ELAINE ZHOU, MD
In medical school, a classmate once shared with me his surprise that many patients addressed him as “doctor,” not realizing that he was a medical student. He remarked that it made him uncomfortable that patients reflexively elevated him to that role despite his limited medical knowledge. He was a tall, White man with a beard and glasses.
As an Asian woman who is 5 feet 2.5 inches tall, I never had that experience as a medical student. On the contrary, even now as a senior resident, I have found myself having to reaffirm my role as physician in numerous patient interactions.
THE CHALLENGE OF BUILDING PATIENT TRUST
Patients still ask me every single day when I introduce myself, “Are you really the doctor?” Many of them address the male medical student in the room as the doctor. Other patients end visits by thanking me as “the lady” or “the nurse,” even though I introduced myself as a physician.
Patients often have expectations about what a doctor should look like. For new physicians, not fitting into those expectations can be an early roadblock to building a trusting therapeutic relationship with patients. During my medical training, I have learned how to navigate the awkwardness of reminding patients of my position. I have practiced speaking, sitting, and conducting myself in ways that emphasize my expertise in order to reassure patients that I am qualified to manage their care.
Engendering patients’ trust is a skill that every doctor—regardless of sex, race, and stature—must develop. Building trust is more difficult, however, when people have preconceived ideas of what your role should be based on your appearance or demographics. When a nurse, administrator, or fellow doctor addresses me as “Doctor” in front of a patient, it sends a powerful message that reinforces my role and increases my patient’s confidence in me. On the other hand, when a colleague omits my professional title, this confidence may be blunted.
These dynamics often play out in other professional spheres. Academic meetings can be high-stress environments where speakers attempt to persuade, teach, and influence their audiences. Using or omitting professional titles such as “Doctor” can have a powerful effect on the listeners’ unconscious bias. At my residency, there is an equal number of male and female faculty and many females are in leadership positions, including both the VA and BT chiefs of staff and the associate residency director. Interestingly, I have noticed that, even during grand rounds, female attendings are at times addressed by their first names, whereas male attendings are addressed by their formal professional titles, which shows how subtle and subconscious this can be.
PART OF A LARGER PROBLEM
The use of professional titles is a small, subtle component of gender inequity in medicine. More obvious contributors to this problems include compensation disparities between male and female physicians, a deficit of women in leadership positions, and an unequal division of child care and domestic responsibilities between men and women.1 Numerous studies, however, show that both men and women hold implicit and explicit biases against women in leadership positions.2 The seemingly small act of stripping a female physician of her professional title undermines her qualifications and authority in her professional role and perpetuates these implicit biases. It also promotes imposter syndrome among women—feelings of inadequacy and fraudulence despite concrete measures of success and ability. Imposter syndrome has been shown to affect women disproportionately and can lead to higher rates of burnout.3
I do not actively recognize these problems on a day-to-day basis or feel overtly burdened by my gender. In my department, women are equally represented, and there are many brilliant female doctors in leadership positions. On reflection, however, I realized that I approach my clinical practice and academic career differently because of my gender. Perhaps to some people, the omission of a professional title does not seem like a big deal. However, when there are already subtle biases that women have to actively combat, it’s one more thing that takes energy and authority away from female physicians who are working to advance their careers and to care for patients.
1. Butkus R, Serchen J, Moyer DV, Bornstein SS, Hingle ST. 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. https://doi.org/10.7326/m17-3438
2. Hansen M, Schoonover A, Skarica B, et al. Implicit gender bias among US resident physicians. BMC Med Educ. 2019;19:396. https://doi.org/10.1186/s12909-019-1818-1
3. Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout among American medical students: a pilot study. Int J Med Educ. 2016;7:364-369. https://doi.org/10.5116/ijme.5801.eac4
JIWEI SHENG, MD
When a faculty member approached my residency class about penning an article addressing gender inequity in ophthalmology, specifically the selective use (or omission) of titles for female physicians, my first reaction was, “This is still happening?” I have frequently seen female physicians and medical students mistakenly identified as nurses and ancillary staff, but I had not noticed that women were also less likely to be addressed as “Doctor” by their colleagues in the workplace. To readers who rolled their eyes, I apologize sincerely for my ignorance and contribution to the problem.
A great deal of attention has been paid to this particular disparity between male and female physicians in the past several years. A frequently referenced study from 2017 showed male physicians introducing other male colleagues by their doctoral title 72.4% of the time compared with 49.2% of the time for their female colleagues (P = .0016) during internal medicine grand rounds. On the other hand, female introducers addressed both male and female colleagues by their formal titles more than 95% of the time.1 Numerous stories of US female physicians facing this same issue at their respective institutions have been published; they are disproportionately introduced by their first names, whereas their male colleagues are called “Dr. [last name].”2-4
DESPITE PROGRESS, THERE’S STILL WORK TO DO
Female physicians are an established and ever-rising influence in academic ophthalmology. Past AAO President and current CEO Dr. David W. Parke II authored a statistical report showing the growth of female ophthalmologists in leadership positions.5 Except for chairman, women hold executive titles in major specialty societies and make up 50% of the Academy’s council leadership positions. Currently, there is an equal ratio of female to male ophthalmology residents. The numbers paint an optimistic picture, but leadership numbers do not necessarily correlate with other areas. As Dr. Parke pointed out, “Work still needs to be done in some areas to fully neutralize the inappropriate impact of gender on promotion, recognition, and compensation.”
In my program, two of five fellowship directors and the residency associate program director are women. The chief of services at both the county and VA hospitals are women, and there are roughly equal numbers of male and female faculty. Reflecting on my past 2 years in training, I appreciate that our senior faculty frequently chose to address everyone, including themselves, by first name. I believe this practice helped to alleviate the rigidity of hierarchy in medicine and to promote the inclusion of residents as colleagues. I cannot recall any predilections in seating among the attending faculty at grand rounds or inclinations to introduce colleagues differently by gender, but maybe I was too busy figuring out how not to look incompetent in front of everyone to notice.
Naturally, I was surprised when a highly accomplished faculty mentor brought this topic to our attention and shared some of her recent experiences. One such interaction was over a business email chain, where an administrator conspicuously referred to her by first name while concurrently addressing two male attendings as “Doctor.” When she privately and politely asked this administrator to address her equally in the professional setting, the response was regrettably accusatory and unapologetic. This administrator was not a physician. This administrator was also a woman
In this era of increasing racial and political tensions, we must stay vigilant. Progress toward a nondiscriminatory, merit-based system in medicine must continue. I ask that we continue to promote awareness of gender inequities and recognize that an issue as subtle as the use of professional titles has deeper and broader implications. The problem extends beyond doctor to doctor, patient to doctor, or even male to female. There is a tendency to downplay or challenge female physicians who advocate for equal recognition. The key, I believe, is for men to take equal part in striking down inconsistencies and lead by example to normalize gender equality. Being a silent supporter is not enough. There is so much power in advocating for change when you stand on the other side.
1. Files JA, Mayer AP, Ko MG, et al. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. J Womens Health (Larchmt). 2017;26(5):413-419.
2. Neumann J. Why are female doctors introduced by first name while men are called ‘Doctor’? The Washington Post. June 24, 2017. www.washingtonpost.com/national/health-science/why-are-female-doctors-introduced-by-first-name-while-men-are-called-doctor/2017/06/23/b790ddf2-4572-11e7-a196-a1bb629f64cb_story.html. Accessed April 26, 2021.
3. Ro C. Why we use women’s professional titles less than men’s. BBC. February 24, 2021. https://www.bbc.com/worklife/article/20210216-why-do-professional-titles-actually-matter. Accessed April 26, 2021.
4. Friedrich P. What’s in a title? When it comes to ‘Doctor,’ more than you might think. The Conversation. December 5, 2019. https://theconversation.com/whats-in-a-title-when-it-comes-to-doctor-more-than-you-might-think-127979. Accessed April 26, 2021.
5. Parke DW. Gender and leadership. EyeNet Magazine. June 2017. https://www.aao.org/eyenet/article/gender-and-leadership. Accessed April 26, 2021.