The Surgeon’s Cap Bias

The Surgeon’s Cap Bias: Intelligence, Respect and the Enemy of Feminism
By Emily Haque, BSA*

Tags: feminism, gender bias, implicit bias, surgery, women in medicine

On the first day of my surgical clerkship, I briskly followed my attending, a vascular surgeon, around the pre-op bay while ruminating about whether or not I was too close to him, if I should stand, if I should sit, if I should put my hair up or leave it down, or even if I should ask him a question. As he towered over me, I decided to keep quiet and avoid bothering him at all costs. I didn’t know why I was so intimidated by him. In past clerkships, my superiors encouraged me to express my knowledge to gain respect. The OR felt different.

Dr. Koven’s “Letter to the young female physician” had briefed me on the war I would eventually fight during medical school.1 I contemplated for years whether I was strong enough to fight my way through the medical battlefield of sexism and self-inflicted doubt. In medical school, I was blinded by the belief that medicine was already making significant progress. In fact, the year I entered medical school was the first year that women made up the majority of first-year medical students.2 The growing army of female physicians reassured me my arsenal was enough to be taken seriously as a worthy physician. However, it wasn’t until I actually stepped foot on the field that I realized I was loaded with naïve optimism thinking that the war for gender equality in medicine was almost over.

When asked quiz questions, I promptly answered what I knew to be correct, but his responses offered me no affirmation. Instead, I was ambushed with a “Not exactly” followed by a long-winded explanation of exactly what I had just said seconds ago. Eventually, I surrendered answering future questions knowing that my response would not get me the respect I craved, at least not with this surgeon.

I donned my blue shoe covers and matching face mask quickly. I gathered my long brown hair and reached for the bouffant cap as my attending reached for a surgeon’s cap. I stared at him as he tied the straps behind his head and put his hands on his hips, standing erect like a General. Marching into the OR hallway, still mesmerized by his perfectly fitting cap, I felt the warm breath inside my mask suddenly stop. I was shot with the sudden realization that no matter how smart I was, or how determined I was, I would never be able to wear a surgeon’s cap.

The author in the surgical suite

Historically, men were doctors and women were nurses.3 Habitually, gender identification relies on the generalization that men have short hair and women have long hair. The surgeon’s cap was designed for short-haired people and the bouffant caps were long-haired people. The binary identification of “doctor” versus “not a doctor” that is engrained in our subconscious is strongly influenced by whether one is wearing a surgeon’s cap or a bouffant cap.

When a person with this societal bias looks at a surgeon’s cap, her brain makes this association: surgeon’s cap = short hair = only men = doctor. While sight of a bouffant cap triggers this association: bouffant cap = not short hair = woman = not a doctor. Over time, the chronology of this thought process was lost, but the symbolism of the surgeon’s cap has remained.

‘I couldn’t wear it, even if I was a surgeon.’ This thought rattled my brain throughout my clerkship. If I wanted to wear the surgeon’s cap and the respect that came with it, would I have to cut my hair? My long hair serves as an expression of my femininity. I should not have to sacrifice my identity as a woman to win the respect that men are simply handed. This piece of blue disposable fabric somehow attacked my self-esteem and left my optimism defeated. I was ready to raise the white flag, but there were small beacons of hope that helped me transform this complaint into a mission.

The following week, I stood in the corner against the cold walls of the OR, awaiting the my new surgical attending to arrive. I anxiously prayed to the surgeon gods that he would be nice. We had started scrubbing when my resident told me Dr. White had just come in. I surveyed the OR to try and introduce myself to him when I realized that I was a casualty of surgeon’s-cap bias. Dr. White had long blonde hair tucked into a bouffant, perfect eye makeup and purple clogs. I had assumed Dr. White was a man and fell victim to the gender bias that I despised. I continued to look around and realized Dr. White, along with the entire OR, were only women: anesthesiologist, scrub nurse, circulator, residents, med student – all women in a place dominated by men for years.

I thought the battle for gender equality in medicine had been lost, but clearly there are still soldiers fighting for it. In 2019, the AAMC reported that for the first time in history, women comprised the majority of all US medical students.4 Recently, there were even headline-making studies which found that patients taken care of by female physicians had better outcomes than patients taken care of by male physicians.5 I used to think that I should act more like the men, so I could get respect like the men. I now realize that the best way to get respect as a woman physician, is to be a woman physician. It is our own responsibility to enforce the changes needed in medicine to help curate the image of the genderless physician. The symbolism of the surgeon’s cap is dynamic. We are gaining ground with each and every woman that chooses to become a doctor, and with the male colleague that respects her equal power.

When you don the surgeon’s cap before tomorrow’s procedure, remember its true meaning: woman = man = doctor.

References:

  1. Koven S. Letter to a Young Female Physician. New England Journal of Medicine. 2017;376(20):1907–9.
  2. Association of American Medical Colleges. More Women Than Men Enrolled in U.S. Medical Schools in 2017 [Internet]. 2017. Available from: https://www.aamc.org/news-insights/press-releases/more-women-men-enrolled-us-medical-schools-2017
  3. Navarro V. Women in Health Care. New England Journal of Medicine. 1975;292(8):398–402.
  4. Association of American Medical Colleges. The Majority of U.S. Medical Students Are Women, New Data Show [Internet]. 2019. Available from: https://www.aamc.org/news-insights/press-releases/majority-us-medical-students-are-women-new-data-show
  5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Internal Medicine. 2017Jan;177(2):206.

* Author Bio: Emily Haque is a fourth-year medical student at Texas A&M College of Medicine. Her upbringing as a first-generation American coupled with her passion for music helps her view medicine with a uniquely wide lens. She currently resides in North Texas and will be applying dermatology during the upcoming 2020 – 2021 application period. Email: Emily.HaqueATtamu.edu

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3 comments on “The Surgeon’s Cap Bias

  1. humanemedicine on said:

    From Bhushan Kumar, Emeritus Professorof Dermatology, Chandigarh, India:

    Interesting piece. Looks it is from a revolutionary feminist who must have felt slighted sometimes in life- school, college or medical school, at home or in a relationship. This is an overreaction to certain things- some of them may be imaginary.

    In our days not long ago- there was hardly any stress on education for women- for whatever reasons. In the professional colleges a certain percentage of seats were reserved for girls-to ensure fair representation and promote equality, more participation of women in all affairs, spheres and participation in public life outside the home. Gender bias maybe/ may have been a part of the system in some ways and to some extent but to express it in such strong terms for everybody is close to being pathological. To target the shape of the ‘Surgeon’s Cap’ in the OT as a sign of discrimination is too much. You can select the cap which fits your hair style. Many men have long hair and many women have short hair- what is so special to it? Since ages- because of the rigors of living in the stone age or the like through the ages- the women were protected and so supposedly given / chose the duty to look after the household and children. As the situation improved women came to the fore or rather brought to the front and offered best of the opportunities for outdoor activates (education, games, job etc. including also the exalted position of the author). Women have received the present position in just less than hundred years- with the background history of many thousand years of male dominance / protection. Even now there is either separate queue for women or ladies first, at many places indicating respect and protection. Change of attitude in the society is always slow and you cannot hasten it to the level and speed of your liking. If ‘the’ doctor in USA feels discriminated- she has not seen other societies in the world.

    I pity but also sympathize with her and pray that she progresses in her career without bias and prejudice.

  2. humanemedicine on said:

    From Katherine Peeler, M.D.: Emily – great essay. I tried to leave a comment on the website, but I kept getting an error.

    Thanks for sharing (and thanks to David Elpern for publishing and to my father for sharing it with me). As a friendly counter response to my father’s comment below your essay on the website, I think your original sentence was spot on. Gender should and does matter. While my father and you are right that man=woman=doctor, I believe your point in that sentence is that you wear your womanhood proudly, and the more we can highlight we are women and we are doctors, the farther along we will get towards gender equality. ​

    Best of your in your derm residency coming up, and keep writing!

  3. humanemedicine on said:

    From Richard Ratzan: very nice
    as a man whose wife and daughter are physicians, i would disagree slightly on one point, a point i know you endorse:
    not:
    “I now realize that the best way to get respect as a woman physician, is to be a woman physician.”
    but:
    “I now realize that the best way to get respect as a woman physician is to be the best physician i can be.”

    people (mentors, students, administrators, patients) whose respect and opinion you truly value will all think that way and when they look at you won’t be looking at your clothing or hair

    but very nice essay

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