Most attending physicians with whom she worked during her general surgical training were white men who, she believes, had "little interest in mentoring [her] and little experience with female surgery residents." Although she had little contact with female surgeons during her residency, Dawson found that they fell roughly into three categories. The first group, she maintains, included women who became or tried to be "macho." They made callous statements about patients and bragged about their sleepless nights; they were "surgeons first and only incidentally female." The second group included women who tended to "maximize" their femininity and "minimize the difficulties and sexism encountered during residency." They always wore makeup, Dawson notes wryly, "even in the middle of the night." The third group, more difficult to identify, were the women who were "changed and wounded" by what happened to them during their residencies. They were more apt to be quiet and "rarely spoke of their pain."

When Dawson looked into research on women and minorities in medicine, she found an emerging literature on the topic but little about the "impact of medicine on women." She found very little on female physicians of color. Her own experience and the dearth of data on black female physicians, particularly surgeons, were the impetus for her inquiry.

The longest section of the book concerns six black general surgeons who had completed their residency training 5 to 15 years earlier. Chapter 4 includes selected data from the interviews with the six women, which focused on their decisions to become general surgeons, their accounts of their residency experiences, their characterizations of general surgeons, their descriptions of the overall effect of residency on their lives, and their characterizations of their lives before and after residency. Chapter 5 contains Dawson's analysis of these interview data, on the basis of which she develops a model of the surgical residency experience for black women: immersion, distancing, surfacing, and transcendence.

For readers outside medical culture, Forged by the Knife will be an interesting account of what residency training is like in general, and in particular for those whose sex and race place them in the minority among physicians. For readers in medicine and medical education, parts of the book will be less compelling, because they cover well-known territory. Dawson's review of the literature on women and medicine also contains familiar names and references. Some of the writing has not made the transition from dissertation to book; Dawson uses bothersome side headings and sometimes repeats the same quoted material to make different points. Nonetheless, the book contains fascinating details, most of them in the uncensored language of black female surgeons, whose observations provide penetrating lenses on the culture of surgery. Some of their stories about being surgical residents are recollections of a lonely, exhausting "boot camp"; some focus on the camaraderie and closeness among fellow sufferers; some concern themselves with the nonreflective, "just don't have time to think" nature of the residency experience. Their narratives are full of challenges faced by women in surgery -- for example, what one called the "Catch-22" of having to choose between being a "psychobitch" and being "passive." Surprisingly (to me), most of the informants found their sex to be more problematic than their race during their surgical residencies, although one cited difficulties encountered at the intersection of the two: "If I had a complication in residency, I was always the example. But if someone else had a complication who had skin of a different color or different gonads it was the exception."

Dawson and her informants suggest that it is possible to overcome the effects of the "spirit-crushing" years of overwork and exhaustion. For some of the difficulties they have encountered, they offer common-sense solutions that should be embraced by directors of surgical residency programs who are committed to creating humane environments for all residents; one of these is providing on-site day care for women who want to breast-feed or who just want "to go and see [their kids] for lunch." Other suggestions include mentoring and the addition of supportive measures to deal with difficult and often traumatic clinical experiences. Forged by the Knife explores previously undocumented phenomena that are relevant to medical educators, those concerned about the development or dwindling of empathy in medical trainees, and those interested in sexism and racism in medical education. It is a book that should interest all medical educators.

Delese Wear, Ph.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.