“I just assume they don't know that I'm the doctor”: Gender bias and professional identity development of women residents

Abstract

Background

The increasing entry of women into medicine, a traditionally male‐gendered institution, has revealed much about the gendered politics of medical practice. Women are required to negotiate conflicting gender‐normative roles and expectations as they develop their professional identities. Relatively little is known with regard to the study of gender identity and professional development in emergency medicine (EM), with even fewer studies specifically examining women EM residents.

Methods

This was a qualitative, semistructured interview study conducted at the Emory University Emergency Medicine Residency. Women residents in their first, second, and third years of training were recruited for participation through residency listservs. Interviews were completed using a virtual platform until thematic saturation was reached. Interviews were recorded, professionally transcribed, and coded by two study investigators. The study team met throughout the process to identify codes and themes from the interviews.

Results

A total of 11 interviews were completed. Participants self‐identified as Black (five), White (two), biracial (two). and South Asian (two) and represented all levels of training. Participants identified challenges to providing clinical care and conveying their competency related to their gender and role as physicians in training. Common challenges included role confusion and questioning of their decisions by both patients and colleagues. They identified other aspects of their identity as facilitators for care delivery, specifically race as a facilitator when caring for race‐concordant patients. Participants described strategies developed to navigate gender‐specific challenges including routinely providing justification for their clinical decisions. Participants also described a need for interventions at the departmental and institutional levels to improve allyship and bystander behaviors.

Conclusion

Women residents actively negotiate tensions between their gender and role as physicians and develop multifaceted strategies to address challenges in care delivery. Because residency training is a challenging yet formative time in developing one's professional identity, it is important to consider interventions that support women residents and the unique challenges they face.

INTRODUCTION

In the past several decades, medicine in the United States has become increasingly accessible to women, who now comprise half of all medical students. ¹  Women have also made significant headway in traditionally male‐dominated subspecialties, such as general surgery, and are particularly prominent in medical subspecialties such as obstetrics/gynecology and pediatrics. ²  Women remain underrepresented in emergency medicine (EM); however, with women comprising 36% of current residents—a proportion that has plateaued since 2005. ² However, the entry of women into medicine (dubbed the “feminization of medicine”) has revealed much about the gendered politics of medical practice. ³ For example, some authors have speculated that women physicians would humanize the profession and help improve the quality of patient care, while others have suggested that women would compromise the professional and social standing of physicians, thus diminishing their status and compensation. ⁴ , ⁵ Ethnographic studies of women in medicine have had mixed findings, with some demonstrating no qualitative difference between men and women as they graduate from medical school, while others indicate that women do indeed hold different values and resist patriarchal structures as they choose specialties. ⁶ , ⁷

The undercurrent in this debate is that medicine is a male‐gendered institution that requires women physicians to negotiate conflicting roles and expectations as they develop their professional identities. Residency is a brief but formative time in the development of a physician's professional identity. ⁸ In this transition from medical students to attending physicians, residents are particularly at risk of dissonance between their personal and professional identities. This dissonance may lead to emotional distress, burnout, and self‐doubt—especially as related to clinical competency. ⁹  These difficulties may be exacerbated by residents’ gender, race, and socioeconomic backgrounds. ¹⁰

There is significant complexity when considering the gendered expectations of women residents’ behavior in direct clinical leadership positions. Studies have demonstrated the conflict between roles and expectations for women residents when leading emergency department (ED) codes and resuscitations and communicating with nurses. ¹¹ , ¹² , ¹³ For example, Kolehmainen et al. ¹¹ showed that ideal code leaders should display male‐gendered characteristics (by speaking with a deep, loud voice; using clear, direct communication; and appearing calm). Women described stress associated with having to violate gender norms to meet these expectations, and some adopted rituals such as putting on a white coat or pulling back their hair to signal the erasure of their gender while leading a code. Similarly, Linden et al. ¹² showed that a directive style (in contrast to a communicative or collaborative approach preferred by women) was more effective when leading a resuscitation team. While these studies add important insights to our understanding of gender in the ED setting, they focus exclusively on codes and resuscitations. It is therefore unclear how gender manifests in nonemergent clinical tasks and routine interactions with patients, ED staff, and other physicians.

To address these complexities, programmatic interventions to support women in EM have focused on mentorship, networking, and career and professional development. ¹⁴ , ¹⁵ , ¹⁶ However, most of these interventions target women attending physicians rather than residents.

To our knowledge, there are no studies specifically examining women EM residents, who are often actively negotiating tensions between their gender and professional identities in a uniquely unpredictable setting. Our study examines women in an EM residency to better understand how their gender relates to their professional identity as physicians and how they negotiate and manage their multiple identities as women, physicians, and residents. The objectives of this study were to elucidate the ways that gender manifests in the experiences of women EM residents, to better understand the strategies they use to manage difficulties associated with their gender, and to elicit strategies residency programs could utilize to support women EM residents during training.

MATERIALS AND METHODS

Study design

We conducted semistructured interviews between October and December 2020 to illuminate the complex relationship between women EM residents’ gender and their professional development. We chose this approach to facilitate a flexible exploration of women residents’ experiences of their gender, its relationship to their professional identities as physicians, their status as EM trainees, and the strategies they employ to manage these identities in the clinical space and the professional realm more generally.

Study setting and population

Eligible participants were self‐identified women in the EM residency training program at Emory University School of Medicine, a 3‐year academic training program in Atlanta, Georgia. The primary training site for this residency is a large, public, Southeastern urban academic ED with over 140,000 annual visits. Women made up 48% of the residents and 49% of faculty in the program at the time of data collection. There is a mentorship group for women at this program with a rotating, literature‐based curriculum.

The study design and protocol was reviewed by the Emory University School of Medicine Institutional Review Board and informed verbal consent was obtained from all participants. The study methodology adhered to the consolidated criteria for reporting qualitative studies (COREQ). ¹⁷

Study protocol

Semistructured interviews were conducted with participants using an interview guide developed by the coauthors to explore participants’ experiences and perceptions of their gender, their status as EM residents, how their gender relates to their professional identity, strategies they have employed to manage these identities in the clinical space and the professional realm more generally. Before commencing the study, the coauthors piloted and refined the interview guide ensure that the questions were not leading and were easily understood by participants. Questions were developed to reflect and extend current ideas in the EM literature and were informed by the authors’ experiences as women EM physicians at various career stages (ranging from residents to midcareer faculty).

Eligible participants were self‐identified women residents in the EM residency training program at Emory University School of Medicine. Participants were recruited through email communication using existing resident email groups and in announcements in meetings and other departmental venues. The emails and announcements originated from two of the coauthors (a resident and a junior faculty member at the time of the study). The interviews were carried out on a one‐on‐one basis over a virtual video platform due to COVID‐19 pandemic restrictions. Participant demographics were collected including race and level of training.

Eleven women residents were interviewed using a semistructured framework. Participants were asked about aspects of their identity (with specific attention to gender) and how it affects their role as a physician in training, both challenges and advantages they experience when conveying competency as residents, and strategies they employ when/if they feel their competence is undermined. They were also asked how residency‐driven initiatives may alleviate these challenges. Interviews ranged from 20 to 50 min in length. Interviews were audio recorded utilizing the virtual video platform and transcribed using a professional transcription service.

We are cognizant of the power differential that exists between attendings and residents in training, which may have influenced the experiences shared by residents in this study. To mitigate any discomfort that may have been felt by participants, all interviews were performed by the first author, who was a woman EM resident at the same residency program at the time the study. None of the coauthors held a position of leadership within the residency program at the time of the study. One author (ML) previously served as associate program director in the residency; however, she did not carry out any of the interviews or participate in the recruitment process. All participants were advised that their responses would be deidentified to preserve their anonymity. Participants also had the option to decline to answer questions in the interview or to terminate the interview prior to completion, although no participants did so.

Data analysis

Data were analyzed using reflexive thematic analysis based on Braun and Clarke's six‐stage process. ¹⁸ , ¹⁹ The reflexive approach to thematic analysis utilizes an organic and flexible coding process, one that utilizes collaboration between team members in generating themes and capturing meaning organized around a central concept or idea (here, gender and professional identity development). This approach to thematic analysis is particularly beneficial in its ability to deliver rich and nuanced understandings of complex topics.

Following transcription, the team members familiarized themselves with the data through multiple readings of the transcripts. The data were coded by two team members (TS and AZ) and developed into an unrefined map of codes and themes. The study team met throughout the analysis process to continue refining the codes and themes through an iterative process. themes were identified semantically (e.g., taken from concepts voiced directly by participants); however, the study team also considered deeper, latent concepts within the data. We prioritized reflexivity throughout our analysis, a process of continuous reflection on how our experiences, values, and preconceptions as researchers affect the interpretation of data. ²⁰ , ²¹

RESULTS

A total of 11 interviews were completed with women residents. Participants self‐identified as Black (five), White (two), biracial (two), and South Asian (two) and represented all levels of training, PGY‐1 to ‐3. Several prominent themes were identified related to participants’ identity, conveying competency as physicians in training and strategies employed to convey competency when challenged (see Table 1 for themes and representative quotes).

TABLE 1.

Themes and representative quotes

Theme/subtheme	Representative quote
Identity and physician trainee role	As a person of color, I just feel I'm just a little bit more aware of interactions […] the number of times I've run into patients that remind me of a family member or just something that really triggers like, “Man, I feel like I have a perspective on this that other people don't.” I think that you maybe stick out less when you're a guy on a different service. They'd maybe just assume that you actually belong there as opposed to when you're a female, they're like, "Who are you? What's your job here? What are you doing here?" And the only reason that I say that is because I just feel like I have to establish my role so frequently. Speaking about specifically being a female in medicine, there have been interactions that I've had that I have, whether or not it's been the case, been like, “I don't know if you would've spoken to me that way if I looked different or if I were bigger or a man.” Oh, yeah. “I introduce myself as a doctor and then halfway through, they'll be on the phone or something, and they'll be like, “Oh, the nurse is here.” And I'm like, "I just said I was your doctor." I'm like, "You just didn't hear me at all." So I expect that half the time now when I walk in that unless they repeat back to me that I'm the doctor, I just assume they don't know that I'm the doctor.
Challenges in developing competency	There are times where I feel like I have to repeat myself either for rounding or something. I feel like there are times where I have to just speak a little louder so they can hear me. There are times where‐‐ there have been times where people questioned me. […] They're like, "No, you're not a doctor, you look like a kid." Yeah, I feel like, for example, when you're running a trauma resuscitation and you, as the physician or head of the bed, and you're asking for things to be done or you're calling things out, I feel like I get a lot of pushback or attitude from the female nurses that I have witnessed my male counterparts not getting any of […] And running codes, running resuscitations, and being in a position of authority where you're asking people to do stuff, even though it's teamwork, it's just not always well received, where I know that men don't have that issue in the same role as me. And so it [microaggressions] started to definitely steal the enjoyment that I had from just coming to work and taking care of patients and continuing to learn how to do that because my mind became focused on, "Who's going to disrespect me today? What is it going to be? Because we've just been on a roll lately, so it just feels like it's bound to happen, and how am I going to handle it?"
Strategies developed to portray competency	I always have to explain my thought process to show people that I am competent, and I know I have good reasoning behind my actions. Like I said, with nurses, it's a very different bond, so always trying to be super nice. And if they question anything, sometimes I feel like I have to really explain, sometimes overexplain. If they are like, "Oh, I don't see why we're doing this." And I never try and do like, "Because I said so," but I will try and kind of overexplain. And I'm not going to lie. Sometimes I feel like I'll use super medical words sometimes when I'm describing things just to show like, "Okay, I know what I'm talking about." And same when it comes to consults. So I feel like as a female, you just really have to, one, articulate your voice. If you're not loud—well, I don't want to say loud. But if you're not able to read a room and kind of make sure that you're heard in a respectful way, then I feel like you may get pushback that men usually kind of just have a voice that just kind of projects.
Strategies for leadership driven interventions	So there's definitely some educational opportunities when it comes to not only just us as women residents and learning from each other and how we handle these situations and trying to figure out good strategies, but opportunities for educating our male colleagues when it comes to allyship and allyship behaviors and ways that they can be helpful. I do really mean it when I say that our male attendings need to have more awareness about what's going on in regards to the female residents. Because there have just been numerous times where I've had to stand up for myself, but there's someone who's above me who could do the same thing and it'd actually have an impact. And I think that there is a place for doing these training sessions about diversity and inclusion and sexism in the workplace. But I think you have to actually be there and see it to really know what's happening and you have to genuinely want everyone to have a culture that changes and buy‐in by everybody. And I think that it doesn't matter how many sessions you make people attend. If they don't buy into this cultural change, it's not going to work.

Identity and physician trainee role

All participants reported that gender was a salient aspect of their identities and often regarded being a woman as a “constraint” in the clinical environment. Participants highlighted that patients frequently commented on their appearance including age and stature (e.g., being young and petite). Moreover, participants reported that being a woman led to role confusion, because patients and other hospital staff assumed that women residents were nonphysician members of the care team. Women residents in this study reported that such interactions led them to regularly question whether this differential treatment was based solely on their gender, postulating that their male colleagues likely do not experience such assumptions. Participants responded to these situations by regularly reiterating their role as physicians. Finally, participants described encounters in which they were confused for medical students or other positions of less “seniority” despite conducting resident‐level work. This was especially noticeable if a male medical student was present during the clinical encounter.

Participants expressed that they leveraged different aspects of their identities to deliver care as physicians in training. An important theme shared by most participants was that of shared identities with their patients, which allowed them to empathize with and understand different patients’ perspectives. Most notably, participants who self‐identified as racial minorities expressed that their race was the most important aspect of their identity (rather than their gender), often serving as a facilitator when caring for race‐concordant patients. Conversely, participants also reported that being a racialized minority posed additional challenges when interacting with colleagues, making participants targets of microaggressions and racism or “vicarious racism” through witnessing acts of racism. A number of participants discussed how their experiences immigrating to the United States or belonging to an immigrant community was a salient aspect of their identity that helped them connect with patients from immigrant communities.

Challenges in perceptions of competency

When asked to define clinical competency, participants listed components such as a comprehensive fund of clinical knowledge, being able to tailor medical knowledge to patients’ unique social and cultural contexts developing effective and efficient communication skills, and caring about each patient's health needs and outcomes. Notably, no participant described gender as a component of or contributor to clinical competency. Nevertheless, participants described instances in which their competency was questioned because of their gender, sometimes by patients but, more commonly, by their colleagues. Narratives shared highlighted clinical encounters (e.g., in which the participant was the code or resuscitation leader), in which their decision making was challenged, dismissed, doubted, or poorly received. Women residents in this study reported receiving “pushback” or resistance to their clinical plans that was clinically unwarranted or disproportionately negative in comparison with the treatment of male residents. Importantly, participants noted that this resulted in medical care and treatments that were ignored, significantly delayed, or questioned until confirmed by the attending physician. Consequently, participants reported feelings of embarrassment, shame, and questioning of their own skills, especially if these interactions were witnessed by other members of the care team (e.g., during a resuscitation). Ultimately, women residents perceived being judged by different (often higher and more complicated) expectations than their male counterparts. Women residents also perceived that they were subject to unnecessary criticism for minor errors or disagreements with nursing colleagues.

Strategies developed to portray competency

Participants described a number of strategies employed to address interactions in which their competency was questioned or undermined. Strategies discussed included overpreparing prior to providing instructions (e.g.. rehearsing phrases and rationales in advance), providing instructions with qualifiers or overexplaining to justify decision making, repeating instructions regularly, and apologizing regardless of whether an apology was warranted. In code situations particularly, participants described strategies unique to their gender including needing to announce and routinely reestablish their position as the code leader, projecting their voice, and repeatedly articulating a clear plan to remind team members of their position as a leader. A theme that was frequently discussed was that of a “complex power dynamic” between colleagues, mainly nursing colleagues. This was described as women residents having to establish collaborative or “friendly” relationships with colleagues while balancing assertiveness as a leader, being careful not to be perceived as “aggressive.” This often resulted in women residents experiencing “role strain” or feeling that they need to engage in activities beyond their designated role to establish or maintain collegial relationships. Notably, most participants expressed angst and uncertainty regarding the most effective method for addressing these scenarios, often replaying narratives and expressing the desire to have responded differently. This highlights the complexity of navigating such interactions for women residents and, more importantly, the lingering effects of these experiences.

Suggestions for leadership‐driven interventions

While participants described a number of individual strategies they employed to address challenges they experienced, they also expressed the desire for interventions at a department and institution level. During interactions where women residents felt particularly undermined, they described occasions in which coresidents or attendings were present but did not intervene, resulting in feelings of frustration and helplessness. Residents perceived a lack of allyship due to either ignorance of the issues at hand or limited understanding of how a bystander can intervene. A common theme elicited was the opportunity for educational interventions to aid in the recognition of microaggressions and to provide training for bystanders to appropriately intervene (including targeted educational materials for all members of the care team). Participants reported positive experiences with anonymous reporting systems and reflective discussions/sessions related to gender bias during regular conference time. The existence and support of a program‐specific women's professional development group was also perceived as an important avenue for support and broader interventions.

DISCUSSION

To our knowledge, this is the first study to evaluate the impact of gender identity and professional development of women EM residents. Our study suggests that other components of women residents’ identities (e.g., race or ethnicity) may be more salient than gender in the clinical setting. Moreover, our study suggests that racial or ethnic minority status may be flexibly leveraged by residents to build rapport and trust with patients. This finding is likely influenced by our residency's primary training site, which has a longstanding history of serving Atlanta's Black and other racialized minority communities. ²² , ²³  Moreover, our department is explicitly committed to diversity in resident recruitment. Our findings suggest that diversity of resident workforce may have distinct advantages in the clinical space.

Nevertheless, being a woman was consistently regarded as a constraint during clinical work. Women residents in our study specifically reported challenges in being perceived as equally competent to their male counterparts. Women residents therefore had the added burden of navigating challenges to or undermining their leadership and clinical decision making. Our interviews revealed a need for education on microaggressions and strategies for upstander behavior.

Our findings are consistent with other studies that have explored challenges experienced by women residents when leading resuscitations and the ways they embody specific physical appearances to overcome these challenges (e.g., fastening their hair, adjusting their posture, and wearing a white coat). ¹¹ , ¹² , ²⁴ Our study builds on these findings by focusing on cognitive adjustments women residents employ not only to lead resuscitations but also to provide care for patients in the ED. Women residents in our study felt pressured to adjust their mannerisms to balance a constant tension between “being a leader” or “fitting in.” This adjustment leads to role incongruity, which is defined as the perception that women are less effective or viewed less favorably when pursuing a leadership role in comparison to male counterparts. ²⁵ Consequently, women may modify their behavior to take on more traditionally masculine traits like projecting their voice, fastening their hair, and adjusting their posture.

Another common theme was the challenging of resident authority and competency by nursing staff. Previous studies explored the complex, gender‐based relations between EM residents and nurses, demonstrating that women residents perceived gender‐based discrimination perpetrated by nurses. ¹² , ²⁶ Women residents reported the need to provide an explanation when administering orders to ensure completion of said orders as well as general questioning of their abilities by nursing staff. Our study shows consistent findings. Women residents’ instructions were challenged or dismissed, causing them to justify and overexplain their decision‐making process. In one study of nurses’ evaluation of EM residents, there was a 50% prevalence of negative comments about women residents compared to just 21% about men despite similar examination scores and residency‐directed evaluations. ²⁷ Thus, difficulties reported in this study are not limited to residents’ perceptions but are indicative of real and ongoing tensions.

Residency training is a formative time in physicians’ identity development. ⁸  Negative experiences relative to residents’ gender, race, and/or ethnicity may have effects beyond residency. Interventions at this stage in training may help close the gender, race, and/or ethnicity gaps within our profession. ²⁸ One intervention suggested by participants is the need for bystander training and intervention. A bystander is a witness to a behavior that could lead to something high risk or harmful who makes the choice to intervene to improve the situation. ²⁹ One strategy for bystander intervention is the four D’s: direct (check in), delegate (tell another person who can help you intervene), distract (interrupt the situation or redirect individuals who may be at risk), and delay (check in with the impacted parties after the incident and continue with follow‐up). ³⁰ An upstander strategy is the LIFE model: lead (notice the situation), identities (interpret it as problematic), feelings (assume personal responsibility), and evaluation (know what to do and intervene safely). ²⁹ Others have described interventions such as case‐based unconscious bias training, workshops, and use of simulation. ³¹ , ³²

Finally, we found that for racial minorities, race was the most significant component in shaping one's identity. Further exploration of how intersectionality relates to the professional identity and development is necessary to better understand experiences and challenges and to develop effective interventions, recognizing that interventions that target only gender bias may fall short in efficacy if all important components of one's identity are not considered.

LIMITATIONS

Our study has several limitations. First, interviews were carried out at a single residency program. Thus, the findings reflect the experiences of our residents and their particular training environment and may not be transferable to other programs and/or clinical settings. Specifically, our large percentage of non‐White participants is not representative of EM residents across the country. Second, residents who agreed to participate may have distinct experiences not shared by residents who did not participate in our study. Nevertheless, our study is consistent with previous work in other clinical and residency training sites and suggests patterns of gendered experiences in EM residency that are worthy of continued research. ¹¹ , ¹²  Participants may have felt compelled to take part in this study, as recruitment was led in part by a faculty member. We were cognizant of the inherent power differential between faculty and residents throughout this study and minimized this effect whenever possible (e.g., by limiting interviewing to a resident coauthor, taking steps to deidentify responses). Finally, our study included only women and their experience of gender as EM residents. Thus, findings from our study may not be transferable to other genders, specifically men, transgender, or gender‐nonbinary residents. Future studies are needed to better understand how the full gender spectrum contributes to residents’ experiences and professional identity development.

CONCLUSIONS

Our study demonstrated that women emergency physicians in training must constantly balance and account for their gender identity while developing their professional identity as physicians. Gender alone imposed constraints on how they were perceived as physicians, leading to challenges when portraying competency and frequently being questioned and undermined. As a result, women residents have developed a number of strategies during training to compensate for frequent questioning of their role and decision making processes. As gender inequities likely start during training and are compounded thereafter, it is important that we consider how gender bias impacts women residents and develop interventions to address gender‐specific challenges in training.

CONFLICT OF INTEREST

The authors have no potential conflicts to disclose.

AUTHOR CONTRIBUTIONS

Taylor Stavely: conceived and designed study, acquired data, interpreted data, and drafted and revised the manuscript. Amy Zeidan: conceived and designed study, interpreted data, and drafted and revised the manuscript. Michelle D. Lall: conceived and designed study, interpreted data, and drafted and revised the manuscript. Bisan A. Salhi: conceived and designed study, interpreted data, and drafted and revised the manuscript.

Supporting information

Supplementary Material

Stavely T, Salhi BA, Lall MD, Zeidan A. “I just assume they don't know that I'm the doctor”: Gender bias and professional identity development of women residents. AEM Educ Train. 2022;6:e10735. doi: 10.1002/aet2.10735