#KeyLIMEPodcast 252: Boys don’t cry, and girls aren’t tough – Really?

Reference

Samuriwo et. al. 2020. ‘Man up’: Medical students’ perceptions of gender and learning in clinical practice: A qualitative study Medical Education. 54(2):150-161.

Reviewer

Lara Varpio (@LaraVarpio)

Background

• Today (Feb 6, 2020) the AAMC released its annual faculty salary survey. The good news in there is that faculty salaries increased by 2.3%. The bad news is that the salaries of men and women are not the same. Among clinical faculty, at every level, be it instructors, assistant, associate or full professor or chairs—women earn less than men. For instance, at the full professor level a female will earn almost exactly $80,000 less than a male of the same rank.
• The AAMC also tells us that women are not promoted as quickly or to the same levels as men. And that despite near parity at matriculation to and graduation from medical school, women are underrepresented in the physician workforce.
• This paper helps us to begin to piece together the reach of this gender discrimination. It doesn’t look at practicing physicians. Instead it looks the experiences of medical students.

Purpose

• This study set out to examine how medical students perceive the impact of their gender on their learning experiences in clinical practice within medical education’s community of practice.

Key Points on the Methods

• The authors begin by defining their key terms. They define gender as a sociocultural construct in which certain characteristics are associated with different genders. They are also careful not to conflate gender and with a person’s perceived or actual sexual characteristics – that gender can be conceptualized in a variety of ways
• Given this perspective on gender, the authors make clear justifications for how they oriented their research. The authors explain that they worked from within a constructivist paradigm BECAUSE it supports an orientation wherein reality is conceptualized as a mental construct of the individual who assigns meaning to social phenomena they experience. So this paradigm does not argue that there is one RIGHT way to conceive of gender, but that it is instead a construct.
• Next, the authors selected feminist theory and cognitive apprenticeship theory to inform their research. They justify this by explaining that feminist theory provides a lens through which to explore the sociocultural influences on gender. And that cognitive apprenticeship theory encompasses how people learn by observing and imitating others.
• Data were collected concurrently in two ways. First, the authors conducted interviews focused on participants’ perceptions of the impact of gender on learning in clinical environments. Second, the authors also collected online case reports to collect detailed accounts of specific experiences or cases of those gendered learning experiences
• The authors again offer an excellent justification for these two methods explaining that not everyone was available at the time of the study for the interview so the case study enabled more participation AND that, given the sensitive nature of the research topic, the online case descriptions enabled participants to participate in a completely anonymous way.
• The authors engaged in thematic analysis of the data informed by their theoretical framework they constructed. And they had series of independent coding by one researcher which was then reviewed and confirmed by the rest of the team.
• The reflexivity description offered by the authors is gorgeous. They describe how they used reflexive journals and reflexive dialogue to set out the impact of their particular views on the research. They also have a nice description of how their insider and outsider positions with respect to the participants may have helped to encourage participants to offer rich descriptions fo their experiences.

Key Outcomes

• The first theme reported was the around the predominant gendered culture and career prospects.
• Every participant in this study reported interactions in which is was assumed that they possessed certain traits because of their gender. The women were assumed to be more empathetic but less emotionally stable, and were encouraged to pursue intellectually and emotionally demanding specialties. Men experienced being cast as able to work in emotionally taxing specialties requiring clear thinking under pressure. Male students were expect to display stoicism and emotional detachment
• Female participants explained that, as women, they were expected to be less intelligent than their male peers. They even feigned a lack of confidence in their knowledge to make male attendings feel better. Male participants were guided towards careers requiring physical strength like general and orthopedic surgery. Female participants were guided away from those same fields especially if they planned on having children
• The second theme addressed gendered support and mentorship. All the participants reported that senior doctors, senior surgeons and other care professionals had inherent preference for medical students of the same gender.
• All participants also noted the lack of mentors, scaffolding and senior care providers of the same gender affected their learning and their motivation.
• The learner’s gender influenced the extent to which they were allowed to see patients of a different gender. They reported that senior female physicians assumed that their female patients would prefer to have a female learner in the room. Senior male physicians presumed that their male patients would prefer to have a male learner in the room.

Key Conclusions

• The authors present a gendered apprenticeship theory to explain how the gendered healthcare culture is transmitted to students within a male and a separate female community of practice.
• They propose that there are 2 communities of practice – one male and one female — that perpetuate the gendered experiences, mentorship, opportunities, career choices and internalization of norms
• Each community offers narratives to transmit their values and expectations. The authors referenced atrocity stories that are used to demarcate and maintain the boundaries between different communities. The authors assert that their data reflect stories where women were taught to be lady like and males were told to man up . These stories keep the two communities of practice separate
• They warn that having learners see more patients of the same gender is a risk. They warn that these gendered experiences actually risk the health of patients. If learners are not getting experiences with patients of different genders then their skills and abilities to care for patients of different genders will be threatened. This weakens the overall healthcare system

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