Gendered Innovations in Orthopaedic Science: What’s in a Name?

To my friends, I’m Alexe. To my children, I’m Mom. And to my patients and peers, I’m Dr. Page—except when I’m not.

The name game piqued my interest as an audience member at an orthopaedic meeting last year. While announcing the names of award winners, I was disturbed by a discrepancy in how the moderator recognized the men and the women surgeons. The first few awardees (men and women) were announced by first and last names, but then the moderator presented a woman by her first name only. The man who received the award next was introduced by both his first and last names. The moderator then welcomed the following woman by only her first name, and finished by honoring the last two men with first and last names. The audience politely applauded. I glanced around the room, but no one else seemed to notice the discrepancy.

As an isolated event, this could be dismissed. But personal experience supported by good evidence suggests otherwise.

A Title Gender Gap

For decades, my perception of gender asymmetry in the use of titles has been a personal irritation, but not something I thought to share with others. Yet I recently discovered that it wasn’t just me—the disparity permeates the medical profession [2, 3]. A female professor of medicine took to the lay media to describe a recent experience at a large meeting, with the moderator thanking the male panel members as Drs. #1, #2, #3 . . . and the female panel member as Julie [6]. Annoyed by the episode, she related the event to the (female) chair of her department and their recognition of shared experiences catalyzed a study [3].

The involved department chair shared the results of the study at a meeting I recently attended. As I glanced around the room filled with women orthopaedic surgeons, I saw eyes widen and heads nod. I caught the eye of woman after woman and thought, “This isn’t just me being sensitive or paranoid. This really happens!”

The study tracked speaker introductions at grand rounds by the gender of the moderator and speaker. From a standpoint of equality, parity would have been optimal, but this was not achieved. Women moderators introduced other women by title 98% of the time and used titles slightly less when introducing men at 95%. Men moderating sessions, however, identified women speakers by professional title in only 49% of introductions versus 72% for the men whom they introduced [3]. Putting hard numbers on what had just been a vague uncomfortable sense of inequity opened a door on an observed behavior about which women were reluctant to speak [4].

Through my career, I’ve faced episodes perpetrated by both men and women that denied me use of the doctor honorific while applying it to the men working beside me. As a resident, being called “honey” seemed sweet from the octogenarians, but less so when followed by “Can you get my bedpan?” I still have my name badge from residency: Dr. Alexandra Page. Despite introducing myself as Dr. Page, patients would peer at my chest to call me Alexandra. Not so for the similarly tagged men working the clinic or ER with me.

As an attending, my patients come to the office to see Dr. Page, eliminating that frustration. Yet even now, disparity persists in meetings and on boards of directors. Decades of volunteering for professional organizations has been rewarded with respectful, collegial relationships with staff members. The standard address in meetings was first name for staff and title for the doctors. But sometimes this standard is violated, and when the norm is not applied equally to men and women, it stings. I had a surprise along this line during a conference call with a woman staff member using my first name while addressing all the male surgeons as doctor. If a staff member knows committee members well enough to address all of us by our first names, that’s certainly fine. But it demeans women when we lose our titles in these exchanges, and the men do not

Implicit Bias Leads to Microaggressions

Why do such episodes happen? Most likely it reflects an unconscious difference in how women are perceived. Implicit (or unconscious) bias refer to the attitudes and stereotypes that influence actions and decisions towards others [5]. The term was originally defined for racial biases, but more broadly, it applies to all feelings towards others, including those based on ethnicity, age, appearance, and gender. Social-gender constructs are influenced by our many exposures with family, friends, education, and the media. While more commonly considered as associations or stereotypes about those unlike ourselves, implicit biases can persist against our those who are like us, as demonstrated by my experience in the conference call [5]. And it is just such actions, when these biases produce behaviors which negatively impact others, that move into the realm of microaggressions.

As with implicit bias, microaggressions, originated from racial prejudices. Defined as brief verbal, behavioral, or environmental indignities, whether intentional or unintentional, microaggressions communicate negative slights toward members of oppressed groups [1]. In the context of gender, subcategories have been described including gender microinsults, often unintentional behaviors or statements that convey a negative message about women [1]. From my perspective, unequal use of honorifics falls here.

Call Me Doctor

What is in a name? A sense of personal identity, both how we perceive ourselves and our impression of how others perceive us. In that context, these small unintentional barbs invisibly marginalize women in a male-dominated field. Perhaps decades of being called “nurse” or “honey” on the wards and in the clinic lowered my threshold. Perhaps my insistence on the use of “Doctor” represents my own insecurity. However, I believe that insecurity emerged in response to social norms that unintentionally or overtly suggested that my position as a physician was somehow of lesser value than that of the man next to me. With more than half of medical school graduates now women, the next generation of doctors may shift the default image of “Doctor.” But applying the hard-earned title less generously to women diminishes that professional shift. Because the clear majority of orthopaedic surgeons are men, the problems observed in the study I mentioned earlier [3] almost certainly are more common in our profession. I believe these slights discourage women in our specialty, and may even discourage young women from entering orthopaedics. That would be a loss for us, for those women, and most importantly, for the patients whom we all wish to serve. The onus is on each of us to be intentional in the ways we use language. Our words and actions can validate or they can demean. We should choose them well.