Anita Chary, MD PhD and Jossie Carreras Tartak, MD MBA Harvard Affiliated Emergency Medicine Residency
Our favorite quote from Esther Choo encourages us to "allow our female trainees to spend less time learning how to walk the fine line between normative and counternormative behaviors and more time simply learning to be physicians." This is the GOAL in medicine. But currently we aren't there. Our female trainees are still getting discordant feedback, feedback about PERSONALITY. And they are still trying to balance on the tightrope between societal expectations and the needs of the patient on the stretcher in front of them, between normative and counternormative, between "masculine" and "feminine", between assertive and bitchy. Here's some great advice on that tightrope walk ladies...
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Female physicians in emergency medicine must act as leaders in many types of clinical situations, such as traumas, codes, and critical procedures. However, we walk a fine line in how we assert our authority, as many leadership qualities are perceived as traditionally masculine traits, and displaying them transgresses common expectations among hospital colleagues of how we should behave. Standing our ground is perceived as being “too assertive” or “aggressive,” advocating directly for our patient care plans seems “domineering,” and blunt, to-the-point communication is seen as “bitchiness.” In contrast, not speaking up for ourselves can lead to gaps in our training—such as missed procedures and leadership positions (1)—and to poor evaluations of our performance (2).
In training, particularly early on in residency, finding a personal leadership style as a female physician can be challenging. Over the course of our training, here are some of the more subtle ways in which female physicians can establish our clinical leadership roles. Many of these tips have been passed on to us by our mentors.
Address people by their names: Learn people’s names and use them. It’s hard, especially when rotating between multiple hospitals, each with a huge nursing staff, but make the effort. It lets people know you value them, facilitates your ability to be a leader, and ultimately will improve patient care.
EMS Report: As EMS is wheeling a patient into their room, be the one to make eye contact with EMS when they give report. A simple phrase such as “Let’s transfer the patient onto our stretcher and then get report” helps set the expectation that you are the person in charge of that patient. Similarly, when EMS finishes giving report, ask the room if anyone has questions for them. Thank EMS before they leave.
Time outs: Time outs occur before major procedures like central lines, intubations, and procedural sedations, and are critical for patient safety. They can also be incredibly helpful in establishing your knowledge and role. Being the one to lead the timeout can show that you know what’s going on and you know and appreciate everyone’s roles. As an example, here is a script: Pause - Are we all ready for our time out? Patient ID - This is patient XX. DOB is XXX. Summary of procedure - We are about to do a procedural sedation and cardioversion. Review Roles - I am [name] and am the resident doing the sedation. Dr. [X] is the attending supervising the sedation and cardioversion. Kerry is our nurse who will be documenting. John is our nurse who will be giving meds. Ben is our tech on the monitor. Once the patient is sedated, I will charge the Zoll and cardiovert. Plan – We will use etomidate 10 mg for the sedation. I will cardiovert. Ben will help grab an EKG afterwards. Feedback - Does everyone agree? Does anyone have questions or concerns?
Traumas and Codes: When a trauma or code is called in advance, prompt each person in the room to introduce themselves and state their roles. In addition to establishing your role as the person in charge, it also gives you an opportunity to assign critical roles like airway and procedures. Once the resuscitation begins, be the constant voice in the room. Think aloud. When people hear you talking constantly, they know you’re in charge. Summarize frequently—sometimes, more than you think is necessary. It helps everyone else understand what’s going on, and it helps establish that you’re in charge.
Handling conflict: When there are disagreements about patient care decisions, make sure to: 1) acknowledge the other party’s concerns, 2) overtly state your rationale, and 3) remain open to suggestions. An example of a common scenario where staff opinions differ about patient care is the management of violent patients. Nurses are often more vulnerable to patient aggression than physicians, because nurses spend more time at bedside with verbally and physically abusive patients in contrast to physicians who perform an initial assessment and brief re-evaluations. However, physicians are trained to avoid physical restraints and forced chemical sedation because they can be physically and emotionally harmful to patients in the short and long term. It’s important to acknowledge the unique position and risks that nurses face and to open the floor to other ideas. This is an example of how a conversation could start: “I understand that this patient was verbally abusive to you, and I’m very sorry about that. We are giving this patient food not to reward their behavior, but to de-escalate them and avoid restraining them. However, if there are other measures you think we should try instead, I am open to suggestions. What are your thoughts?”
Societal expectations make it hard for women in medicine—and in most other fields—to assert their leadership without appearing confrontational. Employing a clear communication style and being deliberate about inviting collaboration can make a difference in how we are perceived as leaders. We owe it to ourselves to maximize our educational opportunities and optimize our professional development.
References
1. Hansen M, Schoonover A, Skarica B, Harrod T, Bahr N, Guise JM. Implicit gender bias among US resident physicians. BMC Med Educ. 2019 Oct 29;19(1):396. doi: 10.1186/s12909-019-1818-1.
2. Santen SA, Yamazaki K, Holmboe ES, Yarris LM, Hamstra SJ. Comparison of Male and Female Resident Milestone Assessments During Emergency Medicine Residency Training: A National Study. Acad Med. 2020;95(2):263-268. doi:10.1097/ACM.0000000000002988
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