By Kari Oakes
When Shawnté James, MD, picked up the phone at work recently, a male physician on the other end was calling for a peer-to-peer review of a patient’s insurance issue.
“Hi, this is Dr. Y, calling to speak with Shawnté about patient X. Is she available?” asked the physician. “No,” replied Dr. James, an assistant professor of pediatrics at MedStar Georgetown University Hospital, Washington.
She related the rest of the interaction in a recent tweet:
“I’m Dr. XY calling a peer-to-peer review of a denial. Is Shawnté available?”
Him: “Is she in today?”
Me: “There’s no Shawnté here.”
Him: “Oh this is the number I have for Dr. Shawnté James”
The tweet, along with many others that used the hashtag #MyFirstNameIsDoctor, struck a chord among female physicians on Twitter. In tweets of their own, they related instance after instance of peers, coworkers, and patients assuming first-name familiarity with them – but not their male colleagues.
“This time it’s a peer-to-peer review. Last time it was being introduced to new hospital leadership as, ‘Shawnté, one of our pediatricians,’ ” Dr. James said in an interview. “The truth is, for physician women – particularly women of color – this is a regular occurrence.”
Data show an ongoing problem
Objective evidence that female physicians and scientists are significantly less likely than their male peers to be addressed by their titles came in a just-published study of presentations at the annual meeting of the American Society for Clinical Oncology in 2017 and 2018.
Narjust Duma, MD, the study’s first author, described her growing awareness of the problem.
Dr. Duma recalled a session on the last day of the ASCO 2018 meeting. Five presenters were speaking – four men and a woman. “The woman is the one who knows the most about this subject. She’s the only one at the table who’s a full professor,” Dr. Duma, assistant professor of hematology/oncology at the University of Wisconsin–Madison, said in an interview. “And then everybody is introduced as ‘Dr. So-and-so,’ and when they come to her, they introduce her as ‘Julie.’ ”
“Is it just me?” Dr. Duma asked herself. The same day, she began a Twitter poll to ask whether her female peers were experiencing this phenomenon, and got an “overwhelming” response.
“We need data to learn the extent of the problem,” she said she realized.
The ASCO annual meeting afforded an ideal opportunity for data gathering, said Dr. Duma, because presentations are recorded and written transcripts generated. Dr. Duma assembled a research team that had a 50-50 gender balance and racial and ethnic diversity. The team combed ASCO transcripts to code introductions according to whether title and surname were used or whether speakers were addressed by first name only.
After excluding videos that did not capture speaker introductions, Dr. Duma and collaborators were left with 781 videos to watch and code.
Female speakers overall were less likely to be addressed by their professional title (62% vs. 81% for males, P less than .001). Male introducers used professional titles 53% of the time when introducing female speakers, and 80% of the time when introducing male speakers (P less than .01). No gender differences were seen when females were the introducers (J Clin Oncol. 2019 Oct 11. doi: 10.1200/JCO.19.01608).
Looking further, male introducers addressed female speakers by first name only in 24% of the cases. Female introducers used first names only with female speakers 7% of the time, a statistically significant difference. “This is the part that is really sad,” said Dr. Duma.
She and her coauthors also performed multivariable analysis to adjust for factors such as seniority and geographic location; after adjustment, males were still over 2.5 times as likely as females to be introduced with their professional title, and females were nearly six times as likely as males to be introduced by their first names only. When the introducer was male, a female speaker was over three times more likely to be introduced by her first name only.
Dr. Duma and colleagues are working with the ASCO 2020 planning team to develop a template that standardizes presenter introductions. They’re also planning for prospective data collection at that meeting, and will include self-reported race and ethnicity data for presenters and introducers who choose to provide it.
“We do not plan to create a ‘her versus him’ battle,” said Dr. Duma. “The goal is to use this hardcore data to bring attention to the problem.” She pointed out that, though fewer females introduced other females by first name only, the problem wasn’t limited only to male introducers at ASCO.
“The problem is unconscious bias. Nobody’s exempt,” said Dr. Duma. She related that she herself had just sent a work-related email to a female colleague that addressed her by her first name, and had copied many of their mutual colleagues. Realizing her gaffe, she held herself to her own standard by apologizing to her colleague and copying everyone who saw the first email. “The goal is to bring attention to the difference, so we can improve gender bias in medicine together.”
Patient interactions: Sometimes, a delicate balance
What’s the right approach when a patient, uninvited, addresses you by your first name? Natalie Strand, MD, had been thinking about the best way to handle this sticky situation for some time. Recently, she tried it out on a patient and shared her approach in a tweet:
So proud of myself!
After introducing myself as Dr. Strand to a patient, he looked at my name badge and said- oh, so Natalie.
Usually I’m stuck feeling afraid to rock the boat…
“Yes, but I go by Dr. Strand at work! “
I finally said it!!!
— Natalie Strand (@DrNatStrand) October 11, 2019
There was an awkward moment with the patient, Dr. Strand acknowledged, “but we moved past it.”
Asserting one’s hard-earned status despite a societally ingrained desire to please or to avoid confrontation can be difficult, she acknowledged, but it’s worth it. Put simply, she said, “I want to be called Dr. Strand.”
The importance of this issue can sometimes be hard for male colleagues to understand, said Dr. Strand, who practices outpatient interventional pain medicine at the Mayo Clinic, Scottsdale, Ariz. “The people that have privilege – they don’t see it as privilege. And that’s not anybody’s fault. That’s just the reality of it, because that’s the norm. … That’s why putting a name to microaggression and microinsults is so powerful, because once you name it, then you can respond to it.”
Beginning from a point of mutual professionalism is a good place to start, Dr. Strand said in an interview. She always begins by addressing her patients by their surname and waits for patients to invite her to call them by their first names. “The most professional approach is the best first step,” she said. When she has a longstanding relationship with patients and she knows that trust and mutual respect have been established, she may also invite first-name familiarity.
“Patients don’t do this to be mean,” emphasized Dr. Strand, adding that, particularly with older patients, “they are trying to be sweet.” That’s part of the difficulty in finding a gentle but firm way to bring the relationship back to a professional footing.
Judging by the responses she’s gotten from other female physicians, this delicate situation, and the best way to ask for professionalism with patients, is a common struggle. Many of her female peers have said they’ll consider adopting her approach, she said.
“Male physicians are our allies,” said Dr. Strand. “The needs of the patients come first. This isn’t about power; it’s not about holding a power differential against the patient. It’s about having a culture of mutual respect, and being seen as a physician. Not as a female physician, not as a male physician. Just being seen as a physician, so you can act as a physician.”
Whether they come from patients or peers, said Dr. James, who adroitly called out the physician reviewer who asked for her by first name, “These microaggressions are uncomfortable to address at the time they occur – but they are teachable moments that we should all take advantage of. Usually, a gentle correction, such as, ‘I prefer to be addressed as Dr. James while at work,’ is sufficient.” However, she added, “sometimes, a firmer ‘I feel disrespected when you address me by my first name to colleagues and patients’ is needed.”
This article was updated 10/15/19.