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.