism on health outcomes.

2. Be curious-question the use of race & ethnicity whenever you come across it in education, research, policy and clinical practice.

3. Use evidence- screen people based on their symptoms, personal medical history, family history and lifestyle-not the colour of their skin.

4. Remember- race is a risk marker for structural determinants of health, including systemic racism. Racism is a reversible risk factor for poor health outcomes. The difference is in acknowledging the order in which to intervene on the pathway to poor outcomes.

5. Racism can have a biological impact on health through an increased allostatic load( stress response), biological weathering( wear and tear), psychological burden and behavioural adaptations.

We must teach people that health inequities result from systemic racism, not false notions of biological differences. For example, the research shows that Black, African and Caribbean women experience higher rates of postpartum haemorrhage and PPH ( heavy bleeding after pregnancy). To mitigate this, some groups have included “ Black, African and Caribbean” race & ethnicity as a risk marker in clinical screens that reduce PPH but acknowledge that increased morbidity in Black, African and Caribbean women could be due to differential treatment, e.g. delayed recognition and response to evolving PPH. Evidence shows that health workers respond differently to racially minoritised people’s pain and distress. Pulse oximeters used routinely in clinical settings miss lower levels of hypoxemia in darker skin people. Health workers may be unable to spot ‘pallor’ and other signs of anaemia in darker skin tones. Having fibroids or thalassaemias like sickle cell, which are more prevalent in Black, African and Caribbean individuals, can increase your risk of haemorrhage. Not all Black, African and Caribbean women are affected by these conditions. This is distinctly different from saying being Black, African, and Caribbean automatically makes you bleed more.

To keep people safe using risk assessment, we must specifically state the true drivers of risk and then address them. Else we will continue to treat the symptoms, not the source of the problem.

Examples of Race Correction in Clinical Medicine

Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740

Firstly, I believe that power and privilege are good- IN MODERATION.

Power grants access to resources that can influence our chances of achieving goals and influencing others. Power gives us opportunities and freedom. Why wouldn’t you want power?

Secondly, power is not random.

Power is socially constructed by dominant groups and historical events with enduring consequences today. The ultimate consequence is that power gives access to more resources such as education, wealth, health, security, protection from environmental toxins, and nutrition. In this race of life, some of us will start a couple of steps ahead. Where you start is dependent on how much dominant ‘currency’ you possess.  This currency, broadly speaking, relates to identity, networks, norms, and values, which are weighted based on your immediate context.

 As a researcher exploring the lived experiences of Black women accessing reproductive health care, being a Black woman gives me power in this space because I have an ‘insider’ status. However, ‘Black women’ are not a monolith. As an African woman, I have more cultural ‘currency’ on issues relating to African women compared to those affecting, for example, Caribbean women.

Being a Black woman who is also an obstetrics & gynaecology doctor may give me power in some situations due to society’s perceived hierarchical status of the medical profession. In a different context, however, my medical affiliations may position me as an outsider, perceived as part of a group that has historically enacted reproductive injustice towards women of colour.  Have you been in situations where you’ve held the currency of power and the privileged position of being an insider? Equally, have you had experiences where you have felt powerlessness and the disadvantages of being perceived as an outsider?

What is positionality?

 Positionality is the position from which we see the world around us. It’s dependent on our identity, reflects on our worldview and how we approach things in social contexts. Different dimensions of our identities often, unknowingly, shape interactions we have in our schools, communities, work environments and academic fields. Our positionality determines our gaze and impacts who we choose to collaborate with, what we prioritise, how we ask questions, make decisions and interpret findings.

Why is it important to know about our positionality?

 An awareness of one’s positionality helps us understand that objectivity is an illusion. Positionality is a reflexive process of appreciating biases, power, privilege, dominance and oppression in ourselves and others. Positionality helps us build empathy and courage to address unfair power dynamics to promote equity and social justice.

 Various aspects of one’s identity confer advantages and disadvantages. Dominance is an aspect of our identity that gives us power based on social norms and values. Due to the history of the world, many societies are dominated by standards which prioritise white, male, cis-gendered, heteronormative, European, North American, middle-class, non-disabled and Christian values.

There is absolutely nothing innately wrong with being white, male, cis-gendered, heteronormative, European, North American, middle class, non-disabled and Christian. However, it is problematic when these identities are upheld as the universal standard, even in spaces where these do not represent the majority. Identities, norms, values, and networks only become problematic when they ‘other’, dominate and unfairly give advantages to a few whilst disadvantaging the majority. Therefore, dominance is the root of all systems of oppression.

Are you still with me?

We all have dimensions of our identity that put us in a place of dominance that others often see but are invisible to us. This is the essence of the final P of health equity- privilege.

 We are frequently resistant to recognising our individual privileges because being privileged is associated with not having worked hard for whatever resources we may have access to. But I argue that it is possible to have worked hard and also benefit from privileges you have not earned and have little control over, for example, your gender, your race & ethnicity, the family and social class into which you were born, your passport, etc.

As privileged beings, we tend to highlight aspects of our identity where historically or socially, our role is that of the oppressed versus the oppressor( beneficiary/ dominant). For example, white working-class men might tend to recognise the socio-economic challenges of being working class but fail to notice the social advantages of being white and male. As a Black nondisabled English-speaking woman, I am more likely to notice the disadvantage of being Black and female in some spaces and less likely to appreciate the advantage of speaking English and not having to navigate the London tube as a wheelchair user.

Privileges are like automatic doors that swing open as we approach them. It’s hard to appreciate doors when they are opened to you. We only notice them when the automatic function fails and we slam straight into a hard glass surface(ouch!)

 Because we are a product of our environments and lived experiences, it is normal for us to understand people, values and norms closer and more similar to ours. Beyond our centre, we have biases. Our biases lie at the edge of our positionality privileges and lived experiences. This is our blind spot-the source of resistance, discomfort and lack of empathy in these conversations.

I believe that power and privilege are NOT a zero-sum game. The real issue is too much pIE.

 The concept of a zero-sum game means if I gain, you lose and vice versa. It implies that there are only so many slices of pie to go around. And is particularly appealing to those with the most pie, scarcity or fixed mindsets.

The reality is that society is suffering from situations where certain groups engorge themselves on more pie than they can digest, whilst others can barely scrape at crumbs.

How much pie do you actually need?!

I believe that there is no zero-sum game in redistributing power because the benefits must be viewed in the medium to long term. It is possible to share power and privilege by recognising that you can never truly lose what you have already benefited from in the past. Resist the seduction of a scarcity mindset and appreciate that when individuals are given a fair, level playing field to succeed, the whole of society benefits from their success and maximal self-actualisation in the long term.

As I stated earlier, I believe that power and privilege can be good things. However, too much pie, power and privilege is a bad thing.

The moment our privileges and power begin to encroach on another’s autonomy, freedom for self-determination and actualisation is the moment we become problematic. Excessive privilege and power, once recognised, can only be redistributed intentionally and fairly by introducing accountability.

 In summary, understanding, acknowledging and then interrogating power, positionality, and privilege is the first step to addressing health inequities.

 So, once we know better, then we can do better. Doing better involves an active choice.

I look forward to continuing our conversation about ACTION in part two, “Prescribing Power: Allyship & Accompaniment”.

P.S

As always, if my thoughts this week struck a cord, piqued your interest, or you’d like to explore some of these ideas further or have questions, leave a comment and write to me HERE.

Exciting news! In June, I was invited to speak at the prestigious RCOG World Congress in London, attended by 2300 delegates from 84 countries. My talk on the intersection of race and obstetrics & gynaecology was featured as one of the conference's highlights. Since then, I've received multiple positive messages encouraging me to share the information from my talk on this blog.
This week, I've created a special voice-over recording to accompany the presentation of my talk, titled "Why Do We Keep Talking About Race in Obstetrics & Gynaecology?". This talk represents a culmination of my professional goals to inspire constructive dialogue on equality, diversity, and inclusion. I aim to champion proactive and sustainable solutions to the inequalities that impact our workforce, patients, and service users in obstetrics and gynaecology.
Addressing these issues is not only a matter of social justice but also directly impacts patient safety, quality of care, and economic resource allocation.

As Professor Camara Jones states, inequalities "sap resources from the whole of society," including you!

I invite you to join the conversation, comment, and share this post to help bring about meaningful change in our quest for equality, diversity, and inclusion.

Enjoy!

Presentation made using PREZI and available HERE or by scanning the QR code.

resources

RUN AND BUY THIS BOOK: Divided: Racism, Medicine & Why We Need to Decolonise Healthcare by Dr Annabel Sowemimo

WATCH

• Harvard Audio-Visual Resource on how to reduce your own biases: Outsmarting Implicit Bias

• Professor Camara Jone’s Famous TED Talk on Youtube: Allegories on Racism

  LISTEN

• Harvard Medical School PGSSC’s Anti-racism statement: Available here

• Race & Health Podcast: Lancet Series on racism, xenophobia, discrimination and health

  RCOG RET resources

• RCOG eLearning Module: What we can do to reduce racism

• RCOG eLearning Module: What is Differential attainment

• Okolo ID, Khan R, Thakar R. Differential attainment, race and racism: levelling the playing field in obstetrics and gynaecology. Obstet Gynaecol Reprod Med 2022; 32: 152– 8.

• Okolo, I.D., Prasad, M., Siddiqui, F., Mountfield, J., Khan, R., Ward, S., Peregrine, E., Joash, K., Bowen, S., Agboola, B., Edwards, C., Elkhatim, S., Dore, S. and Thakar, R. (2023), A race to the finish line. Obstet Gynecol, 25: 92-96. https://doi.org/10.1111/tog.12863

  GMC

• General Medical Council. What is Differential Attainment?

• General Medical Council. How to Support Successful Training for Black and Minority Ethnic Doctors: Actions and Case Studies for Medical Royal Colleges and Faculties. London: General Medical Council; 2020

  OTHERS

• Boston Medical Center. Health Equity Multidisciplinary Grand Rounds

• Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health 2000; 90: 1212– 15.

• Alliance For Innovation on Maternal Health: Quality Improvement Racial Disparities Bundle

• Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet 2020; 396(10257):1125-1128.

This week I reflect on identity, narratives and statistics. Focusing on how stories formed through statistics can create stereotypes that normalise and embed damage within minoritised identities and communities.

I will introduce you to the concept of ‘damage-centred work’, which I confess, I have engaged with.

(I explain terms used in the video at the bottom of the page)

This week’s vlog is inspired by a famous letter written in 2009 by Professor Eve Tuck.

In her letter to communities, she warns us against engaging in damage-centred research- “research that intends to document peoples’ pain and brokenness to hold those in power accountable for their oppression. This kind of research operates with a flawed theory of change: it is often used to leverage reparations or resources for marginalized communities yet simultaneously reinforces and reinscribes a one-dimensional notion of these people as depleted, ruined, and hopeless."

If we perceive individuals and communities as damaged, we will never expect them to survive, let alone thrive.

Damage-centred work is common. It shows up in research, advocacy, policy, healthcare and education. It distracts us from focusing on the environments and wider structures which act as barriers or facilitators of wellbeing( education, nutrition, protection from environmental toxins, human rights, fair justice systems, safe housing, patient-centred health care, gainful employment etc.). It is often benevolent. But good intentions are not enough.

I now understand that to tackle inequities, I must recognise and reject damage-centred work and aim instead to do work which addresses inequities by acknowledging the multiple realities, including:

1. There are solutions, Strengths, assets, priorities and value systems within individuals and communities

2. Current disparities aRE legacies and manifestations of oppression

3. oppression is rooted in history, power and privilege.

4. to address inequalities, we must interrogate power.

I can’t wait to dig deeper into this approach with you in future posts.

Explanation of Term Used in This Video:

• Damage-centred work: anything that contributes to individuals being stereotyped as broken, deficient or damaged by focusing only on one dimension of their reality. For e.g., in the UK, more people are now aware that Black women are four times more likely to die during pregnancy. It would be wrong to put ‘Black’ as a risk factor for maternal mortality because it is the experience of being a Black womxn( intersectionality) whilst accessing healthcare and living in society( social determinants of health) that contribute towards that risk. Not simply having Black skin.

• Racially minoritised: a term I use in place of BIPOC (Black, Indigenous & people of colour), POC (people of colour), BAME (Black, Asian & Minority Ethnic)  and BME (Black & Minority Ethnic) recognise that individuals and communities do not naturally exist as minorities; but instead have been assigned this identity in response to dominant socio-economic political narratives and the standard of ‘whiteness’. ‘Minoritised’ intentionally highlights contemporary power imbalances rooted in historical events of slavery, colonisation, and other systems of oppression.

• Intersectionality: the acknowledgement that everyone has their unique experience of discrimination and oppression. It explains how this experience is compounded when people have multiple minoritised identities. For e.g. whilst women may experience sexism in society, Black lesbian cis-gendered women may experience sexism compounded by racism, compounded by homophobia.

• Misogynoir: a term coined by Moya Bailey (an African-American feminist scholar, writer, and activist) to describe the unique combination of misogyny and anti-black racism experienced by Black women. An example of intersectionality!

• Hegemony: cultural, social, political and/or economic dominance of one group over another

P.S

As always, if my thoughts this week struck a cord, piqued your interest, or you’d like to explore some of these ideas further or have questions, leave a comment and write to me HERE.

Five years ago, I experienced the most extreme anti-climax. Following six months of intensive, gruelling studying and coaching by senior colleagues, I smashed the hardest exams of my life on my first attempt-the MRCOG. The MRCOG is the professional board examination for UK practising obstetricians and gynaecologists. You cannot progress in training or become a consultant(attending) without achieving the MRCOG. In 2018 I proudly became a member of the RCOG, celebrating alongside my pals Viner and Gary(pictured below). Our graduation was fantastic! The only person more relieved than myself that day was my poor husband, who had coped with an absent wife for six months.

At the end of it all, I recall being sat on the train back to Edinburgh and thinking,“ Now what?” This feeling of anti-climax was accompanied by confusion and languishing. I knew the next step was to progress through advanced speciality training. I planned on focusing on early pregnancy, acute gynaecology and advanced labour ward practice. Whilst I found hospital medicine exciting and rewarding, I couldn’t quite see the big picture. Something was missing.

Our ikigai is what drives us- why we wake up in the morning and do whatever we do. It motivates us beyond the responsibilities, societal expectations, authorities and negative emotions that may also drive us.

Obstetrics & gynaecology is a seven-year run-through specialist training program. The downside of a run-through clinical training program is that without a natural built-in career break, it is possible to progress without thinking critically about one’s personal and wider career development. Without the right mentorship and sponsorship,  it is easy to fall into the trap of jumping over career hurdles simply because it is ahead of you. Suddenly you are a consultant obstetrician & gynaecologist without a clear understanding of why you do what you do day in and day out.

The sweet spot where these four circles overlap is where you may find your ikigai.

I am passionate about global women’s health. This is likely because of my lived experience as a global citizen. Global health is frequently misunderstood to be healthcare only in low-resource settings in African, Asian and Latin American countries. However, the ongoing impact of migration, climate change and, more recently, the COVID-19 pandemic continue to remind us that we all live and work in resource-limited settings.

Therefore global health is better thought of as the business of reducing inequities within and between countries. Inequities exist globally in Nigeria, India, Brazil and Scotland.

 The COVID-19 pandemic put a spotlight on chronic health inequities amongst racially minoritised people. Three years into the pandemic with significant strains on the NHS,  there has never been a greater need for health systems that proactively tackle inequities- disparities that are preventable, unfair and unjust. Beyond the social justice argument, there is a strong economic, cost-effectiveness and health quality argument for addressing variation in outcomes. These variations cost health systems billions annually. Inequalities cost the NHS £4.8 billion annually! We owe it to the workforce, patients and their families to consider additional factors which influence the quality and impact of whatever prescription or surgical procedure we deliver in a hospital.

In Scotland, I noticed patterns in health inequities- the same groups of people seemed to have worse outcomes. Sometimes they were described as marginalised or vulnerable. The same group were also labelled as “repeat” or “late attenders”, “ non-compliant”, or “difficult to reach”. Negative outcomes became normalised and almost expected. I noticed that in hospitals, we scrutinised individuals’ “bad health” choices but rarely critiqued or interrogated systemic factors that took away choice, acting as structural barriers to good health from these so-called vulnerable and marginalised groups.

 I recall feeling uncomfortable with the realisation of my current limitations as a hospitalist to address deeply rooted structural issues that I now appreciated would continue to limit the outcome of whatever prescription or surgical treatment we provided in the hospital. I felt like I was engaging in an exercise of patching over cracks but wanted to be involved in preventing the cracks.

This is where I found my ikigai in appreciating the impact of social determinants of health (SDH) on variation in health outcomes. Most health workers have become familiar with the concept of SDH. But it is not uncommon to think that addressing SDH should remain squarely in the realm of public health- prevention, promotion, protection, and not acute care. It is surprising how divorced public health teaching is from medical education.

So, I went back to school to advance my knowledge and skills in public health, research methodology, and community co-production. And now, I am committed to addressing unwanted preventable variations in health outcomes by combining my multiple hats as a clinician and community organiser involved in community-based participatory research, which informs policy specifically aimed to eradicate health inequities for Black women living in Scotland. This is my mission statement and a core part of my ikigai.

 I believe it is critical to find our ikigai because it is the key to finding joy in whatever you choose to do.

The Institute of Healthcare Improvement (IHI) state that joy in work promotes wellbeing, healthcare quality and patient safety.

Finding one’s ikigai is an important part of human existence and the key to achieving self-actualisation, the pinnacle of Maslow’s hierarchy of human needs. In the current climate of global workforce strains, it may be a way to address the crises of burnout and attrition.

So how can you find yours?

In finding my ikigai, I firmly reject the superficial, saccharine, toxic positivity definition of happiness. Ikigai is something deeper and more stable. Our ikigai is something deeper that belongs to us, is done voluntarily and brings joy.

Chasing your ikigai can be scary and lonely, so find a community of like-minded people. Be brave. You will likely be told explicitly and implicitly that you cannot do “xyz..”. You may be warned that some of your choices will hamper your career progression. We live in a world where people are anaesthetised by overwork, social media and sugar. Deciding on something other than what is considered the norm will make you stand out. Your actions may trigger negative emotions in people around you. Expect some resistance and surround yourself with a good support system that will energise and inspire you to continue moving forward. Remember, joy is a long game.

Lean into that support when you receive rejection and caution. When you do succeed, bravely share your story to inspire others.

I have survived and thrived in spaces where I am considered the oddball not solely because of my personal ability- but because I have found and held on to my ikigai. I am “being” and “doing” bravely in a community of like-minded individuals.

That’s my secret sauce!

P.S

In future blogs, I may share my reflections on how hospitalists and non-public health practitioners may engage meaningfully in addressing the impact of social determinants of health (SDH) in acute settings through quality improvement( QI), audit, research, significant adverse event reviews ( SAER) and equality, diversity & inclusion training.

Maybe I’ll call it “ Help, which social determinant of health should I address in my 15-minute consultation?”

What do you think?

P.S

As always, if my thoughts this week struck a cord, piqued your interest, or you’d like to explore some of these ideas further or have questions, leave a comment and write to me HERE.

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]]>When Clinical Excellence Isn’t Enough: Finding Ikigai in MedicineLeadershipMedicineCareersIsioma OkoloWed, 27 Dec 2023 07:00:00 +0000https://www.drisiomaokolo.com/blog/self-leadership63b9eb0c3545291f9298eb5a:63b9f8d6cb84542ccbe7665f:64257ab336efff3c93565245

To celebrate the beginning of Spring and the official countdown to my completion of clinical training (CCT), I would like to share my reflections on self-leadership as a clinician working within the NHS in the UK. Self-leadership is a concept I first came across from Dr Kemi Doll - an inspirational academic gynaeoncology consultant and career coach. As a practice, it has been foundational in my journey towards successfully building a diverse career portfolio.

What is self-leadership?

Self-leadership is the ability to influence and direct your own thoughts and actions to successfully reach goals and build a satisfying life.

It is a practice of consistent strategic decision-making using the lens of one’s personal value system and aspirations. It is informed by deep self-awareness, courage and maturity. Self-leadership is a way to practice authenticity, recognise your values and worth and make decisions that are in line with them.

In medicine, we receive both informal and formal training on team leadership. We are expected to demonstrate examples of good leadership by mentoring junior colleagues and leading clinical, research and managerial teams. Little focus is paid to self-leadership. People can find themselves in leadership positions because they excel clinically or academically, without knowing if they can successfully lead a team, let alone themselves.

Medicine as a profession is a culture.

Medical training is long, with high stakes and a rigour comparable to elite athletic and military training. Despite this, preparation for the psychological and emotional intelligence required to support sustainable, healthy medical careers is often lacking. Whilst we are trained on critical reflection in the context of biomedicine and research, there is less consistent high-quality training on critical self-reflection and self-leadership.

We are taught through the formal curriculum and the hidden curriculum of medicine. Objectivity is the goal, with subjectivity and emotions generally viewed as weaknesses. This is in spite of the evidence in favour of the critical role of emotional intelligence in high performance, decision-making, and positive work cultures.

We are not taught to understand and explore our ikigai-the driving force of daily lives. The run-through nature of our training enables doctors to abdicate the role of critical reflection on long-term personal and professional development to chance, check boxes and superiors.

This is why I believe all doctors in training should take time out to explore areas of interest that reflect their values and aspirations in addition to medicine.

Self-leadership as a clinician can be challenging, because we are trained to conform, excel at pattern recognition and abdicate career decisions to pre-existing paths.

Guidelines, and evidence-based medicine are our bread and butter. Our training strips away our individual identity replacing it with a new collective professional identity - ‘the medic’, who is objective, respectful, resilient and compassionate towards, but also distanced from patients. Conformity is further enforced by our workload. We are anaesthetised by overwork due to staff shortages, low morale, and burnout.

There is little headspace or capacity to reflect in the face of exhaustion-but remember resting is our superpower!

Why is Self-Leadership Important?

I believe that self-leadership is the key to career longevity, success and joy in work. It allows you to identify, own and protect your value by bravely and consistently acting to create a career that brings you fulfilment. Self-leadership allows you to take control of your career when circumstances appear seemingly out of your control. As an NHS clinician, I have found this concept transformational and will be forever grateful for the work of Dr Kemi Doll.

Medicine as a career is a beast of a marathon, not a sprint. Many of us will work in conditions where we have dwindling autonomy on our rotas, operating schedules and clinic lists. Additionally, in the wake of the COVID-19 pandemic, globally, the healthcare workforce is experiencing extreme strain with record levels of burnout, attrition and poor mental health. Increasing workforce capacity will not happen overnight. As a profession, I believe we must prioritise and enable self-leadership in the wake of these pressures.

I have learnt about self-leadership initially by failing at it woefully, then by studying and learning through career coaching. It is a skill that I continue to improve on with daily practice. I hope you find some of these tips of good use. If you fail at it, just try again.

1.    Identify your IKIGAI. You must identify your core values, aspirations, strengths and weaknesses in order to lead yourself effectively. What do you stand for? What are you absolutely not willing to compromise on? Read my previous blog on discovering your Ikigai before coming back to the last 4 steps. Working with a career coach may also help you begin with step 1.

2.   Surround yourself with informed believers. Informed believers ( a term coined by Dr Kemi Doll) are people in your life who understand your context and believe in your cause. You do not need to convince them. They do not belittle your ideas or offer alternative pathways based on their own fears and standards. They are distinct from uninformed believers ( like friends or family) because they have specific knowledge of your professional context. Informed believers are mentors who strategise with you and sponsors who endorse you by speaking your name in rooms when you are absent. Find them, share your Ikigai with them and make them part of your accountability circle. Be wary of taking advice from informed non-believers who may advise you based on their own standards, fears and aspirations. You have no business taking advice from someone who cannot see or understand your vision.

3. Take Action. Acting is a self-leadership skill that requires us to move beyond contemplation in the face of uncertainty. It means getting started by taking direct steps towards a goal you are trying to achieve. To take action, we must overcome imposter syndrome, perfectionism and procrastination. After completing steps 1 and 2, take a leap of (informed) faith and create your path by walking the path. Set up the meeting, write the proposal, sign up for that course, update your LinkedIn profile and reach out to that contact today!

4. Learn how to change your mind. Being a good leader requires regular self-auditing, adaptability and humility. We must be willing to recognise, admit then pivot when a certain path (partnership, project, mentorship) is not working or fails because an assumption we made is incorrect. Changing your mind does not automatically mean you are unreliable and fickle. It indicates that you have a consistent value system and are reflecting and responding appropriately when you find yourself in circumstances in conflict with that value system.

5. Hold your vision. This may seem in direct conflict with step 4. However, holding your vision is a skill in managing uncertainty when things do not go as planned. It is being steadfast after performing the self audit that tells you you’re still on track but can't quite see the path. As a leadership skill, it helps us manage the discomfort of failure, rejection, unexpected pushback and challenges. It requires us to continue walking the path even when we come across a muddy patch because we are armed with the knowledge of our core values and aspirations and surrounded by a tribe of informed believers who have our backs.

To further cement this concept of self-leadership, think back to a time when you were part of a team led by someone who seemed to have no awareness of the team’s core values, mission, strengths or weaknesses. Have you worked under a leader who was crippled with indecision and could not take action? What if your team leader refused to change course even when the project was headed for a clear disaster? You can imagine how confusing, frustrating and challenging it must be to be part of such a team.

I have found that at the most challenging points in my career, the main source of discomfort has been decision-making. All five steps of self-leadership involve making different decisions using a consistent lens. This lens is executing a career based on your value and aligning your work with your purpose. Go forth and lead yourself.

Good luck!

P.S

As always, if my thoughts this week struck a cord, piqued your interest, or you’d like to explore some of these ideas further or have questions, leave a comment and write to me HERE.

Up until recently, I did not know how to rest. I grew up and am still surrounded by messages about work, productivity, my value, and identity. Hard work was a cornerstone value in my family. Unlike the stereotype of many African parents-I was not pushed to study medicine( business, engineering, or law). But I was forced to be excellent at whatever I chose to do. I wrote about this in 2018 when I explained that “ Naija no dey carry last” and shared my discovery of my Nigerian privilege.

 I have been blessed with the gift of good sleep and the uncanny ability to sleep in the most inconvenient locations. Once my head hits a  pillow, I pass out. I am the champion of post-on-call slumps- straight 24 hours spent in a semi-recumbent state- half asleep, half Netflix-ing. I am privileged to be able to afford travel and now have the ‘correct’ passport for spontaneous, relatively cheap city breaks. I have travelled to multiple countries worldwide and enjoy a good staycation. At work, I make sure I take assigned work breaks.

Rest is crucial. It rejuvenates us. It boosts our bodies, moods, memory and immune system. Rest allows us to keep functioning at our optimal level. Resting gives us the space to reflect and discover our spark- our reason for being or ikigai, which I have previously written about.

I BELIEVE ALL THIS YET, I have often felt guilty about resting. Subconsciously I associated resting with laziness or weakness.

So much so that I would work at only two paces- 100% or 0%, and rest only in response to extreme exhaustion- the 24-hour slump I mentioned earlier.

I now appreciate that rest is both turning off and turning down. But ultimately, it is the absence of distraction.

We live in a world where we are constantly distracted and seeking out distractions- compulsive screening of e-mails between seeing patients, scrolling through social media and reading long WhatsApp threads. I learnt to rest at work and at home by firstly recognising these distractions and re-labelling these as opportunities to pause.

To rest, you must aim to reduce distractions and expend less energy such that you gradually build up your reserves over time.

As I type this, I imagine the cynical eye-rolls of parents and overworked NHS colleagues struggling with childcare, understaffed and already stretched rotas. I have total sympathy for us. Rest can seem out of reach when our A&E departments are packed with patients who have waited for hours, or when your four medical pagers keep going off in a synchronised rhythm of chaos; or your toddler decides that today they must be held and carried 24/7. Our wards could do with extra nurses and midwives, and our doctors continue to be stretched thin with long-term rota gaps. It would be nice to have a peaceful toilet break without a tiny person closely in tow.

When you can barely take your assigned breaks, or have a newborn who is cluster feeding, how on earth can you even dream of resting at work?

But I believe the work never stops, so we must stop. By this, I mean firstly insisting on taking a break; and then intentionally gradually incorporating rest in our lives- at home and at work when we notice a pause. Noticing pauses in our day is a skill that requires continuous practice.

Rest should ideally be proactive and planned, not reactive and random.

Beyond taking a break every few hours, I have learnt to notice pauses in my day. In the few minutes between seeing patients in a clinic or awaiting the next theatre case, or at the end of a ward round, I have learnt to sit still and enjoy guilt-free resting. Sometimes I’ll enjoy a snack, some water; listen to music and a few words from a podcast I’m following whilst waiting. I may spend two minutes on Headspace. I  do not check my inbox for e-mails between patients. I am engaging in less multi-tasking and doom scrolling through the news and social media. I also rest by being present whilst conversing with colleagues during these pauses. I notice people’s faces when I talk with them.

Think back to the last three conversations you had today. You may have sat opposite them and looked at them, but do you recall seeing their faces? You probably were a bit distracted if you didn’t see their faces.

I do frequently fail to notice the pauses and revert back to my old habits. When I catch myself, I laugh at myself. I’m no longer hard on myself for failing to rest. I keep trying, and I am getting better at it gradually. I have noticed a significant increase in my energy levels. I have more capacity for creativity and connection. Resting is truly my secret weapon.

Rest is essential. Rest is the cure for burnout. Rest is self-love. Rest is resistance to the dominant problematic narrative around productivity.

So, in summary, we create space in our lives by intentionally resting over the course of our days, weeks, and months. We can rest during the natural pauses in our day, as well as take regular breaks. Waiting to bulk rest over a month-long holiday in Bali is not sustainable.

The truth is work never stops whether you work as a full-time mum, portfolio manager, charge nurse or junior doctor in the orthopaedic ward. You must notice the natural pauses and then pause.

Your work won’t stop, so you have to stop. Rest up.

In future posts, I look forward to sharing my top tips on how to say “ NO”. Another superpower we must all cultivate in order to rest and find our ikigai.

P.S

As always, if my thoughts this week struck a cord, piqued your interest, or you’d like to explore some of these ideas further or have questions, leave a comment and write to me HERE.