Hospital employees and patients sometimes still need ‘gentle clarification’ that their female physician is not the hospital social worker or some other junior functionary, writes a senior ICU resident in the New England Journal of Medicine.
Dr Loren Rabinowitz writes:
“As the senior resident in an intensive care unit (ICU), I had just finished a particularly difficult discussion with a patient’s family. My patient was an elderly man with advanced dementia and a weak heart who had collapsed at home. Now that he was ventilator-dependent and showing no signs of meaningful neurologic function, his wife asked that he not undergo cardiac resuscitation if his heart were to stop beating.
“The family left the ICU, and I sat down to document our conversation and place a do-not-resuscitate (DNR) order in his chart, a task that, at our hospital, can be performed only by senior trainees or attending physicians. The telephone in the unit rang. ‘The patient’s wife wants to talk with his doctor,’ the unit clerk called. Confused, I picked up the phone. ‘I need to talk to Dr W,’ she said, asking for my intern, who had met the patient’s family only briefly earlier in the day. ‘He’s on another call. Is there something I can help you with?’ I asked. ‘No, I need to speak with the doctor directly,’ she repeated.
“I paused for a moment, considering whether it was worth clarifying that I was a physician (and one with more seniority), but decided that this woman’s day had been challenging enough. I waited for Dr W to finish his other call and silently handed over the phone. I listened to the patient’s wife repeat our conversation and ask Dr W to document that her husband should not undergo resuscitation. Then, I waited for his response – for him to clarify that he was the most junior physician on the team and placing a DNR order was not a task he was able to perform or that I was his senior resident and had already placed the order honouring her and her husband’s wishes.
“He did neither.”
Rabinowitz writes further: “Last year, two studies on women in medicine made national headlines – one describing how patients treated by female doctors have better outcomes than those treated by male doctors and another detailing the specific challenges that women face during medical training. As the #MeToo movement has shown in recent months, sexual harassment in the workplace is ubiquitous. Sexism, harassment’s more insidious cousin, is so common in medical training that I don’t know of a female colleague without at least one story about her experience with it.
“Women are vastly underrepresented in leadership positions in medical schools and hospitals, despite having leadership aspirations similar to those of their male counterparts. But in 2017, for the first time, more than half of medical school entrants were women. Interventions that shift the way physicians advance in academic medicine have been explored as a path toward reducing the gender gap in leadership positions at an institutional level. The Association of American Medical Colleges has designed online and in-person training courses on unconscious bias for physician search committees, with the hope that this education will change the way physicians are hired, promoted, and compensated.
“The growing number of women entering medical school means that a large proportion of women in medicine are young – students, trainees, and junior faculty members – and may be decades away from sitting in deans’ chairs or on search committees. Self-advocacy can feel impossible, even as we advocate passionately for patients under our care. Perhaps small steps such as taking ownership of our roles as physicians, enlisting allies, and educating our trainees, students, and patients can provide a starting point for the movement toward workplace equality.
“Hospital employees and patients will be seeing more female doctors in the coming years. Sometimes, however, they will still need gentle clarification that their female physician is not the hospital social worker (as I was recently incorrectly identified by a fellow female physician). A recent study of speaker introductions at internal medicine grand rounds revealed that even when women are acknowledged as physicians, they are more likely than men to be introduced informally: women were referred to by their professional titles 49% of the time, as compared with 72% for male speakers.5 This finding has important implications. Calling women by first names in a setting in which men are referred to by formal, professional titles is a tacit acknowledgment that women are perceived as less important, even as their contributions are publicly recognised during grand rounds.
“I have counselled many female students and interns on the importance of properly introducing oneself as a medical student or doctor. Correcting a misperception can feel more challenging. On that day in the ICU, I failed to assert my own identity. On the one hand, it seemed like the wrong time and place to advise an overwhelmed, soon-to-be widow that she was engaging in sexism. On the other hand, acknowledging sexism’s presence is necessary, even though doing so is nearly always uncomfortable. Broaching the topic is especially difficult in the emotionally fraught context of dealing with sick patients and their families. Next time, I hope I will find a way to be both kind and clear about my role in patient care.
“While reading a New York Times article about the challenges faced by female doctors, I was initially surprised that it was written by a male physician. Then, I was grateful. I have been fortunate to have wonderful mentors, many of them male, who championed my aspirations and served as extraordinary role models. We need more male colleagues to recognize the added challenges associated with being a woman in medicine and to actively engage in ending gender bias. I recently sat on a panel discussing women in medicine for students at my medical school. The panellists included women in various sub-specialties and stages of postgraduate training. I was thrilled to see that of the hundred or so students present, at least a dozen were men. They spoke up. They asked questions. I felt proud to hear female voices amplified by male students interested in becoming advocates for their female colleagues.
“Several hours after that initial conversation in the ICU, I mentioned to my intern that perhaps the patient’s wife didn’t realise that I, too, was a physician, and that moving forward, it might be important to explain the roles of various providers on the patient’s care team. My intern, a bright and compassionate young man, immediately felt terrible that he had not corrected the patient’s wife. Then he told me how frustrated he gets when, perhaps because of the colour of his skin, he is confused for a patient transporter, a physical therapist, or a janitor.
“We had both sat through medical school lectures on implicit biases as they relate to patients and health disparities. Until that day in the ICU, it hadn’t occurred to either of us to apply the lessons we learned from bias training to our peers and other hospital personnel, or that it might be our obligation to educate patients about their unconscious biases regarding their health care providers.
“That moment of mutual acknowledgment that we all have blind spots and wrestle with how we perceive and are perceived by others will remain among the most important of my residency training. As physicians, we strive to treat all our patients equally. It is imperative that we do the same for our colleagues.”
[link url="https://www.nejm.org/doi/full/10.1056/NEJMp1802228"]New England Journal of Medicine article[/link]