MY CODE PAGER went off that evening while cross-covering, and I rushed to the patient room to hear the bedside RN saying, “Patient needs blood.” The room was filled with the bedside nurse, emergency response team nurse, respiratory therapist and a patient care assistant.
Clueless, I asked the bedside RN for the recent events, concerns and reasons for blood transfusion. “Because the patient is bleeding,” the ERT RN said with disdain. Oversimplifying the obvious was less of an issue than her tone of voice. Ignoring the comment, I gathered from the bedside RN that the patient had had sacral wound debridement earlier that day and was oozing around the wound. I threw in quick orders to bring up the sinking BP and asked the RN to help me turn the patient for an exam.
While she was reviewing the recent documentation and lab parameters, the ERT RN demanded that the patient be transferred to the ICU. “Hang on,” I insisted. “Let’s see how the patient responds. Let’s prepare and hold two units of packed red blood cells, please.” That was met with an eye-roll from the ERT RN—and as I paged orthopedics to come to the bedside, I heard some under-the-breath muttering among the ERT team. Sensing disagreement, I asked the ERT nurse about her concerns and explained that the patient might need to go to the OR before transfer to the ICU.
Gaps in pay and publications are easy to track. It’s harder to assess differences in the levels of assistance and respect you receive.
“We don’t disagree with your management,” she responded sternly. “Just order everything you want at once.” The orthopedic attending who soon joined us made it clear the bleeding couldn’t be controlled with hemostatic techniques or surgical interventions. That’s when I called the ICU team to transfer the patient for overnight monitoring. By now, the patient was hemodynamically stable and expressing gratitude for our team effort.
Conflict, or bias?
During the interaction, I saw a patient conveying appreciation, a bedside RN showing compassion, an ERT team fiercely advocating and a specialist team standing by until the patient was stable. Yet I left the room full of questions. It felt like the ERT team and I were both working together and against each other. I was not sure if my recommendations were unclear, unpopular or unwelcome, or why they’d evoked the RN’s responses.
Was it a disagreement over patient management or a personality conflict? I pushed the interaction to the back of my mind until it resurfaced weeks later over a casual weekend dinner with a female colleague. After I narrated the incident, my friend said, “Many female physicians across the country encounter gender bias. Don’t take it personally.”
Over the years, I have heard anecdotes about subtle sexism in medicine in interactions between men and women clinicians. But I wasn’t sure that gender bias could be at the core of what had been for me a difficult interaction. Because I chose at the time to not revisit the incident (more on that below), I instead read to learn more. Now, I had different questions: Would the situation have been different if I was a male physician? And do female physicians face challenges in their interactions with female nurses?
Evolving data
Gender disparities in health care exist in different shapes and forms. They range from being somewhat measurable to subjective and prone to adjectives like “too sensitive” or “emotional.”
The gaps in pay, leadership advancement, NIH grants and publications are easy to track. It’s harder to assess the impact of being perceived as a nonphysician or the differences in the levels of assistance and respect you receive, compared to male counterparts. The subjectivity of such complaints is a further complication, making it hard to distinguish gender disparity from differences in opinions, preferences, personalities and judgments.
But we do have evolving data about female physicians’ interactions and the challenges they face in relationships with female nurses. In studies from the late 1990s, female nurses voiced a preference for working with female rather than male physicians, noting better communication and greater work satisfaction. 1,2
But subsequent studies found that female residents and physicians perceived bias from female nurses. In one study, female nurses approached female physicians on a more egalitarian basis and were both more comfortable communicating with them and more hostile toward them.3 Several studies highlighted female physicians’ concerns about challenging communication and assistance patterns in female nurse-physician interactions. One study noted, for instance, that female nurses were significantly less likely to clean up sharps for female physicians than male physicians.
Others reported that female nurses expected female doctors to respond more positively to their suggestions.4-6 Female residents, on the other hand, reportedly received lower mean ratings from nurses than male residents, while female PGY-1s received disproportionately fewer positive and more negative comments than male PGY-1s. They also described communicating with ancillary staff as a challenge, especially when providing direct orders.7-9
Impact and solutions
Concerns about gender bias in female nurse-physician relationships are more than hurt feelings or a clash of egos. Interprofessional collaborations can improve patient outcomes, lower health care costs, increase job satisfaction and maintain patient safety.10-12 Nurse-physician conflicts, on the other hand, are thought to contribute to job dissatisfaction and burnout.
Keeping gender bias out of nurse-physician interactions requires better communication, mutual respect, acceptable workloads, and defined roles and expectations, not hierarchy. But addressing the root cause means uncovering long-existing implicit biases and implementing mainstream gender consciousness and sensitization, even in gender-concordant interactions.
Organizations should audit and recognize any gender patterns in peer, patient, and nursing evaluations and feedback for physicians. Looking into what reduces work satisfaction or degrades the work environment for female physicians can also uncover gender bias that may be both hidden and commonplace.
High-pressure collaboration
I didn’t seek out that ERT RN to address what felt like a standoff. I wanted to avoid another confrontation, realizing only later that the incident may have warranted a one-on-one discussion. I may have learned that what seemed like unprofessionalism was fallout from a particularly brutal shift. Or I may have heard about long-simmering problems between cross-covering physicians and the early response team, problems that might be resolved with new protocols and lines of communication.
Or, if bias was at play, perhaps my feedback would be a good starting point to tackle it. Certainly, conflicts are unavoidable in female nurse-physician interactions, as in any high-performance, high-pressure collaboration. Further, disagreements between a nurse and a physician team can be good for patient safety and outcomes.
However, the conflict has to be productive and can’t be coming from a place of unconscious bias. Societal gender-based roles and hierarchical practice models may influence female nurse-physician interactions—but gender biases need to be recognized and kept out of the equation. That’s the only way we can provide excellent patient care through nurse-physician collaborations and curb stress, burnout and discontent at work.
Taru Saigal, MD, is a hospitalist and assistant professor at Ohio State University in Columbus, Ohio.
REFERENCES
1 Women in a women’s job: the gendered experience of nurses. Sociol Health Illness. 1992; 14: 510-527
2 Interpersonal communication satisfaction and biological sex: nurse-physician relationships.Commun Res Rep. 1997; 14: 24-32
3 Zelek, B., Phillips, S.P. Gender and power: Nurses and doctors in Canada. Int J Equity Health 2, 1 (2003). https://doi.org/10.1186/1475-9276-2-1
4 Women in a women’s job: the gendered experience of nurses. Sociol Health Illness. 1992; 14: 510-527
5 Interpersonal communication satisfaction and biological sex: nurse-physician relationships.Commun Res Rep. 1997; 14: 24-32
6 Silent bias: challenges, obstacles, and strategies for leadership development in academic medicine—lessons from oral histories of women professors at the University of Kansas. Acad Med. 2016; 91: 1151-1157
7 The doctor-nurse relationship: how easy is it to be a female doctor co-operating with a female nurse?.Soc Sci Med. 2001; 52: 189-202
8 Attitudes of female nurses and female residents toward each other: a qualitative study in one U.S. teaching hospital.Acad Med. 2004; 79: 291-301
9 Gender matters: internal medicine resident perceptions of gender in medical training.J Gen Intern Med. 2017; 32
10 Gender bias in nurse evaluations of residents in obstetrics and gynecology.Obstet Gynecol. 2015; 126: 7s-12s
11 Tjia J., Mazor K. M., Field T., Meterko V., Spenard A., Gurwitz J. H. Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. Journal of Patient Safety. 2009;5(3):145–152. doi: 10.1097/pts.0b013e3181b53f9b.
12 Rosenstein A. H. Nurse-physician relationships: impact on nurse satisfaction and retention. American Journal of Nursing. 2002;102(6):26–34.
Published in the July/August 2021 issue of Today’s Hospitalist
