Skip to content

MEdIC Series: The Case of the Woman in White

2017-01-04T18:32:43+00:00

LabCoatsOnce upon a time nurses were all women in hats and white skirts and doctors were readily identifiable by their formal dress, and deep, masculine voices. Changes in demographics, fashion and the health care teams have shattered these stereotypes.  In doing so, it has become more difficult for our patients and fellow practitioners to identify the diverse members of a modern health care team.

This week we present the case of Jenny and Justin:  a couple of residents who are struggling with the assumptions of their patients and colleagues that result from their youthful looks and – in Jenny’s case – gender.

The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@BoringEM), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month (yep, we’re late this month, sorry!) we will pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses will be made available for download in pdf format – feel free to use them!

If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching game to the next level.

The Case

Submitted by Dr. Amy Walsh (@docamyewalsh)

Justin Chin walked in for his overnight shift, logged into the computer, and prepared to get sign-outs from the evening team. He noticed Jenny Whitely exiting a patient room wearing her crisp, rarely used white coat and struck up a conversation.

“Hey Jenny, how’s it going?”

“Oh, fine, busy,” she muttered as she briefly look up and smiled fleetingly, barely making eye contact.

In that moment, it struck Justin just how much Jenny looked like one of the harried junior residents on Internal Medicine. Next to an enormous stack of charts and paperwork, with her hair pointing in about 3 different directions and donning a white coat, Jenny definitely seemed a bit… off.

Determined to get to the bottom of this rather abrupt change, Justin prodded further: “What’s the deal with your white coat?”

“Hmmm?”

“Did you decide to switch to IM or something?” he joked.

“Oh, I’d almost forgotten I was wearing it! No… I’m still EM through and through…” she said, snapping out of her paperwork induced daze. She briefly smiled, but then the look in her eye changed, however, and her face dropped as she continued: “I’m trying something new.”

“What do you mean?”

“Well, I think I’ve been asked how old I am eight times this week, and I’ve been frustrated by being mistaken for a nurse or an RT. Then the straw that broke the camel’s back was that a patient asked me if ‘they’ were going to discharge her.”

Justin could certainly relate to her impatience with questions about age. He had heard his fair share of “You look like you’re twelve!” from patients himself. But he didn’t understand what she meant about ‘they’, so he asked, “Was she admitted or referred to another service?”

“No! Here’s the kicker…I asked her what she meant… and this 40-year-old lady asked if a doctor would finally come see her!”

Justin had never… ever… seen Jenny so riled up. Clearly this was really bothering her. He sat down in the chair next to her, and asked: “I don’t understand. Why don’t they think you’re the doctor?”

“I’m not sure.”

“And your new fashion choice is related to this… how?”

“I’m wearing the white coat to see if people take me more seriously.”

“Why don’t you just introduce yourself as Dr. Whitely?”

“I do!!” she said, clearly exasperated by his suggestion.

“Then why do they think you’re a nurse?” Justin asked, his brows furrowed in confusion.

“I don’t know for sure… but I think it’s because I’m young. And a woman.”

“Nah, I think you’re being overly sensitive!” he said, patting Jenny gently on the back. “I mean, I get the ‘How old are you?’ a lot too. You know, if the patient’s sixty-five, we’re probably younger than their kids, but this is the 21st century.  Nearly half of all med school graduates are female. I’m certain you aren’t treated differently because you’re a woman.”

“I disagree. Gender biases still exist!  Maybe you just don’t see it because you’re a guy?”

“Maybe,” Justin shrugged. He still wasn’t convinced, but she was right, maybe he didn’t share Jenny’s experiences. Who was he to question Jenny’s experience as a female doctor?

Questions for Discussion

  1. As a young person, how do you cultivate a sense of authority and respect in your patients?
  2. How do you discuss differences in gender expectations and sexism within your residency program or medical school?
  3. Is there a problem with female physicians being mistaken for nurses? If so, what are the issues that might arise from this misperception?

We look forward to hearing your thoughts over the week (November 1-8, 2013).*

*Update (November 8, 2013):  On November 8, 2013 we posted the expert & community responses to this above case. Click HERE for a link to the Expert & Community responses, which include words from:

Thanks as well to Dr. Amy Walsh (@docamyewalsh) for developing the case.

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.  Also, as always, we will generate a curated community commentary based on your participation below and on twitter.  We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at CanadiEM.org
Brent Thoma, MD MA
  • Caroline Cottrell

    I actually like the fact that the hierarchical relationship between physicians and patients has changed, but it can cause confusion. I was once sent to a waiting room after a mammogram to hang out until the radiologist could see me. Shortly, a youngish man in a tee shirt and jeans came into the room. Initially I thought he might be a delivery man of some kind. Not so. He was the radiologist. I learned a valuable lesson about assumptions that day. I also am very appreciative of the profound change in the relationship between doctors and nurses. For many years I almost expected to see nurses tug their forelock and to this day I know many nurses for whom the word of the doctor is law. Now, however, the relationships i witness are much more collegial with physicians and surgeons interacting with nurses as the professionals they are!! Overall there seems to be a much more clear recognition that patient, doctor, and nurses (to say nothing of all the adjunct health care professionals) are in this together.

    • Brent Thoma

      Thanks for commenting Caroline! I agree and am a big fan of the team-based relationships that have developed. At the same time, I wonder if the confusion in rules is detrimental to care. ie – if you never realized that man was the radiologist and thought you had never seen a doctor would that color your perception of your care? How can we preserve the good in this change while avoiding problems like that? I feel like this actually is fodder for a whole new MEdIC on ‘professional attire’ and ‘identification.’

      • Caroline Cottrell

        I’m not sure, Brent, if I’m the right person to ask. I have huge respect for medical professionals and the work they do, but I am not intimidated by them and so I am pretty assertive about ensuring that I know what I need to know before they get out of the room. I’m really good at asking a lot of questions and working the language barrier (yes there is one) until I feel informed. This is not the case for many who simply accept what they hear, with or without understanding what the doctor is talking about. More to the point, I do know that what is seen as a more casual approach is especially difficult for older patients and this is more the case in attempts to differentiate nurses from LPNs or other people working on the floor. Older people are not always able to read the name badges without appearing rude or invasive. So not an easy issue. The idea of scrub is a good one, but it too does nothing help folks work out who is whom. To reiterate though, I’m much more concerned with what a doctor knows than what he or she wears.

        • TChanMD

          Brent explained to me that your role/perspective in the healthcare system is that of the patient.

          Thanks so much for coming out to comment with us Ms. Cottrell. Patient experiences and responses are so very important to help highlight or contrast our thinking.

          Speaking of nametags – my name is written as:
          DR. TERESA
          Chan

          The TERESA is actually 2 times bigger…

  • TheSGem

    Brent you never come up with “Boring EM” topics.
    I like never having to decide what to wear to work. Wearing scrubs is one of the benefits of working in the ED.

    There does need to be an easy way for everyone (patients, staff, allied health, etc) to identify who is who. This can be very important in a chaotic/emergent situation.

    While I do not wear a white coat the idea has been growing on me lately. Every since listening to SmartEM with David Newman discuss the history of the white coat. We co-opted the uniform from scientists to give medical doctors credibility. Perhaps we need to look at our uniform again based on the new gender realities.

    Until then I will continue to wear my ruby-red shoes. I can click my heels twice and say “there is no place like emerg”. It does have the benefit of masking the blood. Kids seem to find them disarming too.

    Keep up the good work Brent…

    • Brent Thoma

      Thanks Ken!! I totally agree regarding the scrubs – love them!

      And interesting thoughts on the white coat. I think professional dress is definitely a topic worthy of discussion, but I think we just used it in this case to get at the underlying issue. Why are assumptions made that young looking people and females are often assumed to be something else? And what, if anything, should/can they do about it?

      I like the shoes 🙂

    • amywalsh

      My husband mentioned that to me today. He said if he came to the hospital and saw me, he would assume I was a nurse because of the lack of white coat. He claims he would assume that men without a white coat were nurses too (or not doctors anyway), though I’m not sure I believe him 🙂 I’m also excited that someone else wears ruby red shoes to work! The Dorothy factor does brighten some days.

      • TChanMD

        It’s true… Odds are if you’re a young female in a hospital you’re probably an RN… then maybe a Physio, SW, RT, OT, Admin person…

        Doctors are probably one of the rarest birds in the hospital mix anyways…

        With the way things are changing though, health care providers are fast becoming mainly female!! Since nursing schools have not gone the way of 50/50, we will have more ladies doing all the jobs.

        The other day in our ED, we had 24 hour Lady Doc coverage of the ED… and a full line of male nursing colleagues. One family said it was totally confusing initially. But, when I asked what they meant, they said it was confusing in a good way… and that they found it lovely that the ‘traditional gender roles’ were being broken down! 😀

    • TChanMD

      I think the inspiration for this case is owed to Drs. Amy Walsh and Nikita Joshi for a conversation they had a few wks ago on Twitter. Amy has been one of our first guest authors on the MEdICS case. I am glad you liked the topic!

      I like your point about re-examining attire now that physician-hood has become ‘legitimate’ and ‘scientific’. The history of the White Coat is very interesting – as it was a way to ‘re-brand’ the doctor/surgeon (who had been previously viewed as either snake oil salesperson or bloodletting vampire).

      In an age of evidence-based medicine now, we are also noting that our patients may want different things from us…

      What Doctors ‘want’/think (sort of older, 2004 newspaper article):
      http://news.bbc.co.uk/2/hi/health/3706783.stm

      Some studies suggest that our older patients prefer their doctors in White Coats
      http://www.ncbi.nlm.nih.gov/pubmed/10435357

      And parents also prefer their doctors in white coats (at least optically)
      http://www.ncbi.nlm.nih.gov/pubmed/8751171

      Love to hear more of your thoughts! 😀

      Thanks for reaching out Ken (@TheSGem:disqus)

      • Brent Thoma

        Agree Teresa! Specifically regarding the idea, I agree completely that Amy and Nikita deserve the credit! If we could more explicitly acknowledge Amy as the author of the case that would be great as well but I’m not sure how we could best do that. It will be quite clear in the pdf of course.

  • KANieder

    I’ve been doing this long enough not to be confused for a nurse anymore (having your own office for years helps with that). I do wear a white coat, not because more studies support it than don’t but because as a woman, my clothing has fewer pockets to put the accouterments of my trade–pens, business cards, regular prescription pads, controlled substance prescription pads, iPhone w/medical apps and mini iPad for anatomy lessons. Sexism still exists aplenty in medicine but with age comes some respect. I enjoyed the case and will send it to my medical student daughter. She’s only a first year so probably too early for an opinion in regard to the white coat.

    • TChanMD

      Thanks for your response Dr. Kanieder. It’s true, you need pockets as a doctor! 😀

      Pragmatically, we also need warmth too sometimes (and women’s attire ALSO seems to sometimes not be suited for the A/C riddened hallways of your average hospital).

      That said…

      I don’t wear a white coat, but instead 4.5 years ago when I was a junior resident we made these track jackets that have our Emergency Medicine branding upon them. (I also now buy men’s cargo pants that have multiple pockets. Can you believe there are pants with 7 pockets!?!) These ‘EmergWear’ jackets are now the ‘overcoat of choice’ for almost all our residents and many faculty members.

      The occasional physician still wears a white coat. But curiously, they are all our more experienced lady physicians. 😀 Interesting to contrast to your experience!

  • Lindsay Melvin

    This case rings true for me on many levels. As a young woman, but a senior resident, I’m often mistaken for a nurse and even more often get comments about how young I appear.

    1. When asked about my age, I will laugh and tell patients that I take it as a compliment. This works well – patients are not usually trying to be offensive, and it helps to cultivate a sense of age by making a joke. If the patient is truly affronted by my young appearance, I will explain my level of training and usually that suffices – but this is rare! I then go about my business – I find by behaving respectfully and professionally to my patients cultivates respect from them.

    2. We have not discussed this in my residency program, actually. Would be interesting to see how others tackle it!

    3. I absolutely have no problem being mistaken for a nurse. We have different but entirely complimentary roles in the health care system. I just gently correct patients as to who I am, or why my role is different – they meet so many faces (often mostly in scrubs in the ER), I can’t possibly expect them to keep it perfectly clear!

  • little kid doctor

    I don’t think this is a so much a dress code issue. Its more of an issue of stereotypes engrained in our culture. Physicians as a demographic have changed only recently. I’ve read a blog more recently (wish I could find it) written by a female physician frustrated about this gender/age bias in medicine.Patients have this notion that physicians are middle aged men and anything that deviates from that stereotype is confusing. In her blog this MD (mentioned above) comments that often patients will defer to a the male medical student/resident in the room for their opinion after she’s explained a course of treatment as the staff physician. I’ve seen this exact situation rounding in teaching teams on a varied number of rotations. Female physicians, despite appropriate dress and identification, are so often not taken seriously by patients.

    As a young female resident I can relate and have been equally frustrated on many occasions. Especially when working with a specialist in a clinic I often get asked if they will still see the real physician after I see them. I’m not sure if this is gender or age discrimination or both. Once in the CCU a patient asked the nurse to send the little kid doctor back in the room. As least he acknowledged I was the doctor.

    • TChanMD

      Hi ‘little kid doctor’:

      I totally can relate to your situation.

      1) I think the blog you’re thinking of is…
      http://www.slate.com/blogs/xx_factor/2013/09/20/i_m_not_a_nurse_i_m_a_female_doctor_but_thanks_for_the_compliment.html

      2) Just in prep for this case, I took some notes from yesterday night’s shift (Halloween) – these are all slightly altered (to protect patients’ and families’ confidentiality) but still convey the sentiment of the actual conversations.

      Pt #1) I got asked if ‘THE doctor’ would come in after me… and I said, “Oh! That would be me! And yes, I’ll be coming back to see you again.” “Oh, you’re too young to be a doctor…”
      Pt #2) “How old ARE you??”

      Pt #3) Angry Patient: “Is the real doctor going to see me sometime soon?” Me: “Yes.” Angry Patient: “Then where is he?” Me: “There’s no he… there’s just little old me.” Less Angry Patient: *Laughs* “Sorry.” *looks sheepish*

      Pt #1) “I still don’t believe it… You’re a DOCTOR? Not even a resident??” (we’re in a teaching centre town, the pt’s understand the difference).

      Pt #3’s husband) “How long have you been doing this?” Me: “Well, I’ve been working in healthcare for almost half a decade…” Husband: “Seriously?” Me: “Take out your phone and google ‘asian women aging comic’…”

      (Comic here: http://imgur.com/DDr8t)

      And then the shift got busy (about 4 hours in), so I stopped keeping track…

      Anyways…
      It’s been interesting for me as a young-looking female physician – especially now since some of my patients expect attending physicians to be (a) Male; (b) Older and perhaps taller.

      But I also sometimes secretly like NOT immediately being noticed as ‘the doctor’:

      As a teacher in an academic centre, sometimes I like being able to ‘blend into the crowd’ (e.g. when I’m observing a senior resident run a code). Being a shorter, female doc helps me fly under the radar there sometimes and blend in – so i can see how the guests transport teams or paramedics (if they don’t recognize me) interact with our residents… 😀

      Anyone else use ‘camouflage’ techniques like this?

      T

      • little kid doctor

        http://nomadicgp.wordpress.com/2013/07/21/sorry-but-are-you-really-a-doctor/

        Here is the blog I was referring to above. Took me a while to find it.

        I also find humor helps and educating patients on just how much training I’ve done. Patients usually are not upset and come around after you show confidence in your explanation of their condition. The point is though that a male MD often doesn’t have to make the same efforts.

        • TChanMD

          But I won’t change my gender just to be subject to less discrimination… And must still find agency within this system. My technique has been to use humor. I prefer that to other techniques that I have seen (anger, lashing out, conflict, pessimism, complaints, getting all huffed up).

          I do find that confidence (e.g. speaking clearly about the topic) and in a well-informed manner, while providing ++ answers in a patient-centred way usually wins everyone over (even if my jokes do not). In other words, when I ACT like the doctor they expect (regardless of my gender, my stature, my phenotype) – that’s when I get credibility.

          No sense in bitter. I can role model change. Point it out. Elevate it to something that other females might do (e.g. be funny, articulate, credible).

  • Being married to a female doctor (pediatrician no less!), I have indirect exposure to Jenny’s problem. Working at a training program, I get to see it nearly daily as well.
    Patients have a tough time distinguishing roles in the hospital environment. They often aren’t listening until the second or third sentence it seems, so starting with “I’m Dr. SoandSo” can be forgotten just as easily as most of us forget names.
    I like the white coat. Not necessarily because of the pocket or the warmth, but because it clearly delineates who I am. However, some people work at places where the janitors, nursing students, cafeteria ladies, and newspaper men wear them, so it might not be as helpful.
    At our residency we had a specific color coded scrub system. EM residents wore black. Nurses wore blue. Techs wore magenta. Respiratory wore hunter green. Attendings wore dark gray. If you didn’t have your appropriate color as a resident/attending, the dress code made you wear your coat. Seemed to work reasonably well.
    In the end, the fact that young women are joining the physician ranks in much higher numbers will break the older person concepts of “women are nurses, men are doctors.” It’s pretty apparent with the younger generation that gender isn’t as big an issue (at least at my N=4).

    • TChanMD

      Totally agree – thanks for sharing your thoughts Justin. There is a huge and palpable shift going on – and definitely so in emergency medicine. Last year with my group of seven graduands from our program there were 4 of 7 women.

      That said, we were one of the first big group of predominantly female years… and as I went through, I felt the coaching seemed to be different, subtly. Some people have noted above that sometimes some ladies need to be reminded to step up (though I do also think junior residents also need to be empowered likewise)…

      In light of those experiences, I wonder if there are other training-related gender issues?

      We are enculturated differently from a very early age. I think this article sort of comments on some of these differences – which I think ultimately have ramifications towards the way we coach and teach female residents.
      http://www.psychologytoday.com/blog/the-science-success/201101/the-trouble-bright-girls

      Beyond that, I have anecdotally heard that the gender gap has manifested in some of the following ways:

      1) Male attendings not being comfortable with commenting on women who may not be appropriately dressed for the workplace…

      2) Certain ‘dirty mnemonics’ (you know, like the racy ones for the carpal bones or cranial nerves) not being shared across the gender divide.

      3) Feedback manifesting in very different tones; or being ineffective if not tailored to the needs of a different cultural expectation.

      Do others have similar or different experiences?? Are these one off events, or subtle systemic issues that peak out from beneath the veneer of ‘modern gender equity’?

  • Danica

    I think a solution to this problem (the “who is who” part at least) would be to start in
    early health professions education emphasizing the importance of introductions.
    I volunteered to run the Med-1s mock OSCE last year. This is an annual
    event where the then 2nd years put on a practice OSCE to calm the nerves of the
    Med1s with a new and very different assessment format then they’ve likely been
    used to in the past.

    In my station, not a single person introduced themselves, who they were, or what they were
    there for (they all did really well in other areas though! Proud teacher
    moment! :] ). Granted, OSCEs are artificial scenarios anyway, and it’s sort of
    implied/assumed that when you enter the room that the patient already knows
    what you’re going to do, who you are and that you have consent, etc. But I was very surprised. No one has ever explicitly told me to always
    introduce myself in patient encounters – I’ve sort of always just done it. I don’t know if it’s protocol or not.

    But I tried to really emphasize that even if it’s an OSCE, get in the practice of always
    introducing yourself and your position now, because with all of the people that
    come in/out in the hospital every day, *I* often don’t know if they’re nurses,
    doctors, RTs, PTs, janitors, dietary staff, etc. So how on earth can I expect the patients to
    know !?!?! Should emphasize importance of saying, “Hi, I’m so-and-so, and I’m a (3rd year medical student/1st year nursing student/4th year resident/etc.)

    Hope I made an impact on them, even if it was a small one. 🙂

  • Michelle Johnston

    A very interesting issue. The Emergency Departments (like most of medicine) have become much more egalitarian, and traditional hierarchies have devolved. This is reflected in clothes and roles and attitudes. Societal expectations perhaps have not changed so fast. Having had decades of this type of misunderstanding, being a young- (-ish 🙂 ) female doctor, I see two responses/solutions. These are similar to the excellent comments above.
    1. It’s all in the attitude, not the apparel. A firm handshake, a look in the eye and a strong ‘Hello, my name is…. I’m the senior doctor.’ repeated over and over again until it’s ingrained.
    Sometimes we need to remember that respect needs to be earned, not expected.

    2. Realising that the patient is (usually) not being offensive. ED visits are stressful events for patients, and they are not their most socially savvy. Patients can be ignorant of many things going on in the ED, and we oft-times just need to let it go, and move on.

    Gender biases are unlikely to go away anytime soon 🙂

    • TChanMD

      Hi Dr. Johnston! Lovely to have you return to comment again this month! 😀
      I am sure there is a psychiatrist in the crowd that might read into this… but I find the best way to actually ‘ingrain’ the fact that I’m the attending has been through the use of irony and humor. (For instance, I crack jokes about looking like a 10th grader or the hospital volunteer…)

      I then transition to discussing their care… and their goals… and attempt to always leave them with the impression that I am there to care for them as best I can within my capacity as their emergency physician.

      No RCT to show which method works best, but I have found personally these strategies work quite well together…

      I wonder what other strategies you have seen/used?

  • Michelle Gibson

    When I was a resident (many moons ago), a fellow resident did her resident research as follows (she did go through ethics for this before anyone asks!) – please note this was 15+ years ago, so I might have the details wrong, but I know the gist is correct.

    RNs on an inpatient unit were asked to fill out a questionnaire, based on two scenarios that described RN and resident interactions. I’ve now forgotten the first scenario, but the second one was that the resident carried out some procedure or other, and the questions focussed around what the RNs response would be if the resident left stuff to be cleaned up (including sharps disposal, I think – but I’m stretching back now!)

    The RNs were randomized to receive 1 of 2 versions of the scenarios – so scenario 1 in version A had a male resident, and in version B, it was a female resident; and then reverse that for scenario 2. I believe the RNs were to assume it was themselves in the scenario. RNs were told the study was about resident and RN interactions, but not that it was about gender.

    So… care to guess? The results showed that RNs had different expectations of female residents over male residents. They were more critical of female residents who left things to be cleaned up, though I think they were approximately equal in their ratings of those who left sharps out – again, please note my memory might be faulty.

    As a supervisor and program director in a small centre who seeks 360 input, I will admit I have to keep this in mind, albeit in a minor way. Some team members (not just RNs) just react differently to different genders, or at least have different expectations. I’ve seen it both ways- males who are very quiet are often take as being “aloof” and females who are more vocal can be taken as “aggressive”. My job is to figure out if the person is actually aloof or aggressive.

    My early morning, semi-coherent, wow-my-memory-is-failing-me thoughts!

    • TChanMD

      Thank you for sharing that. Was this paper ever published?

      • Michelle Gibson

        Hm – no idea. I saw it presented at resident research day. Since I can only remember the resident’s first name, don’t think I can find it!

    • amywalsh

      Fascinating point! Your colleague’s project certainly runs in parallel to a lot of research in the business community as well. It reinforces the fact that most differences in expectations and treatment are related to unconscious bias (by women and men) rather than overt sexism or hostility toward women.

  • Anand Swaminathan

    I think the first thing to remember is what my Chairman always tells us; in medicine, it’s not about you, it’s about the patient. Will dressing more professionally change that relationship? I don’t think so. There are some studies that show for ED MDs it doesn’t make a difference but who knows. I know that I provide better care without a shirt and tie or white coat because I’m more comfortable and I can be myself.
    It’s important to establish who you are when you walk in the door. A couple of us had a twitter discussion on this based on the recent article in the lay press. I am a younger attending so I feel the pain. I always say “I’m Dr. Swami, the attending physician” or “I’m Dr. Swami, the physician in charge.” As a resident, after seeing the patients not get it too many times, I started saying, “I’m Dr. Swami, I’m the doctor who is going to be taking care of you in the Emergency Room.” I think that saying doctor twice (or three times if you can work it in comfortably) helps because often the patients are distracted by other things (like are they dying) and don’t hear it when we say it. Similar to how much of discharge instructions get lost.
    As far as the white coat itself, I don’t wear it for a number of reasons:
    1. Not sure where mine is
    2. It’s a fomite
    3. Too hot
    4. Creates hierarchy with the nurses and residents
    5. Creates a barrier between me and patients

    Maybe this is all just me justifying what I do. I do feel the pain of the younger doctors and have noticed the difficulty many of my female colleagues have. In fact, where I work, I would say that the majority of the female docs where white coats and only about 30% of the men do.

    • TChanMD

      Thanks for your comments Dr. Swami! 😀

      Big fan of your segments on EM:RAP over the years. Very flattered you took the time to engage with us on MEdICS!!

      The University of Ottawa crew weighed in via twitter with this link last night (it is a digest of a paper):
      http://frontdoor2healthcare.wordpress.com/2013/07/11/professionals-should-dress-professionally/

      The Paper in Question is a bit older…

      Rehman, S. U., Nietert,
      P. J., Cope, D. W., & Kilpatrick, A. O. (2005). What to wear today?
      Effect of doctor’s attire on the trust and confidence of patients. The American journal of medicine, 118(11), 1279-1286.
      http://www.sciencedirect.com/science/article/pii/S0002934305003517

      The quote of note from the paper’s conclusion:
      “Respondents overwhelmingly favor physicians in professional attire
      with a white coat. Wearing professional dress (ie, a white coat with
      more formal attire) while providing patient care by physicians may
      favorably influence trust and confidence-building in the medical
      encounter.“

      But this was an ex vivo study.

      I’m wondering if a caring physician who sits down with you at the bedside would overcome superficial biases such as dress code? Or do we inevitably judge a book by its cover?

  • amywalsh

    Early in residency I felt uncomfortable introducing myself as Dr. Walsh. I would often say “I’m Amy Walsh, I’m your doctor.” Though my intent was to be more informal and reduce the power gradient between physician and patient, I think that in introducing myself in this way, I was unintentionally communicating that I was not yet comfortable with the idea of myself as a doctor. Though I still certainly still get asked about my age or have cases of mistaken identity, walking into the room with a handshake and an “I’m Dr. Walsh, the supervising doctor” seems to mitigate this somewhat. On the other hand, in the transition to “attending-hood” I’ve had to deal more with misconceptions about my age and qualifications from other staff in the ED (unit clerks, techs, etc.) which is fine for the first couple shifts, but gets frustrating if it persists after 3 or 4 introductions to a person.

    Beyond the issues of communication and establishing respect, I notice that I sometimes react emotionally to patients’ biases. Based on the patient’s tone, questions about my age or occupation sometimes feel as if they are challenging my knowledge or authority to make decisions. Similarly, because male colleagues do not experience this particular form of bias, some will attribute differences in how one is treated entirely to an individual physician’s behavior (lack of commanding presence, not introducing herself, etc.) rather than acknowledging that systemic gender bias exists. As I mentioned above, this bias is typically unconscious (and not malicious), and just as common amongst women as men, but acknowledging the existence of these biases means a lot.

    • anne smith

      Amy I totally agree with you here – When I started practicing medicine, I would often introduce myself as ‘Anne Smith’ – but soon realised that then no one realised I was a doctor.The patients in particular would also continue to call me ‘sister’ unless I made it clear who I was. There was also a clash with the current nursing culture in our country – where even nurses my own age call me ‘doctor’, not ‘Anne’ – not that I expect them too!

      So now I introduce myself as ‘Doctor Smith’ to patients and ‘Anne Smith’ to nursing staff and let them decide what to call me.

  • Michelle

    Let me be the 28th commenter on this amazing discussion thread. I too have dealt with the “how old are you” and “when is the doc coming to see me” when I first started as an attending, although it’s happening less often. I’m hoping it’s because I’m more clear when I’m introducing myself as the supervising physician vs my looking WAY older…

    Regardless, I echo all the comments. I also do not wear a white coat. It’s part of why I love working in the ED. I also love showing solidarity amongst the ED team with the MDs, RNs, and auxiliary staff all wearing scrubs. The key is in a clear introduction. For me, I often say”Hi I’m Dr. Lin and I’m the supervising ED physician” and follow it up immediately with “And how is the team treating you today?” It implies that you are overseeing their care ultimately. It’s kind of like when the owner/manager of a restaurant stops by to see how your meal is going.

    In the end, not all patients will get it, but I anticipate this will change as the culture and gender split of Medicine evolves over time. As long as their care is not compromised, I’m ok with the slow evolution.

  • Gary Dufresne DO, FACEP

    I have a manuscript that had not been published yet, “White Coat Optional: physician attire and gender bias.” It is a prospective trial addressing exactly this issue. I would love to share with your followers. Do you have a way to post it?
    gary.dufresne@gmail.com

  • K Cooper

    While not currently practicing in academics, the scenario presented and experiences related in other comments are very familiar to me and bring a simultaneous knowing grin and underlying gritted teeth to my face. I too am a female physician plagued by what might be denoted in a chart as “appears younger than stated age”. In addition, I practice in a relatively large private EM group dominated by men (I am one of 6 females in a group of 34). In the non-academic world, many patients are even less accustomed to young and/or female physicians than they might be at a tertiary academic institution, as there are not the frequent interactions with house staff inherent to those facilities. Over the year since completing residency, I have forced myself to not allow others’ biases to color my perception of what I should wear, as adding a white coat does nothing to increase my competence and serves only to make me uncomfortable. However, I have somewhat changed what I do in the department based on comments from patients and other staff. During residency I would frequently start an IV, draw blood or some other typically “nursing” task to help move things along in the department. I never thought anything of it until I arrived at my new job and after the second time nursing was behind and I threw in an IV and drew labs while conducting my H&P, one of the senior nurses took me aside and told me “Honey, you’re never going to be respected as the doctor you are if you keep doing things we are supposed to be doing.” She was right–despite the fact that I am a fairly assertive personality and introduce myself as Dr. Cooper with a smile and a handshake, if I don’t stick to more typically “physician” tasks, the patients do seem more confused about my identity and role.

    • TChanMD

      The issue around ‘role identity’ is definitely something that is important to discuss, I think: What ARE the ‘definitional behaviours’ of an RN or MD??

      Are these culturally set within EDs, hospital systems, provinces/states, countries? In some parts of the world, MDs are in charge of drawing blood (e.g. Quebec, UK) – who decides what’s an RN vs. MD job? How do you sort this out? For trainees, it’s important for them to learn about these nuances/subtleties as they become our professional identity.

      Therein lies the BIG question, eh? (Yes… I am VERY Canadian)

  • It still comes down to what the patient expects. While we can’t fix a couple serious prejudices that patients will have (age, gender, race), we can fix some of the others. Listen to Greg Henry about what they patient perceives. Don’t have stubble, don’t dress like a hobo, don’t have facial tattoos, etc. If society (and the government) deem that what is important is the patient’s experience, and not necessarily the medicine, then we will have to adapt or quit.

  • Alia Dh

    Being mistaken for a nurse has never insulted me. Most
    nurses are my age, and they’re lovely, caring, fun people. This past week in
    the ED on multiple occasions I’ve been asked how young I am, if I was a
    nurse, or “when the doctor is coming.” Coming off IM and Peds rotations, where
    I was quite rarely asked if I was a nurse and more often asked how I could be
    “such a young doctor” I’ve had some time and space to reflect on the things I
    am doing, and the things my attendings and staff are doing, to perpetuate these
    viewpoints in our patients. While I often feel that there is are helpless “tones”
    to discussions about gender bias in medicine, I think that if we accept our
    actions as intentional, perhaps we needn’t feel so helpless and frustrated: we
    as young women can “own” our identity and be intentional about our actions.

    I’ve explained to some patients that I am an intern and only
    7 months away from finishing medical school, after being asked why I am a nurse
    or when the doctor is coming. It’s led to some discussions with patients that
    have shown me what I am doing to give the impression of bounding youth/vitality/nursing
    skills. I want to own my actions, and as a neophyte clinician I need to know
    what I am doing to take ownership of how my patients perceive me—now and in the
    future.

    1. I’ve been told that I smile too much to be a
    doctor—that they don’t’ see doctors smiling a lot. This could be because I’m
    still “green” and not jaded/tired/worn/bored, it could also be because when I
    look at my male colleagues I don’t think they smile this much either. I do smile a lot: I love the ED and I
    love being at work. I don’t think this necessarily reflects a gender bias in
    medicine, I think this reflects gender differences in life in general, and a
    little personality difference too. This is one article I’ve read about
    differences in smiling in men and women: http://www.sciencedaily.com/releases/2003/03/030319080920.htm.
    Statistically nursing is a female dominated field, so maybe there’s more
    smiling coming from our nurses, and as a “smiler” maybe that’s why people find
    it hard to believe I’m a physician. I think our patients are sending us a
    message here—we need to take a lesson from our nursing colleagues and smile
    more! If you think I’m a nurse because I look happy, well I think that speaks
    to some issues in my profession.

    2. Dress has been mentioned a few times here. I’ve
    been told that I don’t look like a doctor because I’m “little.” I’m not tall
    (at all) and even the shortest scrubs need to be cuffed so they don’t sweep the
    floors behind me as I walk. Can I change how I dress in the ED? Not without
    bringing undue mystery fluids home with me on my civies. Will a white coat
    help? Maybe, but it also will hinder my ability to relate to my patients and to
    do what I intend to—remove as many barriers between me and my patients as I
    can. That’s a decision I make, and I own it—not wearing a white coat allows me
    to achieve my goal of being open and approachable. Being small works in my
    advantage—I am able to ask more personal questions and get more personal
    answers, and often come out with a little extra information than perhaps others
    might. We all recognize nurses are able to tell us such personal, important,
    and relevant information about patients—maybe that’s because they come across
    as friendlier and approachable: I want to channel that as much as I can.

    3. I recently sutured up a patient’s hand, and when
    he asked, “are you stitching or is the male doctor going to do it?” I had no
    choice but to answer honestly: I’m going to do it and it’s going to be great.
    While my patient may have been slightly hesitant because I was a student (or
    because I was a woman? I’ll never know), I think there’s a lot that can be said
    for a little confidence to help reassure patients. There have been multiple
    studies and articles (mostly from the business world) about how women are less
    likely to assert themselves, less likely to step forward and volunteer for a
    task, and even are more likely to settle for less in negotiations. This is one
    of my favorite Ted talks about it : http://www.ted.com/talks/sheryl_sandberg_why_we_have_too_few_women_leaders.html.
    There have been occasions where I may have stepped back, or been hesitant, and I
    think patients see that, and I think my male colleagues may be less likely to
    show this hesitation. I would be remiss if I neglected to mention the staff and
    attendings who continually come to my support—in front of patients, and in
    private—encouraging me to step up and trust my skills. This reflects bias in
    the way women are raised, girls are taught, and some very deep-seeded
    differences in child development. Attendings—male and female—can champion this
    change for their students, but at the stage of development that I am at,
    there’s a risk of no one rallies for me, I may never have learned to rally for
    myself.

    4. I’ve had patients tell me that they don’t see medicine as a
    male dominated field, of my patients actually said “are you kidding me? Lady
    docs are the best ones…it’s about time you all started taking over.” I
    certainly appreciated his enthusiasm. There’s a rich history in medicine, and
    it’s mostly male dominated. I can’t blame anyone for the fact that mostly men
    have treated our patients—the average 80 year old has had mostly male
    physicians. I think what I’ve mentioned above reflects how women can actively
    and intentionally change medicine for the better: I think patients recognize
    that medicine is more accessible, and that the pedagogy of paternalism is
    beginning to change…or at least I hope they will over my career span. I don’t
    really like what medicine was 50 years ago—I like that times are changing and
    medicine is changing, and I think women have a huge part in that, especially as we create and own our identity not as women in a male dominated field, but as women in a field we belong in, and are shaping.

    • Susan Shaw

      GREAT response, Alia, and great attitude!

      • Brent Thoma

        I totally agree Dr. Shaw!

        As a male that (despite my smily-ness) only occasionally gets asked “aren’t you too young to be a doctor?” I haven’t had as much to add in this discussion. However, I think your positive attitude and ability to intentionally reflect on your experiences will be assets that help you deal with whatever comes at you in the future.

        Reading through this discussion and your articulate reply has helped me to understand the issue better. I will be sure to take any opportunity I can to support junior residents and medical students as you describe.

  • Susan Shaw

    Great case (again!) Amy and Brent. I was 22 at convocation, and turned 23 right before starting residency so heard “but you look so young?” on many occasions throughout my training. Because I did look so young. Because I was young. Most awkward time was when MY VERY FIRST PATIENT that I cared for as an attending asked me “So how long have you been doing this?” as I was performing an axillary nerve block. My nurse colleague quickly spoke up saying “Oh I’ve been working with Dr Shaw for years” which was true thanks to the five years she had worked with me as I completed my residency. I don’t hear this comment nearly as often now that I’ve been in practice for 12 years – now it feels nice!

    Back to your scenario….

    You can only control what you put out there, not how people react or perceive. But you can help create clarity and understanding by clearly introducing yourself, your role and how you fit in to the patient’s care team each and every time. It took me a few years to realize how absolutely vital this is, and to find words that patients and families can understand and remember. I introduce myself each and every time I work with patients and families as in my line of work (ICU) most people are completely overwhelmed by the number of doctors, nurses, RTs, physios, pharmacists, social workers, students, OTs… that might meet them each and every day.

    In terms of appearance, various studies describe various findings about what patients prefer but to me the key items are professional behaviour, a name tag that says who you are, and professional dress. Even though studies says a white lab coat is preferred, I personally don’t wear one anymore. You can read more that I’ve written on this at the HQC blog http://blog.hqc.sk.ca/2012/06/25/what-not-to-wear/ It’s a barrier between me and my patient, gets dirty, and I find them uncomfortable. I learned the hard way that even when you jump out of bed in the middle of the night, you should try to dress somewhat professionally. Jeans and a sweatshirt might be easy and comfy at 3am but it is confusing to the mother of the trauma patient you raced in to help manage.

    I also have been mistaken for a nurse on many occasions. Not as often as I used but again, I’m better at clearly introducing myself and explaining my role. I try to see it as a compliment – RNs are highly skilled, trained professionals with a fantastic reputation. But its does niggle me especially when young women assume I must be a nurse because I’m a female who works in healthcare…

    The bigger problem is that the skills of the nurse are different. It can be confusing and even detrimental to the patient if I try to fulfill a patient’s request that should be directed at the nurse (within reason). What if the patient is being fasted? What if the patient has a mobility risk that I’m not aware of or needs that I don’t even know of never mind know how to meet. Thing is (and this is a good thing), as the hierarchy gets flattened (yay) and we move more towards true team-based medicine, roles will likely shift even more. We need to learn how to work together better. Our curricula don’t address this adequately and we better figure this out soon!

    So I’d coach Jenny (as I try to coach all my students regardless of age and gender) to focus on a short succinct introduction, repeat this every time (while adjusting to the needs of the patient and family) and neat professional attire. I’d also help her work on a response that she can use when she gets asked about her age and role – a calm, confident reply would hopefully help both her and her patient feel comfortable as they work together to solve the patient’s issues.

    Susan

    • Brent Thoma

      Thanks for the great reply!! The post you wrote for the HQC is also very well done. We’ll definitely have to reference it in the final draft!

  • femalemedstudent

    I am a final-year female medical student in Ontario. Since first month of medical school, my female class-mates and myself have noticed – and made light of – the fact that patients constantly mistake us for nurses (e.g. on our clinical skills teaching days).

    It is not a rare occurrence to be standing at the nursing station on IM or Peds next to male desk clerks, male nurses or female nurses and be asked by patients to bring their food, give directions or change someone’s diaper. On my ER rotation, I had to try to look mean/ angry and speak with an expression-free face to not be confused with one of the nurses (it works). I also make direct eye contact and make my voice deeper when dealing with the aggressive young male under the influence or demanding patients in order to be taken seriously.

    I have noticed this phenomenon mainly in community hospitals where patients and the rest of the allied team aren’t used to too many young female doctors. As well, wearing the white coat on rotations like Ophthalmology and Dermatology with a nice dress/ heels certainly helps. Lastly, when I am rounding on my patients, I usually have to say “have you seen your nurse today?”, and “I am a medical student working with the doctors here”, or “well, you’d have to ask that from your NURSE, I am going to examine you”. From speaking to my male class-mates, this is purely a female med student/ physician phenomenon.

    As a final note, I just wanted to mention that this is not just an occurrence in the hospital/ work setting. A lot of times in response to “I study medicine”, I have heard “to become a nurse?”
    I completed a PhD prior to medical school and am interested in a surgical specialty. The undermining of my ability – and all women for that matter – to obtain an “MD” by the general public is disheartening at best.

    Maybe we need more media coverage of the large number of female physicians and medical students in Canada today to change public perception…

    • Susan Shaw

      I’m sorry that you’ve been given the impression that looking mean/angry or expressionless is part of conveying a professional demeanour to both patients and staff. I probably get asked by patients and families every day to help them get food, personal care or give directions. And i know it happens to me more than my male colleagues. I strongly advise you to take advantage of each time someone reaches out to you for help. Give directions, assure the person asking for help that you will assist them by helping them find the person best suited to handle their request, and most importantly, follow through. You and your patients will feel better about the work you are doing. And you will build better relationships with the rest of your colleagues as you continue on in your chosen profession. My favourite surgeons to work with are the ones that emulate the behaviours I would want them to have if they were caring for my mum. Kindness, a willingness to listen and a willingness to help no matter what the request.

      Good luck to you as you head into the CaRMS cycle. Check out Brent’s advice for CaRMS applicants (boringEM.org) – he has some great advice for students prepping for the process

    • TChanMD

      First off, thank you Dr. ‘femalemedstudent’ for your comments. Also, thank you very much Dr. Shaw for a great response. I would like to echo many of Dr. Shaw’s sentiments: I am sorry you have had to “try to look mean/ angry and speak with an expression-free face to not be confused with one of the nurses (it works)”.

      I’ll be honest with both of you… I have actually found the opposite.

      I am all of 5’2″ and, due to my diminutive nature, I do have to compensate sometimes with reinforcements (e.g. calling a code white for an agitated patient). That said, for non-delirious patients, I often do find that a more gentle approach has often been more successful.

      Once upon a time, as a senior resident, I actually went right up to an angry patient who was acting out and asked him if he might sit down with me so I could examine his wound. My attending was standing within ear shot, and had actually alerted security to go with me as he was expecting an altercation…

      But, because of my approach the patient actually became less angry, apologized, and then sheepishly allowed me to take care of him. Now, it is impossible for me to know whether it was my technique, my demeanour or my gender that allowed me to diffuse the situation… All of those things, in that combination allowed me to handle the situation.

      That said, just like a sepsis bundle, sometimes its the combination of things that make success happen. My suggestion would be to consider varying your practice during your training until you isolate more techniques that are COMPATIBLE with your outlook. If you’re a happy person, I am sad you feel you have to become ‘angry’ to be treated as a physician. Maybe reading the entries on this page with give you some examples of how to be treated with respect… without compromising your personality or personal values.

      Thanks to both of you again for sharing your thoughts!

    • Brent Thoma

      femalemedstudent,

      These experiences sound very frustrating. You entered medical school with a lot of knowledge (a PhD no less!) and certainly deserve respect. However, I’m concerned that your response (looking mean/angry/expressionless) might make your patients/colleagues less comfortable confiding in you and, as a result, decrease the quality of care that you are able to provide.

      While I will never be able to experience what you have, I think the possibility that you are making that trade-off is important to consider on your path to becoming a surgeon.

      Thanks you for contributing your perspective.

    • amywalsh

      I think a lot of us can relate to your experiences regarding studying medicine “to become a nurse” and as you can tell from the existence of this case that many of us have been delicately navigating our own ways through gender bias and professional identity. And I’ve certainly encountered varying levels of frustration. Part of my goal in writing the case was to help open a discussion to identify strategies in which women feel that they are rewarded rather than penalized for being themselves. Thank you for sharing your experience and I hope that as you find your niche you feel comfortable sharing your authentic self with your patients.

  • alittleCPR

    Great topic! Here are a few thoughts:

    1. As a young person, how do you cultivate a sense of authority and respect in your patients?

    As a former junior resident, I can certainly recall experiences of taking care of a patient and then being asked when the doctor was going to see them. I used to get upset about this, but realized that the source of this confusion was a combination of my patient demographics and the way I was presenting myself.

    Now:

    *I try to set the tone with the introduction. I do my best to speak confidently and introduce myself. For patients that have difficulty hearing, I will hold my nametag closer at their eye level.

    *I speak assertively and respectfully to the patient and their family

    *If the patient asks me to do something that is outside my training and better done by a PCA or a nurse, instead of trying to muddle through a patient transfer, I politely tell them that I will find the appropriate person to help them

    2. How do you discuss differences in gender expectations and sexism within your residency program or medical school?

    It is extremely important for learners to understand the role that gender expectations play in interpersonal dynamics between physicians and patients. I have definitely had experiences where the patient speaks/acts one way with me and does a 180 when the male attending enters the room. Or better yet, when the patient only looks at
    the male medical student observer even though I am the one addressing them.

    A frank acknowledgement and discussion of the role that these expectations play can help the learner gain insight into the patient encounter. The worst case would be a learner leaving their ER experience dejected thinking that they did something “wrong” when there
    are factors that they cannot control that impact the encounter.

  • anne smith

    I know I am so far behind here and this topic has been discussed extensively, but if anyone is interested – here are my thoughts

    I dont wear a white coat – this is quite uncommon in South Africa. There are a couple of physicians who do but personally I have found it uncomfortable. I wear ‘normal’, professional clothes and am very aware as a woman in medicine to make sure that I am ‘covered up’ sufficiently. This may sound ridiculous and self explanatory but I cannot tell you how many female medical students or interns I have seen wearing shirts that are a bit too low cut or sleeves that are a bit too revealing. I certainly dont want my patients staring down my chest while I examine them, so I err on the side of modesty.

    I wear a clearly visible name badge marked ‘Dr Anne Smith – specialist’ – and introduce myself with a firm handshake as ‘Dr Smith’. When I was younger I was often asked ‘when is the doctor going to see me?’ after I had finished examining the patient – but this is happening less and less now that I am in a more senior position. I am now often called in by a junior as the ‘second opinion’ and so the patients are aware that I am a doctor.

    As for being mistaken for nursing staff – wow this happens every single day! I am not too sure why – in our setting, nurses wear uniforms – blue or white scrubs with epaulettes displaying their qualifications and seniority, and most doctors wear ‘normal’ clothes, or scrubs after hours. I think the association that ‘all women in medicine must be nursing staff’ is still persistent especially with older patients. If patients mistake me as a nurse, I dont take it personally – just correct them and move on.

    As for sexism in the departments in which we work – this is an often difficult topic to tackle. In the South African EM community, we are very lucky in that our group is quite evenly spread and there are a lot of women in senior positions. Some of the other departments are not so lucky – I recall my surgical registrar friend being enraged at an academic meeting when the HOD commented ‘Why cant our female registrars look more like that?’ after a presentation by a particularly pretty and skinny female drug rep.

    So its a challenge.

    I certainly am very aware of how I conduct myself, especially among male colleagues in a more informal setting – there are still different standards that exist for how men and women are ‘allowed’ to behave. I try never to lose my temper at work ( women who do so are often labelled ‘hysterical’ or ‘over reactors’) and in a more social setting I keep an eye on things like coarse language and the banter that normally goes on. Women and men have quite different ways of communicating and one must keep this in mind. If there is alcohol involved, as a woman you have to be particularly careful not to put yourself in a situation where your integrity may be compromised. You cant just be ‘one of the boys’!

    Wow, I sound like a bit of a prude – I am not really but I think women sometimes have to work harder to ‘prove’ they are professionals – and its all about how you present yourself. A confident, strong handshake, frequent eye contact and a clear, low pitched voice are all great tools.