“I'm too used to it”: A longitudinal qualitative study of third year female medical students' experiences of gendered encounters in medical education

Abstract

Although the number of women entering medical school has been steadily rising in the USA, female medical students continue to report instances of sexual harassment and gender discrimination. The full spectrum of such experiences and their effect on the professional identity formation of female students over time remains largely unknown. To investigate these experiences, we interviewed 12 third year female medical students at a private New England medical school over several points during the 2006–2007 academic year. Using theoretical frameworks of gender performance and the centrality of student–patient and student–supervisor relationships, we were better able to understand how female medical students interpret the role of ‘woman doctor’ and the effect of negative and positive gendered interactions on the evolution of their professional identity. We found that participants quickly learned how to confront and respond to inappropriate behavior from male patients and found interactions with female patients and supervisors particularly rewarding. However, they did not feel equipped to respond to the unprofessional behavior of male supervisors, resulting in feelings of guilt and resignation over time that such events would be a part of their professional identity. The rapid acculturation to unprofessional behavior and resignation described by participants has implications for not only professional identity formation of female students but specialty choices and issues of future physician workforce.

Introduction

The number of women in medicine has risen steadily over the past three decades, with females now comprising almost 50% of all American medical school matriculates (Barzansky & Etzel, 2008). Despite this relatively rapid rise in the number of women within this once all-male profession, studies have shown that female medical students in the U.S. continue to experience high rates of gender discrimination (Nora et al., 2002; Stratton, McLaughlin, Witte, Fosson, & Nora, 2005; Wear, Aultman, & Borges, 2007). More recent work has attempted to clarify how male and female students differentially view their own professional identity formation as physicians (Blanch, Hall, Roter, & Frankel, 2008; Gude et al., 2005). However, little work has been done to localize the professional identity formation of female students within the larger framework of a largely masculine medical hierarchy and constantly evolving professional relationships. We therefore utilize a dual theoretical framework of gender performance and the centrality of relationships to analyze the longitudinal gendered experiences of third year female medical students and their effect on professional identity formation.

Early sociological work such as Becker's “Boys in White” provides a useful starting point for understanding the process of American medical socialization. As Becker pointed out that “science and skill do not make a physician; one must also be initiated into the status of physician; to be accepted, one must have learned to play the part of a physician in the drama of medicine” (Becker, Geer, Hughes, & Strauss, 1961, p.4). Numerous studies have described the socialization process that occurs during medical training as students learn how to be “initiated” into their profession (Beagan, 2000; Becker et al., 1961; Shapiro, 1987), conforming to the dominant culture and becoming more homogenized over time (Shapiro, 1987). The transition from pre-clinical to clinical years of medical training is an important period in the socialization process (Beagan, 2000) and largely signifies the beginning of professional identity formation for physician trainees. In this new learning environment, a complex series of clinical encounters with peers, patients and supervisors, medical students first experience the “hidden” and “informal curriculum” (Hafferty & Franks, 1994), which has a substantial and profound effect on medical education (Karnieli-Miller, Vu, Holtman, Clyman, & Inui, 2010). It is during this time that students subtly learn “what medicine values,” (Delvecchio Good, 1998, chap. 6 & 7; Karnieli-Miller et al., 2010). The clinical years of medical education are almost entirely based upon hierarchical team dynamics and interpersonal relationships that can either enhance or impair learning (Conrad, 1988; Daugherty, Baldwin, & Rowley, 1998; Dyrbye et al., 2009; Richman, Flaherty, Rospenda, & Christensen, 1992). Unlike other professions, both male and female medical students in the U.S. routinely report experiences of harassment and belittlement (Richman et al., 1992; Sheehan, Sheehan, White, Leibowitz, & Baldwin, 1990), and complacency is seen as a crucial component of both learning and professional advancement (Wear & Aultman, 2005).

Much of the earlier work on medical socialization, however, largely ignores gender and “talk[s] mainly of boys becoming medical men” (Becker et al., 1961, p.3), reflecting an outdated white male demographic of medical students. More recent work has shown that women report greater levels of abuse than men, and that for both genders, experiences of mistreatment and harassment have been shown to have profound implications on student well-being and learning (Dyrbye, Thomas, & Shanafelt, 2006; Richman et al., 1992). Yet, mistreatment and harassment are only a small fraction of the types of gendered experiences that female medical students encounter during their clinical training (Babaria, Abedin, & Nunez-Smith, 2009) and little is known about the process of socialization in medical school as it occurs for female medical students. Beagen's study of Canadian medical students and the effect of gender, class and race on their experiences is one of the few that touches upon how female students are socialized, describing how students adopt the prevailing [male] culture and learn to neutralize their gender in mannerisms, behavior and dress (Beagan, 2000).

Prior work focusing specifically on gender and professional identity has been centered around differential attributes between male and female students. Multiple studies have documented that although female students tend to perform equally to their male peers on objective assessments of their clinical skills, they consistently report less confidence in their abilities and significant anxiety over their performance (Blanch et al., 2008; Kilminster, Downes, Gough, Murdoch-Eaton, & Roberts, 2007; Whittle & Eaton, 2001). Similarly, male medical students are more likely than female students to feel like they are “doctors” by the end of medical school (Gude et al., 2005). Interestingly, in some studies, although male and female students enter medical school with similar levels of stress and anxiety, females report increased anxiety about their skills compared with males by the third year, suggesting the milieu of medical education may be differentially affecting confidence levels (Blanch et al., 2008). These gender differences are often perpetuated by external bias, with female students being rated consistently as ‘less confident’ than their male peers (Kilminster et al., 2007) and or referred to as “nurses” rather than “doctors” by other staff and patients (Houry, Shockley, & Markovchick, 2000).

Other scholars have examined gender differences in professional identity formation by examining what attributes are valued within medical culture. As one historian of women in medicine states, “Indeed a central theme in the story of women in medicine has been the tension between ‘femininity,’ ‘feminism’ and ‘morality,’ on the one hand; and ‘masculinity,’ ‘professionalism,’ and ‘science,’ on the other” (Morantz-Sanchez, 2000, p. 200). Hinze's 1999 sociological study of the gendered hierarchy of medical specialties exemplifies the complex gender performance that underlies individual attributes of ‘confidence’ or ‘toughness’ in medicine. Participants defined the most “prestigious” specialties, such as surgery, as having “hands-on” experiences and “balls,” (Hinze, 1999, p. 12). What becomes valued then, in terms of professional identity, is defined by male attributes and a male-defined system of behavior.

There is a gap between these two literatures, one on medical student socialization and the other on gender and professional identity, with neither addressing the question of how female medical students develop a professional identity that takes into account the gendered aspects of medical culture. We set out to understand how these problems of gender and professional identity manifest themselves and are addressed by female students during the third year of medical school. Our analysis is organized around two main concerns. The first, borrowed from gender theory, is the idea of gender performance. As Judith Butler describes, “what is called gender identity is a performative accomplishment compelled by social sanction and taboo,” (Butler, 1988, p. 520). We contend that professional identity, like gender identity, is being constantly made and re-made. As third year medical students get drawn into the culture of medicine, they learn how to perform the role of doctor; for female medical students, this learning process includes learning how to perform or enact the role of ‘woman doctor,’ (Butler, 1988). We posit that “woman doctor” is not a fixed construct, but a dynamic identity that represents female students' reconciliation of their identities as females and physicians-to-be. This identity is constantly evolving based upon student experiences, but is informed by institutional culture and stereotypical gender roles.

Our second analytic mainstay is the centrality of relationships to the formation of professional identity in medicine, notably the student–patient and student–supervisor relationships. As Haidet et al. have concluded, “Students proceed through medical school embedded in complex webs of relationships that exert a powerful influence (both positive and negative) on their formation as physicians,” (Haidet et al., 2008, p. 382) and it is likely these relationships that enact much of the hidden curriculum that has been previously described (Hafferty & Franks, 1994). Through our participants' accounts of these relationships, we are able to see in which contexts they develop a coherent identity and at what points their attempts at becoming female physicians falter. Issues of power become central in the analysis of these relationships. The student–patient and student–supervisor relationship exhibit parallel power differentials (Ekstein & Wallerstein, 1958), such that the student's power in the student–patient relationship parallels the supervisor's power in the student–supervisor relationship. Position in the hierarchy and the associated power over those lower in the hierarchy shape the educational experience and the associated process of identity formation. Utilizing theories of the performance of gender and the centrality of relationships, we sought to characterize how gender effected the professional identity formation of third year female medical students.