Are women better psychiatrists?

“Hi Dr. Sutherland, I’m Norah, your new resident.”It was the first of July, and as usual there was a certain degree of chaos in the hospital, as the first days of summer bring not only swallows and butterflies, but also flocks of new junior staff. This is mostly a problem for the training grades, where students are suddenly promoted to residents, and have significant levels of responsibility for the first time. Although that can be an issue for senior doctors like me in having to adjust to the newcomers, the bigger problem obviously affects patients. Sadly, there is even some evidence that being a patient admitted to hospital in the first few days of a new staff year is riskier than a month or so later.Fortunately for me and my patients, Norah was in her final year of training and was working with me to polish up her skills, rather than starting out on her first few days as a doctor. This burnishing was partly in preparation for hoping to join us as a new psychiatrist colleague soon, but also to get ready for her final exams that were the last hurdle before being released from the confines of a long training, and finally being able to work unsupervised.I had been aware of her, as I am vaguely aware of all the residents in our program, but I hadn’t properly met her before. Looking at her on that first day I saw a pleasant and relaxed lady, who was maybe a little older than the average resident. Although I didn’t know her well, it was clear that many of our nurses did, and she was repeatedly high-fiving the staff who greeted her and who welcomed her to the unit. They all seemed pleased at her arrival, and I knew this to be a good sign since word quickly gets around among nursing staff about the occasional resident who is difficult to work with, and who then finds that their shadow precedes them into their new job.As her first weeks went by Norah demonstrated her natural ability in the job, and also how well she slotted into the multidisciplinary team. Medicine these days is very team-based, and psychiatry uses larger groups than many other medical specialties, consisting of nurses, psychologists, occupational therapists, social workers, pharmacists, and sometimes chaplains and dieticians. Norah appeared to be immediately friendly with them all and I was impressed, and perhaps a little jealous, of her easy familiarity with our more difficult coworkers.“I saw you chatting with Bella.” I said one day, naming our colleague who handled any referrals to long term care placements. “How did it go?”“Fine–she’ll take our patient, no problem. Why are you looking at me like that?”“Ummm. Well, I guess I haven’t always found referrals through Bella to go so smoothly.”“Actually, she said something similar about you. So why don’t you just route things through me while I’m here.” I come from a generation of doctors where men predominated, not only in absolute numbers, but also in the number of senior positions they held in hospital-based specialties. Norah represented the change in medicine that we had all seen coming for a few years. The undergraduate class of medical students was now always more than 50% female, and our residency program was filled with more women than men, so much so that in one unusual year there was only one lad, who received looks of sympathy or envy depending on the observer’s viewpoint. Norah was one of a long series of female final-year residents who came to work with me, and who then gradually reset the gender balance among our senior staff. I have now reported to several female bosses in different areas of my work, and the world of medicine that was once so testosterone-fuelled has been softened by estrogen in my lifetime, and for the better.In addition to our daily work together on the inpatient unit, Norah and I sat down once a week for some more specific exam preparation, and there I saw a different side of her.“I’m really quite worried about this,” she said. “It’s so much like a performance. Especially the Long Case.”As well as the written papers that test a candidate’s textbook knowledge, the final exams featured a Long Case where candidates were required to interview a patient for an hour, with examiners watching, and then spend another hour fielding questions about what they had done, and how they would treat the patient going forward. And Norah was right, there certainly was an element of performance to it. Exam takers obviously had to focus on the patient they were assessing, but simultaneously there was the need to make sure that the examiners could see what was happening, and I remembered from my own exams how building a therapeutic alliance with my patient had to be combined with an element of playing to the gallery.As we practiced these exams together, I could still see her natural skill but now there was something else as well, a hesitancy in her presentation and question-answering that wasn’t there in our day-to-day work. Although I remembered my own anxieties from the days when I had to go through the same process, I also recalled enjoying the performance element to the Long Case. This triggered a memory of some papers I had read long ago in the psychology literature about gender differences in personality traits, seeming to suggest that men might do better in competitive performance tasks. So, prompted by Norah’s instinctive excellence on the ward, her natural engagement with the team, and the mismatch with her performance anxiety in an exam setting, I went back to read more.What personality traits make a good psychiatrist? I knew that my own introversion wasn’t a great asset, but I had managed to establish good working relationships with my team, even if it had taken me a couple of years to do so, compared to the few weeks that an extrovert Norah had needed. When you ask patients what traits they would like to see in their mental health clinician they tend to want someone who cares, and who is a good listener. These personality styles are widely seen to be more female than male, and if patients do make a request about the sex of their treating physician it is usually female, and almost no one ever asks for a male therapist.But do men and women actually differ in any meaningful way in personality attributes? This is a difficult and controversial subject, involving questions about whether there are innate differences, or whether any perceived difference is a result of gendered social conditioning as children grow up to be adults. And it is complex enough to disentangle when viewing gender as a binary construct, never mind the reality of non-binary gender identities that ought to inform our modern approach to the world. Beyond that there is a further layer of difficulty, because any supposed differences might be partly determined by the perception of the observer. We live in a world where men are expected to be more assertive and women are assumed to be more nurturing, and so maybe we just see what we are looking for. As I read my way through the literature, I found numerous sex differences in personality being proposed, almost always along the lines that you would traditionally expect. Men were measured to be more assertive, and women more empathetic, and under competitive performance conditions men did seem to do better. Most studies that looked at gender differences in caring and listening found that women were better at both. However, any difference between men and women on average was dwarfed by the large range of abilities within the male population, and so too among women. This was shown graphically by normal distribution curves for each characteristic, but with the female curve situated just to one side of the male distribution. The peaks of each curve showed how indeed women were better listeners on average, but the massive overlap of the two curves indicated that any one man could easily be a better listener than any one woman. So, Norah’s fine interpersonal skills on the inpatient unit might be partly determined by being female, but more likely she was just ‘good with people’ in a way that a man could be as well. I also thought of colleagues I had known over my many years of work. There were lots of men who I thought were excellent psychiatrists, and highly empathetic, but also some who weren’t. And although I increasingly knew many brilliant female colleagues, I was also aware of a couple of women about whom everyone seemed to think: ‘why on earth did you choose psychiatry for a career when you are so manifestly unsuited for it?’ Eventually I couldn’t face reading any more densely written research papers, and I ended up concluding that although gender differences in personality traits might be real, they were likely too small to be important, especially when compared to the large range of individual variation in personalities, regardless of gender. The months passed, and Norah’s work remained so good that people began to offer her jobs for when she had qualified. She also improved in her Long Case preparation sessions, but still retained an air of anxious uncertainty when being observed in an interview. Finally, the time came for her exam, and after a last preparation session with me she went off (a little hesitantly) to do her Long Case in a faraway city. When she walked onto the ward on her first day back, her body language told everyone the answer before they had to ask—her natural cheerfulness shone more brightly than ever, to the point where she lit up the nurses’ desk and all around her. When she finally detached herself from the crowd and the congratulations and we had a moment alone, then she told me about the exam. The patient she was given was an anxious woman who she had to interview under the stony-faced gaze of two older male psychiatrists, which inevitably had some effect on Norah’s confidence. She thought she had done relatively well, despite her nerves, and then she came to the final moments of her interview.“Is there anything that you would like to ask me before we finish?” she asked her patient.“No,” came the answer. “But . . . ”The lady was glancing sideways at the two male examiners and hesitating over her reply, but when it finally came it gave Norah the boost that set her up well for the rest of the exam, and hinted at her forthcoming success.“No disrespect intended but . . .” and her patient looked away from the examiners and turned her gaze softly onto Norah, “. . . it would be so nice to have a female psychiatrist.”Dr JP Sutherland is the pseudonym for a practicing psychiatrist. The Medical Post has independently verified his identity, and he writes here anonymously to provide an added layer of privacy for his patients. His case reports are non-fiction, but the names and other identifying details have been changed. Read more of his work here at www.jpsutherland.com

Are women better psychiatrists?

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