The survey response rate was 61% (110/181). Of the respondents, 64 identified as women, 1 as non-binary, and 45 as men. We limited statistical analyses to participants who identified as women or men due to sample size limitations; of note, the non-binary individual did screen positive for stereotype threat (SVS score > 18). Women were significantly more likely than men to have a score indicating experiencing gender-based stereotype threat (77% vs 0%, p < 0.001).

Of the 110 survey respondents, 39 offered to participate in focus groups. Thirteen were ineligible because they were men or non-binary, and 6 were ineligible because they screened negative for vulnerability to stereotype threat. We recruited from the 20 willing and eligible survey respondents and conducted 2 focus groups with 7 and 3 participants. The pilot focus group included 7 recently graduated residents. In total, 17 women participated in 3 focus groups. We identified 4 themes describing women’s experiences of gender bias and impacting vulnerability to stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship.

Residents described gender norm tensions while leading teams, making clinical decisions, and giving orders to nurses and other staff. They felt that societal expectations of their behavior as women were at odds with requirements for successfully performing their job. Participants universally described challenges to fulfill stereotypically feminine approaches of being collaborative and friendly, while still being “decisive and authoritative” (FG3-7). One participant described “I get feedback, I’m not assertive enough….so then I’m more assertive. And then I get feedback that I’m being confrontational…so then I’m way less assertive. And then I get feedback again that I smile too much and that I am not assertive enough. And so it’s impossible to strike this perfect balance” (FG3-1). This type of negative feedback reinforced to participants “how thin of a tight rope you are traversing” (FG2-3) and they felt “penalized” (FG3-4) when attempting to be authoritative.

Such gender norm tension also manifested in participants’ descriptions of the differing expectations of them compared to men peers: “the expectation is that you always have to be emotionally present as a woman, and when you’re not, it’s like you’re failing. And then for our male colleagues, the expectation is not that they always need to be emotionally present. So when they aren’t, that’s fine…when they are, it’s extra amazing” (FG2-3). Another participant described how men colleagues received more credit, especially with regard to stereotypically feminine qualities: “everyone’s like, ‘Wow, he’s a really good listener…People are impressed with him for listening instead of just expecting it like they would of you” (FG3-2). These multifaceted expectations consumed mental energy: “exhausting…to be in that space where you’re like, am I nice enough? Am I supportive enough? Am assertive enough? Am I all these things enough?” (FG2-3). These feelings led women to conclude that they were held to higher standards than men, with wide-ranging and conflicting expectations for their behavior.

Nonetheless, many participants took pride in the perception that they brought valuable interpersonal skills and high emotional intelligence. One participant shared her ability to “empower different members of the team and bring in everyone’s skills” (FG2-2). Still, they felt when their communication and collaborative skills shined too much, their clinical strengths would go underrecognized. One participant recalled getting feedback from an attending, “‘What a great job you do bringing snacks for the team’…I was so offended…write something about my clinical acumen” (FG2-2). Despite taking pride in their emotional strengths, altogether participants felt burdened by the need to be both warm and authoritative simultaneously, in an environment in which other people seemed to prioritize their warmth and judge them differently than men’s.

Participants experienced frequent gender-based microaggressions from other care providers and patients, and overt sexual harassment from patients. These experiences caused participants to doubt their own potential. A common form of microaggression was being misidentified as non-physicians and “incessantly being called nurse” (FG1-4). Microaggressions threatened participants’ sense of worth and capability as physicians: “it gets reinforced, these notions that, ‘Oh, you’re not supposed to do this.’ Because, ‘Oh, are you a nurse?’ Or, ‘Are you sure you’re a doctor? Have you graduated high school yet?’” (FG3-2). These constant assumptions that participants were non-physicians seeded doubt in their abilities, promoting vulnerability to stereotype threat.

Participants recalled distracting, derogatory comments regarding their speech and appearance from other physicians and patients. One participant recalled “I was doing an echo on a patient. The whole time, he’s like, ‘… You’re so pretty. I’m so glad I get to watch you while you do this echo’…completely degrades my position and my professional place…I’m just doing the echo and getting sexually harassed the whole time” (FG3-1). While the constant microaggressions eroded participants’ confidence, overtly sexist incidents stood out in their intensity: “those big mega experiences, that shook my confidence for months afterwards and still makes me afraid for when I’m going to be in that situation again” (FG3-5). Another participant worried about the impact on learning: “If you’re being harassed by a patient, what is the chance that you’re actually going to remember any of the clinical knowledge that happened in that encounter?… Not a lot of memory forming when the cortisol is coursing through you” (FG3-7). Altogether, microaggressions and sexual assault made participants feel they did not belong in the physician role, detracted from their learning, and caused self-doubt.

Participants reported that patients, other physicians, and other care providers regularly questioned their authority as resident physicians. Lacking authority made it difficult to carry out their responsibilities, particularly in high-acuity clinical situations. Multiple participants described leading code blues as particularly challenging: “I was doing it in the way that you’re supposed to, which is speak loudly and clearly, and make clarifications…the feedback I was getting was, ‘Don’t you dare tell me what to push. We’ve been running codes for 20 years. We know how to do this. Don’t you dare tell us how to do compressions’…later, I found out that the nurses who were on that night had given feedback to the ICU supervisor ‘The code leader had been very bossy’” (FG3-5). One participant summarized, “when you know you’re supposed to be in charge and there’s no ambiguity, it’s still hard to be in charge” (FG3-4). Another participant described being interrupted and ignored while trying to give instructions to a team of nurses during a rapid response: “[I] felt… what am I doing wrong here as a leader that I can’t get this done?…I still struggle with that a little bit….every time I get that feedback or those types of interactions where my role is questioned, it shakes my confidence a little bit. Same with patients, when patients question it too, I’m like, do you really want me as your doctor?” (FG2-1). Doubt from patients about their competence also negatively affected participants, including one who reported hearing: “You seem very nice, but you really seem like you don’t know what you’re doing” (FG2-2). Participants’ experiences with lack of authority across multiple contexts diminished their confidence and led them to question their ability to perform their job, though all felt retrospectively that they were capable.

Because participants felt it was difficult to gain respect, some avoided situations that made them vulnerable, even at the expense of missing learning opportunities. Although a common physician practice at all levels is to run questions by colleagues, participants reported that engaging in this practice could prompt others to assume they were insufficiently competent. One resident described asking a colleague to check a patient with her: “I’d been managing this patient the whole night and then had done a lot of good initial triaging and management, afterwards I left the room feeling like I had completely failed in a way…the way that this backup person came in…quite condescending, being like well, did you think about this? Should we do this too?” (FG2-3). Similarly, participants hesitated to ask questions because it undermined their authority: “asking questions, it’s an invitation for someone to mansplain to me essentially” (FG2-2). Participants deliberately avoided asking questions and considered this to have a direct negative impact on their learning. Even as senior team members, they had difficulty earning respect from interns, colleagues, and attendings: “One of my male co-residents was like, ‘No, that’s absolutely wrong. This person is in a different type of shock’…. then the attending was like, ‘Oh, yeah. That’s not right.’…then we went into the room and did the exam all together. It was clear that my assessment was correct…[I] had been totally shut down in front of the entire 20 people there, and then actually I was right and no one bothered to say a damn thing” (FG3-3). These dynamics led participants to feel they needed to prove themselves through double checking and gathering evidence to be sure they were right before speaking up, or not speak at all.

Participants described ways of trying to exude authority. Many opted to wear a white coat and display their badges prominently: “wear that badge that says, ‘DOCTOR’, in all capital letters like a shield” (FG2-2). Participants ruminated about how to modify their appearance to gain respect and resented that they had to consider these matters: “if I look more put together, will people respect me more or less?” (FG3-3). Nonetheless, any authority they did have felt tenuous and rumination about how to establish authority consumed mental energy.

Participants related acts of support and allyship that helped overcome the consequences of gender bias and stereotype threat. One ICU attending pre-emptively acknowledged that men tend to crowd out women when viewing x-rays, encouraging men to step back and women to step up. Attendings also exhibited allyship by affirming clinical decisions or standing behind the participant so the team would address her during rounds. Participants recalled that both men and women displayed acts of allyship, though women tended to recognize and acknowledge microaggressions more frequently. Many participants described interactions in which no one responded in the moment but later acknowledged that gender bias had occurred; participants appreciated that they noticed but also highlighted this missed opportunity to educate the team in the moment.

Though support from colleagues was appreciated, some participants lamented that they did not have a stronger internal sense of worth. When seeking jobs and networking opportunities, they hesitated more than they observed their male colleagues doing: “it wasn’t until my husband, who’s a man, was like, ‘Your worth is here, and you’re asking for things here’…. I feel like it’s unfortunate that it takes a man to remind me that I’m worth more than I think I am” (FG1-1). Participants appreciated when mentors, often women, shared their own struggles with confidence and offered encouragement. Although support in the form of allyship and mentorship helped participants cope with gender bias, they remained vulnerable to stereotype threat in an environment where the threats to confidence were frequent.