Let's start with a well-known riddle.
A boy and his dad are going home from soccer practice when a drunk driver hits the car. The boy is rushed to the hospital for emergency surgery. The boy's father dies at the scene.
The trauma surgeon sees the patient and says: "I cannot operate on this boy; he is my son."
How can this be? How can a dead father show up to operate on his son? Maybe the father somehow survived? Maybe it's the boy's stepfather?
If you are stumped, you are not alone. Answer: The surgeon was the boy's mother.
Malini’s turn: That riddle is my reality
As a woman in the third year of my cardiothoracic surgery residency, I find this old story resonates with my training experience more often than I expected. When I introduce myself to patients for the first time, they commonly mistake me for the nurse or the physician assistant (PA).
The comments usually are benign, and I'm quickly accepted once I patiently clarify the situation. Sometimes the patients have good reason for their confusion.
Once I told a patient we needed to talk about his upcoming surgery. Thinking he might be feeling chilly, I brought him an extra blanket. He asked to speak with the physician.
I smiled and gently corrected him.
"I'm so sorry! I thought you were maybe the new nurse coming on for the shift," he replied.
I told him not to feel awkward, as he was far from the first person to make that mistake. But then he really surprised me.
"Well, it's just that during my previous admissions, I had never had a physician bring me an extra blanket," he said.
Once we started talking, it was clear he trusted the medical information I was providing, and respected my opinion. Sadly, that's not always the case.
As easy to correct as these presuppositions can be, this is an issue that surfaces frequently, and can be wearing over time. These biases are not limited to our patients, nor are they always subtle. Female physicians often feel they are met with less respect and confidence than their male counterparts from the outset despite providing equally good (and one study argues even better!) patient care. We are given less help from non-physician staff than our male colleagues. Although women make up more than 50 percent of average medical school classes, there are fewer women in academic chairmanships and medical leadership roles than men, and women are consistently paid 18 percent less than their equally qualified, equally productive male colleagues.
I know from my more senior female colleagues that income gaps are getting lower, glass ceilings (while still present) are getting higher, and respect from hospital staff for female surgeons is broader than among a previous generation of surgical trainees. The fact that I can even be a female surgical resident with a forum to discuss the challenges of gender bias with an interested audience is progress. We are headed in the right direction, but there is still quite a way to go.
Stereotypes and gender bias exist in medicine, just as in other parts of life. But all of us, patients and physicians alike, can surely strive to better acknowledge the increased spectrum of personal characteristics and strengths that diversity affords the practice of surgery.
Jason’s turn: It’s awkward for men, too
I'm in the first year of my residency, and so far no patients have ever asked me if I am their nurse or PA. On the contrary, I'm often called "doctor" even before I have introduced myself as such.
At first, I took that dynamic for granted.
During rounds one morning, I walked into a patient's room, following a fellow and senior resident – both with more experience than I — who are women. The patient greeted me first. Even after we introduced ourselves and our roles, he continued to look to me when asking questions or saying what he wanted.
I've seen similar reactions often enough to be convinced that gender bias, some subconscious and some overt, is a real problem in medicine.
No matter how subtle, these biases are manifestations of male privilege. Before evaluating my competence or the number of years I've trained, too many patients decide that I look like a surgeon and assume that I am fit to play the part. Sometimes, I allow these encounters to boost my confidence, telling myself that I have earned their trust even if I have not. That is privilege.
As I grow more aware of this dynamic, I realize that these situations carry heavy implications. Some physicians will incorrectly be met with more skepticism and less respect than their counterparts. They may receive less help. Furthermore, a recent study demonstrated that this perception, not just related to gender, but also to race, ethnicity, age, and even appearance, is reality for more than half of all physicians in the U.S. That has lasting emotional consequences for the physician, and may even harm the quality of a patient's care if they bypass a doctor who doesn't look as if they think a doctor should.
Tensions of progress
It is important to remind ourselves that when patients or colleagues treat us in a certain way, part of it may be attributable to who we are or what we have accomplished. Or it may be due to the privilege we enjoy. Failing to understand this only perpetuates the problem, and makes the privileged grow content as beneficiaries of implicit bias – and not through their own skill.
Like fossils formed in sediments, the biased comments we field reflect social perceptions and norms of the past. Unfair as they are, they also are tensions of progress that expose antiquated notions so they can be held up to scrutiny.
Implicit bias, while less vitriolic than explicit discrimination, is harder to erase. Beyond gender, there are countless divisions based on race, religion, politics, and more that we must strive to overcome. Policies can take us only so far. The remaining battles can be won only with deeper awareness.
Each time we feel these tensions of progress, at least we can be reassured that being undeterred by who we are and what we aspire to do constantly challenges society to move forward.
Malini Daniel, M.D., is a third-year resident in cardiothoracic surgery, and Jason Han, M.D., is a first-year resident in the same program at the Perelman School of Medicine at the University of Pennsylvania.