Many have heard this riddle: “A father and his son are in a car accident. The father dies instantly, and the son is taken to the nearest hospital. The doctor comes in and exclaims ‘I can’t operate on this boy.’ ‘Why not?’ the nurse asks. ‘Because he's my son,’ the doctor responds. How is this possible?” Unfortunately, the riddle continues to stump many, revealing the unconscious gender bias that still pervades our society.
This story is not a #metoo or #ilooklikeasurgeon story. It is, however, a story about gender. The story of a workplace complaint about something I said. What, you ask, was the offence? I asked a nurse to call me “doctor.”
I have had the privilege of being a surgeon for 6 years. I take pride in my workplace where equity and inclusivity are core values. From the day I first set foot in the operating room, I have been addressed almost universally by my first name by everyone. Until recently, I had not thought much about it. I welcomed flattening the operating room hierarchy and strengthening collegiality, because I believed it encouraged the type of team work and communication that leads to excellent patient care. On one particular day, I was speaking with a patient immediately before his operation, when an affable and competent female nurse entered the room: “Hi Karen!” The patient looked at me, slightly perplexed at the informality, and we proceeded with a successful thyroidectomy. I assumed that the dropping of “Dr. Devon” was unintentional so I later casually mentioned to the nurse that I felt it would be most appropriate in the presence of an awake patient for me to be addressed as Doctor. Sometime thereafter, I was summoned to my Department Chief's office because the nurse had complained about me.
I questioned several male and female surgical colleagues of varied races/ethnicities, ages, and sexual orientations. The men informed me that this “un-titling” rarely happens to them and yet were not surprised by the incident. The women surgeons anecdotally confirmed the conclusions of Dr Files et al1: that most female physicians have been had their professional title withheld in some capacity. In their study, women speakers introduced by men at grand rounds were significantly less likely to be addressed by professional title than were men introduced by men.1 Furthermore, when women speak up about this de-professionalization, there is usually backlash. If this nurse's intent was that she and I be equals, then why did not she speak with me directly? Although I do not know if the study above was submitted elsewhere, it was ultimately published in the Journal of Women's Health,1 suggesting that this type of systematic gender “microaggression” is only important to those with a special interest in women's health. Resonating further, the nonpeer-reviewed but widely read spoof medical website Gomerblog recently joked: “female physician changes first name to ‘Doctor.”’2
Does my “entitlement” matter or is my request out-of-line, dated, and selfish? There are a few reasons I feel it is appropriate and really does matter. First and foremost, I am here for my patient who is here to be cared for by their doctor—particularly in one of the most anxiety-provoking situations a person is subject to, surgery under general anesthesia. For them, my title and degrees not only promise expertise but also convey that I am present and prepared to act in my professional role. When I think about professionals in my own life, I imagine I could call my Rabbi, “Michael.” There would likely be no repercussions, except that I do not want him to be Michael the dad, gardener, and generally interesting guy. I want him to be my Rabbi, who can confidentially advise and guide me based on his years of religious study, experience, and commitment to his profession. For me, this applies even were we to have a chance encounter at a shop, but particularly in his workplace. How I address him, and how he is addressed by others, is also how I perceive him, and how he is likely perceived by others. Similarly, I believe most patients do not want to see Karen-the friend, -mom, and -wife on the day of their surgery, but Dr Devon the surgeon taking responsibility for their life. Although studies have investigated how patients prefer to be addressed, we do not really know how patients would prefer to address their physicians. I feel that there is something in a title, and what I lost that day was the primacy of my identity as a surgeon—in a moment when that identity was so critical.
Sociologists and linguists have known for ages that the words we choose are critical and represent thoughts and feelings. Where I work, we frequently receive notices specifying a staff member's preferred pronoun—usually referring to gender. I have learned that when someone is referred to by the wrong pronoun, it can make them feel invalidated, disrespected, or dismissed. The corollary is that when you never call Dr Spiegel “Jim,” but tend to call me “Karen,” I receive a message that our work or expertise are not equivalent. A recent publication by colleagues on reducing gender bias in surgery summarizes the shortcomings in our system, and one recommendation is that women use formal titles.3 They also suggest surgeons ought to “refuse to participate in undermining gossip that questions the general competence of female physicians, and consider whether they are referring less remunerative or more non-operative cases to women.”3
Finally, I wish I could stop apologizing for my earned title. I attended 3 competitive and prestigious institutions and worked thousands of hours through most of my young adult life to gain the confidence, privilege, and responsibility that “doctor” bestows. My deeper disappointment that this negative interaction was with another woman highlights a parallel hierarchy that one cannot ignore, the hierarchy between nurses and physicians. Where physicians stand as professionals may have changed over the last century due to several important political and health care movements, and a renegotiation of this position may already be underway. Gjerberg and Kjolrod4 explore the impact of the increasingly female physician workforce on the historically male-female relationship of the doctor and nurse. The majority of participants described the relationship between female doctors and female nurses as much more difficult than the relationship between male doctors and female nurses. They tied this to female physicians’ feelings of lack of respect, assistance, and belonging, and define strategies female physicians have used to combat this, including the establishment of friendship.4 A publication in the American Journal of Nursing5 reflects specifically on the use of names: “when you allow physicians to refer to you by your first name only … you forfeit your individuality and personhood and reinforce the medical hierarchy.” One nurse commented: “‘Well, I think it's important for patients to respect their doctors,’ … considering last name and title to be a sign of respect.” The authors recommend symmetrical naming practices with physicians, which I agree with, however they go on to state that calling the physician by “his” first name in front of a patient would diminish the medical mystique in a way that is positive for the patient.5 This last statement is where our opinions differ. Are some professional titles of rank or leadership designation in place to maintain safety and protocols? Ought we diminish the aviation mystique by stripping pilots of “captain” and “first officer”? What about police “officers” or those in defense forces? Although we know that enhanced communication and decreased hierarchy in the operating room enhances patient safety, to my knowledge, the impact of using first names for physicians has not specifically been studied. Future research should ask how naming affects team interactions and a clearly articulated code of conduct for operating room naming may be warranted. Most importantly, we ought to be consistent across age, race/ethnicity, and gender.
Women in medicine have met great challenges and made great advances, yet data are accumulating on the ways in which we are disadvantaged through pay, leadership opportunities, promotions, and the type of daily unintentional microaggression that this story highlights.3,6 Burnout among physicians, in particular female physicians, is extremely high. This is less likely due to being overworked than to feeling undervalued for the work being done.6 Calling women physicians by their first names is just one way in which our culture systematically prevents professional advancement in surgery, and there is a need for a policy agenda to address these. The recently published white paper of the #BeEthical campaign is a call to health care leaders to recognize ending gender workforce disparities as an ethical imperative.6 Among other things, there needs to be equity in training, elimination of the “motherhood penalty,” active consideration of promotion with transparent criteria, and zero tolerance for harassment.3
This event made me reflect upon the implicit bias that I carry and the broader systemic barriers to women's advancement.6 I hope that telling it will urge people to turn their own unconscious biases into conscious, explicit actions that will help to bridge the ever-present gender gap in surgery. So, the next time you see me in my jeans at the grocery store, with my toddler, please feel free to call me Karen. But at work, please call me by my name: Doctor.