The Confidence Gap: An Application to Women in Medicine

As a third year medical student, when your attending pulls you aside on the wards, you naturally begin to wonder what you’ve done wrong.

How was my presentation on rounds?

Was it too long?

Was it disorganized?

Were my differentials broad enough?

The list goes on…

But to my great surprise, my attending was merely trying to compliment me on a job well done and a clerkship marked with growth. I’m not sure why I was expecting the opposite. I know my work ethic. I know how much time I spend with my patients and in preparation for presentations. Why did I question myself?

Why as women do we oftentimes prevent competence from breeding confidence?

As of 2019, more female medical students were enrolled in U.S. medical schools than male yet women continue to be underrepresented in health care leadership.

Could lack of confidence be a contributing factor?

Here's the data:

A study conducted by the Johns Hopkins and NYU Schools of Medicine assessed medical students’ confidence in answering curricula-related questions, accuracy in responses, and differences in either confidence or accuracy between genders. Over one thousand medical students participating in the study, answering either multiple-choice or true-or-false questions, and rating their confidence level as either, “I’m sure,” “feeling lucky,” or “no clue.”

Results showed that female medical students were more accurate than their male counterparts overall (61.4% vs 60.3%, p = 0.04) and stratified by confidence level (80.5% vs. 78.3% for “I’m sure” responses, p = 0.002; 53.5% vs 49.8% for “feeling lucky” responses, p = 0.001).

However, women were less confident than men, rating their confidence level as “I’m sure” significantly less often than men (39.5% vs 44.4%, p = 0.001).

Additionally, research suggests that gender differences in clinical confidence can be perceived by others. In a study conducted by the Indiana University School of Medicine, one hundred and forty-one third year medical students were videotaped in their objective structured clinical examinations (OSCEs). Trained coders rated the confidence level of the students on a scale of 1 (not at all confident) to 9 (extremely confident). The mean confidence level was 5.58 (SD = 1.38).

Female medical students were rated significantly less confident than their male peers (female mean = 5.33, SD = 1.38; male mean = 5.80, SD = 1.30; p < 0.05), particularly at the beginning of their interactions with the standardized patient.

One possible explanation suggested by the authors is that women may ultimately have confidence in their abilities but value modesty and humility more than men.

Other explanations in the literature include concern about future workload and gender inequity in the workplace. For example, female medical providers report less support for research, fewer mentoring opportunities, and fewer academic resources than men (Nomura, Yano, & Fukui 2010).

What should we do about this?

For those of us still in training or seeking career advancement, fake it ‘til you make it (within reason, of course). We are performing at an equal or even higher level than men, yet we are not aligning competence with confidence.

Lack of confidence may predispose us to poor physician-patient relationships and missed opportunities for professional advancement.

Let’s continue to build the confidence of female physicians-in-training and mentor or sponsor those who particularly impress us. Simple words of encouragement from my attending physician have greatly increased my clinical confidence.

I challenge practicing physicians to similarly commend trainees that are improving and performing well. If the person is exceptionally impressive, consider mentorship or sponsorship, offering guidance and actively advocating for their advancement in the workplace.

References

Blanch D, Hall J, Roter D, & Frankel R. Medical student gender and issues in confidence. Patient Educ Couns. 2008 Sep; 72(3): 374-81.

Nomura K, Yano E, & Fukui T. Gender differences in clinical confidence: a nationwide survey of resident physicians in Japan. Acad Med. 2010 April; 85(4): 647-53.

Theobald J, Gaglani S, & Haynes M. The association between confidence and accuracy among users of a mobile web platform for medical education. Ann Intern Med. 2015 Mar; 162(5): 395-6.