Associate Professor of Medicine, OHSU Division of Hospital Medicine, and Program Director for the Internal Medicine Residency Program

A medical detective on the trail of academic master, for herself and other women

In her last year as an undergraduate at the University of New Mexico, Sima Desai, M.D. R '98 was a volunteer "cuddler" in the university hospital's neonatal unit where she cared for babies born to drug addicted mothers. "The babies were often inconsolable," she recalled, "and you would sit for hours rocking them and holding them." The experience became indelibly imprinted in her memory. Its effect on her is also emblematic of a compassion and sensitivity that has dominated the entire tapestry of her career.

That experience made it painfully difficult for her to choose internal medicine over pediatrics when the time came to set the course of her career. She was sure pediatrics would be her specialty. But she was surprised in med school by how much she enjoyed her internal medicine rotations. "It was the complexity of thinking that I found so challenging. I felt it was like being a medical detective, listening to stories and trying to tease out what was important and what you could let go of."

Now, nearly two decades later, Dr. Desai leads one of the most highly touted internal medicine residency programs in the country where the mission is teaching not just the clinical sciences but also the pure art of teasing out the truths of a patient's condition. To that end, one of the overarching themes in talks she gives to medical students and residents is the fundamental importance of listening with care to the stories patients tell.

"You might hear a patient's story while proceeding through your differential diagnosis, ordering and interpreting tests and providing a treatment plan," she said in remarks at the 2011 OHSU School of Medicine hooding ceremony for graduating medical students. But hearing, she asserted, is not the same as listening. That involves probing for what she calls "the story under the story, the one that might light the way to the correct diagnosis." It's that kind of interaction, she said, that makes the patient-doctor relationship most effective – and potentially a life-saving one.

In residency, a shot of confidence

The sensitivity and compassion extolled in Dr. Desai's speeches is mirrored in her kind and genteel demeanor. She is self-deprecating to a fault, despite a formidable list of honors and achievements. She credits many of her successes to mentors who stepped in at critical points in her career urging her to reach beyond her own self-imposed limits. She blossomed during her residency at OHSU in large degree, she insists, because of the confidence others had in her abilities.

It was her selection as chief resident that did the most to bolster her sense of self-worth. "Becoming a chief resident was not something I thought about. I saw people who wanted to be chief residents because they were the smartest people. In internal medicine, it's an honorary additional year. "We had so many amazing people in my class, I thought, please! Never in a million years." When she was prodded, she insisted, "That's not me. I'm not the person you think I am. Then I thought maybe I should at least try and if I don't get it, fine. And then the shock. I got it."
 

A work ethic beyond reproach, rooted in her parents’ example

She concedes that an almost punishing work ethic – one instilled by her parents' example – has been the personal quality most instrumental in her success. "My parents are the primary reason that I am where I am now – because it's basically been hard work. Their work ethic was beyond reproach and I think they taught my sister and me, not by being overt but by actually doing the work they did and having the same expectation of us."

Dr. Desai's parents immigrated to the United States from India in the 1960s when her father, who already had a master's degree in geology, came to study for a second master's degree in mining engineering at what then was the Missouri School of Mines and Metallurgy. He took a job in the copper mining facilities in Silver City, N.M., the town where Dr. Desai was born. The family moved three years later to Carlsbad, N.M., where she and her younger sister Nina grew up. Her mother, a Sanskrit scholar – a specialty for which there was little call in New Mexico, Dr. Desai quips – ultimately became a technical librarian at the U.S. Department of Energy's Waste Isolation Pilot Plant in Carlsbad, one of the world's deepest geological repositories for radioactive waste. Both Dr. Desai and her sister worked at J.C. Penney as young teenagers and had side jobs all through high school and college. "We never spent money. We used all of it for our educations."

As a child of immigrant parents, Dr. Desai's sense of "otherness" cast a shadow over her youth. "Discrimination was a fair constant for much of my growing up years," she says. "We were the only dark-skinned people in the area." Dr. Desai and her sister endured taunts at school, and their father faced even worse treatment. Outside their home they always felt they were being judged. "We would really dress up just to go grocery shopping, for example, because we felt not looking your best was unacceptable. Our family was integrating into a society that was not my parents' for sure, and I was straddling two worlds. "Learning to adapt in both, she thinks, has made it hard for her to think in absolutes. "It's why I view the world in shades of gray." She recoils from judging people, she says; she tries to understand them and adapt.

Gender discrimination didn't manifest itself during her years in college or medical school, although she does remember a palpable feeling of discomfort in med school during her surgical rotations, where the men far outnumbered the women. But she has become more aware of it in recent years. "Women may dominate half of medicine, but that doesn't mean things are okay. There'sstill a lot of work to do. Subtle things continue to happen. It was only recently that I ran into one of the most overt instances of discrimination I've had as a woman. "Dr. Desai is reticent about sharing details but says it resulted in a degree of loss. "I've had some recovery, but I'm paying attention to these things now when I wasn't before."
 

Finding the teacher within

If getting the nod to be a chief resident was the capper on her residency years at OHSU, it was the invitation she got from Dr. Alan J. Hunter that she looks back on as one of the biggest breaks of her career. He asked her to join him and other clinicians in shaping a teaching program at OHSU for hospitalists – internists who take care of patients while they are hospitalized. "It launched every other aspect of what I do now," she says. "It was an opportunity of a lifetime."

She along with Drs. Rebecca Harrison, Scott Sallay and Peter Sullivan, assisted Dr. Hunter in developing the Medicine Teaching Service, the precursor of the Division of Hospital Medicine, now headed by Dr. Hunter. "The idea was to develop a cadre of people whose primary interest was to teach," said Dr. Desai. OHSU was among the pioneers in a specialty that has proliferated across the country since then; the number of hospitalists has grown from a few hundred to over 30,000.

Until then Dr. Desai didn't see herself as a teacher, although she was moving in that direction without realizing it, she says. Her focus had been on being the best physician she could be. But in the process she was learning things she really wanted to share. As chief resident, she was tapped to do much more educating and found that teaching really was her calling. One of the secrets of being a good teacher, she believes, is not trying to bowl people over with your knowledge but keeping a sensitive eye out for those who aren't getting it and figuring out what can be done to help them.
 

“Stirring the pot from behind”

Has Dr. Desai followed any particular strategies for climbing her way up the rungs of the career ladder? "I wish I could say that I was purposeful, that I knew I was going to do this thing and then that thing. I never thought to myself, one day I will be X. "It has mostly been the intervention of mentors who helped push her career along, she says.

One strategy she does credit, however, is the time and energy she has devoted to committee work. She started out with the Code 99 committee, which deals with issues surrounding patients who enter respiratory or cardiac arrest and which she chaired for three years. In 2005, she served on the search committee for a new OHSU president. She served on the OHSU Diversity Advisory Council and co-chaired the Women in Academic Medicine Committee. She is active in the American College of Physicians, was chair of the ACP Council of Young Physicians, and is a member of the Oregon chapter of the Governor's Council and chair of the Program Planning Committee.

The OHSU committees she served on helped her step outside her internal medicine environment and learn more about the institution. "It allowed me to be more effective in my own system." Her work with the national and local ACP, she says, has exposed her to many extraordinary people and has allowed her to grow in ways that she otherwise might not have, she thinks. "When you are outside of your institution, people don't know anything about you and it allows you to try on new ways of being and to push yourself in ways that you otherwise wouldn't."

Although Dr. Desai wants more attention to be paid to the needs of women in academic medicine, for one thing, she does not regard herself as someone who bucks the system. "I have never been a wave-maker and I think that stems from my family. But I sure do appreciate wave-makers and am always amazed at the clarity they have to see when something is wrong. I'm happy to jump on their coattails, stirring the pot from behind. If there were something I could change, I would love to be a wave-maker."

She struggles to maintain a good balance between work and her personal life. Her six-year old-son has happily found many playmates. "I'm lucky if I get a hello and he's gone again," she said. As he's gotten older, however, the tug of wanting to spend more time with him has only grown stronger. She is making more time for him and her partner of 16 years, a retired critical care nurse, in the early evenings, which she compensates for by working later into the night. "That actually works for me and it works for my family and it seems to give me the kind of balance I need."

As she looks back on all she's accomplished so far in her career, Dr. Desai offers one parting thought. "I could not have done any of this without the support of my partner who has been there for me every step of the way, allowing me growth and unconditional love."
 

Lessons Learned, Lessons Shared: Advice from Dr. Desai

Dr. Desai's advice to young women in academic medicine?

• First and foremost, seek mentors early. Whatever feelings you have about yourself, it's possible not all of it is correct. Having mentored a number of women medical students and residents, I think they suffer a lot more than men do from the imposter syndrome. They think: 'I'm not good enough, I'm not this, I'm not that.' I deal with this a lot more in women than I do in men. Women I have mentored have not seen their potential in the way that I think they could. They need a knowledgeable outsider who can say to them, yes, you are correct about this, but, no, you're wrong about that. That's essential.
   
• Be aware that, even though the number of women in medical schools and residency programs now is about equal to the number of men, discrimination continues to happen. Things are a lot better, but that doesn't mean things are okay. What happens to women now is far more subtle and harder to define. It's very important that women keep a sharp eye out for these things and meet in discussion groups to talk about ways to address the problems they identify.
   

Article written by Harry Lenhart