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Strategies of Female Teaching Attending Physicians to Navigate Gender-Based Challenges: an Exploratory Qualitative Study

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Strategies of Female Teaching Attending Physicians to Navigate Gender-Based Challenges: an Exploratory Qualitative Study ORIGINAL RESEARCH Strategies of Female Teaching Attending Physicians to Navigate Gender-Based Challenges: An Exploratory Qualitative Study Nathan Houchens, MD1,2*, Martha Quinn, MPH3, Molly Harrod, PhD4, Daniel T Cronin, MD1,2, Sarah Hartley, MD1,2, Sanjay Saint, MD, MPH1,2,4 1Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; 2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; 3School of Public Health, University of Michigan, Ann Arbor, Michigan; 4VA Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. BACKGROUND: Women in medicine experience with which to respond to these challenges were evaluated discrimination, hostility, and unconscious bias frequently through semistructured in-depth interviews, focus and with deleterious effects. While these gender-based group discussions, and direct observations of rounds. challenges are well described, strategies to navigate and Observations were documented using handwritten field respond to them are less understood. notes. Interviews and focus groups were audio recorded OBJECTIVE: To explore the lived experiences of female and transcribed. All transcripts and field note data were teaching attending physicians emphasizing strategies analyzed using a content analysis approach. they use to mitigate gender-based challenges in clinical MAIN OUTCOMES: Attending experience levels ranged environments. from 8 to 20 years (mean, 15.3 years). Attendings were DESIGN: Multisite exploratory, qualitative study. diverse in terms of race/ethnicity. Strategic approaches to gender-based challenges clustered around three themes: SETTING: Inpatient general medicine teaching rounds in female attendings (1) actively position themselves as six geographically diverse US academic hospitals between physician team leaders, (2) consciously work to manage April and August 2018. gender-based stereotypes and perceptions, and (3) PARTICIPANTS: With use of a modified snowball sampling intentionally identify and embrace their unique qualities. approach, female attendings and their learners were CONCLUSION: Female attendings manage their roles identified; six female attendings and their current (n = 24) as women in medicine through specific strategies to and former (n = 17) learners agreed to participate. both navigate complex gender dynamics and role model MEASUREMENTS: Perceptions of gender-based approaches for learners. Journal of Hospital Medicine challenges in clinical teaching environments and strategies 2020;15:454-460. © 2020 Society of Hospital Medicine he demographic composition of physicians has shifted The approaches and techniques of exemplary teaching dramatically in the last five decades. The number of attending physicians (hereafter referred to as “attendings”) women matriculating into medical school rose from 6% have previously been reported from groups of predominant- in the 1960s1 to 52% in 20192; women accounted for 39% ly male attendings.15-18 Because of gender-based challenges Tof full-time faculty in 2015.3 Despite this evolution of the physician female physicians face that lead them to reduce their effort gender array, many challenges remain.4 Women represented only or leave the medical field,19 there is concern that prior schol- 35% of all associate professors and 22% of full professors in 2015.3 arship in effective teaching may not adequately capture the Women experience gender-based discrimination, hostility, and approaches and techniques of female attendings. To our unconscious bias as medical trainees5-9 and as attending physi- knowledge, no studies have specifically examined female cians10-13 with significant deleterious effects including burnout attendings. Therefore, we sought to explore the lived expe- and suicidal thoughts.14 While types of gender-based challenges riences of six female attendings with particular emphasis on are well described in the literature, strategies to navigate and re- how they navigate and respond to gender-based challenges spond to these challenges are less understood. in clinical environments. *Corresponding Author: Nathan Houchens, MD; Email: [email protected]. METHODS edu; Telephone: 734-845-5922; Twitter: @nate_houchens. Study Design and Sampling Published online first July 22, 2020. This was a multisite study using an exploratory qualitative ap- Find additional supporting information in the online version of this article. proach to inquiry. We aimed to examine techniques, approach- Received: December 20, 2019; Revised: April 23, 2020; es, and attitudes of outstanding general medicine teaching Accepted: May 16, 2020 attendings among groups previously not well represented © 2020 Society of Hospital Medicine DOI 10.12788/jhm.3471 (ie, women and self-identified underrepresented minorities 454 Journal of Hospital Medicine® Vol 15 | No 8 | August 2020 An Official Publication of the Society of Hospital Medicine Strategies to Navigate Gender-Based Challenges | Houchens et al [URMs] in medicine). URM was defined by the Association of sations within and peripheral to the team, and patient–team American Medical Colleges as “those racial and ethnic pop- interactions. After each visit, researchers met to compare and ulations that are underrepresented in the medical profession combine field notes. relative to their numbers in the general population.”20 A mod- ified snowball sampling approach21 was employed to identify Interviews and Focus Groups attendings as delineated below. Researchers then conducted individual, semistructured inter- To maintain quality while guaranteeing diversity in geogra- views with attendings and focus groups with current (n = 21) phy and population, potential institutions in which to observe and former (n = 17) learners. Focus groups with learners varied attendings were determined by first creating the following in size from two to five participants. Former learners were oc- lists: The top 20 hospitals in the U.S. News & World Report’s casionally not available for on-site focus groups and were in- 2017-2018 Best Hospitals Honor Roll,22 top-rated institutions terviewed separately by telephone after the visit. The interview by Doximity in each geographic region and among rural train- guide for attendings (Appendix 1) was adapted from the prior ing sites,23 and four historically Black colleges and universities study16 but expanded with questions related to experiences, (HBCUs) with medical schools. Institutions visited during a pre- challenges, and approaches of female and URM physicians. A vious similar study16 were excluded. Next, the list was narrowed separate guide was used to facilitate focus groups with learn- to 25 by randomly selecting five in each main geographic re- ers (Appendix 1). Three current learners were unable to partic- gion and five rural institutions. These were combined with all ipate in focus groups due to clinical duties. All interviews and four HBCUs to create a final list of 29 institutions. focus groups were audio recorded and transcribed. Next, division of hospital medicine chiefs (and/or general This study was determined to be exempt by the University medicine chiefs) and internal medicine residency directors at of Michigan Institutional Review Board. All participants were each of these 29 institutions were asked to nominate exempla- informed that their participation was completely voluntary and ry attendings, particularly those who identified as women and that they could terminate their involvement at any time. URMs. Twelve attendings who were themselves observed in a previous study16 were also asked for nominations. Finally, rec- Data Analysis ommendations were sought from leaders of relevant American Data were analyzed using a content analysis approach.25 Medical Association member groups.24 Inductive coding was used to identify codes derived from Using this sampling method, 43 physicians were identified. the data. Two team members (MQ and MH) independently An internet search was conducted to identify individual char- coded the first transcript to develop a codebook, then met acteristics including medical education, training, clinical and to compare and discuss codes. Codes and definitions were research interests, and educational awards. These character- entered into the codebook. These team members continued istics were considered and discussed by the research team. coding five additional transcripts, meeting to compare codes, Preference was given to those attendings nominated by more discussing any discrepancies until agreement was reached, than one individual (n = 3), those who had received teaching adding new codes identified, and ensuring consistent code awards, and those with interests involving women in medicine. application. They reviewed prior transcripts and recoded if Research team members narrowed the list to seven attendings necessary. Once no new codes were identified, one team who were contacted via email and invited to participate. One member coded the remaining transcripts. The same code- did not respond, while six agreed to participate. The six attend- book was used to code field note documents using the same ings identified current team members who would be rounding iterative process. After all qualitative data were coded and on the visit date. Attendings were asked to recommend 6-10 verified, they were entered into NVivo 10. Code reports were former learners; we contacted these former learners and invit- generated and reviewed by three team members to identify
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