Don’t Call Me Lucky: on female physicians’ experiences of gender bias from patients

author’s note: updated and edited 10/26/18 from the original version, “Don’t Call Me Lucky,” initially published on Doximity’s Op-(m)ed on 10/18/18.

I recently came across an eye-opening passage on gender bias by the author Chimamanda Ngozi Adichie. The excerpt from her book is as follows:

Theresa May is the British prime minister and here is how a progressive British newspaper described her husband: “Philip May is known in politics as a man who has taken a back seat and allowed his wife, Theresa, to shine.”

Allowed.

Now let us reverse it. Theresa May has allowed her husband to shine. Does it make sense? If Philip May were prime minister, perhaps we might hear that his wife had “supported” him from the background, or that she was “behind” him, or that she’d “stood by his side,” but we would never hear that she had “allowed” him to shine.¹

This struck home, as I experience something similar in the exam room on a near daily basis. Patients, and/or their family members, tell me how lucky I am that my husband is home with the kids while I am at work.

But imagine, like the above example with the prime minister, if we reversed the conversation. For a male physician whose wife is the stay-at-home parent, it might go something like this:

Patient: Doctor, do you have a family, children?

Doctor : Yes, I do. Three children.

Patient (shocked): Three children! Doctor, how do you do it all?

Doctor: Well, not all by myself of course. My wife has suspended her career to be the stay-at-home-parent in our family.

Patient: (incredulous) Your wife stays home with the kids? You’re so lucky she’s willing to do that, and let you work!

I highly doubt this conversation has ever happened to any male physician in practice anywhere.

But I grin and bear it every day.

I should consider myself so lucky, for my husband allowing me to work.

Adichie further writes:

“Allow” is a troubling word. “Allow” is about power. … But here is a sad truth: Our world is full of men and women who do not like powerful women. We have been so conditioned to think of power as male that a powerful woman is an aberration…We ask of powerful women: Is she humble? Does she smile? Is she grateful enough? Does she have a domestic side? Questions we do not ask of powerful men, which shows that our discomfort is not with power itself, but with women.²

And, indeed, it has been the rare patient who has not shown some level of discomfort when they hear of the “reversed” roles of me and my husband.

In order to relieve the tension in the room, I often make some sort of little self-effacing joke. To show my “domestic side.” It is only then that the discomfort dissipates. I have a better understanding from Adichie now of why this is.

My patients see me as an aberration, and I have to show them that I have a humble, domestic side. To reassure them that I am not.

But why? I shouldn’t have to describe myself as “lucky” that my husband has an equal-minded attitude as to roles and responsibilities with the kids and the home. Any more than a male physician would say it about his wife.

It is the fault of society, not mine, that in the case of a physician-parent with a stay-at-home spouse, a woman is called “lucky,” while for a man, it’s taken for granted as the status quo.

So I’ve decided for myself, to try to not allow patients to get away with these comments. To try to not feel an obligation to show a humble, domestic side, in order to relieve their discomfort about my being a woman in a powerful role. Perhaps some of them are elderly. Perhaps some of them are of a different culture or generation. But that doesn’t excuse gender bias, any more than it would any other form of bias.

To female physicians, these kinds of comments from patients and their families, overt or disguised, constitute gender bias. And gender bias is a form of sexual harassment.

Dr. Esther Choo and colleagues recently published in NEJM a powerful piece on the need to end sexual harassment in medicine — Time’s Up for Medicine? Only Time Will Tell.

They highlight the recent National Academies of Science, Engineering, and Medicine (NASEM) consensus report, which showed that, “sexual harassment is common across scientific fields, has not abated, and remains a particular problem in medicine, where potential sources of harassment include not just colleagues and supervisors, but also patients and their families.” (emphasis added).

Dr. Choo has also brought national attention to patient prejudice and bigotry in the Emergency Room, in a tweet that received widespread attention in 2017.

For me, it has been eighteen years since I graduated from medical school. I had hoped, and believed, that things had improved for the next generation. But the NASEM report shows that nothing has changed.

As I read, wrote and researched this piece, a tide of memories from my training and early career years surged. Here are just a few:

• The time as an internal medicine resident. When the family member of an unconscious patient wouldn’t get off the phone to answer my questions. He stared me in the eyes, the phone to his ear, and continued his phone conversation as if I didn’t exist. Deaf to my explanations that I was the doctor, the senior resident on the team. Until I, humiliated, had to let the male intern take over the questioning. Lucky for that patient and his family I was there to supervise the intern perform the LP (lumbar puncture, aka spinal tap).
• The innumerable times that, even after introducing myself by my doctor title, patients and family members referred to me as the nurse, social worker, fill-in-the-blank-with-a-non-physician role…. And the innumerable times I was told that I didn’t “look like” a doctor. As if that made their comments okay…
• The time in my first year of practice, when I entered the exam room to have an older male patient scold me as if I were a child. Scowling and tapping his watch, his voice raised to a threatening tone, “Where have you been, young lady?”
• The time I was stalked by two men, “friends” of a patient, during a late-night ER shift as a 4th-year medical student on an away rotation. So that I had to ask for security to escort me to my housing at the end of my shift. The sleepless night of staring at the flimsy locks on the windows in the student housing.
• Another episode as a 4th-year medical student, physically cornered by a patient in a deserted hallway. The visceral memory of his fist out of nowhere pressed into my side, just above my right kidney. Trapped against the wall, hateful words whispered in my ear. Then the double trauma of the embarrassed looks of the residents and attending physician when I fled to the team (comprised of men and women) for help. Being made to feel silly and weak. Like I was exaggerating what happened. “Don’t worry, he’s being discharged tomorrow.” As if that solved the problem.

I realize now this was an inexcusable inappropriate response by my superiors. But at the time I didn’t take any further action.

Why would I? When the message I received loud and clear from my team was that this wasn’t something one complained about. If one was a female student. As if, it was somehow my fault it happened at all.

All these years later, I was validated to read in the companion perspective article in NEJM, Ending Sexual Harassment in Academic Medicine, by Drs. Dzau and Johnson, the following:

Adding to the power differential is a culture that accepts some degree of suffering as a matter of course. Medical education and training is notoriously grueling and competitive, with long hours, extensive workloads, and unrelenting pressure to perform. Often, human lives are on the line. It’s hard to find the time to sleep or eat, let alone file a harassment complaint… In a profession that often eschews any perception of weakness or vulnerability, women don’t want the negative attention a complaint will bring. (emphasis added)

My examples may seem so disparate that one has nothing to do with the other. But I would argue the opposite, they are all related. The minimization by my supervisors of the trauma of my experience as a student at the hands of that patient exists in a continuum with the dismissals female physicians make on a daily basis of the belittling and marginalizing comments made by patients and families in the exam room.

Is one potentially more harmful than the other? No doubt, physically, yes. But as Dr. Choo and her colleagues wrote:

“… sexual harassment encompasses an array of verbal and nonverbal behaviors that ‘convey hostility, objectification, exclusion, or second-class status about members of one gender.’ Since all forms of harassment have negative effects on women’s careers and on their physical and psychological health, there is no clear rationale for ignoring the full range of behavior that falls under this umbrella. Failure to take into account the vast majority of incidents of sexual harassment compromises our response to the problem.” (emphasis added)

In another insightful perspective from earlier this year, JAMA Internal Medicine March 2018, the editor’s note sums it up well: “The impact of a cascade of small injustices that women physicians deal with every day undermines our daily work and collectively sends a demeaning message about our worth in the workplace.”

Drs. Dzau and Johnson write that they “…are calling on our fellow leaders in academic medicine to commit to a systemwide change in culture and climate aimed at stopping sexual harassment before it occurs.”

But I think those of us in practice can evoke a culture change as well. For those of us in clinical practice, let’s all, women and men, commit to zero tolerance for gender bias from our patients. There’s no such thing as an ‘innocent’ comment when it comes to gender bias.

Because we, together, can be powerful. We don’t have to diminish who we are.

References:

1. Chimamanda Ngozi Adichie. Dear Ijeawele, or A Feminist Manifesto in Fifteen Suggestions. Alfred A. Knopf. New York and Toronto, 2017. Page 21.
2. Chimamanda Ngozie Adichie. Dear Ijeawele, or A Feminist Manifesto in Fifteen Suggestions. Alfred A. Knopf. New York and Toronto, 2017 Pages 22, 24.

Are you a physician that has a story of harassment and gender bias from a patient or their family? Let’s start a conversation. Please comment.

Originally published at The Hopeful Cancer Doc.