On labels

Let’s play a word association game.

I am going to say something and I want you to say out loud the first image that comes into your head… Are you ready?

… Orthopaedic surgeon.

A stereotype is a cognitive shortcut. It’s a way of getting from A to Z, bypassing all of the letters in between. For those of you who have read Daniel Kahneman’s work think of it as a form of system 1 thinking. These stereotypes allow rapid decisions to be made without all of the data available. We use this type of snap judgment all of the time in medicine. It is what allows us to spot the septic child from across the room. It helps us to figure out who is drunk and who has something more serious going on. It allows us to make rapid-fire decisions based on very little real evidence.  But, as I hope you’ll see, there are times when this system can fail us.

My goal in this post isn’t a lofty one. It is to make you stop and think. I’m going to write about how we look at other specialties – ‘them‘ or the ‘out-group‘, in cognitive psychology parlance – and why we should throw away the stereotypes.

There are many stereotypes that we have been beholden to for far too long. The best example of this is the role of women in medicine. Please listen to Dara Kass and Jenny Beck-Esmay to really understand the inequities and what the FEMinEM team is doing to promote change. I’m only going to touch briefly on some of their challenges and leave it to them to educate you.

I imagine that when I asked you to think of an orthopaedic surgeon your brain took a few cognitive leaps and came up with something like the guy on the left. I want you to stop now and engage your brain instead and think of the orthopaedic surgeons you do know. Do they conform to this stereotype?

Stewart Morrison is an orthopaedic registrar with an interest in social media and health. I’ve never seen him do press-ups in the department to get pumped up before a joint reduction, and he has actually published papers. He is the sort of orthopaedic trainee that this classic Christmas BMJ paper was written about.

What about anaesthetists? What do you picture when you say this word out loud? Unless it is your chosen specialty then you might think they are all cryptic crossword solving eggheads. We use the shorthand of stereotypes to describe any craft group that is not our own.

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Media versus medical stereotypes

We have moved on from the days of barber-surgeons who judged, like Robert Liston,  on the sharpness of their steel and the speed of their saws. Now the general public compares us to what they see on television. ER was my first real exposure to television medics (Doctor Who doesn’t count). When, in 1994, I sat down to watch the first episode, strangely enough, during my first late shift as a medical student in the emergency department of Chelsea and Westminster Hospital, I was instantly hooked. Here were real, flawed doctors, who had bad days and good days and whose lives were infinitely more interesting than my own. It became a standard to which my working day was judged.

There was the charming paediatrican (Doug Ross) who was softly spoken and always a winner with the children; the arrogant surgeon (Peter Benton) who would snap at anyone that dared to contradict him; and the puppy dog medical student (John Carter) who wanted to see everything and do everything. As I looked around at the real doctors I was working with I looked for those characteristics that confirmed my media-enhanced views of them. Were the paediatricians sleeping with anything that moved? Were the trauma surgeons really as narcissistic as Benton?

Bucknall et al. compared three core personality traits – the dark triad of narcissism, Machiavellianism and psychopathy – in a cohort of 248 health care professionals – with a control group of ‘normal’ people. The medicos scored consistently lower across all three domains than Joe Public. Not the result you were expecting, I am sure. Doctors are no more underhand or arrogant than the person on the street.

(Spoiler alert – paediatricians are not conniving psychopaths. If you really want to know where your specialty lies then you can take a look here.)

All this use of stereotypes is just a joke, isn’t it? Just a laugh, a bit of friendly banter? Nobody gets hurt, do they?

“In-groups” versus “Out-groups”

In emergency medicine, there is a familiar “us against the world” approach to life. This may help form strong in-group bonds but it does not help our relationships with the people we have to work with every day. If a member of your team behaves badly you tend to think they are having a bad day. We attribute their bad behaviour with situations beyond their control (lack of sleep, pressure from bed managers, hunger) and we attribute their good behaviour to something intrinsic and wholesome. They are just good/kind/wicked-smart/emotionally intelligent people. Unfortunately, there is a tendency to do the complete opposite with ‘them‘ (members of the out-group). And so, if a member of the in-patient neurosurgical team is rude, it is because all neurosurgeons are rude. Or, to given another example, if a surgeon is behaving in an allegedly arrogant fashion the tendency is to lump all surgeons together. Rather we should consider this trait as an aspect of one individuals personality. The tendency to change ones opinion depending on whether someone is us or them is called attribution bias.

The stereotype threat

My mother always said to me, “If you can’t say anything nice, don’t say anything at all“. Nowhere is this more clear than in the use of stereotypes. What happens if you keep on hearing something negative about your gender, your race or your chosen profession? There is a very real risk that the fear of conforming to the negative aspects of a given stereotype can lead to impaired performance and well-being. Why does this happen? Pennington et al. postulate a number of possible reasons…

If you are bombarded with negative images of your profession then any of these may come into play. This can have adverse long-term consequences as well.

What can happen if someone is chronically exposed? Woodcock and colleagues suggest it may lead to domain disidentification. This occurs as the victim places less and less importance and interest in the questioned behavior. A surgeon, constantly (and wrongfully) thought of as an arrogant member of an elitist group might become aloof and disinterested in interacting with other healthcare workers. Female surgical trainees, who have a higher degree of stereotype perception, have poorer psychological well-being than those who do not believe in the stereotype. Non-surgeons do not seem to face the same burden.

Asking for help

In an interview with Scott Weingart, Peter Brindley gave an example of the long term adverse effects of stereotyping. He recounted a (perhaps apocryphal) take of an emergency not asking for outside help when things were going wrong.

“Why didn’t you call for backup? the EM physician was asked.

“Because they were rude and condescending to me” they replied.

“How long ago was that?”

“Eleven years.”

It is easy to extrapolate that you might not ask your anaesthetic colleagues for help if you perceive them to be aloof. You might not involve the surgeons early in a case if you think they are arrogant.

The stereotype and the student

Imagine starting your first ever surgical rotation and your entire world view of a surgeon is based on an outdated stereotype. How do you think that would affect your interaction with the team, with your supervisor? How do you think it would impact on your learning opportunities? Students listen to what we say. Ajaz et al. had a great term for it – BASH (Badmouthing, Attitudes and Stigmatizing in Healthcare). They surveyed almost a 1000 medical students and 40.4% thought it was an acceptable form of team bonding, a form of friendly banter, just a joke. Interestingly, though, they felt that the higher up the ladder you climbed then the more negative the bad-mouthing became. When consultants referred to GP’s as idiots it made them really question whether they wanted to go into that specialty. Erickson et al found that graduates of medical schools which denigrated general practice where much less likely to go into primary care than those who graduated from schools who promoted a positive experience.

Career choice, then,  may be based on a stereotype rather than fact, with negative stereotypes leading to less enrollment in particular specialties. A couple of resourceful researchers scoured the internet for jokes related to particular medical specialties, extracted the core traits and then compared them with the core traits of certain craft groups suggested by medical students. They found that there was a high degree of correlation between what the students though that general surgeons were like (despite having had little to no contact with them) and what the jokes suggested they were like.

Cut it out…

What interventions can we put in place, then, to reduce the use of stereotypes and the resultant stereotype threat?

1.People are people

The most important thing to remember is that human beings are complicated creatures with a lifetime of stories. When I was in medical school I spent an enjoyable year going to screen-writing classes, learning how to tell the stories I wanted to tell. The best scripts and the best stories have complex, three-dimensional characters, full of subtlety and nuance. In a film you may only have 1 hour and 47 minutes to discover the sort of person Dr. Jed Hill is. In real-life you have much more time, as well as the ability to interact, to figure out that surgeons are not self-centred narcissists that think they are God.  By demoting a surgeon to this stereotype, writers are doing their audience no favours. The character becomes a brash cartoon of a person.

2. Put the kettle on

Emotional intelligence (EI) is the ability to take a step back and be aware of your own emotions and their impact on others. The surgeon of yesteryear may have been lacking in EI  but that is certainly not true of them now. In a study by Stanton et al. the stereotypical view that a surgeon is a ‘doer‘ not a ‘thinker‘ took a beating as they compared the EI of both surgeons and psychiatrists and found no difference. If you want to learn more then take a look at this fascinating read from Stobbs and Ward.

In order to avoid falling foul of the stereotype we also, then,  need to display emotional intelligence and realize that our initial feelings about X specialty may be false and founded entirely on supposition and not fact. One of the best ways of doing this is just to sit down and talk with then as human beings. Put the kettle on and have a chat. When you find out your local neurosurgeons feelings about the oeuvre of chanteuse Taylor Swift they become a person, not a stereotype.

3. Share the love

When a specialist comes to review a patient I advise the junior doctors I work with to go in with them. By watching an expert they can observe, first hand, other professionals at work and learn from them. They can see how they interact with the patients and the staff around them. And they can create their own opinion of the specialty, based on fact, not fiction.

4. Role modeling best behaviour

Do you badmouth other specialties on the phone or in the tea room? When you do so you are perpetuating the stereotype. The juniors you are chatting with are going to pick up on your language choices and mirror them. Think how powerful it would be if the message that they picked up was one of inclusivity, rather than exclusivity. It is not ‘us‘ and ‘them‘ but a broader ‘us‘ against the disease, the illness, the problem that needs solving.

This is another aspect of the hidden curriculum of professionalism that is often hidden from the teachers as well as the students. Only by being more aware of our own behaviour can we hope to influence others.

5. Things can change

You may think of yourself as a very small part of a massive machine – a tiny blue dot in the universe of healthcare – but you can make a difference. The work of the FEMinEM team has highlighted gender inequality in terms of pay, opportunities and working conditions. The #Ilooklikeasurgeon hashtag flew around the world to remind everyone, medics and laypeople alike, that you do not have to be an arrogant white male to be a surgeon. With over a billion twitter impressions the online world was reminded that there is no such thing as a stereotypical surgeon. There is diversity in every specialty. It is exactly this diversity that makes us better at looking after our patients.

Perhaps we should start viewing these stereotypes in the same we view horoscopes – with a healthy dose of scepticism and disbelief. There is no stereotypical surgeon or paediatrician or anaesthetist or emergency physician. There are only doctors, trying to do their best for patients.

A final thought

You’ve heard enough from me so I am going to leave the final thought to Chuck Wurster…

As physicians we should all strive to be the nicest doctor in the hospital.

The physician that our colleagues would want if their family was sick.

Knowledgeable and kind!

I may never be this doctor but I am gonna try everyday.

Who’s with me? #choosekind

— Chuck Wurster (@ChuckWurster) December 18, 2017

Selected references

Ajaz A, David R, Brown D, Smuk M, Korszun A. BASH: badmouthing, attitudes and stigmatisation in healthcare as experienced by medical students. BJPsych Bull. 2016 Apr 1;40(2):97-102.

Antonoff MB, Stamp N. The# NYerORCoverChallenge: What it means for women in cardiothoracic surgery. The Journal of thoracic and cardiovascular surgery. 2017 Oct 1;154(4):1349-51.

Aronson J, Burgess D, Phelan SM, Juarez L. Unhealthy interactions: the role of stereotype threat in health disparities. American journal of public health. 2013 Jan;103(1):50-6.

Bellodi PL. The general practitioner and the surgeon: stereotypes and medical specialties. Revista do Hospital das Clínicas. 2004 Feb;59(1):15-24.

Bucknall V, Burwaiss S, MacDonald D, Charles K, Clement R. Mirror mirror on the ward, who’s the most narcissistic of them all? Pathologic personality traits in health care. Canadian Medical Association Journal. 2015 Dec 8;187(18):1359-63.

Burgess D. Can a Brief Values Affirmation Help Achieve Gender Parity Within the Surgical Profession? The Promise and Limitations of “Wise” Interventions. Journal of graduate medical education. 2016 Jul;8(3):439-41.

Carpenter J. Doctors and nurses: stereotypes and stereotype change in interprofessional education. Journal of interprofessional care. 1995 Jan 1;9(2):151-61.

Erikson CE, Danish S, Jones KC, Sandberg SF, Carle AC. The role of medical school culture in primary care career choice. Academic Medicine. 2013 Dec 1;88(12):1919-26.

Gofton W, Regehr G. What we don’t know we are teaching: unveiling the hidden curriculum. Clinical orthopaedics and related research. 2006 Aug 1;449:20-7.

Gomez E, Wright JG. A simple strategy to reduce stereotype threat for orthopedic residents. Canadian Journal of Surgery. 2014 Apr;57(2):E19.

Harendza S, Pyra M. Just fun or a prejudice?–physician stereotypes in common jokes and their attribution to medical specialties by undergraduate medical students. BMC medical education. 2017 Dec;17(1):128.

Hean S. The measurement of stereotypes in the evaluation of interprofessional education. Interprofessional Education: Making it Happen. 2009 Oct 23:143.

Hill EJ, Bowman KA, Stalmeijer RE, Solomon Y, Dornan T. Can I cut it? Medical students’ perceptions of surgeons and surgical careers. The American Journal of Surgery. 2014 Nov 30;208(5):860-7.

Holmes D, Tumiel-Berhalter LM, Zayas LE, Walkins R. ” Bashing” of medical specialties: Students’ experiences and recommendations. Family medicine. 2008 Jun 1;40(6):400.

Hunt DD, Scott C, Zhong S, Goldstein E. Frequency and effect of negative comments (” badmouthing”) on medical students’ career choices. Academic Medicine. 1996 Jun 1;71(6):665-9.

Kay AC, Day MV, Zanna MP, Nussbaum AD. The insidious (and ironic) effects of positive stereotypes. Journal of Experimental Social Psychology. 2013 Mar 31;49(2):287-91.

Logghe H, Jones C, McCoubrey A, Fitzgerald E. # ILookLikeASurgeon: embracing diversity to improve patient outcomes.

Maurin D, Pacault C, Galès B. The jokes are vectors of stereotypes. Example of the medical profession from 220 jokes. Presse medicale (Paris, France: 1983). 2014 Dec;43(12 Pt 1):e385-92.

Osgood CE, Stagner R. Analysis of a prestige frame of reference by a gradient technique. Journal of Applied Psychology. 1941 Jun;25(3):275.

Oxtoby K. Do the classic specialty stereotypes still hold true for today’s doctors. BMJ Careers. 2013 Dec;17.

Pennington CR, Heim D, Levy AR, Larkin DT. Twenty years of stereotype threat research: A review of psychological mediators. PLOS one. 2016 Jan 11;11(1):e0146487.

Pettitt BJ. Medical student concerns and fears before their third-year surgical clerkship. The American journal of surgery. 2005 Apr 30;189(4):492-6.

Salles A, Mueller CM, Cohen GL. Exploring the relationship between stereotype perception and residents’ well-being. Journal of the American College of Surgeons. 2016 Jan 31;222(1):52-8.

Schrauth M, Kowalski A, Weyrich P, Begenau J, Werner A, Zipfel S, Nikendei C. Self-image, real physician’s and ideal physician’s image: a comparison of medical students 1981 and 2006. Psychotherapie, Psychosomatik, medizinische Psychologie. 2009 Dec;59(12):446-53.

Silva MM, Freischlag JA. Challenge accepted: Social media as a stereotype change agent. The Journal of thoracic and cardiovascular surgery. 2017 Oct 1;154(4):1354-5.

Sollami A, Caricati L, Mancini T. Ambivalent stereotypes of nurses and physicians: impact on students’ attitude toward interprofessional education. Acta Bio Medica Atenei Parmensis. 2015 Mar 13;86(1Suppl):19-28.

Stabile BE. The surgeon: a changing profile. Archives of Surgery. 2008 Sep 15;143(9):827-31.

Steele CM. A threat in the air: How stereotypes shape intellectual identity and performance. American psychologist. 1997 Jun;52(6):613.

Stobbs N, Ward E. Do modern-day surgeons break the stereotype and show emotional intelligence in their leadership?. The Bulletin of the Royal College of Surgeons of England. 2014 Sep;96(8):e5-8.

Subramanian P, Kantharuban S, Subramanian V, Willis-Owen SA, Willis-Owen CA. Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. BMJ. 2011 Dec 15;343:d7506.

Veysman B. Physician, know thyself. Bmj. 2005 Dec 22;331(7531):1529.

Woodcock A, Hernandez PR, Estrada M, Schultz P. The consequences of chronic stereotype threat: domain disidentification and abandonment. Journal of personality and social psychology. 2012 Oct;103(4):635.

Woolf J, McManus IC. Medical stereotypes and medical realities. British medical journal (Clinical research ed.). 1987 Jun 27;294(6588):1660.