Women leaders in hematology: Inspirations &amp; insights
Authors: Doris Quon, Meera Chitlur, Madhvi Rajpurkar, Mindy Simpson, Sarah O'Brien, Veronica Flood, Loan Hsieh, Suchitra Acharya, Rebecca Kruse‐Jarres, Suman Sood, Jennifer Maahs
Journal: American Journal of Hematology (2016)

Dr. Carol Kasper is a hematologist and Director Emeritus at the Orthopaedic Hemophilia Treatment Center in Los Angeles, California. Dr. Kasper is well known for her work on the diagnosis and treatment of hemophilia over the past 40 years. During her career, she has held numerous leadership positions within the field, including Vice President Medical of the World Federation of Hemophilia (WFH), Vice President of the National Hemophilia Foundation (NHF), and Chair of the Medical Advisory Board of the Hemophilia Foundation of Southern California. She has received many awards for her work, including two career achievement awards from the NHF (2000 and 2007), the Brinkhous Award for Excellence in Clinical Research (1992), the George F. Davignon Lifetime Professional Achievement Award (2005), and a lifetime achievement award from the Hemostasis & Thrombosis Research Society (HTRS; 2008). Carol K. Kasper, MD Jeanne M. Lusher, MD Roshni Kulkarni, MD Marilyn Manco-Johnson, MD Margaret V. Ragni, MD, MPH Joan Cox Gill, MD Diane Nugent, MD Donna DiMichele, MD Cindy Leissinger, MD Barbara A. Konkle, MD Amy Shapiro, MD Dr. Kasper received her undergraduate degree from the University of Chicago (1954) before completing her medical degree at the University of California, San Francisco (1959). She then completed a residency in internal medicine and a fellowship in hematology. Dr. Kasper later joined the faculty at the University of Southern California (USC) and became professor emerita in 1999. Over the course of her distinguished career, she has published over 200 scientific papers, monographs, and book articles in the field of hematology. Dr. Kasper currently trains hematology fellows at the Orthopaedic Hemophilia Treatment Center. Dr. Doris Quon: The first question is: how did you even get involved in medicine? Dr. Carol Kasper: I was always interested in articles on medicine that I read in ordinary magazines, like Time or Newsweek or Reader's Digest. I realized that I had an interest, but it wasn't so strong. I knew I just wanted to do something worthwhile. I thought a little bit about the law, and [knew] that I wanted to do something challenging. A lot of my friends and relatives, my parents, thought that medicine would be good for me. And when the kids in the dorm said, “You really ought to be a doctor,” then I thought, “Well, maybe they see something that I haven't completely seen [in] myself yet.” I was more serious, I think, and they thought that's what a doctor ought to be. But there was no particular experience that led me to medicine. It was not a highly informed decision. Dr. Quon: Looking back, would you change that? Dr. Kasper: I've enjoyed it, so I don't think I would change it now. I must say that it was difficult at the time. I found medical school to be a hard slog because a great deal was expected of us to learn so much in such little time, and I had to study very hard. So it was difficult, but I'm glad I did it. Dr. Quon: How did you get into hematology? Dr. Kasper: I really don't quite know where the spark for hematology came from. I just picked up an interest as we went along. I used to joke a little bit about it—I joked that it was because blood was so pretty! I was very fortunate when I thought about hematology as being attractive. At the time, I had met a lady who was a cardiologist and who was the wife of a hematologist, and she said, “Well, if you like hematology, this is where you should apply”; and I was really lucky because I had a fellowship with an excellent person. He was very big in coagulation, Dr. Paul Aggeler. He had tremendous integrity, and he was not at all a proud kind of a guy. So it was a wonderful experience for me. Dr. Quon: When you first got into medicine, did you think that it would be challenging given that you were a woman? Did you think it would be more challenging than it would have been for a man? Dr. Kasper: Well, I did… there were various snide remarks that people would make like, “You're taking up a man's place in medical school. The man will practice; a woman won't! She'll just get married and have children and drop out”—that was a common assumption, and one had to sort of fight that. I remember one of my interviews, which was with the dean of a medical school who said, “What will you do if your husband doesn't allow you to work?” And I said, “I'm not going to marry somebody who doesn't allow me to work!” And he said, “Well, you have a lot to learn about life.” I did get admitted to that medical school, so I can't say that any of the snide remarks that I've ever run into have kept me from a job or an appointment. They just told me what the attitude was of the questioner, but they didn't keep me out at any point that I know of. Dr. Quon: Do you remember your medical school class having very many women? Dr. Kasper: Mine had more than average. I think that this was very unusual. The class before had two or four, and ours had ten in a class of 80-something. But then, the following year, after us, they went back to only four females in the class. Dr. Quon: Interesting. Do you think the medical field is actually becoming more supportive of women in the field? Dr. Kasper: I think it's become more the norm to have women in the field. I hope that salaries can keep [us] supported. I remember once when an editor of the New England Journal of Medicine gave a talk at USC about the future in medicine. He said, “Well, now that we're getting all of these women in medicine, we won't have to pay them so much.” Dr. Quon: There is a disparity between pay across all jobs, not just in medicine, unfortunately. Dr. Kasper: Yes; but, alas, it doesn't cost any less for women to go to medical school than it does for men. Dr. Quon: Yes. So for a lot of male doctors, they get married and they have the woman at home “to take care of the home.” You think that was more difficult for you being a woman? Dr. Kasper: I think this is a major issue when both the man and the woman have professions. If you're a hematologist, it's a profession that requires a fairly big population to draw from. So you probably aren't going to get along in that profession in a small town. So I think the first big problem is, can you and your spouse both find jobs in the same town? And then the next big thing is trying to take care of the children. The hard part, I think, is while they are young [since] they need so much attention. I was very fortunate because my parents lived less than a mile away. They were delighted and wanted to babysit. It certainly solved that huge problem for me. I would say to any woman I'm advising that those are the hard years and they don't last forever. And once the children are teenagers, there's a lot they can do themselves. And even when you get to be, say, 50, that is not the end. In fact, for a lot of women, it's when they blossom because the kids are grown or grown enough and they don't have to take care of them every minute. Dr. Quon: We talked a little bit about why you went into hematology. What made you go into the area of coagulation? Dr. Kasper: I think that was more happenstance because my chief, Dr. Aggeler, was a big clotter. He was very well known in the clotting field. I didn't realize that. I was learning a lot of clotting while I was with him. We had patients with hemophilia in his small practice, and he was trying out the new concentrates on them. These were very early concentrates being made by Cutter Labs across the [San Francisco] Bay and [at] Berkeley. The patients would come in and we would do very nice, detailed half-lives on them. The patients were delighted and they were very interested. And I was learning a lot about coagulation. And then, a mutual acquaintance of mine and of Dr. Sam Rapaport at USC knew that Dr. Rapaport was looking for somebody for Orthopaedic Hospital because, although the hemophilia program had been at USC since 1962, by 1966, he knew that concentrates would be coming out and [that] they were specific. There was one for factor VIII and another for factor IX, so you had to be sure what type of hemophilia the patient had; and then you had to be able to measure the clotting factors. There wasn't a coagulation laboratory at this center yet, so that was my job. I came here to be the first person trained as a hematologist to [establish] a coagulation lab 1. Dr. Quon: Is finding a mentor really important? Dr. Kasper: It certainly is, and I don't think people have just one. You meet people who are good to you, or you like them. You become friendly with them. Somebody who did me favors was Dr. Judy Pool of Stanford University. She was in and out of the lab, and I became acquainted with her. Behind the scenes, she had arranged the committee that decided on the Bethesda assay. Before that, there was a multiplicity of inhibitor tests; and she said there should be one. And the NIH [National Institutes of Health] appointed a committee, and she had me appointed chair. And I said, “Who me? There are people on this committee who know more about it.” And she said, “Just do it!” And, you know, it really was important to just do it because then my name was attached to it, and I got some credit out of it 2, 3. It's interesting—I find that, sometimes, people who are not closely related to you will sometimes just be helpful. Somebody who was helpful at USC was a pediatric hematologist, Dr. Darlene Powers. When we would go to the American Society of Hematology meetings, I would often room with her and with a couple of other women and she used to preach at us a little bit, the younger women. She'd say, “For a promotion, what you really need is papers, papers, papers! Don't just believe what the faculty handbook tells you.” She told us what we really needed to get promoted. I appreciated that because the men in my department didn't come forth with that information quite as bluntly. So there were these women who just sort of volunteered in their way. They were not responsible for me. They just put a little lesson in my ear. Dr. Quon: Do you think that women have a supportive attitude, to support other women? Dr. Kasper: I think there are some women who are nice and supportive and others who aren't, of course, but it's interesting that they can be supportive of people who are not just immediately under them. So your mentors may be scattered. I think you can't just focus on a single individual to be your mentor. You get your mentoring where you can and find friendly people where you can, and some of them will be men. Dr. Quon: Is there a best time to find a mentor, or do you just sort of take advice when it sounds like good advice? Dr. Kasper: I think you have to. I think you never know when somebody will come along who has some decent advice to hand you, and you just have to keep your ears open. I think it's also okay for a younger woman to ask a more senior woman, “What do you think I need to do to get ahead?” It's okay if you just have a friendly conversation. If she doesn't know anything or she doesn't want to answer, she can brush it off kindly. But if she knows something, if she has some advice to give, she can give it. Dr. Quon: What is it like to be considered a pioneering woman in hematology? Dr. Kasper: I never thought of myself that way. I have never really thought about being a woman in some of the various positions that I've been in. Either they have been held in the past by women, or it felt quite natural to be in them. I know that I have wound up in some leadership positions. Sometimes I have felt underqualified and I've thought there could be somebody better to do this job but, at the moment, there isn't anybody available. So, okay, I'll do it, and I'll do it as best I can. I should also say that I don't think people should necessarily think that they have to be in leadership positions because it can be a two-edged sword. If a woman wants to be a big academic success, she needs time to do research and write papers. Being the chair of this and the chair of that takes time and energy. Dr. Quon: Indeed. Do you think you were better equipped, because you're a woman, to take care of the patients with a chronic disorder such as hemophilia and von Willebrand disease? Dr. Kasper: I think that women, in general, are socialized to be patient in the moral sense, to have patience with sick people and irritable people more than men are. So I think that maybe, in general, women are well suited to [care for] the chronically ill, the people who never really get well. At this hospital, I saw the contrast between the surgeons who wanted to fix the broken limb and then be very happy that the whole case was over with, and the patients were enormously grateful—they were just overflowing with gratitude because now they were better. The patients who have chronic illnesses don't necessarily ever get to the point of being so well that [they] have that tremendous relief, which would lead them to expressing a lot of gratitude. I think that the patients are grateful, it just doesn't come up a lot. Dr. Quon: I know patients are very grateful. Many of them who you've taken care of as children remember you and remember you fondly… What do you think about gene therapy now, and do you think that's the wave of the future or do you think there will be other sorts of therapeutics? Dr. Kasper: Some of these other therapeutics are really interesting. The fun thing is to see all these new approaches coming along. There have been so many drug developments in hemophilia; even some that are not clotting factors, which are other approaches to hemostasis. Regarding gene therapy, I have hopes that it should work. I'm aware of all of the obstacles and think eventually they'll be solved. It'll be here one of these days. Dr. Quon: Any final words of advice for young females like myself who are interested in going into hematology, hemophilia, or other leadership positions? Dr. Kasper: I hope that you enjoy it; and leadership is needed, even though it's not always easy, and it doesn't always come naturally. Dr. Kasper has dedicated her career to understanding and advancing the care of hemophilia patients from both a clinical and scientific standpoint. She has been involved with hematology since completing her fellowship in 1962 and starting at the Orthopaedic Hemophilia Treatment Center in Los Angeles in 1966. She has contributed tremendously to the field of hemophilia from her early work in establishing a coagulation laboratory at the Orthopaedic Hemophilia Treatment Center to help diagnose patients with bleeding disorders, to chairing a committee that defined the inhibitor assay, the Bethesda Unit, which is still in use today. Dr. Kasper has been involved in clinical research in the area of coagulation therapeutics, doing pioneering work on the use of desmopressin (DDAVP) in bleeding disorders 4, and publishing extensively on new factor concentrates 5. However, I think her biggest and most impressive contribution is her leadership role, nationally and internationally, to improve the care of all hemophilia patients. She has served as Vice President Medical and member of the Medical Advisory Board of the WFH, Vice President of the NHF, and a member of the Medical and Scientific Advisory Council (MASAC) of the NHF. The end result of her efforts has been strengthening the community and expanding access of care to those with inherited bleeding disorders. She has given tirelessly to the hemophilia community and is indeed a role model for those who are entering the field of hemophilia, and to women in particular, having accomplished so much early on in a time when gender bias made it difficult for women to advance. Mentorship is a critical component in the development of any career. I feel that I have been incredibly fortunate to have the benefit of Dr. Kasper's mentoring. She has been an integral part of my training since I was a fellow at UCLA and even to today! Dr. Kasper is well known to be a true pioneer in the field of hemophilia, and brings the full depth of her knowledge to teaching members of the hemophilia community. She enjoys imparting her extensive knowledge to junior trainees in a patient and stepwise fashion. Dr. Kasper is incredibly generous with her time; she realizes that we are not “self-made” and that it takes time for young people to develop and learn. Dr. Kasper incorporates the history of the field into her teaching style, which provides important context for understanding the unique challenges encountered by hemophilia patients and how best to help our patients overcome these challenges. She not only provides useful advice on “things to do” based on her past experiences, but also highlights what not to do to avoid costly mistakes. When I ask for her opinion on a subject, she has honest and helpful feedback. This feedback is instructive, but is also encouraging and supportive. Dr. Kasper has had an enormous impact on my growth professionally and I only hope that I can “groom” the next generation of hemophilia treaters with the same passion and enthusiasm that she used with me. Dr. Jeanne Lusher is internationally recognized as an expert in the development and management of factor VIII (FVIII) and factor IX (FIX) inhibitors 6-8, as well as the analysis and clinical study of new clotting factor concentrates for the treatment of bleeding disorders. Until her retirement in 2013 from Wayne State University School of Medicine in Detroit, Michigan, Dr. Lusher served as Co-Director of the Hematology/Oncology Division, Medical Director of the Special Coagulation Laboratory at Children's Hospital of Michigan, the Marion Barnhart Hemostasis Research Endowed Chair, and a Distinguished Professor of Pediatrics. Her main areas of interest have included immune thrombocytopenia, the etiology and pathogenesis of inhibitor antibodies against FVIII 9, splenic structural physiology in hematologic/oncologic disorders in children, platelet–vessel wall interactions, and the development of new assay methods in blood coagulation. Over the course of her career, Dr. Lusher has taken on many leadership roles within the field, including serving as Chair of the Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation (NHF), Chair of NHF's Education Committee, Chairman of the International Society on Thrombosis and Haemostasis (ISTH) FVIII/FIX Subcommittee, Chairman of the ISTH Scientific and Standardization Committee, member of ISTH's Council, Co-Chair of the American Thrombosis and Hemostasis Network (ATHN) Board, and Chair of the American Board of Pediatrics Sub-Board on Hematology/Oncology. She has received numerous awards for her work, including NHF's Brinkhous Award for Outstanding Clinical Research, Humanitarian Award, Career Achievement Award, and Visionary Award for Women's Bleeding Disorders; the Hemostasis & Thrombosis Research Society (HTRS) Distinguished Career Award; the American Society of Pediatric Hematology/Oncology (ASPHO) Distinguished Career Award; and was elected as a lifetime member of Wayne State University's Academy of Scholars, which is the highest honor to be bestowed upon a member of the faculty. In addition, she has published over 270 peer-reviewed publications, nine books, and over 60 book chapters. Although Dr. Lusher has retired, she remains an active member on committees of the NHF, ATHN, and HTRS, as well as holding a position on the editorial board of Haemophilia. Dr. Lusher earned her medical degree from the University of Cincinnati College of Medicine (1960) and completed postgraduate training in pediatrics at the Charity Hospital of Louisiana at New Orleans. She received fellowship training in hematology/oncology at Tulane, Children's Hospital of Michigan, and Washington University in St. Louis. Dr. Meera Chitlur: Dr. Lusher, please tell us what made you go into the field of medicine. Dr. Jeanne Lusher: When I was in high school, I envisioned myself having a career in music. My mother was a piano teacher and I was immersed in music, playing in the orchestra and the band. While I was in high school, I went down to the College of Music in Cincinnati for piano lessons and to play in their orchestra. I also played a very large pipe organ at our church. It was very good for me that I spent so much time down at the College of Music because I got to see a lot of students there who played much better than I did and couldn't find a job afterwards. And so I thought that while I can really enjoy music, I don't think it's a good career choice for me. The other things I really loved in high school were the biological sciences. While I was in high school, I volunteered at a chronic disease hospital 2 days a week. I was interacting with a lot of elderly people with chronic disease problems and I found it very challenging and satisfying, so I thought I'd like to be a geriatrician. I then went into a premed program in college and continued to spend my time off doing things that were related to medicine. I worked in a research lab with animals at Proctor & Gamble. I spent my summers in Madison, Wisconsin where I worked in labs at the Wisconsin General Hospital; I had the opportunity to learn a number of lab techniques while I was there. So, it was kind of a natural progression that I went into medicine. Dr. Chitlur: What made you choose hematology as a specialty? Dr. Lusher: While I was the chief resident in pediatrics at the Charity Hospital in New Orleans, our staff hematologist left rather suddenly to take another job elsewhere. We had lots of children who were on chemotherapy research protocols of the Southwest Oncology Group, as well as children with hematologic problems, and no one who was in charge of them. So I thought I'd better take this on and become more knowledgeable about these protocols and so forth. I started going to the meetings of the Southwest Oncology Group…I got very involved in hematology and oncology the year that I was chief resident. Then our chairman of pediatrics called me in and said, “We need a full-time hematologist here, so I've arranged for you to go to work with Dr. Wolf Zuelzer in Detroit as a hematology fellow. When you finish that, you will come back here to New Orleans.” It's hard to imagine, but I said, “Okay, I'll do it.” I had never been to Michigan, never heard of Dr. Zuelzer, never thought of doing something like that, but I went to Detroit and it was a wonderful experience! Suddenly, I was in this top-notch fellowship program at the Children's Hospital of Michigan with all kinds of patients, all types of hematologic problems, including acute leukemia. I just found it very exciting to be there, with all the things that I could see and learn about and become involved with. There were some very good labs, including the coagulation laboratory, which was an excellent learning experience. Dr. Chitlur: I know you have mentioned another story about how your interest in coagulation started. Could you please tell us about that? Dr. Lusher: When I was a pediatric resident at Charity Hospital, a little girl was admitted through the emergency room and came to me as a patient. She came in with profuse bleeding and, after the work-up, it turned out that she was a rare girl with hemophilia (hemophilia A). I realized in the process of doing the work-up that I knew very little about coagulation. I tried to learn as much as I could while taking care of her, and ended up writing an article about her because she was such a rare case of hemophilia in a female 10. So that was one reason I got interested in coagulation. Then when I came to Detroit as a fellow, after I had been here for a relatively short period of time, I found out that the Department of Physiology at the medical school here had a major focus on blood coagulation. The Chairman (Dr. Walter Seegers) was a famous coagulation expert, and many people in his department were interested in various aspects of blood coagulation. I started going to the conferences and the programs that they had, which sparked my interest in hemostasis and blood coagulation. I also got involved with a couple of the faculty in that department, one of whom (Marion Barnhart, PhD) became one of my key mentors. While I was a fellow, I realized that even though we had children with all sorts of hematologic disorders and leukemias, we rarely had solid tumor patients because, for some reason, either the surgeon or somebody else was taking care of them and we didn't see them. So, I arranged to go to Washington University in St. Louis as a trainee of the American Cancer Society, specifically to learn more about solid tumors. However, by the time I got there, I had become so interested in coagulation that I spent a lot of time going to the adult hemostasis rounds and conferences (headed by Dr. Sol Sherry)… I ended up spending more time with them than I did with childhood solid tumors. When I came back to Detroit as a junior faculty person, I was doing a little bit of everything in hematology and leukemia, but certainly my major interest from that point on was in coagulation. Dr. Chitlur: What challenges did you encounter in the field of medicine because you were a woman? Did you ever feel like you were being held back because of that? Do you think that the medical field is becoming more open to having women in it? Dr. Lusher: I never felt like I was being discriminated against or had any problems because I was a woman. However, when I was a medical student, there were very few women students, and when I graduated from medical school in 1960, there weren't many women who went into fields other than pediatrics or OB/GYN [obstetrics/gynecology], sometimes internal medicine. I think most medical fields are now much more open to women; you see women physicians in a whole variety of specialties. And that's a very good thing! Dr. Chitlur: Who was your mentor and how did he or she contribute to your life? It looks like you've had maybe more than one mentor at different stages of your career. Dr. Lusher: Right. When I went to Charity Hospital as a pediatric resident, Dr. Norman Woody became my mentor. I really developed my self-confidence as a physician during the period that I was at Charity Hospital. I knew that I had somebody I could call on if I needed any help, someone who was always there and gave good advice; although, he wasn't in the field of hematology, he was in metabolic diseases and their genetic influences and was doing a lot of research. I was sent off doing part of his research, getting samples from patients and their families in outlying areas. He was a great mentor when I was a resident. Then when I came to Detroit, Dr. Wolf Zuelzer, the head of the Child Research Center and Hematology/Oncology, was an excellent mentor, as was Dr. Marion Barnhart in the Physiology department—I did a lot of research with her. I had other mentors along the way, but those were the major ones. Dr. Chitlur: How important do you think it is for a person to find a mentor? Dr. Lusher: I think it's very important, personally. I really think you can gain a great deal from a mentor. I don't mean just in terms of didactic clinical things, but in having common interests and as someone who's been there and seen whatever problems there might be or how you should approach things going ahead. The mentor can help the mentee to see a better way to do things, even outside of the hospital. Dr. Chitlur: I can tell from my firsthand experience how important your mentorship has been in my career. What, in your opinion, would be the most important role of the mentor in the progress of the mentee? Dr. Lusher: I think it's important to have a mentor who is enthusiastic about your field and engages mentees to work on clinical and laboratory research projects and presentations early on and is able to nicely critique them in a positive way. I also think it's important for the mentor to convey to the mentee how essential it is to develop real expertise in some aspect of our specialty, so that you can be immediately recognized by peers around the country as a top expert in it. Another example is encouraging mentees to sit near the front at meetings and ask questions… I've experienced this myself—if one is sitting further back in a large audience, it's intimidating as a junior person to stand up and ask a question or make a comment. But if you're sitting right near the front and not looking at all these people behind you, it really is easier to ask questions and make comments. And people see you, too. It's also important to convey to the mentee that they should go out of their way to meet as many colleagues as possible at meetings and to establish collaborations. That is extremely helpful for people who want to go into leadership positions. Dr. Chitlur: As my mentor, you went out of your way to take me around and introduce me to people… I cannot tell you how important that was, especially for me to establish those connections. I think that, without that step, it can be very hard for a mentee like me to find the right people to collaborate with. Do you have any specific advice for women, or anybody for that matter, who want to rise up to a leadership position in medicine? Dr. Lusher: I think it's very important to develop a real expertise in some area(s) so that you can be recognized as the expert, or one of the top experts, in some aspect of your specialty. I also suggest to meet as many colleagues as possible and establish collaborations; and if you are offered a leadership position, to take it with enthusiasm and determination. Even though a leadership position may take up a great deal of one's time, I think it is well worth the effort. Dr. Chitlur: What would your advice be to somebody entering the field of medicine now, and your advice on choosing a subspecialty in hemostasis or hematology? Dr. Lusher: I think for someone choosing a specialty, it's important to do what you'r