The EM Expert Mindset – A Female Perspective

Dr. Patricia Lee is an EM physician in Calgary, Alberta and an Assistant Professor at the University of Calgary in the Department of Emergency Medicine. She reached out to me after listening to Episode 200 How EM Experts Think Part 1 as a longtime supporter of EM Cases, to highlight the importance of recognizing challenges that female-identifying EM physicians may face before, during and after ED shifts. She offers practical solutions to these challenges that may resonate with many EM Cases listeners…

When reflecting on the factors that influence an EM expert’s mindset, it is important to consider the social identities that have shaped their experience as a physician. Gender-based stereotypes and cultural norms may affect a physician’s communication style, leadership skills and management of cognitive load and flow. Societal expectations have significant impacts on the emotional labor and mental load for some women physicians outside the workplace which may further strain the cognitive burden in the clinical setting.

Pre-shift preparation

One study found female physicians with children spent 100 minutes more per day on household activities and childcare than male physicians (adjusted for work hours outside the home). Those 100 minutes can disrupt the ability to regularly accomplish high intensity exercise, additional sleep, or meditation that are thought to improve performance on shift.

• Running the list and handover: Just like on a busy ED shift, these skills help refocus your mental processing to the tasks at hand by checking them off systematically. Before every shift, my husband and I review outstanding domestic tasks, childcare and puppy pickups and anticipated challenges in the same way we would outline a handover plan for a patient in the ED. We also vocalize the backup plans and contingency planning for additional resources (this seems intuitive for many male physicians when they leave work, but daycares and schools often call mom first). This helps me clear my brain to maximize the available working memory for the cognitive load of the ED.
• Commute multi-tasking: I use this time to make that handover, eat/hydrate and use the moment after I park to take 3 breaths and reset.

Some women approach ED shifts with an acute awareness of the emotional and cognitive labor required to navigate patient care and team dynamics. This heightened awareness may lead women to mentally prepare for the interpersonal dynamics of their shift in addition to the clinical workload, considering how they can lead with empathy while still maintaining boundaries to protect their own well-being. I check the shift schedule before starting to see which colleagues are working, when my resuscitation time is scheduled, and from which physicians I receive and give handover. This helps inform my approach to checking in on colleagues for caffeine needs, knowing who I call for help with resuscitations, sedations or flyby questions. I keep an eye out for my incoming handover physician to ensure they don’t get stuck in a vortex of reassessments and leave the shift at a reasonable hour.

Managing interruptions

Observational data suggest that female physicians are interrupted on shift more frequently than their male colleagues. Whether for a glass of water, a warm blanket, directions, help to the bathroom – women physicians are often mis-identified for non-physician members of the health care team. Women receive 25% more messages from staff and patients, and on average spend 15% longer with patients due to gendered patient expectations to address emotional and social needs. The implications of responding abruptly to interruptions may weigh heavier on women when societally we are expected to be kind, compassionate and empathetic. This can raise tension in professional relationship with health care team members.

• I have found taking time at home to build scripts has reduced the cognitive load in the moment of responding to interruptions
  • “I’m not your nurse but I can redirect you to someone who can help with X”
  • “I’m not the team member best equipped to help you with X and I can help you find that person”
• Wearing identifying colored scrubs, white coats or large name tags can be helpful to reduce mis-identification
• Finding a quiet space in the ED away from visible patient care areas or waiting rooms to chart and process to reduce interruptions

Resuscitation preparation, leadership styles and communication considerations

Many classically desirable characteristics of Emergency Physicians are stereotypically masculine – direct, authoritative, assertive, confident – and may directly conflict with expected gendered behaviors when applied by women physicians. Qualitative observational data suggest that when female physicians use directive language and behavior, it can be received differently by nurses and attending preceptors, negatively impacting evaluation and feedback in ability and work ethic.

• Before any big resuscitation I take a moment for myself to visually put on my “big girl resus pants” as a reminder that I have equal ability and expertise to be a leader despite any stereotypes or biases.
• I am deliberate in my pre-briefs when time allows to not only review the incoming patient’s priorities but to also establish relationships, role clarity and my own leadership attention to team psychological safety and inclusivity.
• Clear summaries with working diagnoses, signposting and upcoming priorities reinforce leadership, while allowing for the “what am I missing” invitation for team member input.
• Establishing leadership early in dictating EMS handover is an effective way to identify who is in charge and set up roles and expectations.
• Learning to use physical attributes to command attention during a busy resuscitation – as a short female I find sometimes I need to expand my physical space by standing on a stool, raising my voice and dialling down the volume followed by an “all eyes on me” moment to redirect and re-establish authority.
• There is great power in admitting uncertainty and vulnerability – asking more questions, advocating for investigations or consultant opinions which goes against traditional values of decisiveness and certainty. I try to hold space for diagnostic uncertainty when it is indicated and lean into my team which helps me avoid premature anchoring.
• Lastly, leaning into the softer communication tools in checking in after tough cases, acknowledging the interplay of emotions and validating experiences with team members, are an ED physician’s superpower and should be emphasized to all physicians as they build community and make a difference in team building, wellness and longevity. 

Post-shift decompression

Women physicians may face a “second shift” of domestic labor after they complete their clinical duties. Some strategies I employ to compartmentalize and separate the divide between clinical and home responsibilities:

• Budgeting time at work to fully complete charting and billing so I may be fully present when I reach my family
• Taking 30 seconds while sitting in my car before walking into my home, to employ mindfulness breathing techniques
• Giving myself the time on the drive home to reflect on challenging cases or interactions that have the potential to weigh heavily in my thoughts
• If I identify unresolved emotions or ruminations I reach out by text message to one of my pre-identified “failure friends” or trusted colleagues to debrief at a later time
• I also engage my medical spouse to quickly debrief
• I have found my three year old is interested in what “mommy does at work” and explaining challenges of the health care system in very simple terms to him does wonders for mental processing. This allows me to close the emotional file temporarily and switch gears to focusing on my family. 

Implicit gender bias and societal norms can have unique effects on female Emergency Physician workflows. Advocacy in gender equity, institutional policies and attention to workplace culture can help address these effects as well encourage positive impacts of emotional labor to team dynamics and patient care.

References

1. Recognizing and addressing implicit gender bias in medicine. Katrina Hui, Javeed Sukhera, Simone Vigod, Valerie H. Taylor, Juveria Zaheer. CMAJ Oct 2020, 192 (42) E1269-E1270.
2. Sex Differences in Time Spent on Household Activities and Care of Children Among US Physicians, 2003-2016. Ly, Dan P. et al. Mayo Clinic Proceedings, Volume 93, Issue 10, 1484 – 1487.
3. Sheppard, Gillian, et al. “Towards Gender Equity in Emergency Medicine: A Position Statement from the CAEP Women in Emergency Medicine Committee.” Canadian Journal of Emergency Medicine, vol. 23, no. 4, 2021, pp. 455–59.
4. Nadkarni, Ashwini, and Jhilam Biswas. “Gender Disparity in Cognitive Load and Emotional Labor—Threats to Women Physician Burnout.” JAMA Psychiatry (Chicago, Ill.), vol. 79, no. 8, 2022, pp. 745–46.
5. Guptill, Mindi, et al. “Deciding to Lead: A Qualitative Study of Women Leaders in Emergency Medicine.” International Journal of Emergency Medicine, vol. 11, no. 1, 2018, pp. 1–10.
6. Marshall, A. , Dyrbye, L. , Shanafelt, T. , Sinsky, C. , Satele, D. , Trockel, M. , Tutty, M. & West, C. (2020). Disparities in Burnout and Satisfaction With Work–Life Integration in U.S. Physicians by Gender and Practice Setting. Academic Medicine, 95 (9), 1435-1443.
7. Brucker, Krista, et al. “Exploring Gender Bias in Nursing Evaluations of Emergency Medicine Residents.” Academic Emergency Medicine, vol. 26, no. 11, 2019, pp. 1266–72.
8. Linden, Judith A., et al. “The Intersection of Gender and Resuscitation Leadership Experience in Emergency Medicine Residents: A Qualitative Study.” AEM Education and Training, vol. 2, no. 2, 2018, pp. 162–68.
9. Plug, Ilona, et al. “Physicians’ and Patients’ Interruptions in Clinical Practice: A Quantitative Analysis.” Annals of Family Medicine, vol. 20, no. 5, 2022, pp. 423–29.