Michelle Lall, MD Unconscious biases exist everywhere and medicine is no exception. These biases are developed at a young age and strengthened over time. Unconscious bias refers to social stereotypes about certain demographics or groups of people that individuals form outside of their own conscious awareness. The traditional association of men with work and women with family and of men as physicians and women as nurses has long been held. How many times have you been mistaken for the nurse? How many times have you heard “You are the doctor?” with an air of surprise.
I have experienced gender bias from a young age. I can remember being asked as a high school student “Wow, you plan to be a doctor? Do you plan to be a mother?” Another biased assumption that professional women cannot, do not or choose not to have families. When I was in undergrad, as a woman, I was in the minority with my classmates, but the premed group was collegial. There was bias from advisors but not from my peers. I still remember my premed advisor telling me “You are a woman so you need to wear a skirt suit to your medical school interviews. Don’t wear pants.”
I remember thinking Isn’t it obvious from my appearance that I am a woman. Why would I need to wear a skirt? What?! Women wear pants. Throughout my medical school rotations, there were the comments from patients “Hi honey; sweetie; I am surprised you are going to be a doctor? Or you aren’t the nurse?”
During residency, there were many of the same comments from patients. There was the occasional “ER why would you want to do that? You have to be really tough to do that” with the implication that as a woman I am not tough enough. During residency, I felt fully supported by my peers and faculty, but there was bias that seemed to be most pronounced with senior women nurses. “Aren’t you going to get help to do that reduction. You aren’t strong enough” I am not sure if this was unconscious bias, gender bias or just the “hazing” that often goes on between residents and nurses. The bias still continues in my everyday practice. As the woman physician side by side with the male nurse, the patients’ still frequently state “Wait, you are the doctor and he is the nurse?” We have all experienced bias in one form or another but what is its impact?
There is little data in the medical literature regarding the presence and impact of unconscious and gender biases in medical education. A recent study by Morgan et al. sought to investigate if a difference exists in medical student evaluations of male and female faculty physicians on four required clinical rotations obstetrics and gynecology, pediatrics, surgery and internal medicine. They found that female physicians received lower scores on the evaluation item “overall quality of teaching” in all four clinical rotations. This discrepancy was largest in the surgery rotation and smallest in internal medicine. The discrepancy was present in both nonsurgical and surgical clerkships and in both male and female predominant fields.
They found no difference in faculty evaluations based on medical student gender. The differences on individual rotations were not significant, although they were all weighted towards the male attendings. However, when all the evaluations were summarized together, there was a statistically significant advantage in being male.
This study corroborates evidence found a couple of year ago with online teaching evaluations. This study, What’s in a Name: Exposing Gender Bias in Student Ratings of Teaching, had 2 instructors teach online courses and blinded the students to their gender. The researchers took two online course instructors, one male and one female, and gave them two classes to teach. Each professor presented as his or her own gender to one class and the opposite to the other.
Students gave professors they thought were male much higher evaluations across the board than they did professors they thought were female, regardless of what gender the professors actually were. When they told students they were men, both the male and female professors got a bump in ratings. When they told the students they were women, they took a hit in ratings. Because everything else was the same about them, this difference has to be the result of gender bias. This was not a medical student study, but it certainly adds fuel for thought.
The Morgan study demonstrates that the transient relationships between medical students and faculty physicians may be subject to unconscious gender bias. Without additional or sufficient information, students may unconsciously to some degree evaluate their faculty through “the lens of gendered expectation.” The interactions between students and faculty would be expected to suffer from unconscious biases as these biases are more likely to be relied upon in situations of ambiguity, multiple competing tasks with limited time, and lack of significant information.
These findings are in contrast to a large study of resident evaluations of faculty, which showed no significant difference based on faculty gender. This might be because residents interact with faculty for longer periods of time and in multiple contexts and have sufficient information to evaluate the faculty and thereby do not resort to unconscious bias.
This study highlights subtle differences based on physician gender, providing further evidence of disparities for women in academic medicine. Of concern is that the lower evaluation scores of female faculty may contribute to the promotion gap for women. Teaching evaluations and awards are of paramount importance for clinical educators. For all of us, our ability to teach is highly weighted in the promotion process for those on clinician educator promotion tracks. Additionally, women win fewer teaching awards than men. Is this because of unconscious bias? Is this because men are still the majority of faculty in Emergency Medicine? The majority of these men are also older caucasians. Age and race/ethnicity also impact unconscious bias and these were not collected and analyzed in the Morgan study. It will be important for future studies to assess gender, age and race/ethnicity in data analyses attempting to detect bias.
As educators, this is an area we should be focusing on. We need to initiate an active dialogue to increase awareness of unconscious biases in all areas of medicine. Awareness followed by acknowledgement are the first steps in fostering gender equality.
References:
1. Student Evaluation of Faculty Physicians: Gender Differences in Teaching Evaluations DOI: 10.1089/jwh.2015.5475
2. Impact of Gender on Teaching Evaluations of Faculty: Another Example of Unconscious Bias? DOI: 10.1089/jwh.2016.29008.kte