“At my interview for residency at a prestigious midwestern university hospital, the chairman asked me if my low grades in a few classes were due to “ chasing boys”. (sic) Then he said as long as I had more blood going to my pelvis than my brain I did not belong in his residency.”
When Dr. Marjorie Stiegler asked for 30 stories of gender bias for an upcoming talk, she got a near constant stream of responses like this one from Dr. Anne Stohrer, in the following days. Women from all over the world shared their experiences, recounting both subtle and horrifying narratives.
I’m giving a keynote on gender bias in medicine.
I want to tell 30 stories. What’s yours?
Give me a personal anecdote to share.
Stand up and be seen. It will make the world a better place.
— Marjorie Stiegler, MD ☤ (@DrMStiegler) June 7, 2019
As a woman surgeon, when I saw the first few responses, I initially felt validated. Clearly, there were other women physicians with experiences similar to mine. However, as more and more women shared the microaggressions, harassment, and blatant discrimination they had faced, I became more and more disconcerted.
In addition to being a practicing surgeon, I have studied bias and gender stereotypes in medicine for the last decade. I have endured many hurtful comments, including when a senior surgeon mused on why we train women to become surgeons when they’re only going to go off and have babies. Of course, he said this to me, a surgical trainee at the time.
Despite being acutely aware—both academically and from my personal experience—of the ways in which women are disadvantaged in medicine, I was still shocked at the number of women who came forward to share their stories publicly. The wide-ranging toxic insults hurled at them were eye-opening, even for me.
Medicine has long been a male-dominated field. But that is changing. In 2017, for the first time, more women than men enrolled in medical school. Interestingly, though, this is not a sudden or dramatic change. Women have been more than 45% of medical students since the late 1990s. Yet women are underrepresented in leadership in healthcare; only 18% of medical school deans and only 13% of healthcare CEOs are women.
Just like women in other male-dominated fields, then, perhaps it is not surprising how much unprofessionalism and harassment women have tolerated in healthcare. The experiences reported by women in response to Dr. Stiegler’s post included, among others, not being seen as a doctor, experiencing sexual harassment, and segregation. Other narratives included bias against men, patient experiences, and men supporting women. All together, these stories illustrated the daily life of women physicians and how far we are, even in this modern era, from the ideal of gender equity.
Can Women Be Doctors?
Data suggest that women’s expertise as physicians is often not recognized. In one study, researchers assessed whether physicians introduced their peers with or without their title. Although women introduced both men and women with their title, men only used women’s titles about half the time. Similarly, a study of national awards given to physicians found that these awards are very rarely given to women. Certain awards had never been given to women. The stories women shared illustrated these data.
After seeing a woman doctor, patients seem to not always realize they have seen a physician. A patient who had seen Dr. Nasreen Alfaris later complained to patient relations that she had been referred to this center “to see a doctor…NOT a woman!” Similarly, after Dr. Janelle Lindow saw a patient, the patient asked her when they were going to see the doctor. Dr. Melissa Hanson learned that a patient she had operated on and taken care of asked why he had not seen a doctor for his entire stay (even though Dr. Hanson had seen him daily).
This confusion was not limited to outpatient clinic visits. When Dr. Kristalyn Gallagher was meeting with a patient in the preoperative area the day of surgery, the patient’s husband asked Dr. Gallagher and the other woman surgeon on the case how much of the surgery they would do compared to “the surgeons,” who he thought were the two male medical students hovering in the background.
Still others had stories similar to mine, with authority figures questioning women’s suitability for medicine. A psychologist said to Dr. Jenny Bencardino that “A woman steals away the place from a man who will actually practice Medicine after graduation. Women get married and that is the end of it.” Along with asking women in their interviews whether they plan to have children, these questions reveal a fundamental preoccupation with women’s reproductive organs and a false assumption that having children means they can no longer be physicians. It’s no wonder, then, that so many women in medicine doubt ourselves.
A recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM) found that women in medicine are even more likely to be harassed than women in science, technology, engineering, and math fields. More than half of women faculty experience sexual harassment, and female medical students are more than twice as likely to be harassed than those not in science, engineering, or math. Sexual harassment is associated with worse mental health and lost productivity and is likely associated with attrition. As the recent #MeToo and #TIMESUP movements have shown, harassment is, unfortunately, rampant in many professions, including medicine.
One urologist shared a comment that a visiting professor had made to her when she was in training, looking down her scrub top and calling her “genetically blessed.” Years later, she still wears turtlenecks under her scrubs to avoid this unwanted attention.
While observing a complicated case later that year, a visiting professor looked down my scrub top and declared me "genetically blessed". My attending did not come to my defense in that moment, nor approach me later to check on how I was doing. I still wear turtlenecks in the OR.
— Mage of #KeepYourBehindAtHome 👸🏾 (@catjacarol01) June 7, 2019
Harassment can come from colleagues, as it did in that case, but it is common from patients as well. Dr. Margaret Gatti-Mays recounted a patient who commented on her physique, saying, “I’m sure your husband is happy that you keep such a nice body.” Dr. Gatti-Mays responded by asking him if he would say something like that to a man. Having spoken with women physicians all over the country on this topic, I know that many women struggle with what to say in these moments and often let these comments go without redirection. There are many reasons for this, including recognizing the vulnerability of patients and wanting to maintain an effective patient–doctor relationship. Medical students are taught to always put the patient first, and for women, this sometimes comes at our own risk.
People are quick to judge women for both wanting to have children and for not having them. Just as people have gendered expectations of women’s behavior—expecting them to be kind, nurturing, gentle—people also expect women to get married and have children. In medicine, this can lead to concern about their commitment to the job. On the other hand, data show that women surgeons are less likely than their male colleagues to be married and are also less likely to have children. Unfortunately, since this runs counter to expectations, women without children often find themselves having to discuss their personal lives with colleagues who seem to judge their personal choices.
When she told an interviewer she wanted to have children, Dr. Roxanne Sukol was told that she couldn’t be both a mother and a doctor. She consequently delayed her entry to medical school for 14 years. It is hard to know how many patients missed out on her care in the intervening years. Similarly, when Dr. Kia Nicholson was preparing to perform a procedure for a patient, the patient asked her who was taking care of her children, implying that she was not a good mother—even though he did not know whether she even had children.
Before Dr. Alexandra Anderson had children, she was told that she was “a waste of good looking and intelligent genetics and fertility.” Over and over again, women are judged for having children (for not being committed to their job) or not having children (for not fulfilling a societal expectation). When a woman’s fitness for a job will be assessed based on her competence rather than her fertility, we will know we have made progress.
When there were fewer women in medicine, it was not uncommon to have a space for doctors that was reserved for men, and a space for nurses that was reserved for women. This meant women physicians were excluded from informal networking and conversations. Where Dr. Paula Whiteman trained, the physician lounge was in the men’s locker room. While her male colleagues could collaborate and network during that time, she was relegated to changing in a bathroom and waiting for them to come out.
When I was a surgical intern, there was the men's locker room with a lounge area where all the male surgeons, residents, and interns would sit, discuss cases, who knows what else BECAUSE WOMEN were not allowed. Literally we had to change in a ladies bathroom and wait in the OR.
— Paula Whiteman, MD, FACEP, FAAP (@DrPaulaWhiteman) June 7, 2019
Dr. Robyn Pugash had a similar experience, being told she was not welcome in the doctors’ lounge. Her supervisor took it one step further, telling her she would be raped if she dared go into that lounge.
While these experiences are less common today, it is still the case that women are often excluded from men’s networks. While men are sharing information on the golf course or over drinks, women are left on their own. It’s no wonder, then, that the majority of leaders are men. In addition, women are less likely to be sponsored than are men. This means that men are given more important opportunities, such as speaking at national meetings and writing invited commentaries in medical journals.
Recent data suggest that women can leverage their networks for success, too. When researchers examined social networks and job placement after graduate school, they found that women with a female-dominated inner circle of social connections were placed into higher-level jobs than those whose inner circle was dominated by men. Unlike the Queen Bee Phenomenon, which suggests that women compete with rather than help each other, these data suggest that women may be each other’s best supporters. However, this can only happen in a context that is not laden with gender discrimination; when gender discrimination abounds, Queen Bee behavior is promoted.
Misogyny & Tone Policing
Overt misogyny may be less common today than in the past. However, according to the NASEM report, women are still exposed to sexual advances, lewd jokes, disparaging comments, unwanted touching, stalking, and assault in the workplace. Comments disparaging women fall in the category of gender harassment, which is the most common category of sexual harassment experienced by women.
Dr. Rashmi Chauhan Mehta shared the commentary made to her when her second daughter was born. The obstetrician apologized for the sex of the baby, assuming she would be disappointed to not have had a son. Dr. Anna Volerman was told by a senior colleague, quite simply, that “women achieve less than men.” This is reminiscent of the comment made by the former president of Harvard College, Larry Summers, when he suggested (erroneously) that women are not as good at science as are men.
When a male anesthetist walked into a surgeons’ lounge that happened to have several women in it at the time, he said, “Look at this! It’s like a goddamned Tupperware party in here.” With that one comment, he reduced these highly trained specialists to women who, in his view, belong in the home. Never mind the fact that to become a surgeon, these women would have completed 4 years of college, 4 years of medical school, and 4-9 additional years of surgical training. In his mind, they were only good for selling Tupperware.
One of the most common experiences of women professionals is being told that their tone is not correct. Along those lines, Dr. Audrey Provenzano was told that her voice was too high for her to be taken seriously. She was advised to hire a voice coach to overcome this deficit. Reducing women to their domestic role, their appearance, or their voice undermines their competence.
Bias about Men
As I wrote in an academic article published in the American Journal of Surgery, our expectations for people based on their gender can be harmful to both men and women. We surveyed both men and women surgical trainees and asked them to what extent they worried that they were being judged for their gender. We found that the more concern people expressed about gendered expectations, the worse their psychological well-being. Consistent with these data, some of the responses to Dr. Steigler included bias against men.
Dr. Dawn Clark described how her husband, an obstetrician/gynecologist, was told he would have a hard time finding a job because he was a man (most of the physicians in that field are women). Visiting a hospital, Dr. Madhav Swaminathan and his host noted that while there were a number of pictures on the walls celebrating nurses in honor of National Nurses Week, there were no pictures of men. This is a type of environmental microaggression, similar to having auditorium walls covered with portraits of old white men. While there is growing recognition that the latter might be harmful, there has been less concern about situations in which men are the minority. Nevertheless, gendered expectations box in both men and women, restricting their range of emotions and experiences.
The same biases and attitudes that impact women physicians’ professional experiences can also affect patients. This is clear when we look at data on healthcare disparities, including maternal mortality and breast cancer outcomes. The most recent well-known example of this was Serena William’s experience after she had her daughter. As she described in an interview with Vogue magazine, she knew there was something wrong with her breathing. She suspected having a blood clot in her lungs, but those taking care of her delayed tests that would confirm the diagnosis. Unfortunately, the same bias that led to her being treated that way also impacts whether women’s heart attacks are treated properly and whether their pain is taken seriously.
Several patients brought these data to life by sharing the disturbing treatment they encountered. Stephanie described her struggle to get care for her newborn who had a severe congenital heart defect. Despite taking him in numerous times, it was only when the baby’s father came along that the problem got diagnosed.
When Stacy went to the emergency room with a serious infection, she was labeled as “hysterical” when she was crying from her pain.
Seeking care for breast cancer, Anna Jacobson was counseled by her surgeon that she should choose lumpectomy since that would be a better outcome for her husband. As she was trying to come to terms with her cancer diagnosis, the surgeon unfortunately was focused not on her needs, but on the desires of her husband.
Men Supporting Women
Given the male predominance in medicine, women clearly cannot succeed without at least men as mentors. In recent years, the hashtag #HeForShe has been used to signify men who are allies. Since the #MeToo movement, however, there has been increasing concern from men about mentoring women. A recent report suggests that 60% of male managers are uncomfortable mentoring women. As pointed out by Mia Brett, women are more likely to be harassed or assaulted by men than they are to make false accusations. The logical implication, then, is that women should actually stop working with men, not the other way around. Yet, to advance within male-dominated professions, of course this would be maladaptive.
Hey men worried about false accusations. You’re statistically much much much more likely to sexually harass or assault me than being the victim of a false accusation from me.
And yet I don’t refuse to work with you
— Mia Brett (@QueenMab87) January 31, 2019
Some men joined the thread, advocating for women. Dr. Michael Ditillo responded to a comment about whether a woman of small stature could be a surgeon by talking about his wife, who is also a surgeon, saying, “No One pushes her around. It ain’t the size of the surgeon in the fight but the size of the fight in the surgeon.”
Hahahah…. my wife @md_castanon is “size-challenged” and a woman, and NO ONE Control’s a trauma bay like she does and No One pushes her around. It ain’t the size of the surgeon in the fight but the size of the fight in the surgeon pic.twitter.com/OhijkFg2em
— Michael Ditillo (@mikeditillo) June 7, 2019
Dr. Jonathan Braman raised several important points related to pay equity. There is a significant gender pay gap in medicine, with men specialists earning up to $32,000 more than women specialists. Some argue that this gap is due to men taking care of more patients (measured in something called work Relative Value Units, or wRVUs). Dr. Braman explains why women may not have the same access to revenue as do men, partially because they spend more time in service and teaching activities than do men.
What is most frustrating is that in talks w/ my (female) junior partners, they are usually sweating their productivity as much as I do/did, but not having the same success accessing productive revenue generating stuff.
It’s more insidious than simply work=$. Barriers are real.
— Jonathan P. Braman (@shouldergeek) June 7, 2019
Dr. Nancy Stewart was one of several women who commended specific men who had supported her. Indeed, given the predominance of men in leadership in healthcare, it stands to reason that having the support of men is instrumental for women’s success.
Where Do We Go Now?
The vulnerability and experiences women shared in response to Dr. Stiegler’s tweet demonstrate what it’s like to be a woman physician in 2019. While there may be less overt sexism now than in the past, women continue to be treated as second-class citizens. Women of color, transgender men and women, and members of the LGBTQIA community all face additional obstacles over and above those faced by white women.
As in other fields, there is growing recognition of the potential benefits of diversity for patient care. In recent years, several studies have suggested that women may provide better care for patients than do men. One study evaluated the outcomes of patients admitted to hospitals with common problems such as pneumonia or heart failure. Patients who were taken care of by women were less likely to require hospital readmission and were less likely to die within 30 days of their hospitalization. A similar study looked at the outcomes of patients operated on by men and women surgeons and found that those taken care of by the latter were less likely to die within 30-days of surgery.
Given these data, it is our duty to curb the constant flow of bias and harassment toward women in medicine. As we raise awareness of how gender bias negatively impacts women’s careers, we have to recognize that awareness alone is insufficient to bring about change. And culture change is sorely needed.
Leaders must initiate intentional change by way of active promotion and sponsorship of women. They must foster inclusive and respectful workplaces. In order to do this, they also need to assess policies and practices to ensure they are family-friendly, flexible, transparent, non-discriminatory, and equitable and that outcomes are tracked over time. Part of the reason professions such as medicine are such fertile ground for harassment is the steep hierarchy; reducing that may lead to more equity.
Gender bias and harassment are harmful in all industries, but in healthcare, the damage is potentially passed on to our patients. In a recent commentary in the New York Times, Dr. Danielle Ofri wrote about how physicians bend over backward and sacrifice ourselves to take care of our patients. If we are willing to go to such lengths for our patients, why don’t we put more effort into fighting for safe and equitable workplaces for ourselves?
We are taught that the patient is first, and we are last. While altruistic, this paradigm is harmful. We need to recognize that we cannot provide optimal care if we ourselves are not healthy and safe. We can do both—we can take care of ourselves, which can enable us to better care for our patients.
With the recent launch of TIME’S UP Healthcare, the women in healthcare are rising up to say, “No more!” I hope more men like Dr. Ditillo and Dr. Braman will stand with us and say we can do better. Change will not come out of hopes, prayers, and good intentions. What we need is action, and the time to act is now.