I was raised as “the son my father never had.” I grew up fishing and hunting with the boys or roaming the middle of the soccer field as “controlled chaos”. I was called “bossy” and “outspoken,” as I was typically telling other kids what to do, coming up with ideas and plans and then implementing them. I was raised in a home with a physician father and a full-time working mother, one of the highest-ranking female employees in her bank in our state. I truly did not see gender differences in my childhood. I believed I was equal to males. Medical school was the first time I noticed gender differences at all. I remember calling my mother with a sense of wonder. “This is a thing? I'm different than boys?” But I couldn't put my finger on what exactly the differences were. I just knew I felt it. Then I went to residency, and “woah”. Despite being at the top of my class, my evaluations made me cry, regularly. Ugly cry. I had to learn to “play nice” with nurses, techs and ancillary staff to get things done in a way that the males around me never had to do - I cleaned the pelvic exam room more times on a shift than ANY resident, EVER. It wasn’t until I graduated and started hearing other women’s stories and researching gender differences that I began to appreciate that this wasn’t a “ME” thing but a “WE” thing. It WAS and IS a gender thing.
To start delving into this topic, it is best to have some background in gender bias and the related theories from psychology literature. Overt gender bias is an explicitly endorsed personal belief about a sex, whereas implicit bias is more elusive. One is unaware that it is operating, and it may be at odds with what that person actually believes, but still influences their judgment and actions (1). Most of what we will be focusing on is implicit bias, although overt gender bias is not extinct in our society. There are also descriptive and prescriptive forms of gender bias. Descriptive gender bias is how men and women actually are, describing qualities or behavioral tendencies that are desirable for each sex (1-2). Descriptive norms are considered synonymous with gender “stereotypes”(2) or character traits. Prescriptive gender bias describes how men and women “should be,” thus defining norms for acceptable behavior (1-2). The combination of descriptive and prescriptive expectations make up the “gender role” (1). These “gender roles” define males as “agentic,” possessing characteristics, such as assertiveness, controlling, independent, self-confident and dominating, whereas women are characterized by “communal” traits (concerned with the welfare of others), such as affectionate, nurturing, dependent, and gentle (2-3). The prescriptive gender biases state women should act in a “communal” fashion, but they also specify what women should NOT do. Women should NOT engage in stereotypically male or “agentic” behaviors or possess those “agentic” character traits (1-3).
That was a LOT of psychology and definitions. What does it all mean? Society expects women to act in a nurturing, sympathetic, caring way and NOT to act in a competitive, driven, and assertive manner. So what happens to us “Type A” women who are driven to succeed, who want to compete in the classroom/work environment and who want to achieve? Well, first of all, we may have to work HARDER to be considered competent when compared to our male colleagues. And second, we will pay a price for our success, since we are acting out of line with our gender norms.
Why do we have to work harder? Medicine, science and leadership are all considered agentic domains, so women “should be” less likely to be competent or successful in these fields based off prescriptive gender norms (3). Studies have shown that in agentic domains, identical work is rated lower when performed by a woman, and evaluators require MORE proof of women’s skills than men’s skills to be convinced that they are competent (2-3). A study was done having undergraduate students rate an employee based on their CV for a job that was stereotypically male. The gender and the individual’s prior success were the details that were adjusted in the study. They found no significant difference between males and females in terms of competence rating when the individual’s prior success was made explicit. When, however, the information about performance was left ambiguous, the female employee was rated as significantly less competent than the male (2). So women are often assumed to be less competent (by both male and female evaluators) until they have clearly proven their competence, whereas males are often presumed competent from the start.
Once they have proven themselves competent in this agentic domain, women then pay a price for their success, titled a “likeability penalty” or “backlash”. This penalty is because their success in an agentic career or leadership position violates their prescriptive gender roles. They often manifest stereotypically “male” or agentic characteristics instead of the expected communal attributes. This leads to unfavorable evaluations. Sheryl Sandberg gives a great example of this in her book, Lean In (4). She discussed a study done in 2003 by Frank Flynn and Cameron Anderson where they tested perceptions of men and women in the workplace. They took a case study about a female entrepreneur who used her personality and professional network to gain success. Half of the students read the story with the name of the entrepreneur as Heidi. The other half read the same case story but with the name Howard. The students were then polled and found Heidi and Howard to be equally competent, but Howard was a more appealing colleague. Heidi was seen as selfish and not someone that you would want to work for or work with. When women are successful, they are deemed less likeable, more interpersonally hostile and more personally derogated1. This “likeability penalty” is not just office drama. It can strongly affect a woman’s evaluations, promotions, job opportunities and salary (1). Success and likeability are, unfortunately, negatively correlated for women.
How do these gender roles play a part in medicine? First, our specialties in medicine can be characterized as more “agentic” vs “communal”. For example, communal specialties are ones that involve care of families and children and are not considered highly technical. These fields are considered lower status, often lower salary, and have a higher percentage of female physicians. Other more agentic fields, such as orthopedics, neurosurgery and neurology, are perceived as higher status, more technical, and more male-dominated. Medical students likely experience a significant number of subtle messages related to gender bias that influence their career direction to align with gender stereotypes. Below is a table from Carnes et al. (3) depicting the effects of gender roles on specialty.
How else does our sex affect us as women in medicine? Remember that “likeability penalty” we talked about. Well, wait until you see your evaluations! In medical school, my evaluations were great. I aced my classes while trying not to be a “gunner” along the way. But as I stepped into the role of a resident, the role of a physician CARING for the patient, the role of needing to get things done to save a life, my evaluations changed. In fact, they screamed, “You have a vagina!" And not in a good way. Peers labeled me called bossy, bitchy, and arrogant. I thought they were my personality flaws, something intrinsically wrong with me and how I was practicing as a physician. I called my senior, one of the most amazing doctors I know, crying about how mean my evaluations were, how everyone hated me. She promptly pulled up her evaluations and read them aloud to me over the phone. I stopped crying and started laughing. They were EXACTLY the same as mine but even meaner. My faculty evals also showed significant dichotomy. I was either overly-confident and arrogant, or not confident enough and needed to make swifter decisions with more self-assurance. I could never sort out how to improve because of mixed messages. In emergency medicine (EM), a couple of studies were recently done looking at the effects of gender on evaluations. The first study looked at quantitative feedback using the EM milestones, and found that during their intern year, men and women were considered equally competent, but by graduation, the males attained higher milestones than the females across all subcompetencies, concerning for a gender gap in evaluations (5). The second study looked at the qualitative feedback that the residents received and found that women received less consistent feedback then the males and that feedback often referred to personality traits (6). Males typically received consistent feedback on what they needed to do to improve, while females would get mixed messages, especially regarding autonomy and assertiveness (6). Despite the strides we have made in integrating women into the workplace and the field of medicine, the gender specific traits that allow women to succeed are considered “MALE” and unappealing or "bitchy" when women possess them, as shown in previous gender studies.
Evaluations show conflict related to gender, but do those conflicts occur in our clinical practice? Decidedly YES! As a resident running a code, I learned to swaddle my commands for epinephrine or resuming CPR with please and thank you. I delivered them gingerly, without any angst in my voice, despite the person DYING in front of me. When I became an attending, I watched one of my strongest female residents run a resuscitation. I noticed her voice changed. Her normally faint southern accent became thick and syrupy. I pulled her aside after and asked her if it was intentional. It was. She had learned to thicken her accent to make her commands sound “sweeter” to the nurses. Recently, a study of internal medicine residents confirmed what I had been witnessing in my own medical education and the education of my female residents. Gender stereotypes can influence how we run a code, how we save lives. This study, titled “Afraid of being witchy with a ‘B’” by Kolehmainen et al. looked at the character traits associated with ideal code leadership, finding them to be decidedly “agentic”. Code leaders were assertive and authoritative, standing tall at the foot of the bed while calmly and emotionlessly orchestrating the room (7). The female residents discussed their difficulties in using directive language and the increased stress they faced when violating prescriptive gender norms (7). These residents were expressing a fear of “backlash,” the social censure that women receive from acting in ways that counter stereotypical behavior (7). We, as women in medicine may suffer that same “likeability penalty”(5) when running a resuscitation to save a life. This “likeability penalty” can affect our evaluations as residents, our future job opportunities and promotions, and potentially even our salary (2). In her commentary piece entitled, “Damned If You Do, Damned if you Don’t: Bias in Evaluations of Female Resident Physicians,” Esther Choo implored medical educators to “allow our female trainees to spend less time learning how to walk the fine line between normative and counternormative behaviors and more time simply learning to be physicians" (8).
So now, armed with an understanding of the complexity of gender biases how they impact our medical education and clinical care, how do we proceed? First, we, as women in medicine, do NOT have to copy men. We are punished socially when we try to take on the autocratic “male” way of leadership. But our communal traits make us strong collaborative leaders. We can use this to our advantage. As stated my Carnes et al. women are more likely than men to lead with a collaborative or transformational leadership style, which is consistently found to be the most effective style of leadership (3). Collaborative leaders have an open, team-building approach to their work environment. They allow information to be shared openly. They seek feedback, suggestions and ideas from those they work with or those they are leading. They facilitate brainstorming within their team. We can succeed by highlighting our strengths, not assuming the strengths of men. Second, while in training and adjusting to added stress of violating gender norms, young women in medicine can employ some strategies to increase their confidence, such as tying their hair back, wearing a white coat, power-posing, or standing on a stool for additional height (7). These small adjustments may make residents in training more comfortable with assuming a more assertive role. We, as women, fight more than men with imposter syndrome - the feeling that we don't belong at the table. In our case, the feeling that we don't belong in medical school, that we really aren't smart enough or good enough. The feeling that we have been tricking people all along into thinking we are good enough, but we obviously know that we are NOT good enough. Imposter syndrome is a blog post all on it's own, but use confidence boosting tweaks to fight your imposter syndrome. And the third and final way to proceed is to ALL the women reading this, educators or learners, we need to beware of our own gender biases, acknowledge and examine them. We, as educators, can be the HARDEST critics at times on our female learners, the first to criticize them for being overly confident or outspoken or bossy. And we, as learners, should also be careful how we interpret feedback - don’t assume the feedback is “bitchy” just because it’s from a female. We all need to examine our gender biases and realize when they are taking effect. Then we need to pull each other up, instead of tearing each other down.
1. Eagly, Alice H., and Steven J. Karau. “Role Congruity Theory of Prejudice toward Female Leaders.” Psychological Review 109, no. 3 (2002): 573–98. https://doi.org/10.1037//0033-295X.109.3.573.
2. Heilman, Madeline E., Aaron S. Wallen, Daniella Fuchs, and Melinda M. Tamkins. “Penalties for Success: Reactions to Women Who Succeed at Male Gender-Typed Tasks.” Journal of Applied Psychology 89, no. 3 (2004): 416–27. https://doi.org/10.1037/0021-9010.89.3.416.
3. Carnes, Molly; Christie Bartels; Carol Isaac; Anna Kaatz; and Christine Kolehmainen. 2015. “Why is John More Likely to Become Department Chair than Jennifer?” American Clinical and Climatological Society. 126: 197–214.
4. Sandberg, S. (2013). Lean in: Women, work, and the will to lead (First edition.). New York: Alfred A. Knopf.
5. Dayal, Arjun, Daniel M. O’Connor, Usama Qadri, and Vineet M. Arora. “Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training.” JAMA Internal Medicine 177, no. 5 (May 1, 2017): 651. https://doi.org/10.1001/jamainternmed.2016.9616.
6. Mueller, Anna S., Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O’Connor, and Vineet M. Arora. “Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis.” Journal of Graduate Medical Education 9, no. 5 (October 2017): 577–85. https://doi.org/10.4300/JGME-D-17-00126.1.
7. Kolehmainen, Christine, Meghan Brennan, Amarette Filut, Carol Isaac, and Molly Carnes. “Afraid of Being ‘Witchy With a “B”’: A Qualitative Study of How Gender Influences Residents’ Experiences Leading Cardiopulmonary Resuscitation.” Academic Medicine 89, no. 9 (September 2014): 1276–81. https://doi.org/10.1097/ACM.0000000000000372.
8. Choo, Esther K. “Damned If You Do, Damned If You Don’t: Bias in Evaluations of Female Resident Physicians.” Journal of Graduate Medical Education 9, no. 5 (October 2017): 586–87. https://doi.org/10.4300/JGME-D-17-00557.1.