Matt Sherrer (Host 1): Welcome to The Fresh Flow Podcast. Excited for another episode. Mitchell, how are you, buddy?

Mitchell Tsai (Host 2): I am good. How are the mountains of Tennessee?

Host 1: Yeah. I was going to launch right into that. Just back from the mountains of Tennessee. I was a camp counselor last week. I had to come back to work so I could relax. It was amazing. The views from the mountains, the smoky mountains in the morning and the sunrise, unbelievable. So, my question to you is: Where's that place nearby up there in your neck of the woods? That kind of scenic place where you can go to get away and unwind and just see incredible scenery. What's that place up there near you?

Host 2: I think one of the best things about living in Vermont is that my commute to work's about 10, 11 minutes a day. But once you leave the confines of the hospital and the university campus, it's pretty much around you. You got the Adirondacks to the West and Lake Champlain, and then you got the Green Mountains to the east. And so, it is a beautiful place to live. And so, you really don't have to go anywhere to be there.

Host 1: I want to come up there and do some smallmouth fishing in Lake Champlain-- that would be incredible-- but you never invite me. So, I guess I'll have to book it myself.

Host 2: You're welcome to come.

Host 1: Well, where we really need to go for scenic views is to Utah, right? So, how about-- with that segue-- you introduce our guest for today?

Host 2: So, I'm going to buck tradition and I'm actually going to do a traditional introduction here for Dr. Hopf. She's a Professor and Executive Director of Faculty Development Academic Affairs in the Department of Anesthesiology, Perioperative and Pain Medicine. She's an Adjunct Professor in the Biomedical Engineering Department. She's a Co-Director of the University of Utah Coaching and Advancement Network, and they're one of the benefactors for the University of Utah Athletics, and we'll get back to athletics in a little bit. She's also been the President-- or she still is the president-- of the Academic Senate at the University of Utah. But it is a pleasure to have you here. I think we met 15 years ago and what you've done with your career is amazing. So, welcome, Dr. Hopf.

Host 1: Thank you, Dr. Hopf, for being here.

Harriet Hopf, MD: Thank you both. I am so delighted to be here. And a little bit like you've described me as the jack-of-all-trades professor, I feel like you've given me questions to prepare for that are the jack-of-all-trades questions.

Host 1: That's the scene inside Mitch's head right there.

Host 2: So, we'll start off with the hard ones, and they'll get easier as we get a little more comfortable here. But I think your research has spanned the gamut of wound healing, prevention of surgical site infections to environmental sustainability to sort of gender equity the leadership in our specialty.

I think in Academic Medicine, there's a tendency to think about I-shaped people, individuals that have a deep level of expertise. And by contrast in design thinking, you want T-shaped people, right? People with a deep level of expertise and a broad range of interests. And it's clear that you are one of those individuals in our specialty. Can you talk about how balancing everything that you do has sort of informed how you figure what you've done, what you're going to do next?

Harriet Hopf, MD: Wow. Yeah. Great question. And I will say, I think, we are prefacing or predicating this discussion in part on the recent Anesthesia article by Meghan Lane-Fall and her collaborators, which elucidates these four primary pathways. Pathways, sort of the four I styles, which are clinician administrator, educator and investigator. And then, that rounded scholar, which I think is more the kind of person I is. And I is, I am-- I do know how to grammar.

I want to say, first, I love that paper because it highlights the diversity of ways to contribute to our discipline and to contribute to medicine and to contribute more broadly. And all of them are valuable in preparing people to lead. And so, I don't like to say, "Oh, there's one best way to be. I appreciate the variety of colleagues that I work with, and all that they bring to the work that I do. So if I think about those terms of the four phenotypes that they identified, I am clearly that sort of rounded individual, which I like to call the jack of all trades, which we know goes along with master of none.

I like that you talk about the depth, the T depth. I think the T can never be as deep as the I, right? Because you just don't have time in your life to be as deep. So, I want to talk a little bit first about the sort of specializing phenotypes, because I think they are really important to our specialty. They have this deep passion and commitment to one of the areas that's really important to us. And I view that sort of single-minded pursuit of excellence as critical to our success, right? We need people who want to take deep dives. When I think about the jack-of-all-trades, there's sort of a trade off, right? You can't have the same depth, but the breadth of your work really drives that synthesis that's crucial for applying and implementing the important work of the specialists across those domains.

So, I love having all types of those people in our ecosystem. And this is something I actually learned from Mike Cahalan, who we might talk about later, who was one of my primary mentors and who was the person who obviously recruited me to Utah. One of the things I loved about him was how much he valued the people who were primary clinicians, right? What he would say is we would not have tenure-line faculty if we didn't have people who wanted to be in the OR every day, right? And they are doing great work to advance care, but also they are giving me the capacity to not to be in the operating room every day to do the work I want to do. And they are often feeding me the questions that I want to answer. So, I think, what I love about the paper most is that what they found was all four of the types can be leaders. And they just look a little bit different in how they got there. So, that's sort of my like first big take on have you done what you've done.

 I think a core arc of my career that's sort of infused really everything I do has been the idea of teaching and coaching faculty and also trainees and staff, although faculty are really my comfort zone to take credit for their accomplishments, and for the strengths and competencies that allowed them to achieve those accomplishments. So, I think one of the things when we talk about these phenotypes and we sort of think about what kind of a person you are, is it kind of loses track of, to me, what's most important, which is what's your big goal, right? So, not "I want this leadership role," or "I want to get promoted," or "I want to publish that paper," or "I'm hoping to get to work on Friday." But how are you going to change the world? What's your legacy? And I like to talk about that with people who just are starting. Because I think, when I think about the importance of that is, if you've got a big goal, it's much easier to tell your story of why you did things and how they all fit together to make the argument. It's easier to tell your story when you know what your story's about . But it's also sort of really important for figuring out the bucket or buckets that you want to focus on in your career, right? Is there some question you have to answer? Then, maybe you want to be an investigator. Is it that you need to make education better for the next generation? Then, maybe be an educator? Do inefficient and ineffectual processes make you tear your hair out? Then, maybe you want to be a clinician administrator, right? And then, you can fix those problems.

So, that, I think, is sort of how people end up down those paths. I think it's really helpful to sort of think about what your big goal is. And then, what I thought about doing is how can I incorporate my big goal into every piece of the work that I'm doing, right? Like, I am doing research on surgical site infection prevention. I'm going to chair the Perioperative Infection Control Committee. I'm going to write book chapters. That was the pinnacle of my career when Mike Cahalan asked me to write a book chapter on wound healing for anesthesiologists, right? I'm going to teach medical students and residents and fellows about infection control. So, it's all going to kind of come together. It's going to be what I am known for clinically. So, I think that's one thing.

But I also have to say our lives are hard because especially if you're a clinician, you don't have a whole lot of nonclinical time, academic time to decide what you want to do, right? And if you're like me and everything interests you and you're trying to do everything all at once, either you have to have a reduced clinical commitment or you're not going to get anything done. And so, I think it's really good for people to focus, especially early on.

And then, I think one of the natural things that happens, that means most people don't want to be jacks of all trades or just can't figure out how to get there. Once you've been established as one of those phenotypes, the specialized phenotypes, there are real barriers to diversifying, right? If I think about my colleagues who are in investigation, education or administration as sort of their real something that you can see, that's primarily what they do, that big goal has allowed them to say no to things that doesn't advance the work they think they have been called to do, right? And that's a good thing.

I will also say if you have the burning questions and you select the investigator path, your mentors will strongly encourage you to focus almost all of your energy on that difficult challenge of getting funded, getting results, getting published, doing all that work. I will say I think I never had a mentoring meeting throughout my whole first 15 years of my career that they didn't tell me I needed to focus. So obviously, I struggled with trying to be that. And then, their chairs say, "I'm not going to give you administrative responsibilities because I want you to be able to focus on your research." And that's really valuable for getting established as an investigator, but it's also a barrier to becoming a T, right?

And then, as that portfolio narrows, there are more and more barriers to increasing your work in other areas. You're specialized, so your leaders just think narrowly about what kind of opportunities to offer you. It takes a lot of effort to kind of figure out how to jump into the other area. You are joining something later on and you're not an expert in it, you're a novice. And so, you have to have sort of learn how to do that.

What about me? How did I kind of avoid that, like, getting specialized? I think my main driver in life is that everything is interesting to me. And I think that's great and it all ties together. That has advanced my big goals. I love research. I love education. I love making clinical care better. Although honestly, I've sort of moved on from that as I'm near the end of my career. And what really makes me excited is making policy better because policy is what drives success. I cannot do the same thing every day. I need variety. So, I would have a hard time always being in the lab or always being in the operating room or always being in the educational space. So, I like dabbling in everything. It opens this wider range of opportunities, right? I haven't had barriers to doing everything because I've just done everything from the beginning. On the other hand, it takes you longer to become the true expert, right? So, you're kind of wandering the wilderness for a long time while people are going, "Is she a serious person?" Like, "Is she doing anything valuable?" And then, all of a sudden, it kind of all comes together and it's phenomenally powerful.

So, that would be kind of my thoughts around I think it's really important to think about how you want to organize your career. I think it's also important to keep in mind that specializing early gives you an advantage, and also keep your eyes open for how it can narrow down what your opportunities are. And I'll say, did I have well-defined big goals when I started? No, they were mostly just things that irritated me that I'm like, "I'm going to fix these things." But that's why now I'm like, "I wish you guys would think about not just the next thing you need to accomplish," but like how does it all hang together? Just look at everything you're doing in your life and take that to turn into your big goal.

Host 2: Harriet, one of the things that sort of resonates with me here is, you know, Steve Jobs gave the commencement address at Stanford, I think it was 2006, but one of the things he talked about was that you can only connect the dots looking backwards, right? And that's why when he dropped out of Reed College, he went to go learn about calligraphy and actually change the fonts for Macintosh and invented fonts, basically.

And so, it's this idea of how do you specialize, but still kind of bounce around with different ideas and come up with the ideas, pick them up, look at them, see if they actually work. And then, I think that, you know, the underlying message for leadership is that you need to make sure that you connect the people that need to meet each other, right? And how do you create the culture or the organizational structure? And yes, you know, we can go to the ASA Meeting with 20,000 other anesthesiologists, but how do we find the opportunities to connect with the individuals where a light bulb might go on from our interaction? Google does this, right? They have free gourmet cafes, just so that there might be that one random encounter in one day that two people spark an idea.

Host 1: As you were talking, it made me think of Stephen Covey, right? Start with the end in mind. It's something that I've--

Harriet Hopf, MD: Are you Ron?

Host 2: Is he really?

Harriet Hopf, MD: Are you kidding? Of course, he is.

Host 1: I didn't know that. That's awesome. Very cool. Yeah. Start with the end in mind. Sinek would say, "Know your why," right? Just kind of be on a purpose-driven pathway, and it's something that I didn't really see or get in the beginning. And I guess as you get a little further along in your career and you start to ask those questions of, "Do I want to do this or do I not?" Does it fit into my strategy? Does it fit into my purpose?" But it's never too early to start thinking about that.

Harriet Hopf, MD: Yeah. And I actually have to say, I mean, I think I've been driven by deep purpose since like I was five. I didn't call it being driven by a deep purpose or my why. But I actually think one of the things I talk to people about is "What is the thing that annoys you that you want to fix?" Right? Like, to me, "And what are the things that annoyed me that I wanted to fix?" Being told that, "Okay, it's great. You're working with this surgeon. He's been NIH-funded for 25 years. Yes, go do your research with him." And then, Ron Miller said to me, "But it's got nothing to do with Anesthesia." And I was like, "Oh yeah, let me prove that. It annoys me that anesthesiologists don't understand how crucial they are in enhancing host defense and controlling delivery of oxygen and other critical factors and reducing cross-contamination in the operating room." There's lots of ways that we contribute that are kind of invisible. It annoyed me that our clinical track faculty made less money and that their contributions were never celebrated. And yet, it was so obvious to me how big their contributions were.

So, I think sort of I have this, like, "Okay, I'm going to prove that we could do something to improve surgical site infection as anesthesiologist. I'm going to go be a tenure-track faculty member, and I am going to work my way up to being associate Dean for Academic Affairs so I can lead the effort to revise our promotion and tenure criteria to really have metrics for education and clinical practice advancement and administration, and also have metrics for just writing papers. And getting grants is not the same as having impact," right? So, those are things that I want to fix.

And then, the last thing I want to fix is people don't communicate well, and there's always these arguments. And then, the arguments grow bigger and bigger, because no one knows how to kind of make people talk to each other. And so, I sort of think about like my whole career arc is, I am really irritated, I have to go fix this thing. But I feel like that's probably true for a lot of people, right?

Host 1: Yeah. You said something that made me think, and it's something that I've kind of felt similarly, is that as anesthesiologists we often don't realize the impact that we could really have. You said that, "Hey let me prove this to you. Let me prove to you how we can have a role." That's something that Rick Dutton, for example, had a paper on patient experience and said most of the things that influence patient perspective are outside of our control. And I kind of challenged them and said, "Well, what if we could control that? What if we could participate?" And Rick being as cool as he is said, "All right, cool. Let's write something on that." It's kind of what you said, right? Is that kind of the driving force of how you said, "We can have more of an impact on wound healing, oxygen delivery, et cetera? And let me show you just what a leadership role we can take on"?

Harriet Hopf, MD: Yeah. And I will say I think it's even bigger than that in a way. I think anesthesiologists with our training, with our experience, are uniquely qualified to be leaders to understand systems. And I sort of experienced this big time. So, our just retired Senior Vice President for Health Sciences is an anesthesiologist, Mike Good. Our current Chief Surgical Officer is an anesthesiologist, Smitha Warrier, back in 2020 when I had been through being Associate Dean for Academic Affairs. And then, I worked as a special assistant in the office for faculty. And when we were in a transition of our provost to President and then she needed to hire a new provost, I got appointed as the Interim Associate Vice President for faculty for the university as a whole, the first health professions person to hold that job. It was obviously only going to be interim for various reasons. But I knew everybody in the university.

And so, we all closed down in the spring of 2020 with COVID. And then, we were reopening in the fall of 2020 and there were lots of stuff in place for how we're going to manage classrooms. But what the provost realized was people wanted events to start happening on campus. And in the first couple weeks of August, a bunch of universities opened and then immediately closed with an outbreak. And so they were like, "We want to reopen, but we want to reopen and stay open." And so, I got a call from the provost and he said, "Harriet, we were talking today that we need some help with sort of how do we hold safe events on campus? And we need someone with expertise in infection control, who's from the health campus for credibility, who knows and is valued and appreciated by all of our deans and who's connected to the Athletics Department." And honestly, when we look at that Venn diagram here, there's only one person in it. "So, I hope you are willing to be our special assistant." And so, I spent that year sort of working to develop our protocols for how to hold events on campus, and successfully allowed a creation of a process so that we could reopen the campus safely. We never had to shut down. That was a truly joyous event. And I believe that, again, that systems thinking the way anesthesiologists are about patient safety, the way we're about communication, all helped me be a better leader. And in fact, as I'm at a cabinet meeting for COVID, the president of the university said, "Harriet, you are our Swiss army knife. We know we can pull you out whenever we need you." And then, she said, "And I'm noticing you, anesthesiologists, are leading everywhere now and you should be, and I need to hire more of you." And so, I think, I maybe have done this more than average, but I do think that the way, for example, when we're in the operating room, we see the whole picture, right? The way we're everywhere in the hospital, the way we have taken the challenge as a specialty to fix things for patient safety reasons, for healthcare worker benefits, right? Like, I just feel like we have this systemic approach that really makes us better leaders. And honestly, that's again, where there's the four phenotypes. But I think if you're an anesthesiologist, no matter what specialization or non-specialization you're focused on, you're bringing that skill or those skills that you've learned to how you're doing that work.

Host 1: Amen. I agree. What was it? Conroy, Lebarsky and Newman a few years ago, anesthesiologist as health system leaders, incredible paper that says exactly what you're saying right now.

Harriet Hopf, MD: Yeah, it's cool.

Host 2: I was just going to argue, fortune favors the prepared. And you're prepared.

Harriet Hopf, MD: Yeah. No, I think it's true. I mean, I think, one of the things I see a lot is people are impatient. They're like, "I've been training for so long, I don't want to take that extra year to do something else." And I will say I got a great perspective on this once upon a time, which was back after I'd been on the faculty for two years and this was planned. My husband and I took 14 months off and did a trip around the world, because we knew we wanted to travel when I finished, but we needed to have money. I needed to pay off my loans. And so, when I joined faculty, I said to Ron Miller, "Hey, yes, I would love to join your faculty. I just want to let you know in two years I'm planning to take a year leave of absence and do a travel around the world. Is that okay with you?" And he's like, "Yeah, that sounds fine." And I was like, "Cool."

So, about four months before we leave, I go in and I say, "We're leaving in September. Remember you said this would be okay?" And he said to me, "Are you actually going to do that? It's going to ruin your career." I was like, "Well, yeah, I'm going to take that risk." But in fact, it did not ruin my career. In fact, being gone for a year made it so that I no longer had surgeons say, "Get your attending in the room" because I had done my residency and fellowship there, and now I'm an attending and they don't really notice that you've gotten more senior.

But also, nothing had really changed in the year I was gone. Like, there's no big seismic changes in a year, right? And when I came back, I had all these experiences that made me better at my job. And so, one of the things I try to tell early career people is take that extra time to learn those extra things. It's going to pay off big time in the future, even if it doesn't pay off big time now. And I took Latin in college because, I don't know. I'm interested in everything, that's why. And my favorite thing I took outta that class was a saying, which is festina lente, which means make haste slowly. And I think that is something I kind of need to have up on my wall. I see this all the time in administration, right? Like I. Administration always wants to make changes quickly. And they're like, "We do not have time. It's urgent. We do not have time to ask everybody's opinion." But it takes them six times as long because they roll it out and there's some things that they missed. Whereas if they'd spent an extra couple months just finding out what people thought was good, they would've found those couple of pinch points that they could have fixed before it got rolled out. So, it's hard. We now have a legislature that like, "Couldn't you graduate your students in three years from college? Because that would be so much faster for them." And I'm like, "But what are they losing? Have we thought about what they're losing?" And I think students also kind of want to get out there. They don't want to have as much debt. And I get it, but somehow we have to communicate better the value of spending the time to learn more things.

Host 2: I also took Latin, Harriet, and I just wanted to say, I'm glad it wasn't semper ubi, sub ubi, so we'll just leave that for the guest.

Harriet Hopf, MD: Yes, yes. No, I think partly it's because I've never been in a rush to do things, so I sort of needed to justify that.

Host 2: So, we've touched upon it. You trained with Dr. Ron Miller. you've trained with Dr. Mike Cahalan, the giants in our specialty. And there is a saying that, you know, we stand on the shoulders of giants. I actually think that we build a network, right? And you said it at the beginning of the podcast about deep purpose. Gulati at Harvard Business School and then Nadella at Microsoft talk about deep purpose in the sense that you have to look backwards and fly forwards to basically lead. So, we've gotten hints of it. But how did Dr. Miller and Dr. Cahalan influence-- I mean, obviously, one, they gave you the freedom to do what you wanted to do. But then, there's always a need maybe just to control the exploration to make sure that you are going in the right direction. But how did they impact you?

Harriet Hopf, MD: Yeah. I think I'll start with Ron. I'll say the single most big thing that Ron did for me was I was in the middle of my review for promotion to associate professor. I was in the In Residence series at UC, which is all the same requirements of tenure, but you have a one-year contract. So, it's an interesting mechanism. So, I did not have tenure until I got to Utah. But he called me into his office to tell me that it didn't look like it was going to go through. People were concerned that I wasn't independent, and they were concerned that I wasn't first author under enough papers, and they were concerned there wasn't enough work. And I was like, "Well, but I collaborate with all these people across the country and those first authors are mostly medical students and residents. And that's why I'm the second author. And he is like, "Well, does your CV say that?" And I'm like, "Don't people just know that?" So, I think that was kind of my first introduction to the CV seems like a pain. But actually, it's a really valuable communication tool. So, I revised it. I put in. I now have a little asterisk that shows who the trainee co-authors are. I put down all my collaborations across the country and the world. And I received the inaugural UCSF Graduate Students Association Mentoring Award Just that moment in time. And so, all of that got me over the hump. But I think that was such a valuable thing that Ron did for me, he was the one who really set me forward on that, you have to say what you did. He was also very interested in sort of the business aspects of Medicine, I think, before many people were. And he had a lot of really valuable things like we spend all our time on the trying to prevent people from doing the wrong thing, but that is like wasted effort. Put your effort on the people who are doing the good work, give them support and do not create rules that make it harder for them to move forward in order to kind of keep these people who are probably not going to do the right thing anyway from doing the wrong thing. So, I think those were my two big learnings from him. And I think in that sort of Piece of it, I see a lot of what my coaching work has been, which is how do we help faculty sort of see where they're going? How do we help people have better conversations so they don't get themselves in trouble?

Mike, on the other hand, I really think I learned leadership from Mike, leadership in a different way. Mike was my primary anesthesia mentor at UCSF. And he sort of enabled my wanting to do this sort of well-rounded approach. He was like, "Harriet, you do not have to clear the tenure bar by the highest anybody has ever cleared it. You just have to get over it." And that was just a really freeing thing to say for me to go, "It's okay for me to be doing the things I want to do. I have to make sure that I capture them and express them well." And I think that I think you cannot be a successful well-rounded person if you can't express what you did and what your value is.

I think, as an investigator, you don't have to be able to communicate as well, because people see that you publish something, got a grant. And they assume that it's important whether or not it is right. But we're trying to be well-rounded. So, Mike was really valuable for that. And then, he recruited me here in Utah. I was very interested in leadership opportunities. During my time at UCSF, Ron was chair there for 27 years. He had been chair for 24 years. When I got there, the vice chairs were by and large the same people who were vice chairs when I was a resident. And so, I just didn't see a lot of opportunity to gain leadership in the department. And I'd sort of been doing some stuff outside the department, but I really wanted to be a leader.

And so, a big part of why I came to Utah was-- I said to Mike, "Look, I really want leadership opportunities. And I'm not really seeing them here. UCSF is a bigger place there. Everybody wants leadership. I don't know, there's lots of reasons for it, but that was sort of my perception. And Mike said, "Well, I don't have any leadership to offer you now, but I promise you we'll get you leadership." And so, that's sort of like, "What does it mean to be so trustworthy that someone's willing to jump ship to a new place?" And I just was sure that would work. And as, I think you can tell, it worked. It was good. It all turned out well.

But I think Mike learned a lot about leadership from Ron. I think Mike was a great mentor for me partly because he himself was such a well-rounded person, right? He did deep work in echocardiography, right? But he was also one of the best educators I ever had. I really learned a lot from him about that. He was an amazing administrator. And I think he learned some lessons from UCSF that he applied in reverse when he became chair, which I really appreciated. Just sort of in the way he managed the department, you could see here were the things that irritated him. And you cannot be a chair and not irritate people, right? No matter how great you are as a chair, you're going to do some things that aren't perfect. And that is actually why I think chairs should only serve for 10 to 15 years, because they got blind spots that are going to kind of start to royal a little bit and they're going to do other fabulous stuff.

But eventually, the things that they aren't great at are going to start to become bigger. So, you need a new person to come in and focus on a different set of things. But anyway, Mike was also just a wonderful, caring person. And working with him in the operating room was huge for my development. I will say I am terrible at taking advice. To be honest, I already told you, people told me to focus more. I never did. Ron told me, "Oh, you're going to work with a surgeon." I was determined to prove to him wrong that surgery and Anesthesia aren't married in some way.

But the first thing Mike said to me early on when I was on my Cardiac rotation was, "You should go into Cardiac Anesthesia." I was like, there is nothing less interesting to me than the heart." I know you shouldn't say that as an anesthesiologist, but I'm like, "it pumps oxygen to the skin, but it doesn't even do that very well," right? Like, it's a pump. It's not very interesting. But what was wonderful about him was he didn't kind of go, "Okay, then I'm not going to mentor you, because you don't want to go into Cardiac Anesthesia." It was like, "Okay, let's see what it is you want to do." And then, the other thing was he kept saying, "You should be a golfer. You'd be a great golfer." And I'm like, I am with Mark Twain. It is a good walk spoiled, right? It is not my game. And so, it was okay. He kept reminding me that I should play golf. I met my husband. He was like, "Hey, do you want to go play golf?" And I was like, "I don't know if I really want to play golf." Anyway, we went and played golf together once or twice, and now he has never played golf again. So, I feel like that was my triumph in that. He did not turn me into a golfer. I turned him out of a golfer into a hiker.

Host 1: You won. You won.

Host 2: So for our audience members, Harriet is a three-sport athlete in college, basketball, softball, high jump. And I think the LPGA just called Harriet, they're going to wait for you to get on the tour, because you could probably make it. So no, but Mike Cahalan's message about satisfies. Herbert Simon is an important one. We have to know when to pull back the reins and focus our energies on something else. .

And then, the other piece is, I think, of leadership, right? And coaching, mentoring, design thinking and medicine, right? That the basic platform is empathy, right? And for a leader to understand where somebody could go or wants to go, I think that's probably one of the most important skillsets that we have as anesthesiologists.

Host 1: So, we talked a lot about leadership. Harriet, one of the areas where you've really been a titan and led is in researching and promoting gender equity. Where are we in 2025? Do we have a long way to go? Have we made up ground? Where do we stand right now?

Harriet Hopf, MD: So, I will say, I mean, I graduated from medical school in 1986. So, I have a long recognition of kind of how life has gone. I will also say, my mother is an Emerita Professor of Botany at NC State University. and so, I got to watch her progress through this system. She was a graduate student. My parents were both graduate students when I was a kid. And I'll say I can see enormous change, but I think what we've done is we've fixed the easy stuff, which wasn't that easy. And what we have left is really, really hard.

So if I think about my mom's career, in 1958, she was a graduate student in Botany. And she was married and she was pregnant and she was kicked out of her program because she was pregnant. Now, we fast forward to 1965 when I started kindergarten, she went back to graduate school. Now, it's sort of a different terrain. But still, it was not a popular thing to do. Her first faculty position was at Dartmouth through a variety of shenanigans. It ended up being a halftime tenure-track role, which didn't even have a policy around it. And every three years, they had to decide whether to renew her contract. And every three years-- she was one of the very first women there. I think she was the only woman on the faculty there except for an emerita professor who had been a lab tech for decades as a phycologist, algae person, but then was promoted to professor a few years before she retired and was world famous. So, it was not a welcoming place, but every three years, the, faculty would vote not to renew her contract. And then, the dean would go, "You can't do that." She's having way too much success, like a patent for video-enhanced contrast microscopy, right? So, she was a very successful scientist. And then, she got recruited down to Wake Forest with tenure at the rank of Associate Professor. So, she went there. But then, a few years later, it's about time for her to get promoted to professor, and the chair calls her in and says, "Well, you and Joe are up for promotion to professor this year. I can't help noticing that your CV is substantially stronger than his. I'm afraid if you go up at the same time, he won't get promoted. So, I'm going to ask you to wait a year." And then, a few years later she got recruited to NC State where they doubled her salary and had a fabulous end of her career.

So if I look at that, I go, all of those are things that could only happen much more subtly now today, right? Like, there is still a lot of, "Oh, I don't think she's quite ready for promotion" that goes on, but no one is going to say, "I'm not going to promote you now, because a guy might not get promoted, right? So, I can recognize. And when I was a kid, she couldn't have her own credit card, she couldn't take a loan, right? Like, all of those things were different. So now, I have a lot of rights. Now, life is much better. What's hard now is, one hopes, nobody's going to do those things, right? But what happens is just subtle things that make it harder for women to succeed. So, sometimes men say to me, "Perhaps you feel this way. Boy, we can't say anything nowadays. There's so many limitations on language." And my response to that is, "Yeah, it is hard, isn't it, to not be able to just say what you think, which I have been doing my entire career?" Because you cannot succeed as a woman unless you figure out how to be both agentic and empathetic, right? Like not too agentic. but also then you don't want to be weak, but also you just can't do anything right, right?

And I will share my favorite sort of string of studies that I think really highlights how hard this is for women. So, they have medical students do a simulation on BLS or ACLS, running a code, right? And they judge them on how they're doing. And the women medical students are judged as not showing good leadership skills, not showing as good leadership skills, right? They just aren't really doing it well. And so, there's like, "Oh, we got to teach women how to be better leaders." So then, there's a study in residence where they script a code, and all of the residents say exactly the same thing from the script. And the women are judged as having less skill at leadership. So, they're saying exactly the same thing, but it's viewed as not being good leadership. So, there's this sort of like women don't know how to lead codes, they're just not as good at it.

But then, there's a publication where they look at teams that run actual codes in the hospital. We can look at return to spontaneous circulation, and we can look at do they get out of the hospital? Let's look at teams of physicians and nurses running it. Is it two men, a man and a woman, a man and a woman in the other direction, or two women? And it turns out when two women run the code, they have better outcomes. Now, it's a small thing, right? Obviously, you're not going to wait for an all-woman team. if you have a cardiac arrest, you're going to let whoever. But the women's outcomes are better. And that is sustained by lots of other studies, right? There's a million studies that show women practitioners tend to have small but significant, better outcomes. And I think part of that is because women are judged as not quite as good, you know, to get tenure. Generally, women need three more publications than men, right? Like, a lot of things are judged as not quite as good because it's whole subjective component. But I also think there's a component of who we're filtering out, like we are filtering out the women who can't navigate that. And that women have to develop a better set of leadership skills. And what are the leadership skills women have to develop? How to communicate, how to connect, how to do all those things. Things that everyone should be doing as leaders, and it makes them better.

And then, the final thing is women are less likely to be overconfident. And so, they follow guidelines and that is probably the single most important thing, right? And so, I think when I think about what's going on for women, we are judged as less good leaders, even though we tend to maybe have better leadership skills, because we had to develop all those better leadership skills to get to leadership. If a woman makes a mistake, like if a woman surgeon has a complication, the referring surgeon will never refer her another patient. If a male surgeon has a complication, people go, "Oh, yeah, complications happen. I'll keep referring, right? So, I think that's, to me, the hard part. And now, there's sort of a narrative, "Oh, she's only there because she's a woman." Oh, they're only there because whatever." And I think the opposite is actually true, that you had to do some stuff better to get across that bar. And so, I think things are great. I think it's hard. We've had a seismic shift in who's in the workforce and who's leading. And that means that people who might 30 years ago have just expected to be a leader, may not be the leader they thought they would be.

Now, one response to that might be perhaps I should develop better leadership skills. But the other response is, "These women are taking my job." But it's really nuanced. It's really hard to do it. I think the most effective thing is just to call things out when they happen to say to people, "Oh, yeah. I know it's really hard when you can't say anything. Like, I've not been able to say anything for my whole career, right?

One of the other things, I mean, clothing. How much time do you spend thinking about what you're going to wear? No one cares what you wear. As a woman, I feel like no matter what I wear, someone is going to judge it. And men's clothes, you just say, These" are my measurements." And then, you buy the clothes and it's always consistent and you know what you're getting. Women's clothes, who knows what size I wear? I have to figure out who my designers are, who make clothes from my body type.

One of my favorite stories about this sort of inequity for women, and I will say when you see me, you will notice I wear a shell, a blazer, and black pants. I have a uniform. I don't have to think about it. It does not take up time in my life. Why did I do that? Way back, I'm a new faculty member and we're having one of our semi-formal dinners, right? To which the men are going to wear a tuxedo, right? They got one. They wear it every time. And we're in the lounge. And one of the faculty, a man, says to me, "Are you going to wear that purple velvet thing again to this event?" This purple velvet cocktail dress I had was my favorite dress I've ever owned." It was fabulous. It looked fabulous. But he was like, "You wear that all the time. You need something new." And then, there were two women in the lounge and like, "Oh yeah, you should go out shopping, Harriet. This would be so great. You got an opportunity to buy new clothes."

Here's the thing, I am six feet tall. I cannot find clothes easily. When I find something perfect, I just wear it to death. I hate shopping. My mom shopped for me until I was about 35 years old. But I thought, "Well, I can't wear the purple thing again." I drove. I got down at San Francisco General Hospital. I drove down to Stanford because you can't buy clothes for me in San Francisco because it's aimed at shorter women. I go down to Stanford, I go to the Nordstrom. I try on a dress, it's a St. John Knits. If you haven't heard of that, they are expensive. And I'm like, "It's okay. Maybe I should get this. And I called my sister. It was before we could send pictures. I just called her, I had a cell phone and I call her and I go-- She is quite into fashion-- I go, "I'm thinking about buying the dress," and I describe it. And she's like, "You don't sound that excited about it, Harriet. How much does it cost?" And I went, "$750." And she says, "Was it blessed by the pope?" And then, I come back to reality. And I just wore the purple thing with pride. And then, I will say, a couple years later, I actually got a tuxedo made and wore a tuxedo to events as sort of my way of getting back. But I look back on that and I think here was an evening I could have spent writing a paper, going for a hike. But no, I drove down to Stanford trying to find a different thing to wear, even though the person who brought it up wore the exact same tuxedo he always did. So, I think there's a lot more work that women have to do to make sure that they're not doing something wrong.

Host 2: When you think about the power of demography, right? And as things changed in the population, do you think it's going to accelerate the rate of the change of what you envision? Do you think it's going to accelerate or do you think it's just going to be a constant struggle to maintain what we have or what we're trying to do?

Harriet Hopf, MD: Right now, it's crashing and burning, as you might notice. I don't know if it's entirely crashing and burning internally. I will say, someone said to me once a leader, it feels like the LGBTQ community has made lots of progress. Do you think they push too hard and move too fast and that's why there's all this backlash? I said, "Well, do you think their experience of it has been that it's been moving too fast?"

So to me, we're at an interesting inflection point that really calls for more communication, right? Like, I think about higher education and the pickle we find ourself in. I think we do great work. We all know how important higher education is, but have we been communicating it in a way that is obvious to people who are not in higher education, who just accept its value? And so, I've seen a lot of really good work on institutions explaining what's so important about the research they do, explaining their impact on the economy. We have this Kem Gardner Center that puts out policy briefs. There are demographic Utah trends arm of the university. And they have a really nice, what is the value of higher education policy brief that just shows the billions of dollars of value that the university brings to the state, right? So, I think this is true for all of these things, perhaps we have to figure out language that reverberates for people that is more persuasive. And also, this idea of meeting people where they are and finding out what their challenge is. Like, what are you afraid of?

Host 1: Well, we're getting to the end of our time and this has kind of become a tradition for the Fresh Flow Podcast. What would you tell yourself a few decades ago if you could give yourself advice now, as you kind of said on the tail end of your career, early on, what would current Harriet Hopf say to maybe three-decades-ago Harriet Hopf.

Harriet Hopf, MD: Yeah, I mean, I told you already, I have disclosed I'm not good at taking advice, so I'm not sure Harriet Hopf's going to take this advice. And I will also say I've done okay, despite not taking advice. I actually think sometimes people take advice too much. I think that's a big problem that people are like, "Well, this person told me this is what I have to do, so I'm going to go do it even though it's not my dream."

But aside from that, I'm going to say something that you may not believe, but is true. My preference is very strongly introverted. So, I'll have to go be by myself for a couple hours after finishing this, right? Like, I show up as enthusiastic and expressive in public, but I really need to be alone. And so, I think my advice would be figure out earlier how to ask for things, how to go talk to leaders, how to let people know what your goals are, how to ask for advice that you might ignore, and how to ask for sponsorship, because I think that's something I would love to have done even in college. My son went off to college and was connected so tightly with all his professors and did all these things with them. And I was like, "Boy, I wish I had done that when I was in college." But it was just something I didn't have the capacity to do.

Over time, I will say I learned how to network, but I learned workarounds to, "I'm just going to go up to people." So, learned how to network earlier, learned those skills. Like, I can't introduce myself, but I'm happy to introduce someone I'm mentoring. Go be on committees and say smart things, and then people will ask you to be on more committees. Because I think I started out as the least likely person to have a big network in my mind, and now, I would say I'm the person that people are like, "Ask Harriet. She knows everybody." Maybe that just takes a long time to build, but just that idea of people do not know what you want unless you tell them.

Host 1: Good stuff. Mitchell, final thoughts, man?

Host 2: Got some good news for you, Matt.

Host 1: What's that?

Host 2: We're part of Harriet's network now.

Host 1: I know. I'm pretty pumped up. This has been awesome. Harriet, thank you so much for doing this. This has been a blast. And I could sit and talk with you about leadership stuff for another two hours, but we'd bore people to death by the end of it. This has been fantastic. Thank you.

Harriet Hopf, MD: Thank you both so much. What a great conversation. Thank you for letting me get on my little soapbox a few times. And also, thank you for doing this podcast, which I've really enjoyed listening to them.

Host 1: Thank you so much. I appreciate that. We're having a blast. We're having a good time. This was just a crazy idea and it has led us to meet some really cool people. So, thanks for being on with us today.

Harriet Hopf, MD: All right, thank you.

Host 1: All right, guys. That's it for this edition of The Fresh Flow Podcast. We will catch you on the next one.