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 one 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 allows us to spot the septic child from across the room. It helps us 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 will write about how we look at other specialities – ‘them‘ or the ‘out-group‘, in cognitive psychology parlance – and why we should throw away the stereotypes.
We have been beholden to many stereotypes 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 will 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, engage your brain instead, and think of the orthopaedic surgeons you 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 speciality 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 ours.
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 mine. It became a standard to which my working day was judged.
There was the charming paediatrician (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 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 healthcare 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 want to know where your speciality 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 team member behaves badly, you tend to think they are having a bad day. We attribute their bad behaviour to 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 give another example, if a surgeon behaves in an allegedly arrogant fashion, the tendency is to lump all surgeons together. Rather we should consider this trait as an aspect of one individual’s personality. The tendency to change one’s opinion depending on whether someone is us or them is called attribution bias.
The stereotype threat
My mother always said, “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. postulates several possible reasons…
Proposed mechanisms
Subjective mechanisms
- Anxiety
- Evaluation apprehension
- Performance expectations
- Explicit stereotype endorsement
Cognitive mechanisms
- Working memory
- Cognitive load
- Thought suppression
- Mind-wandering
- Negative thinking
Motivational mechanisms
- Effort/motivation
- Self-handicapping
- Vigilance
- Dejection
If you are bombarded with negative images of your profession, 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 behaviour. 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 doctor 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 if you think they are arrogant.
The stereotype and the student
Imagine starting your first surgical rotation, and your entire worldview 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 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 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 GPs as idiots, they questioned whether they wanted to enter that speciality. Erickson et al. found that graduates of medical schools which denigrated general practice were much less likely to go into primary care than those who graduated from schools that promoted a positive experience.
Career choice may be based on a stereotype rather than fact, with negative stereotypes leading to less enrollment in particular specialities. A couple of resourceful researchers scoured the internet for jokes related to particular medical specialities, extracted the core traits and then compared them with the core traits of certain craft groups suggested by medical students. They found a high correlation between what the students thought 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 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. In medical school, I spent an enjoyable year attending screenwriting classes, learning how to tell the stories I wanted to tell. The best scripts and 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 and the ability to interact to figure out that surgeons are not self-centred narcissists who think they are God. By demoting a surgeon to this stereotype, writers do their audience no favours. The character becomes a brash cartoon of a person.
2. Put the kettle on
Emotional intelligence (EI) is taking a step back and being aware of your 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 look at this fascinating read from Stobbs and Ward.
To avoid falling foul of the stereotype, we also need to display emotional intelligence and realize that our initial feelings about X speciality may be false and founded entirely on supposition and not fact. One of the best ways of doing this is to sit down and talk with them as human beings. Put the kettle on and have a chat. When you discover your local neurosurgeon’s 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 speciality, based on fact, not fiction.
4. Role modelling best behaviour
Do you badmouth other specialities on the phone or in the tea room? When you do so, you are perpetuating the stereotype. The juniors you chat with will pick up on your language choices and mirror them. Think how powerful it would be if the message that they picked up were 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 and 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 small part of a massive machine – a tiny blue dot in the healthcare universe -, 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 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 speciality. 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 will 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
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