This O&G Magazine feature sees Dr Nisha Khot in conversation with RANZCOG members in a broad range of leadership positions. We hope you find this an interesting and inspiring read. Join the conversation on Twitter #CelebratingLeadership @RANZCOG @Nishaobgyn

Dr Neelam Bhardwaj

FRANZCOG

I first heard of Dr Neelam Bhardwaj when I moved to Melbourne in 2010. In casual conversation with my next-door neighbour, a lady of Sri Lankan origin, she realised that I was an O&G and shared the story of her mother who had arrived in Australia in the 1970s, having completed a degree in pharmacy in Sri Lanka. Finding herself pregnant soon after arrival, she had tried very hard to find a doctor who would provide culturally appropriate care. At the time, Dr Bhardwaj was one of only two female obstetricians of subcontinental origin in Melbourne and had been a comfortable choice. Years later when my neighbour was pregnant, she didn’t think twice about choosing Dr Bhardwaj for pregnancy care. I was fascinated by this story of an O&G who came from my part of the world and had helped bring two generations of the same family into this world. When I eventually met Neelam, she was a soft-spoken, gentle and kind person willing to take a newly arrived doctor like me under her wing.

This column has over the last three years featured many specialist leaders in O&G, but this is the first time we are featuring a woman international medical graduate of Indian origin. The White Australia policy meant that non-white international medical graduates only arrived in Australia in the 60s and 70s. Many of them faced (and continue to do so) racism, discrimination and bullying. They rarely brought up these issues, choosing instead to focus on their work and their family. Their contribution to the Australian healthcare system cannot be overstated.
international medical graduates like Dr Bhardwaj were in truth, the embodiment of Donald McGannon’s famous quote, ‘Leadership is action, not a position.’ They may not have held the traditional leaderships positions of Clinical Director, Executive Director etc but, by their actions, they laid the foundations for future generations of international medical graduates (myself included) to embrace leadership in all its forms. They gave us the confidence to speak up against discrimination and racism.

Australian healthcare has a long way to go to achieve true equity, diversity and inclusion. If you feel otherwise, I gently suggest that you do a back-of-envelope exercise: count the number of women of colour in leadership positions in your department and divide this number by the total number of women of colour in the department. Do the same with other groups for comparison. Any department that has a large non-white staff with predominantly white leaders has a problem. Any department that has a large female staff with predominantly male leaders also has a problem. Add the two problems together and a very uncomfortable picture emerges. We should not shy away from this. Instead, we should call it out and address it. The time for lip-service is past, it is now time for action.

I want to know about your early years. Where did you grow up? Where did you do your basic medical training?

I was born in India. My father was a WWII fighter pilot and, in his civilian life, in-charge of the airports in India and frequently required to move to different cities. This meant that as a young girl, I travelled all over India and got to experience the rich diversity of the country. We ultimately settled down in India’s capital city, New Delhi and this is where I did my senior school years and basic medical training. I am very fortunate to be an alumnus of the prestigious Maulana Azad Medical College in New Delhi, lovingly referred to as MAMC (M’aam C). The foundation stone for MAMC was laid in 1959 at the site of the old Delhi Central Jail which had seen its share of political prisoners, arrested for their role in India’s freedom struggle. The College bears the name of India’s first education minister, Maulana Abul Kalam Azad. It was officially opened in 1961 and its first batch of graduates had 60 students. I belong to one of the batches in the first decade of its existence to complete MBBS from this institution.

(Author’s note: I digress with a nugget of information for readers about another medical college located in Delhi called the Lady Hardinge Medical College. Established in 1916 and named after Lady Hardinge, the wife of the then Viceroy of India, Baron Hardinge, this was and still is a medical college just for women. Lady Hardinge recognised the challenges that women in India in the 1900s faced with access to higher education and raised funds to set up a medical college exclusively for women. Sadly, she passed away in 1914 and did not live to see the college inaugurated. The first batch consisted of 16 women students and the college has maintained its reputation as a premier medical institution).

What was your journey as an international medical graduate and why did you choose to specialise in O&G?

I completed my internship in 1972 in India and immediately after, moved to Melbourne. I had arrived too late in the year to be able to apply for a training position. The resident jobs in O&G for the year had already been allocated. So, initially I did a stint in psychiatry and haematology. It turned out to be a great experience because I learned how the Australian health system worked and also got to make some friends. I joined the Queen Victoria Hospital in Melbourne in 1975 as a trainee in O&G. I was one of only five women trainees in O&G in Victoria and the only international medical graduate .

As an undergraduate in India, I had seen firsthand the lack of good medical care for women during my O&G rotation. We had a whole ward dedicated to women with puerperal sepsis. Women would come in bullock carts from the villages in obstructed labour and it would take them two days to get to the hospital. Women would have evacuations for incomplete miscarriages performed with no anaesthetic because it was not considered worthy of the time and effort of going to theatre for an evacuation. These experiences made a huge impact that stayed with me even after I left India. I was inspired to follow in the footsteps of two inspiring women Professors of O&G in India during my undergraduate years who were expert clinicians and empathetic communicators. And yes, India had world-renowned women Professors of O&G before Australia!

What was your experience of training in O&G in Melbourne in the mid-70s?

It was not easy competing with local graduates for a training position in O&G. I was an outsider, I had no local connections, no one knew me. I had to start at the beginning and prove myself. Initially, it was slow, time consuming and repetitive. As I gained more confidence, I was able to apply for a training position. Along the way, I made lifelong friends and mentors. My training was a little fragmented with rotations to the old PANCH hospital in Preston and Western General Hospital in Footscray, rather than concentrated at a single tertiary hospital. This was the only option available to me at the time and I embraced all my rotations happily because each provided a unique learning opportunity.

As a woman and an international medical graduate, did you experience discrimination and how did you deal with it?

I had an advantage in that although I was an international medical graduate , my postgraduate training was in Australia. This helped a lot because it was recognised as being local experience. I suppose if I had come to Australia as a fully qualified specialist, I may have faced questions and suspicions about the validity of my training. I did not experience blatant racism or discrimination but there was certainly an undercurrent of it. When I applied for registrar positions, I was asked about my plans to have a family. This was considered a very valid question to ask at an interview! When I first arrived in Melbourne, I didn’t have any formal Western clothes, so I wore one of my nicest sarees for an interview. I was asked, ‘How on earth do you deliver babies in that?’

Some perceptions were very entrenched. I remember a time when I was called to assist a colleague at caesarean section at the old St Andrews Hospital. We were in scrubs and had just made a cup of coffee while discussing the case we were about to start. A senior male obstetrician walked in and asked us to make him a cup of tea. He was very polite, of course, just like he would have been with the tea ladies, which he presumed we were because of our ethnicity. I think these perceptions and biases have changed over time.

There were instances when you would be overlooked for senior leadership positions although you were better qualified and had more experience than the person who eventually got appointed to the position. At the time it was disappointing but there were very few avenues for formal complaints. In the 70s, it was pretty much take-it-or-leave-it. Over the years, we all faced racism and gender discrimination to a lesser or greater extent and now, as we mature, we face ageism. So, I can say that I have now faced the full triad of the ‘isms’.

But despite these challenges, migrant doctors have made massive contributions to the Australian health system, both in public healthcare and private healthcare. The presence of migrant doctors has contributed greatly to the understanding of the health needs of migrant communities and develop a greater empathy for women who are vulnerable, who don’t have family supports, who don’t speak English, who depend on family members for financial security. Migrant doctors have been a success story and have raised the profile of the entire migrant community. Australian trainees have benefitted from the wealth of experience that migrant doctors bring with them and are able to impart to trainees who will probably never encounter those rare conditions and complications in their clinical practice in Australia.

How did you cope with being far away from your own family?

In the 70s, my weekend on-call shift started on a Saturday morning and finished on Monday afternoon. They were long, tiring hours but we didn’t know any different then. These long hours didn’t leave much time to brood over things that you were missing. In those days, keeping in touch with family in India was not easy. If you wanted to make a phone call, you had to be connected by an operator and the phone calls were very expensive. You could only afford to make phone calls once a month. But the excitement of learning surgical procedures and acquiring new skills kept me going.

When I finished training and was just setting up a private practice, my marriage ended. I found myself in the unenviable position of being a single medical mum with no family support and an obstetric private practice. At that point, I was seriously considering giving up my practice. Fortunately, my parents took it in turns to come to Melbourne and live with me for the next decade, helping me bring up my two boys while still maintaining my practice so I had an income. I also had really supportive colleagues who became my Australian family and helped me not just with the practicalities but also on an emotional level. I would not have been able to manage on my own and I owe my parents not just my success but also the success of my sons. My boys grew up knowing that there was always a grandparent at home when they came back from school, and it made all the difference to them.

What has given you the greatest joy?

My work has always been my source of joy. Even after a tiring night on-call, I always leapt out of bed in the morning with a sense of excitement about what the day would bring. Having the confidence that you were really making a difference in the lives of those who trusted you with the most precious time in their life, when they were having a baby, was a very special feeling. And when they referred their sisters, friends, aunties, cousins, daughters and even granddaughters to you because of this trust and the belief that you would be able to help, that gave me the greatest joy of all. I had a solo O&G practice for 33 years and have looked after two and sometimes, three generations women from the same family. I feel very privileged to have had these wonderful experiences.

What has been your involvement with RANZCOG or other organisations?

I have contributed locally on city councils, health committees and boards. I am a founding member of a charity called Disha (www.disha.org.au) that raises funds for worthwhile causes like vital equipment for hospitals in Melbourne including The Royal Children’s Hospital and The Royal Women’s Hospital.

I have enjoyed training and mentoring a new generation of specialists in O&G. I have been an examiner for undergraduate medical exams as well as fellowship exams for RANZCOG. I have presented at meetings and conferences. The highlight for me was a trip to Mongolia, meeting the doctors there and helping establish a colposcopy facility at a women’s hospital in their capital city, Ulaan Baatar.

Raising my family as a single mother while maintaining a busy obstetric practice left very little time to get involved in major roles within RANZCOG or in other organisations. So, I didn’t put my hand up for these roles. It is heartening for me to see young consultants participate in RANZCOG leadership and help shape the future of O&G training in Australia. I know we have come a long way in addressing some of the barriers that existed when I was a newbie but there is more to be done.

What advice do you have for junior doctors or medical students considering a career in O&G?

This discipline is one that is full of opportunities and the different subspecialties mean that there is so much choice available for each trainee to go down a unique path. Trainees often worry about quality of life and work-life balance given the long hours. But I think the future is one of group practice rather than solo practice. Patients are embracing this model as well. I would encourage medical students and junior doctors to not be put off by the thought of long hours.

My other bit of advice is to never underestimate the importance of lived experience. Simulation and reading are a very important addition, but they can’t replace real patient interactions. Hands-on experience is the most valuable and will teach you lessons that will stay with you for a lifetime. If you are interested in O&G, spend as much time as you can during your rotations speaking to patients, assisting in theatre, caring for women in labour and postnatally. I acknowledge that the pandemic has severely affected the ability to get hands-on experience and I hope we will find ways to make up for lost time.

If you could go back in time, is there anything you would do differently and why?

I never appreciated the potential of this new (at the time) discipline called IVF. It was being born in front of my eyes, but I didn’t realise how important it would become. Looking back, I am amazed at the speed with which the science has progressed. I wish I had had foresight and not been so involved with obstetrics at the time. I would have loved to explore fertility treatment options and study reproductive technology.

Your career has spanned a time of significant change in O&G. Could you describe your experience of managing these changes?

Yes, there have been many, many changes in the 35+ years that I have been practicing as a specialist O&G. If I describe some of the things that were the norm in the 70s, you will find it difficult to believe that I am talking about Melbourne and not some medieval town. The 70s and 80s were a time when our thinking about women’s health and practice of O&G grew by leaps and bounds. I had the great pleasure and privilege of learning with the great pioneers in our specialty. Indulge me here while I reminisce…

The first CTG machines (from memory) were installed in the Queen Victoria Hospital in the mid-70s. Prof Carl Wood had learned about this new method of monitoring the fetus in labour and he was the one who introduced CTG monitoring to Victoria. At the time, we could only capture the fetal heart activity by attaching a little screw in the baby’s scalp. It would often fall off when the patients were writhing in labour and had to be put back on. We used guarded surgical blades to get fetal blood from the scalp for testing of pH. Labour analgesia for primigravidas was heroin! Multis got morphine but can you imagine using heroin as routine analgesia?! We used black silk sutures for episiotomies and one of my jobs as a Year 1 resident was to go from bed to bed with my trolley removing these sutures. These wards were the old Nightingale wards with beds separated by curtains so there was very little privacy for women. Ultrasounds hadn’t been introduced to Melbourne hospitals, so we diagnosed placenta previa by X-ray after placing a metal grid on the woman’s abdomen and using a complicated way of measuring where the fetal presenting part was in relation to the grid and trying to work out where the placental edge was. Amniocentesis was done on the ward by the resident, without ultrasound guidance. We palpated the mother’s abdomen and used our hands to work out a ‘safe’ place to put the needle in! We were doing amniocentesis for L:S ratio (Lecithin:Sphingomyelin) to decide timing of delivery by calculating lung maturity. Laparoscopic surgeries were the new thing and we used unipolar diathermy for tubal sterilisation. This gave way to the use of the Fallope ring for the same procedure. This was also the time when IVF was just starting to take shape as a real option for management of fertility.

Another welcome change was that menopause became a real thing! There had never been any menopause clinics anywhere in the country and women were usually expected to put up with symptoms. The only help they had was the various traditional medicines, potions and creams sold over the counter, most of which didn’t work. I first heard of a dedicated menopause clinic at Prince Henry’s Hospital. As an aside, the fact that most of the hospitals I have mentioned no longer exist is also symbolic of the changes that have occurred in the last 50 years.

Leboyer births were all the rage in the 70s. Dr Frédérick Leboyer, a French physician, had published Birth Without Violence in 1974 in which he argued that babies felt pain, anxiety and suffering and that the manner in which they came into the world shaped the adults they would become. His method involved keeping the birth room dimly lit and quiet, to reduce sensory overload on the baby, not holding the baby upside down and spanking its bottom or whisking it away to be examined immediately after birth (these were all the norm at the time). Dr Leboyer drew a lot of scorn from the medical fraternity at the time, but practice did change.

Trends came and went, and we had to evolve with these changes. In my time, we all started as generalist O&Gs. Subspeciality training was not an option. Usually, with time and experience, some of us developed special interests, but the majority stayed in a generalist role. All the technology and knowledge that we now have available to us was in its infancy at the time. It was a very exciting time. You really didn’t know what would come next. To cope with the rapidly changing scenario, you had to be open: to learn new things, to trial new technology, to accept that there could be a better way to do a particular procedure. You could not have a closed mind. You had to keep up with new information and remember, at the time, information was either in the form of a journal or presented at a conference. If you came across a rare condition, you had to go back to your trusted texts and read up about it. Access to information was not easy but you tried your best to keep up and stay abreast of all the emerging research.

What are your future plans as you approach retirement?

I am currently working part-time doing office gynaecology and dermo-gynaecology. I am looking forward to spending more time playing tennis, learning to bake, catching up on reading, going to galleries and live theatre. Most of all, I am looking forward to not missing out on all the milestones achieved by my grandchildren. Looking back, I missed some of my sons’ milestones because I was at work. I have made up my mind that I don’t want to repeat that with my grandchildren. I have six gorgeous grandchildren and I am really looking forward to being part of their childhood and growing years.