Doing Gender: An Anthropologist’s Look at Gender in #CBME

(During our annual general meeting of the editorial board, we realized that our editorial board was unbalanced and did not include a trainee’s perspective. In the spirit of co-production we’re working to correct this shortcoming.  Part of our solution is to introduce Eve as our newest editor.  Welcome! Eve is a senior trainee in emergency medicine, while simultaneously completing grad school.  In other words, she’s pretty amazing.)

-Jonathan (@sherbino)

By Eve Purdy (@purdy_eve)

How does gender affect the assessment of competence? This article applies an anthropologic framework, “Doing Gender”, to explore recently published data showing that senior female emergency medicine residents attain competence less readily than their male colleagues. In this context, anthropology can help answer some questions but in the process of doing so forces us to raise many more.

The most recent KeyLime podcast “The Gender Gap in Direct Observation Assessment” [1] reviewed a brilliant paper by Dayal et al “Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training” [2]. If you have not read the paper yet, you must!

Dayal et al.’s research convincingly shows that while male and female residents start out residency at similar levels, by senior residency, males achieve 23/23 milestones more readily than their female colleagues [2]. This is not the only paper that shows a difference between genders in resident evaluation of competence. Meyerson et al. showed that gender was the only predictor, in addition to PGY level, in determining operative autonomy for surgical residents [3]. These data leave readers with more questions than answers.

• Is the way we define competence gender bias?
• Are the tools we use to assess competence gender bias?
• Do the people using the assessment tools have implicit gender bias?
• Are senior male residents actually more competent? If so, why?
• What about our environment makes it easier for males, or more challenging for females, to demonstrate competence?
• What about our educational curriculum sees male residents gain competence faster?
• Will we see the same pattern in non-acute care specialties?

Eve, the senior resident in emergency medicine, was terribly disheartened by this paper. But Eve, the anthropologist and woman, was not at all surprised by the findings. We can look to anthropology to help us understand this phenomenon.

Anthropology and Medical Education

For a primer on anthropology and how it relates to medical education please click here [4].  Fundamentally, anthropology is the study of culture – the abstract set of beliefs and values that lie behind people’s behaviour. My column on ICE will focus on applying anthropology to medical education – so stay tuned! Key activities of anthropologists include building and testing theoretical frameworks through a variety of robust, largely observational and qualitative, methods.

Doing Gender – A Framework For Understanding Gender and Competence

One pre-existing framework that can be applied to the above phenomenon is “Doing Gender” which was developed by Joan Cassell [5]. She is a medical anthropologist who studied female surgeons in the early 1990s but the framework has been applied and used beyond the walls of the hospital by feminist anthropologists since. Cassell found that female surgeons did not fit nicely into any of the previous feminist theories. Up until her study, difference theory – the concept that men and women are fundamentally different, bringing different behaviours and values to their interactions with the world – had dominated.

Cassell observed that both male and female surgeons could be caring and compassionate and they could both be abrasive and dominating. There were not distinct disparities in their behaviour, yet the results in the social context could be profoundly different. Cassell put forward the concept that individuals have a sex but they actually do gendered behaviours. She subscribed to the concept that gender is negotiated and constructed. Simultaneously there are cultural expectations about how each sex should act. When there are disparities between one’s sex, and the gendered behaviours they exhibit, conflict arises. This conflict can be both external and internal. For female surgeons, conflict was much more common than their male counterparts for whom some stereotypically female gendered behaviours (caring, compassion) are within the socially acceptable expectations of a male physician. Cassell found that patients, chiefs, nurses, colleagues, and learners all had ideas about what appropriate female conduct should be and had developed ways of enforcing and rewarding gender appropriate behaviour.

Doing Gender in Medical Education

So how does this theory help us reconcile the data Dayal et al. present? It must make both educators and learners reflect carefully on their own understanding of gender, gendered behaviours, and how they negotiate gender in the context of their clinical/educational context. An open dialogue is the starting point.

I transitioned to the senior resident role just a few months ago.  When I think about the tasks in the department that I find most challenging they are ones in which I must exert dominance. I am not a particularly reserved person but I worry about offending allied health by asking again when tasks have not yet been completed, and I sometimes struggle with authoritatively commanding a room in a resuscitation when necessary. Part of this has to do with my experience, and I trust will fade with time, but there are certainly activities that I engage with on daily basis that are counternormative to my gender. As per Cassell’s framework and my experience and observation this creates conflict. Other female residents leading codes express the same sentiments [6]. In my fairly supportive setting, this conflict is likely predominantly an internal one but I may not know the extent of the external ripples. Fortunately, I have had a number of supportive teachers who openly speak with me about how gender might affect my performance on these specific tasks. These highly conflicting gendered moments, however, are not the norm.

Not every competency in the emergency department is rooted in stereotypically male behaviours, in fact, most of my job aligns quite well with our cultural expectations of how female physicians should behave. But what we see from Dayal’s data is that it is not just in instances of resuscitation or under high acuity competencies that male residents surpass their female colleagues. They are faster at achieving competence in every single domain. Frankly, I just don’t believe it. Let me rephrase, I believe their data but I don’t believe that this can possibly be true. Their findings represent something that the authors could not measure. I have a couple of hypotheses.

Implicit Bias

There is likely implicit bias in assessment. This actually doesn’t need much more explanation. We might, unknowingly and without any form of malicious intent, be more favourable in the assessment of male residents than female residents. Perhaps, we may see this more clearly in the senior resident years as male residents become more readily socialized into departments than their female colleagues. This is unlikely a new phenomenon, but rather one unmasked by our now available and robust assessment data. Regardless, we cannot now “un-know” that this exists.

Home and Departmental Domestic Responsibilities

Female residents may have more competing demands. Perhaps women are in fact slower to achieve competence, but not because they are any less proficient, but simply because they have more on their plate. The fact that women have more domestic responsibilities is well established. I venture a guess that female residents, in addition to having more home responsibilities than their male counterparts, also have more “domestic responsibilities” within the department too. I am not going to find anywhere in a paper but I am quite confident that the likelihood of a chest tube tray being pre-set up in anticipation of a procedure is much higher for male physicians than for females. I am sure that female physicians are more commonly asked to find non-existent (at least in our department) pillows and blankets. Perhaps, like female supreme court judges, women residents are interrupted more which could have significant cognitive and performance consequences [7]. Women may also be taking on extra tasks including research, teaching, and administration, to boost their resumes for hiring because they recognize the significant gender gap they face on the other side of residency [8]. Individually these realities may seem insignificant but collectively they may slow the rate of their achievement of purely clinical competence.

The Way Forward

So where do we go from here? In the short term I encourage you to talk about this paper at your journal clubs and department meetings. I would also consider sharing it with nurses and allied health practitioners within your group. This urgently needs to be a discussion initiated with all residents. Specifically, giving women the space and mentors to explore the above phenomena is essential. Culture is local. In certain groups and in certain specialties this may be a more predominant issue. For others it may resonate less but the conversation is essential to bringing the concept to the forefront. Next, as an educational community we must engage in further research to understand not only how widespread this issue is, but also why it is happening. As we move to a fully competency-based model of assessment for all residency programs in Canada, a top priority for educational researchers needs to be whether this type of assessment is going to be biased against women or other vulnerable groups. If so, in what contexts? At what stages? Dayal’s paper adequately sounds alarm bells that this model of assessment may be at risk of significant bias. I cannot overstress how concerning this is. We must pay attention to the signal.

Finally, as a society we will continue to reshape our concept of doctor. We can think about how we enforce and reject gender stereotypes. We can reshape our cultural expectations of what gendered behaviours are appropriate in which contexts. We can rethink how we define success in residency and beyond.

References

1. Frank J., Sherbino J., & Snell L. 2017. The Gender Gap in Direct Observation Assessment. KeyLime Podcast. Published July 4, 2017. Available at http://keylimepodcast.libsyn.com/138-the-gender-gap-in-direct-observation-assessment.
2. Dayal A., O’Connor DM., Qadri U., & Arora VM. 2017. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training. JAMA Internal Medicine.
3. Meyerson SL., Sternbach JM., Zwischenberger JB., & Bender EM. 2017. The effect of gender on resident autonomy in the operation room. Journal of Surgical Education. E pub ahead of print http://www.jsurged.org/article/S1931-7204(17)30254-4/fulltext.
4. Purdy, E. 2017. #AnthroEve: An intro to anthropology and medical enculturation. Online. Available at https://canadiem.org/anthropology-and-medical-enculturation/.
5. Cassell, J. 1997. Doing gender, doing surgery: women surgeons in a man’s profession. Human Organization; 56(1): 47-52.
6. Kolehmainen, C. et al. 2014. “Afraid of being witchy with a ‘b’”: a qualitative study of how gender influences residents’ experiences leading cardiopulmonary resuscitation. Academic Medicine; 89(9): 1276-1281.
7. Jacobi T., & Schweers D. 2017. Female Supreme Court Justices are interrupted more by male justices and advocates. Harvard Business Review, April.
8. Freund KM. et al. 2016. Inequities in academic compensation by gender: a follow-up to the national faculty survey cohort study. Academic Medicine; 91(8): 1078-1073.

Featured image from Wikipedia

Image 1 via Eve Purdy (personal photo)

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