Thursday, December 21, 2017

Drs. X, Y, Z, and Julia. Drs. X, Y, Z, and Anita.

Files JA, Mayer AP, Ko MG, Friedrich P, Jenkins M, Bryan MJ, Vegunta S, Wittich CM, Lyle MA, Melikian R, Duston T, Chang YH, Hayes SN. Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias. J Womens Health (Larchmt). 2017 May;26(5):413-419.

Gender bias has been identified as one of the drivers of gender disparity in academic medicine. Bias may be reinforced by gender subordinating language or differential use of formality in forms of address. Professional titles may influence the perceived expertise and authority of the referenced individual. The objective of this study is to examine how professional titles were used in the same and mixed-gender speaker introductions at Internal Medicine Grand Rounds (IMGR).

A retrospective observational study of video-archived speaker introductions at consecutive IMGR was conducted at two different locations (Arizona, Minnesota) of an academic medical center. Introducers and speakers at IMGR were physician and scientist peers holding MD, PhD, or MD/PhD degrees. The primary outcome was whether or not a speaker's professional title was used during the first form of address during speaker introductions at IMGR. As secondary outcomes, we evaluated whether or not the speakers professional title was used in any form of address during the introduction.

Three hundred twenty-one forms of address were analyzed. Female introducers were more likely to use professional titles when introducing any speaker during the first form of address compared with male introducers (96.2% [102/106] vs. 65.6% [141/215]; p < 0.001). Female dyads utilized formal titles during the first form of address 97.8% (45/46) compared with male dyads who utilized a formal title 72.4% (110/152) of the time (p = 0.007). In mixed-gender dyads, where the introducer was female and speaker male, formal titles were used 95.0% (57/60) of the time. Male introducers of female speakers utilized professional titles 49.2% (31/63) of the time (p < 0.001).

In this study, women introduced by men at IMGR were less likely to be addressed by professional title than were men introduced by men. Differential formality in speaker introductions may amplify isolation, marginalization, and professional discomfiture expressed by women faculty in academic medicine.

You graduate from medical school and get your MD degree. At first, when someone calls you “doctor,” you look around and wonder who they’re talking to, but after years of hard work and sleepless nights, you realize you really are a card-carrying “doctor.”

If you’re a woman, however, you start to realize that a lot fewer people call you “doctor” than your male colleagues. At first, it’s subtle. And you shrug it off. Then you wonder if you’re just being hypersensitive, or imagining things, or worse, somehow inadvertently sending off some “informal” vibe that signals you “prefer” that colleagues and patients call you by your first name. But when you get together with other women physicians you realize it’s not just you. Every female doctor has had the experience of being called by her first name from the podium, in the exam room and in groups, while the men were called “doctor.”

Dr. Julia Files, physician and researcher inspired and activated our team to prove we weren’t crazy. Here’s the story of the proverbial straw that broke Julia’s back.

A sinking feeling overtook me as I realized what had just happened.  I was an invited speaker at an event where I shared the program with three male physicians each of us speaking on topics in our areas of expertise. The moderator (male) ended the program by thanking “Drs. X, Y, Z, and Julia.” Wow! This wasn’t the first time I’d been inappropriately addressed by my first name in a professional setting, but it was certainly the most public and glaring incident. Had he intended to strip me of my professional title? Did anyone else notice? Does this happen to other women, or is it just me? Instead of being appropriately proud of my contribution to the program I was stuck trying to process why this happened to me (again).

Then just two weeks later, it happened to my friend, colleague, and co-investigator, Dr. Anita Mayer.  Dr. Mayer was speaking at a program, and I was a member of the audience.  As if on cue, the male moderator ended with a thank you to the speakers, “Drs. X, Y, Z, and Anita”!  This time my “wow” propelled me to action.

So Dr. Files assembled and led our team to study this phenomenon in a scientific manner. An informal poll confirmed that every female physician we asked, regardless of practice type, specialty or geographic location had experienced this. Worse, on the few occasions women had spoken up, they were treated as petty, oversensitive, or worse, mocked. We searched; there wasn’t anything published in the literature that validated our experience. We even looked at business, law, science and other fields. Nothing.

So we set up our own study to compare gender differences in introductions. The venue was medical grand rounds, which at most medical centers is the formal weekly educational session for faculty and learners. The majority of participants in both the role of speaker and audience member are peers holding MD, PhD, or MD/ PhD degrees. At medical grand rounds one expects formality in speaker introductions and as a result, there really shouldn’t be gender differences.

Analysis of data from 6 months of videotaped introductions, left us gratified, validated and saddened at the same time.  We confirmed that whether doctors are introduced as “doctor” depends on the gender of who introduces them. Women introducing any grand rounds speaker used “doctor” virtually all the time (96 percent) regardless of the speaker’s gender. Men, on the other hand, were less “formal” overall; across all speaker introductions by men, only 2/3 ever included “doctor.”

Our real validation came when we looked at the gender of the speaker being introduced. Among introducers, there was a distinct gender difference in their use of titles; male speakers were introduced by men as “doctor” 72 percent of the time, but less than half of the women were introduced as “doctor” This is both statistically and socially significant.

Our research team did a little happy dance and quickly wrote up our results. Our enthusiasm was tempered when two journals rejected the manuscript, in part because the reviewers didn’t really think the results were “a thing.” But now that our work’s been published, the response from other doctors and professional women across many fields has been gratifying and corroborated our collective encounters with this particular type of gender inequality.

Failure to acknowledge a woman’s hard earned professional title while men are awarded theirs, even when unintentional, has profound implications and reinforces the perception of women having lower status. This deprofessionalizing serves to activate stereotype threat and internalized sexism, at a time when a woman needs to be at peak performance, whether she’s speaking, teaching, or caring for patients. Since learners and patients witness this, it’s a very powerful lesson to them as well.

We hope to see meaningful change as a result of our study. There’s no reason to believe that this behavior is intentional, or even noticed by men. One senior male physician, reflecting on our publication told me that while he believed the findings, he didn’t think they were that widespread or bothersome to most women — until he recalled that his physician daughter had recently expressed her displeasure at being introduced by her first name as her hospital’s newly appointed chief medical officer. He then sent her a copy of our paper!

Our goal is to support and lift up other women who share our journey, and these data help us spur change. If we must, we’ll do it one introduction at a time.

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