Clerkships
The Effect of Gender on the Clinical Clerkship
Experiences of Female Medical Students:
Results From a Qualitative Study
Palav Babaria, Sakena Abedin, MD, MA, and Marcella Nunez-Smith, MD, MHS
Abstract
Purpose
To characterize how female medical
students perceive the role of gender
within their medical education during the
transition to the clinical curriculum.
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Method
In 2006 –2007, the authors conducted a
qualitative study consisting of in-depth
interviews with 12 third-year female
medical students completing their first
clinical clerkship. Participants were
purposefully selected from a single New
England medical school to represent a
range of ages, ethnicities, and prior life
experiences.
Close to fifty percent of all medical
school matriculates in the United States
are women, and the number of women
entering medical school continues to
increase.1 Most of the existing research
about women in medicine, largely limited
to female physicians posttraining, has
demonstrated that gender often negatively
influences their professional experiences.
Prior studies have shown that women in
academic medicine are underrepresented
at the professorial rank and are
compensated less than are their male
colleagues even after adjusting for
academic productivity.2–5 Ash et al’s6
2004 study surveying 1,814 female faculty
Ms. Babaria is a fourth-year medical student, Yale
University School of Medicine, New Haven,
Connecticut.
Dr. Abedin is a graduate student, Program in the
History of Science and Medicine, Yale University,
New Haven, Connecticut.
Dr. Nunez-Smith is assistant director, Yale
University Robert Wood Johnson Clinical Scholars
Program, and assistant professor, Department of
Internal Medicine, Yale University School of
Medicine, New Haven, Connecticut.
Correspondence should be addressed to Ms.
Babaria, Yale University School of Medicine, IE-61
SHM, PO Box 208088, New Haven, CT 06520-8088;
telephone: (203) 785-6454; e-mail: (Palav.babaria@
yale.edu).
Academic Medicine, Vol. 84, No. 7 / July 2009
Results
Participants (1) struggled to define
their role on the wards and often
defaulted to stereotypical gender roles,
(2) perceived differences in the nature
of their workplace relationships
compared with the nature of male
medical students’ workplace
relationships, (3) had gendered
expectations of male and female
physicians that shaped their
interactions with clinical supervisors, (4)
felt able to negotiate uncomfortable
situations with patients but felt unable
to negotiate uncomfortable situations
with supervisors and attendings, and
members revealed an average base salary
deficit for female physicians of $11,691
compared with male colleagues, and the
deficit increased with seniority.
In addition to such career advancement
considerations, up to 70% of female
faculty report gender-based discrimination
and sexual harassment.7–9 A study in 2000
interviewed both male and female
academic physicians regarding perceived
gender discrimination and found
statistically significant differences (P ⬍
.001) between the experiences of male
and female physicians.7 Forty-eight
percent of female physicians reported
having experienced sexist comments or
behavior (compared with 1% of male
colleagues), and 30% reported experiencing
severe harassment, such as sexual
solicitation, threats, or coercive sexual
advances (compared with 3% of male
colleagues).7 These experiences are
associated with other important outcomes,
such as low career satisfaction.7,10 Carr
et al’s8 in-depth 2003 qualitative study
examined the effect of gender
discrimination on the experiences of female
faculty. Participants who had experienced
gender discrimination reported lower self-
confidence and self-esteem, cynicism
towards their academic work environment,
isolation, and a lack of institutional
(5) encountered a “gender learning
curve” on the wards that began to
shape their self-view as future female
physicians.
Conclusions
Despite increased numbers of women in
medicine, issues of gender continue to
have a substantial impact on the medical
education of female students. Institutions
can design interventions about gender
issues in medicine that expand beyond a
focus on sexual harassment to address
the complex ways in which students are
affected by issues of gender.
Acad Med. 2009; 84:859–866.
response to such experiences. When
interviewed, women in academic medicine
also frequently cite the lack of equitable
mentorship as one of the major barriers to
career advancement.
Qualitative studies have also previously
described the potentially negative impact
of gender on the professional relationships of
female physicians. Female physicians
have described tension with female
nurses in the workplace, resulting from
what they perceive to be differential
treatment of male and female physicians.11,12
Female physicians perceived that
they had to be “nicer” and more
“accommodating” to nursing staff and
also received less technical assistance
caring for patients and cleaning than did
their male colleagues.12
The consistency of the findings across the
existing research literature has triggered
the development of numerous policies
and programs to increase the support of
women in medicine during the past 15
years. Many universities have established
offices of Women in Medicine to assist
female faculty and students in addressing
gender bias, instituted mandatory sexual
harassment trainings, and increased
efforts to recruit more female faculty who
can serve as role models for female
859
Clerkships
medical students in addition to
diversifying the faculty.2,13
Although research into the professional
experiences of practicing female
physicians has been comprehensive, less
is known about the experiences of female
medical students. The majority of research
involving female medical students has
focused on rates of medical student abuse
and sexual harassment.14 –17 In Nora et
al’s14 14-school survey from 2002, 83% of
female medical students reported having
experienced gender discrimination in a
variety of clinical and nonclinical
settings. Such experiences were most
prevalent in university hospitals and on
core clerkships (notably surgery and
obstetrics– gynecology). Several studies
have documented that both male and
female students report significantly
higher rates of gender discrimination in
their clinical clerkships than during the
first two years of medical school,14,18,19
suggesting that the structure of clinical
education, as well as interactions on the
wards, lend themselves to greater rates of
gender-based discrimination compared
with classroom learning. Interestingly,
studies that have further examined
what students mean by “gender
discrimination” and “sexual harassment”
suggest that students actually perceive less
gender discrimination and harassment as
they progress through medical school,
likely because of acculturation.20 As Nora
et al20 hypothesize in a 1993 study,
“Perhaps people ‘buy into’ certain
settings for their own psychic survival
and/or to increase the likelihood of
their success. In these instances, the
organizational culture is accepted over
time.” Wear et al’s17 2007 qualitative
study looked specifically at the
perceptions of sexual harassment among
contemporary female medical students.
Participants reported frequent “sexual
innuendo, explicit sexual banter, or crude
language”; however, as Wear wrote, “not
one of the students we interviewed
went so far as to label any of it ‘sexual
harassment,’ even after our initial
definition was read to them prior to each
focus-group.”
Given that many students seem to shy
away from using the terms “sexual
harassment” and “gender discrimination,”
targeted questionnaires may fail to
capture the full extent to which female
medical students experience such
behavior. Despite this shortcoming,
860
national surveys have clearly documented
that female medical students report
gender bias at significantly higher rates
than do their male peers, but they do not
provide any further insight into the range
of experiences attributed to gender that
female medical students may have.
Given the increasing numbers of women
in medicine and the substantial policy
changes to support gender diversity in
medicine, understanding the influence of
gender on the experiences of the next
generation of female physicians is
paramount. Therefore, we conducted a
qualitative study of female medical
students transitioning from a preclinical
to a clinical curriculum in order to
characterize how gender influences their
training experience.
Method
Study design and sample
We conducted in-person, in-depth
interviews with 12 female third-year
medical students to characterize their
gender-related experiences during the
first month of clinical clerkships. To
ensure the anonymity of the limited
number of participants, we have chosen
not to identify the name of the institution
within the text. We used a qualitative
methodological approach because we
sought to generate hypotheses regarding
how gender affects the experiences of
female medical students that would
provide better understanding of previous
quantitative surveys.21 Only females were
considered for participation in this study,
as it specifically examines the experiences
of women in medicine. In addition,
students who did not intend to complete
an entire year of clinical clerkships were
excluded from the study, as this study
was part of a longitudinal cohort study.
We identified and recruited a purposeful
sample of female medical students, paying
particular attention to characteristics such
as age, self-identified racial/ethnic
background, prior life experiences, non-
English primary language, undergraduate
institution, and relationship status.22 Two
invited students declined to participate
(one student cited time constraints, and
the other expressed concerns about the
potentially negative impact of participating in
the study on her future career), so two
other students were identified and
recruited to replace them. The research
protocol was approved by the
institutional human investigation
committee. We obtained signed consent
from all participants.
Data collection
From June 2006 to June 2007, in addition
to a baseline interview conducted prior to
starting their third year and an exit
interview at the completion of their third
year, we interviewed our cohort of 12
female medical students after the
completion of each 4- or 6-week clinical
clerkship. This current analysis focuses
only on interviews describing the
experiences of subjects after their first
month of clinical clerkships given the
unique experiences that participants
reported during their initial encounters
with clinical medicine. Future analyses
will examine participant perspectives
throughout the clinical year. One
member of the research team (P.B.)
conducted all interviews; the interviewer
was a female medical student doing
clinical clerkships at the time of the
interviews. We purposefully chose to
have a single interviewer who was
gender- and role-concordant with the
interviewees, as similarities between
researchers and key informants, such as
gender or work role, can often facilitate
rapport and therefore yield rich data.14,23,24
All interviews were conducted in-person,
with only the interviewer and a single
participant present, and averaged 35
minutes. Audiotaped interviews were
transcribed, and transcripts were verified
by the interviewer. Interviews started
with the general question, “What do you
think the impact of gender has been, if
any, on your experiences on the wards
during the past rotation?” Follow-up
probes then examined the participants’
views regarding interactions with
patients, medical staff, and other medical
students. Additional questions asked
participants about the impact of gender
on educational learning and about
participants’ views on male medical
students’ experiences (List 1).
Data analysis
Given that our objective was to generate
themes that are germane to health services
research, we applied the principles of
inductive reasoning to guide our data
analysis and interpretation.25 A diverse
coding team comprising a medical
student, an internist, and a pediatrician,
representing a variety of racial/ethnic and
religious backgrounds, developed an
Academic Medicine, Vol. 84, No. 7 / July 2009
 Clerkships

Five common and original themes

List 1 characterized the experiences of third-
Standard Guide for Interviews Conducted With 12 Female Third-Year Students at year female medical students during their
One New England Medical School, 2006 –2007 first month of clinical clerkships. Female
medical students (1) struggled to define
● Do you think gender and issues of gender have impacted your experiences on the wards? If so, how?
their place on the wards and often
● How have these experiences impacted your learning on the wards?
defaulted to stereotypical gender roles,
● Please describe any specific incidents that you experienced or observed in which gender played a role.
(2) perceived differences in the nature of
● Do you think your experiences on the wards have differed from those of men in your class? If so, how?
their workplace relationships compared
with male medical students’ workplace
initial code structure based on a was used to assist with data management relationships, (3) had gendered expectations
preliminary reading of three randomly and retrieval. All participants reviewed a of male and female physicians that shaped
chosen transcripts. The code structure summary of the themes after data analysis their interactions with clinical
then evolved in an iterative process. The was completed, and they endorsed the supervisors, (4) felt able to negotiate
code team met regularly to revise and content of the findings.27 uncomfortable situations with patients
refine the code structure using the but felt unable to negotiate
constant comparative method of data uncomfortable situations with
analysis. Newly coded text was compared Results supervisors, and (5) encountered a
with previously coded text to identify “gender learning curve” on the wards
new themes and expand existing themes We interviewed 12 female medical
students after the first month of their that began to shape their self-view as
on the code structure.26 future female physicians.
third-year clinical clerkships, representing a
Transcripts were independently line-by- range of ages, race/ethnicities, and prior Female medical students often defaulted
line coded by code team members using life experiences (Table 1). Students to stereotypical gender roles as they
the final code structure that comprehensively participated in one of seven different struggled to define their place on the
defined all codes. The code team had clinical specialty clerkships across a wards
group meetings at regular intervals to variety of clinical settings. There were
reconcile differences between coded often several participants per clerkship, Most participants expressed confusion
transcripts by negotiated consensus.27 representing different hospitals and during the first month of clinical
Scientific software, ATLAS.ti 5.0 (Berlin), clinics. rotations about the third-year medical
student role, describing it as “a difficult
transition” and “awkward.” One
participant described her first rotation as
Table 1 “crazy” with the concomitant transition
Characteristics of 12 Female Third-Year Students at One New England Medical of residents. She questioned,
School Participating in a Qualitative Study of the Effect of Gender on Clinical
Clerkship Experiences, 2006 –2007 What is the role of the medical students
in that environment? Because I’m there to
Characteristic No. (%)
learn, and to work with patients . . . but
Median age (range), in years 25 (23–30) when I don’t know what I’m doing, it’s
hard for me to do that for patients. So . . .
Race
......................................................................................................................................................................................................... I think that has been sort of challenging
White 9 (75) (Emergency Medicine/Anesthesiology).
.........................................................................................................................................................................................................
Black 2 (17)
.........................................................................................................................................................................................................
Asian 1 (08) Many female medical students were
Marital status
surprised to find themselves defaulting to
......................................................................................................................................................................................................... self-described stereotypically feminine
Single 5 (42)
......................................................................................................................................................................................................... behaviors within this period of
In a relationship 5 (42) uncertainty, such as focusing on assisting
.........................................................................................................................................................................................................
Married 2 (17) nursing or support staff, nurturing
Parent 1 (8) patients, or becoming more apologetic.
Undergraduate education completed at a single-sex institution 2 (17) Whether participants viewed these
behaviors positively or negatively varied
Took time off before coming to medical school 7 (58)
......................................................................................................................................................................................................... depending on who was involved in the
Median gap in years (range) 2 (1–6) interaction. Most students who identified
Month 1 clerkship “feminine” behavior during interactions
.........................................................................................................................................................................................................
Emergency medicine and anesthesia 3 (25) with their residents and attendings
.........................................................................................................................................................................................................
Medicine 2 (17) described those situations negatively. One
......................................................................................................................................................................................................... participant, when asked how gender
Neurology 1 (8)
......................................................................................................................................................................................................... affected her interactions on the wards,
Obstetrics–gynecology 1 (8)
......................................................................................................................................................................................................... expressed surprise at how “apologetic”
Pediatrics 2 (17) she found herself in interactions with her
.........................................................................................................................................................................................................
Psychiatry 2 (17) clinical team. She would ask, “I’m sorry,
.........................................................................................................................................................................................................
Surgery 1 (8) did I do that right? Did I do this right? Is

Academic Medicine, Vol. 84, No. 7 / July 2009 861

Clerkships
this how you want this done?” As she
explained, “I didn’t take as much
initiative as I thought I would, and to me,
to me it was very clear that I was doing
that because I felt like . . . I didn’t fit in”
(Surgery). Another participant described
a similar situation in which she and a
male medical student incorrectly
performed an EKG on a patient:
Then we had to come and do it again
and. . .. And I was the one apologizing
about how we put the leads on wrong and
really it wasn’t—we put the leads on as a
team, me and [the male medical student]
. . . but because I was the one apologizing
about it the patient remembered me as
the one that messed up the EKG (Internal
Medicine).
In contrast, participants who exhibited
self-described stereotypically feminine
behavior during interactions with
patients and support staff reflected on
those such situations positively, describing
themselves as “helpful” and
“appreciated.” One participant explained
that her “ability to be caring and
nurturing has been really helpful,”
especially with elderly female patients
(Emergency Medicine/Anesthesiology).
Another participant on her surgery
clerkship described similar satisfaction
assisting support staff:
The good moments . . . mostly moments
where I felt really helpful . . . I would do
something stupid, like pick up a piece of
paper off the floor and some tech would
smile at me. And those were the days that
I would feel good about myself.
Female medical students perceived
differences in the nature of their
workplace relationships compared with
male medical students’ workplace
relationships
Participants perceived substantive
differences between the types of
relationships they formed on the wards
compared with relationships formed by
their male counterparts. Many participants
described forming closer bonds with
support and nursing staff than with their
clinical supervisors. One participant
described an encounter with a nurse
“who’s notoriously antagonistic with
doctors.” When the student assisted the
nurse in moving a patient, the nurse
“flipped in a heartbeat,” confiding in the
student about her daughter’s struggle
with an eating disorder. The participant
attributed this interaction to her gender,
stating, “And I just got this whole story
862
from her like in a half hour standing in
the middle of this patient’s room. I don’t
know if that would have happened if I
were a guy—it probably wouldn’t have”
(Internal Medicine).
Several participants felt that, though
they formed relationships with the
predominantly female nursing and
support staff, their male classmates were
forming relationships with attendings,
who were most often male. Some
participants felt they were at a disadvantage
because of the difference in quality
between the relationships they formed
with attendings and those formed by
their male counterparts. One student of
color felt that it was “harder [to] relate to
older white men and have an interaction,
attachment and relationship . . . because
we don’t have much in common.” She
felt that finding similarities with
attendings was a “big part of evaluations
and . . . being included in procedures”
(Emergency Medicine/Anesthesiology).
Some participants also felt that, in
addition to forming closer relationships
with male students, attendings also had
different expectations for male and
female medical students. One participant
on her surgical rotation initially felt
grateful that she was not being asked
questions. However, she soon realized
“that I just wasn’t being pushed to read
because I wasn’t being asked questions.”
She described a “stark difference”
between herself and the male medical
student on the rotation, explaining that
her team was “asking him all the . . .
questions so that he’d get all the right
answers.”
Some participants thought these differential
relationships and expectations would have
ramifications on their future careers. As
expressed by one participant,
I think the outcome of this is going to be
that the relationships and bonds that I’ve
formed in this year are going to be very
much, ones of—where I feel like I’m
supporting female interns and nurses, and
that the males in my class are going to
come out with a lot of powerful
relationships with people who are going
to write them recommendations for
future powerful positions . . . it’s kind of
important . . . And it’s really shown me,
this past month, how easy it is to get
ahead when you’re a man. It’s not that I
didn’t know that already, it’s just made it
more clear (Surgery).
Gendered expectations of male and
female physicians shaped how female
medical students interpreted their
interactions with clinical supervisors
Many female students described having
low expectations of encounters with male
supervisors on the wards and anticipated
that such interactions would be
uncomfortable. For instance, several
students reported having had anxiety
regarding the potential of working with
all-male teams and expressed surprise
when they had good learning experiences
with male physicians. One student
thought she “would feel uncomfortable at
times” when she discovered that she was
working with all-male attendings and
residents on her psychiatry rotation. As
she described, however, “Not at all . . .
some people, especially older men, tend
to still believe that women have these
defined roles, but, yeah, [the male
attendings and residents] basically
showed me otherwise, throughout the
whole rotation, I mean everybody.”
Participants described their encounters
with male physicians in laudatory terms
when their experiences surpassed their
relatively low expectations. One participant
“found the residents who were often the
better teachers were the male residents.”
As she explained, “[They] were the ones
who sort of pushed me to do things
more, and who were friendlier and gave
me more feedback, and encouraged me
to also sort of be more comfortable”
(Obstetrics–Gynecology). Another
participant expressed similar views, that
“males push you harder, they act more
confidently, they ask you more questions,
and they expect you to know more.” She
concluded, “I want male attendings, I
want male residents. I don’t want to have
female residents anymore because I don’t
think I’d learn as much if I had females”
(Neurology).
In contrast to their stated apprehension
about working with male teams, many
participants expressed excitement about
possibly working with female role models
during clinical clerkships. One participant
described working with almost
exclusively female residents during her
anesthesiology rotation. She spoke of her
“great interactions” with them and being
able to talk about “how they balance their
career with the rest of their life.” In
some situations, students found that
relationships with female supervisors
fulfilled their expectations and were very
Academic Medicine, Vol. 84, No. 7 / July 2009

rewarding. For example, one student on
psychiatry described dealing with an
inappropriate patient: “The [female
clinical supervisor] . . . and I both had
this very, very, strong reaction that he
was this very sleazy guy. . .. I actually had
some really good discussions with her
about that.”
Some students also related specific
expectations that they had for female
supervisors that were often based on “warm
and fuzzy” female stereotypes. Students
expressed surprise and sometimes criticism
when female supervisors did not fulfill
these expectations. As one student on her
pediatrics rotation described,
I did notice though, that the women . . .
they were very sharp, very professional . . .
put together and they didn’t have that
stereotypical warm and fuzzy mode about
them. . .. And that wasn’t what I was
expecting at all. . .. And that was difficult
for me to adjust to initially. I didn’t find
them very approachable. The men that
were that way, I would approach them the
same, but for the women it was sort of
startling and a bit intimidating and I was
less willing to approach them and start
building some sort of relationship but it
took much longer for me to feel
comfortable around a woman with that
sort of presence (Pediatrics).
Almost all students described some
disappointment in their encounters with
female residents and attendings. One
student contrasted her experience with
male and female physicians, explaining
that the males were “more attentive” and
that the two female attendings “basically
didn’t acknowledge my presence.”
Another student expressed surprise when
she, too, concluded that she “liked a lot
of the male residents better than the
female residents.” As she described, “I
sort of had this moment when I realized,
yeah, I like this resident, I like this one, I
don’t like this one so much and then I
realized, wow, in general I’m liking the
men more and that’s really weird to
me. . .. I didn’t expect that” (Obstetrics–
Gynecology).
Female medical students felt able to
negotiate uncomfortable situations with
patients but felt unable to negotiate
uncomfortable situations with
supervisors and attendings
Most female medical students experienced a
range of uncomfortable situations during
the first month. Uncomfortable
situations with patients usually involved
Academic Medicine, Vol. 84, No. 7 / July 2009
patients flirting, making remarks about
participants’ appearance or gender, or
calling participants “nurse.” One student
described feeling “uncomfortable and
frustrated and angry” when being
referred to as “nurse.” She explained,
There is absolutely no reason why
someone who is female would not be able
to care for, think hard enough, or put in
as many hours— or whatever they think
would limit a woman to the point where
you wouldn’t assume she was a doctor. . ..
I feel like . . . it undermines what I’ve put
in to get there (Pediatrics).
Many students reported feeling
comfortable addressing inappropriate
patient behavior by the end of their first
clerkship experience. One student described
addressing older men who had “more old-
fashioned views of women and the roles
of women”: “I make it very clear upfront
that I’m a medical student—not a nurse,
not an assistant” (Emergency Medicine/
Anesthesiology).
Despite describing many male supervisors as
“better teachers,” a majority of students
also reported that most uncomfortable
situations they encountered on the wards
involved male residents or attendings.
Such situations ranged from feeling
uncomfortable in a male-dominated
culture to unsolicited attention from
male residents and attendings. One
student described the “culture of
guyness” she experienced on the wards
that she felt was often unrecognized by
male attendings and residents:
Just today we had this conversation about
some male patient who was found
masturbating by the attending. And so
ensued five minutes of jokes about
masturbation—I mean male
masturbation and basically all the men
laughing and all the women standing
back— even though we were all standing
in a circle. I mean . . . that’s pretty explicit
(Surgery).
Another student described her
interactions with a male attending in
more blunt terms:
Dr. [Y] stared at every girl’s chest. And
nobody ever said anything about it. He
wouldn’t look you in the face, he would
look at your chest when he was talking to
you. . .. And he did it to every girl, every
single female (Neurology).
Some participants explained that their
unfamiliarity with the medical system
and medical culture during their first
month of rotations prevented them from
Clerkships
navigating uncomfortable situations with
attendings and residents who were their
supervisors. Such students often deferred
to what they perceived to be the existing
culture, despite their discomfort. One
student described her interactions with
an attending:
It’s pretty freakin cold in the OR and I
would get goose bumps and [the male
attending] would rub the back of my
arms with his hand, and then he got the
resident doing it too, it was just a little
strange, I have to admit, and I was like
“Huh. . . . How do I deal with this?” I’ve
never had anyone rub my arm for goose
bumps. . .. Would I have preferred that it
didn’t happen? Absolutely. It’s not exactly
that I asked for, wanted, or solicited in
anyway, but did I feel comfortable saying,
“Could you please not do that?” I mean it
was my first week of rotations, I didn’t
know what was appropriate at that time . . . so
I didn’t say anything (Emergency
Medicine/Anesthesiology).
Female medical students encountered a
gender learning curve on the wards that
began to shape their self-view as future
female physicians
Some female medical students also began
to identify what sort of behavior was
required of female physicians based on
their experiences. We termed this type
of learning on the wards the “gender
learning curve” to describe the process of
identifying and responding to workplace
gender roles. Students perceived that
there were higher workplace expectations
for female physicians and felt that the
medical environment required women
to be “more serious” and “prove”
themselves. One student felt that male
physicians “joke around more” and
“seem more accessible.” In contrast, she
felt that many female physicians “seemed
just a lot colder.” She attributed such
differences to her perception that “women
have to be more serious because they
have to command more respect and the
men get it more automatically and so
they’re freer to joke around (Obstetrics–
Gynecology).” Another student expressed
similar views after two weeks on
pediatrics, that “male doctors had this air
of, they had a right to be doctors . . . and
females had to prove that they were going
to be, should be doctors . . . it was harder
for women to prove that” (Neurology).
Some participants described what they
perceived as necessary behavior for female
physicians. One participant observed how
her female attending “never talked about
863
Clerkships
her personal life except to say that it was
her son’s birthday.” As the participant
concluded: “She was so professional,
always talking about intelligent things.
And I think that was something that I
realized is necessary, when you’re a
female doctor” (Neurology).
Several participants described feeling that
they, too, had to “prove” that they were
competent, as compared with their male
counterparts. One participant described
feeling nervous about “proving that I’m
just as good or just as smart.” As she
explained,
I just want to make sure that I don’t
end up looking like one of the female
residents who doesn’t know anything and
doesn’t have any confidence. I don’t want
to look like that. Seeing [female resident]
makes me want to not be like her
(Neurology).
Some women felt that based on their
experiences, they would not be able to
meet the demands of being a woman in
medicine. As one student who is also a
mother described,
I came in thinking you know, whatever I
want I’ll do. And now it’s like, no. I want
an easy residency, easy 10 years of practice
and then I’ll do—if I’m not satisfied, then
I’ll do something different. It’s such a
shame. I think it’s a shame because I
remember going to the Women in Medicine
talk and they’re like—someone was like,
“I’m not practicing,” and I remember
thinking this is ridiculous. And now I’m . . .
in the same position and I’m not like,
“I’m not practicing,” but . . . my career is
determined by my kids and my family at
this point. So it’s, I think it’s really
interesting that two years ago I thought
whatever the world had to offer I could
take it on and now I know I can’t do it
(Psychiatry).
Discussion
Although significant attention has been
paid to supporting gender diversity in
the physician workforce, we found that
gender has a substantial impact on the
experiences of female medical students as
they start their clinical clerkship training.
Perhaps surprisingly, participants described
both positive and negative gender-related
experiences that extended far beyond
issues of sexual harassment in the
workplace. Regardless of previous life
experiences, specialty rotation or
clerkship site, several themes emerged
from the data that suggest female medical
students share a commonality of
864
workplace interactions that are affected
by gender. In addition, they perceive
these interactions to differ substantially
from the workplace interactions of their
male classmates. These findings have
important implications, because targeted
interventions to date have primarily
focused on recruiting and supporting
female faculty and developing policies on
sexual harassment.2,13 Our data reveal
that although female medical students
mentioned sexual harassment, these
experiences were neither as pervasive nor
as formative as other gender-related
experiences that shaped their clerkship
rotations and ideas about women in
medicine.
Our findings suggest that female students, in
addition to the clinical learning curve well
associated with third-year clerkships, also
encounter a “gender learning curve.”
The curve reflects acculturation to
stereotypical male and female workplace
roles and expectations. Similar to prior
studies,28 our participants described
being especially vulnerable and struggling
to define their place on the wards during
their first clerkship. Particularly when
facing uncomfortable situations with
attendings or supervisors, participants
often felt unsure of how to react and
accepted what they perceived to be the
prevailing workplace culture as the norm.
Such impressionability during the first
clinical clerkship may accentuate the
gender learning curve.
Our findings reveal that many aspects of
female medical students’ experiences are
affected by gender, including interpersonal
relationships, career ambitions, and
behavior on the wards. A number of
participants reflected on the “culture of
guyness” on the wards and felt that the
culture of medicine valued stereotypically
male characteristics more than female
characteristics. Multiple studies have
documented that female medical students
have higher rates of medical school
attrition than their male classmates29 and
report significantly more doubt about
whether they should have chosen to enter
the field of medicine.30 The experiences
that our participants report may only
exacerbate the doubt and isolation that
many female medical students feel. Prior
work done on the experiences of both
female and racial/ethnic minority
students has focused on the role of the
culture of medicine and the hidden
curriculum components of medical
school that isolate such students.31,32
Strategies that solely address issues of
sexual harassment in undergraduate
medical education often fail to address
these cultural phenomena. Adopting
more comprehensive programs that
examine the gendered culture within
medicine may improve the experiences of
women in medicine.
Our participants also described being
unprepared to address most of the
uncomfortable situations they faced on
the wards. Previous work with female
faculty has shown that women who felt
unequipped to deal with gender
discrimination reported its effects on
their self-confidence, isolation, and
career development as well as regrets
about choosing to enter medicine.10,33
Similar patterns with female medical
students suggest that this process starts
earlier than residency or practice. If
medical institutions want to create equal
opportunities for women in medicine,
interventions will need to be targeted
earlier.
The findings of this study do have some
limitations. All of the participants hailed
from a single medical school class at a
private, New England medical school.
Some of the findings may reflect the
experiences of this particular class and
the policies of this school and may not
be generalizeable to other parts of the
country or public institutions. However,
we purposefully sampled a diverse group
of students representing a range of
specialties, hospitals, and clinics to
minimize such variations in institutional
culture. Future work involving interviews
with male medical students would
complement this study, providing a point
of comparison between the experiences
of male and female medical students.
Comparing male and female perspectives
would have allowed us to determine
whether some of our participants’ experiences
were due to their role as medical students,
in addition to issues of gender. If male
perspectives revealed differences in
the way male and female students
characterize gender dynamics in medical
education, it would further support our
findings. In addition, assessing whether
male students are aware of the gender
differences that their female peers
perceive would provide valuable insight
for medical educators. Strengths of this
study include gender- and role-
concordant interviewing, the diversity of
Academic Medicine, Vol. 84, No. 7 / July 2009

the coding team, the use of rigorous
qualitative methodologies such as
audiotaping and transcription, and
participant verification of findings.
This study has numerous implications
for medical educators and clerkship
directors. As these results demonstrate, it
is necessary to expand the framework of
gender discrimination beyond sexual
harassment to include the myriad ways in
which gender affects the lives of female
medical students. Programs that only
focus on prevention of or responses to
sexual harassment do not address the
more subtle forms of gender stereotyping
experienced in the early years of medical
training.
Interestingly, this study revealed a number of
potential contradictions in the
perspectives of our female medical
student participants. Students described
discomfort with a “culture of guyness”
and reported uncomfortable situations
typically involving male clinical
supervisors, yet they credited male
physicians with often being better
teachers. Conversely, students often
wished to work with more female
supervisors, but they almost universally
reported disappointing experiences with
female attendings and residents. These
seemingly paradoxical viewpoints likely
result from the varying expectations
students have of male and female
supervisors in the workplace. All of our
participants described relatively low
expectations for interactions with male
supervisors compared with female
supervisors. Participants reflected on
these differential expectations,
commenting on how women in medicine
are expected to be “more serious” and
“prove” themselves, resulting in
female supervisors who are often
unapproachable and off-putting to
students. Participants also described strict
and narrow expectations they had of
female physicians, such as being “warm
and fuzzy,” that made it difficult for
female supervisors to meet these
expectations.
The number of negative encounters that
female students reported with female
supervisors also suggests levels of
internalized sexism resulting in students
devaluing female attendings. These views
may also complicate female mentorship
programs and gender-concordant team
interactions. These perceptions need to
Academic Medicine, Vol. 84, No. 7 / July 2009
be actively discussed and counteracted.
Given that students often do not approach
administrators to discuss such issues,
programs might consider creating
frequent “check-ins” with students to
provide a structured opportunity for
student–faculty discussion.
In our study, female students also felt that
male colleagues formed consequentially
different relationships with male attendings.
Instituting evaluation systems that
provide for 360-degree evaluations,
where not only attendings, but patients,
nurses, and support staff provide student
evaluations, would more
comprehensively assess the performance
of all students.
Lastly, longitudinal qualitative work is
needed to examine the range of experiences of
female medical students over time. Such
work would identify patterns of the
impact of gender and lead to more
effective interventions that extend
beyond sexual harassment to address the
entirety of female medical students’
experiences.
Disclaimer
The authors received funding from the Yale
University School of Medicine Office of Student
Research and the Yale University School of
Medicine Office of Education. The funding
sources played no role in the design of the study,
the collection, analysis, and interpretation of the
data, or the decision to approve publication of
the finished manuscript. The corresponding
author also had full access to all of the data in the
study and takes responsibility for the integrity of
the data and the accuracy of the data analysis.
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Teaching and Learning Moments
Not So Routine Follow-up
That Monday morning at the clinic
started out like any other—the buzz of
nurses directing patients to examination
rooms, overhead pages filling the air,
and residents milling about before the
start of their clinics. A few hours into my
morning rounds, I had developed a good
rhythm—reviewing the patient’s chart,
then recording a history and performing
a physical, followed by a review with my
preceptor, back to see the patient again,
dictating the follow-up letter, and
arranging for a follow-up visit.
Her name was towards the end of the
list that day. “Routine follow-up” was
listed as the reason for her visit. My
preceptor and I quickly perused her
chart before going in—an 82-year-old
female with locally advanced colon
cancer that had been resected about
two years earlier. She had survived her
surgery, and no adjuvant therapy
was administered. Her chart also
made note of “mild to moderate
Alzheimer’s.” The radiologist’s notes
on her latest CT scan were not
reassuring—“lesions most consistent
with local recurrence and metastatic
disease.” Her blood markers (CEA)
were trending upwards and were
ominously flagged for being elevated.
866
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1973–1992. J Am Med Womens Assoc. 1995;
50:204 –206.
30 Moscarello R, Margittai KJ, Rossi M.
Differences in abuse reported by female and
male Canadian medical students. CMAJ.
1994;150:357–363.
This was not shaping up to be a
routine follow-up visit after all.
She was waiting accompanied by her
husband when we entered the room.
“I’m doing great. I can walk lots. I feel
healthy. I have a good appetite,” she
replied in response to our first
question. We then went on to share
the results of her most recent scan and
blood tests. Her husband, being hard
of hearing, leaned in, his mind and
ears focused on what we were telling
him. “So what does that mean?” he
asked moments after we had told
them that the cancer was back, a sign
that his cognitive state was not too far
behind his wife’s. Our patient had a
puzzled and worried look on her face,
her eyes darting between us and her
husband. She knew something was
wrong but couldn’t quite place her
finger on it. Wanting to reassure us,
she again repeated, “But I feel so
good. I can walk. I have a great
appetite.” We agreed these were
indeed good signs, but inside we knew
that her current health would not last
for too long. Together, we went over
the options for active therapy, and one
by one each was ruled out as a
possibility. We introduced the couple
to the idea of palliative care and
31 Dyrbye LN, Thomas MR, Eacker A, et al.
Race, ethnicity, and medical student well-
being in the United States. Arch Intern Med.
2007;167:2103–2109.
32 Lempp H, Seale C. Medical students’
perceptions in relation to ethnicity and
gender: A qualitative study. BMC Med Educ.
2006;6:17.
33 Carr PL, Gareis KC, Barnett RC. Characteristics
and outcomes for women physicians who work
reduced hours. J Womens Health (Larchmt).
2003;12:399 – 405.
psychosocial support and provided the
appropriate resources along with a
follow-up appointment in the near
future.
After our encounter, I had a chance to
reflect on what had just transpired.
Between their medical illnesses and
cognitive decline, this couple’s ability
to cope with life was teetering on the
edge. They were living independently
at the time, but that would soon have
to change. What started out as routine
and predictable drastically changed by
the end of the visit. This particular
follow-up took a little more than half
an hour of my time, but it had thrown
the rest of their lives into chaos. It
served as a poignant reminder of the
responsibility that we as physicians
have to take every encounter, however
routine it might appear, as one that
could have far-reaching ramifications
for our patients.
George Kurien and Christopher de
Gara, MB, MS
Mr. Kurien is a fourth-year student, University of
Alberta Faculty of Medicine and Dentistry,
Edmonton, Alberta, Canada; (gkurien@ualberta.ca).
Dr. de Gara is professor of surgery, University of
Alberta Faculty of Medicine and Dentistry,
Edmonton, Alberta, Canada.
Academic Medicine, Vol. 84, No. 7 / July 2009