MEdIC: The Case of the Woman in White – Expert and Community Response

By Teresa Chan, MD, MHPE November 09, 2013 0 comments

The Case of the Woman in White brought out passionate replies from the ALiEM community. While Brent Thoma (@Brent_Thoma) and I (@TChanMD) have hosted several passionate discussions on MEdIC cases, none of which have inspired such deep and thoughtful responses. Both male and female attendings, residents, medical students and even a patient weighed in.

Amy Walsh explains how and why this case was conceived:

Women in medicine face lower salaries and challenges in reaching leadership positions within our profession. However, it is not this that dominates the conversations among my female peers, but the day to day stereotypes and misconceptions. During residency, an attending expressed her frustrations about patients stating on her Press-Ganey evaluations that they had never seen a “doctor.” She cited this as a key reason she wore her white coat to work, while others in our department did not. The frustration of being mistaken for a nurse was a frequent topic of discussion over after shift beers. Peers were often frustrated when patients asked the male nurse for his treatment plan rather than addressing their questions to the female doctor. If female residents were not delicate with their frustration about being mistaken for a nurse, nursing staff often took offense. Several months ago, Nikita Joshi (@njoshi8) surveyed the twitterverse regarding their white-coat wearing habits. It sparked a conversation regarding authority, respect, and age and gender expectations that led to the creation of this case.

Amy Walsh, MD (@docamyewalsh)
Author of The Case of the Woman in White

This follow-up post includes

The responses of our medical education experts, Drs. Michelle Welsford (@WelsfordM) and Kirsten Weerdenburg (@KirstenYeh)
A summary of insights from the ALiEM community derived from the twitter discussion and comments
Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities

Expert Response 1: Avoiding the Professional Identity Crisis

Dr. Michelle Welsford, BSc MD ABEM FACEP CCPE FRCPC
Associate Professor, Division of Emergency Medicine, McMaster University

In light of the gender composition of most medical schools, this is a very relevant case. The increase in the number of women in medical school has been noted; they often comprise more than half of medical school classes.¹ Some international medical and nursing literature has recognized that this dramatic shift may be creating some issues around ‘professional role identity’.² Other literature has noted tensions between female medical trainees and other female health care providers due to shifting cultural norms.^1,2 I wonder if the young female doctor in this case is manifesting symptoms of this larger issue – in that there is a culture shift, and role identification is not as easy as “Man=Doctor; “Female=Nurse? Is young Jenny using the white coat as her way of forming her identity as a physician?

There is a balance and trade-off for all women physicians between wanting to be easily “recognized” as the physician by your patients and not wanting to make that a negative statement about being a nurse. I tend to find myself pretty far to the latter side. I don’t mind patients, and most people, confuse me with a nurse. I want them to recognize us as a team and am more interested that the patient gets good care and that everyone is respectful.

The only time I care to even correct that misconception is when:

A patient or family doesn’t think they have been seen by the doctor. Often with a smile, I’ll just clarify: “Oh, I am your doctor.”
Another physician (usually a resident) is in anyway rude about something they want from me when they think I am a nurse – “I’m the Emergency Medicine attending physician, how can I help you with that?” When that is answered with an apology, I know I have made my point: Don’t be rude to anyone.

Mostly, I just ignore the misunderstanding in that I respond to the person asking for a nurse and help them however I can. Sometimes, I may very gently correct the patient: “Sure, I’ll tell your nurse, I’m your doctor and we work together!” At times, I might even need to strategically remind fellow physicians “Sure, I think the nurse is really busy, but perhaps we can do this…”

I work mostly with nurses and embrace that and don’t care about the labels. During a resuscitation, when I am the team leader, it becomes clear to everyone that this is my job. At those points, my body language and presence ensure that all eyes are on me with clear communication between all team members. We have a culture of mutual respect which comes from our teamwork and shared interests in patient care. I don’t feel I need a white coat to earn that respect.

I think the looking young part is very common for both genders. Obviously, this will change with age! However, in this instance, the perceptions of patients about the identity of their doctor may very well be linked to the white coat.³ One study found that there may be a perceptual benefit to utilizing a white coat, especially in patients over 70 years of age who felt that the white coat helped them to identify their doctor.³ Although I know that the white coat can be perceived positively by patients, I prefer to create that positivity through a healthy working team – I don’t need a white coat for that.

Expert Response 2: Whither the White Coat

Dr. Kirstin Weerdenburg Yeh, MD FRCPC
Pediatric Emergency Point-of-Care Ultrasound Fellow, Hospital for Sick Children, Toronto

Since the 1970’s there have been increasing numbers of women in medicine, but research (and the MEdIC commentary this week) shows that gender issues still have a substantial impact on their medical education, post-graduate training and career.^1,4 Gender issues have many manifestations in medical education.

Women may struggle to define their role on the wards during clinical clerkship and see differences in: their relationships with members of the health care team (in particular nurses), patient-doctor communication, and their patients’ perceptions of them as a physician.^1,4,5 As a young woman and fresh graduate from fellowship in Pediatric Emergency Medicine, I get mistaken for a nurse quite often by patients, parents, residents and consultants. I have spoken to other female trainees and this tends to be the perceived norm. When I trained in the US for my pediatric residency I was required to wear a white coat. Now that I think about it, I was never mistaken for a nurse or other member of the allied health team at that time. Despite this, upon returning to Canada for my fellowship training where this is no longer a requirement, I still decided not wear a white coat (even for the increased number of pockets), because I find it heavy and cumbersome.

In preparation for this case response I did some field work while chatting with trusted nursing colleagues. It was riveting to learn that they were surprised about my mistaken identity! When I asked if they had any explanations about why patients (and their parents) were confused about my identity, each of them stated that they thought it was probably because I didn’t wear “normal” clothes or a white coat.

Could it really be possible that physician gender role assignment all comes down to our attire? Upon reflection, I think that our attire may partly affect patient and family perceptions of my role. But at the end of day, I know it doesn’t change my patient care, so I will continue to be white coat free. Over the years I have come up with my own way of dealing with these gender issues. Now that I am more senior, I like to share these tips with the women I teach:

Make it clear who you are and what your role is at the onset of the patient interaction. If they get it wrong, gently correct them by explaining again. If there is a patient/family communication white board in your patient’s room, write your name in the “doctor” space when you arrive.
If you are upset about being mistaken for a nurse or someone else, talk to someone about it. Consider joining the ‘Women in Medicine’ groups that many medical schools have to access other female physicians who could serve as mentors and advisors. A sympathetic ear or experienced advice is all we need sometimes. Reaching out to develop role models of the same gender may be helpful in dealing with gender-related issues.
Recognize that although nurses or other allied health professionals and physicians may have differing roles, there is still a great deal of overlap. We all work together as a health care team to provide superior health care.

Curated from the Community

A qualitative methodology was used to curate the community discussion. Tweets and blog comments were analyzed, and four overarching themes were extracted from the online discussions. Prior to publication, we sent this analysis to one of our community members to perform a ‘member check’ to ensure credibility. Thank-you to all of our discussion participants.

This week we hosted a great discussion about what happens when a doctor’s phenotype does not match with patient expectations. As some stated stereotypes are pervasive (LKD) and unlikely to be resolved soon (MJ). That said, we had over 40 substantive tweets and forty pages of comments (more than 8000 words!). The following is a collection of some of the key themes that emerged from the analysis.

1. The White Coat: To Wear or NOT to Wear – therein lies the question!

There was actually roughly equipoise in terms of endorsement for the White Coat. As Ken Milne (@TheSGEM) points out, the origins of the white coat come from an era where physicians were re-branding themselves as ‘scientists’. There was a non-linear debate with individuals on our blog comments or on Twitter stating their allegiance to the ‘White Coat’ or not.

The following are some Pros/Cons discussed:

Pros	Cons
Easily identifies you (KM, EK)	Acts as a fomite (carries ++ Germs) (AS)
Older patients expect this brand (EK)	Gets too hot (AS)
Gives you extra Pockets (KN)	Creates undesired hierarchy with the patients (AS)
Provides warmth	Puts a barrier between physician and patient (AS, AD)

Patient Perceptions: Like judging book covers vs. reading books

Increasing amounts of evidence suggest that if asked, patients prefer doctors in white coats.⁶ Of course, most of this evidence isn’t qualitative in nature, so we don’t know why this is the case. That said, our participants largely remarked that the way you conduct yourself (from the confidence you portray to the words you speak) probably can overcome the superficial judgements made purely on looks. (TC, SS, BT, MJ, ML)

This week we’ve had colleagues of all ages and size weigh in – and the trend seems to hold true – size (and age) matters not, but not as much as you carry and portray yourself. Many acknowledged having their position quest-ioned by patients due to their youthful appearances. (AS, BT, TC) Most acknowledged that they could not change this fact – and that they found ways to work around the issue by:

Using humor (TC, LM)
Portraying their competence (through explaining things) or confidence (TC, D)
Stating simple facts (e.g. ‘I’ve sutured many times before.’ Or ‘I’m the supervising attending physician’) (SS, ML, MJ)

Identity Matters

The general consensus of the group was that ensuring that patients know your role within the system is important. Nurses, RTs, OTs, Health Care Aides, Doctors – we all play different roles. Our participants felt strongly that ‘gently correcting’ and explaining our unique roles is important – and may inherently be a part of how to establish identity.

Mind the (Gender) Gap

This week’s case seemed to resonate with different audience members in different ways. Many seemed to think it is important to discuss this topic, but rarely done. Our guest case-author (Amy Walsh) stated: “…how to have that [conversation without] sounding whiny or shrill?”

Our community members remarked on the role of attending-led discussions on the topic and more open discussions between females and their coaches. Discussing the topic openly and acknowledging differences were deemed important by many – and empathetic male attendings were lauded for acknowledging the differences and support. One colleague even stated he might consider wearing a white coat as a show of support for the women who do too.

Ultimately, in our present culture, men and women are still socialized differently. And as such, there may be different needs. We must, however, as teachers consider the differences in training that occur for learners of both genders. Some participants questioned whether there was truly enough awareness that the gender gap still existed, or whether there was reluctance to acknowledge these differences still existed at all, or worse that the biases had become engrained and insidious (AW). Some unique training needs discussed:

Avoiding high vocal pitch during critical incidents (e.g. breaking bad news) (AW)
Fewer apologies (AW)
Establish authority (EC)
May have different relationships with other colleagues (LM)

General Tips for Identity Formation (With or Without a White Coat)

Identify yourself clearly: State your name, your role clearly – while the patient is listening. Wear your name tag visibly. Not introducing yourself can make you come off as ‘rude’ and undermine the doctor-patient relationship.
Do not get offended: It’s usually a stressful time for our patients, and they may make mistakes. Patients and colleagues are often not aware of the tacit biases. The physician gender mix in the hospital is still weighted to more males than females, though this is changing. Cultural biases are unlikely to change quickly, so try to establish a consistent explanation that responds to issues around gender, age or whatever peeves you (SS).
Your appearance matters: Even though it matters, there are some factors that are much harder to change (age, ethnicity, gender). There are others that are within your control (wearing white coat, scrubs, dress clothes).
Don’t stop being you: This seemed to be a big theme. One student stated she was told she smiled too much (AD) while another stated that she felt she needed to be ‘angry’ to gain respect. Most participants suggested that it was crucial to stay true to your identity (whether that be because you don’t feel comfortable in a white coat, or just like to smile).
Respect cultural boundaries for role identity: Establishing your patient care roles and respecting the limits of your expertise/training is important. A phenomena known as ‘role confusion’ occurs when the lines start to blur. This may mean not doing tasks that you may know how to do (e.g. starting IVs), if that’s what nurses culturally at your institution do.

Links suggested by the community participants are listed below.

Thanks to all of the contributors

Twitter Participants	Blog Participants
Teresa Chan (@TChanMD)	Teresa Chan
University of Ottawa EM (@EmergOttawa)	Alia Dh (@alia_dh)
Esther Choo (@choo_ek)	Danica
Nikita Joshi (@njoshi8)	K Cooper
Edmund Kwok (@eddeestyle)	Caroline Cottrell
Lindsay Melvin (@LMelv)	Gary Dufresne
Lisa Fields (@Practical Wisdom)	Michelle Gibson (@MCG_MedEd)
Megan Ranney (@meganranney)	Justin Hensley (@EBMGoneWild)
Malkit (Mona) Singh (@monasingh)	Michelle Johnston
Minerva (@minervies)	Michelle Lin (@M_Lin)
Amy Walsh (@docAmyEWalsh)	Lindsay Melvin (@LMelv)
Claudia William (@DrCSWilliam)	Ken Milne (@TheSGEM)
Women Surgeons (@WomenSurgeons)	KANieder (@docnieder)
	Susan Shaw (@drsusanshaw)
	Anand Swaminathan (@EMSwami)
	Brent Thoma (@Brent_Thoma)
	Amy Walsh (@DocAmyEWalsh)
	‘Little Kid Doctor’
	‘femalemedstudent’
	‘alittleCPR’

Case and Responses for Download

The use of this case and its expert responses are encouraged for the purposes of continuing medical education and faculty development.

The Case of the Woman in White: Expert and Community Summary (PDF)

We’d love to hear how you’ve used these resources! So if you do please email <teresamchan(at)gmail.com> or tweet us (@Brent_Thoma and @TChanMD) to let us know.