In this installment of Living a Full Life, Guest Editor Jame Abraham, MD, FACP, spoke with Ariela L. Marshall, MD, Director, Women’s Hemostasis and Thrombosis Program at Penn Medicine. Along with her clinical and research activities, Dr. Marshall is also an advocate for women’s health and equity in the medical workforce.

ARIELA L. MARSHALL, MD

On the niche area of women’s thrombosis and hemostasis: “There are a lot of unanswered questions about how to best manage pregnancy, contraception, and fertility, and menopausal symptoms in women with bleeding disorders or thrombophilia.”

On redefining leadership: “We need to change our view of who can be an accomplished leader. Once there are more women in leadership positions, we can create a culture of equity that changes the framework of how we define good leaders and what it takes to become a good leader.”

On mentoring: “I always ask my mentees what they are hoping to get from this mentoring relationship and what can we help each other with. I try to give honest and practical advice, because you want people involved in that decision-making process.”

Ariela L. Marshall, MD, was born in California, but at age 6, her family relocated to Salem, on the northern outskirts of Boston. “I don’t have any physicians in my family and never was one of those people who knew they wanted to be a doctor from the time they were 5. I attended public school and then went to Harvard University for undergraduate studies as an economics major. But when I began taking some biology electives, I realized the scientific way of looking at the world was much more natural to me than economics and felt that medicine was more aligned with my personality and what I wanted to do in life,” she revealed.

Dr. Abraham asked about her decision to enter hematology-oncology, and Dr Marshall replied: “During college, I simultaneously decided I wanted to be a doctor and to pursue a career in hematology- oncology. I’d done some clinical research in lung cancer and shadowed a terrific mentor, a junior faculty member at my institution who was fantastic and generous with his time even when trying to build his own career from the ground up. He gave me clinical research opportunities, let me present at national meetings on work we had done together, and let me shadow him in the clinic, so that cemented my decision to go into heme/onc.”

Another Valued Mentor

After receiving her medical degree from Harvard University Medical School, Dr. Marshall did an internal medicine residency at the Hospital of the University of Pennsylvania and then a hematology/oncology fellowship at Dana-Farber Cancer Institute in Boston. “After fellowship, my next career move was a shared decision-making situation with my husband, who’d finished his fellowship training when I was just starting mine. He’s an electrophysiologist and got a great job offer at Mayo Clinic, so we did a long-distance relationship while I finished my fellowship. Mayo offered me a great job on staff, and although we also explored plenty of other opportunities at institutions across the country, we ultimately felt that Mayo was the place that maximized career opportunities for both of us as junior faculty,” she said.

During Dr. Marshall’s time at the Mayo Clinic, she was mentored by Alexandra Wolanskyj-Spinner, MD, who nurtured Dr. Marshall’s clinical and sociopolitical passions. “She is such a strong woman in medicine, and I connected with her, first on career development and then on balancing work and family obligations. She also mentored me as I went through fertility challenges and eventually after I had a young child at home… She’s a full professor now at Mayo and a bright, shining light.”

Asked about her path toward her specific niche in hematology, Dr. Marshall responded: “I have a long-standing interest in women’s rights and women’s health. I went into fellowship thinking I would be a breast cancer doctor, but I found I was much more attuned to benign hematology, particularly the thrombosis and hemostasis side of things.” Dr. Marshall continued: “I like this specific area of women’s thrombosis and hemostasis, where there are a lot of unanswered questions about how to best manage pregnancy, contraception, and fertility, and menopausal symptoms in women with bleeding disorders or thrombophilia. It really comes down to a lot of discussion with patients and shared decision-making, and I like that part of medicine.”

Redefining Leadership

Dr. Marshall pointed out that although we have reached parity in terms of the number of women going into medicine, the road to leadership positions has not maintained that same equitable trajectory. “I think two areas really need improvement to increase the number of women in leadership positions, whether it be clinical or administrative. First, it starts with what can the system do to make things more welcoming and equitable for women. And second, the system needs to change in terms of what are we looking for as a leader. In other words, we need to change our view of who can be an accomplished leader. Once there are more women in leadership positions, we can create a culture of equity that changes the framework of how we define good leaders and what it takes to become a good leader,” she noted.

Can the major organizations such as ASCO do a better job to promote gender equity? “As a benign hematologist, I’m a little bit more familiar with ASH than ASCO, but I think any big specialty society must first start by analyzing the data and asking the hard questions. Who are your leaders? What’s the gender and racial equity makeup of any medical society, and what type of leadership positions do people have? An often-quoted message from the business world is women don’t go up for promotions or leadership roles unless they are 110% qualified, whereas men may try out for a role when they feel 70% qualified. Addressing that endemic mindset will require continuing work from women leaders in the field, fostering an emerging generation of strong women mentoring younger women as they begin their careers in hematology-oncology.”

Women’s Health Needs

Women with bleeding disorders suffer from multiple bleeding symptoms, especially gynecologic and obstetric bleeding; according to Dr. Marshall, these bleeding disorders commonly go untreated. “When I first got involved in women’s thrombosis and hemostasis disorders, I discovered the depth of the challenges in this subset of patients. We just completed a very small study looking at women’s experiences and quality of life with bleeding disorders. We found that many older women with diagnosed bleeding disorders would be at home for a week every month with horrible menorrhagia, not able to go out into the world and function. But they were never told to see a physician or that the bleeding was manageable,” she explained.

Dr. Marshall continued: “If they did talk to their doctor, often a male ob/gyn, they were told it was something they’d have to learn to live with or to have a hysterectomy. We’ve also found that a percentage of these women were advised not to get pregnant, as it was too high risk. Yes, it’s a small population of patients, but the impact these disorders have on health and overall quality of life is huge,” she commented.

Article in The New York Times

A 2016 survey of female physicians in the Journal of Women’s Health discovered that nearly one in four who had tried to have a baby had been diagnosed with infertility, almost double the rate of the general public. In 2021, Dr. Marshall was interviewed by TheNew York Times to shed some light on this conundrum.

Dr. Marshall elaborated: “I was interviewed for the Times about physician infertility, because of some work I had done with a couple of colleagues who, like me, have all experienced infertility as women in medicine. We realized it’s quite common, because we’ve sacrificed our fertile years to the high demands of our career. Plus, if you choose to have a family, it’s a decision not always looked on very favorably by many programs, so it’s a very difficult choice. In my case, I put off family building for several reasons and don’t think I would have done things differently, except I might have made the choice to freeze my eggs during training or at least to think about it. In the Times article, we sought to raise awareness so women in medicine can feel like they can discuss this delicate issue, which is a powerful first step,” she said. To that end, Dr. Marshall helped to create an infertility task force with the American Medical Women’s Association.

Mentoring and Cultural Competency

There is literature to support that mentorship not only improves job satisfaction, but also improves productivity and facilitates personal growth. According to Dr. Marshall, mentoring is a personal style, and hers relies on honest discussion. “I don’t try to sugarcoat things. I always ask my mentees what they are hoping to get from this mentoring relationship and what can we help each other with. And I will give them very honest answers, whether it concerns career building or interpersonal relationships along the way. Obviously, all of that’s influenced by my own personal experiences, but I try to give very honest and practical advice, because you want people to be involved in that decision-making process,” she explained.

Guest Editor

Jame Abraham, MD, FACP

Dr. Abraham is Acting Chair of the Taussig Cancer Institute and Chair of the Department of Hematology and Medical Oncology at Cleveland Clinic. He is also Professor of Medicine at Cleveland Clinic Lerner College of Medicine.

Dr. Abraham asked Dr. Marshall how physicians can learn cultural competency skills. She replied: “Cultural competency is a broad term, and the way I think about it is interacting with people who have different backgrounds than yours. It can be anything from gender, to race, to ethnic background, to where you did your medical training, to socioeconomic status. And I think medical schools are getting it. There are a lot of programs and training out there. It’s still an uphill battle, but we’re making progress,” said added.

Work/Life Integration

When the discussion turned to maintaining a healthy work-life-balance, Dr. Marshall commented: “Some days, it definitely does not feel like I have balance, but the terminology is changing from work/life balance to work/life integration. In other words, how can you bring aspects of your career and your family into some sort of integration instead of the traditional bifurcation we think of. And finding ways to reduce friction helps the integration process. Having fun at work and off work is a great way to stabilize one’s life. I’m fortunate in that I love my work. And I’m a big foodie, so that’s one way I integrate pure pleasure with the work component in life. I maintain a database of all the restaurants in big cities I’ve been to or want to try. Finally, I love to travel, which I’m getting back into now, but you know how it is, with COVID not quite behind us.”

Words of Advice

In closing, Dr. Marshall shared some valuable advice regarding professional paths. “There are three things to assess about a job offer. First, the WHAT: is what you would be doing on a day-to-day basis a good fit for your personality and passion? Second, the WHERE: does the location geographically support you in terms of nearness to friends and family and also does the institution and system you are joining support your career development? Third, the HOW MUCH: how much would you be paid? I tell my mentees that a great job offer may optimize two of these three things but it’s almost impossible to find an offer that optimizes them all, so it’s important to know what matters most to you personally. Additionally, your career is always going to have bumps and unexpected changes. It’s not the predefined straight path to success it used to be in college, medical school, residency, and fellowship, but if you feel like the overall trajectory is up, that’s fine. Keep open to opportunity when it knocks because it will. Academic hematology-oncology is very demanding, but it is tremendously rewarding if you remain focused and passionate about your career.”