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What is known about the topic?

While gender-based bias affects providers across medicine, there remains a literature gap specific to the Canadian emergency medicine clinical environment.

What did this study ask?

This study sought to understand how the gender of emergency medicine attending physicians and trainees affects their experiences in the ED.

What did this study find?

Findings show that gender inequity exists within the Canadian emergency medicine clinical environment and negatively affects women-identifying providers.

Why does this study matter to clinicians?

Perceived gender-based bias in emergency medicine impacts women trainees and physicians. We outline key changes that will improve gender equity in emergency medicine across Canada.

Introduction

While women comprise about half of current Canadian physicians and trainees, only 31% of emergency medicine physicians identify as female [1]. Women trainees are less likely to express interest in emergency medicine compared to men, which may be attributed to gender bias [2, 3]. Often, this stems from perpetuated implicit gender biases, which are subconscious feelings and prejudices that arise from personal experience, societal stereotypes, and cultural context [4]. Across medicine, women physicians and trainees disproportionately experience gender inequity compared to their male-identifying colleagues [5,6,7,8,9,10]. Prior research has shown that gender inequities exist across several levels—patient care, career advancement, and personal life.

Female emergency medicine physicians have been shown to experience higher rates of gender discrimination and receive unwanted inappropriate comments [6]. Interestingly, patients, physicians, and nursing staff were reported to be the most frequent sources of discrimination. Gender-based bias can further affect the career development and well-being of women physicians and trainees [5,6,7,8,9,10,11]. Evidence has demonstrated that women are less likely to be recognized as physicians by patients and tend to receive more gender-stereotyping comments. Comments include referring to women as “honey” or “sweetie,” viewing young women as inexperienced, and asking intrusive personal questions [7, 8, 12]. Women must prove to their patients that “yes, they are the doctor,” where repetitive role misidentification can lead to feelings of inadequacy and mistrust [13].

Although instances of provider gender inequity are well documented within other specialties in medicine, there remains a gap in the literature specific to the Canadian emergency medicine clinical environment. Through analysis of the experiences of emergency medicine providers across Canada, this study aims to illuminate the perceived role that gender plays within the clinical space.

Methods

Study design and setting

Using a qualitative study with a thematic analytical approach, participants were recruited from a cross-section of urban, community, and rural EDs across Canada [14]. This study received ethics approval by the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.

Participant recruitment

Using purposive and snowball sampling, participants included emergency medicine attending physicians, resident physicians, and medical students who had completed either core or elective emergency medicine rotations. Participants were eligible to participate if they practiced or trained in Canadian EDs. Individuals were excluded from participating if they did not practice or train in EM or were pre-clerkship medical students.

Data collection and analysis

A semi-structured interview guide was created with a team of emergency medicine physicians (MB, DD, EB), medical student (GJ), and research scientist (MW), based on themes derived from evidence-based literature and secondary data provided by the Canadian Association of Emergency Physicians (CAEP) Gender Equity Working Group [5, 6, 15,16,17,18,19] (Online resource 1).

The survey was piloted and revised with consultation from the research team. Informed consent and demographic data were collected, and interviews were conducted by one researcher (GJ) from May to December 2022 through the online video-conferencing platform Zoom [20] (Online resource 2). Interviews were audio recorded, transcribed verbatim, and de-identified. Interviews continued until data saturation was reached and there were an equal number of women and men in the entire sample to ensure varied perspectives from individuals that practice in EM. Data saturation was a point in data collection where conducting additional interviews did not contribute to new ideas or themes emerging [21].

Thematic analysis, using an inductive and deductive approach, was undertaken to identify emerging patterns in the data through an experiential lens using NVivo12 [22, 23]. To maintain reflexivity throughout the study, both coders, who were medical students, consciously made note of potential biases. Trustworthiness was achieved through qualitative research criteria of credibility, transferability, dependability, and confirmability [24]. This is comparable to quantitative research criteria of validity and reliability. Achieving trustworthiness criteria ensures rigor in qualitative research and provides confidence in a study’s methods, data, and interpretation [25]. Triangulation was achieved by interviewing three separate participant groups and by having all data independently double coded by two researchers (GJ, MS). Triangulation enhances study credibility by mitigating bias in qualitative research [26]. The study followed SRQR reporting guidelines.

We acknowledge that gender is a personal experience that encompasses a spectrum of identities. Participants used both female/male and woman/man terms interchangeably throughout the interviews; thus, we utilized both sets of terms throughout the paper to reflect participant’s understanding of and reference to gender.

Results

Characteristics of study participants

Thirty-four individuals (17 women, 17 men) from ten institutions across four provinces in Canada participated. Complete demographic data can be seen in Table 1.

Table 1 Demographic data
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Thematic analysis

Six themes were identified that describe gender-based bias within emergency medicine clinical practice. Additional supporting quotations can be seen in Table 2.

Table 2 Additional supporting quotations
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Theme 1: women experience gender bias in the form of microaggressions

Common microaggressions include role misidentification and inappropriate comments about appearance. Male participants were not recipients of microaggressions and often witnessed microaggressions directed to female physicians and trainees. Typical sources were from patients, colleagues, and allied healthcare professionals.

“You'll introduce yourself as the doctor and you'll do their whole history, physical, make a plan, tell them the plan, discharge them and then they're like, ‘Oh am I not going to see the doctor today?’ And I'm like ‘Oh god, like I am the doctor.’” (Resident, woman).

“I feel privileged as that individual who doesn't have to reassert themselves as ‘Yes I am the physician.’ […] People's assumption I think is that I'm the attending physician in the room.” (Attending, man).

Participants expressed difficulty in garnering the respect of a healthcare team in acute situations as a woman. This created an unnecessary burden and undermined female physicians and trainees' confidence.

“Oftentimes if another tall man walks into the room, then my authority will be undermined.” (Attending, woman).

Theme 2: women experience imposter syndrome and question their role in the clinical environment from compounding experiences of gender bias.

Women described developing imposter syndrome throughout their training which continued into their years as staff. Participants found it difficult not to doubt themselves when they were repeatedly reminded that they do not belong.

“It just makes you question your, in a weird way, worth. […] Over time the more you even subconsciously thought, ‘That's not your role. That's not your role. That's not your role.’ I think sometimes it can contribute to feeling like maybe I don't belong here.” (Attending, woman).

Most women felt that they were unaware of imposter syndrome until learning about it on their own. Delayed understanding can further impact individual well-being and career development.

“It wasn't until I did a bit more of this kind of diversity, equity, and inclusion type of work, and understanding it that I realized a lot of my imposter syndrome is simply a result of being undermined over and over again. […] You don't feel like you're a competent physician at the end of the day because you're getting these external signals that you should be something else.” (Attending, woman).

Male participants found that they were respected in their role and did not experience imposter syndrome.

“People just respect what I have to do.” (Resident, man).

Theme 3: women provide more patient care to women patients and vulnerable populations

While women expressed gratitude and purpose in providing trauma-informed care to patients; with that can arise an increased burden of feeling like a token woman. Women participants reported perceiving that they were asked to see women patients based on their own gender identity more than their male colleagues.

“Being a woman […] is advantageous at times because patients with perpetrators of violence who identify as male tend to see female identifying figures, […] they tend to be a little bit more comfortable with them […] and honest about their disclosures.” (Clinical clerk, woman).

“You're going to always be the token woman who has do the gynecological exam when a woman [patient] comes in.” (Attending, woman).

Female staff felt that sensitive exams and counseling are not well remunerated in the ED, and there can be a dissonance in wanting to provide excellent care and be compensated appropriately.

“Females tend to be asked more to do things that are time consuming and less well remunerated.” (Attending, woman).

Interestingly, several male trainees lacked opportunities to perform gynecological exams on female patients, which can ultimately impact their clinical skills.

“Opportunities—I don't want to say taken away from you—but sometimes you might have to modify the procedures you need to do based on the gender you're in. […] I don't think it's a major negative impact, but more of like a small, maybe deviation for a potential learning opportunity.” (Resident, man).

Theme 4: gender-related challenges with family planning and home responsibilities affect work-life balance

Participants agreed that the childbearing parent typically encounters more challenges with balancing responsibilities between work and life. This further extends into maintaining career productivity and attaining clinical opportunities.

“Especially when I was pregnant sometimes people will make comments like, ‘Oh, you'll have to drop out of residency.’” (Resident, woman).

“There are sometimes when it is more challenging to be the birthing parent and female. […] I had three kids; with each child I've still been able to maintain academic momentum and professional momentum. I don't know if that would have been the case if I were the birthing parent.” (Attending, man).

Medical students can be impacted by biases that women are unable to be both successful emergency medicine physicians and have families. Trainees may have doubts pursuing emergency medicine due to perceptions of a culture that is not supportive of them.

“Male preceptors […] will sometimes make comments when I would talk to them about my decision of doing the 5-year vs. 2 + 1 emerg program of, ‘Oh, well you also have to consider that you'll be a mom one day and a wife.’ […] And I was like, dude I didn't even tell you if I want kids or if I want to be married or anything.” (Clinical clerk, woman).

Theme 5: allyship and sponsorship are important for the support and development of women physicians and trainees

Both allyship, showing support for a disadvantaged group that you are not a part of, and sponsorship, using social capital to advance opportunities for others, are integral to support women physicians and trainees.

“We rely on the word of men to other men to kind of get our issues across. I just wonder why it's not enough for us to be listened to in the first place.” (Resident, woman).

Most women felt that receiving support specifically from male colleagues provided more opportunities in leading resuscitations and high acuity procedures, and diffused micro- and macroaggressions in the clinical space.

“There's male staff physicians that will intentionally step out of the room when a female resident is leading [a code] so that the interdisciplinary staff are forced to have to direct things to the resident.” (Resident, woman).

“I’m trying to be very cognizant and open about some of the potential challenges that our female colleagues may experience. […] Perhaps, advocating for female trainees in the workplace, not just as a response to a negative event, but in an overall promotional capacity.” (Attending, man).

Theme 6: women value discussing shared experiences with other women to debrief situations, find mentorship, and share advice

Women across stages of training found relationships with other women in emergency medicine to be crucial in cultivating their own career.

“When female trainees may not see themselves reflected in the profession or don't think that it will be supportive of their gender, they just won't apply, they won't even put an application in.” (Attending, man).

“I remember the first time I worked with a female attending and I just remember it was a very good shift because I just felt like I could see myself in this person's shoes.” (Clinical clerk, woman).

Partaking in women groups were beneficial for females to debrief gender bias in the ED and share unique advice. Women found these groups empowering and supportive of their career progression.

“I worked to cultivate female-only spaces for myself in emerg because I think there are a ton of male-only spaces naturally. […] We need to create space for women by women about women.” (Resident, woman).

Discussion

Interpretation

This study explored gender bias within the clinical practice of emergency medicine in Canada using a sample of emergency medicine physicians and trainees. Six themes were identified that encompassed microaggressions, imposter syndrome, patient care, work-life balance, allyship and sponsorship, and shared experiences. The identified themes provided several avenues for improvement to address the barriers preventing gender equity.

Previous studies

Previous studies have demonstrated that gender bias is a prominent issue across medicine and disproportionately affects women-identifying emergency medicine providers [5, 6, 10, 27,28,29]. Similar to prior research, female participants in our study described more microaggressions in the workplace and received less trust from patients and providers compared to male participants [13]. Other literature speaks to the idea that imposter syndrome experienced by women providers stems from ongoing gender bias [30,31,32]. Our participants described that feelings of inadequacy were not due to their own shortcomings but from repetitive questioning of their competency. Interestingly, there are few studies exploring the utility of allyship and sponsorship in emergency medicine, although it has been found to be crucial in supporting women physicians/trainees in other medical specialties [33,34,35]. Our participants endorsed the benefits of effective allyship and sponsorship to both reduce gender bias and empower women. Further, trainees that anticipate having increased family care work in their future may find emergency medicine less appealing as a career due to stereotypes related to traditional gender roles perpetuated by departmental cultures and societal expectations. As identified by participants, some emergency medicine preceptors commented to women trainees that a career in emergency medicine is not feasible if they desired to be married or start a family in the future. Assumptions regarding what specialties trainees are interested in based on their gender can lead to discriminatory treatment that prevents women from entering the field [36, 37].

Strengths and limitations

As with most qualitative research and use of purposive and snowball sampling to recruit participants, sampling bias is a concern. While effort was made to ensure that participants with varied perspectives were interviewed, there may be experiences not fully captured in this study, such as individuals with non-binary gender identities and diverse racial identities, and family medicine trained emergency medicine physicians. This limits the transferability of findings to these groups of emergency medicine physicians and trainees. Given that participants were asked to describe past experiences, recall bias could be affecting the data. Further, despite the interview guide not referencing sex terminology with respect to gender identity many participants used sex and gender terms interchangeably. This may reflect participant’s own understanding and reference to gender. Perhaps individuals used the terms interchangeably, because they found their sex and gender identity to be congruent. As the sample was limited to participants with binary gender identities, interpretations cannot be drawn as to how individuals with diverse gender identities would use the terms. The use of sex and gender terminology as synonyms may also reflect a lack of understanding of gender identities and a possible avenue for knowledge interventions.

There are several noteworthy study strengths. To our knowledge, this is the first qualitative study in Canada to examine gender-based bias in emergency medicine clinical practice and further adds to the current expanding evidence base. This study involved a cross-section of emergency medicine physicians and trainees across the country and had an equal representation of women and men, which allowed for comparison of experiences and amplified that the recurrent themes of gender inequity exist across Canada. The qualitative study design allowed us to gather in-depth perspectives on the lived experiences of impacted individuals and the individuals who witnessed it. Data saturation gave assurance that no major themes were missed in the study sample.

Clinical implications

This research has informed three recommendations for institutions to consider when aiming to improve gender equity:

  1. 1.

    Increase awareness and education to empower providers to make small changes in their everyday practice: Gender equity training can be incorporated into simulation training, department rounds, or workshops. One study used a gender-based microaggressions simulation case to encourage discussion surrounding gender bias and practice addressing microaggressions in the ED [38]. Authors noted that the session was met with positive feedback and provided participants with tools to address microaggressions in their own practice.

  2. 2.

    Provide training and advice to all providers on how to be an effective ally and sponsor: Educational interventions can be augmented by including training on effective allyship. Female participants described the benefits of sponsorship and allyship; however, felt that oftentimes the onus fell on them to educate their colleagues. An allyship workshop that was piloted in a pediatric center focused on individual accountability and speaking up against discrimination through allyship [39]. The workshop was successful in increasing awareness and self-reflection, and empowering participants to respond to discrimination.

  3. 3.

    Policies should be created with gender equity in mind: Residency training and early career often coincide with prime childbearing years for women, which makes it challenging to start a family without formal and equitable policies [40, 41]. A comprehensive return-to-work policy was piloted and met positively with stakeholders at Stanford’s ED that focused on standardized parental leave, return-to-work clinical scheduling guidelines, breastfeeding, childcare, and related resources [42].

Research implications

Future research should include participants who identify as gender-diverse and from additional intersectional identities to understand their unique perspectives and guide proposed initiatives. As well, research could focus on investigating factors that affect trainee’s choice for and against a career in emergency medicine.

Conclusion

Gender inequity in emergency medicine affects women-identifying providers at all levels of training and practice across Canada. Perceived gender bias in the clinical space can then negatively impact career development, well-being, and clinical performance. Institutions are encouraged to self-reflect on their emergency medicine departmental culture and consider implementing tailored interventions that target the barriers identified in this study. We hope that by enacting these changes that emergency medicine in Canada can work toward being a more equitable and inclusive specialty, that will both attract a new generation of gender-diverse providers and improve the clinical space for women-identifying physicians and trainees.