Opinion: How Does Gender Bias Affect the ED, and How Do We Address It?

It’s Monday morning. You walk into a well-lit room, taking in the familiar surroundings of several colleagues in easy conversation, laughing and joking. You can’t help but feel a change in the atmosphere when you are noticed. The conversation comes to a halt, and you hear someone mutter, “Now we’re in mixed company.”

This scene may bring to mind a woman accidentally walking into a men’s locker room. In reality, this is not uncommon for women physicians in emergency medicine.

As our news feeds fill with stories of women stepping forward to call out sexual harassment and discrimination, we watch with grim recognition. Gender bias in the workplace often occurs through exploitation of gendered power dynamics, causing women to be treated differently and subsequently fall behind in systems historically built around men. At this critical juncture, we have an obligation to look within our medical community to identify and remedy sexism, from frank harassment to subtle but equally damaging unconscious bias. Marginalization and discrimination do not need to be intentional to cause harm, and in many cases, men are not even aware of the harm they cause.¹

Emergency medicine is a male-dominated field. Although the medical field has shifted overall to near gender parity for enrolled medical students, only 27 percent of emergency physicians are women.^2,3 Evidence suggests women are also at a statistical disadvantage in emergency medicine training. A recent article found that women training in emergency medicine received inconsistent feedback on their work when compared to men. While men were consistently told how to improve clinical skills, women received conflicting advice, often centering on assertiveness and confidence.⁴

Another study found that while women and men entered emergency medicine training with similar skill sets, by the end of residency, men achieved training milestones at a higher rate than women. The achievement gap was measured as equivalent to a full three to four months of training.⁵

We must ask ourselves what sort of culture exists in our field that causes women to fall behind.

In discussions with female colleagues across several institutions, we discovered common themes. Many male doctors seem unconsciously uncomfortable working with female doctors, and the social environment of the emergency department often centers on gender norms. We hear remarks disparaging female physicians who make more money than their significant others, jokes about women’s clinical judgment being clouded by feelings, and questions about whether women may be inherently less suited for the job.

Emergency medicine is not alone; gender-based exclusion has been described in other medical subspecialties and at multiple training levels.^6,7 Female medical students reported a broad range of discriminatory behaviors from male attendings, such as failing to make eye contact, employing only male pronouns when referring to physicians, and disproportionately encouraging male students compared to their female counterparts. Medical students even reported that these smaller actions disrupted learning more than blatant harassment and discrimination.⁸

Studies show gendered stereotypes adversely affect women’s work performance.^9,10 Repeated comments that reinforce gender stereotypes, either blatant or subtle, exert a substantial force that influences not only women’s training but also their identity as doctors. One study found that female medical trainees did not feel equipped to navigate unprofessional behavior from male superiors. As a result, the women experienced guilt and resignation that this would become a part of their professional identity.⁷

Personal relationships built early in our medical careers lay the foundation for our professional trajectory. In studies of gender gaps in academic medicine, bias in the workplace is often cited as a limiting factor for career advancement.¹¹ If jocularity and a sense of camaraderie are restricted to our male colleagues from the start of training, this could have downstream career effects.

Even though seemingly subtle, repeated comments and acts of gender discrimination add up to a substantial force that causes women to question their legitimacy and place in medicine, affecting both their careers and their identities as women and physicians.

Let’s Take Action

How do we fix this? We propose three immediate actions for leadership in our field:

1. Implement bias intervention training and discussions. Bias interventions can occur on both an individual and institution-wide scale. Attendings can incorporate their own awareness of gender bias to reduce the impact of implicit bias on resident evaluations.¹² Residency programs should incorporate data-driven implicit bias education into their lectures and grand rounds. A randomized controlled trial of bias interventions found that faculty members trained to acknowledge and actively disrupt their own bias habits were better able to promote gender equity.¹³

2. Work to increase the ratio of women faculty members and create mentorship programs for female residents. A narrative review of studies on women in academic medicine found that a lack of mentorship constitutes a significant barrier for many women who wish to pursue an academic career.¹¹ Seeing women in positions of leadership inspires other women and helps create an environment supportive of female physicians and trainees. Inviting female lecturers and speakers and creating mentorship and networking events for women are also structured ways for programs to support their female residents.

3. Promote and support research on gender in medicine. Research on the manifestations and impacts of gender bias in our field must be encouraged. This includes increasing support from academic journals for publication of material related to gender bias and creating platforms for sharing ideas, such as the FemInEM conference. This scholarly work ultimately benefits all of us, and academic departments should provide financial support and academic recognition equal to similar departmental administrative and academic endeavors.

All emergency physicians, both men and women, must recognize the presence of sexism within our field and take action to reduce its effects. Let’s acknowledge this issue, open up dialogue, and together build a stronger, more inclusive space for us all.

Dr. Deluca (left) and Dr. Min-Venditti (right) are PGY-3 emergency medicine residents at Detroit Receiving Hospital. Dr. Saxena (center) is PGY-2 emergency medicine resident at John’s Riverside Hospital in Yonkers, New York.