Abstract

Background

Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities.

Objective

To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat.

Design

We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat.

Participants

The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September–November 2019. Focus groups were conducted at UCSF in Spring 2020.

Approach

The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources.

Key Results

Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women’s experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship.

Conclusions

Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women’s vulnerability to stereotype threat.

References

  1. Butkus R, Serchen J, Moyer DV, et al. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med. 2018;168(10):721-723.
  2. 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(2):206-213.
  3. Mehrotra A, Morris M, Gourevitch RA, et al. Physician characteristics associated with higher adenoma detection rate. Gastrointest Endosc. 2018;87(3):778-786.e5.
  4. Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ. 2017;359:j4366.
  5. Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. Experiencing the culture of academic medicine: gender matters, a national study. J Gen Intern Med. 2013;28(2):201-207.
  6. Fassiotto M, Hamel EO, Ku M, et al. Women in academic medicine: measuring stereotype threat among junior faculty. J Womens Health. 2016;25(3):292-298.
  7. Hu YY, Ellis RJ, Hewitt DB, et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med. 2019;381(18):1741-1752.
  8. Winkel AF, Telzak B, Shaw J, et al. The role of gender in careers in medicine: a systematic review and thematic synthesis of qualitative literature. J Gen Intern Med. 2021;36(8):2392-2399.
  9. Stead W, Manne-Goehler J, Blackshear L, et al. Wondering if I’d get there quicker if I was a man: factors contributing to delayed academic advancement of women in infectious diseases. Open Forum Infect Dis. 2023;10(1):ofac660.
  10. Iyer MS, Way DP, MacDowell DJ, Overholser BM, Spector ND, Jagsi R. Bullying in academic medicine: experiences of women physician leaders. Acad Med. 2023;98(2):255.
  11. Dandar VM, Lautenberger DM. Exploring Salary Equity Among Medical School Leadership. Washington, DC: Association of American Medical Colleges; 2022. https://store.aamc.org/leadership-compensation-equity-report-exploring-salary-equity-among-medical-school-leadership.html. Accessed October 26, 2023.
  12. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294.
  13. Barnes KL, McGuire L, Dunivan G, Sussman AL, McKee R. Gender bias experiences of female surgical trainees. J Surg Educ. 2019;76(6):e1-e14.
  14. Cochran A, Hauschild T, Elder WB, Neumayer LA, Brasel KJ, Crandall ML. Perceived gender-based barriers to careers in academic surgery. Am J Surg. 2013;206(2):263-268.
  15. ACGME Data Resource Book Academic Year 2021-2022. Chicago, IL: Accreditation Council for Graduate Medical Education; 2022. https://www.acgme.org/globalassets/pfassets/publicationsbooks/2021-2022_acgme__databook_document.pdf. Accessed October 26, 2023.
  16. Wheeler M, de Bourmont S, Paul-Emile K, et al. Physician and trainee experiences with patient bias. JAMA Intern Med. 2019;179(12):1678.
  17. Klein R, Julian KA, Synder ED, et al. From the Gender Equity in Medicine (GEM) workgroup. Gender bias in resident assessment in graduate medical education: review of the literature. J Gen Intern Med. 2019;34(5):712-719.
  18. Kolehmainen C, Brennan M, Filut A, Isaac C, Carnes M. Afraid of being “witchy with a ‘B’”: a qualitative study of how gender influences residents’ experiences leading cardiopulmonary resuscitation. Acad Med. 2014;89(9):1276-1281.
  19. Sharma M. Applying feminist theory to medical education. The Lancet. 2019;393(10171):570-578.
  20. Crenshaw K. On Intersectionality: Essential Writings. New York: The New Press; 2017.
  21. Spencer SJ, Steele CM, Quinn DM. Stereotype threat and women’s math performance. J Exp Soc Psychol. 1999;35(1):4-28.
  22. Burgess DJ, Joseph A, van Ryn M, Carnes M. Does stereotype threat affect women in academic medicine?. Acad Med. 2012;87(4):506-512.
  23. Creswell JW, Clark VL. Designing and Conducting Mixed Methods Research. Thousand Oaks (CA): Sage Publications; 2017.
  24. Bunniss S, Kelly DR. Research paradigms in medical education research. Med Educ. 2010;44(4):358-366.
  25. Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77-84.
  26. Bullock JL, Lockspeiser T, Del Pino-Jones A, Richards R, Teherani A, Hauer KE. They don’t see a lot of people my color: a mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships. Acad Med. 2020;95(11S):S58-S66.
  27. Spencer SJ. The Effect of Stereotype Vulnerability on Women’s Math Performance. [Doctoral thesis]. Ann Arbor (MI): University of Michigan; 1993.
  28. Morgan, DL. The Focus Group Guidebook. London: Sage Publications Limited; 1997.
  29. Santen SA, Yamazaki K, Holmboe ES, Yarris LM, Hamstra SJ. Comparison of male and female resident milestone assessments during emergency medicine residency training: a national study. Acad Med. 2020;95(2):263-268.
  30. Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Med Teach. 2020;42(8):846-854.
  31. Dedoose Version 9.0.62, cloud application for managing, analyzing, and presenting qualitative and mixed method research data (2022). Los Angeles (CA): SocioCultural Research Consultants, LLC www.dedoose.com.
  32. Nelson J. Using conceptual depth criteria: addressing the challenge of reaching saturation in qualitative research. Qual Res. 2017;17(5):554-570.
  33. Barry CA, Britten N, Barber N, Bradley C, Stevenson F. Using reflexivity to optimize teamwork in qualitative research. Qual Health Res. 1999;9(1):26-44.
  34. Schoonenboom J. Routledge Handbook for Advancing Integration in Mixed Methods Research. New York: Routledge; 2022. Chapter 4, Developing the Meta-Inference in Mixed Methods Research through Successive Integration of Claims. p. 55–70.
  35. Bartels C, Goetz S, Ward E, Carnes M. Internal medicine residents’ perceived ability to direct patient care: impact of gender and experience. J Womens Health. 2008;17(10):1615-1621.
  36. Mueller AS, Jenkins TM, Osborne M, Dayal A, O’Connor DM, Arora VM. Gender differences in attending physicians’ feedback to residents: a qualitative analysis. J Grad Med Educ. 2017;9(5):577-585.
  37. Dayal A, O’Connor DM, Qadri U, Arora VM. Comparison of male vs female resident milestone evaluations by faculty during emergency medicine residency training. JAMA Intern Med. 2017;177(5):651-657.
  38. Ju M, van Schaik SM. Effect of professional background and gender on residents’ perceptions of leadership: Acad Med. 2019;94:S42-S47.
  39. Pennington CR, Heim D, Levy AR, Larkin DT. Twenty years of stereotype threat research: a review of psychological mediators. Pavlova MA, ed. PloS one. 2016;11(1):e0146487.
  40. Gartner RE, Sterzing PR. Gender microaggressions as a gateway to sexual harassment and sexual assault: expanding the conceptualization of youth sexual violence. Affilia. 2016;31(4):491-503.
  41. de Bourmont SS, Burra A, Nouri SS, et al. Resident physician experiences with and responses to biased patients. JAMA Netw Open. 2020;3(11):e2021769.
  42. McIntyre RB, Paulson RM, Lord CG. Alleviating women’s mathematics stereotype threat through salience of group achievements. J Exp Soc Psychol. 2003;39(1):83-90.
  43. Marx DM, Ko SJ. Superstars “like” me: the effect of role model similarity on performance under threat. Eur J Soc Psychol. 2012;42(7):807-812.
  44. Marx DM, Roman JS. Female role models: protecting women’s math test performance. Pers Soc Psychol Bull. 2002;28(9):1183-1193.
  45. Carnes M, Devine PG, Manwell LB, et al. Effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial. Acad Med. 2015;90(2):221-230.
  46. Girod S, Fassiotto M, Grewal D, et al. Reducing implicit gender leadership bias in academic medicine with an educational intervention. Acad Med. 2016;91(8):1143-1150.
  47. Aronson J, Fried CB, Good C. Reducing the effects of stereotype threat on African American college students by shaping theories of intelligence. J Exp Soc Psychol. 2002;38(2):113-125.
  48. Blackwell LS, Trzesniewski KH, Dweck CS. Implicit theories of intelligence predict achievement across an adolescent transition: a longitudinal study and an intervention. Child Dev. 2007;78(1):246-263.
  49. Johns M, Schmader T, Martens A. Knowing is half the battle: teaching stereotype threat as a means of improving women’s math performance. Psychol Sci. 2005;16(3):175-179.
  50. Martens A, Johns M, Greenberg J, Schimel J. Combating stereotype threat: the effect of self-affirmation on women’s intellectual performance. J Exp Soc Psychol. 2006;42(2):236-243.
  51. Woodcock A, Hernandez PR, Estrada M, Schultz PW. The consequences of chronic stereotype threat: domain disidentification and abandonment. J Pers Soc Psychol. 2012;103(4):635-646.

Topic

JGIM

Author Descriptions

Department of Medicine, University of California, San Francisco, San Francisco, CA, USA

Annabel K. Frank MD, Rebecca A. Berman MD & Karen E. Hauer MD, PhD

School of Medicine, University of California, San Francisco, San Francisco, CA, USA

Jackie J. Lin MD & Patricia O’Sullivan EdD

Department of Medicine, MetroHealth Medical Center, Cleveland, OH, USA

Sophia Bellin Warren MD

Department of Medicine, University of Washington, Seattle, WA, USA

Justin L. Bullock MD

Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA

Lauren E. Malishchak MD & Maria A. Yialamas MD

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