Patients May Not Be All That Biased

There is a lot of research on how women in male-dominated areas (e.g. management or politics) are in a somewhat “damned if you do, damned if you don’t” situation. When they present themselves in a warm and feminine way their demeanor is at odds with what the field requires (e.g. they’re not perceived as “real leaders”), but if they present themselves in a masculine, assertive way, they’re not perceived as “real women” and thus disliked. So is that also the case in surgery? A recent study by Marie Dusch and colleagues suggests that this may not necessarily be the case, at least not from the patients’ perspective.

They presented patients in a general hospital with short scenarios describing either a male or a female surgeon who presented themselves in either a feminine or masculine way. Moreover, they were described as either performing breast cancer surgery or lung cancer surgery. Somewhat surprisingly (at least to me) patients did in general not prefer male surgeons over female surgeons or masculine surgeons over feminine ones. Neither did they prefer masculine male surgeons to feminine male surgeons or feminine female surgeons to masculine female surgeons – nor the opposite. In fact, the only significant result they found was that for lung cancer surgery, masculine surgeons were seen as more competent regardless of gender.

While it is important to replicate these results before drawing strong conclusions, this study nevertheless shows that gender stereotypes in surgery may be slowly changing or at least not be as pervasive among patients as we might assume.

Guest Blog: Take it Like a Man

Oooh, exciting! This week we have a guest blog! The awesome Tiffany from Surgery at Tiffany’s (a blog which I can highly recommend) has kindly agreed to share her response to out post about whether or not women in surgery are less confident than their male counterparts.

If you are interested in guest blogging on this site some time, please get in touch. It would be great to make guest blogs a somewhat regular thing! But now, without further ado, here is what Tiffany has to say:

When I was accepted into plastic surgery training back in my mid-20’s, I was the only female plastic surgery trainee in the state. There was only one female plastic surgeon working in town, but she was trained overseas and imported into our hospital. She was my mentor and ally. She told me stories of her training and gave me valuable insight into the minds of my male colleagues.

When I first started training, I used to get upset about every little thing. She used to shake her head at me and said that I should toughen up, use my stiff upper lip, and basically grow a tough hide. But it wasn’t until she said to me ‘Take it like a Man’ that I realised to succeed and survive my training, I needed to be like my male colleagues. I needed to be one of them.

Behaviour

Short of wearing pants and ties, I started to observe my colleagues. They don’t cry when they get upset (well, maybe only when they were very very drunk), and they tell you as it is when they are. However, when I started to behave like one of the boys, people’s response to me was completely different. When one of my male colleagues started to rant and rave about something that had not been done for his patients, deathly silence ensued, and the nurses scrambled to do his bidding. When I mention that a certain instruction was not followed, nurses shrugged their shoulders at me and I was called a bitch behind my back.

Once, I watched one of my colleagues brush off a female patient’s concern as if it didn’t really matter. The patient reacted by shrugging her shoulders and put it down to ‘he’s a man, he doesn’t understand.’ Yet when I inferred a similar response to her complaint, she carried on about how that I was an unsympathetic doctor and should have been more understanding of her feelings.

So I learnt my lesson. I had to be tough like a male, but I needed to behave like a female, because my co-workers and my patients expected me, as a woman, to be more perceptive to their feeling, to be gentler, thoughtful, considerate and compassionate. All the qualities of their mothers.

Competency

And yet what did people expect of my abilities as a female?

There are several facets to this issue. Firstly, people make assumptions that you understand certain aspects of their lives, or have specific skills because you are female. Patients often tell me that they have specifically chosen me as their surgeon because I am female. That they know I will pay more attention to detail, that my work would be more delicate and that I have gentler hands. I have found these ideas vocalised more from female patients, although the back-handed sexist compliment makes an appearance now and then from the male patients: ‘Female hands are made to do fine embroidery, your sewing would be better.’ This is all inference without evidence. Some of the best microsurgeons I have had the privilege of learning from, are male surgeons with big clumsy-looking hands who couldn’t sew a hem to save their lives.

Some tell me that I would better understand what results they are after because I am female. One of my specialties is cosmetic and reconstructive breast surgery. Even my colleagues have presumptions and send their wives to me as a preference because I would know what beautiful breasts are supposed look like. I have my suspicious that it was more because they hesitate to have one of their male colleagues handling their wives’ bosoms. I often joked with them that beauty is in the eye of the beholder, and unless their wives are lesbians, what I thought would not really matter. Not to mention, as far as I was concerned, you are too big if you are bigger than me. Without fail, their gaze would lower to the A cup push-ups I wore hidden under my dress. The disappointment in their eyes when they come back up to my face is almost comical.

An interesting social survey that was done locally in my state by the Plastic Surgeons’ Society showed that majority of women preferred a male plastic surgeon for cosmetic procedures, but female plastic surgeons for reconstructive procedures (e.g. after cancer surgery, or for treatment of congenital deformities). I guess this may just be a reflection of the underlying reasons for these procedures. Most of the patients who have cosmetic procedures book in because they want to look attractive for the opposite sex, whilst those who have reconstructive procedures proceed for their own self-esteem.

But realistically, are male surgeons better than female surgeons? My personal experience is that overall, the common public perception is that male surgeons are more competent. It is not that unusual for my patients to ask for a second opinion specified to be from a male surgeon. It is also not uncommon that patient find it easier to accept an opinion (especially one that they do not agree with) from a male surgeon. Sometimes I would argue patients until I am blue in the face about my decision, and yet when my male colleague comes to the same conclusion, the answer is a meek ‘Yes, whatever you think is best, doctor.’ It is also not uncommon that when I am doing ward rounds with my junior male residents, the patients look to them to reassurance, assuming that they are the doctors in charge.

This perception is not just restricted to patients. I have had male colleagues who have volunteered to take difficult cases from me because they felt that it was stress I didn’t need or the procedure would be too long for me. I have had to stop myself being a ‘hypersensitive girl’ and ask them if they were questioning my competency; instead, I would often smile sweetly and tell them that ‘you are so thoughtful, but I really enjoy the challenge’. There is also no doubt that my male colleagues are particularly protective of me at times. Once I was bullied by a male colleague from another specialty, because he was not willing to accept that he made a mistake with my patient, an incident which I unfortunately had to bring up at the morbidity and mortality (M&M) meeting. The next thing I knew, two male surgeons from my department cornered the poor man in the tea room two days later. Ever since the incident, that particular surgeon seemed to be awfully fond of stairs when we bump into each other at the hospital lifts. The male protectiveness didn’t just come from senior staff either. When I have had to visit the secure unit (prison hospital) to see some patients with my junior residents, I have had male residents trying to protect me from seeing obnoxious abusive patients. Sweet, but totally unnecessary. I was more effective in getting the prisoners to comply with their therapy than any other surgeon. Apparently a pissed off female surgeon is a lot more terrifying than a male one.

Confidence & Self-Esteem

So with such behaviour surrounding female surgeons, you would think we have no confidence or self-esteem in ourselves. Yes and No. I believe these are two very different things.

Confidence is a projection, or a façade as I’d like to think. This is something a lot of female surgeon learn very quickly early on in their career, because a show of weakness or doubt, especially in front of our male colleagues or senior staff, was a sign we didn’t have what it took to be a good surgeon. Being decisive and making good clinical judgement is the crux of a good surgeon. Several times throughout my career it was emphasised to me that you could teach a monkey to operate, but you could never teach it to choose the right operation. Personally, I don’t think it is hard to project the illusion of confidence, because you see it around you constantly from all your colleagues. I don’t need to puff up my chest or spit at my feet, but when I announce my decision to the team, it is clear to all and sundry that it was my way or the highway.

Self-esteem, however, is another matter. It is no secret that females are more introspective than males. Looking at the gender difference in the psychology of cause and reason – females tend to blame themselves, and males tend to blame external factors. This is no different in surgery. How many times during an M&M have I had to listen to my male colleagues go on and on about how the surgical instruments they were using were old and unreliable, about how the patients were non-compliant, about how the disease was so advanced or that the patient’s anatomy was abnormal. Whereas I hear female surgeons lament about how they should have done this, thought about that, or even not have taken on the challenge in the first place. Whenever an unexpected problem occurs, the female will look inside themselves for reasons rather than recognise that sometimes the patient’s pathology defeats even the best surgeons.

This is something I constantly remind my female trainees (and myself from time to time). I tell them that there has never been any evidence that female surgeons are less competent than male surgeons. Yet, we have an innate inferior complex about ourselves. We tend to beat ourselves up when things go wrong. Then we are tempted to fall in a heap of self-pitying mess. I often tell them that we can’t ignore this female psyche we possess, if anything, it makes us a better surgeon because we are constantly evaluating ourselves. But we have to have the insight to understand that too much of it can be debilitating. Good surgeons should be able to move on from their complications, ‘failures’, and mistakes – to learn from it, and start the next case as a completely fresh problem. We shouldn’t be accumulating ‘baggage’ which erode our self-esteem, because our patients rely on us making the right decisions for them at every crucial moment – and the right decisions are never made when self-doubt takes over the decision making process.

Confidence and self-esteem does go hand in hand. The more self-esteem one possesses, the easier it is to project confidence. However, the biggest trick in the trade is to be able to take criticisms, scrutinies, mistakes and failures on the chin, and yet still project the same confidence so that both your colleagues and your patients will continue to have faith in your abilities. If being a female means you are more critical of yourself, this is not necessarily a bad thing, it just need to be moderated. Having good support from a sympathetic colleagues (male or female) can also go a long way.

Even though surgery is slowly being ‘infiltrated’(as one of my male colleagues like to put it), by females, it is still very much a male-dominant area of medicine; partly due to diminishing remnants of the ‘Old-boys’club’ attitude, but mostly due to its unrelenting hours and commitment. A career in surgery is unconducive for the stereotypical role of women – one of bearing babies, spending time with family, home making and baking cookies. Honestly, the only babies I see are those in the hospital, and the only baking I do is with a diathermy.

So until we have more female surgeons, and society start to see us as the norm, my belief is that we should Take it like a Man, but Give it like a Woman.

Female and Male Surgeons’ Interactions with Patients

There are a number of benefits of involving patients in medical decision making, from legal concerns to quicker recovery in surgery patients. But do surgeons themselves see these benefits? And if so, to what degree do their actual interactions with patients reflect this? Are there gender differences? A study by Garcia-Retamero and colleagues can give us some answers.

They collected data from a diverse sample of surgeons from 60 different countries and found that the majority of surgeons agreed that involving patients in medical decision making was desirable. The preference for a collaborative role was more pronounced among female compared to male surgeons. However, when asked about their usual (rather than ideal) role in medical decision making, women were much less likely to be collaborative compared with men – 81% of female surgeons reported that their role was usually “active” (rather than collaborative), compared to 45% of men.

The authors suggest that this discrepancy between preferred and usual roles might be due to the fact that women may feel the need to act in a more “masculine” way in order to be seen as an authority but another possibility might be that female surgeons are simply more critical of their own behaviour.

Are Women in Surgery Less Confident Than Their Male Counterparts?

Research in achievement domains such as the workplace and education shows that while men over-estimate their performance, women under-estimate how well they are doing. This is especially true in areas that are stereotyped as being “masculine”. It could thus reasonably be expected that this would also be the case in surgery.

However, Rebecca Minter and colleagues investigated this issue in a study and found that this wasn’t the case. While they did find a trend such that female general and plastic surgery residents under-estimated their performance to a greater extent than their male counterparts, this difference did not reach significance. There were also no gender differences with regards to actual performance.

Together with the study we reported on last week, this is promising. It seems that the perception of women in surgery as less competent is changing not only in the general public, but also in the eyes of those women who are involved in surgery themselves.

Stereoypes, They Are a-Changin’

While women are generally seen as more warm and caring, men are perceived to be more competent. Unfortunately, these stereotypes are especially pronounced in male dominated fields such as surgery. However, a study by Kamyar Noori and Allyson Weseley gives hope that these stereotypes are slowly changing.

In their experimental study they presented men and women with the profile of either a male or a female physician who was either a surgeon (and thus a member of a male dominated field) or a dermatologist (a member of a female dominated field) and then asked them about their perceptions of warmth, competence and willingness to see the physician. Surprisingly, neither specialty nor gender influenced the perception of competence. Women, even those in a male dominated field, were perceived as just as competent as their male counterparts. Interestingly, the stereotypes around how caring the physicians were perceived to be depended on who was asked: While men rated female physicians as more caring regardless of specialty, women tended to rate those in counter-stereotypical fields (i.e. the female surgeon and the male dermatologist) as more caring.

Overall, this study gives hope that gender stereotypes in medicine may indeed be changing. Go humanity!

The Rejection of Successful Women as Role Models

Women in fields in which they are under-represented often name the lack of female role models as a barrier in their careers. Yet, research often finds that the successful women who are available are often rejected. They are seen as pushy, overly masculine and cold and generally not as someone most women can identify with – even when no information indicating these traits is given. But why is that?

A study by Parks-Stamm and colleagues suggests that this might be a strategy to protect our beliefs about our own competence. In other words, if we saw a successful woman as highly competent and on top of that as nice and likable, this might undermine our own confidence. After all, how are we supposed to compete with that? The authors tested this idea by presenting men and women with information about a highly successful woman. In some cases, this woman was described as warm and likable, whereas in other cases no such information was given. Unsurprisingly, both men and women in the former condition described her as less pushy and cold than those in the latter condition. What was interesting, however, was that those women who had been told that the successful target was warm and nice, rated their own competence as lower compared to those who were able to penalise the potential role model.

So what does this mean? Should successful women be presented as unlikable and cold? Certainly not. It is, however, important, that they are described in ways that make them seem attainable. Evidence for this claim comes from a second study by the authors in which they show that the negative effect of preventing women from penalising the role model disappears when they are given positive information about their own future success.

Female Role Models in Surgery

When talking about areas in which women remain under-represented such as surgery the lack of female role models is a frequently mentioned key problem. More often than not the solution then seems to be to just present girls and women with a woman in a stereotypical male occupation. But is it really that simple? An interesting study by Laurie Rudman and Julie Phelan suggests that it is not.

The authors presented biographies of men and women in either stereotypical or counter-stereotypical professions to female students. So while one group read about a female nurse and a male surgeon, the other group read about a male nurse and a female surgeon. A control group read about animals. Contrary to what might have been expected, the women who had read about stereotypical men and women as well as those who had read about counter-stereotypical men and women both showed less interest in “masculine” professions compared to the control group. It is easy to see why this happened in the group that read about stereotypical men and women: Their gender stereotypes were activated and reinforced. But what about the other group? After all the students in the counter-stereotypical group had just read about women who could succeed in surgery! The authors’ explain this finding by something called upward comparison threat. This effect refers to the fact that when comparing oneself to someone more successful, rather than feeling inspired, one often feels threatened as the success seems unattainable. In other words, rather than thinking “She can do it, so I can probably do it as well”, female students may have thought something along the lines of “Wow, she is so successful. I don’t think I could ever be like her”. This in turn lead to them perceiving themselves as even less fit for atypical professions then before exposure to these “role models”.

So does this mean that female role models are useless at best or even detrimental? By no means. It simply shows that the way in which role models can benefit women in surgery and other stereotypical masculine professions is not as simple and straightforward as one might think. It is not enough to just throw a successful female surgeon out there and hope for the best. It is important that other women can relate to her, feel that her success is attainable and thus get inspired to follow her footsteps.