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A young woman in medicine:Facing challenges of patient-level bias

“Does your Mommy know you’re here?” asks the patient as he enters my clinic. The 76-year-old man has put me in an impossible situation. He may or may not know my age, but he knows full well that he’s put the young woman in her place, leaving little room for us to graciously acknowledge our differences or his surprise at seeing a young woman in charge. He sidesteps me and sits down in the chair I offer, saying nothing more in the silence that follows. For the record, my mother is indeed aware that I am there. Admittedly, my efforts to become an academic gastroenterologist also have bewildered her alongside my other life choices: to obtain more than a bachelor’s degree, to marry only in my 30s, to delay having children. Although matriculation rates in medical schools have been higher for women than men for the past two years, and young female doctors populate training programs and junior faculty positions across the country, patients are still getting used to us.1 There has been increasing attention focused on the systematic ways women face discrimination within medical institutions and from peers, but we have so far paid relatively little attention to the experience of female physicians upsetting the expectations of our patients.2 Studies have consistently suggested that female physicians lower mortality rates for patients in areas from myocardial infarction to elderly care.3,4 In addition to closer adherence to evidence- based guidelines and higher standardized test scores, the authors of one these studies partially attributed this difference to female internists offering “more patient-centered care.”4 Women are supposed to be more emotionally skilled and more inclined to communicate with and connect with their patients. What is not discussed, however, is the difficulty that gender bias on the part of our patients adds to our everyday practice. I suspect that my experiences are not rare. We may do better for patients, and are certainly just as skilled as our male counterparts, but it doesn’t feel that way when we walk into a room. During a recent week on call as an attending gastroenterologist, I noted that seven days out of seven, someone – usually a patient or family member – commented directly to me on how young I looked. Not all took the form of inquiring about my parents, but remarks along these lines were uttered multiples times every day. One patient, after his colonoscopy and a conversation in which I delivered a diagnosis of colon cancer, told me that he “felt comfortable with me [telling him this news], even though I was so young.” The crow’s feet at the corner of my eyes and the fatigue in my face during a week on call do not enhance my youthfulness, of this I am sure. Neither does the fact that I have spent nearly a decade in specialty training after medical school. I suspect instead that seeing a young woman in my position is somewhat disconcerting. The septuagenarian mother of another patient put it best when she exclaimed, “Why, if I saw you on the street, I’d never believe you were a doctor!” Historians and sociologists of medicine have noted for decades how reforms in medicine also have changed the nature of the doctor-patient relationship, but as a profession we haven’t sufficiently discussed the jarring questioning of female authority, in part because it’s largely invisible. When male colleagues join me in an examination room with a patient, the comments aren’t made. Nevertheless, over the next decades we will face a profound change as the profession becomes increasingly more diverse, even as our patients will, in some cases, have had decades of experience without regular contact with female physicians. Medical schools and training programs will need to find ways to address this reality directly, because it affects nearly every aspect of being a physician, from how we respond to questions about our competence to how we choose to physically present ourselves. In some regards, I have sympathy for my patients’ confusion: Female physicians have indeed become normalized in a relatively short time. Most of us don’t have mothers who also went into medicine, and the examples we have of pioneering female physicians are by presumption never about ordinary experiences. Female physician narratives almost universally highlight the great odds that women have overcome in order to enter the profession. Dr. Helen Brooke Taussig succeeded as a female cardiologist, becoming the first female president of the American Heart Association in addition to overcoming adult-onset hearing loss. Dr. Elizabeth Blackwell was rejected multiple times from medical schools and then ridiculed when she was admitted as a joke. Dr. Rebecca Lee Crumpler overcame racial discrimination as she became the first female African American to earn a medical degree. Despite these high-profile successes, change came slowly, and as recently as 1970, only 7.1 percent of physicians were female, and those were concentrated in pediatrics and psychiatry.5 Barriers are nowhere near this high for women to enter medicine in 2018: This reality represents the triumph of these earlier pioneers, for which I am incredibly grateful. It has never been a better time than now for women in medicine, but its normalcy presents precisely the conundrum. In 2018, it is not Dr. Taussig or Dr. Crumpler who walks into the room: Odds are that it is an ordinary physician who does. I count myself incredibly fortunate despite these challenges. The opportunity I have been given to take the Hippocratic Oath, to improve my patients’ health and well-being, is one I would trade for no other. But I am no Helen Brooke Taussig. And neither are my female colleagues. That’s not a problem. Equality will be achieved not when exceptional women succeed, but when ordinary women are treated no differently than ordinary men. At best, I am a highly qualified and dedicated physician, one who consciously strives each day to improve. For now, when a patient enters the room with that misguided question, I embrace the opportunity to challenge existing biases. I consider my options, and then I smile broadly and say, “Why yes, sir. Yes, she does.” And then we carry on.

References 1. Applicants and matriculants data, 2017. Washington, DC: Association of American Medical Colleges ( data/facts/applicantmatriculant/). 2. Rotenstein LS, Jena AB. Lost Taussigs – The Consequences of Gender Discrimination in Medicine. N Engl J Med 2018;378:2255-7. 3. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med 2017;177:206-13. 4. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A 2018;115:8569-74. 5. Kletke PR, Marder WD, Silberger AB. The growing proportion of female physicians: implications for US physician supply. Am J Public Health 1990;80:300-4.

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