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Academic Medicine:
doi: 10.1097/ACM.0b013e3181a8130c
Clerkships

The Effect of Gender on the Clinical Clerkship Experiences of Female Medical Students: Results From a Qualitative Study

Babaria, Palav; Abedin, Sakena MD, MA; Nunez-Smith, Marcella MD, MHS

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Author Information

Ms. Babaria is a fourth-year medical student, Yale University School of Medicine, New Haven, Connecticut.

Dr. Abedin is a graduate student, Program in the History of Science and Medicine, Yale University, New Haven, Connecticut.

Dr. Nunez-Smith is assistant director, Yale University Robert Wood Johnson Clinical Scholars Program, and assistant professor, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.

Correspondence should be addressed to Ms. Babaria, Yale University School of Medicine, IE-61 SHM, PO Box 208088, New Haven, CT 06520-8088; telephone: (203) 785-6454; e-mail: (Palav.babaria@yale.edu).

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Abstract

Purpose: To characterize how female medical students perceive the role of gender within their medical education during the transition to the clinical curriculum.

Method: In 2006–2007, the authors conducted a qualitative study consisting of in-depth interviews with 12 third-year female medical students completing their first clinical clerkship. Participants were purposefully selected from a single New England medical school to represent a range of ages, ethnicities, and prior life experiences.

Results: Participants (1) struggled to define their role on the wards and often defaulted to stereotypical gender roles, (2) perceived differences in the nature of their workplace relationships compared with the nature of male medical students’ workplace relationships, (3) had gendered expectations of male and female physicians that shaped their interactions with clinical supervisors, (4) felt able to negotiate uncomfortable situations with patients but felt unable to negotiate uncomfortable situations with supervisors and attendings, and (5) encountered a “gender learning curve” on the wards that began to shape their self-view as future female physicians.

Conclusions: Despite increased numbers of women in medicine, issues of gender continue to have a substantial impact on the medical education of female students. Institutions can design interventions about gender issues in medicine that expand beyond a focus on sexual harassment to address the complex ways in which students are affected by issues of gender.

Close to fifty percent of all medical school matriculates in the United States are women, and the number of women entering medical school continues to increase.1 Most of the existing research about women in medicine, largely limited to female physicians posttraining, has demonstrated that gender often negatively influences their professional experiences. Prior studies have shown that women in academic medicine are underrepresented at the professorial rank and are compensated less than are their male colleagues even after adjusting for academic productivity.2–5 Ash et al’s6 2004 study surveying 1,814 female faculty members revealed an average base salary deficit for female physicians of $11,691 compared with male colleagues, and the deficit increased with seniority.

In addition to such career advancement considerations, up to 70% of female faculty report gender-based discrimination and sexual harassment.7–9 A study in 2000 interviewed both male and female academic physicians regarding perceived gender discrimination and found statistically significant differences (P < .001) between the experiences of male and female physicians.7 Forty-eight percent of female physicians reported having experienced sexist comments or behavior (compared with 1% of male colleagues), and 30% reported experiencing severe harassment, such as sexual solicitation, threats, or coercive sexual advances (compared with 3% of male colleagues).7 These experiences are associated with other important outcomes, such as low career satisfaction.7,10 Carr et al’s8 in-depth 2003 qualitative study examined the effect of gender discrimination on the experiences of female faculty. Participants who had experienced gender discrimination reported lower self-confidence and self-esteem, cynicism towards their academic work environment, isolation, and a lack of institutional response to such experiences. When interviewed, women in academic medicine also frequently cite the lack of equitable mentorship as one of the major barriers to career advancement.

Qualitative studies have also previously described the potentially negative impact of gender on the professional relationships of female physicians. Female physicians have described tension with female nurses in the workplace, resulting from what they perceive to be differential treatment of male and female physicians.11,12 Female physicians perceived that they had to be “nicer” and more “accommodating” to nursing staff and also received less technical assistance caring for patients and cleaning than did their male colleagues.12

The consistency of the findings across the existing research literature has triggered the development of numerous policies and programs to increase the support of women in medicine during the past 15 years. Many universities have established offices of Women in Medicine to assist female faculty and students in addressing gender bias, instituted mandatory sexual harassment trainings, and increased efforts to recruit more female faculty who can serve as role models for female medical students in addition to diversifying the faculty.2,13

Although research into the professional experiences of practicing female physicians has been comprehensive, less is known about the experiences of female medical students. The majority of research involving female medical students has focused on rates of medical student abuse and sexual harassment.14–17 In Nora et al’s14 14-school survey from 2002, 83% of female medical students reported having experienced gender discrimination in a variety of clinical and nonclinical settings. Such experiences were most prevalent in university hospitals and on core clerkships (notably surgery and obstetrics–gynecology). Several studies have documented that both male and female students report significantly higher rates of gender discrimination in their clinical clerkships than during the first two years of medical school,14,18,19 suggesting that the structure of clinical education, as well as interactions on the wards, lend themselves to greater rates of gender-based discrimination compared with classroom learning. Interestingly, studies that have further examined what students mean by “gender discrimination” and “sexual harassment” suggest that students actually perceive less gender discrimination and harassment as they progress through medical school, likely because of acculturation.20 As Nora et al20 hypothesize in a 1993 study, “Perhaps people ‘buy into’ certain settings for their own psychic survival and/or to increase the likelihood of their success. In these instances, the organizational culture is accepted over time.” Wear et al’s17 2007 qualitative study looked specifically at the perceptions of sexual harassment among contemporary female medical students. Participants reported frequent “sexual innuendo, explicit sexual banter, or crude language”; however, as Wear wrote, “not one of the students we interviewed went so far as to label any of it ‘sexual harassment,’ even after our initial definition was read to them prior to each focus-group.”

Given that many students seem to shy away from using the terms “sexual harassment” and “gender discrimination,” targeted questionnaires may fail to capture the full extent to which female medical students experience such behavior. Despite this shortcoming, national surveys have clearly documented that female medical students report gender bias at significantly higher rates than do their male peers, but they do not provide any further insight into the range of experiences attributed to gender that female medical students may have.

Given the increasing numbers of women in medicine and the substantial policy changes to support gender diversity in medicine, understanding the influence of gender on the experiences of the next generation of female physicians is paramount. Therefore, we conducted a qualitative study of female medical students transitioning from a preclinical to a clinical curriculum in order to characterize how gender influences their training experience.

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Method

Study design and sample

We conducted in-person, in-depth interviews with 12 female third-year medical students to characterize their gender-related experiences during the first month of clinical clerkships. To ensure the anonymity of the limited number of participants, we have chosen not to identify the name of the institution within the text. We used a qualitative methodological approach because we sought to generate hypotheses regarding how gender affects the experiences of female medical students that would provide better understanding of previous quantitative surveys.21 Only females were considered for participation in this study, as it specifically examines the experiences of women in medicine. In addition, students who did not intend to complete an entire year of clinical clerkships were excluded from the study, as this study was part of a longitudinal cohort study.

We identified and recruited a purposeful sample of female medical students, paying particular attention to characteristics such as age, self-identified racial/ethnic background, prior life experiences, non-English primary language, undergraduate institution, and relationship status.22 Two invited students declined to participate (one student cited time constraints, and the other expressed concerns about the potentially negative impact of participating in the study on her future career), so two other students were identified and recruited to replace them. The research protocol was approved by the institutional human investigation committee. We obtained signed consent from all participants.

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Data collection

From June 2006 to June 2007, in addition to a baseline interview conducted prior to starting their third year and an exit interview at the completion of their third year, we interviewed our cohort of 12 female medical students after the completion of each 4- or 6-week clinical clerkship. This current analysis focuses only on interviews describing the experiences of subjects after their first month of clinical clerkships given the unique experiences that participants reported during their initial encounters with clinical medicine. Future analyses will examine participant perspectives throughout the clinical year. One member of the research team (P.B.) conducted all interviews; the interviewer was a female medical student doing clinical clerkships at the time of the interviews. We purposefully chose to have a single interviewer who was gender- and role-concordant with the interviewees, as similarities between researchers and key informants, such as gender or work role, can often facilitate rapport and therefore yield rich data.14,23,24 All interviews were conducted in-person, with only the interviewer and a single participant present, and averaged 35 minutes. Audiotaped interviews were transcribed, and transcripts were verified by the interviewer. Interviews started with the general question, “What do you think the impact of gender has been, if any, on your experiences on the wards during the past rotation?” Follow-up probes then examined the participants’ views regarding interactions with patients, medical staff, and other medical students. Additional questions asked participants about the impact of gender on educational learning and about participants’ views on male medical students’ experiences (List 1).

List 1
List 1
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Data analysis

Given that our objective was to generate themes that are germane to health services research, we applied the principles of inductive reasoning to guide our data analysis and interpretation.25 A diverse coding team comprising a medical student, an internist, and a pediatrician, representing a variety of racial/ethnic and religious backgrounds, developed an initial code structure based on a preliminary reading of three randomly chosen transcripts. The code structure then evolved in an iterative process. The code team met regularly to revise and refine the code structure using the constant comparative method of data analysis. Newly coded text was compared with previously coded text to identify new themes and expand existing themes on the code structure.26

Transcripts were independently line-by-line coded by code team members using the final code structure that comprehensively defined all codes. The code team had group meetings at regular intervals to reconcile differences between coded transcripts by negotiated consensus.27 Scientific software, ATLAS.ti 5.0 (Berlin), was used to assist with data management and retrieval. All participants reviewed a summary of the themes after data analysis was completed, and they endorsed the content of the findings.27

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Results

We interviewed 12 female medical students after the first month of their third-year clinical clerkships, representing a range of ages, race/ethnicities, and prior life experiences (Table 1). Students participated in one of seven different clinical specialty clerkships across a variety of clinical settings. There were often several participants per clerkship, representing different hospitals and clinics.

Table 1
Table 1
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Five common and original themes characterized the experiences of third-year female medical students during their first month of clinical clerkships. Female medical students (1) struggled to define their place on the wards and often defaulted to stereotypical gender roles, (2) perceived differences in the nature of their workplace relationships compared with male medical students’ workplace relationships, (3) had gendered expectations of male and female physicians that shaped their interactions with clinical supervisors, (4) felt able to negotiate uncomfortable situations with patients but felt unable to negotiate uncomfortable situations with supervisors, and (5) encountered a “gender learning curve” on the wards that began to shape their self-view as future female physicians.

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Female medical students often defaulted to stereotypical gender roles as they struggled to define their place on the wards

Most participants expressed confusion during the first month of clinical rotations about the third-year medical student role, describing it as “a difficult transition” and “awkward.” One participant described her first rotation as “crazy” with the concomitant transition of residents. She questioned,

What is the role of the medical students in that environment? Because I’m there to learn, and to work with patients … but when I don’t know what I’m doing, it’s hard for me to do that for patients. So … I think that has been sort of challenging (Emergency Medicine/Anesthesiology).

Many female medical students were surprised to find themselves defaulting to self-described stereotypically feminine behaviors within this period of uncertainty, such as focusing on assisting nursing or support staff, nurturing patients, or becoming more apologetic. Whether participants viewed these behaviors positively or negatively varied depending on who was involved in the interaction. Most students who identified “feminine” behavior during interactions with their residents and attendings described those situations negatively. One participant, when asked how gender affected her interactions on the wards, expressed surprise at how “apologetic” she found herself in interactions with her clinical team. She would ask, “I’m sorry, did I do that right? Did I do this right? Is this how you want this done?” As she explained, “I didn’t take as much initiative as I thought I would, and to me, to me it was very clear that I was doing that because I felt like … I didn’t fit in” (Surgery). Another participant described a similar situation in which she and a male medical student incorrectly performed an EKG on a patient:

Then we had to come and do it again and…. And I was the one apologizing about how we put the leads on wrong and really it wasn’t—we put the leads on as a team, me and [the male medical student] … but because I was the one apologizing about it the patient remembered me as the one that messed up the EKG (Internal Medicine).

In contrast, participants who exhibited self-described stereotypically feminine behavior during interactions with patients and support staff reflected on those such situations positively, describing themselves as “helpful” and “appreciated.” One participant explained that her “ability to be caring and nurturing has been really helpful,” especially with elderly female patients (Emergency Medicine/Anesthesiology). Another participant on her surgery clerkship described similar satisfaction assisting support staff:

The good moments … mostly moments where I felt really helpful … I would do something stupid, like pick up a piece of paper off the floor and some tech would smile at me. And those were the days that I would feel good about myself.

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Female medical students perceived differences in the nature of their workplace relationships compared with male medical students’ workplace relationships

Participants perceived substantive differences between the types of relationships they formed on the wards compared with relationships formed by their male counterparts. Many participants described forming closer bonds with support and nursing staff than with their clinical supervisors. One participant described an encounter with a nurse “who’s notoriously antagonistic with doctors.” When the student assisted the nurse in moving a patient, the nurse “flipped in a heartbeat,” confiding in the student about her daughter’s struggle with an eating disorder. The participant attributed this interaction to her gender, stating, “And I just got this whole story from her like in a half hour standing in the middle of this patient’s room. I don’t know if that would have happened if I were a guy—it probably wouldn’t have” (Internal Medicine).

Several participants felt that, though they formed relationships with the predominantly female nursing and support staff, their male classmates were forming relationships with attendings, who were most often male. Some participants felt they were at a disadvantage because of the difference in quality between the relationships they formed with attendings and those formed by their male counterparts. One student of color felt that it was “harder [to] relate to older white men and have an interaction, attachment and relationship … because we don’t have much in common.” She felt that finding similarities with attendings was a “big part of evaluations and … being included in procedures” (Emergency Medicine/Anesthesiology).

Some participants also felt that, in addition to forming closer relationships with male students, attendings also had different expectations for male and female medical students. One participant on her surgical rotation initially felt grateful that she was not being asked questions. However, she soon realized “that I just wasn’t being pushed to read because I wasn’t being asked questions.” She described a “stark difference” between herself and the male medical student on the rotation, explaining that her team was “asking him all the … questions so that he’d get all the right answers.”

Some participants thought these differential relationships and expectations would have ramifications on their future careers. As expressed by one participant,

I think the outcome of this is going to be that the relationships and bonds that I’ve formed in this year are going to be very much, ones of—where I feel like I’m supporting female interns and nurses, and that the males in my class are going to come out with a lot of powerful relationships with people who are going to write them recommendations for future powerful positions … it’s kind of important … And it’s really shown me, this past month, how easy it is to get ahead when you’re a man. It’s not that I didn’t know that already, it’s just made it more clear (Surgery).

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Gendered expectations of male and female physicians shaped how female medical students interpreted their interactions with clinical supervisors

Many female students described having low expectations of encounters with male supervisors on the wards and anticipated that such interactions would be uncomfortable. For instance, several students reported having had anxiety regarding the potential of working with all-male teams and expressed surprise when they had good learning experiences with male physicians. One student thought she “would feel uncomfortable at times” when she discovered that she was working with all-male attendings and residents on her psychiatry rotation. As she described, however, “Not at all … some people, especially older men, tend to still believe that women have these defined roles, but, yeah, [the male attendings and residents] basically showed me otherwise, throughout the whole rotation, I mean everybody.”

Participants described their encounters with male physicians in laudatory terms when their experiences surpassed their relatively low expectations. One participant “found the residents who were often the better teachers were the male residents.” As she explained, “[They] were the ones who sort of pushed me to do things more, and who were friendlier and gave me more feedback, and encouraged me to also sort of be more comfortable” (Obstetrics–Gynecology). Another participant expressed similar views, that “males push you harder, they act more confidently, they ask you more questions, and they expect you to know more.” She concluded, “I want male attendings, I want male residents. I don’t want to have female residents anymore because I don’t think I’d learn as much if I had females” (Neurology).

In contrast to their stated apprehension about working with male teams, many participants expressed excitement about possibly working with female role models during clinical clerkships. One participant described working with almost exclusively female residents during her anesthesiology rotation. She spoke of her “great interactions” with them and being able to talk about “how they balance their career with the rest of their life.” In some situations, students found that relationships with female supervisors fulfilled their expectations and were very rewarding. For example, one student on psychiatry described dealing with an inappropriate patient: “The [female clinical supervisor] … and I both had this very, very, strong reaction that he was this very sleazy guy…. I actually had some really good discussions with her about that.”

Some students also related specific expectations that they had for female supervisors that were often based on “warm and fuzzy” female stereotypes. Students expressed surprise and sometimes criticism when female supervisors did not fulfill these expectations. As one student on her pediatrics rotation described,

I did notice though, that the women … they were very sharp, very professional … put together and they didn’t have that stereotypical warm and fuzzy mode about them…. And that wasn’t what I was expecting at all…. And that was difficult for me to adjust to initially. I didn’t find them very approachable. The men that were that way, I would approach them the same, but for the women it was sort of startling and a bit intimidating and I was less willing to approach them and start building some sort of relationship but it took much longer for me to feel comfortable around a woman with that sort of presence (Pediatrics).

Almost all students described some disappointment in their encounters with female residents and attendings. One student contrasted her experience with male and female physicians, explaining that the males were “more attentive” and that the two female attendings “basically didn’t acknowledge my presence.” Another student expressed surprise when she, too, concluded that she “liked a lot of the male residents better than the female residents.” As she described, “I sort of had this moment when I realized, yeah, I like this resident, I like this one, I don’t like this one so much and then I realized, wow, in general I’m liking the men more and that’s really weird to me…. I didn’t expect that” (Obstetrics–Gynecology).

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Female medical students felt able to negotiate uncomfortable situations with patients but felt unable to negotiate uncomfortable situations with supervisors and attendings

Most female medical students experienced a range of uncomfortable situations during the first month. Uncomfortable situations with patients usually involved patients flirting, making remarks about participants’ appearance or gender, or calling participants “nurse.” One student described feeling “uncomfortable and frustrated and angry” when being referred to as “nurse.” She explained,

There is absolutely no reason why someone who is female would not be able to care for, think hard enough, or put in as many hours—or whatever they think would limit a woman to the point where you wouldn’t assume she was a doctor…. I feel like … it undermines what I’ve put in to get there (Pediatrics).

Many students reported feeling comfortable addressing inappropriate patient behavior by the end of their first clerkship experience. One student described addressing older men who had “more old-fashioned views of women and the roles of women”: “I make it very clear upfront that I’m a medical student—not a nurse, not an assistant” (Emergency Medicine/Anesthesiology).

Despite describing many male supervisors as “better teachers,” a majority of students also reported that most uncomfortable situations they encountered on the wards involved male residents or attendings. Such situations ranged from feeling uncomfortable in a male-dominated culture to unsolicited attention from male residents and attendings. One student described the “culture of guyness” she experienced on the wards that she felt was often unrecognized by male attendings and residents:

Just today we had this conversation about some male patient who was found masturbating by the attending. And so ensued five minutes of jokes about masturbation—I mean male masturbation and basically all the men laughing and all the women standing back—even though we were all standing in a circle. I mean … that’s pretty explicit (Surgery).

Another student described her interactions with a male attending in more blunt terms:

Dr. [Y] stared at every girl’s chest. And nobody ever said anything about it. He wouldn’t look you in the face, he would look at your chest when he was talking to you…. And he did it to every girl, every single female (Neurology).

Some participants explained that their unfamiliarity with the medical system and medical culture during their first month of rotations prevented them from navigating uncomfortable situations with attendings and residents who were their supervisors. Such students often deferred to what they perceived to be the existing culture, despite their discomfort. One student described her interactions with an attending:

It’s pretty freakin cold in the OR and I would get goose bumps and [the male attending] would rub the back of my arms with his hand, and then he got the resident doing it too, it was just a little strange, I have to admit, and I was like “Huh…. How do I deal with this?” I’ve never had anyone rub my arm for goose bumps…. Would I have preferred that it didn’t happen? Absolutely. It’s not exactly that I asked for, wanted, or solicited in anyway, but did I feel comfortable saying, “Could you please not do that?” I mean it was my first week of rotations, I didn’t know what was appropriate at that time … so I didn’t say anything (Emergency Medicine/Anesthesiology).

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Female medical students encountered a gender learning curve on the wards that began to shape their self-view as future female physicians

Some female medical students also began to identify what sort of behavior was required of female physicians based on their experiences. We termed this type of learning on the wards the “gender learning curve” to describe the process of identifying and responding to workplace gender roles. Students perceived that there were higher workplace expectations for female physicians and felt that the medical environment required women to be “more serious” and “prove” themselves. One student felt that male physicians “joke around more” and “seem more accessible.” In contrast, she felt that many female physicians “seemed just a lot colder.” She attributed such differences to her perception that “women have to be more serious because they have to command more respect and the men get it more automatically and so they’re freer to joke around (Obstetrics–Gynecology).” Another student expressed similar views after two weeks on pediatrics, that “male doctors had this air of, they had a right to be doctors … and females had to prove that they were going to be, should be doctors … it was harder for women to prove that” (Neurology).

Some participants described what they perceived as necessary behavior for female physicians. One participant observed how her female attending “never talked about her personal life except to say that it was her son’s birthday.” As the participant concluded: “She was so professional, always talking about intelligent things. And I think that was something that I realized is necessary, when you’re a female doctor” (Neurology).

Several participants described feeling that they, too, had to “prove” that they were competent, as compared with their male counterparts. One participant described feeling nervous about “proving that I’m just as good or just as smart.” As she explained,

I just want to make sure that I don’t end up looking like one of the female residents who doesn’t know anything and doesn’t have any confidence. I don’t want to look like that. Seeing [female resident] makes me want to not be like her (Neurology).

Some women felt that based on their experiences, they would not be able to meet the demands of being a woman in medicine. As one student who is also a mother described,

I came in thinking you know, whatever I want I’ll do. And now it’s like, no. I want an easy residency, easy 10 years of practice and then I’ll do—if I’m not satisfied, then I’ll do something different. It’s such a shame. I think it’s a shame because I remember going to the Women in Medicine talk and they’re like—someone was like, “I’m not practicing,” and I remember thinking this is ridiculous. And now I’m … in the same position and I’m not like, “I’m not practicing,” but … my career is determined by my kids and my family at this point. So it’s, I think it’s really interesting that two years ago I thought whatever the world had to offer I could take it on and now I know I can’t do it (Psychiatry).

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Discussion

Although significant attention has been paid to supporting gender diversity in the physician workforce, we found that gender has a substantial impact on the experiences of female medical students as they start their clinical clerkship training. Perhaps surprisingly, participants described both positive and negative gender-related experiences that extended far beyond issues of sexual harassment in the workplace. Regardless of previous life experiences, specialty rotation or clerkship site, several themes emerged from the data that suggest female medical students share a commonality of workplace interactions that are affected by gender. In addition, they perceive these interactions to differ substantially from the workplace interactions of their male classmates. These findings have important implications, because targeted interventions to date have primarily focused on recruiting and supporting female faculty and developing policies on sexual harassment.2,13 Our data reveal that although female medical students mentioned sexual harassment, these experiences were neither as pervasive nor as formative as other gender-related experiences that shaped their clerkship rotations and ideas about women in medicine.

Our findings suggest that female students, in addition to the clinical learning curve well associated with third-year clerkships, also encounter a “gender learning curve.” The curve reflects acculturation to stereotypical male and female workplace roles and expectations. Similar to prior studies,28 our participants described being especially vulnerable and struggling to define their place on the wards during their first clerkship. Particularly when facing uncomfortable situations with attendings or supervisors, participants often felt unsure of how to react and accepted what they perceived to be the prevailing workplace culture as the norm. Such impressionability during the first clinical clerkship may accentuate the gender learning curve.

Our findings reveal that many aspects of female medical students’ experiences are affected by gender, including interpersonal relationships, career ambitions, and behavior on the wards. A number of participants reflected on the “culture of guyness” on the wards and felt that the culture of medicine valued stereotypically male characteristics more than female characteristics. Multiple studies have documented that female medical students have higher rates of medical school attrition than their male classmates29 and report significantly more doubt about whether they should have chosen to enter the field of medicine.30 The experiences that our participants report may only exacerbate the doubt and isolation that many female medical students feel. Prior work done on the experiences of both female and racial/ethnic minority students has focused on the role of the culture of medicine and the hidden curriculum components of medical school that isolate such students.31,32 Strategies that solely address issues of sexual harassment in undergraduate medical education often fail to address these cultural phenomena. Adopting more comprehensive programs that examine the gendered culture within medicine may improve the experiences of women in medicine.

Our participants also described being unprepared to address most of the uncomfortable situations they faced on the wards. Previous work with female faculty has shown that women who felt unequipped to deal with gender discrimination reported its effects on their self-confidence, isolation, and career development as well as regrets about choosing to enter medicine.10,33 Similar patterns with female medical students suggest that this process starts earlier than residency or practice. If medical institutions want to create equal opportunities for women in medicine, interventions will need to be targeted earlier.

The findings of this study do have some limitations. All of the participants hailed from a single medical school class at a private, New England medical school. Some of the findings may reflect the experiences of this particular class and the policies of this school and may not be generalizeable to other parts of the country or public institutions. However, we purposefully sampled a diverse group of students representing a range of specialties, hospitals, and clinics to minimize such variations in institutional culture. Future work involving interviews with male medical students would complement this study, providing a point of comparison between the experiences of male and female medical students. Comparing male and female perspectives would have allowed us to determine whether some of our participants’ experiences were due to their role as medical students, in addition to issues of gender. If male perspectives revealed differences in the way male and female students characterize gender dynamics in medical education, it would further support our findings. In addition, assessing whether male students are aware of the gender differences that their female peers perceive would provide valuable insight for medical educators. Strengths of this study include gender- and role-concordant interviewing, the diversity of the coding team, the use of rigorous qualitative methodologies such as audiotaping and transcription, and participant verification of findings.

This study has numerous implications for medical educators and clerkship directors. As these results demonstrate, it is necessary to expand the framework of gender discrimination beyond sexual harassment to include the myriad ways in which gender affects the lives of female medical students. Programs that only focus on prevention of or responses to sexual harassment do not address the more subtle forms of gender stereotyping experienced in the early years of medical training.

Interestingly, this study revealed a number of potential contradictions in the perspectives of our female medical student participants. Students described discomfort with a “culture of guyness” and reported uncomfortable situations typically involving male clinical supervisors, yet they credited male physicians with often being better teachers. Conversely, students often wished to work with more female supervisors, but they almost universally reported disappointing experiences with female attendings and residents. These seemingly paradoxical viewpoints likely result from the varying expectations students have of male and female supervisors in the workplace. All of our participants described relatively low expectations for interactions with male supervisors compared with female supervisors. Participants reflected on these differential expectations, commenting on how women in medicine are expected to be “more serious” and “prove” themselves, resulting in female supervisors who are often unapproachable and off-putting to students. Participants also described strict and narrow expectations they had of female physicians, such as being “warm and fuzzy,” that made it difficult for female supervisors to meet these expectations.

The number of negative encounters that female students reported with female supervisors also suggests levels of internalized sexism resulting in students devaluing female attendings. These views may also complicate female mentorship programs and gender-concordant team interactions. These perceptions need to be actively discussed and counteracted. Given that students often do not approach administrators to discuss such issues, programs might consider creating frequent “check-ins” with students to provide a structured opportunity for student–faculty discussion.

In our study, female students also felt that male colleagues formed consequentially different relationships with male attendings. Instituting evaluation systems that provide for 360-degree evaluations, where not only attendings, but patients, nurses, and support staff provide student evaluations, would more comprehensively assess the performance of all students.

Lastly, longitudinal qualitative work is needed to examine the range of experiences of female medical students over time. Such work would identify patterns of the impact of gender and lead to more effective interventions that extend beyond sexual harassment to address the entirety of female medical students’ experiences.

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Disclaimer

The authors received funding from the Yale University School of Medicine Office of Student Research and the Yale University School of Medicine Office of Education. The funding sources played no role in the design of the study, the collection, analysis, and interpretation of the data, or the decision to approve publication of the finished manuscript. The corresponding author also had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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