Editors’ Note: In this article, the word “female” is used as an adjective and “women” as a noun by convention but without the intention of conflating sex and gender. The author and editors recognize that these words, as colloquially used, do not accurately reflect distinctions between gender and sex or depict how individuals identify their gender.
Explore This IssueACEP Now: Vol 40 – No 03 – March 2021
When you think about “women in medicine,” whose faces do you see? Whose voices are represented? Who sits at the leadership table? As I near the end of residency training, I want to reflect critically on the importance of appreciating the diversity within women in medicine rather than viewing the group as homogeneous, with individuals having approximately the same goals and needs.
In 2019, an article was published in a major emergency medicine journal entitled, “Does Physician Gender Have a Significant Impact on First-Pass Success Rate of Emergency Endotracheal Intubation?” There was, unsurprisingly, no significant difference between the first-pass success rates of female and male physicians.
The manuscript sparked shock, anger, and surprise within my community of female emergency physicians. We immediately questioned the premise of the article and felt offended that the research group was even asking the question. And we were not alone: Med Twitter blew up with vitriol, and there were enough complaints that the paper was retracted soon after publication. However, in hindsight, the paper reflected something that many of us in the United States had not thought to consider: Though we have a long way to go here, there are parts of the world where barriers to achieving gender parity in medicine are far greater. A study that might initially strike us as offensive may have actually been a necessary one to counter negative stereotypes about women’s professional abilities.
The study in question was conducted in South Korea, where female physicians are in the minority. The research group had intended to “confirm that there is no physician gender effect on the first pass success rate,” as the corresponding author tweeted, which could have potentially helped establish female physicians as equally effective proceduralists in a predominantly male field. Only after my initial negative reaction to the manuscript, and after it was retracted, did I consider the local cultural context of clinical practice in the study site. It contrasts with my own—I work at a renowned academic hospital where our leading airway expert is a female physician and where our faculty and residents generally expect that male and female physicians perform equally.
In qualitative and ethnographic research—my areas as a medical anthropologist—we have a principle called “reflexivity,” the deliberate examination of how one’s own identity and values influence the research process. Standard qualitative results reporting guidelines include an expectation that manuscripts address reflexivity. The first author of the retracted paper was a female medical student. The corresponding author wrote about raising daughters and believing in women’s potential in what amounted to an apology letter for upsetting the international community of physicians. Would a statement in the manuscript about reflexivity have helped frame the study? Did the journal’s reviewers consider how the study might be received internationally and accordingly advise the authors? Was there an opportunity for the editors to contextualize the paper rather than retract it?
Context matters. Women’s experiences practicing medicine vary all over the world. Despite the inequalities in daily interactions, promotion, and pay that female physicians continue to face in the United States, we do have advantages compared to female physicians in many other countries.
We are making progress, but women in medicine are not a monolith, either in the United States or elsewhere. If we fail to see that, we’ll be hindered in our efforts to advance women’s medical careers and professional opportunities. This example made me think about challenges closer to home.
Despite introducing ourselves as “Dr. [last name]” and wearing white coats with “DOCTOR” badges affixed, patients often assume female physicians are nurses, technicians, and, for people of color, transport or custodial staff. We advocate for proper professional recognition not because we devalue these other important jobs but because role confusion leads to poor patient care and because we want to combat societal stereotypes that women are not doctors.
Throughout training, several of my female co-residents and I noticed our supervising male senior residents and attendings introducing themselves to our patients by their first name. While not poorly intentioned, it made it more awkward for us to introduce ourselves as “Dr. [last name],” as we preferred. In response, a group of us led residency-wide conversations to encourage all residents and attendings to introduce themselves as “Dr. [last name].” We hoped this would make it easier for female physicians to introduce themselves as such and ensure that their roles in patient care are understood. We thought we were doing something to improve the professional experience of female physicians across the board. But we had not thought about all the possible impacts this could have on our colleagues.
One of our female co-residents courageously spoke up, saying that she did not like to be introduced by her last name. Patients could easily recognize her last name as Hispanic, and she feared they would assume that they were receiving inferior care or single her out in some way, such as interrogating her about her training or asking for a different physician.
It was an important realization. Good intentions are necessary but not sufficient. Doing what we think is good for women in medicine may not serve all female physicians. My co-resident’s comments led our group to a discussion about privilege—the advantages or immunities enjoyed by a powerful group, often without that group’s awareness—to the disadvantage of other groups.
For many, it can be less comfortable to talk about privilege in terms of race and ethnicity than in terms of gender. Patients less frequently question physicians with Euro-American last names. Even accents can lead patients to ask physicians about their ethnicity, nationality, or training. When patients do so with Euro-American physicians, it is often couched as part of a pleasant conversation, in contrast to a common succession of questions faced by minority physicians: “What kind of a last name is that?” “Is that an American name?” “Where are you from?” “Where did you go to medical school?” And what’s implied: “Are you really qualified to be my doctor?”
The middle road approach our residency came to was asking individuals to consider their own privilege—or lack thereof—in deciding how to introduce themselves. It was not simple. It took time. But it was worth doing to encourage inclusion.
Our diversity as women in medicine goes beyond race, ethnicity, and nationality. Throughout medical school, graduate school, and residency, various groups for women in medicine have sponsored lectures, panels, and workshops about work-life balance. This is almost always a euphemism for parenting and task-sharing with your husband. These events often feature a successful straight white female physician, perhaps with a stay-at-home husband. Just as frequent are the panels that inevitably devolve into a discussion about daycare versus nannies.
Meanwhile, some of my female colleagues have had difficulty conceiving and, after multiple rounds of in vitro fertilization, decided not to have children. My LGBTQIA+ colleagues are encountering a different set of challenges and expectations, ones not usually covered in what are frequently heteronormative events. Some of my colleagues stopped going to women’s group meetings because work-life balance sessions just didn’t apply to their circumstances often enough to be helpful.
Conversations about finding peace in relationships and parenting are undeniably important, particularly given the stigma surrounding these topics for female physicians. It is imperative, however, that we not equate “women in medicine” with “work-life balance” or with a particular set of assumptions about family life. Perhaps within events about balancing career with family and relationships, we could be more inclusive of stories of divorce and joint custody arrangements. We could talk about adoption, surrogacy, egg freezing, and gay and transgender physician parenting. We must also ensure that women in medicine events encompass a broad range of issues faced by female physicians. I am grateful that my residency’s women’s initiative features workshops on résumé building, contract negotiations, and responding to workplace microaggressions.
Know Your Own Shoes
The space of “women in medicine,” as it is currently configured, is not the most comfortable for those who may have another primary identity—as a racial/ethnic minority or LGBTQIA+ individual, for example. Social movements offer plentiful lessons that approaching women as a homogeneous group with needs based purely on gender caters to the needs of some while disregarding the needs of others.
We often hear the phrase, “Put yourself in someone else’s shoes.” But it’s also important to know your own shoes. What is the lens through which you see the world? What privileges do you have? What are your unique needs as a woman in medicine? After answering these questions, it can become easier to consider how other women experience medicine and how to tailor support for their professional development. There is a distinction between invitation and inclusion. The former is easy; the latter requires deep self-reflection and can lead to powerful change.
“The Equity Equation” is curated by Dara Kass, MD, and Jenice Baker, MD, FACEP.
Dr. Chary is chief resident at a Harvard-affiliated emergency medicine residency in Boston.