100% of Female Resident Physicians Report Gender-based Discrimination by Patients

Gender-based discrimination (GBD) in medicine is usually thought of as unequal pay, unequal representation in leadership and slower career advancement for women, all of which have been established in multiple studies. However, research has also demonstrated that for resident physicians, patients are the most frequent source of GBD.

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Anna Alaska Pendleton, MD, surgical resident at Massachusetts General Hospital, Cristina R. Ferrone, MD, surgical director of the Liver Surgery Program in the Division of General Surgery and gastroenterological surgeon in the Mass General Cancer Center, and colleagues recently conducted the first quantitative analysis of patient-derived GBD against residents. They found it is experienced by the majority of both male and female residents, but most forms are significantly more common for women, who also have more severe consequences. The findings are detailed in The American Journal of Surgery.

Study Methods

The research team devised a 40-item online survey and presented it to 25 residency program directors at three academic medical centers in the Boston area. A total of 12 program directors, representing 11 specialties, gave permission for their residents to receive the survey. Between April and August 2019, the confidential survey was sent to all 645 current resident physicians within these programs via a secure web platform.

Survey Responses

The overall response rate was 48% (n=309) and women represented 55% of respondents. There were no significant differences between male and female respondents in age, race, ethnicity, post-graduate year or type of specialty (medical vs. surgical).

Respondents reported the following with regard to the prevalence of GBD in their experience:

• Approximately 86% of respondents reported having experienced patient-derived GBD (hereafter, GBD) during their residency
• 100% of women reported GBD vs. 69% of men (P<0.001)
• The higher prevalence of GBD experienced by female residents persisted across resident age, race, institution, postgraduate year and type of specialty
• On a 0–10 scale (0=none; 10=very frequent) the average frequency of GBD was 6.4 for women vs. 1.6 for men (P<0.001)

Numerous forms of GBD were experienced significantly more frequently by women than men (P<0.001 for all comparisons):

• Being mistaken for a nurse (98% of women vs. 27% of men)
• Referred to by term of endearment (e.g., "honey" or "sweetie", 90% vs. 60%)
• Referred to by first name (89% vs. 60%)
• Negative or inappropriate remarks from a patient that were specific to the physician's gender (75% vs. 27%)
• Being mistaken for a non-physician or non-nurse employee (e.g., housekeeping, food service, physical therapist) (71% vs. 31%)
• Asked to perform non-medical tasks such as bring food tray (93% vs. 73%)
• Encountering mistrust due to physician's gender (71% vs. 30%)
• Receiving hugs or other inappropriate physical contact (58% vs. 26%)

The only form of GBD more common for men than women was having a patient request a physician of another gender (39% vs. 20%; P=0.01).

Where reporting GBD was concerned:

• The majority (97%) of residents who experienced or witnessed GBD did not formally report the incident, with no difference between men and women
• Of the 10 residents who formally reported GBD, only one said something was done as a result
• Among the residents who did not report GBD, the most commonly cited reasons were "I didn't think anything would happen as a result of the report" (68%), "I was too busy" (52%), and "I didn't know how" (43%)
• "Fear of negative personal or professional consequences" was cited as a reason for not reporting by 21% of women vs. 11% of men (P=0.047)

Finally, respondents shared the impacts of GBD in their experience:

• 42% of women vs. 23% of men said GBD had affected the quality of their care (P=0.02)
• 33% of women vs. 16% of men said GBD had affected their sense of personal safety (P=0.04)
• Women were also significantly more likely than men to say GBD had affected their risk of burnout (70% vs. 20%), personal well-being (63% vs. 12%), self-doubt (60% vs. 14%) or job satisfaction (58% vs. 18%) (P<0.001 for all comparisons)

Toward Evidence-based Interventions

A growing body of literature supports the serious individual and system-wide costs of GBD. Providing a safe working and learning environment for medical trainees aligns with the primary goal of providing optimal patient care, and health care institutions should make it a priority to address GBD.

A treatment agreement or "code of conduct" shared with patients at hospital admission may help lay the groundwork for mutual respect. Possible responses to outright harassment and abuse by a patient include having interactions with medical personnel chaperoned by a second staff member and putting a warning in the patient's chart.

All three centers involved in this study have robust mechanisms for reporting GBD, including sexual harassment officers, confidential phone lines and employee assistance/relations programs. However, as the survey results show, many physicians in training don't believe appropriate, confidential action will be taken if they file reports. A cultural shift at the institutional level is necessary to help resident physicians feel safe about reporting.

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