Evaluating implicit gender bias at Canadian otolaryngology meetings through use of professional title

Abstract

Objectives

Increasing numbers of women enter medical school annually. The number of female physicians in leadership positions has been much slower to equalize. There are also well‐documented differences in the treatment of women as compared to men in professional settings. Female presenters are less likely to be introduced by their professional title (“Doctor”) for grand rounds and conferences, especially with a man performing the introduction. This study reviewed the Canadian Society of Otolaryngology–Head and Neck Surgery (CSOHNS) meetings from 2017 to 2020 to determine the proportion of presenters introduced by their professional title and whether this varied by gender.

Methods

Recordings from CSOHNS meetings were reviewed and coded for introducer and presenter demographics, including leadership positions and gender. Chi‐squared tests of proportion and multivariate logistic regression was used to compare genders and identify factors associated with professional versus unprofessional forms of address.

Results

No significant association was found between professional title use and introducer or presenter gender. Female presenters were introduced with professional title 69.6% of the time, while male presenters were introduced with professional title 67.6% of the time (P = 0.69). Residents were introduced with a professional title with the most frequency (75.8%), while attending staff were introduced with a professional title with the least frequency (63.0%) (P = 0.02).

Conclusions

The lack of gender bias in speaker introductions at recent CSOHNS meetings demonstrates progress in achieving gender equity in medicine. Research efforts should continue to define additional forms of unconscious bias that may be contributing to gender inequity in leadership positions.

Key Points

• Significant findings of the study: Significant gender bias in the use of professional titles does not appear to exist at Canadian national meetings. However certain groups still are referred to by their professional title more frequently than others, which may contribute to inequity.

• What this study adds: Differential use of professional title by gender has been examined in other specialties, but this is the first examination in otolaryngology. There are few specialties without gender differences in professional title use, and otolaryngology can be added to their number.

INTRODUCTION

Though medicine was historically dominated by men, over the past several decades the number of women entering medical school annually has continued to increase. By 2004, there were equal numbers of men and women graduating from Canadian medical schools, and in more recent years, women have become the majority in many programs. ¹ A similar trend has been observed in American medical school entrants. ²

Despite the increasing number of female‐identifying medical students and physicians, there are still well‐described differences in the treatment of female medical professionals compared to males, by colleagues, allied health, and patients. In addition to overt forms of sexism, female medical students and physicians must also manage more subtle forms of gender bias. When compared to male colleagues, women are more likely to be given negative evaluations despite equal competency. ³ , ⁴ , ⁵ Female residency applicants are more prone to the use of negatively biased language in reference letters. ⁶ Women are underrepresented in leadership positions, have less overall compensation, are less likely to have lead authorship on publications, less likely to receive grant funding, and less likely to be speakers at medical conferences. ⁵ , ⁶ , ⁷ , ⁸ , ⁹ When female physicians do present at medical conference and grand rounds, they are less likely to be introduced by their professional title, especially with a man performing the introduction. ¹⁰ , ¹¹ , ¹²

With a shift to virtual platforms in light of the COVID‐19 pandemic, the Canadian Society of Otolaryngology–Head and Neck Surgery (CSOHNS) has recorded many of the talks and workshops at their annual national meetings. This study reviewed available recorded meetings, which encompassed four previous CSOHNS annual meetings, to investigate whether there was any difference in professional address between male and female presenters and introducers.

METHODS

Data collection

This study was approved by the research ethics board at Western University (Project ID 119323). Publicly available national CSOHNS meeting video and audio recordings from 2017 to 2020 were reviewed. For a presentation to be included, the complete introduction must have been included in the presentation recording, and the presenter must have had an advanced degree (MD, PhD). Presentations were excluded if: presenter did not have an MD and/or PhD or it was unknown, presenter was not introduced, presenter introduced themselves, introduction was not recorded, introduction was not in English, or the incorrect name was used for the presenter. For the purposes of this study, Masters’ degrees or other professional designations were not considered advanced degrees, as this would not necessitate introduction with a professional title of “Doctor.”

Variables were extracted from the meeting program and from online searching via institutional websites, search engines, and social media. Variables related to the “presenter” (the individual delivering the presentation) and the “introducer” (person introducing the speaker) were collected, including gender, leadership roles, degree, and leadership position. When possible, gender identity was verified via pronouns used by the presenter or introducer, otherwise presenting gender was determined from information and photographs available on institutional websites. Presentation specific variables collected included the type of presentation (podium, invited speaker, award presentation, panel, or workshop), and the Otolaryngology–Head & Neck Surgery subspecialty. This included presentation in the Poliquin resident research competition, an annual CSOHNS event offering prizes for best resident research project. Lastly, whether or not professional address (Dr. First Name, Dr. Full Name, Dr. Last Name or Last Name, MD/PhD) was used to introduce the speaker was recorded.

Data analysis

A descriptive analysis of study outcomes was undertaken. Frequency statistics and counts of study variables, including presenter and introducer gender, rank, and presentation type, were summarized. In addition, Pearson χ ² tests of proportion were calculated to evaluate the association between gender of the presenter, gender of the introducer, presentation category, leadership position, and academic ranking, and professional title use (yes/no). Gender differences in presentation type (award presentation, invited speaker, research competition, scientific presentation, or workshop) and presentation category (by subspecialty) were also examined using Pearson χ ² tests of proportion. Data were analyzed using the statistical package for the social sciences (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 27.0; IBM Corp). Statistical significance was set at P < 0.05.

RESULTS

Presenter and introducer characteristics are summarized in Tables 1 and 2, respectively. Overall, 499 independent presentations were analyzed from CSOHNS meetings 2017–2020. Sixty‐nine presentations were excluded due to introduction not being captured, individual introducing themselves, or presenter not holding an advanced degree (MD/PhD). Men made up most introducers (73.1%) and presenters (73.3%). Attending surgeons comprised 59.4% of presenters, and 37.3% were residents. Workshops and scientific presentations made up the majority of analyzed presentations at 51.3% and 28.5%, respectively.

Table 1.

Presenter characteristics at the 2017–2020 Canadian Society of Otolaryngology–Head and Neck Surgery Annual Meetings.

Characteristics	Number (%)
Presenter gender
Female	133 (26.7)
Male	366 (73.3)
Year
2017	154 (30.9)
2018a	46 (9.2)
2019a	71 (14.2)
2020	228 (45.7)
Presentation category
General	97 (19.4)
Education	39 (7.8)
Facial Plastics & Reconstructive Surgery	18 (3.6)
Head & Neck	132 (26.5)
Laryngology	25 (5.0)
Otology	56 (11.2)
Pediatrics	27 (5.4)
Rhinology	68 (13.6)
None	37 (13.6)
Type of presentation
Award Presentation	20 (4.0)
Invited Speaker	19 (3.8)
Poliquin Resident Competition	62 (12.4)
Scientific Presentation	142 (28.5)
Workshop	256 (51.3)
Presenter rank
Attending staff	296 (59.4)
Resident	186 (37.3)
Other	16 (3.2)
Presenter leadership roleb
Yes	121 (24.3)
No	377 (75.7)
Professional title used
Yes	293 (68.1)
No	137 (31.9)

^a Total number of presentations less for years 2018 and 2019 due to fewer recordings being available.

^b Leadership role defined as: Director, codirector, chair, chief, head, lead, president, or regional representative.

Table 2.

Introducer characteristics at the 2017–2020 Canadian Society of Otolaryngology–Head and Neck Surgery Annual Meetings.

Characteristics	Number (%)
Introducer gender
Female	122 (24.4)
Male	365 (73.1)
If attending, introducer academic rank
Assistant Professor	133 (30.6)
Associate Professor	153 (35.3)
Professor	148 (34.1)
Introducer leadership rolea
Yes	271 (60.2)
No	179 (39.8)

^a Leadership role defined as: Director, codirector, chair, chief, head, lead, president, or regional representative.

Professional titles were not used to introduce 31.9% of presenters. No significant association was found between professional title use and either introducer gender or presenter gender; female introducers used a professional title to introduce the presenter 73.1% of the time, while male introducers used a professional title to introduce the presenter 66.7% of the time (χ ² (1) = 1.57, P = 0.21). Female presenters were introduced with a professional title 69.6% of the time, while male presenters were introduced with a professional title 67.6% of the time (χ ² (1) = 0.16, P = 0.69).

A statistically significant association between professional title use and presentation type was found (χ ² (4) = 28.85, P < 0.001) (Figure 1). Every resident (100%) in the Poliquin resident research competition was introduced using their formal title. A statistically significant association between presenter rank and professional title use was also found (χ ² (3) = 7.50, P = 0.02) (Figure 1). Residents were introduced with a professional title with the most frequency (75.8%), while attending staff were introduced with a professional title with the least frequency (63.0%). Speakers with a leadership role (57.0%) were less likely to be introduced by a professional title than speakers with no leadership role (72.0%) (χ ² (1) = 8.39, P = 0.004). There was no difference in likelihood of professional title use if the introducer had a leadership role (60.2%) or did not (39.8%) (P = 0.56).

Figure 1.

Professional title use by introducer rank (attending staff vs. resident). “Yes” indicates a professional title was used; “no” indicates no professional title in introduction. There was a statistically significant association between presenter rank and professional title use (χ ² = 7.50, P = 0.02).

When assessing whether they were gender differences in presentation type, there was no statistical significance (P = 0.92). However, when assessing gender differences in presentation categories, there were significant differences (P < 0.01). A higher percentage of males presented in the following subspecialty categories: facial plastics and reconstructive surgery (94.4%), general otolaryngology (68.0%), head and neck oncology (80.3%), laryngology (52%), otology (80.4%), pediatric otolaryngology (63.0%), and rhinology (88.2%). The only category that had a higher number of female presenters was education at 66.7%.

DISCUSSION

Gender bias is a well‐described phenomenon in medicine, with female medical students and physicians navigating gender inequity throughout their training and careers. There are well documented differences in the treatment of women as compared to men in professional settings, by patients, allied health, and fellow colleagues. ⁵ , ⁶ , ⁸ Previous studies have shown that female presenters are less likely than males to be introduced by their professional title (“Doctor”) for grand rounds, especially with a man performing the introduction. ¹⁰ Files et al. showed that when the introducers were female and the speaker was male, formal titles were used 95.0% of the time. On the other hand, when a male was introducing a female speaker, formal titles were only used 49.2% of the time. Gender differences in speaker introductions has been examined in the context of specialty conferences and national meetings as well. A study examining the rate of professional address at an international oncology conference found female speakers were significantly less likely to have a professional title used than males, particularly if the introducer was male. ¹¹ Similar findings were published regarding the American Society of Colon and Rectal surgery. ¹³ This is important, as the use of professional title speaks to the perceived credibility of the presenter. If there is a difference based on gender, it raises concern for implicit gender bias.

The present study did not show any significant gender differences in use of professional address in speaker introduction at CSOHNS Annual Meetings 2017–2020. Our findings are consistent with similar studies examining gender difference in use of professional title at two American national society meetings. Huang et al. showed no difference in the use of professional introductions for male and female speakers at the 2017–2019 American Society for Radiation Oncology Annual Meetings. ¹² Similarly, Davuluri et al. showed no gender difference in professional address at the 2017–2019 American Urological Association annual conference. ¹⁴ To date, professional title use has not been examined within otolaryngology conferences in the United States or Internationally, and this study represents the first such work in otolaryngology.

While the lack of gender bias in introductions at recent CSOHNS meetings is encouraging, our data do still show gender inequity in overall numbers of speaker and introducer gender. Males made of up most introducers and speakers, at 74% and 73%, respectively. Men were also significantly more likely to present in all subspecialties except for education. Gender bias in medicine is important to discern as it is likely partially contributing to inequities in leadership positions. Despite increasing numbers of female‐identifying medical students, the number of female residents, faculty, and physicians in leadership positions, especially in surgical subspecialties, has been much slower to equalize. ⁹ In OHNS in the United States, there continues to be a large disparity in the proportion of female trainees and attending surgeons, with 33% of residents and 28% of staff identifying as women. ⁹ In leadership, the numbers of women are even lower—14% of full professors, 13% of program directors, and only 3.5% of department chairs are female in the US. ⁹ , ¹⁵ These numbers are not published in Canada, but informal discussion with the CSOHNS administrative staff revealed that only 205 of 838 members, encompassing residents, staff, and emeritus, are female (24.4%). There is presently only one female department chair of the thirteen Canadian academic Otolaryngology‐Head and Neck Surgery programs. In the United States, an audit of female representation at otolaryngology meetings revealed that only 16.9% of elected or invited opportunities were occupied by women. ⁹

There was difference in professional address between use of professional title when introducing a resident (73.9%) versus attending staff (57.1%). We hypothesize that this difference could be due to the collegiality among staff members attending the CSOHNS annual meeting, as our specialty in Canada represents a relatively small and tight‐knit community. There was also a significant difference in professional address with regard to leadership role. Speakers with a leadership role (54.1%) were less likely to be introduced by a professional title than speakers with no leadership role (70.9%). Attending staff introducers may know their established colleagues quite well, and feel comfortable using informal address. However, it is also important to consider this as a potential source of inequity within the otolaryngology community. A recent paper examining professional title use in grand rounds presentations in obstetrics and gynecology found that those introducers with a higher academic rank were less likely to use professional titles. ¹⁶ The authors postulate this may be due to a power differential or hierarchy structure in the specialty. Inconsistent use of professional titles may contribute to a culture of ongoing inequity between junior and more senior colleagues. Consistent use of professional titles in formal settings, regardless of professional status, will assist in breaking down these hierarchical relationships, creating a more equitable environment for all.

A limitation of this study is that we relied on a binary definition of gender when gender exists as a spectrum. We also used our own interpretation of gender based on the name, appearance, and pronouns of the introducer and presenter. Finally, many of the recordings in 2017 and 2018 were not appropriately stored and therefore were unavailable for analysis. Within these limitations, we were able to make a reasonable assessment of the state of gender equity in use of professional titles within otolaryngology, while recognizing future studies may be needed. In particular, duplicating this study in large American or International meetings where presenters and introducers might be less likely to know one another may add further insight into the role gender might have on professional title use.

CONCLUSION

The lack of gender bias in speaker introductions at recent CSOHNS meetings is encouraging and demonstrates progress in achieving gender equity in medicine. Research efforts should continue to define additional forms of unconscious bias that may be contributing to gender inequity in medicine.

AUTHOR CONTRIBUTIONS

Kylen Van Osch: study design, data collection, analysis, manuscript preparation, final approval of manuscript. Agnieszka Dzioba: study design, statistical analysis, manuscript editing, final approval of manuscript. Khadija Ahmed: data collection, manuscript editing, final approval of manuscript. Andrew MacDonald: data collection, manuscript editing, final approval of manuscript. Jamila Skinner: data collection, manuscript editing, final approval of manuscript. Harley Williams: data collection, manuscript editing, final approval of manuscript. Julie E. Strychowsky: data collection, manuscript editing, final approval of manuscript. M. Elise Graham: study conception and design, analysis, manuscript editing, final approval of manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

Institutional ethics approval was obtained for this study. This manuscript is the authors own work, and has not been published or submitted elsewhere.

Van Osch K, Dzioba A, Ahmed K, et al. Evaluating implicit gender bias at Canadian otolaryngology meetings through use of professional title. World J Otorhinolaryngol Head Neck Surg. 2024;10:12‐17. 10.1002/wjo2.96

DATA AVAILABILITY STATEMENT

Data is available upon reasonable request.