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ER Goddess

ER Goddess

Conflict between Female EPs and RNs? It's in the DNA

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000554292.33158.ce
    communication, professional relationships
    communication, professional relationships:
    communication, professional relationships

    I don't think of myself as a female physician. I put on my white coat and handle whatever comes into the ED, no excuses. That mentality leaves no room for worrying about how my gender affects my ability to do my job, but I have learned not to set myself up for disappointment by expecting to be treated the same as male colleagues. When I face difficulty trying to lead an ED team, it helps me to remember that gender biases may be contributing to my struggle.

    I wonder how many other women in medicine have felt to blame when they experience a problem with another woman on their team. I previously wrote about how women's bias against women can create struggles for female EPs. (EMN 2018;45[5]:1; The question is why. It's not because female physicians or nurses are difficult; it's because significant biological and sociological reasons make female workplace relationships challenging. It helps female EPs to know for their own wellness that hard-wired evolutionary reasons make our dynamics with female nurses differ from male physicians' dynamics with them.

    Women's expectations of other women are written into our DNA. If our female hunter-gatherer ancestors did not cooperate, they didn't survive to pass on their genes. As Joyce Benenson put it in Warriors and Worriers: The Survival of the Sexes, “Even if a male dies while fighting off other males, provided he has impregnated a few responsible females, he will have successfully transmitted his genes.” (Oxford University Press, 2014.)

    Unlike men, women needed to cooperate with other women to ensure their offspring's survival. Behaviors that allowed mothers to get along with others were essential for procuring the help and resources they needed during and after pregnancy to keep their children alive and pass on their genes, so these behaviors are preferentially represented in women's genomes. Biologically, a transgression of a female friendship is high stakes because it can endanger the children, say the authors of In The Company of Women. (New York: Penguin Putnam, 2001.)

    Women have evolved to avoid such transgressions by being better at reading social cues and nuances of meaning from tone of voice and facial expression, allowing us to maintain peaceful interactions. But we occasionally misconstrue them, which gets us in trouble.

    Women operate by unspoken rules to avoid trouble with each other. These rules emerge at a young age and by adulthood have become embedded as a set of unconscious gender-based filters. Core friendship rules, as described by Anne Litwin, PhD, in New Rules for Women, include loyalty and trustworthiness, the ability to keep confidences, unconditional acceptance, and equality. (Third Bridge Press, 2014.)

    Don't Compete or Speak Up

    These can make it difficult for women to disagree without it feeling personal. Men can have a vehement disagreement and go out for a beer, but women have a harder time separating a business conflict from a personal relationship. They are more likely to interpret any disagreement as interpersonal disharmony. The rule that women expect to stay at the same level and not get ahead of each other can make them feel uncomfortable with women in authority. Dr. Litwin reported that many of her female clients find it is more difficult for them than for male colleagues to get things done when working with female staff. Many female EPs have experienced this; our job makes us authorities over other women, which violates the rules and makes the environment ripe for conflict.

    What do women do with their anger in the face of evolutionary instinct to preserve relationships? It's dangerous from a biological standpoint to express it directly, so we evolved to avoid altercations and not jeopardize our survival and that of our children. Our rules tell us “not to compete, not to speak up, not to draw attention to ourselves, and most definitely not to act too powerful or other girls won't like us and may even reject us.” (In The Company of Women. Penguin Putnam, 2001.)

    How are we supposed to express our frustration and sense of betrayal when someone violates the rules? Women feel angry just like men, but “because open conflict is not acceptable behavior for girls, girls fight with body language and relationships instead of fists and knives,” Dr. Litwin wrote. We use indirect aggression to avoid social disapproval and minimize retaliation. That includes verbal and nonverbal covert behaviors that could seem innocuous but are intended to hurt, such as eye rolling, insulting comments, silence as a weapon, and spreading rumors. You can imagine the toxic effects.

    Where does that leave women in emergency medicine? We desperately want to avoid indirect aggression among coworkers, but sometimes we have to violate women's rules to do our job. Consequently, we find ourselves in a maze of impossible double binds, a term meaning that a person receives conflicting cues so that obeying one is disobeying the other. If we use language to help other women feel comfortable (“Don't you think?” “Perhaps”), we come across as unsure, yet we sound unfriendly if we use communication with female colleagues that is to the point. Simply giving other women orders violates the rule of equity. Some ED situations, however, simply require strong decisive orders. Damned if we do, damned if we don't.

    The double binds facing female leaders leave many feeling like Goldilocks, forever worrying about appearing too hard or too soft instead of just right. Sadly, we are often not aware of them even though they profoundly affect our experience. We may think we or our coworkers are difficult rather than realizing that a violation of gender-based expectations is making us perceive each other that way. Rest assured that problems with other women doesn't mean that you or they are doing anything wrong. Simply recognizing that is a great start. Let's use our understanding of the pitfalls in women's professional relationships to navigate around them.

    Next month: Tips for dealing with women at work without backlash

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    Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns at

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